FUNDA Q & A 42.

) Which of the following is not to be included in the nursing

interventions for a client receiving oxygen therapy?
Concepts of Man and His Basic Human Needs A.) Place a “Non-smoking” sign at the bedside
1.) The theory on man as a Biopsychosocial and Spiritual B.) Place the client in semi-fowler’s position
34.) The following are appropriate nursing actions when C.) Place sterile water into the oxygen humidifier
performing percussion, vibration and postural drainage, D.) Lubricate nares with oil to prevent dryness of the mucous
EXCEPT: membrane
A.) Verify doctor’s order ANS: D
B.) Perform the procedure before meals and at bedtime > It is inappropriate to lubricate nares with oil when the client is
C.) provide good oral hygiene after the procedure receiving oxygen therapy. Oil ignites when exposed to
D.) Each position during postural drainage should be assumed compressed oxygen
for 30 minutes 43.) When assessing respiration, the nurse describes the
ANS: D following EXCEPT:
> This is inappropriate nursing action during chest A.) Rhythm
physiotherapy. Appropriate is to assume each position during B). Effort
postural drainage for 10 to 15 minutes C.) Rate
35.) Which of the following nursing actions is inappropriate D.) Depth
when providing steam inhalation therapy? ANS: C
A.) Check doctor’s order > When assessing respirations, the nurse should count the
B.) Cover the eyes with moist washcloth rate, not simply describe it.
C.) Place the spout 3-4 inches away from the patient’s nose 44.) The small hair-like projections that line the
D.) Place the patient in semi-fowler’s position tracheobronchial tree, which sweep out debris and excessive
ANS: C mucous from the lungs are called:
> This inappropriate nursing action when providing steam A.) Cilia
inhalation therapy. Appropriate is to place the spout at least 12 B.) Vibrissae
inches from the patient’s nose. C.) Macrophages
36.) To be effective, steam inhalation should be rendered for at D.) Goblet cells
least: ANS: A
A.) 5-10 minutes > Cilia are small hair-like projections that line the
B.) 15-20 minutes tracheobronchial tree
C.) 30-45 minutes 45.) The following are appropriate nursing diagnoses for clients
D.) 60-70 minutes with oxygenation problems:
ANS: B A.) Ineffective airway clearance related to tracheobronchial
> To be effective, steam inhalation should be rendered for at secretions
least 15-20 minutes B.) Ineffective breathing pattern related to decreased energy
37.) The correct pressure of the wall suction unit when and fatigue
suctioning an adult patient is: C.) Impaired gas exchange related to altered oxygen-carrying
A.) 95-110 mm Hg capacity of the blood
B.) 100-120 mm Hg D.) All of these
C.) 50-95 mm Hg ANS: D
D.) 10-15 mm Hg > All of these (A,B, and C) are appropriate nursing diagnoses
ANS: B for clients with oxygenation problems.
> The correct pressure of the wall suction unit when suctioning ---Basic Human Needs: Nutrition----
an adult patient is 100-120 mm Hg 46.) The regulating center for fluid and food intake are located
38.) Which of the following is inappropriate nursing action in their
when performing oropharyngeal suctioning? A.) Thalamus
A.) Place the client in semi-fowler’s or lateral position B.) Hypothalamus
B.) Measure length of catheter from the tip of the nose to the C.) Medulla oblongata
earlobe. D.) Pons
C.) Lubricate suction catheter with alcohol ANS: B
D.) Apply suction during withdrawal of the suction catheter tip: > The regulating centers for food and fluid intake are found in
ANS: C the hypothalamus
> When performing oropharyngeal suctioning, it is 47.) The enzyme that initiates digestion of starch in the mouth
inappropriate to lubricate catheter with alcohol. Alcohol may is:
irritate mucous membrane of airways. Appropriate is, use A.) Amylase
sterile water or sterile NSS. B.) Sucrase
39.) The maximum time for applying suction is: C.) Maltase
A.) 5-10 seconds D.) Lactase
B.) 10-15 seconds ANS: A
C.) 15-20 seconds > The enzyme that initiates digestion of starch in the mouth is
D.) 20-30 seconds salivary amylase
ANS: B 48.) Which of the following structure prevents gastric reflux?
