NURSING PRACTICE I: Basic Foundation of Nursing and Professional Practice

PREBOARD EXAMINATION Nursing Practice I: Basic Foundation of Nursing and

Professional Practice GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test questions
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded
will invalid your answer.
3. AVOID ERASURES.
4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.
5. Write the subject title “NURSING PRACTICE I” on the box provided.
Situation: Nursing is a profession. Miss Perez is a newly appointed nurse in a hospital in Manila.
Born May 1993, her knowledge of nursing profession development is Required in order to
project the profession in a way that it uplifts the standard of nursing.
1. Miss Perez defined nursing as the following except:
A. Assisting individual, family, and community in attaining health
B. Assisting in basic health needs
C. Establishing nursing diagnosis and implementing nursing care
D. Diagnosing, treating, prescribing medication and doing minor surgery

2. PNA was established:

1. In 1922
2. In 1926
3. With Mrs. Rosario Delgado as the first president
4. With Mrs. Anastacia Tupas as the first president
A. 1 and 3
B. 1 and 4
C. 2 and 3
D. 2 and 4

3. As a national nurses’ association, PNA is characterized by the following, except:

A. Both a professional body and labor union
B. Affiliated with the International Council of Nurses
C. Advocating improved work and life condition of nurses
D. Accrediting body for continuing education program

4. CPE units per year are needed for license renewal. The number of CPE units in 3 years should
be:
A. 20 units
B. 30 units
C. 60 units
D. 100 units

5. To manifest that you want to quit from your job and discontinue the services you render after
the completion of a contract, you will file a/an:
A. Certificate of resignation
B. Honorable dismissal
C. Certificate of termination
D. Resignation letter

6. Jenny plans to resign from her job as a staff nurse. She must give an advance notice of:
A. 15 days
B. 30 days
C. 45 days
D. 60 days

7. If a nurse filed a sick leave and plans to return to work after, she must show her:
A. Back to work certificate
B. Fit to work certificate
C. Death certificate
D. Medical certificate
8. A certificate that will show that a nurse met the requirement set by the Philippine Government
to practice the profession is:
A. Diploma
B. Certificate of passing
C. Nursing License
D. Board certificate/CoR

9. Nurses in the Philippine Government also felt the need to organize themselves, this led to the
creation of:
A. National League of Government Nurses
B. National League of Filipino Government Nurses
C. National League of Philippine Government Nurses
D. Philippine Government Nurses Association

10. The founder of NLPGN, during her lifetime, exemplified professional dignity, high level of
intelligence and leadership ability, as well as moral integrity. She was a good model, who, like
Florence Nightingale, initiated reforms and worked for the improvement of the nursing
profession and health care in the Philippines. The name of the NLPGN Recognition award was
also named after her.
A. Anastacia Giron Tupas
C. Betty Meritt
B. Francisca Delgado
D. Annie Sand

Situation: Anicieto is an elderly client who is immobile and sedentary.

11. Anicieto is frequently complaining of dry skin. Which of the following is the best way to
prevent dry skin?
A. Wash the skin with mild soap and water
B. Avoid exposure to cold or low humidity
C. Apply lotion or skin moisturizer
D. Massage the skin gently to stimulate oil production from the sebaceous glands
12. Which of the following is a frequently used dressing for pressure sores?
A. Transparent
B. Wet to dry
C. Wet to moist
D. Hydrogel

13. Heat is an old remedy for aches and pain. People equate heat with comfort and relief
because:
A. It is safer than cold application
B. It causes a local anesthetic effect
C. It promotes blood circulation and tissue oxygenation through vasodilation
D. Slows bacterial growth

14. Heat and cold application should not exceed:

A. 10 minutes
B. 15 minutes
C. 30 minutes
D. 1 hour

15. A client with deep wounds underwent Hydrocolloid dressing. Which of the following is true
with regards to this dressing?
A. They provide good wound visibility
B. They could last indefinitely until the wound heals
C. They can be molded to uneven skin surfaces thus best used in pressure ulcers
D. The client could not shower or bath with such dressing

Situation: You are a nurse conducting a statistical analysis in your research entitled “The Effect
of Gingko Biloba in Enhancing Memory and Retention Among 4th Year High School Students.”
16. What is the independent variable?
A. The effect of gingko biloba
B. Memory and retention
C. Gingko biloba
D. Enhancing memory and retention

