d.

Weigh all the urine saturated pads together and

use a conversion calibration to calculate the urine
Subject: NLOA
output
Date: September 25, 2021
Lecturer: Ma’am Leny, Sir Jethro, Sir Abang Calculating the difference between a dry pad and a
saturated pad will provide an accurate calculation of the
Prelims Rationalization
urine output.
1. The most common vitamin deficiency seen in alcoholics
5. To assess the kidney function of a patient with an
is:
indwelling urinary catheter, the nurse measures his
a. Thiamine
hourly urine output. She should notify the physician if
b. Riboflavin
the UO is:
c. Pyridoxine
a. Less than 30 ml/hr
d. Pantothenic acid
b. 64 mL in 2 hours
Chronic alcoholism results in thiamine deficiency and c. 90 mL in 3 hours
other symptoms of malnutrition. One factor underlying d. 125 mL in 4 hours
alcohol-induced brain damage.
Indicates hypovolemia or oliguria and is indicative of
2. Which of the following is incorrect about a patient with kidney function. May be due to infection, obstruction, or
dysphagia? drugs.
a. The patient will find pureed or soft foods such as
6. A manual method of promoting urine elimination is:
custards, easier to swallow than water
a. Encouraging fluid intake
b. Fowler’s or semi-fowler’s position reduces the risk of
b. Compressing over the suprapubic area.
aspiration during swallow
c. Administering bethanecol chloride (Urecholine)
c. The patient should always feed himself d. Inserting an indwelling urinary (Foley) catheter
d. The nurse should perform oral hygiene before
assisting with feeding Can expel urine from the bladder. Other choices are not
manual methods.
Patients with this condition are at risk for aspiration.
7. Situation: Mr. K enters the ER in HPN crisis. Indications
for TPN include all of the following except:
3. A caloric count involves:
a. Hypertensive crisis
a. Recording all food and fluid consumed by a patient
b. Obstruction of the GI tract
in 24 hours
c. Malnutrition
b. Asking the patient if he has had any food or fluids
d. Hypermetabolism or catabolism
other than those on the meal tray
c. Having the dietitian calculate the amount of calories HPN crisis is not an indication for TPN. It is used when
consumed the GIT is totally not available for use.
d. All of the above.
8. All of the ff. patient situations suggest a need for TPN
Helps determine how much food, fluids, and calories a except:
patient consumes in 24 hours. a. Esophageal cancer
b. Enterocutaneous inflammatory bowel disease
4. An accurate method of calculating the daily urine
c. Lack of oral nutrition for 5 days or longer
output of an incontinent patient wearing pads or
d. Loss of 5% usual body weight over 2 months
diapers is to:
a. Estimate the urine output
It must be that loss of 7% or more of usual body weight
b. Count the number of urine-saturated pads
over 2 months so that the patient should be placed in
c. Weigh a dry pad and each urine saturated pad and
TPN.
use a conversion calibration to calculate the urine
output. 9. Mr. K is taken off TPN and progresses to a liquid diet.
Which of the ff. meals is an example of a bland, full-
liquid diet?

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 a. Orange juice, cooked farina, coffee, and 4 oz of milk 14. Situation: Mr. P is admitted with a Dx of UTI. Which of
b. Apple juice, cream of broccoli soup, 1 cup of vanilla the ff. would be a top priority interdependent nursing
ice cream, gelatin, and 4 oz of milk intervention based on a physician’s order:
c. Pineapple juice, a bran muffin, cooked oatmeal, and a. Change the patient’s position, and have him exercise
4 oz of milk b. Administer saline enema
d. Orange juice cream of cauliflower soup, custard, and c. Provide the patient with a high fiber diet
tea d. Limit the patient’s fluid intake to 800 mL/day

