--Nursing Process--

1.) Which of the following is incorrect statement 8.) The client with fever had been observed to
of nursing diagnosis? experience elevated temperature for few days,
A.) High risk for ineffective airway clearance followed by 1 to 2 days of normal range of
related to pneumonia temperature. The type of fever he is
B.) High risk for injury related to dizziness experiencing is:
C.) Constipation related to decreased activity A.) Intermittent fever
and fluids as manifested by small, hard, formed B.) Relapsing fever
stool every three days C.) Remittent fever
D.) Anxiety related to insufficient knowledge D.) Constant fever
regarding surgical experience
9.) Which of the following is NOT an appropriate
2.) Which of the following would NOT be a basis nursing action when taking oral temperature?
for establishing priorities in client care? A.) Wash the thermometer from the bulb to the
A.) Actual problems take precedence over stem before use
potential concerns B.) Place the thermometer under the tongue
B.) Attend to equipment and contraptions first, directed towards the side
such as IV fluids, urinary catheter, drainage C.) Take oral temperature for 2-3 minutes
tubes, before the client D.) Take oral temperature using a thermometer
C.) Airway should always be given highest with pear-shaped bulb
priority
D.) Clients with unstable condition should be 10.) The following are contraindications to oral
given priority over those with stable conditions. temperature taking EXCEPT:
A.) Dyspnea
3.) Which of the following is an incorrect B.) Diarrhea
statement of outcome procedure? C.) Nasal-packing
A.) Ambulates 30 feet with cane before D.) Nausea and vomiting
discharge
B.) Discusses fears and concerns regarding the 11.) Which of the following nursing actions is
surgical procedure during preoperative teaching inappropriate when taking the rectal
C.) Demonstrates proper coughing technique temperature?
after the teaching session A.) Assist client to assume lateral position
D.) Reestablishes normal pattern of bowel D.) Lubricate thermometer with water-soluble
Elimination lubricant before use
C.) Hold the thermometer in place for 2 minutes
--Assessing Health-- D.) Instruct to strain during insertion of the
4.) The primary factor responsible for body heat Thermometer
production is:
A.) Metabolism 12.) The following are correct nursing actions
B.) Release of thyroxine when taking the radial pulse EXCEPT:
C.) Thyroxine output A.) Put the palms downward
D.) Muscle activity B.) Use the thumb to palpate the artery
C.) Use two to three fingertips to palpate the
5.) The heat-regulating center is found in the: pulse at the inner wrist
A.) Medulla oblongata D.) Assess the pulse rate, rhythm, volume and
B.) Thalamus bilateral equality
C.) Hypothalamus
D.) Pons 13.) The difference between the systolic
pressure and the diastolic pressure is:
6.) A process of heat loss which involves the A.) Apical rate
transfer of heat from one surface to another is: B.) Cardiac rate
A.) Radiation C.) Pulse deficit
B.) Conduction D.) Pulse pressure
C.) Convection
D.) Evaporation 14.) When measuring the blood pressure, the
following are nursing considerations EXCEPT:
7.) The following statements are true about body A.) Ensure that the client is rested
temperature EXCEPT: B.) Use appropriate size of BP cuff
A.) Core body temperature measures the C.) Initiate and deflate BP cuff 2-3 mm Hg/sec
temperature of deep tissues D.) Read upper meniscus of mercury
B.) Highest body temperature is usually reached
between 8:00 P.M. to 12:00 M.N. 15.) The process involved in the exchange of
C.) Elderly people are at risk of hypothermia due gases in the lungs is:
to decreased thermoregulatory controls and A.) Diffusion
decreased subcutaneous fats B.) Osmosis
D.) Sympathetic response stimulation decreases C.) Hydrostatic pressure
body heat production D.) Oncotic pressure
16.) The primary respiratory center is: 24.) Which of the following is correct nursing
A.) Medulla oblongata action when collecting urine specimen from a
B.) Pons client with indwelling urethral catheter?
C.) Carotid and aortic bodies A.) Collect urine specimen from the urinary
D.) Proprioceptors drainage bag
B.) Detach the catheter from the connecting tube
17.) Which of the following primarily affects BP? C.) Use sterile needle and syringe to aspirate
A.) Age urine specimen from the drainage port
B.) Stress D.) Flush the catheter with sterile NSS before
C.) Gender collection of urine specimen
D.) Obesity
25.) The following are independent nursing
18.) The following are social data about a client interventions for a febrile client EXCEPT:
EXCEPT: A.) Administer paracetamol 500 mg. tab every 4
A.) Patient’s lifestyle hours PRN for temperature 38.5 C
B.) Religious practices B.) Increase fluid intake
C.) Family home situation C.) Promote bed rest
D.) Usual health status D.) Keep the client’s clothing clean and dry

