Fundamentals of Nursing

1. According to her a person behaves as a totality and is greater than the sum of its parts and that the person creatively interacts with the environment. Betty Neuman Martha Rogers Imogene King Ida Jean Orlando She defined that caring is universal and is diversed. Although all people can provide care, their care varies from social structures around them. Jean Watson Myra Levine Sister Callista Roy Madeleine Leininger According to this theory, there will be illness if the ability to provide care to self is not adequate to provide the demands of the self. Adaptation model Self-care theory Health-Illness continua Conservation Theory Benner s Stages of Clinical Competence describe the action of this nurse as guided by maxims and that they can perceive the situation as a whole. Competent Advanced Beginner Proficient Expert There are various models of health, one of which defines that health is the ability to actualized or realized a person s potentials. Adaptation model Role Performance model Eudomonistic model Optimal level of functioning model Which is most true about acute illness? Usually has a slow onset Many must learn to live with increasing physical limitations and discomforts Characterized by severe symptoms of relatively short period of time Often have periods of remission and exacerbation A nurse is having difficulty reading a physician s order for a medication. The nurse knows that the physician is very busy. The nurse should: Call a pharmacist to interpret the order Call the physician to clarify the order Consult the unit manager to help interpret the order Ask the unit secretary to interpret the physician s handwriting Under what circumstance is it considered acceptable practice for the nurse to document a nursing activity before it is carried out? When the activity is routine When the activity is to be carried out immediately When the physician orders you It is never acceptable The newly admitted client complaints of vertigo and headache. The nurse knows that vertigo is what type of data? Primary data, Overt data B. C. D. Primary data, Covert data Secondary data, Subjective data Primary data, Objective data
o o

A. B. C. D. 2.

10. A client is febrile having a temperature of 38.7 C and surges to 40 o and goes back down to 38.7 for 3 times today in a typical pattern, The nurse knows that this is what type of fever: A. Intermittent B. Constant C. Remittent D. Relapsing 11. While reviewing a chart of a patient, the nurse notes that the last recorded temperature was 40oC. There is no documented intervention. The nurse should: A. Call the nurse at home to validate wheter the medication was given B. Ask the supervisor C. Ask the client wheter she had received any medication for the fever D. Retake the temperature 12. An adult client arrives at the emergency room with vital signs of o o PR=120, RR=40, T = 37.6 C. the nurse should give priority to: A. Obtaining additional vital signs such as BP B. Give supplemental oxygen at 4 lpm C. Position to semi-fowlers D. Refer to physician 13. The nurse is about to take the blood pressure of an obese patient. To accurately obtain the blood pressure reading, the nurse should: A. Keep the arm elevated than the heart when taking the BP B. Use a cuff that is two thirds of the diameter of the client supper arm C. Ask the patient to remove any jewelry worn D. Tell the client to alterntely clench and open the examined hand

A. B. C. D. 3. A. B. C. D. 4.

A. B. C. D. 5. A. B. C. D. 6. A. B. C. D. 7.

14. A 2 y/o is hospitalized with AGE and dehydration. Which of the following methods is best for evaluating the skin trgor of the patient? A. Pinch the tissue of the forearm while the client is sitting B. Pinch tha abdominal tissue while the child is in supine position C. Pinch the skin at the lower extremities while the client is in supine position D. Pinch the lateral forearm of the client while in supine position 15. The nurse is assessing for an African-American patient with dark-skin pigmentation. The patient was diagnosed of having hepatitis. To check for jaundice it is best assessed at the client s: A. Palms and soles B. Sclera C. Hard Palate D. Nail beds 16. This is a primary lesion characterized as fluid-filled, palpable with less than 1 cm in diameter A. Bulla B. Wheal C. Papule D. Vesicle 17. The Snellen s chart is about to be used by the patient to check for his visual acuity. Which of the following identifies the accurate procedure for the visual acuity? A. Both eyes are assessed together, followed by the assessment of the right eye, then the left at a 20 feet distance B. One eye is assessed first and then the other, followed by the assessment of both eyes at a distance of 20 feet

a. b. c. d. 8. A. B. C. D. 9. A.

