FUNDAMENTALS OF NURSING

BOARD-SENSITIVE GRAND CLOSE-DOOR COACHING

EXPECTED AND UNEXPECTED CONCEPTS (PHASE 2)PAST BOARD EXAM 1 NLE 2021
Screened and Prepared by: PROF. MELODY JAO BAUTISTA RN,MSN
PNLE NOV 21-22,2021

SITUATION 1- While in the ward, you are assigned to clients with problems related to the gastrointestinal tract.
1. The nurse is preparing Mr. Lim for cleansing enema. When administering enema the maximum height at which the enema can
should be held from the level of the bed is:
a. 14 inches b. 10 inches c. 16 inches d. 12 inches
2. While administering the enema, Mr. Lim complains of abdominal cramps. Which of the following would be the MOST appropriate
action of the nurse?
a. clamp the tubing a few minutes till the cramps subside then continue c. stop the procedure and refer to the attending
physician
b. pull the rectal tube slowly till the cramps subside d. lower the enema can to slow down the inflow of the enema
solution
3. Following surgery Mrs. Mora developed abdominal distention. To achieve maximum effectiveness how long should the rectal tube
be left in place?
a. 5 minutes b. 15 minutes c. 30 minutes d. 50 minutes
4. For ensuring that the nasogastric tube (NGT) is in place, the nurse prepares to feed Mrs. Mora using the open system. With a 30ml
syringe, the nurse proceeds with the feeding following this sequence.
1. Hold the NGT high to prevent back flow and then clamp
2. Open clamp and raise or lower the syringe to regulate flow of formula
3. Remove the plunger of the syringe and attach to NGT
4. Fill up the syringe with feeding formula
5. Add 30 to 60 ml of water to irrigate syringe allowing it to run down the NGT
a. 2,3,4,1,5 b. 1,3,2,5,4 c. 3,4,2,5,1 d. 4,3,1,2,5
5. The nurse is to perform gastric gavage. What should be the best position of the client while the gastric tube is being inserted?
a. supine position b. high fowler’s position c. Trendelenburg’s position d. low fowler’s position
SITUATION 2- Proper Nutrition and elimination are important to health and the nurse has an important role to play in assisting
people from various age groups obtain proper information
6. Roman, 36 years old is diagnosed with peptic ulcer and asks you what food is best to add to his diet so as not to exacerbate his
symptoms. Your BEST response would be for him to take
a. leafy green vegetable dishes c. mocha, café latte and other similar drinks
b. citrus fruit juices or shakes d. milk regularly 3-4 times daily
7. You are assigned to Mrs. Dulay, a client with an order for cleansing enema. While doing the procedure, the client groans and
complains of abdominal cramping. Your MOST appropriate initial nursing action would be to:
a. reduce the flow of the fluid by clamping the enema tubing
b. instruct the client to relax, inhale and exhale slowly
c. lower the height of the enema container
d. push the rectal tube further in by 2 inches
8. An elderly client you are taking care of has fecal incontinence for 3 days now. He is able to tolerate food but has no control of his
bowel movement. He has soft watery stools and uses adult diapers. While caring for his client you will watch out closely for risk of:
a. increased abdominal cramping c. malnutrition and weight loss
b. perineal and anal skin breakdown d. falls when he tries to go the bathroom
9. Dennis, 5 years old, is brought to the hospital for severe diarrhea. You are aware that a major problem that may develop that will
adversely affect Dennis would be:
a. severe abdominal cramping c. severe fluid electrolyte imbalance
b. excessive passing of flatus d. irritation of the anal sphincter
10. Miss Reyes, a client who had abdominal surgery under general anesthesia, is still in the recovery room. You are aware that
clients who went through general anesthesia will most likely experience:
a. absence of peristalsis c. immediate return of gastrointestinal motility
b. tolerance for soft diet immediately after operation d. excessive gas formation noted upon auscultation
SITUATION- 3- Mariza, a staff nurse in the surgical ward, has been assigned to take care of Mrs. Jose a 58 year old client who has an
endotracheal tube
11. Nurse Mariza’s objective is to improve client’s respiration after she noted thickened tenacious secretions. To loosen the
secretions, the MOST appropriate nursing intervention is to:
a. instill mucomyst into the endotracheal tube and frequently turn client unless contraindicated
b. administer humidified oxygen and place in side lying or prone position unless contraindicated
c. increase fluid intake and ask client to do deep breathing and coughing exercises
d. Assess client’s respiratory status and perform clapping to loosen secretions.
