UNIVERSITY OF LA SALETTE COLLEGE OF NURSING PRELIMINARY EXAMINATION RLE-007 FUNDAMENTALS OF NURSING PRACTICE 1.

Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? a. Providing a back massage b. Feeding a client c. Providing hair care d. Providing oral hygiene 2. The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the clients temperature? a. Oral b. Axillary c. Radial d. Heat sensitive tape 3. A nurse obtained a clients pulse and found the rate to be above normal. The nurse documents this finding as: a. Tachypnea b. Hyper pyrexia c. Arrhythmia d. Tachycardia 4. Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair? a. Bend at the waist and place arms under the clients arms and lift b. Face the client; bend knees and place hands on clients forearm and lift c. Spread his or her feet apart d. Tighten his or her pelvic muscles 5. A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the clients body temperature? a. Oral b. Axillary c. Arterial line d. Rectal 6. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a client is: a. Fowlers position b. Side lying c. Supine d. Trendelenburg 7. A client is hospitalized for the first time, which of the following actions ensure the safety of the client? a. Keep unnecessary furniture out of the way b. Keep the lights on at all time c. Keep side rails up at all time d. Keep all equipment out of view 8. The ability of the body to defend itself against scientific invading agent such as bacteria, toxin, viruses and foreign body a. Hormones b. Secretion c. Immunity d. Glands

9. Which of the following is the most important purpose of hand washing a. To promote hand circulation b. To prevent the transfer of microorganism c. To avoid touching the client with a dirty hand d. To provide comfort 10. Which of the following technique involves the sense of sight? a. Inspection b. Palpation c. Percussion d. Auscultation 11. A technique in physical examination that is use to assess the movement of air through the tracheobronchial tree: a. Palpation b. Auscultation c. Inspection d. Percussion 12. It refers to the manner of walking a. Gait b. Range of motion c. Flexion and extension d. Hopping 13. The nurse asked the client to read the Snellen chart. Which of the following is tested? a. Optic b. Olfactory c. Oculomotor d. Troclear 14. Another name for knee-chest position is: a. Genu-dorsal b. Genu-pectoral c. Lithotomy d. Sims 15. Resonance is best described as: a. Sounds created by air filled lungs b. Short, high pitch and thudding c. Moderately loud with musical quality d. Drum-like beating of the heart 16. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as: a. Tachypnea b. Eupnea c. Orthopnea d. Hyperventilation 17. The correct sequence for assessing the abdomen is: a. Tympanic percussion, measurement of abdominal girth, and inspection b. Assessment for distention, tenderness, and discoloration around the umbilicus. c. Percussions, palpation, and auscultation d. Auscultation, percussion, and palpation 18. High-pitched gurgles head over the right lower quadrant are: a. A sign of increased bowel motility b. A sign of decreased bowel motility c. Normal bowel sounds d. A sign of abdominal cramping 19. A patient about to undergo abdominal inspection is best placed in which of the following positions? a. Prone b. Trendelenburg c. Supine d. Side-lying

20. For a rectal examination, the patient can be directed to assume which of the following positions? a. Genupectoral b. Sims c. Horizontal recumbent d. All of the above 21. During a Romberg test, the nurse asks the patient to assume which position? a. Sitting b. Standing c. Genupectoral d. Trendelenburg 22. If a patients blood pressure is 150/96, his pulse pressure is: a. 54 b. 96 c. 150 d. 246 23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) this temperature reading probably indicates: a. Infection b. Hypothermia c. Anxiety d. Dehydration 24. Which of the following parameters should be checked when assessing respirations? a. Rate b. Rhythm c. Symmetry d. All of the above 25. A 38-year old patients vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported? a. Respiratory rate only b. Temperature only c. Pulse rate and temperature d. Temperature and respiratory rate 26. Which element in the circular chain of infection can be eliminated by preserving skin integrity? a. Host b. Reservoir c. Mode of transmission d. Portal of entry 27. Which of the following will probably result in a break in sterile technique for respiratory isolation? a. Opening the patients window to the outside environment b. Turning on the patients room ventilator c. Opening the door of the patients room leading into the hospital corridor d. Failing to wear gloves when administering a bed bath 28. Which of the following patients is at greater risk for contracting an infection? a. A patient with leukopenia b. A patient receiving broad-spectrum antibiotics c. A postoperative patient who has undergone orthopedic surgery d. A newly diagnosed diabetic patient 29. A natural body defense that plays an active role in preventing infection is: a. Yawning b. Body hair c. Hiccupping d. Rapid eye movements 30. All of the following statements are true about donning sterile gloves except: a. The first glove should be picked up by grasping the inside of the cuff. b. The second glove should be picked up by inserting the gloved fingers under the cuff outside the glove. c. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and pulling the glove over the wrist d. The inside of the glove is considered sterile