17. What is the dependent variable?

A. The effect of gingko biloba
B. Memory and retention
C. Gingko biloba
D. Enhancing memory and retention

18. The research design best used in this research is:

A. Experimental
B. Non-experimental
C. Descriptive
D. Qualitative

19. The hypothesis developed was: Gingko biloba improves memory and retention. This is an
example of:
A. Simple, directional
B. Simple, non-directional
C. Complex, directional
D. Complex, non-directional

20. Gingko biloba has an effect on memory and retention best describes which type of
hypothesis?
A. Simple, directional
B. Simple, non-directional
C. Complex, directional
D. Complex, non-directional

21. Which of the following is the best null hypothesis (H0) for this study?
A. Gingko biloba has no effect on enhancing memory and retention
B. Gingko biloba has an effect on enhancing memory and retention
C. Gingko biloba has no effect on enhancing memory and retention of 4th year high school
students
D. Gingko biloba has an effect on enhancing memory and retention of 4th year high school
students

22. Which of the following best represents the alternative hypothesis (Ha) for this study?
A. Gingko biloba has no effect on enhancing memory and retention
B. Gingko biloba has an effect on enhancing memory and retention
C. Gingko biloba has no effect on enhancing memory and retention of 4th year high school
students
D. Gingko biloba has an effect on enhancing memory and retention of 4th year high school
students

23. Which of the following is the average P value as threshold to determine the plausibility of the
null hypothesis? A. P=0.05 C. P=0.001 B. P=0.01 D. P=0.5

24. If the study is statistically highly significant, it would reflect a p value of?
A. p=0.05
B. p=0.01
C. p=0.001
D. p=0.5
25. Supposed that your alternative hypothesis has a 1 in a hundred chance of accepting the null
hypothesis, has a 99% chance of being correct, and has a 1 in a hundred chance that the null
hypothesis is true. Your P value will be?
A. P=0.99
B. P=0.01
C. P=0.001
D. P=0.5

Situation: Survey and Statistics are important parts of research that is necessary to explain the
characteristics of the population.
26. All but one of the following is not a measure of central tendency.
A. Mode
B. Variable
C. Standard deviation
D. Range

27. It reflects the most frequent value that appears in the set data.
A. Mean
B. Mode
C. Median
D. Ratio

28. In the values: 87, 85, 88, 92, 90, the mean is:
A. 88.2
B. 88.4
C. 87
D. 90

29. In the values: 80, 80, 80, 82, 82, 90, 90, 100, the mode is:
A. 80
B. 82
C. 90
D. 85.5

30. In the values: 80, 80, 10, 10, 25, 65, 100, 200, the median is:
A. 71.25
B. 22.5
C. 10 and 25
D. 72.5

Situation: As a peri-operative nurse, you are aware of the correct processing methods for
preparing disinfection.
31. As an OR nurse, what is your foremost consideration for selecting chemical agents for
disinfection?
A. Material compatibility and efficiency
B. Odor and availability
C. Cost and duration of disinfectant process
D. Duration of disinfectant and efficiency

32. Before you use an instrument disinfectant, it is essential that you:

A. Rinse with tap water followed by alcohol
B. Wrap the instrument with sterile cloth
C. Dry the instrument thoroughly
D. Rinse with sterile water

33. You have a critical heat labile instrument to sterilize and are considering using high level
disinfectant. What should you do?
A. Cover the soaking vessel to contain the vapor
B. Double the amount of high level disinfectant
C. Test the potency of the high level disinfectant
D. Prolong the exposure time according to manufacturer’s direction

34. To achieve sterilization using disinfectant, which of the following is used?

A. Low level disinfectant immersion for 24 hours
B. Intermediate level disinfectant immersion for 12 hours
C. High level disinfectant immersion for 1 hour
D. High level disinfectant immersion for 10 hours

35. Bronchoscope, thermometer, endoscope, ET tube, cystoscope, are all best sterilized using
which of the following?
A. Autoclaving at 1210C in 15 minutes
B. Flash sterilizer at 1320C in 3 minutes
C. Ethylene oxide gas aeration for 20 hours
D. 2% Glutaraldehyde immersion for 30 minutes

Situation: Health promotion is the priority nursing responsibility. The nurse should be able to
promote the client’s well-being and identify ways on improving the client’s quality of life.