19.) The systematic manner of collecting data ------Basic Human Needs: Oxygenation----
about the client by listening to body sounds with 26.) The common opening between the
the use of stethoscope is: respiratory and digestive system is:
A.) Inspection A.) Pharynx
B.) Palpation B.) Larynx
C.) Percussion C.) Trachea
D.) Auscultation D.) Bronchus
> Auscultation is listening to body sounds with
the use of stethoscope 27.) The right lung has:
A.) 2 lobes
20.) The following are appropriate nursing B.) 3 lobes
actions when performing physical health C.) 4 lobes
examination to a client EXCEPT: D.) 5 lobes
A.) Ensure privacy of the client throughout the
procedure 28.) The amount of air that remains in the lungs
B.) Prepare the needed articles and equipment after forceful exhalation is:
before the procedure A.) Functional residual capacity
C.) Assess the abdomen following this B.) Residual volume
sequence: right lower quadrants C.) Tidal volume
D.) When assessing the chest, it is best to place D.) Minute volume
the client in side lying
29.) Cheyne-Stokes breathing is:
21.) Which of the following is inappropriate A.) Slow, shallow respirations which result to
nursing action when collecting clean-catch inadequate alveolar ventilation
midstream urine specimen for routine urinalysis? B.) Difficulty of breathing in reclining position
A.) Collect early morning, first voided specimen C.) Marked rhythmic waxing and waning of
B.) Do perineal care before collection of respirations from very deep to very shallow
specimen breathing and temporary apnea
C.) Collect 5-10 mls of urine D.) Shallow breaths interrupted by apnea
D.) Discard the first flow of urine
30.) The best position to promote maximum lung
22.) Which of the following nursing actions is expansion is:
incorrect when performing Benedict’s test? A.) Supine
A.) Collect 24-hour urine specimen B.) Retractions
B.) Ensure that Benedict’s solution remains C.) Noisy breathing
unchanged after heating it D.) Semi fowler’s
C.) Add 8-10 drops of urine
D.) Interpret that the urine is negative for 31.) The characteristic manifestation of airway
glucose when the color remains blue obstruction is:
A.) Bradypnea
23.) Heat and acetic acid test is done to B.) Retractions
determine C.) Noisy breathing
A.) Presence of albumin in the urine D.) Tachypnea
B.) Presence of glucose in the urine
C.) Presence of ketones in the urine 32.) The following are appropriate nursing
D.) Presence of RBC in the urine interventions to promote normal respiratory
function EXCEPT:
A.) Adequate fluid intake
B.) Minimize cigarette smoking
C.) Deep breathing and coughing exercises
D.) Frequent change of position among bedridden clients
33.) The initial manifestations of hypoxemia are 42.) Which of the following is not to be included
A.) Restlessness, tachycardia in the nursing interventions for a client receiving
B.) Dizziness, faintness oxygen therapy?
C.) Headache, blurring of vision A.) Place a “Non-smoking” sign at the bedside
D.) Dyspnea, retractions B.) Place the client in semi-fowler’s position
C.) Place sterile water into the oxygen humidifier
34.) The following are appropriate nursing D.) Lubricate nares with oil to prevent dryness of
actions when performing percussion, vibration the mucous membrane
and postural drainage, EXCEPT:
A.) Verify doctor’s order 43.) When assessing respiration, the nurse
B.) Perform the procedure before meals and at describes the following EXCEPT:
bedtime A.) Rhythm
C.) provide good oral hygiene after the B). Effort
procedure C.) Rate
D.) Each position during postural drainage D.) Depth
should be assumed for 30 minutes
44.) The small hair-like projections that line the
35.) Which of the following nursing actions is tracheobronchial tree, which sweep out debris
inappropriate when providing steam inhalation and excessive mucous from the lungs are
therapy? called:
A.) Check doctor’s order A.) Cilia
B.) Cover the eyes with moist washcloth B.) Vibrissae
C.) Place the spout 3-4 inches away from the C.) Macrophages
patient’s nose D.) Goblet cells
D.) Place the patient in semi-fowler’s position
45.) The following are appropriate nursing
36.) To be effective, steam inhalation should be diagnoses for clients with oxygenation problems:
rendered for at least: A.) Ineffective airway clearance related to
A.) 5-10 minutes tracheobronchial secretions
B.) 15-20 minutes B.) Ineffective breathing pattern related to
C.) 30-45 minutes decreased energy and fatigue
D.) 60-70 minutes C.) Impaired gas exchange related to altered
oxygen-carrying capacity of the blood
37.) The correct pressure of the wall suction unit D.) All of these
when suctioning an adult patient is:
A.) 95-110 mm Hg ---Basic Human Needs: Nutrition----
B.) 100-120 mm Hg 46.) The regulating center for fluid and food
C.) 50-95 mm Hg intake are located in their
D.) 10-15 mm Hg A.) Thalamus
B.) Hypothalamus
38.) Which of the following is inappropriate C.) Medulla oblongata
nursing action when performing oropharyngeal D.) Pons
suctioning?
A.) Place the client in semi-fowler’s or lateral 47.) The enzyme that initiates digestion of starch
position in the mouth is:
B.) Measure length of catheter from the tip of the A.) Amylase
nose to the earlobe. B.) Sucrase
C.) Lubricate suction catheter with alcohol C.) Maltase
D.) Apply suction during withdrawal of the D.) Lactase
suction catheter tip:
48.) Which of the following structure prevents
39.) The maximum time for applying suction is: gastric reflux?
A.) 5-10 seconds A.) Pyloric sphincter
B.) 10-15 seconds B.) Internal sphincter
C.) 15-20 seconds C.) Cardiac sphincter
D.) 20-30 seconds D.) Sphincter of Oddi

