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A. Vaginal instillation of conjugated estrogenB. Urinary catheterization
PNLE I for Foundation of Nursing C.
D.
Nasogastric tube insertion
Colostomy irrigation
1. Which element in the circular chain of infection can be
eliminated by preserving skin integrity? Answer: B. The urinary system is normally free of
microorganisms except at the urinary meatus. Any procedure
A. Host that involves entering this system must use surgically aseptic
B. Reservoir measures to maintain a bacteria-free state
C. Mode of transmission
D. Portal of entry 7. Sterile technique is used whenever:
Answer: D. In the circular chain of infection, pathogens must A. Strict isolation is required
be able to leave their reservoir and be transmitted to a B. Terminal disinfection is performed
susceptible host through a portal of entry, such as broken skin. C. Invasive procedures are performed
D. Protective isolation is necessary
2. Which of the following will probably result in a break in
sterile technique for respiratory isolation? Answer: C. All invasive procedures, including surgery,
catheter insertion, and administration of parenteral therapy,
A. Opening the patient’s window to the outside require sterile technique to maintain a sterile environment.
environment All equipment must be sterile, and the nurse and
B. Turning on the patient’s room ventilator the physician must wear sterile gloves and maintain surgical
C. Opening the door of the patient’s room leading into asepsis. In the operating room, the nurse and physician are
the hospital corridor required to wear sterile gowns, gloves, masks, hair covers,
D. Failing to wear gloves when administering a bed bath and shoe covers for all invasive procedures. Strict isolation
requires the use of clean gloves, masks, gowns and
Answer: C. Respiratory isolation, like strict isolation, equipment to prevent the transmission of highly
requires that the door to the door patient’s room remain communicable diseases by contact or by airborne routes.
closed. However, the patient’s room should be well Terminal disinfection is the disinfection of all contaminated
ventilated, so opening the window or turning on the supplies and equipment after a patient has been discharged to
ventricular is desirable. The nurse does not need to wear prepare them for reuse by another patient. The purpose of
gloves for respiratory isolation, but good hand washing is protective (reverse) isolation is to prevent a person
important for all types of isolation with seriously impaired resistance from coming into contact
who potentially pathogenic organisms.
3. Which of the following patients is at greater risk for
contracting an infection? 8. Which of the following constitutes a break in sterile
technique while preparing a sterile field for a dressing change?
A. A patient with leukopenia
B. A patient receiving broad-spectrum antibiotics A. Using sterile forceps, rather than sterile gloves, to handle
C. A postoperative patient who has undergone orthopedic a sterile item
surgery B. Touching the outside wrapper of sterilized material
D. A newly diagnosed diabetic patient without sterile gloves
C. Placing a sterile object on the edge of the sterile field
Answer: A. Leukopenia is a decreased number of leukocytes D. Pouring out a small amount of solution (15 to 30 ml)
(white blood cells), which are important in resisting infection. before pouring the solution into a sterile container
None of the other situations would put the patient at risk for
contracting an infection; taking broadspectrum antibiotics Answer: C. The edges of a sterile field are considered
might actually reduce the infection risk. contaminated. When sterile items are allowed to come in
contact with the edges of the field, the sterile items also
4. Effective hand washing requires the use of: become contaminated
A. Soap or detergent to promote emulsification
9. A natural body defense that plays an active role in
B. Hot water to destroy bacteria
C. A disinfectant to increase surface tension preventing infection is:
D. All of the above A. Yawning
B. Body hair
Answer: A. Soaps and detergents are used to help remove C. Hiccupping
bacteria because of their ability to lower the surface tension D. Rapid eye movements
of water and act as emulsifying agents. Hot water may lead to
skin irritation or burns Answer: B. Hair on or within body areas, such as the nose,
5. After routine patient contact, hand washing should last at traps and holds particles that contain microorganisms.
least: Yawning and hiccupping do not prevent microorganisms
from entering or leaving the body. Rapid eye movement
A. 30 seconds
marks the stage of sleep during which dreaming occurs.