C. D.

Let the patient stand at 20 feet from the chart then instruct to read the largest line on the chart Instruct the patient to cover the R eye and then read the largest line on the chart then uncover both eyes and continue reading and lastly assess the function of the L eye

C. D.

A 36 y/o mother with undiagnosed psychiatric disorder An emancipated (living on their own) minor

18. When preparing to assess the vagus nerve, the nurse should prepare which of the following equipment: A. A tuning fork B. Salt and Sugar C. A tongue depressor D. A penlight 19. A nurse is reviewing surgical asepsis, in handwashing by surgical asepsis, hands are held: A. Below the elbow, hands are dirtier than the lower arms B. Above the elbow and at the level of the waist, the hands are cleaner that the elbow C. At the level of the elbow, surgical asepsis does not require hands to be above the waist D. Above the elbow, the hands must always be above the waist 20. A. B. C. D. This is considered as the most important aspect pf handwashing: Time Soap Friction Water

25. A nurse is caring for a 4 y/o boy. She knows that the following NANDA diagnosis is most applicable for the toddler: A. Risk for poisoning B. Risk for suffocation C. Risk for suicide D. Risk for Altered Body Image 26. People of any age can fall; elders are particularly prone to falls and injuries. To protect them, it would be best to: A. Wet spots on the floor are prevented B. Keep environemetn orderly and uncluttered C. No scattered rugs on the floor D. Hand bars placed on the bath room 27. A fire started at the ward where the nurse was working. The nurse should put the first priority on: A. Extinguishing the fire B. Rescue patients in immediate danger C. Contain the fire D. Call for help SITUATION: Ms. Gina Cole s oxygenation status is not improving. The doctor orders STAT ABG to the patient. 28. After the ABG sample collection, the nurse s most important intervention is to: A. Apply hot compress on the area to prevent bruise formation B. Do not aspirate the blood, let if flow in the syringe C. Apply pressure on the collection site for 5-10 minutes o D. Insert the needle at a 60 angle 29. The nurse reviews the clients most recent ABG results that include pH of 7.37, pCO2 of 50 mmHg, and HCO3 of 28 mEq/L. Which acidbase imbalance does the nurse use to interpret these results? A. Fully Compensated respiratory alkalosis B. Fully Compensated respiratory acidosis C. Partially compensated respiratory acidosis D. Uncompensated respiratory alkalosis 30. A wise nurse prepares the following materials upon analysis of the result of the ABG: A. Brown bag to breathe to B. Dose of sodium bicarbonate C. A nasal cannula for oxygenation D. A dose of Acetazolamide (Diamox) 31. After 24 hour of monitoring Ms. Gina Cole s pCO2 rised to 60mmHg. What would the nurse expect the doctor to order? A. Do CPR B. Suction the patient C. Attach the patient to mechanical ventilator D. Reschedule patient for another ABG reading 32. The nurse knows that Gina Cole s condition is brought about by which of the following: A. Hyperventilation due to increased metabolic demands B. Accumulation of acid in the body due to anaerobic metabolism happening C. Hypoventilation due to chest wall injury and possible spinal cord injury D. Due to excessive use of antacids 33. A drug can at least have two names. For example, Ibuprofen (Motrin) is chemically known as 2-p-isobutylphenyl propionic acid. The nurse knows that Ibuprofen is the generic name of the drug. What does the generic name stands for? A. it describes the chemical and structural name of the drug. B. it is also known as the proprietary name. C. it usually describes the active ingredient of the drug. D. it is name of the drug given by the manufacturer.