40.) To evaluate effectiveness of suctioning, the 49.) Which of the following nutrients remains in
nurse should primarily: the stomach for the longest period?
A.) Auscultate the chest for clear breath sounds A.) Fats
B.) Assess the respiratory rate B.) Proteins
C.) Check the skin color C.) Carbohydrates
D.) palpate the pulse rate D.) Water

41.) The oxygen administration device preferred 50.) The pancreatic enzyme which completes
for patients with COPD is: digestion of fats is
A.) Nasal cannula A.) Amylase
B.) Oxygen tent B.) Lipase
C.) Venturi mask C.) Trypsin
D.) Oxygen hood D.) Rennin
51.) Kwashiorkor is a condition characterized by: 61.) To assess the adequacy of food intake,
A.) Calorie deficiency which of the following assessment parameters is
B.) Vitamin Deficiency best used?
C.) Protein deficiency A.) Food preferences and dislikes
D.) Mineral deficiency B.) Regularity of meal times
C.) 3-day diet recall
52.) Which of the following is most effective D.) Eating style and habits
nursing measures to relieve anorexia EXCEPT:
A.) Provide small, frequent feedings 62.) Prolonged deficiency of vitamin B12 leads
B.) Remove unsightly articles from the patient’s to:
unit A.) beriberi
C.) Provide three full meals a day B.) Pernicious anemia
D.) Provide good hygienic measures C.) Pellagra
D.) Peripheral neuritis
53.) The following factors increase calorie
requirements EXCEPT: 63.) The vitamin necessary for absorption of
A.) Cold climate calcium is:
B.) Activity and exercise A.) Vit D
C.) Fever B.) Vit A
D.) sleep C.) Vit C
D.) Vit E
54.) The following are good sources of calcium
EXCEPT: 64.) Vit. K is necessary for:
A.) Cheese A.) Bone and teeth formation
B.) Milk B.) Integrity of skin and mucous membrane
C.) Soy products C.) Blood coagulation
D.) Carbonated drinks D.) Formation of RBC

55.) Which of the following is the richest source 65.) The following are signs and symptoms of
of iron? dehydration EXCEPT:
A.) Mongo A.) Weight loss
B.) Milk B.) Decreased urine output
C.) Malunggay leaves C.) Elevated body temperature
D.) Pechay D.) Elevated BP