> The maximum time for applying suction is 10 to 15 seconds. A.) Pyloric sphincter
This is to prevent hypoxia B.) Internal sphincter
40.) To evaluate effectiveness of suctioning, the nurse should C.) Cardiac sphincter
primarily: D.) Sphincter of Oddi
A.) Auscultate the chest for clear breath sounds ANS: C
B.) Assess the respiratory rate > The cardiac sphincter also known as lower esophageal
C.) Check the skin color sphincter prevents gastric reflux
D.) palpate the pulse rate 49.) Which of the following nutrients remains in the stomach for
ANS: A the longest period?
> To evaluate effectiveness of suctioning, the nurse should A.) Fats
primarily auscultate the chest for clear breath sounds B.) Proteins
41.) The oxygen administration device preferred for patients C.) Carbohydrates
with COPD is: D.) Water
A.) Nasal cannula ANS; A
B.) Oxygen tent > Fats remains in the stomach for 4 to 6 hours; carbohydrates
C.) Venturi mask for 1 to 2 hours; protein 3 to 4 hours
D.) Oxygen hood 50.) The pancreatic enzyme which completes digestion of fats
ANS: C is
> Venturi mask is the preferred device for oxygen therapy A.) Amylase
among clients with COPD. B.) Lipase
C.) Trypsin
D.) Rennin > The best indicator of nutritional status is the weight
ANS: B 61.) To assess the adequacy of food intake, which of the
> Lipase is the pancreatic enzyme that completes digestion of following assessment parameters is best used?
fats A.) Food preferences and dislikes
51.) Kwashiorkor is a condition characterized by: B.) Regularity of meal times
A.) Calorie deficiency C.) 3-day diet recall
B.) Vitamin Deficiency D.) Eating style and habits
C.) Protein deficiency ANS: C
D.) Mineral deficiency > Dietary diary e.g. 3-day diet recall, is the best assessment
ANS: C parameter for adequacy of food intake
> Kwashiorkor is protein deficiency 62.) Prolonged deficiency of vitamin B12 leads to:
52.) Which of the following is most effective nursing measures A.) beriberi
to relieve anorexia EXCEPT: B.) Pernicious anemia
A.) Provide small, frequent feedings C.) Pellagra
B.) Remove unsightly articles from the patient’s unit D.) Peripheral neuritis
C.) Provide three full meals a day ANS: B
D.) Provide good hygienic measures > Prolonged Vit B12 deficiency results to pernicious anemia
ANS: A 63.) The vitamin necessary for absorption of calcium is:
> Providing small frequent feedings is most effective nursing A.) Vit D
measure to relieve anorexia B.) Vit A
53.) The following factors increase calorie requirements C.) Vit C
EXCEPT: D.) Vit E
A.) Cold climate ANS: A
B.) Activity and exercise > Vit D promotes absorption of calcium
C.) Fever 64.) Vit. K is necessary for:
D.) sleep A.) Bone and teeth formation
ANS: D B.) Integrity of skin and mucous membrane
> Sleep reduces calorie requirement by 10 to 15% . A,B,and C C.) Blood coagulation
are factors that increase calorie requirement. D.) Formation of RBC
54.) The following are good sources of calcium EXCEPT: ANS: C
A.) Cheese > Vit K is necessary for blood clotting. Prolonged deficiency of
B.) Milk this vitamin leads to bleeding
C.) Soy products 65.) The following are signs and symptoms of dehydration
D.) Carbonated drinks EXCEPT:
ANS: D A.) Weight loss
> Carbonated drinks are not sources of calcium. A,B and C are B.) Decreased urine output
good sources of calcium. C.) Elevated body temperature
55.) Which of the following is the richest source of iron? D.) Elevated BP
A.) Mongo ANS: D
B.) Milk > Elevated BP is not a sign of dehydration. A,B,C are signs and
C.) Malunggay leaves symptoms of dehydration.