21. The nurse enters the room of a client on airborne precaution due to tuberculosis. Which of the following are appropriate actions by the nurse? 1. Wears a protective mask, covering the nose and mouth 2. Handwashing before and after removing the gloves, after suctioning the secretion 3. Disposing the suction catheter tip in the yellow trash bag found in the hallway 4. Removes any used equipment on the client s room A. 1,2,3 only B. 4,2,1 only C. 1,2 only D. 1,2,3,4 22. Of the following statements, all are surgical asepsis principles, except: A. All objects used in the sterile field must be sterile B. Sterile objects that come in contact to unsterile items are considered unsterile already C. Sterile items that are out of the sterile nurse s range of vision are considered sterile D. Honesty and alertness are essential qualities in maintaning surgical asepsis 23. Prior to any invasive procedures, an informed consent is then needed. The nurse s major role in this instance is to: A. Explain the procedure, benefits, risks and alternatives to the patient. B. Alleviate the patient s anxiety by providing comfort measures C. Explain in simple words the results of the examination. D. Act as witness in securing the consent. 24. The nurse knows that an informed consent is a written or expressed permit given voluntarily by a competent individual after a full disclosure of information regarding the procedure was done by the responsible healthcare worker. Which among the following cases below depicts an invalid consent: A. A 29 y/o mother with hypertensive disease B. A 15 y/o pregnant mother, whose consent is given by her parents

1. 34. The nurse prepares an enteric-coated medication, Aspirin (Aspec) 80mg/tab p.c. The nurse administers the drug correctly if she will give the medication: A. uncrushed, before eating B. crushed, with meals C. uncrushed, after eating D. uncrushed, in between meals 2. 3. 4. 5.

manually extract the hardened feces first to avoid the need for the medication. place the patient on left side-lying and insert the suppository gently as far as you can. ask the patient to bear down while inserting the suppository. protect herself by gloving her hand first. refrigerate the suppository first so that it does not melt. A. 2,3,4,5 B. 2 and 4 only C. 2 only D. 1,2,3,4,5

SITUATION: Twin babies, Maria and Mario, 2y/o were brought by their mother to the hospital because of diarrhea and fever. Both were confined in the Pediatric ward and you, as a nurse, is assigned to take care of the twins. 35. Mario suddenly develops a fever, with temperature of 38.5oC.The nurse prepares the medication and is ready to give it to the baby. To ensure that the medication is to be given to the right patient, the nurse should: A. ask the patient to state his name B. check the identification band C. remove the diaper of each twin and check their gender. D. A and B 36. An antibiotic is to be ordered to the babies, the nurse assumes that which of the formula for computing pediatric doses will the doctor utilize in his computation, if the doctor will utilize the babies age in years. A. Clark s rule B. Fried s rule C. Young s rule D. BSA rule 37. The nurse notes that the babies are not allergic to the medication and prepares the medication. The nurse has a stock of Ampicillin 250mg in a 2cc dilution. Compute for the dose to be given in one administration and within 24 hours. Adult dose for Ampicillin is 500mg. A. 0.6 ml (one dose) and 3.4 ml (in 24 hours) B. 6.67 ml (one dose) and 13 ml (in 24 hours) C. 0.5 ml (one dose) and 2 ml (in 24 hours) D. 0.6 ml (one dose) and 2.4 ml (in 24 hours) 38. Mario s fever was thought to be caused by otitis media(ear infection). He was then prescribed to be given an ear drop, Otocort 2 drops on both ears. The nurse effectively administers the medication if: A. the nurse pulls the pinna up and back before giving the medication B. the nurse pulls the pinna down and back before giving the medication C. the nurse drops the medication directly to the ear canal D. warms the solution first under a warm water to prevent discomfort to the patient E. B, C, D only F. B and D only 39. The patient is to be given her regularly taken antihypertensive drug of Amlodipine 50mg/tab OD. Nurse prepares the medication and approached the patient. The patient commented that the medication looked differently from what she usually takes. A wise nurse would: A. B. C. D. Tell the patient that you will ask her doctor and leave the medication at the bedside Tell the patient that you could not be wrong and give the medication Tell the patient that you will come back after re-checking the medication Tell the patient that this is a new medication and it really looks different

41. To ensure the safe and effective administration of medication, there are three (3) check points to be observed in sequence, which are during: A. B. C. D. verification of the order, the drug computation and after the drug administration. verification of the order, the drug preparation and before returning the medication container drug preparation, verification of order and before returning the medication container. drug preparation, verification of order and after the medication administration.