36. The nurse is caring for a 16-year old female client who isn’t sexually active. The client asks
if she needs a Papanicolau test. The nurse should reply:
A. Yes, she should have a Pap smear after the onset of menstruation
B. No, because she isn’t sexually active
C. Yes, because she’s 16 years old
D. No, because she is not yet 21 years old

37. The nurse is assessing a client who complains of abdominal pain, nausea, and diarrhea. When
examining the client’s abdomen, which sequence should the nurse use?
A. Inspection, palpation, percussion, auscultation
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, palpation, percussion
D. Palpation, auscultation, percussion, inspection

38. The nurse is speaking to a group of women about early detection of breast cancer. The
average age of women in the group is 45.
Following the Philippine Cancer Society guidelines, the nurse should recommend that the
women should:
A. Perform a breast self-examination annually
B. Have a mammogram annually
C. Have a hormonal receptor assay annually
D. Have a physician conduct a clinical examination every 2 years

39. The school nurse is planning a program for a group of teenagers on skin cancer prevention.
Which of the following instruction should the nurse emphasize on her talk?
A. Stay out of the sun between 1 pm and 3 pm
B. Tanning booth is a safe alternative for those who wish to tan
C. Sun exposure is safe, provided the client wears a protective clothing
D. Examine skin once per month, looking for suspicious lesions or changes in moles

40. An employer establishes a physical exercise area in the workplace, and encourages all
employees to use it. This is an example of which level of prevention?
A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Passive prevention

Situation: Mrs. Vergara is now the chief nurse of a hospital in Manila. She is clinically reviewing
different management styles and theories that will best help her in running the nursing services in
the hospital.
41. Which leadership style best empower the staff towards excellence?
A. Autocratic
B. Situational
C. Democratic
D. Laissez faire

42. As nurse manager, Jillian enjoys her staff of talented and well-motivated individuals. She
knew the leadership style to suit the needs of this kind of people is called:
A. Autocratic
B. Participative
C. Democratic
D. Laissez faire

43. A fire has broken in Jillian’s unit. The best leadership style suited in cases of emergencies
like this is:
A. Autocratic
B. Participative
C. Democratic
D. Laissez faire

44. Mrs. Vergara is thinking of introducing the Primary Nursing Model Approach. You
understand that in this nursing model:
A. The nurse manager assigns tasks to the staff members
B. Critical paths are used in providing nursing care
C. A simple registered nurse is responsible for planning and providing individualized nursing
care
D. Nursing staff are led by an RN leader in providing care to a group of clients

45. Evaluation as administrative process is best described as:

A. Obtaining commitment of members to do better
B. Follow-up activities that have been stated
C. A continuing process of seeing that performance meet goals and targets
D. Informing personnel how well and how much improvement has been made

Situation: Mr. Delos Reyes, 70 years old, was suddenly rushed to the hospital because of severe
chest pain. On admission, he was diagnosed to have an acute myocardial infarction and was
placed in the ICU.

46. While he is in the ICU, he executes a document that lists the medical treatments he chooses
to refuse in case his condition becomes severe to a point that he will be unable to make decisions
for himself. The document is:
A. Living will
B. Power of attorney
C. Last will and testament
D. Informed consent

47. After one day, the patient’s condition worsened and he felt hopeless. He requested the nurse
to remove the oxygen. The nurse should:
A. Follow the patient because it is his right to die gracefully
B. Refuse the patient since euthanasia is not accepted in the Philippines
C. Follow the patient as it is his right to determine the medical regimen he needs
D. Refuse the patient and encourage him to verbalize his feelings

48. Euthanasia is an ethical dilemma which confronts nurses in the ICU because:
A. Decisions has to be made quickly, often under stressful situations
B. Decisions has to be made based on societal norms
C. The choices involved do not appear to be clearly right or wrong
D. A client’s legal rights co-exist with the nurse’s professional obligation

49. The personal conviction that euthanasia is absolutely wrong in any situation is:
A. Personal value
B. Legal obligation
C. Ethical issue
D. Immoral belief

50. Mr. Delos Reyes felt better after 3 days but recognized the severity of his illness. He
executed a document authorizing his wife to transact any form of business in his behalf in
addition to all decisions relative to his confinement. This document is referred to as:
A. Power of attorney
B. Informed consent
C. Medical record
D. Living will

Situation: Nursing as a profession. The nurse should have a background on the theories and
foundation of nursing as it has influenced what nursing is today.

