1
FUNDAMENTALS OF NURSING DIAGNOSTIC PRACTICE EXAM WITH
QUESTIONS AND ANSWERS 2026 VERSION
who missed the last scheduled visit with her obstetrician
1. The equivalent of 100.8 degrees Fahrenheit in Celsius is require?
A. 38.2 C. 39.4 A. Partially compensatory
B. 38.7 D. 40.1 B. Supportive-educative
C. Universal intervention
FORMULA: F – 32 (5/9) = C D. Wholly compensatory
2. Dorothy underwent diagnostic test and the result of the
(A) is applicable for patients with limited mobility and can do
blood examination are back. On reviewing the result, the
partial self-care while (D) is for immobile and unconscious
nurse notices which of the following as abnormal finding?
patients who can needs total care from the nurse. (C) involves
A. Neutrophils - 60%
needs that are needed by all individuals or patients.
B. Creatinine – 0.9 mg/dL
C. Erythrocyte sedimentation rate - 25 mm/hr
7. Guillermo is allergic to non-steroidal drugs (NSAID). Which
D. Blood urea nitrogen – 15 mg/dL
of the following would be the LEAST relevant practice to
ensure that the nurse who is preparing the drugs for the
NORMAL: 0-20 mm/hr. Any increase in ESR indicates an
patient in the medication room becomes aware of his
inflammatory process.
allergy?
Neutrophil (60-70%), creatinine (<1 mg/dL) and BUN (10-20
A. The medication administration record has a note on it
mg/dl) are all normal. Elevated neutrophil indicates ACUTE
that patient is allergic to NSAID
inflammation while BUN & creatinine indicate renal damage.
B. Paste a note that patient is allergic to NSAID on the
Creatinine is more accurate than BUN since BUN is affected
chart cover
by diet, fluid intake and muscular activity.
C. Have the patient wear a red identification bracelet
labeled 'With allergy'
3. When doing physical examination as part of the nursing
D. Place a note in the patients medication box that he
process, the nurse should have sufficient understanding of
has an allergy
basic nursing procedures and skills. While auscultating
Mario's lung fields, the nurse compares the Lung sounds.
The question asks what the nurse IN THE medication room
The nurse applies a systematic pattern by:
can be made aware of the patient’s allergy. The patient cannot
A. listening from anterior to posterior
be with the nurse in the medication room.
B. assessing from top to bottom
C. comparing lung sounds side to side
8. Care of patients with intravenous fluids is one of the major
D. comparing from interspace to interspace.
responsibilities of a nurse. A nurse caring for a client with
PICC line (peripherally inserted central line) knows that
Chest auscultation involves listening to breath sounds from
the tip of the IV access is located in the
side to side, comparing left and right lung fields as it goes from
A. Basilic vein C. Right atrium
top to bottom.
B. Cephalic vein D. Antecubital vein
4. Who pioneered the idea of the nurse-client relationship
A PICC line is inserted in a peripheral vein with its tip placed at
and interactive process?
the right atrium. B, C, and D are the insertion sites.
A. Faye Abdellah
B. Florence Nightingale
9. A frail elderly woman undergoes a timed up and go test
C. Hildegard Peplau
with a result of 18 seconds. This means that the client
D. Virginia Henderson
A. moves normally like any other adult
B. is a fall risk
Abdellah focused on 21 nursing problems, Nightingale on
C. is within normal limits for her age and physical
environmental theory, and Henderson on 14 basic needs.
condition
5. The physician ordered a small volume enema to a client D. needs assistance when moving out of bed
with fecal impaction. The client needed further clarification
when she asks the nurse how the solution will work once it This is a test of mobility which involves measuring the time a
is administered. The most appropriate explanation of the person rises from a chair, walks three meters, turn around, and
nurse is that the solution: walk back to the chair and sit down. Completion of the test in
A. Causes distention of the bowel and stimulates the less than 10 seconds is normal mobility; however, for elderly
defecation reflex. adults and those with disability, this may take them 11-20
B. Draws water from the colonic mucosa cause water seconds which is normal for this group. When a patient takes
retention in the lower-colon. . . 21-30 seconds to perform the test, he needs additional
C. Decreases surface tension of stool allowing water to assistance during ambulation. A 30-second or more result
enter stool more readily. signifies a patient is a fall risk.