56.) Which of the following is a good source of 66.) The client is experiencing hypokalemia.
vitamin A? Which of the following should be included in his
A.) Eggs diet?
B.) Liver A.) Banana
C.) Fish B.) Milk
D.) Peanuts C.) Cheese
D.) Fish
57.) The following may be given to relieve
nausea and vomiting EXCEPT: 67.) During insertion of NGT, which position is
A.) Dry toast best assumed by the client?
B.) Milk A.) Low-Fowler’s
C.) Cold cola beverage B.) Semi-Fowler’s
D.) Ice chips C.) High-Fowler’s
D.) Lateral
58.) The most life threatening complication of
vomiting is: 68.) The length of NGT to be inserted is correctly
A.) Aspiration 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
D.) Malnutrition process
C.) From the tip of the nose to the earlobe to the
59.) The vomiting center is found in the umbilicus
________. D.) From the tip of the nose to the earlobe to the
A.) Cerebellum xiphoid process.
B.) Hypothalamus
C.) Medulla Oblongata 69.) When inserting NGT, the neck should:
D.) Cerebrum A.) Flexed
B.) Hyperextend
60.) The best indicator of nutritional status of the C.) Tilted to the left
individual is: D.) In neutral position
A.) Weight
B.) Height
C.) Arm muscle circumference
D.) Adequacy of hair
70.) The most accurate method of assessing 79.) Castor oil acts as a laxative by:
method of placement of NGT is: A.) Providing chemical stimulation of the
A.) Aspiration intestinal mucosa
B.) Testing the pH of gastric aspiration B.) Softening the stool
C.) X-ray study C.) Increasing the bulk of the stool
D.) Introduction of air into NGT and auscultate at D.) Lubricating the stool
the epigastric area.

71.) Which of the following is inappropriate 80.) Which of the following foods should be
nursing action when administering NGT feeding? avoided by the client prevent flatulence?
A.) Assist the client in Fowler’s position A.) Fruit juice
B.) Introduce feeding slowly B.) Cabbage
C.) Place the feeding 24 inches above the point C.) Meat
of insertion of NGT D.) Fish
D.) Instill 60mls of water into the NGT after
feeding 81.) Which of the following antidiarrheal
medications absorb gas or toxic substances
72.) The primary purpose of gastrostomy is: from the bowel?
A.) For feeding A.) Demulcent
B.) For drainage B.) Cabbage
C.) To prevent flatulence C.) Meat
D.) To prevent aspiration of gastric reflex D.) Fish

73.) The most important nursing action before 82.) The most common-side effect of overuse of
gastrostomy feeding is: laxatives is:
A.) Check VS A.) Diarrhea
B.) Assess for patency of the tube B.) Nausea and vomiting
C.) Measure residual feeding C.) Constipation
D.) Check for placement of the tube D.) Flatulence

74.) The primary advantage of gastrostomy 83.) Which of the following should be included in
feeding is: the diet of the patient with diarrhea?
A.) It ensures adequate nutrition A.) Banana
B.) It prevents aspiration B.) Papaya
C.) It maintains integrity of gastro-esophageal C.) Pineapple
sphincter D.) Avocado
D.) It minimizes fluid-electrolyte imbalances
84.) Which of the following fluids may be given
75.) Vit B3 (Niacin) deficiency leads to: to a client with diarrhea?
A.) Pellagra A.) Milk
B.) Beriberi B.) Coffee
C.) Scurvy C.) Tea
D.) Rickets D.) Gatorade