D.) Pechay 66.) The client is experiencing hypokalemia. Which of the
ANS: A following should be included in his diet?
> Among these choices, mongo (a legume) is the richest A.) Banana
source of iron. The richest source of iron is liver, next is lean B.) Milk
meat, then legumes, then green leafy vegetables C.) Cheese
56.) Which of the following is a good source of vitamin A? D.) Fish
A.) Eggs ANS: A
B.) Liver > Hypokalemia is low serum potassium level. Providing
C.) Fish potassium-rich foods like banana and other fresh fruits is
D.) Peanuts effective nursing intervention for this condition
ANS: B 67.) During insertion of NGT, which position is best assumed
> Liver is very good source of fat-soluble vitamins (A,D,E,K) by the client?
57.) The following may be given to relieve nausea and vomiting A.) Low-Fowler’s
EXCEPT: B.) Semi-Fowler’s
A.) Dry toast C.) High-Fowler’s
B.) Milk D.) Lateral
C.) Cold cola beverage ANS: C
D.) Ice chips > During insertion of NGT, the patient is best placed in high-
ANS: B Fowler’s position with neck hyperextended until the tube is in
> Milk does not relieve nausea and vomiting. A,B,C may relieve the oropharynx. Once the NGT is in the oropharynx, the client
nausea and vomiting is instructed to flex the neck and swallow, as the tube is
58.) The most life threatening complication of vomiting is: advanced.
A.) Aspiration 68.) The length of NGT to be inserted is correctly measured;
B.) Dehydration A.) From the tip of the nose to the umbilicus
C.) Fever B.) From the tip of the nose to the xiphoid process
D.) Malnutrition C.) From the tip of the nose to the earlobe to the umbilicus
ANS: A D.) From the tip of the nose to the earlobe to the xiphoid
> The most life-threatening complication of vomiting is process.
aspiration. It causes airway obstruction. ANS: D
59.) The vomiting center is found in the ________. > The length of NGT to be inserted is measured from the tip of
A.) Cerebellum the nose, to the earlobe, to the xiphoid process (N-E-X) which
B.) Hypothalamus is approximately 50cm
C.) Medulla Oblongata 69.) When inserting NGT, the neck should:
D.) Cerebrum A.) Flexed
ANS: C B.) Hyperextend
> The vomiting center in the Medulla Oblongata C.) Tilted to the left
60.) The best indicator of nutritional status of the individual is: D.) In neutral position
A.) Weight ANS: B
B.) Height > When inserting NGT, the neck is initially hyperextended
C.) Arm muscle circumference 70.) The most accurate method of assessing method of
D.) Adequacy of hair placement of NGT is:
ANS: A A.) Aspiration
B.) Testing the pH of gastric aspiration ANS: A
C.) X-ray study > Castor oil provides chemical stimulation to the intestinal
D.) Introduction of air into NGT and auscultate at the epigastric mucosa, to increase peristalsis and promote defecation
area. 80.) Which of the following foods should be avoided by the
ANS: C client prevent flatulence?
> The most accurate method of assessing placement of NGT is A.) Fruit juice
through X-ray. B.) Cabbage
71.) Which of the following is inappropriate nursing action C.) Meat
when administering NGT feeding? D.) Fish
A.) Assist the client in Fowler’s position ANS: B
B.) Introduce feeding slowly > To prevent flatulence, avoid gas-forming foods like cabbage
C.) Place the feeding 24 inches above the point of insertion of 81.) Which of the following antidiarrheal medications absorb
NGT gas or toxic substances from the bowel?