D. Promotes bowel evacuation that provides and
stimulates the defecation reflex. 10. Allen’s test is indicated for which of the following clients? A
client
Small-volume enema uses hypertonic solution, thus attracts A. who needs an arterial line
water into the feces. A and D are for hypotonic and isotonic B. with ulnar nerve damage
enemas, while C for oil retention enema. C. with peripheral neuropathy
D. who is about to undergo glucose test
6. According to Orem’s Self-Care Theory, what type of
nursing activity would a G2P1 mother, 7 months pregnant, This is a test to determine adequacy of peripheral
CIRCULATION.
,2
11. A client is reported to have orthostatic hypotension.
Which of the following would you consider a
sign?
,3
A. Increase in pulse of 40 beats/minute and decrease in A. hypothalamus C. anterior pituitary gland
BP of 30 mm Hg from a sitting to a standing position B. posterior pituitary gland D. thyroid gland
B. A drop of 30 mm Hg in BP from a supine to a
standing position with a rise in pulse of 40 beats/ 18. A suppository is prescribed for the client. When
minute administering the drug, the nurse must place the client in
C. Decrease in pulse by 20 beats / minute and increase which position?
in BP by 20 mm Hg from supine to standing position A. Sim’s C. Lithotomy
D. A sudden drop in BP of 30 mm Hg systolic and 10 B. Dorsal recumbent D. Prone
mm Hg diastolic from lying to sitting or sitting to
standing position Left Sim’s position is the preferred position for any procedure
that involves administration of medication or tube into the
Orthostatic hypotension is measured while a person is lying rectum as the sigmoid colon is located in the left lower
down, sitting AND standing. A 20-30 drop in systolic BP and quadrant of the abdomen.
10-15 drop in diastolic BP when changing position is a positive
finding. B and C are wrong positions for the client. 19. A client is transferred to the medical unit after a
transurethral resection of the prostate. The nurse reviews
12. A post-operative client complains of numbness and the transfer orders. The surgeon's order reads: "Maintain
tingling around his mouth and shows prolonged QT traction on the indwelling triple lumen catheter" Which of
interval on the cardiac monitor. These are associated with the following is the MOST appropriate action of the nurse?
which electrolyte imbalance? A. Tape the catheter to the abdomen and keep client in
A. Hypocalcemia C. Hyperkalemia supine position.
B. Hypokalemia D. Hypercalcemia B. Pull the catheter taut and tape to the thigh alternately
every 6 hours.
The symptom is an early sign of tetany or hypocalcemia. C. Instruct the client to keep both legs together and
Prolonged QT interval reflects a low calcium level. extended all the time.
D. Pull the catheter taut, tape to one thigh and keep the
13. Prevention of infection is one of the essential measures to leg extended all the time.
reduce negative outcomes in health care. Catheter care
must be performed frequently to prevent urinary tract This position maintains traction of the catheter.
infections. How often should the nurse change a client’s
condom catheter? 20. Normal heart sounds originate from the SA node. How
A. Every 24 hours C. every 72 hours many times per minute does the SA node emit electric
B. Every 48 hours D. every 96 hours currents in an adult?
A. 60-100 C. 40-60
Changing the catheter every 24 hours reduces the risk for UTI. B. 50-100 D. 80-120
14. In the physical examination of a patient with abdominal The sinoatrial node is the pacemaker of the heart. It normally
pain, what is the recommended sequence of examination emits 60-100 electric currents per minute. The atrioventricular
techniques? node emits 40-60, while the Bundles of His, 20-40.
A. Inspection, auscultation, percussion, palpation
B. Inspection, percussion, palpation, auscultation 21. When the body responds to stress, epinephrine is
C. Inspection, percussion, auscultation, palpation released producing which physiological response?
D. Inspection, palpation, auscultation, percussion A. Decreased oxygenated blood to vital organs
B. Decreased heart rate
Inspection is always the first technique of physical C. Peripheral vascular dilatation
assessment. In abdominal assessment, auscultation is done D. A more forceful heart beat
first prior to percussion and palpation to prevent altering the
bowel sounds. ABC are the opposite effects of epinephrine.