 12. Nurse Mariza performs endotracheal suctioning. The nurse appropriately does the suctioning procedure when she perform
which of the following:
a. rotates the catheter gently and suctions for not more than 10 seconds each time
b. observes and records the amount and character of the secretions after each suctioning
c. assesses the respiratory and circulatory status after cluster of 5-8 times suctioning
d. observes how long the client tolerates the catheter during the suctioning process
13. In the care of this client the nurse monitors the cuff pressure and takes care to reduce the risk of tracheal issue necrosis by
maintaining the cuff pressure to
a. 30-35mm Hg b. 10-15mm Hg c. 40-45mm Hg d. 20-25mm Hg
14. When taking care of Mrs. Jose Mariza preforms oral and nasal care every 2 to 4 hours to promote hygiene and comfort. As a
precautionary measure for possible biting down of the oral endotracheal tube the nurse should:
a. request an assistant to hold the patient down c. provide humidified air prior to the procedure
b. use an oropharyngeal airway d. place the client on side lying position
15. The head nurse reminds Nurse Mariza about measures that must be strictly observed when sanctioning the client through the
endotracheal tube. This measure is:
a. turning on the suctioning apparatus during catheter insertion
b. always use rubber gloves when suctioning to prevent infection
c. suction by rotating 2 to 3 times before withdrawing the catheter
d. hyper oxygenating the client before and after the procedure
SITUATION 4- Client record is a structured device where all tasks concerning the diagnostic and treatment process done on the client
are documented. An account of what has occurred between the client or the health care team has to be recorded once interaction
has been undertaken.
16. An entry in the nurse notes for a client with urinary tract infection states: “Encouraged fluid intake to 2,500 ml per day” Which
description of the nurse’s statements applies?
a. it describes the amount of fluid intake desired c. it is incorrect as it lack’s accuracy of measurement
b. it establishes accuracy using an exact measurement d. it does not specify fluids allowed
17. The nurse is recording the treatments administered to her clients. The following information should be included in her charting,
EXCEPT:
a. health teaching c. time administered
b. client’s response compared to previous treatment d. equipment used
18. A male nurse is giving a change of shift report for all clients in the medical unit at the nurse’s station. During this reporting the
nurse is expected to:
a. review the condition of the client by reading the documented information
b. report the condition of the client and compare with what the incoming staff need to know
c. provide significant information about the client as baseline for the next shift
d. read the data about the client objectivity
19. The nurse is preparing Mr. Nick Gomez for transfer from the Intensive Care Unit to his private room. To promote continuity of
care what information should be included in the transfer report?
1. Clients name age, physical and medical diagnosis and allergies
2. Correct health status of the client at the time of transfer
3. Any critical observation and intervention to help the receiving nurse
4. need for special treatment
a. 1 and 2 b. 3 and 4 c. 1,2,3 and 4 d. 1,2, and 4
20. Mr. Douglas Nava, a 55 year old executive, request the nurse if he can read his medical records upon discharge. What is the MOST
appropriate action of the nurse?
a. allow the client to read his chart because of his client’s right c. ask the client to write a written request
b. tell the client that he is not allowed to read his chart d. refer the request of the client to the physician
SITUATION 5- You are caring for a client who is with nasogastric tube (NGT) for feeding.
21. When assessing for the NGT placement, which three methods are often recommended?
1. Measurement of exposed tube length 3. Auscultation method after air injection
2. Visual assessment of aspirate 4. pH measurement of aspirate
a. 2,3 and 4 b. All except 2 c. 1,2,and 3 d.1,2,and 4
22. It is important to maintain patency of the nasogastric tube. The tube is irrigated every 4 to 6 hours. Which solution would you use?
a. Tap water c. Normal saline
b. Bottled water d. Lactated ringer’s
23. When giving tube feedings and medications, which position of the client will reduce risk of reflux and pulmonary aspiration?
a. Supine position with one pillow supporting the head
b. Semi-Fowler’s position with head elevated from 30-450
c. Supine position with the head turned to one side
d. Dorsal recumbent
24. When giving single compressed tablet medication by NGT, it should be crushed and dissolved in water. How would the nurse
APPROPRIATELY administer enteric-coated tablet?
a. Let the client swallow the tablet as is
b. Pulverize the tablet finely to change the tablet form
c. Request the pharmacist to change the tablet form
d. Crush and dissolve in distilled water
25. Diarrhea is a one of the most common complications of tube feeding. Which of the following nursing actions will prevent this
complication?
a. Administer feeding by continuous drip rather than bolus
b. Dilute formula to half the concentration strength
 c. Give high fiber formula
d. Instill liberal amounts of water to flush the tubing before and after feeding
SITUATION 6- Indicators are essential in the measurement and monitoring of quality health care. The nurse plays a key role in the
consistent implementation of standards of care in any unit in the hospital. The following questions apply.