42. The nurse is to give Clonidine(Catapres) 75mcg SL for her hypertensive patient. The nurse does this effectively by: 1. 2. 3. 4. 5. attaching the medication to the mucous membranes of the cheeks placing in under the tongue giving it with a glass of water asking the patient not to swallow or chew the medication educating the patient that the medication is faster and better absorbed thru this route A. 2,3,4,5 B. 1,2 C. 2,4,5 D. 1,4,5 E. 1,2,3,4,5

43. All of these should not be done when giving nitroglycerin patch, except: A. Use bare hands in applying the patch to promote flexibility in giving it B. Shave the area where you will place it if hair is prominent, this encourages maximum absorption C. Chart the necessary data related in giving the patch which only includes the date, time, drug name, and the dosage D. Do not immediately give another patch if the old patch can t be found in the patient s skin. 44. A nurse is giving a medication via z-track method. Which of these actions of the nurse is questionable? A. The nurse preferred to inject into the gluteal muscle rather than the deltoid area B. The nurse stretched the skin approximately 1 inch to one side C. The nurse gently injected the medication and waited for 10 seconds before removing the needle D. After removing the needle the nurse slowly massaged the area to hasten the absorption of medication 45. A patient will undergo Mantoux skin test. Which of the following would be appropriate: A. 3 ml syringe, 25 gauge, 1 inch needle B. Tuberculin syringe, 26 gauge, 3/8 inch needle C. 3 ml syringe, 21 gauge, 1 inch needle D. Tuberculin syringe, 21 gauge, 3/8 inch needle 46. A nurse administered an intramascular medication of iron by the Ztrack method. The medication was given by this method to: A. Provide faster absorption of the medication B. Provide more even absorption of medication C. Reduce discomfort from the needle D. Prevent the drug from irritating sensitive tissues

40. Mrs. Beth Logan develops constipation on her 5 day of hospitalization. A suppository is ordered to her. In giving the medication the nurse should:

th

47. A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. The correct sequence when mixing insulins is: A. Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin B. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NLH insulin. C. Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then withdraw 10 units of regular insulin. D. Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin. 48. A client with chronic obstructive pulmonary disease (COPD) is to use a nebulizer. The observation that indicates the nebulizer is being used incorrectly and additional health teaching by the nurse is necessary would be that the client: A. Place the tip of the nebulizer just beyond the lips B. Hold the inspired breath for at least 3 seconds C. Exhales slowly through the mouth with lips pursed sligthly D. Inhales with lips tightly sealed around the mouthpiece of the nebulizer 49. A laboring mother inadequately bears done making an unequal tear on her perineum. This type of wound is known as: A. Avulsion B. Laceration C. Incision D. Abrasion 50. Which among the following patients is at greatest risk for a shearing force injury to the skin? A. A patient walking without shoes B. A hemiplegic patient lying flat on bed C. An obese patient sitting in fowlers position D. A patient lying on his side 51. This is an ulcer that exhibits full-thickness skin loss, the subcutaneous tissue in already involved and necrotic: A. Stage II B. Stage III C. Stage IV D. Stage V 52. A client s partial thickness burns differ from full-thickness burns in that with partial-thickness burns, the burned area will: A. Require grafting before it can heal B. Be painful, reddened and have blisters C. Have destruction of the epidermis and dermis D. Takes months of extensive treatment before healing 53. The nurse plans to hava a full range of motion exercise to the client. When putting an ankle through ROM the nurse must perform which of the following: A. Abduction, flexion, adduction and extension B. Pronation, Supination, rotation and extension C. Dorsiflexion, planter flecion, eversion and inversion D. Flexion, extension and left anf right rotation 54. A nurse found a client going down the stairs at the middle of the night. When the nurse approached the client, she realized the client was asleep. This disorder is reffered to as: A. Narcolepsy B. Hypersomnia