15. The patient with an acoustic nerve injury may have a 22. The nurse is aware that proper documentation when
positive Romberg’s sign. Which of the following describes taking care of the client is important. The purposes of
a positive Romberg’s sign? client care documentation include the following:
A. Inability to hear a whisper 1. Standardizes plan of care
B. Inability to hear unless the listener is looking at the 2. Communicates vital information about client’s
speaker health status to other health care providers
C. Inability to maintain an upright position with eyes 3. Serves as resource for research and education
closed 4. Serves as a legal document
D. Inability to maintain an upright position with eyes A. 2, 3 and 4 C. 1, 2 and 4
open B. 1, 3 and 4 D. 1, 2 and 3
Romberg’s test is a test of balance and equilibrium. Inability to According to Kozier, 234 are the purposes of documentation.
maintain such indicates an abnormality in the cerebellum.
23. When assessing for the apical pulse, where should the
16. Various methods of documentation are practiced by nurse place the stethoscope?
nursing staff, one of which is the SOAP method. The A. 5th ICS, left midclavicular
SOAP method stands for B. 4th ICS, left midsternal
A. subjective data, objective data, assessment, process C. 5th ICS, right midsternal
B. subjective data, objective data, assessment, planning D. 4the ICS, right midclavicular
C. subject, objection, assessment, process
D. subjective data, objective data, analysis, planning The apical pulse, also known as the point of maximum impulse
is located in the 5th left intercostal space, left midclavicular line.
17. Somatotropin releasing hormone or the growth hormone
releasing hormone is secreted by the:
, 4
24. A client has difficulty walking and needs wheel chair to NPO must be done prior to ultrasound of the bladder in order
facilitate performance of daily activities. Anticipating the to concentrate the bile in the bladder.
needs of the client, the nurse should have the wheel chair
ready by placing it at 30. Cultural sensitivity enables nurses to be responsive to the
A. 60-degree angle to the bed needs of patients with varied cultural background. A client
B. 45-degree angle to the bed practices Islam and his diet must consider his religious
C. 90-degree angle to the bed practices and beliefs. The nurse is aware that this client
D. 30-degree angle to the bed would avoid which of the following?
1. Shrimps and crabs
25. How will a nurse assess the client for pulse deficits? 2. Wine and alcohol drinks
A. Ask a colleague to take the apical pulse together with 3. Fish with scales
her. 4. Pork products like bacon
B. Ask a colleague to take the radial pulse as she is 5. Caffeinated products like cola drinks
taking the apical pulse. A. 2, 4 and 5 C. 3,4, 5
C. Take the apical pulse & compare with the pulse B. 1, 4 and 5 D. 1, 2 and 4
pressure.
D. Take the radial pulse after taking the apical pulse. 31. What is the formula to obtain cardiac output?
A. Heart rate x Diastolic pressure
Assessment of pulse deficit can be done by either the 1-nurse B. Heart rate x Pulse pressure
method or 2-nurse method. The question states “a nurse”. C. Heart rate x Stroke volume
Option B uses the 2-nurse method. D. Heart rate x Systolic pressure
26. Which of the following best describes Cheyne-Stokes Cardiac output is the amount of blood ejected by the heart in
respiration? one minute. It is determined by the heart rate and stroke
A. Abnormally deep, regular, and increased rate volume or the amount of blood ejected by the heart PER
B. Abnormally shallow for 2-3 breaths followed by contraction which is about 70 mL. If a person’s heart rate is 80,
irregular period of apnea multiply it by 70, then the cardiac output is 5,600 mL.
C. Irregular rate & depth with alternating periods of
apnea & hyperventilation 32. A pulse oximetry measures oxygen saturation of the
D. Regular rate & depth with alternating periods of blood. The oxygen saturation reading that is assessed by
apnea & hyperventilation using a pulse oximeter is documented as
A. SaO2 c. PO2
Choice A describes Kussmaul’s respiration. B. SpO2 d. PaO2
27. The nurse implement standards of care to prevent Oxygen saturation is SaO2. When assessed by a pulse
complications related to immobility. A client on bed rest is oximeter, it as reflected as SpO2.
rolled to a lateral position by the nurse. The nurse is
negotiating the move correctly when he: 33. The nurse has a sterile field in front of her and needs to
A. Positions himself at the mid part of the bed and reach something on the other side of the sterile field. To
places both hands at the back of the client and roll maintain the sterile field, the nurse should:
client onto side A. Walk around with the back to the sterile field.