51. Nursing is the protection 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 the population. This is the
most accepted definition of nursing as defined by:
A. PNA
B. ANA
C. Florence Nightingale
D. Virginia Henderson

52. Advancement in nursing leads to the development of the expanded career roles. Which of the
following is not an expanded career role for nurses?
A. Nurse practitioner
B. Clinical nurse specialist
C. Nurse researcher
D. Nurse anesthesiologist

53. The board of nursing regulated the nursing profession in the Philippines and is responsible
for the maintenance of the quality of nursing in the country. Powers and duties of the board of
nursing are the following, except: A. Issue, suspend, revoke certificates or registration B. Issue
subpoena, decus tecum, ad testificandum C. Open and close college of nursing D. Supervise and
regulate the practice of nursing

54. A nursing student or a beginning staff nurse who has not yet experienced enough real
situations to make judgments about them is in what stage of nursing expertise? A. Novice C.
Advanced beginner B. Newbie D. Competent

55. 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. Attained an advanced level of
education C. A holistic understanding and perception of the client D. Intuitive and analytic ability
in new situations Situation: The nurse has been asked to administer an injection.

56. The nurse prepares an IM injection for an adult client using the Z track technique. 4 mL of
medication is to be administered to the client. Which of the following sites will you choose? A.
Deltoid C. Ventrogluteal B. Rectus femoris D. Vastus lateralis
57. In infants 1 year and below, which of the following is the site of choice for intramuscular
injection? A. Deltoid C. Ventrogluteal B. Rectus femoris D. Vastus lateralis

58. Mrs. Morales is obese. When administering subcutaneous injection to an obese patient, it is
best for the nurse to: A. Inject needle at 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 via Z track D. Spread skin or pinch at the injection site and inject needle at a
45-90 degree angle

59. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:
A. Syringe 3-5 mL and needle gauge 21 to 23 B. Tuberculin syringe 1 mL with needle gauge 26
to 27 C. Syringe 2 mL and needle gauge 22 D. Syringe 1-3 mL and needle gauge 25 to 27

60. The rationale for giving medications through the subcutaneous route is: A. There are many
alternative sites for subcutaneous injection B. Absorption time of medication is slower C. There
are less pain receptors in the area D. The medication can be injected while the client is in any
position Situation: A client was rushed to the Emergency Room and you are his attending nurse.
You are assessing the vital signs.

61. After a few hours in the emergency room, the client is admitted to the ward with an order of
hourly monitoring of BP. The nurse finds that the cuff is too narrow and this will cause the BP
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

62. You attached a pulse oximeter to the client. You know that the purpose of this is 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 antihypertensive
medications D. Detect oxygen saturation of arterial blood before symptoms of hypoxemia
develops

63. Through the client’s health history, you found out that the patient smokes and drinks coffee.
When taking the BP of a client who recently smoked or drank coffee, how long should the nurse
wait before taking the client’s BP for accurate reading? A. 5 minutes C. 30 minutes B. 15
minutes D. 1 hour
64. While the pulse oximeter is on the client’s fingertip, you notice that the sunlight is shining on
the area where the oximeter is. Your action will be to: A. Turn on and set the alarm of the
oximeter B. Do nothing since there are no identified problems C. Cover the fingertip sensor with
a towel or bed sheet D. Change the location of the sensor every four hours

65. You are to assess 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 C. 20 minutes B. 15 minutes D. 30 minutes Situation: Oral care is an important part of
hygienic practices and promoting client comfort.

66. 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 side-lying
position with head of bed lowered B. Keep the patient dry by placing a 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

67. A possible problem while providing oral care to unconscious clients is the risk of fluid
aspiration to the lungs. This can be avoided by: A. Cleaning teeth and mouth with cotton swabs
soaked in 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 finger wrapped with wet cotton washcloth
to rub inside the cheeks, tongue, lips and gums D. Suctioning as needed while cleaning the
buccal cavity

68. 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 C. Petroleum jelly B.
Water D. Mentholated ointment