No gastric irritants are included in a full liquid diet. Food It is normal for normal bowel elimination. Positioning
which turn to liquid at room temperature. and exercising are nursing functions would improve
peristalsis but not an interdependent intervention.
10. Later, Mr. K progresses to a soft diet. Which of the ff.
meals is an example of a soft diet? 15. The best position for administering a cleansing enema
a. Broth, lean tender veal, two slices of refined white to facilitate evacuation is:
bread, 1 cup of asparagus, sweet potatoes, one part a. Semi-fowler’s
of margarine, gelatin, and coffee b. Left lateral Sims
b. Two pieces of fried chicken, mashed potatoes, c. Supine
carrots, peas, ½ cup of ice cream, and 8 oz of skim d. Knee-chest
milk This position helps the solution flow by gravity into the
c. A hamburger, French fried potatoes, mixed salad, sigmoid colon.
custard, and cola 16. Inspection of Mr. P’s enema results reveal a blackish
green stool. This can indicate:
Highly seasoned foods are not allowed. a. Upper GI bleeding
b. Impending constipation
11. Mr. K is placed on a sodium-free diet due to his HPN. An
c. Medication Effect
example of a sodium-free meal is:
a. Sodium-free soup, 3 oz of baked chicken, plain d. Bile obstruction
potatoes, plain string beans, a salad with oil and
Medication effect. Many medications and food color
vinegar, a roll with margarine, one small apple, and
stool blackish green.
coffee
b. Split-pea soup, a ham sandwich, potato chips, 4oz of 17. Mr. P develops a dysrhythmia while defecating after
milk gelatin, and decaffeinated coffee receiving an enema. This can be explained by:
c. Bouillon, 3 oz of turkey, sweet potatoes, beets, two a. Anxiety over the procedure
slices of white break with margarine, and custard b. Vagal nerve stimulation
d. Cheese omelet, orange juice, sodium-free roll with c. Fluid and electrolyte imbalance
margarine, gelatin, and tea d. Use of Valsalva’s maneuver Straining.

12. Mr. K is on furosemide therapy. His physician tells him 18. A hypertonic solution enema is prescribed for Mr. P.
to increase his intake of potassium-rich food. All of the The rationale for using this type of solution is to:
ff. contain potassium except: a. Decrease peristalsis
a. Apples b. Relax the anal sphincter
c. Draw fluid from the circulation into the bowel
All the other choices contain potassium.
d. Draw fluid from the mucous membrane into the
13. Additional vit. C is required during all of the ff. periods bowel
except:
19. A hypertonic solution enema is contraindicated for a
a. Infancy
patient who is:
b. Young adulthood
a. Malnourished
c. Childhood
b. Remove the restraint
d. Pregnancy
c. Febrile
Additional vit. C is needed in growth periods. d. Recovering from an appendectomy