B. 1 minute
C. 2 minute
10. All of the following statement are true about donning
D. 3 minutes
sterile gloves except:
Answer: A. Depending on the degree of exposure to A. The first glove should be picked up by grasping the
pathogens, hand washing may last from 10 seconds to 4 inside of the cuff.
minutes. After routine patient contact, hand washing for 30
, D. The inside of the glove is considered sterile
Answer: D. The inside of the glove is always considered to Answer: A. Platelets are disk-shaped cells that are essential for
be clean, but not sterile. blood coagulation. A platelet count determines the number of
thrombocytes in blood available for promoting hemostasis and
11.When removing a contaminated gown, the nurse should be assisting with blood coagulation after injury. It also is used to
careful that the first thing she touches is the: evaluate the patient’s potential for bleeding; however, this is
not its primary purpose. The normal count ranges from
A. Waist tie and neck tie at the back of the gown 150,000 to 350,000/mm3. A count of 100,000/mm3 or less
B. Waist tie in front of the gown indicates a potential for bleeding; count of less than
C. Cuffs of the gown 20,000/mm3 is associated with spontaneous bleeding.
D. Inside of the gown
16.Which of the following white blood cell (WBC) counts
Answer: A. The back of the gown is considered clean, the clearly indicates leukocytosis?
front is contaminated. So, after removing gloves and washing
hands, the nurse should untie the back of the gown; slowly A. 4,500/mm³
move backward away from the gown, holding the inside of B. 7,000/mm³
the gown and keeping the edges off the floor; turn and fold C. 10,000/mm³
the gown inside out; discard it in a contaminated linen D. 25,000/mm³
container; then wash her hands again.
Answer: D. Leukocytosis is any transient increase in the
12.Which of the following nursing interventions is considered number of white blood cells (leukocytes) in the blood. Normal
the most effective form or universal precautions? WBC counts range from 5,000 to 100,000/mm3. Thus, a count
of 25,000/mm3 indicates leukocytosis
A. Cap all used needles before removing them from their
syringes 17. After 5 days of diuretic therapy with 20mg of furosemide
B. Discard all used uncapped needles and syringes in (Lasix) daily, a patient begins to exhibit fatigue, muscle
an impenetrable protective container cramping and muscle weakness. These symptoms probably
C. Wear gloves when administering IM injections indicate that the patient is experiencing:
D. Follow enteric precautions
A. Hypokalemia
Answer: B. According to the Centers for Disease Control B. Hyperkalemia
(CDC), blood-to-blood contact occurs most commonly when C. Anorexia
a health care worker attempts to cap a used needle. Therefore, D. Dysphagia
used needles should never be recapped; instead they should
be inserted in a specially designed puncture resistant, labeled Answer: A. Fatigue, muscle cramping, and muscle weaknesses
container. Wearing gloves is not always necessary are symptoms of hypokalemia (an inadequate potassium level),
when administering an I.M. injection. Enteric precautions which is a potential side effect of diuretic therapy. The
prevent the transfer of pathogens via feces. physician usually orders supplemental potassium to prevent
hypokalemia in patients receiving diuretics. Anorexia is
13.All of the following measures are recommended to prevent another symptom of hypokalemia. Dysphagia means
pressure ulcers except: difficulty swallowing.
A. Massaging the reddened are with lotion 18.Which of the following statements about chest X-ray is
B. Using a water or air mattress false?
C. Adhering to a schedule for positioning and turning
D. Providing meticulous skin care A. No contradictions exist for this test
B. Before the procedure, the patient should remove all
Answer: A. Nurses and other health care professionals jewelry, metallic objects, and buttons above the waist
previously believed that massaging a reddened area with C. A signed consent is not required
lotion would promote venous return and reduce edema to the D. Eating, drinking, and medications are allowed before this
area. However, research has shown that massage only test
increases the likelihood of cellular ischemia and necrosis to
the area Answer: A. Pregnancy or suspected pregnancy is the only
14.Which of the following blood tests should be performed contraindication for a chest X-ray. However, if a chest X-ray
before a blood transfusion? is necessary, the patient can wear a lead apron to protect the
pelvic region from radiation. Jewelry, metallic objects, and
A. Prothrombin and coagulation time buttons would interfere with the X-ray and thus should not
B. Blood typing and cross-matching be worn above the waist. A signed consent is not required
C. Bleeding and clotting time because a chest X-ray is not an invasive examination. Eating,
D. Complete blood count (CBC) and electrolyte levels. drinking and medications are allowed because the X-ray is of
Answer: B. Before a blood transfusion is performed, the the chest, not the abdominal region.