69. A nurse is observed taking all of the following actions when suctioning a patient who has a
newly placed tracheostomy tube. Which of the following actions require intervention? A.
Applying suction for less than 15 seconds at one time B. Administering 100% oxygen prior to
starting suctioning C. Utilizing negative pressure of 120 mmHg during suctioning D. Deflating
tracheostomy cuff for three minutes before initiating suction 70. The major difference between
an antiseptic and a disinfectant is that an antiseptic: A. Destroys pathogenic and non-pathogenic
microorganisms B. Inhibits microbial growth on skin C. Has a shorter duration of effectiveness
D. Destroys pathogens Situation: Ensuring safety before, during, and after a diagnostic procedure
is an important responsibility of the nurse. 71. To help Paul better tolerate the bronchoscope, you
should instruct him to practice which of the following prior to the procedure? A. Clenching the
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 72.
Thoracentesis may be performed for cytologic studies of the 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 73. How will you prevent ascending infection to Arra who has an indwelling catheter? A.
See to it that the drainage tubing touches the level of the urine B. Change the catheter every 8
hours C. See to it that urine is draining freely D. Clean catheter is used since urethral meatus is
not a sterile area 74. A patient’s blood test results reveal a hematocrit level of 66 mg/dL. The
nurse should give priority to which nursing diagnosis? A. Ineffective breathing pattern B.
Activity intolerance C. Hyperthermia D. Dysreflexia 75. A client’s admission urinalysis shows
the specific gravity value of 1.039. Which of the following assessment data would the nurse
expect to find when assessing the client? A. Moist mucous membranes B. Urinary frequency C.
Poor skin turgor D. Increased blood pressure Situation: The staff nurse supervisor requests all the
staff nurses to brainstorm and learn ways to provide health teachings to clients. She wants to
ensure that there are nurses available to do daily health education classes. 76. When Lanie, a
nurse, delegates aspects of client care to the nurse aide who is an unlicensed staff, Lanie: 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 nor evaluate the nurse aide
D. Must know how to perform the delegated task 77. Which of the following is not a legally
binding document but is very important in the care of all patients in any health care setting? A.
Bill of rights as provided in the Philippine constitution B. Scope of nursing practice as defined
by RA 9173 C. Board of nursing resolution adopting the code of ethics D. Patient’s bill of rights
78. Bettina gave the wrong medication to a client. Another nurse employed by the same hospital
as a risk manager will expect to receive which of the following communication? A. Incident
report C. Nursing kardex B. Oral report D. Complaint report 79. Performing a procedure on a
client in the absence of an informed consent can lead to which of the following charges? A.
Fraud C. Harassment B. Assault and battery D. Breach of confidentiality 80. Delegation is the
process of assigning tasks that can be performed by a subordinate. The RN should always be
accountable and should not lose his accountability. Which of the following is a role included in
delegation? A. The RN must supervise all delegated tasks B. After a task has been delegated, it is
no longer a responsibility of the RN C. The RN is responsible and accountable for the delegated
task in adjunct with the delegate D. Follow up on a delegated task is necessary only if the
assistive personnel is not trustworthy Situation: Health care delivery system affects the health
status of every Filipino. As a nurse, knowledge of this system is expected to ensure quality of
life. 81. Which of the following exemplifies the preventive and promotive programs in the
hospital? A. Hospital as a center to prevent and control infection B. Program for smokers C.
Program for alcoholics and drug addicts D. Personal wellness center 82. Which makes nursing
dynamic? A. Every patient is a unique physical, emotional, social, and spiritual being B. The
patient participates in the overall nursing care plan C. Nursing practice is expanding in the light
of modern development that takes place D. The health status of the patient is constantly changing
and the nurse must be cognizant and responsive to these changes 83. During the evaluation phase
for a client, the nurse should focus on: A. All findings of physical and psychosocial stressors of
the client and his family B. The client’s status, progress towards goal achievement, and ongoing
re-evaluation C. Setting short and long-term goals to ensure continuity of care from hospital to
home D. Select interventions that are measurable and achievable within selected timeframes 84.
An adult comes to the clinic because of productive cough. She smokes two packs of cigarette a
day and has a family history of lung cancer and emphysema. Using the principle of heath
promotion, the nurse would interpret the client’s behavior as: A. Using denial to deal with being
at high risk for lung cancer B. Not assuming self-responsibility for her health C. Exhibiting a
Laissez faire attitude toward smoking and her risk for cancer D. Demonstrating passive suicidal
tendencies 85. To set the stage for a successful rehabilitation experience, the rehabilitation nurse