26. You admitted Laura, a 26 year old mother, from Emergency Room for emergency appendectomy. Which of the following will you use
PROPERLY identify the client?
a. Request the client to state her name and the complete name of her physician
b. Ask the client to state her name and birthday
c. Ask the companion to state the client’s name and address
d. Read the name of the client from the chart and name tag
27. You are to do the initial assessment. Which STANDARD PRECAUTION guidelines should be observed?
a. Greet the client by her first name c. Observe hand hygiene
b. Introduce yourself d. Drape the client appropriately
28. It is medication time. The nurse is aware that distraction during any phase of drug administration can cause errors. Select which
strategy can give MOST protection while preparing the medication?
a. Don a medication vest with visible warning. “don’t disturb”
b. Put your cell phone on silent mode
c. Inform your co-staff that you are going to prepare medications for your clients
d. Prepare medication at the bedside
29. Upon entry to the opening room, the client was properly identified. Correct site and procedure shall likewise be identified by which
of the following?
a. Noting proper markings and endorsement
b. Allowing the client and reading the chart
c. Asking the client and reading the chart
d. Verifying from the OR schedule and patient’s chart
30. Personal protective Equipment (PPE) like the face mask when worn correctly offers maximum protection against transmission of
droplets. Below are descriptions of how a mask is worn. Which statement describes a CORRECTLY WORN MASK?
a. With the two loops on either side of the mask, anchor it to both ears and adjust to cover the nose and the mouth
b. Place the mask to cover the nose and mouth with two ties tied at the back of the head
c. The mask is placed to cover the nose and mouth with the four sides snugly fitting against the skin and with the two pairs of
ties separately at the back of the head
d. The mask is placed to cover the nose, ear and mouth tied at the back of the head
SITUATION 7- Maricar, a staff nurse assigned in the medical ward reports during morning shift. All the clients assigned to Maricar have
ongoing intravenous therapy. To ensure safe and quality nursing care, Maricar implements policies, procedures and guidelines set by
the hospital regarding intravenous therapy.
31. At 1000H the attending physician prescribed for a client who is on her 2nd day post hemicolectomy, “Dextrose in water 1000ml with
20mEq potassium chloride to run for 8 hours. “If the intravenous therapy was started at 1100H, how many ml of intravenous solution
will Maricar anticipate to have been infused when she hands off her client to the incoming shift nurse at 1400H.?
a. 375 ml b. 350 ml c. 300 ml d. 320 ml
32. After incorporating 20 mEq potassium chloride into Dextrose 5% water 1000 ml bag, the nurse AVOIDS doing which of the following
nursing interventions?
a. Shake the IV bag
b. Place calibration label on the IV bag
c. With a pen maker, label the IV bag with the incorporated drug
d. Check for color changes in the IV bag
33. When Maricar checked on the intravenous infusion of one of her clients, she noted a label attached to the intravenous tubing with
the date 6/23/20. She understands that the intravenous set will be changed on:
a. 6/25/20 b. 6/24/20 c. 6/27/20 d. 6/26/20
34. The client with ongoing intravenous infusion of Dextrose 5% lactated ringer’s solution rings the call bell and when the nurse
approached her, she pointed to her intravenous (IV) site. When the nurse assessed the IV site she noted that phlebitis has developed.
The nurse does the following nursing interventions EXCEPT:
a. Restart an IV line in a proximal portion of the same arm
b. Reinstruct the clients what not to do while with IV infusion
c. Applies colds mist compress over the IV site
d. Elevate the affected arm on a pillow
35. An elderly client with ongoing IV infusion of dextrose 5% in NaCl 0.9% 1000 ml hung at 1545H was assessed to be slightly dyspneic,
chilling and with increased pulse rate. The IV bag has 400 ml remaining and it was 1630H. The nurse should take which IMMEDIATE
nursing action?
a. Refer to the attending physician STAT c. Slow down the IV infusion
b. Remove the IV cannula d. Put the client in a sitting position
SITUATION 8- Nurse Linda is assigned to the pediatric surgical unit to take care of JV and Billy.