blood of the donor and recipient must be checked for
compatibility. This is done by blood typing (a test that 19.The most appropriate time for the nurse to obtain a sputum
determines a person’s blood type) and cross-matching specimen for culture is:
(a procedure that determines the compatibility of the donor’s
and recipient’s blood after the blood types has been matched). A. Early in the morning
If the blood specimens are incompatible, hemolysis and B. After the patient eats a light breakfast
antigen-antibody reactions will occur C. After aerosol therapy
D. After chest physiotherapy
15.The primary purpose of a platelet count is to evaluate the:
,20.A patient with no known allergies is to receive penicillin A. 18G, 1 ½” long
every 6 hours. When administering the medication, the nurse B. 22G, 1” long
observes a fine rash on the C. 22G, 1 ½” long
D. 25G, 5/8” long
patient’s skin. The most appropriate nursing action would be
to: Answer: D. A 25G, 5/8” needle is the recommended size for
insulin injection because insulin is administered by the
A. Withhold the moderation and notify the physician subcutaneous route. An 18G, 1 ½” needle is usually used for
B. Administer the medication and notify the physician I.M. injections in children, typically in the vastus lateralis. A
C. Administer the medication with an antihistamine 22G, 1 ½” needle is usually used for adult I.M. injections,
D. Apply corn starch soaks to the rash which are typically administered in the vastus lateralis or
ventrogluteal site.
Answer: A. Initial sensitivity to penicillin is commonly
manifested by a skin rash, even in individuals who have not 25.The appropriate needle gauge for intradermal injection is:
been allergic to it previously. Because of the danger of
anaphylactic shock, he nurse should withhold the drug A. 20G
and notify the physician, who may choose to substitute B. 22G
another drug. Administering an antihistamine is a dependent C. 25G
nursing intervention that requires a written physician’s order. D. 26G
Although applying corn starch to the rash may relieve
discomfort, it is not the nurse’s top priority in such Answer: D. Because an intradermal injection does not
a potentially life-threatening situation. penetrate deeply into the skin, a small-bore 25G needle is
recommended. This type of injection is used primarily to
21.All of the following nursing interventions are correct when administer antigens to evaluate reactions for allergy
using the Ztrack method of drug injection except: or sensitivity studies. A 20G needle is usually used for I.M.
injections of oilbased medications; a 22G needle for I.M.
A. Prepare the injection site with alcohol injections; and a 25G needle, for I.M. injections; and a 25G
B. Use a needle that’s a least 1” long needle, for subcutaneous insulin injections.
C. Aspirate for blood before injection
D. Rub the site vigorously after the injection to promote 26.Parenteral penicillin can be administered as an:
absorption
A. IM injection or an IV solution
Answer: D. The Z-track method is an I.M. injection B. IV or an intradermal injection
technique in which the patient’s skin is pulled in such a way C. Intradermal or subcutaneous injection
that the needle track is sealed off after the injection. This D. IM or a subcutaneous injection
procedure seals medication deep into the muscle,
thereby minimizing skin staining and irritation. Rubbing the Answer: A. Parenteral penicillin can be administered I.M. or
injection site is contraindicated because it may cause the added to a solution and given I.V. It cannot be administered
medication to extravasate into the skin subcutaneously or intradermally.
22.The correct method for determining the vastus lateralis site 27.The physician orders gr 10 of aspirin for a patient. The
for I.M. injection is to: equivalent dose in milligrams is:
A. Locate the upper aspect of the upper outer quadrant of A. 0.6 mg
the buttock about 5 to 8 cm below the iliac crest B. 10 mg
B. Palpate the lower edge of the acromion process and the C. 60 mg
midpoint lateral aspect of the arm D. 600 mg
C. Palpate a 1” circular area anterior to the umbilicus
D. Divide the area between the greater femoral trochanter Answer: D. gr 10 x 60mg/gr 1 = 600 mg
and the lateral femoral condyle into thirds, and select the
middle third on the anterior of the thigh 28.The physician orders an IV solution of dextrose 5% in
water at 100ml/hour. What would the flow rate be if the drop
Answer: D. The vastus lateralis, a long, thick muscle that factor is 15 gtt = 1 ml?
extends the full length of the thigh, is viewed by many
clinicians as the site of choice for I.M. injections because it A. 5 gtt/minute
has relatively few major nerves and blood vessels. The middle B. 13 gtt/minute
third of the muscle is recommended as the injection site. C. 25 gtt/minute
The patient can be in a supine or sitting position for an D. 50 gtt/minute
injection into this site.
Answer: C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
23.The mid-deltoid injection site is seldom used for I.M. 29.Which of the following is a sign or symptom of a
injections because it: hemolytic reaction to blood transfusion?