31. Which of the following nursing interventions is considered the most effective form or universal precautions? a. Cap all used needles before removing them from their syringes b. Discard all used uncapped needles and syringes in an impenetrable protective container c. Wear gloves when administering IM injections d. Follow enteric precautions 32. The nurse explains to a patient that a cough: a. Is a protective response to clear the respiratory tract of irritants b. Is primarily a voluntary action c. Is induced by the administration of an antitussive drug d. Can be inhibited by splinting the abdomen 33. When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury? a. Abdominal muscles b. Back muscles c. Leg muscles d. Upper arm muscles 34. All of the following are correct methods in assessment of the blood pressure EXCEPT: a. Take the blood pressure reading on both arms for comparison b. Listen to and identify the phases of Korotkoffs sound c. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated d. Observe procedures for infection control 35. You attached a pulse oximeter to the client. You know that the purpose is to: a. Determine if the clients hemoglobin level is low and if he needs blood transfusion b. Check level of clients tissue perfusion c. Measure the efficacy of the clients antihypertensive medications d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops 36. After a few hours in the Emergency Room, The client is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be: a. inconsistent b. low systolic and high diastolic c. higher than what the reading should be d. lower than what the reading should be 37. If the arm is said to be elevated when taking the blood pressure, it will create a: a. False high reading b. False low reading c. True false reading d. Indeterminate 38. A foreign protein that invades the body is called: a. Antigen b. interferon c. antibody d. invader 39. Immunity obtained as a result of experiencing an illness is known as: a. Passive natural immunity b. Active natural immunity c. Active artificial immunity d. Passive artificial immunity 40. A woman undergoing radiation therapy developed redness and burning of the skin around the breast. This is best classified as what type of disease? A. Neoplastic B. Traumatic C. Nosocomial D. Iatrogenic 41. Also known as STERILE TECHNIQUE A. Surgical Asepsis B. Medical Asepsis C. Sepsis D. Asepsis

42. A substance usually intended for use on inanimate objects, that destroys pathogens butnot the spores. A. Sterilization B. Disinfectant C. Antiseptic D. Autoclave 43. This is a person or animal, which is without signs of illness but harbors pathogen within his body and can be transferred to another A. Host B. Agent C. Environment D. Carrier 44. Refers to a person or animal, known or believed to have been exposed to a disease. A. Carrier B. Contact C. Agent D. Host 45. The third period of infectious processes characterized by development of specific signs and symptoms A. Incubation period B. Prodromal period C. Illness period D. Convalescent period 46. Considered as the WEAKEST LINK in the chain of infection that nurses can manipulate to prevent spread of infection and diseases A. Etiologic/Infectious agent B. Portal of Entry C. Susceptible host D. Mode of transmission 47. Which of the following is the exact order of the infection chain? 1. Susceptible host 2. Portal of entry 3. Portal of exit 4. Etiologic agent 5. Reservoir 6. Mode of transmission A. 1,2,3,4,5,6 B. 5,4,2,3,6,1 C. 4,5,3,6,2,1 D. 6,5,4,3,2,1 48. Contact transmission of infectious organism in the hospital is usually cause by: A. Urinary catheterization B. Spread from patient to patient C. Spread by cross contamination via hands of caregiver D. Cause by unclean instruments used by doctors and nurses 49. Transmission occurs when an infected person sneezes, coughs or laugh that is usually projected at a distance of 3 feet. A. Droplet transmission B. Airborne transmission C. Vehicle transmission D. Vector borne transmission 50. Considered as the first line of defense of the body against infection A. Skin B. WBC C. Leukocytes D. Immunization 51. In hand washing by medical asepsis, Hands are held . A. Above the elbow, the hands must always be above the waist B. Above the elbow, the hands are cleaner than the elbow C. Below the elbow, Medical asepsis do not require hands to be above the waist D. Below the elbow, Hands are dirtier than the lower arms