85.) Which of the following laxative increases

--Basic Human Needs: Bladder and Bowel & Elimination— the bulk of the stool?
76.) Constipation is best described as: A.) Colace
A.) Irregular passage of stool B.) Metamucil
B.) Passage of stool every other day D.) Dulcolax
C.) Passage of hard, dry stool D.) Duphalac
D.) Seepage of liquid feces
86.) The following are appropriate nursing
77.) The accumulation of hardened, putty-like measures to relieve diarrhea EXCEPT:
fecal mass at the rectum is A.) Provide high-fiber diet
A.) Obstipation B.) Promote rest
B.) Constipation C.) Include banana in the diet
C.) Tympanities D.) Avoid fatty or fried food
D.) Fecal impaction
87.) The following are solutions used as nonretention
78.) The following are appropriate nursing enema EXCEPT:
measures to relieve constipation EXCEPT: A.) Tap water
A.) Include fruits and vegetables B.) Carminative enema
B.) Have adequate activity and exercise C.) Normal Saline Solution
C.) Take laxatives at regular basis D.) Fleet Enema
D.) Answer immediately to the urge to defecate
88.) The medication that relieves flatulence is:
A.) Imodium (Loperamide)
B.) Plasil (Metochlopramide)
C.) Prostigmin (Neostigmine)
D.) Colace ( Na Docussate)
89.) The best position of the adult client during 98.) Which of the following is most effective
enema administration is: nursing measure to relieve urinary retention?
A.) Left lateral A.) Allow the patient to listen to the sound of
B.) Supine running water
C.) Right lateral B.) Dangle fingers in warm water
D.) Semi-Fowler’s C.) Provide privacy
D.) Pour warm water over perineum
90.) Which of the following is inappropriate
nursing action during rectal tube insertion to 99.) The best position for female during urinary
relieve flatulence? catheterization is:
A.) Insert rectal tube for 3-4 inches A.) Supine
B.) Use rectal tube size Fr.22-30 B.) Dorsal recumbent
C.) Keep rectal tube in place for 45 minutes C.) Lateral
D.) Insert well-lubricated rectal tube in rotating D.) Semi-Fowler’s
motion
100.) The female urethral meatus is located:
91.) The following are correct nursing actions A.) Above the clitoris
when administering enema EXCEPT: B.) Below the vaginal
A.) Provide privacy C.) Between the clitoris and vaginal orifice
B.) Introduce solution slowly D.) Between the vaginal orifice and anus
C.) Alternate NSS with tap water and soap suds
D.) Increase the flow rate of the enema solution
if abdominal cramps occur

92.) The functional unit of the kidneys is the:

A.) Glomerulus
B.) Bowman’s capsule
C.) Nephron
D.) Tubules

93.) Which of the following initiates voiding?

A.) Valsalva maneuver
B.) Increased intraabdominal pressure
C.) Sympathetic response stimulation
D.) Parasympathetic response stimulation

94.) The following are normal characteristics of

urine EXCEPT:
A.) Appears clear
B.) pH= 3.5
C.) Sp.Gr=1.020
D.) Amber

95.) Frequent scanty urination is:

A.) Urgency
B.) hesitancy
C.) Pollakuria
D.) Polyuria

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

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 ANS: D
> is incorrect statement of nursing diagnosis > This is incorrect nursing action. The best
(refer to NANDA, appendix A). B,C and D are position when assessing the chest is sitting or
correct statement of nursing diagnosis. upright position. This allows assessment of the
ANS: B anterior and posterior chest
> Attend to client first before equipment. A, C ANS: C
and D are basis for establishing priorities in > This is inappropriate nursing action. For
client care routine urinalysis, 3-50 mls of urine specimen is
ANS: D required to yield accurate results
> Outcome criteria should be specific, ANS: A
measurable, attainable, realistic and time-bound. > This is incorrect nursing action. When
A, B and C are correct statements of outcome performing Benedict’s test, collect secondvoided
criteria urine specimen
ANS: A ANS: A
> The primary factor responsible for body > Heat and acetic acid test is done to determine
production is metabolism presence of albumin in the urine.
ANS: C ANS: C
> The heat-regulating center is found in the > When collecting urine specimen from a client
hypothalamus with indwelling urethral catheter, collect urine
ANS: B specimen by using sterile needle and syringe to
> Conduction is the process of heat loss which aspirate urine specimen from the drainage port.
involves the transfer of heat from one surface to ANS: A
another > Administration of antipyretic to a febrile client
ANS: D is dependent nursing intervention, (not
> Is incorrect statement about body temperature. independent nursing intervention)
Sympathetic nervous system releases ANS: A
norepinephrine which increases metabolic rate, > The common opening between the respiratory
thereby increases body heat production. and digestive system is the pharynx
ANS: B ANS: B
> Relapsing fever is “on-and-off” fever > The right lung has 3 lobes
ANS: D ANS: B
> Is not appropriate nursing action when taking > The amount of air that remains in the lungs
oral temperature. Thermometer with pearshaped after forceful exhalation is residual volume
or rounded bulb is used for rectal ANS: C
temperature-taking > Cheyne-stokes breathing is marked waxing
ANS: B and waning of respirations from very deep to
> Diarrhea is not a contraindication for oral very shallow breathing and temporary apnea
temperature-taking ANS: D
ANS: D > The best position to promote maximum lung
> Instructing client to strain during insertion of expansion is Semi-Fowler’s
rectal thermometer is inappropriate. This may ANS: C
cause trauma to the anus. > The characteristic manifestation of airway
ANS: B obstruction is noisy breathing.
> Using the thumb when palpating pulse is ANS: B
incorrect nursing action. The thumb has strong > This is inappropriate nursing intervention to
pulsation and the nurse might be counting her promote respiratory function. Appropriate is
own pulse, instead of the client’s pulse avoid or quit cigarette smoking, not just to
ANS: D minimize it
> Pulse pressure is the difference between ANS: A
systolic pressure and diastolic pressure. > The initial manifestations of hypoxemia are
ANS: D restlessness and tachycardia
> Reading the upper meniscus of mercury will ANS: D
yield inaccurate BP reading. BP reading is done > This is inappropriate nursing action during
by noting the level of the lower meniscus of the chest physiotherapy. Appropriate is to assume
mercury. each position during postural drainage for 10 to
ANS: A 15 minutes
> Diffusion is exchange of gases from an area of ANS: C
higher pressure to an area of lower pressure. > This inappropriate nursing action when
ANS: A providing steam inhalation therapy. Appropriate
> The primary respiratory center is the medulla is to place the spout at least 12 inches from the
oblongata. It contains the central patient’s nose.
chemoreceptors that are stimulated by high ANS: B
levels of carbon dioxide in the blood > To be effective, steam inhalation should be
ANS: B rendered for at least 15-20 minutes
> Stress is the primary factor that affects BP, ANS: B
because of release of norepinephrine by the > The correct pressure of the wall suction unit
sympathetic nervous system. when suctioning an adult patient is 100-120 mm
ANS: A Hg
> Patient’s lifestyle is not a social data ANS: C
ANS: D > When performing oropharyngeal suctioning, it
is inappropriate to lubricate catheter with vomiting is aspiration. It causes airway
alcohol. Alcohol may irritate mucous membrane obstruction.
of airways. Appropriate is, use sterile water or ANS: C
sterile NSS. > The vomiting center in the Medulla Oblongata
ANS: B ANS: A
> The maximum time for applying suction is 10 > The best indicator of nutritional status is the
to 15 seconds. This is to prevent hypoxia weight
ANS: A ANS: C
> To evaluate effectiveness of suctioning, the > Dietary diary e.g. 3-day diet recall, is the best
nurse should primarily auscultate the chest for assessment parameter for adequacy of food
clear breath sounds intake
ANS: C ANS: B
> Venturi mask is the preferred device for > Prolonged Vit B12 deficiency results to
oxygen therapy among clients with COPD. pernicious anemia
ANS: A
ANS: D > Vit D promotes absorption of calcium
> It is inappropriate to lubricate nares with oil ANS: C
when the client is receiving oxygen therapy. Oil > Vit K is necessary for blood clotting. Prolonged