B. Places one hand on the client’s far hip and the other B. Reach across the sterile field.
on the client’s far shoulder rock backward and roll C. Walk around facing the sterile field.
onto side of the body facing him D. Move the sterile field away from her and reach the
C. Assumes a broad stance with the foot nearest the bed object.
placing his arm under the client’s thighs and shoulder
and roll client onto side ABD all violate the principles of aseptic technique.
D. Supports the back and buttocks of the client and
shifts his own weight from the forward to the 34. When obtaining a urine sample from a patient with an
backward foot and roll the client onto side indwelling urinary catheter, where should the urine be
collected?
Choice B is the most appropriate way to turn a patient to the A. From the balloon port of the catheter using a needle.
lateral position. (Kozier) B. From the collection bag.
C. From the collection port using a needle.
28. Which of the following represents ventricular relaxation? D. From the tube near the meatus using a needle.
A. P wave C. Q wave
B. R wave D. T wave Letter A will remove the fluid that anchors the catheter. Urine is
never collected from the collection bag.
P wave represent atrial depolarization/contraction. QRS waves 35. A nurse receives an order to obtain sputum sample for
reflect ventricular depolarization. culture from a client with pneumonia. What action should
be avoided when obtaining the specimen?
29. The nurse is preparing the client for an ultrasound of the A. Having the client brush teeth before expectoration.
gallbladder. Which of the following statements would be B. Instructing the client to take deep breaths before
the most important to prepare the client for the test? coughing.
A. "You will have food and fluids restricted for 4 to 8 C. Obtaining the specimen early in the morning.
hours prior to the test.“ D. Placing the lid of the culture container face down on
B. "Stool in the bowel may cause a reporting of the bedside table.
inaccurate findings.“
C. "There is no special preparation for this procedure. Oral care (A) may be done prior to sputum specimen collection
You may eat and drink as usual.“ as long as antiseptic mouthwash or saline gargles are not
D. "You will be asked to drink a solution of radionuclide 2 done. B facilitates sputum expectoration. C is the preferred
hours prior to the procedure." time to collect sputum. D contaminates the lid of the specimen
container.
FUNDAMENTALS OF NURSING DIAGNOSTIC PRACTICE EXAM WITH
QUESTIONS AND ANSWERS 2026 VERSION
who missed the last scheduled visit with her obstetrician
1. The equivalent of 100.8 degrees Fahrenheit in Celsius is require?
A. 38.2 C. 39.4 A. Partially compensatory
B. 38.7 D. 40.1 B. Supportive-educative
C. Universal intervention
FORMULA: F – 32 (5/9) = C D. Wholly compensatory
2. Dorothy underwent diagnostic test and the result of the
(A) is applicable for patients with limited mobility and can do
blood examination are back. On reviewing the result, the
partial self-care while (D) is for immobile and unconscious
nurse notices which of the following as abnormal finding?
patients who can needs total care from the nurse. (C) involves
A. Neutrophils - 60%
needs that are needed by all individuals or patients.
B. Creatinine – 0.9 mg/dL
C. Erythrocyte sedimentation rate - 25 mm/hr
7. Guillermo is allergic to non-steroidal drugs (NSAID). Which
D. Blood urea nitrogen – 15 mg/dL
of the following would be the LEAST relevant practice to
ensure that the nurse who is preparing the drugs for the
NORMAL: 0-20 mm/hr. Any increase in ESR indicates an
patient in the medication room becomes aware of his
inflammatory process.
allergy?
Neutrophil (60-70%), creatinine (<1 mg/dL) and BUN (10-20
A. The medication administration record has a note on it
mg/dl) are all normal. Elevated neutrophil indicates ACUTE
that patient is allergic to NSAID
inflammation while BUN & creatinine indicate renal damage.
B. Paste a note that patient is allergic to NSAID on the
Creatinine is more accurate than BUN since BUN is affected
chart cover
by diet, fluid intake and muscular activity.
C. Have the patient wear a red identification bracelet
labeled 'With allergy'
3. When doing physical examination as part of the nursing
D. Place a note in the patients medication box that he
process, the nurse should have sufficient understanding of
has an allergy
basic nursing procedures and skills. While auscultating
Mario's lung fields, the nurse compares the Lung sounds.