52. In putting sterile gloves, which should be gloved first? A. The dominant hand B. The non-dominant hand C. The left hand D. No specific order, its up to the nurse for her own convenience 53. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Paul is tachypneic. The nurse understands that tachypnea means: a. Pulse rate greater than 100 beats per minute b. Blood pressure of 140/90 c. respiratory rate greater than 20 breaths per minute d. Frequent bowel sounds 54. The nurse in charge measures a patients temperature at 101 degrees F. What is the equivalent centigrade temperature? a. 36.3 degrees C b. 37.95 degrees C c. 40.03 degrees C d. 38.01 degrees 55. The nurse is caring for a patient with high fever secondary septicemia. When the physician orders a cooling blanket, the nurse understands that it is used to achieve heat loss via: a. Radiation b. Convection c. Conduction d. Evaporation 56. A shrill, harsh sound heard during inspiration with laryngeal obstruction: a. stridor b. stertor c. wheeze d. bubbling 57. Heat loss from the body through continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin: a. Vaporization b. Convection c. Conduction d. Radiation 58. The vital or cardinal signs are: a. body temperature, pulse, blood pressure, basal metabolic rate b. core temperature, surface temperature, pulse, blood pressure c. body temperature, pulse, blood pressure, ventilation d. body temperature, pulse, respirations, blood pressure 59. This pulse site is usually used to measure blood pressure: a. brachial b. carotid c. apical d. popliteal 60. The transfer of heat from the surface of one object to the surface of another without contact between the two objects is called: a. Conduction b. Convection c. Radiation d. Vaporization 61. A wave of blood created by contraction of the left ventricle of the heart: a. pulse b. cardiac output c. blood pressure d. murmur 62. The nurse enters the room of the client on airborne precautions due to tuberculosis. Which of the following are appropriate actions by the nurse? 1. She wears the mask, covering the nose and mouth 2. She washes her hands before and after removing gloves, after suctioning the clients secretions 3. She removes gloves and mask before leaving the clients room

4. She discards contaminated suction catheter tip in a trash can found in the clients room a.) 1 and 2 b.) 1 and 3 c.) 1,2 and 3 d.) 1,2,3, and 4 63. Which of the following is not a subjective data? a. Dizziness b. Chest pain c. Anxiety d. Bluish discoloration 64. The heat-regulating center is found in the: a. Medulla Oblongata b. Hypothalamus c. Pons d. Cerebrum 65. The following statements are true about body temperature EXCEPT: a. Core body temperature measures the temperature of deep tissues b. Highest body temperature is usually reached between 8:00 P.M. to 12:00 M.N c. Elderly people are at risk of hypothermia due to decreased thermoregulatory controls and decreased subcutaneous fats d. Sympathetic response stimulation decreases body heat production 66. The following are contraindications to oral temperature taking EXCEPT: a. Dyspnea b. Diarrhea c. Nasal-packing d. Nausea and vomiting 67. The following are correct nursing actions when taking the radial pulse EXCEPT: a. Put the palms downward b. Use the thumb to palpate the artery c. Use two to three fingertips to palpate the pulse at the inner wrist d. Assess the pulse rate, rhythm, volume and quality 68. The difference between the systolic pressure and the diastolic pressure is: a. Apical rate b. Cardiac rate c. Pulse deficit d. Pulse pressure 69. The characteristic manifestation of airway obstruction is: a. Bradypnea b. Retractions c. Noisy breathing d. Tachypnea 70. All of the following are purpose of inflammation except: a. Increase heat, thereby produce abatement of phagocytosis b. Localized tissue injury by increasing capillary permeability c. Protect the issue from injury by producing pain d. Prepare for tissue repair 71. The first manifestation of inflammation is a. Redness on the affected area b. Swelling of the affected area c. Pain, which causes guarding of the area d. Increase heat due to transient 72. An instrument used for auscultation is: a. Percussion-hammer b. Audiometer c. Stethoscope d. Sphygmomanometer 73. The best position for examining the rectum is: a. Prone b. Sims c. Knee-chest d. Lithotomy

74. Palpating the midclavicular line is the correct technique for assessing a. Baseline vital signs b. Systolic blood pressure c .Respiratory rate d. Apical pulse 75. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? a. Avoid palpation of reported "tender" areas because this may cause the patient pain. b. Quickly palpate a tender area to avoid any discomfort that the patient may experience. c. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. d. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. 76. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a. There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. b. Wash hands before and after every physical patient encounter. c. Wash hands between the examinations of each body system to prevent the spread of bacteria from one part of the body to another. d. Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. 77. During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates: a. vertigo. b. pruritus. c. tinnitus. d. cholesteatoma. 78. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchial sounds c. Borborygmy d. Ronchi 79. Which of the following is TRUE about temperature? a. Thyroxin decreases body temperature b. The highest temperature usually occurs later in a day, around 8 P.M to 12 Midnight c. Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory control and sedentary lifestyle. d. The Cerebellum is the thermoregulatory center in our body. 80. In assessing the abdomen, which of the following is the correct sequence of the physical assessment? a. Inspection, Auscultation, Percussion, Palpation b. Palpation, Inspection, Auscultation, Percussion c. Percussion, Palpation, Inspection, Auscultation d. Auscultation, Percussion, palpation, Inspection