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 (Dehydration) b. Contact precaution
c. Droplet precaution
20. A cleansing enema acts primarily by: d. Standard precaution
a. Removing fluid from the circulation to the bowel
b. Distending the colon and stimulating peristalsis Once you have completed the 1st 2 weeks of regimen,
through colon irritation, leading to evacuation you are already noninfectious.
c. Cleansing the transverse colon
d. Expelling flatus 26. A 20-y.o. patient is admitted with TBHIV. As a nurse you
know that the patient must be placed in:
21. A patient learns that he has a MDRO. What is the best a. Isolation Precaution
response coming from the nurse about MDRO? b. Reverse Isolation
a. The patient will need more than one type of c. Airborne Precaution
antibiotic to kill the organism d. Droplet Precaution
b. The organism has developed a resistance to one or
more broad spectrum antibiotics, indicating that The patient with HIV has a weakened immune system.
the organism will be hard to treat effectively.
27. A patient is scheduled for operation d/t extra PTB in the
c. There are no longer any antibiotic options available
spinal cord. You know that the patient after the
to treat the patient’s infection
operation must be placed in?
d. There are more than one organism in the wound a. Recovery room
causing the infection b. Isolation room
c. Intensive care unit
22. The nurse asked the new nurse about disinfection and
cleaning. Which of the ff. statement showed d. Anteroom
understanding about disinfection and cleaning?
This is because the patient has undergone an operation
a. When cleaning a wound, wipe around the wound
in his spinal cord and he has PTB and this is not for
edge first and then clean wound toward the center
airborne precaution since it’s mode of transmission is
of the wound
different.
b. Disinfecting and sterilizing medical devices and
equipment involve the same procedures 28. A pt. was admitted in the female ward and after a few
c. Cleaning in a direction from the most to the least hours of duty, she is positive with hepatitis B. What will
contaminated area helps reduce infections be the best action the nurse must do next?
d. General environmental cleaning is an example of a. Transfer the patient to another room separate from
medical asepsis. others
b. Relay the result to the doctor and wait for further
23. Which of the ff. is the correct order? (Removing PPEs orders
after going inside the patient’s room.) c. Inform the infection control nurse and let the
• Remove and dispose of gloves. infection control nurse talk to the doctor
• Remove eyewear. d. Inform the patient about the result.
• Untie gown. This intervention is done prior to other choices.
• Untie top and bottom mask strings.
[Link] heard that your co-nurse informed the watcher
•Perform hand hygiene. of the pt. to limit exposure to the pt. because the
24. A newly admitted pt. diagnosed with meningitis. After patient is positive in HIV. What will be the first thing
knowing the case, you place him into:
you will do after hearing this from your co-nurse?
a. Reverse isolation
b. Contact precautions a. Affirm the co-nurse but inform him that this
c. Droplet precaution concerns must be addressed in private and not
d. Standard precaution letting others hear about it, even you must not know
about it
25. A patient was admitted with PTB and is now on his 3rd b. Report this incident to your supervisor for
week of TB regimen. What precaution will the nurse immediate action of the behavior of the co nurse
place the patient?
a. Airborne precaution
© Lynetteskie & Prilang 3
 c. Inform the co-nurse that he can give instructions to infection. Place in order the steps the nurse should
the watcher inside the room of the patient so that take.
no others can hear them • Remove gloves.
d. Inform the co-nurse that only the patient has the • Wash area with soap and water.
right to disclose the info to the watcher about his
• Notify the nurse’s supervisor.
condition and not him.
• Go to the health clinic.
This is to follow the anti-discriminatory Act for patients
with HIV. • Take post-exposure prophylaxis. PEP is most
30. A nurse provides are to a patient tested positive with effective when given within 2 hours of possible
HIV. During her duty, she pricked herself with the used exposure.
needle from the pt. What will be the next thing she will 34. Which situations would require the nurse to obtain a
do? prescription for physical restraints?
a. Go to the nearest faucet and let water run into the a. Elbow restraints used temporarilyfor a toddler while
pricked area. drawing blood
b. Report the incident immediately to the station nurse b. Full padded side rails in the raised position for a
head for further action client during a seizure
c. Report the incident immediately to the infection c. Long leg immobilizer used for a client with a
control nurse fractured tibia
d. Immediately fill out the form on needle stick injury d. Soft ankle restraint to prevent bleeding at the
and submit it to the in charge femoral site following cardiac catheterization.
Do initial and immediate intervention before reporting
31. A 2-y.o. who swallowed an overdose of adult cough
Common physical restraint devices include the writs,
syrup is being d/c from the ED. The parent says to the belt, and ankle restraints. An authorization is needed.
35. The nurse is caring for a client with meningitis identified
nurse, “From now on, I’m going to store all meds in my
top dresser drawer.” Which is the best response by the as N. meningitidis. Which PPE is mandatory for the
nurse? nurse when performing the morning assessment?
a. “Can you lock your dresser drawer?” a. Face shield
b. “Make sure all of your medicines have childproof b. Gown
caps” c. Handwashing
c. “That sounds like a safe plan” d. N95 respirator
d. “You need to keep an eye on your child at all times” MOT: droplet transmission. Equipment used must stay
within the patient’s room. Droplet precaution is DC after