D.) Instill 60mls of water into the NGT after feeding A.) Demulcent
ANS: C B.) Cabbage
> During NGT feeding, the height of the feeding is 12 inches C.) Meat
above the point of NGT insertion, not 24 inches. If the height of D.) Fish
feeding is too high, this results to very rapid introduction of ANS: B
feeding. This may trigger nausea and vomiting. > Absorbent anti-diarrheal medications absorb gas or toxic
72.) The primary purpose of gastrostomy is: substances from the bowel
A.) For feeding 82.) The most common-side effect of overuse of laxatives is:
B.) For drainage A.) Diarrhea
C.) To prevent flatulence B.) Nausea and vomiting
D.) To prevent aspiration of gastric reflex C.) Constipation
ANS: A D.) Flatulence
> The primary purpose of gastrostomy is for feeding ANS: C
73.) The most important nursing action before gastrostomy > The most common side-effect of overuse of laxative is
feeding is: rebound constipation
A.) Check VS 83.) Which of the following should be included in the diet of the
B.) Assess for patency of the tube patient with diarrhea?
C.) Measure residual feeding A.) Banana
D.) Check for placement of the tube B.) Papaya
ANS: B C.) Pineapple
> The most important nursing action before gastrostomy D.) Avocado
feeding is to assess for patency of the tube. This is done by Ans: A
instilling 15-30 mls of water into the tube. > Banana should be included in the diet of the client with
74.) The primary advantage of gastrostomy feeding is: diarrhea. It is rich in potassium and it replaces potassium
A.) It ensures adequate nutrition losses due to diarrhea
B.) It prevents aspiration 84.) Which of the following fluids may be given to a client with
C.) It maintains integrity of gastro-esophageal sphincter diarrhea?
D.) It minimizes fluid-electrolyte imbalances A.) Milk
ANS: C B.) Coffee
> The primary advantage of gastrostomy feeding is, it C.) Tea
maintains the integrity of gastro-esophageal sphincter ( cardiac D.) Gatorade
sphincter) of the stomach ANS: D
75.) Vit B3 (Niacin) deficiency leads to: > Gatorade may be given to a client with diarrhea because it is
A.) Pellagra rich in potassium
B.) Beriberi 85.) Which of the following laxative increases the bulk of the
C.) Scurvy stool?
D.) Rickets A.) Colace
ANS: A B.) Metamucil
> Vitamin B3 (Niacin) deficiency leads to pellagra D.) Dulcolax
--Basic Human Needs: Bladder and Bowel & Elimination— D.) Duphalac
76.) Constipation is best described as: ANS: B
A.) Irregular passage of stool > Metamucil increases bulk of the stool and it provides
B.) Passage of stool every other day adequate mechanical stimulation for peristalsis
C.) Passage of hard, dry stool 86.) The following are appropriate nursing measures to relieve
D.) Seepage of liquid feces diarrhea EXCEPT:
ANS: C A.) Provide high-fiber diet
> Constipation is passage of hard, dry stool B.) Promote rest
77.) The accumulation of hardened, putty-like fecal mass at the C.) Include banana in the diet
rectum is D.) Avoid fatty or fried food
A.) Obstipation ANS: A
B.) Constipation > High fiber die stimulates peristalsis and therefore
C.) Tympanities inappropriate for a client with diarrhea
D.) Fecal impaction 87.) The following are solutions used as non-retention enema
ANS: D EXCEPT:
> Fecal impaction is the accumulation of hardened, putty-like A.) Tap water
fecal mass at the rectum B.) Carminative enema
78.) The following are appropriate nursing measures to relieve C.) Normal Saline Solution
constipation EXCEPT: D.) Fleet Enema
A.) Include fruits and vegetables ANS: B
B.) Have adequate activity and exercise > Carminative enema is used for retention enema. A,C, and D
C.) Take laxatives at regular basis are solutions used as non-retention enema
D.) Answer immediately to the urge to defecate 88.) The medication that relieves flatulence is:
ANS: C A.) Imodium (Loperamide)
> Regular use of laxative is inappropriate nursing measures to B.) Plasil (Metochlopramide)
relieve constipation C.) Prostigmin (Neostigmine)
79.) Castor oil acts as a laxative by: D.) Colace ( Na Docussate)
A.) Providing chemical stimulation of the intestinal mucosa ANS: C
B.) Softening the stool > Prostigmin is cholinergic, so it stimulates peristalsis. It is
C.) Increasing the bulk of the stool used to relieve flatulence
D.) Lubricating the stool
89.) The best position of the adult client during enema B.) Dangle fingers in warm water
administration is: C.) Provide privacy
A.) Left lateral D.) Pour warm water over perineum
B.) Supine ANS: C
C.) Right lateral > providing privacy is the most effective nursing measure to
D.) Semi-Fowler’s relieve urinary retention.