ignites when exposed to compressed oxygen deficiency of this vitamin leads to bleeding
ANS: C ANS: D
> When assessing respirations, the nurse should > Elevated BP is not a sign of dehydration.
count the rate, not simply describe it. A,B,C are signs and symptoms of dehydration.
ANS: A ANS: A
> Cilia are small hair-like projections that line the > Hypokalemia is low serum potassium level.
tracheobronchial tree Providing potassium-rich foods like banana and
ANS: D other fresh fruits is effective nursing intervention
> All of these (A,B, and C) are appropriate for this condition
nursing diagnoses for clients with oxygenation ANS: C
problems. > During insertion of NGT, the patient is best
ANS: B placed in high-Fowler’s position with neck
> The regulating centers for food and fluid intake hyperextended until the tube is in the
are found in the hypothalamus oropharynx. Once the NGT is in the oropharynx,
ANS: A the client is instructed to flex the neck and
> The enzyme that initiates digestion of starch in the mouth swallow, as the tube is advanced.
is salivary amylase ANS: D
ANS: C > The length of NGT to be inserted is measured
> The cardiac sphincter also known as lower from the tip of the nose, to the earlobe, to the
esophageal sphincter prevents gastric reflux xiphoid process (N-E-X) which is approximately
ANS; A 50cm
> Fats remains in the stomach for 4 to 6 hours; ANS: B
carbohydrates for 1 to 2 hours; protein 3 to 4 > When inserting NGT, the neck is initially
hours hyperextended
ANS: B ANS: C
> Lipase is the pancreatic enzyme that > The most accurate method of assessing
completes digestion of fats placement of NGT is through X-ray.
ANS: C ANS: C
> Kwashiorkor is protein deficiency > During NGT feeding, the height of the feeding
ANS: A is 12 inches above the point of NGT insertion,
> Providing small frequent feedings is most not 24 inches. If the height of feeding is too high,
effective nursing measure to relieve anorexia this results to very rapid introduction of feeding.
ANS: D This may trigger nausea and vomiting.
> Sleep reduces calorie requirement by 10 to ANS: A
15% . A,B,and C are factors that increase calorie > The primary purpose of gastrostomy is for
requirement. feeding
ANS: D ANS: B
> Carbonated drinks are not sources of calcium. > The most important nursing action before
A,B and C are good sources of calcium. gastrostomy feeding is to assess for patency of
ANS: A the tube. This is done by instilling 15-30 mls of
> Among these choices, mongo (a legume) is water into the tube.
the richest source of iron. The richest source of ANS: C
iron is liver, next is lean meat, then legumes, > The primary advantage of gastrostomy feeding
then green leafy vegetables is, it maintains the integrity of gastro-esophageal
ANS: B sphincter ( cardiac sphincter) of the stomach
> Liver is very good source of fat-soluble ANS: A
vitamins (A,D,E,K) > Vitamin B3 (Niacin) deficiency leads to
ANS: B pellagra
> Milk does not relieve nausea and vomiting. ANS: C
A,B,C may relieve nausea and vomiting > Constipation is passage of hard, dry stool
ANS: A ANS: D
> The most life-threatening complication of > Fecal impaction is the accumulation of
hardened, putty-like fecal mass at the rectum > Flat sound over the suprapubic area on
ANS: C percussion does not indicate bladder distention.
> Regular use of laxative is inappropriate Accumulation of urine in the bladder will produce
nursing measures to relieve constipation dull sound
ANS: A ANS: C
> Castor oil provides chemical stimulation to the > providing privacy is the most effective nursing
intestinal mucosa, to increase peristalsis and measure to relieve urinary retention.
promote defecation ANS: B
ANS: B > Dorsal recumbent position is the best position
> To prevent flatulence, avoid gas-forming foods during urethral catheter insertion in a female
like cabbage client.
ANS: B ANS: C
> Absorbent anti-diarrheal medications absorb > The female urethral meatus is located
gas or toxic substances from the bowel between the
ANS: C
> The most common side-effect of overuse of
laxative is rebound constipation
Ans: A
> Banana should be included in the diet of the
client with diarrhea. It is rich in potassium and it
replaces potassium losses due to diarrhea
ANS: D
> Gatorade may be given to a client with
diarrhea because it is rich in potassium
ANS: B
> Metamucil increases bulk of the stool and it
provides adequate mechanical stimulation for
peristalsis
ANS: A
> High fiber die stimulates peristalsis and
therefore inappropriate for a client with diarrhea
ANS: B
> Carminative enema is used for retention
enema. A,C, and D are solutions used as nonretention
enema
ANS: C
> Prostigmin is cholinergic, so it stimulates
peristalsis. It is used to relieve flatulence
ANS: A
> Left lateral position is the best position for the
adult client receiving enema. This position
facilitates the flow of the solution into the colon
by gravity
ANS: C
> Keeping the rectal tube in place for 45 minutes
is inappropriate. Beyond 30 minutes rectal tube
causes irritation of the mucous membrane in the
rectal area.
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.
ANS: C
> The nephron is the unit of the kidney
ANS: D
> The PNS promotes contraction of the bladder
and promotes relaxation of urethral sphincter.
Therefore, it initiates voiding.
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
ANS: C
> Pollakuria is frequent scanty urination
ANS: C
> 250-450 mls of urine in the bladder makes an
adult client feel the urge to void
ANS: A