Children are naturally curious and could be attracted to 24 hrs. of antibiotic treatment.
medications which they usually find when exploring the
36. A nurse has received report from the off-going shift that
environment. Prevent accidental drug OD by the ff.
a client is confused and has been identified as high risk
interventions: place them out of sight and use a
for falls. The nurse shares this info with the nursing
childproof lock for the drawer/cabinet. aide. Which finding by the nurse requires intervention?
a. NA has attached a bed alarm to the client’s gown
32. A client is able to partially bear weight and follow the
and bed
nurse’s instructions. Which would be the most
b. NA has been making hourly rounds on the client
appropriate method for the nurse to use to safely
c. NA has lowered the bed and raised all 4 side rails
transfer this client?
d. NA has placed a fall risk ID bracelet on the client’s
a. 1-person stand and pivot with gait belt and walker
wrists
b. 1- person standby assist with walker
Having all 4 side rails up would increase the risk for falls
c. 2- person motorized stand-assist lift
of the patient because the patient is confused and may
d. 2-person stand and pivot with gait belt and walker
try to climb up the side rails.
To determine the most appropriate method to use,
37. A SN performs the morning ax and obtains urine
determine whether the patient can bear weight and is also
specimen from a client with MRSA on contact
cooperative, a safe transfer requires a one person stand and
precautions. The RN intervenes when the student
pivot technique.
performs which action?
33. The nurse accidentally sticks him/herself in the finger
with a client’s contaminate needle. The client has HIV
© Lynetteskie & Prilang 4
 a. Cleans the disposable stethoscope with c. Restlessness (Irritability)
chlorhexidine solution before use with another d. Dysrhythmias
client. Apnea and cyanosis are late signs of hypoxia.
b. Removes the urine specimen cup from the room in a Dysrhythmias are a response to decreased oxygenation
sealed biohazard bag but is also a late sign. Most reflective – restlessness; d/t
c. Scrubs foley catheter collection port with alcohol for lack of cerebral perfusion.
15 seconds before withdrawing a urine specimen 42. The PACU nurse is monitoring several patients who
d. Uses an alcohol-based hand antiseptic solution after received general anesthesia. Which adaptation causes
removing gloves the most concern?
All equipment should be kept inside the room, a. Pain
disinfected, and discarded when no longer needed upon b. Stridor
discharge c. Lethargy
d. Diaphoresis
(yellow container – infectious). It is the most fatal form of sound caused by laryngeal
obstruction and should be the top priority addressed.
38. The nurse is caring for a client who was admitted to the
Possibility of laryngospasm might be present upon
hospital ff. a motor vehicle accident caused by the client’s
intubation. Order of prioritization: ABCDE, Maslow’s,
newly diagnosed seizure disorder. The attending physician
NSG process, physiologic, and then psychologic process.
prescribes seizure precautions for this client. The nurse
prepares to initiate which intervention? 43. When administering O2 via a wall-outlet system, the
action unnecessary for a low liter flow as opposed to a
a. Do not lift the siderails high liter flow is:
b. Prepare to insert a urinary catheter a. Attaching a flowmeter to the wall outlet
c. Remove all linen from the bed b. Providing oral hygiene whenever necessary
d. Set up bedside suction equipment. c. Hanging an oxygen in use sign outside the patients
39. A female nurse in the UCI is caring for a client who is room
intubated and has subclavian central venous access. d. Humidifying the oxygen before it is delivered to the
Which nursing intervention is most important to patient
prevent the spread of infection to this client? The low liter flow system is less drying than the high liter
a. Frequent hand hygiene flow system and humidification is required.
b. No artificial rails
c. Use of chlorhexidine bath wipes 44. The nurse is teaching a patient how to use an incentive
d. Wearing personal protective equipment spirometer. The nurse should assist the patient to
40. A SN prepares to change a large wetto-damp sterile assume which position?
wound dressing and uses a disposable moisture-proof a. Sitting
sterile drape to set up the sterile field. The precepting b. Side-lying
nurse intervenes when the student performs which c. Orthopneic
action? d. Low-fowler’s
a. Holds the package 6’’ (15 cm) above the sterile field For maximum vital lung capacity or thoracic excursion
and drops the sterile gauze into the field because it permits the diaphragm to contract without
b. Opens the sterile gauze package with ungloved pressure.
hands
c. Places the sterile gauze dressings within 2’’ (5cm) 45. Which is the most important action by the nurse after a
from the edge of the sterile drape patient has a thoracotomy?
d. Pours sterile NSS into a sterile basin from a bottle a. Ensure the patient’s intake is at least 3000mL of fluid
opened 30 hours ago. per 24 hours
Sterile NSS (uncapped/recapped) should be consumed b. Provide the patient with adequate medication for
within 24 hours of opening the bottle. pain relief
c. Maintain the integrity of the patient’s chest tube
41. Which is most reflective of an early adaptation to d. Reposition the patient every 2 hours
hypoxia? To avoid the incidence of tension pneumothorax which
a. Apnea could lead to respiratory failure. Priority is a patent test
b. Cyanosis tube for drainage purposes.
© Lynetteskie & Prilang 5
46. The nurse is assessing a post-operative patient. Which c. Provide an explanation of why the oxygen is
complication has most likely occurred when the patient necessary
experiences purulent sputum, dyspnea, and chest pain? d. Request that the order for oxygen be changed to a
a. Hypostatic pneumonia nasal cannula.
b. Hypovolemic shock
c. Thrombophlebitis As a patient advocate, this must be done. Agitated