C. D.

Somnambulism Bruxism

55. As a teenage mother, Pining Garcia admits she has poor nutrition. She heard from a neighbor that spinal defects such as spina bifida can happen to her baby if she will not correct her diet. The nurse knows that this problem is usually encountered by teenage mother with deficiency on what vitamin? A. Vitamin B2 B. Vitamin B9 C. Vitamin B3 D. Vitamin B1 56. A client with multiple abrasiona nd lacerations to the trunk says I cant eat all of this food . The food thath the nurse should suggest be eaten first would be: A. Meat loaf and teas B. Meat loaf and strawberry C. Tomato soup and baked apple D. Tomato soup and buttered bread SITUATION: Mr. Pablo Jabmo, regains his consciousness but can not feel any sensations below his waist. A spinal cord injury is suspected. He can move his lower extremities, affecting also his urination. 57. The nurse is to insert an indwelling foley catheter (IFC) to the patient. She does this properly by: A. Holding the penis tightly perpendicular to the patient s body and inserting the catheter approximately 8 inches. B. Holding the penis not to tight perpendicular to the patient s body and inserting the catheter until the bifurcation of the catheter. C. Holding the unerected penis perpendicular to the patient s body and inserting the catheter until urine is seen flowing and advancing it 2-3 inches more. D. Holding the penis parallel to the patient s body and inserting the catheter approximately until the bifurcation of the catheter. 58. The catheter is successfully attached to Mr. Pablo Jabmo. How will the nurse properly secure the catheter to the patient? A. Secure with plaster in the patient s inner thigh B. Secure with plaster in the patient s abdomen with the tube extended. C. Secure with plaster in the patient s inguinal area going towards the patient s outer thigh D. Secure with plaster in the patient s abdomen ensuring a slack of the tube is provided. 59. The catheter is then attached to a urine collecting bag. The first voided urine thru the catheter was noted to be yellowish amounting to 800 mL. The specific gravity of the urine upon testing was noted to be 1.020. What does this indicate? A. That the patient may be dehydrated B. That the patient is having fluid retention C. That there is no cause for alarm D. That the patient is overhydrated 60. A 24 hour urine sampling was order to assess the kidney function of Pablo Jabmo. The nurse knows that the urine sample will be analyzed for creatinine clearance. The result was 2.5 g/ 24 hours. The nurse interprets this as: A. Normal for his age and gender. B. Increased. Further assess for kidney function. C. Decreased. Increase fluid intake D. Normal although theres a need to limit protein. 61. During the collection of the sample for the 24-hour urine analysis. The nurse observes the following, except: A. Places a Save all urine post in the door of the comfort room B. Gives a clean specimen cup for the urine C. Prepares a large container for the urine and ice at bedside D. Discards the first voided urine and start with the collection with the next urine output

SITUATION: Maddie Lim was rushed to the hospital because of abdominal pain and constipation. 62. Maddie Lim is known allergic to seafoods, specifically shrimps and mussels. Which of the following diagnostic exams would you expect to be defered for the patient? A. Endoscopic procedure B. GI series C. Abdominal ultrasound without contrast D. Fecalysis 63. Esophagogastroduodenoscopy was scheduled for Maddie Lim. Which of the following would the nurse be expected to do: A. Get consent of the patient after explaining the procedure B. Keep patient on NPO for at least 8 hours prior to the procedure C. Give enema or laxative after the procedure D. Assess for allergies to dyes and contrast mediums 64. After the procedure, Maddie Lim was transferred to your unit. She requests for a food. She claims that she is very hungry. The nurse should first: A. Assess for bowel movement and passage of flatus B. Refer immediately to the doctor C. Assess for gag reflex D. Give fluids and foods liberally as this is not contraindicated for the patient 65. Enema was ordered to help him evacuate her feces. The nurse prepares the soap sud solution for the enema. The nurse knows that all but one are true regarding the solution: A. A hypertonic solution that distends and irritates the mucosal membrane of the colon B. Can be made by adding 30 ml of liquid soap to 1L of water C. Needs to be retained for more than 20 mins for it to act D. Can cause rectal irritation and damage. 66. The nurse is ready to administer the enema to the patient. She does the skill adequately if she observes the following, except: A. Places the enema bag at a height of 16 inches B. Checks that the temperature of the solution is about 37.7 oC C. Inserts the rectal tube at least 5 inches to ensure that it lies beyond the internal anal sphincter D. Instructs the patient to bear down upon insertion of the rectal tube 67. What type of enema should the nurse anticipate to prepare to remove excess gas on a patient s abdomen. A. Retention enema B. Nutritive enema C. Carminative enema D. Cleansing enema 68. Among the following patients, the nurse would be cautious on administering an enema to whom: A. Mario, 18 y/o who had a vehicular accident B. Pepita, with abdominal pain due to gastritis C. Jose, a 40 y/o COPD patient D. Susana, with a chief complaint of hematochezia 69. Fecalysis and FOBT was ordered for the patient. The nurse intructs Han Jabmo to collect stool sample. The patient needs further instructions if he does which of the following: A. Takes a sample at the middle of the feces B. Collects the stool sample from a clean tissue paper C. Takes a pea-sized stool sample on an area where visible blood is noted D. Places the stool sample on a sterile specimen cup 70. Prior to the collection of stool sample for FOBT, all but one are contraindicated for the patient: A. Spinach and Pork B. Egg and poultry products C. Citrus fruits D. Paracetamol and NSAIDs SITUATION: Pining Garia s baby contracted a respiratory infection. He needs supplemental oxygen.