The question asks what the nurse IN THE medication room
The nurse applies a systematic pattern by:
can be made aware of the patient’s allergy. The patient cannot
A. listening from anterior to posterior
be with the nurse in the medication room.
B. assessing from top to bottom
C. comparing lung sounds side to side
8. Care of patients with intravenous fluids is one of the major
D. comparing from interspace to interspace.
responsibilities of a nurse. A nurse caring for a client with
PICC line (peripherally inserted central line) knows that
Chest auscultation involves listening to breath sounds from
the tip of the IV access is located in the
side to side, comparing left and right lung fields as it goes from
A. Basilic vein C. Right atrium
top to bottom.
B. Cephalic vein D. Antecubital vein
4. Who pioneered the idea of the nurse-client relationship
A PICC line is inserted in a peripheral vein with its tip placed at
and interactive process?
the right atrium. B, C, and D are the insertion sites.
A. Faye Abdellah
B. Florence Nightingale
9. A frail elderly woman undergoes a timed up and go test
C. Hildegard Peplau
with a result of 18 seconds. This means that the client
D. Virginia Henderson
A. moves normally like any other adult
B. is a fall risk
Abdellah focused on 21 nursing problems, Nightingale on
C. is within normal limits for her age and physical
environmental theory, and Henderson on 14 basic needs.
condition
5. The physician ordered a small volume enema to a client D. needs assistance when moving out of bed
with fecal impaction. The client needed further clarification
when she asks the nurse how the solution will work once it This is a test of mobility which involves measuring the time a
is administered. The most appropriate explanation of the person rises from a chair, walks three meters, turn around, and
nurse is that the solution: walk back to the chair and sit down. Completion of the test in
A. Causes distention of the bowel and stimulates the less than 10 seconds is normal mobility; however, for elderly
defecation reflex. adults and those with disability, this may take them 11-20
B. Draws water from the colonic mucosa cause water seconds which is normal for this group. When a patient takes
retention in the lower-colon. . . 21-30 seconds to perform the test, he needs additional
C. Decreases surface tension of stool allowing water to assistance during ambulation. A 30-second or more result
enter stool more readily. signifies a patient is a fall risk.
D. Promotes bowel evacuation that provides and
stimulates the defecation reflex. 10. Allen’s test is indicated for which of the following clients? A
client
Small-volume enema uses hypertonic solution, thus attracts A. who needs an arterial line
water into the feces. A and D are for hypotonic and isotonic B. with ulnar nerve damage
enemas, while C for oil retention enema. C. with peripheral neuropathy
D. who is about to undergo glucose test
6. According to Orem’s Self-Care Theory, what type of
nursing activity would a G2P1 mother, 7 months pregnant, This is a test to determine adequacy of peripheral
CIRCULATION.
,2
11. A client is reported to have orthostatic hypotension.
Which of the following would you consider a
sign?
,3
A. Increase in pulse of 40 beats/minute and decrease in A. hypothalamus C. anterior pituitary gland
BP of 30 mm Hg from a sitting to a standing position B. posterior pituitary gland D. thyroid gland
B. A drop of 30 mm Hg in BP from a supine to a
standing position with a rise in pulse of 40 beats/ 18. A suppository is prescribed for the client. When
minute administering the drug, the nurse must place the client in
C. Decrease in pulse by 20 beats / minute and increase which position?
in BP by 20 mm Hg from supine to standing position A. Sim’s C. Lithotomy
D. A sudden drop in BP of 30 mm Hg systolic and 10 B. Dorsal recumbent D. Prone
mm Hg diastolic from lying to sitting or sitting to
standing position Left Sim’s position is the preferred position for any procedure
that involves administration of medication or tube into the
Orthostatic hypotension is measured while a person is lying rectum as the sigmoid colon is located in the left lower
down, sitting AND standing. A 20-30 drop in systolic BP and quadrant of the abdomen.
10-15 drop in diastolic BP when changing position is a positive
finding. B and C are wrong positions for the client. 19. A client is transferred to the medical unit after a
transurethral resection of the prostate. The nurse reviews
12. A post-operative client complains of numbness and the transfer orders. The surgeon's order reads: "Maintain
tingling around his mouth and shows prolonged QT traction on the indwelling triple lumen catheter" Which of
interval on the cardiac monitor. These are associated with the following is the MOST appropriate action of the nurse?
which electrolyte imbalance? A. Tape the catheter to the abdomen and keep client in
A. Hypocalcemia C. Hyperkalemia supine position.
B. Hypokalemia D. Hypercalcemia B. Pull the catheter taut and tape to the thigh alternately
every 6 hours.