A. Can accommodate only 1 ml or less of medication A. Hemoglobinuria
B. Bruises too easily B. Chest pain
C. Can be used only when the patient is lying down C. Urticaria
D. Does not readily parenteral medication D. Distended neck veins
Answer: A. The mid-deltoid injection site can accommodate Answer: A. Hemoglobinuria, the abnormal presence of
hemoglobin in the urine, indicates a hemolytic reaction
, occurs more rapidly in ABO incompatibilities than in Rh
incompatibilities. Chest pain and urticaria may be symptoms Answer: D. A drug-allergy is an adverse reaction resulting
of impending anaphylaxis. Distended neck veins are from an immunologic response following a previous
an indication of hypervolemia. sensitizing exposure to the drug. The reaction can range from
a rash or hives to anaphylactic shock. Tolerance to a drug
30.Which of the following conditions may require fluid means that the patient experiences a decreasing
restriction? physiologic response to repeated administration of the drug in
the same dosage. Idiosyncrasy is an individual’s unique
A. Fever hypersensitivity to a drug, food, or other substance; it appears
B. Chronic Obstructive Pulmonary Disease to be genetically determined. Synergism, is a drug interaction
C. Renal Failure in which the sum of the drug’s combined effects is
D. Dehydration greater than that of their separate effects.
Answer: C. In real failure, the kidney loses their ability to 35.A patient has returned to his room after femoral
effectively eliminate wastes and fluids. Because of this, arteriography. All of the following are appropriate nursing
limiting the patient’s intake of oral and I.V. fluids may be interventions except:
necessary. Fever, chronic obstructive pulmonary disease, and
dehydration are conditions for which fluids should A. Assess femoral, popliteal, and pedal pulses every 15
be encouraged. minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
31.All of the following are common signs and symptoms of C. Assess a vital signs every 15 minutes for 2 hours
phlebitis except: D. Order a hemoglobin and hematocrit count 1 hour
after the arteriography
A. Pain or discomfort at the IV insertion site
B. Edema and warmth at the IV insertion site Answer: D. A hemoglobin and hematocrit count would be
C. A red streak exiting the IV insertion site ordered by the physician if bleeding were suspected. The other
D. Frank bleeding at the insertion site answers are appropriate nursing interventions for a patient
who has undergone femoral arteriography.
Answer: D. Phlebitis, the inflammation of a vein, can be
caused by chemical irritants (I.V. solutions or medications),
mechanical irritants (the needle or catheter used during 36.The nurse explains to a patient that a cough:
venipuncture or cannulation), or a localized allergic reaction to
the needle or catheter. Signs and symptoms of A. Is a protective response to clear the respiratory tract
phlebitis include pain or discomfort, edema and heat at the I.V. of irritants
insertion site, and a red streak going up the arm or leg from B. Is primarily a voluntary action
the I.V. insertion site. C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
32.The best way of determining whether a patient has learned Answer: A. Coughing, a protective response that clears the
to instill ear medication properly is for the nurse to: respiratory tract of irritants, usually is involuntary; however
it can be voluntary, as when a patient is taught to perform
A. Ask the patient if he/she has used ear drops before coughing exercises. An antitussive drug inhibits coughing.
B. Have the patient repeat the nurse’s instructions using her Splinting the abdomen supports the abdominal muscles when
own words a patient coughs
C. Demonstrate the procedure to the patient and encourage
to ask questions
D. Ask the patient to demonstrate the procedure 37.An infected patient has chills and begins shivering. The
best nursing intervention is to:
Answer: D. Return demonstration provides the most certain
evidence for evaluating the effectiveness of patient teaching. A. Apply iced alcohol sponges
B. Provide increased cool liquids
33.Which of the following types of medications can be C. Provide additional bedclothes
administered via gastrostomy tube? D. Provide increased ventilation
A. Any oral medications Answer: C. In an infected patient, shivering results from the
B. Capsules whole contents are dissolve in water body’s attempt to increase heat production and the production
C. Enteric-coated tablets that are thoroughly dissolved in of neutrophils and phagocytotic action through increased
water skeletal muscle tension and contractions. Initial
D. Most tablets designed for oral use, except for vasoconstriction may cause skin to feel cold to the touch.
extended-duration compounds Applying additional bed clothes helps to equalize the
body temperature and stop the chills. Attempts to cool the
Answer: D. Capsules, enteric-coated tablets, and most body result in further shivering, increased metabloism, and
extended duration or sustained release products should not be thus increased heat production.
dissolved for use in a gastrostomy tube. They are
pharmaceutically manufactured in these forms for valid 38.A clinical nurse specialist is a nurse who has:
reasons, and altering them destroys their purpose. The
nurse should seek an alternate physician’s order when an A. Been certified by the National League for Nursing
ordered medication is inappropriate for delivery by tube. B. Received credentials from the Philippine Nurses’
Association
34.A patient who develops hives after receiving an antibiotic C. Graduated from an associate degree program and is a
is exhibiting drug: registered professional nurse
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