d. Pneumothorax patients generally tolerate a nasal cannula better than a
Purulent sputum indicates the presence of infection. face mask and is less intrusive.
Hypoventilation, immobility, and ineffective coughing –
stasis of respiratory secretions which result in hypostatic 51. The nurse teaches a patient how to use an incentive
pneumonia. spirometer. The nurse understand that the most
appropriate expected outcome assoc. with the use of an
47. An obese patient has limited mobility after ORIF of a incentive spirometer is:
fractured hip. The nurse should monitor this patient for a. Coughing will be stimulated
the most serious complication of increased blood b. Sputum will be expectorated
coagulability precipitated by immobility which is? c. Inspiratory volume will be increased
a. Muscle atrophy d. Supplemental oxygen use will be reduced
b. Pain in the calf
c. Hypotension It encourages the patient to execute and maintain a
d. Bradypnea sustained inspiration.
Homan’s sign indicative of deep vein thrombosis or
thrombophlebitis. 52. When applying a warm compress. The nurse explains to
48. When assessing a patient, which adaptation indicates the patient that the primary reason heat is used instead
the presence of respiratory distress? of cold is that heat:
a. Rate of fourteen breaths per minute a. Minimizes muscle spasms
b. Productive cough b. Increases circulation
c. Sore throat c. Prevents hemorrhage
d. Orthopnea d. Reduces discomfort
DOB with positioning is a sign of respiratory distress.
Heat increases blood flow to the area by vasodilation.
49. When attempting to apply a pulse oximetry probe.
53. The physician orders chest physiotherapy with
The nurse identifies that a patient’s hands are
percussion and vibration. The nurse should question
edematous. The priority action should be to:
this order when, during the admission assessment, the
a. Attach the probe to one of the patient’s toes
patient informs the nurse a history of:
b. Connect the probe to one of the patient’s earlobes
b. Osteoporosis
c. Wash the patient’s hand before attacking the probe
to the finger Percussion and vibration with a patient who has
d. Encourage the patient to perform active range of
osteoporosis may cause fractures.
motion exercises of the hand
Ideal site for pulse oximetry: fingers. For babies: patient’s 54. The nurse identifies that the teaching is effective when
toes. For adults, the best alternative site is the earlobe. It the pt. says its (pursed lip breathing) purpose is to:
is less affected by decreased blood flow. It is used only a. Precipitate coughing
for intermittent monitoring ROM exercises help reduce b. Help maintain open airways
edema of the hands but could actually take time. c. Decrease intrathoracic pressure
d. Facilitate expectoration of mucus
50. The practitioner’s order reads “6L O2 via face mask.”
The patient who has been extremely confused since This method creates a resistance to the air flowing out of
being in the unfamiliar environment of the hospital, the lungs.
becomes agitated and repeatedly pulls off the mask.
The nurse should: 55. What should the nurse do first if a patient is choking on
a. Tighten the strap around the head food?
b. Reapply the mask every time the patient pulls it off a. Sweep the patient’s mouth with a finger
b. Hit the middle of the patient’s back firmly
© Lynetteskie & Prilang 6
 c. Determine if the patient can make any verbal cells and transports oxygen and carbon dioxide through the
sounds. bloodstream.
d. Apply sharp upward thrusts over the patient’s
xiphoid process 60. The physiological factor that places the older adult at
greatest risk during surgery is a decrease in:
You always assess first. This intervention helps determine a. Skin elasticity
whether the patient is already choking on food indicated b. Bladder emptying
by partial or complete airway obstruction. With partial c. Tolerance for pain
obstruction, the person could still make sounds because d. Respiratory excursion
some air can pass from the lungs through the vocal
Age-related changes in the older adult include calcification of
cords.
costal cartilage (making the trachea and rib cage more rigid),
56. A patient has thick tenacious respiratory secretions. To an increase in the anterior posterior chest diameter, and
best liquefy the respiratory secretions, the nurse weakening of the thoracic inspiratory and expiratory muscles.
should: Identify if the patient has problems in breathing before they
a. Change the patient’s position every two hours undergo surgery. A decrease in respiratory excursion places
b. Encourage the patient to drink more fluid the older adult at risk for complications.
c. Obtain and order for an antitussive agent
d. Teach effective deep breathing

A fluid intake of 2.5-3 L is recommended to maintain

moisture and liquefy secretions.

57. Which action is most effective in meeting the needs of a

patient experiencing laryngospasm after extubation?
a. Ensuring hyperextension of the head
b. Providing positive pressure ventilation
c. Instituting cardiopulmonary resuscitation
d. Administering oxygen by using face mask
A BVM would be beneficial for the patient. PP will push
the vocal cords backward, opening the glottis, which
allows ventilation of the lung.
58. A patient’s Hemoglobin saturation via PO indicates
inadequate oxygenation. What should the nurse do
first?
c. Raise the head of the bed

A nurse can implement this immediate, independent

action. Nurses are permitted to treat human responses.
Raising the head of the bed facilitates the dropping of
the abdominal gravity from the diaphragm, which
permits the greatest lung expansion.

59. Which dx test reflects an adaptation to iron deficiency

anemia?
a. Hemoglobin
b. Platelet count
c. Serum albumin
d. Blood urea nitrogen

Iron is necessary for hemoglobin synthesis. Therefore,

reduced intake of dietary iron results in iron deficiency
anemia. Hemoglobin is the main component of red blood
© Lynetteskie & Prilang 7