71. The most effective and appropriate oxygen-delivery device for the infant would be: A. Nasal cannula B. Non-rebreather mask C. Oxygen tent D. Oxygen hood 72. A. B. C. D. All but one are early indicators of respiratory distress to an infant: Nasal flaring Chest in-drawing Stridor Cyanosis

73. The nurse, upon observation, notes that the infant has irregular, interspersed periods of apnea in a disorganized sequence of breaths. She records this assessment as: A. Kussmaul s breathing noted B. Positive Ataxic breathing C. Biot s breathing appreciated D. Cheyne- Stokes respiration noted 74. The nurse further assessed the respiratory status of the infant. She noted that the chest appears rounded, with AP equal to transverse diameter. She interprets this as: A. Barrel chest and is abnormal B. Normal for the infant C. Pectus carinatum noted D. Pectus excavatum noted 75. An additional assessment of the lung fields revealed continuous, low-pitched, coarse snoring sound. This is interpreted as: A. Crackles B. Rhonchi C. Wheeze D. Rales 76. Pulse oximetry has been ordered for an adult with pneumonia. The best site for placement of the probe is the: A. Toe B. Earlobe C. Finger D. Tip of the Nose SITUATION: After the assessments, it was confirmed that the infant needs nebulization and CPT. The nurse is then tasked to do the intervention to the infant. 77. Considering the patient s age and status and knowing the principles of CPT and nebulization, the following interventions are arranged and done by the nurse as follows: A. Nebulization, Postural drainage, Chest Percussion, Chest vibration, DBE and CE B. Postural drainage, Chest Percussion, Chest vibration, DBE and CE in between nebulization C. Nebulization, Postural drainage, Chest Percussion, and Chest vibration D. Nebulization, Postural drainage and Chest Percussion only

78. The nurse then prepares the nebulization of the patient by putting nebule of Budesonide (a steroid-based bronchodilator) and 1 cc NSS. The nurse is erroneous in giving the medication, when she: A. Gives the medication with a nebulization mask B. Administers the medication thru the mouth using a mouthpiece C. Does not instruct to do DBE during nebulization D. Flicks the sides of the nebulization chamber when it is almost finish

SITUATION: After 3 days of hospitalization, Pining Garcia s child does not improve in condition. On the chest X-ray it was noted that the infant has opacity on the anterior aspect of the apical region of his left lung. 79. Knowing this, how will the nurse position the infant: A. Right-side lying,Trendelenburg position

B. C. D.

Upright cuddled by the mother Reverse trendelenburg, left-side lying Semi-fowlers to the right side