ANS: A 99.) The best position for female during urinary catheterization
> Left lateral position is the best position for the adult client is:
receiving enema. This position facilitates the flow of the A.) Supine
solution into the colon by gravity B.) Dorsal recumbent
90.) Which of the following is inappropriate nursing action C.) Lateral
during rectal tube insertion to relieve flatulence? D.) Semi-Fowler’s
A.) Insert rectal tube for 3-4 inches ANS: B
B.) Use rectal tube size Fr.22-30 > Dorsal recumbent position is the best position during urethral
C.) Keep rectal tube in place for 45 minutes catheter insertion in a female client.
D.) Insert well-lubricated rectal tube in rotating motion 100.) The female urethral meatus is located:
ANS: C A.) Above the clitoris
> Keeping the rectal tube in place for 45 minutes is B.) Below the vaginal
inappropriate. Beyond 30 minutes rectal tube causes irritation C.) Between the clitoris and vaginal orifice
of the mucous membrane in the rectal area. D.) Between the vaginal orifice and anus
91.) The following are correct nursing actions when ANS: C
administering enema EXCEPT: > The female urethral meatus is located between the
A.) Provide privacy
B.) Introduce solution slowly
C.) Alternate NSS with tap water and soap suds
D.) Increase the flow rate of the enema solution if abdominal
cramps occur
ANS: D
> Increasing flow rate of enema solution if abdominal cramps
occur is inappropriate nursing action. Temporarily stop flow of
solution if abdominal cramps occur, until peristalsis relaxes.
92.) The functional unit of the kidneys is the:
A.) Glomerulus
B.) Bowman’s capsule
C.) Nephron
D.) Tubules
ANS: C
> The nephron is the unit of the kidney
93.) Which of the following initiates voiding?
A.) Valsalva maneuver
B.) Increased intraabdominal pressure
C.) Sympathetic response stimulation
D.) Parasympathetic response stimulation
ANS: D
> The PNS promotes contraction of the bladder and promotes
relaxation of urethral sphincter. Therefore, it initiates voiding.
94.) The following are normal characteristics of urine EXCEPT:
A.) Appears clear
B.) pH= 3.5
C.) Sp.Gr=1.020
D.) Amber
ANS: B
> Urine pH of 3.5 if too low. This indicates acidosis. The normal
pH of urine is slightly acidic, an average of 6
95.) Frequent scanty urination is:
A.) Urgency
B.) hesitancy
C.) Pollakuria
D.) Polyuria
ANS: C
> Pollakuria is frequent scanty urination
96.) The volume of urine in the bladder that triggers the urge of
an adult patient to void is:
A.) 50-100mls
B.) 100-200 mls
C.) 250-450 mls
D.) 500-600 mls
ANS: C
> 250-450 mls of urine in the bladder makes an adult client feel
the urge to void
97.) Which of the following is not as assessment finding in
urinary retention?
A.) Flat sound over the suprapubic area on percussion
B.) Smooth, firm ovoid mass at the suprapubic area
C.) Protrusion arising out the pelvis
D.) Frequent passage of small amount of urine
ANS: A
> Flat sound over the suprapubic area on percussion does not
indicate bladder distention. Accumulation of urine in the
bladder will produce dull sound
98.) Which of the following is most effective nursing measure
to relieve urinary retention?
A.) Allow the patient to listen to the sound of running water