The symptom is an early sign of tetany or hypocalcemia. C. Instruct the client to keep both legs together and
Prolonged QT interval reflects a low calcium level. extended all the time.
D. Pull the catheter taut, tape to one thigh and keep the
13. Prevention of infection is one of the essential measures to leg extended all the time.
reduce negative outcomes in health care. Catheter care
must be performed frequently to prevent urinary tract This position maintains traction of the catheter.
infections. How often should the nurse change a client’s
condom catheter? 20. Normal heart sounds originate from the SA node. How
A. Every 24 hours C. every 72 hours many times per minute does the SA node emit electric
B. Every 48 hours D. every 96 hours currents in an adult?
A. 60-100 C. 40-60
Changing the catheter every 24 hours reduces the risk for UTI. B. 50-100 D. 80-120
14. In the physical examination of a patient with abdominal The sinoatrial node is the pacemaker of the heart. It normally
pain, what is the recommended sequence of examination emits 60-100 electric currents per minute. The atrioventricular
techniques? node emits 40-60, while the Bundles of His, 20-40.
A. Inspection, auscultation, percussion, palpation
B. Inspection, percussion, palpation, auscultation 21. When the body responds to stress, epinephrine is
C. Inspection, percussion, auscultation, palpation released producing which physiological response?
D. Inspection, palpation, auscultation, percussion A. Decreased oxygenated blood to vital organs
B. Decreased heart rate
Inspection is always the first technique of physical C. Peripheral vascular dilatation
assessment. In abdominal assessment, auscultation is done D. A more forceful heart beat
first prior to percussion and palpation to prevent altering the
bowel sounds. ABC are the opposite effects of epinephrine.
15. The patient with an acoustic nerve injury may have a 22. The nurse is aware that proper documentation when
positive Romberg’s sign. Which of the following describes taking care of the client is important. The purposes of
a positive Romberg’s sign? client care documentation include the following:
A. Inability to hear a whisper 1. Standardizes plan of care
B. Inability to hear unless the listener is looking at the 2. Communicates vital information about client’s
speaker health status to other health care providers
C. Inability to maintain an upright position with eyes 3. Serves as resource for research and education
closed 4. Serves as a legal document
D. Inability to maintain an upright position with eyes A. 2, 3 and 4 C. 1, 2 and 4
open B. 1, 3 and 4 D. 1, 2 and 3
Romberg’s test is a test of balance and equilibrium. Inability to According to Kozier, 234 are the purposes of documentation.
maintain such indicates an abnormality in the cerebellum.
23. When assessing for the apical pulse, where should the
16. Various methods of documentation are practiced by nurse place the stethoscope?
nursing staff, one of which is the SOAP method. The A. 5th ICS, left midclavicular
SOAP method stands for B. 4th ICS, left midsternal
A. subjective data, objective data, assessment, process C. 5th ICS, right midsternal
B. subjective data, objective data, assessment, planning D. 4the ICS, right midclavicular
C. subject, objection, assessment, process
D. subjective data, objective data, analysis, planning The apical pulse, also known as the point of maximum impulse
is located in the 5th left intercostal space, left midclavicular line.
17. Somatotropin releasing hormone or the growth hormone
releasing hormone is secreted by the:
, 4
24. A client has difficulty walking and needs wheel chair to NPO must be done prior to ultrasound of the bladder in order
facilitate performance of daily activities. Anticipating the to concentrate the bile in the bladder.
needs of the client, the nurse should have the wheel chair
ready by placing it at 30. Cultural sensitivity enables nurses to be responsive to the
A. 60-degree angle to the bed needs of patients with varied cultural background. A client
B. 45-degree angle to the bed practices Islam and his diet must consider his religious
C. 90-degree angle to the bed practices and beliefs. The nurse is aware that this client
D. 30-degree angle to the bed would avoid which of the following?
1. Shrimps and crabs
25. How will a nurse assess the client for pulse deficits? 2. Wine and alcohol drinks
A. Ask a colleague to take the apical pulse together with 3. Fish with scales
her. 4. Pork products like bacon
B. Ask a colleague to take the radial pulse as she is 5. Caffeinated products like cola drinks
taking the apical pulse. A. 2, 4 and 5 C. 3,4, 5
C. Take the apical pulse & compare with the pulse B. 1, 4 and 5 D. 1, 2 and 4
pressure.