helps the client and her family conceptualize their definition of: Downloaded by Summit
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Foundation of Nursing and Professional Practice TOPRANK REVIEW ACADEMY, Inc. Page 6
of 7 A. Wellness B. Quality of life C. Independence D. Active participation Situation: The use of
massage and meditation to help decrease stress and pain have been strongly recommended based
on documented testimonials. 86. Georgia wants to perform a study on this topic entitled: “Effects
of massage and meditation on stress and pain.” The type of research that best suit this topic is: A.
Applied research C. Basic research B. Qualitative research D. Quantitative research 87. The type
of research that does not manipulate the independent variable is: A. Experimental design B.
Quasi-experimental design C. Non-experimental design D. Quantitative design 88. This research
topic has the potential to contribute to nursing because it seeks to: A. Include new modalities of
care B. Resolve a clinical problem C. Clarify an ambiguous modality of care D. Enhance client
care 89. Georgia does review of related literature for the purpose of: A. Determining statistical
treatment of data research B. Gathering data about what is already known or unknown about the
problem C. Identifying if the problem can be replicated D. Answering the research question 90.
Clients’ rights should be protected when doing research using human subjects. Georgia identifies
the rights as follows except: A. Right to self-determination C. Right to privacy B. Right to
compensation D. Right not to be harmed Situation: Ben 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 Jenny’s care plan is to loosen and remove secretions in the airway. 91.
Jenny listens to Ben’s bilateral sounds and finds that congestion is in the upper lobes of the
lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs
when Jenny does percussion would be: A. Client lying on his back and then flat on his abdomen
on Trendelenburg position B. Client seated upright in bed or on a chair then leaning forward in
sitting position then flat on his back and on his abdomen C. Client lying flat on his back and the
flat on his abdomen D. Client lying on his right the left side on Trendelenburg position 92. When
documenting outcome of Ben’s treatment, Jenny should include the following on her recording
except: A. Color, amount, and consistency of sputum B. Character of breath sounds and
respiratory rate before and after the procedure C. Amount of fluid intake of client before and
after the procedure D. Significant changes in vital signs 93. When assessing Ben for chest
percussion or chest vibration, and postural drainage, Jenny 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 restrictions and client’s tolerance for lying flat
94. Jenny prepares Ben for postural drainage and percussion. Which of the following is a special
consideration when doing the procedure? A. Respiratory rate of 16 to 20 per minute B. Client
able to tolerate sitting and lying position C. Client has no signs of infection D. Time of last food
and fluid intake of the client 95. The purpose of chest percussion and vibration is to loosen
secretions in the lungs. The difference between the procedures is: A. Percussion uses only one
hand while vibration uses both hands B. Percussion delivers cushioned blows to the chest with
cupped palms while vibration gently shakes secretions loose on the exhalation cycle C. In both
percussion and vibration, the hands are on top of each other and hand action is in tune with
client’s breath rhythm D. Percussion slaps the chest to loosen secretions while vibration shakes
the secretions along with the inhalation of air Situation: Mrs. Silva, 50 years old, asks about
possible problems regarding her elimination now that she is in the menopausal stage. 96.
Instruction on health promotion regarding urinary elimination is important. Which would you
include? A. Hold urine as long as she can before emptying her bladder to strengthen her
sphincter muscles B. If burning sensation is experienced while voiding, drink pineapple juice C.
After urination, wipe from anal area towards the pubis D. Tell client to empty the bladder eat
each voiding 97. Mrs. Silva talks about her fear of being incontinent due to a prior experience of
dribbling urine when laughing or sneezing, and when she has a full bladder. Your most
appropriate action would be to: A. Tell client to drink less fluid to avoid incontinence B. Instruct
client to start wearing thin adult diapers C. Ask the client to bring an extra underwear “just in
case” D. Teach client pelvic exercises to strengthen perineal muscles 98. Mrs. Silva 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 her wet with
urine D. Making sure that the linen are smooth and dry at all times 99. Which of the following is
the priority nursing action when a urinary catheter has been inserted in a female client with no
urine return? A. Insert the catheter another four inches B. Secure the catheter tubing to the inside
of the thigh C. Encourage the client to increase fluid intake D. Leave the catheter in the vagina
and insert another catheter 100. Which of the following is the most appropriate nursing action
when the nurse has inserted a urinary catheter in a male client but there is no return of urine? A.
Advance the catheter further B. Remove catheter C. Tape the catheter in place and encourage
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