36. JV, 18 months, was admitted for repair of hypospadias. During assessment, which of the following will Linda expect to observe?
a. Absence of urethral meatus
b. Termination of urethra is in the ventral surface of the penis
c. Defect of the urethra on the dorsal surface of the penis shaft
d. Penis has 2 urethral opening located dorsally and ventrally
37. Surgery is the treatment of choice for JV. The nurse understands that the best time for surgery is before the child:
a. Is weaned from diapers b. Is toilet training c. Goes to school d. Walks
38. Linda prepares a nursing care plan for JV. Postoperatively, which of the following is a PRIORITY nursing diagnosis?
a. Risk of infection c. Potential malnutrition
b. Alteration of fecal elimination d. Altered body image
39. Billy, 1 year old, was admitted to the unit from the recovery room post cheiloplasty. Linda would place Billy in which of the following
positions?
a. Lateral b. Fowler’s c. Supine d. Prone
40. When Billy fully recovered from anesthesia the doctor ordered clear liquids as tolerated. Which of the following is the APPROPRIATE
action of the nurse?
a. Allow infant to sip from a cup
b. Use spoon and feed slowly and gently
c. Administer liquids through a medicine dropper
d. Bottle feed the infant
SITUATION 9- Nurse Alpha is caring for Edwin, 40 year old 3rd day post bowel resection, NPO with D5 LR IV 1000 ml at 125 ml/hr.
Laboratory findings show a hemoglobin level of 8 g/dl and hematocrit of 30%.
41. During the physician’s rounds, Dr. Grande made the following orders:
-Gentamycin 80mg IV piggy back in 50 ml D5 water over 30 minutes -Ranitidine 50mg IV in 50 ml D5 water piggy back in 30minutes
- Packed Red blood cells (RBC) 250 ml to run for 3 hours
How many milliliters should Nurse Alpha document as the total intake for the 8 hours shift?
a. 1000 ml b. 350 ml c. 1350 ml d. 1300 ml
42. While reading Edwin’s chart, you are read the laboratory findings as:
-serum potassium 2.2h mEq/L -Sodium 129 mEq/L -Calcium 7.5 mg/L
The nurse would anticipate / prepare which of the following IV solutions to be prescribed?
a. Sodium chloride 0.45% c. Dextrose 5% in lactated ringers solution
b. Dextrose 5% in water d. Normosol
43. Nurse Alpha continued to monitor Edwin who has an ongoing IV and Packed red blood cells (PRBC) transfusion. The client complains
of headache, back ache and the temperature began to spike. Rank the action of the nurse according to PRIORITY:
1. Refer to the attending physician 4. Keep the vein open with NSS
2. Assess the client 5. Document observation and intervention
3. Close the roller clamp of the PRBC
a. 2,3,4,1 and 5 b. 3,2,1,4 and 5 c. 3,4,2,1 and 5 d. 1,2,34 and 5
44. Nurse Alpha identifies risk for wound complications. In case of wound evisceration, the IMMEDIATE action of the nurse is to:
a. Instruct the client to stay quiet in bed as you call for help c. Cover the wound with sterile gauze wet with sterile NSS
b. Apply clean abdominal binder and place the pillow on top d. Call for the surgeon stat
of the wound
45. Edwin has been on NPO since he was operated and asks the nurse when he can have food. Nurse Alpha’s most APPROPRIATE
response is:
a. The dietitian will make their rounds in a while to assess you and other postoperative clients
b. The surgeon will make their rounds to assess your readiness to take in your preferred diet
c. Clear soup will be served as soon as you have bowel sounds
d. You can have sips of water for the mean time
SITUATION 10- Kiko, 8 years old has two chest tubes connected to a disposable water sealed drainage system because of chest injuries
from a vehicular accident.
46. The nurse observed that the drainage from the chest tubes have not increased from the previous shift report. Which of the following
is the PRIORITY action of the nurse?

a. Check the chest tube for kinks c. Document observation

b. Assess for breath sounds d. Change position of the patient
47. Frequent assessment of the closed drainage system is important to ensure appropriate functioning. The nurse observes that the
water level fluctuates with respiratory effort. The nurse consider this as sign of:
a. Trapped air b. An inefficient system c. Patent tubes d. Air leaks
48. The nurse works with a nursing aide. Which of the following is a CORRECT action of the nurse? The nurse directed the nursing aide
to:
a. Always check that clamp is available at the bedside
b. Observe regularly the amount and color of drainage from chest tubes
c. Report signs of patient’s discomforts at the site of the chest tubes
d. Turn the patient regularly and maintain connections of the tubes
49. While the nurse was turning the patient during bed bath, one of the chest tubes was pulled out from its site. Which of the following
will the nurse do FIRST?
a. Reinsert the chest tube c. Cover wound site occlusively
b. Disconnect chest tube from drainage system d. Clamp the chest tube
50. To determine if chest tube are in place and pneumothorax is corrected which of the following will the nurse expect the physician to
order?
a. Tidal volume measurement
b. Arterial blood gas analysis
c. Chest radiograph
d. Thoracentesis