80. The infant is unable to effectively expectorate secretions and manifests signs and symptoms of respiratory distress. As a prudent nurse, the nurse will: A. Administer a bronchodilator B. Secure an order for nebulization C. Do suction independently D. Get a pulse oximeter 81. The nurse observes that the infant breaths 40 cpm and the infant s costal margin goes in as the infant inhales. The nurse knows that this is: A. Normal to an infant as they are abdominal breather B. Chest in-drawing C. Chest retractions D. Stridor in progress 82. The nurse is caring for an infant experiencing respiratory distress who is being treated with CPAP (Continuous Positive Airway Pressure). The nurse is aware that for this treatment to be most effective the infant must be: A. Intubated with respiration maintained by controlled ventilation B. Able to breathe spontaneously C. Frequently stimulated to maintain respiratory rate D. Suctioned frequently to maintain alveolar ventilation SITUATION: On the way to the hospital to visit her wife and her child, Mr. Pablo Jabmo, a chronic smoker and the husband of Pining met a vehicular accident. He was hit hard and was knocked out unconscious. He suffered severe head concussion and was rushed to the nearest hospital. 83. In the ER, he was given a safe dose of oxygen at 1-2 lpm. The nurse in the ER knows that this is done because: A. For some people the diminished oxygen level in their blood initiates their breathing B. For COPD patients, their drive to breathe is the high level of CO2 C. For some people, they may have allergies on increased level of oxygen D. Unconscious patients are at most risk for oxygen toxicity 84. Upon history with the significant others, it was known that Mr. Pablo Jabmo has emphysema. He has been smoking 25 cigarettes a day for 30 years now. The nurse document this as: A. 35 pack years B. 38 pack years C. 40 pack years D. 42 pack years 85. The nurse then initiates measure to promote adequate ventilation to the patient. The nurse finds which of the following order for the patient as erroneous. A. Administer oxygen thru nasal cannula at 2Lpm B. Administer supplemental oxygen thru simple face mask at 5 Lpm C. Position patient on semi-fowler s D. Do suctioning as needed 86. Mr. Pablo Jabmo is now on oxygen therapy. The nurse initiates safety measures when using oxygen, which among the following is unnecessary for the nurse to do: A. Check wirings in the room B. Place a big No Smoking sign C. Turn off the light as this may cause fire D. Avoids using a wool linen 87. Mr. Pablo Jabmo is visited by her wife and her children. Which among the following items brought by the family will alarm the nurse regarding possible sources of fire: A. A Petroleum jelly for the patient s dry lips B. A thick, cotton linen C. An isopropyl alcohol D. A friction toy car of their child

88. The patient receives 3Lpm of oxygen. How much of the oxygen is inspired by the patient using a nasal cannula. A. 24% FiO2 B. 28% FiO2 C. 33% FiO2 D. 36 % FiO2 89. Upon visiting a patient to his room, you observed that the patient is having shortness of breath, with weak and thready pulse, and cyanotic. You also noticed that the IV tubing is filled with air. What will you do first? A. Turn off the IV fluid B. Monitor vital signs C. Quickly ask for help and call the physician D. Administer oxygen 90. In what position will you place the patient who is suspected to have air embolism? A. Tripod position B. Left side-lying position C. Right side-lying position D. Squatting position SITUATION: Pattie Kim, a 60y/o Korean with history of hypertension and heart attack suddenly collapses upon hearing a sad news. 91. Being a nurse neighbor, you saw her collapsed and fell from the stairs. You volunteered to help. Which of the following should be your priority: A. Immediately bring her to the nearest hospital B. Ask for help C. Check for responsiveness D. Give two rescue breaths 92. You are about to assess her airway, knowing what happened to her, you should position her by using: A. Heimlich manuever B. Jaw thrust manuever C. Head tilt- Chin lift manuever D. Head tilt- Chin lift manuever in neutral head position 93. No breathing was appreciated, so you decided to give two artificial rescue breathing. You noted that air bounces back upon giving breaths. By further assessment you noted that Pattie Kim s dentures was obstructing the airway. What should you do next? A. Retilt the head and give breath again B. Assist the patient in standing position and do a heimlich manuever C. Do two successive abdominal thrust D. Do a finger sweep and try removing the dentures 94. The carotid pulse was assessed and noted to be momentarily stopped. You are preapring yourself to do compressions. You are doing it erroneously when you: A. Allow for chest recoil after each compression B. Keep your shoulder perpendicular to the patient s body and your elbows straight C. Gives compressions fast and deep at a depth of 2 inches D. Place you interlaced hand just below the sternal angle 95. You heard a sharp, cracking sound during your compressions. What should you do? A. Stop compression and bring the patient to the hospital immediately B. Lighten your compression to a depth of at least inch to prevent further injury C. Continue giving CPR while assessing for flail chest D. You have fractured the rib of the patient, just give breaths and no compressions 96. The nurse assesses a Pattie Kim have a flail chest injury. Which of the following findings would support the diagnosis? A. Intercostal retractions with cyanosis and hemoptysis B. Chest pain upon deep inhalation C. Respirations of 15 cpm with chest indrawing D. Asymmetrical expansion of the thorax