D. Take the radial pulse after taking the apical pulse. 31. What is the formula to obtain cardiac output?
A. Heart rate x Diastolic pressure
Assessment of pulse deficit can be done by either the 1-nurse B. Heart rate x Pulse pressure
method or 2-nurse method. The question states “a nurse”. C. Heart rate x Stroke volume
Option B uses the 2-nurse method. D. Heart rate x Systolic pressure
26. Which of the following best describes Cheyne-Stokes Cardiac output is the amount of blood ejected by the heart in
respiration? one minute. It is determined by the heart rate and stroke
A. Abnormally deep, regular, and increased rate volume or the amount of blood ejected by the heart PER
B. Abnormally shallow for 2-3 breaths followed by contraction which is about 70 mL. If a person’s heart rate is 80,
irregular period of apnea multiply it by 70, then the cardiac output is 5,600 mL.
C. Irregular rate & depth with alternating periods of
apnea & hyperventilation 32. A pulse oximetry measures oxygen saturation of the
D. Regular rate & depth with alternating periods of blood. The oxygen saturation reading that is assessed by
apnea & hyperventilation using a pulse oximeter is documented as
A. SaO2 c. PO2
Choice A describes Kussmaul’s respiration. B. SpO2 d. PaO2
27. The nurse implement standards of care to prevent Oxygen saturation is SaO2. When assessed by a pulse
complications related to immobility. A client on bed rest is oximeter, it as reflected as SpO2.
rolled to a lateral position by the nurse. The nurse is
negotiating the move correctly when he: 33. The nurse has a sterile field in front of her and needs to
A. Positions himself at the mid part of the bed and reach something on the other side of the sterile field. To
places both hands at the back of the client and roll maintain the sterile field, the nurse should:
client onto side A. Walk around with the back to the sterile field.
B. Places one hand on the client’s far hip and the other B. Reach across the sterile field.
on the client’s far shoulder rock backward and roll C. Walk around facing the sterile field.
onto side of the body facing him D. Move the sterile field away from her and reach the
C. Assumes a broad stance with the foot nearest the bed object.
placing his arm under the client’s thighs and shoulder
and roll client onto side ABD all violate the principles of aseptic technique.
D. Supports the back and buttocks of the client and
shifts his own weight from the forward to the 34. When obtaining a urine sample from a patient with an
backward foot and roll the client onto side indwelling urinary catheter, where should the urine be
collected?
Choice B is the most appropriate way to turn a patient to the A. From the balloon port of the catheter using a needle.
lateral position. (Kozier) B. From the collection bag.
C. From the collection port using a needle.
28. Which of the following represents ventricular relaxation? D. From the tube near the meatus using a needle.
A. P wave C. Q wave
B. R wave D. T wave Letter A will remove the fluid that anchors the catheter. Urine is
never collected from the collection bag.
P wave represent atrial depolarization/contraction. QRS waves 35. A nurse receives an order to obtain sputum sample for
reflect ventricular depolarization. culture from a client with pneumonia. What action should
be avoided when obtaining the specimen?
29. The nurse is preparing the client for an ultrasound of the A. Having the client brush teeth before expectoration.
gallbladder. Which of the following statements would be B. Instructing the client to take deep breaths before
the most important to prepare the client for the test? coughing.
A. "You will have food and fluids restricted for 4 to 8 C. Obtaining the specimen early in the morning.
hours prior to the test.“ D. Placing the lid of the culture container face down on
B. "Stool in the bowel may cause a reporting of the bedside table.
inaccurate findings.“
C. "There is no special preparation for this procedure. Oral care (A) may be done prior to sputum specimen collection
You may eat and drink as usual.“ as long as antiseptic mouthwash or saline gargles are not
D. "You will be asked to drink a solution of radionuclide 2 done. B facilitates sputum expectoration. C is the preferred
hours prior to the procedure." time to collect sputum. D contaminates the lid of the specimen
container.