97. The nurse volunteer continues to give CPR because she knows that all but one are reasons to stop CPR: A. Client has no pulse and breathing after giving CPR for 10 mins B. Emergency team had arrived C. The rescuer is overly fatigued D. The client had recovered

He also loved the 3rd wife very much. He's very proud of her and always wanted to show off her to his friends. However, the merchant is always in great fear that she might run away with some other men. He too, loved his 2nd wife. She is a very considerate person, always patient and in fact is the merchant's confidante. Whenever the merchant faced some problems, he always turned to his 2nd wife and she would always help him out and tide him through difficult times. Now, the merchant's 1st wife is a very loyal partner and has made great contributions in maintaining his wealth and business as well as taking care of the household. However, the merchant did not love the first wife and although she loved him deeply, he hardly took notice of her. One day, the merchant fell ill. Before long, he knew that he was going to die soon. He thought of his luxurious life and told himself, "Now I have 4 wives with me. But when I die, I'll be alone. How lonely I'll be!" Thus, he asked the 4th wife, "I loved you most, endowed you with the finest clothing and showered great care over you. Now that I'm dying, will you follow me and keep me company?" "No way!" replied the 4th wife and she walked away without another word. The answer cut like a sharp knife right into the merchant's heart. The sad merchant then asked the 3rd wife, "I have loved you so much for all my life. Now that I'm dying, will you follow me and keep me company?" "No!" replied the 3rd wife. "Life is so good over here! I'm going to remarry when you die!" The merchant's heart sank and turned cold. He then asked the 2nd wife, "I always turned to you for help and you've always helped me out. Now I need your help again. When I die, will you follow me and keep me company?" "I'm sorry, I can't help you out this time!" replied the 2nd wife. "At the very most, I can only send you to your grave." The answer came like a bolt of thunder and the merchant was devastated. Then a voice called out : "I'll leave with you. I'll follow you no matter where you go." The merchant looked up and there was his first wife. She was so skinny, almost like she suffered from malnutrition. Greatly grieved, the merchant said, "I should have taken much better care of you while I could have !" Actually, we all have 4 wives in our lives a. The 4th wife is our body. No matter how much time and effort we lavish in making it look good, it'll leave us when we die. b. Our 3rd wife ? Our possessions, status and wealth. When we die, they all go to others. c. The 2nd wife is our family and friends. No matter how close they had been there for us when we're alive, the furthest they can stay by us is up to the grave. d. The 1st wife is in fact our soul, often neglected in our pursuit of material, wealth and sensual pleasure. Guess what? It is actually the only thing that follows us wherever we go. Perhaps it's a good idea to cultivate and strengthen it now rather than to wait until we're on our deathbed to lament

98. When the General Adaptation Syndrome is activated, FIGHT or FLIGHT response would be initiated. Which of the following is true reagarding this statement? A. Pupils will constrict B. Lungs will bronchodilate C. Gastric motility will increase D. Micturition will be initiated 99. During stress response, the body responds. All of the following occurs, except: A. Decreased blood clotting B. Bronchial dilatation C. Mydriasis D. Inotropic response to the heart 100. Some physiologic needs can be manifested by a dying person; one is air hunger. Simple nursing intervention for air hunger would include: A. Giving oxygen via cannula B. Giving mouth care C. Opening the windows D. Attaching to mechanical ventilator

There was a rich merchant who had 4 wives. He loved the 4th wife the most and adorned her with rich robes and treated her to delicacies. He took great care of her and gave her nothing but the best.