PRACTICE EXAM FOR
OLFU
Situation – Richard has a nursing diagnosis of ineffective airway
clearance related to excessive secretions and is at risk for infection
because of retained secretions. Part of Nurse Mario’s nursing care
plan is to loosen and remove excessive secretions in the airway.
Mario listens to Richard’s bilateral sounds and finds that congestion is in
the upper lobes of the lungs. The appropriate position to drain the anterior
and posterior apical segments of the lungs when Mario does percussion
would be:
A. Client lying on his back then flat on his abdomen on
Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in
sitting position then flat on his back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
When documenting outcome of Richard’s treatment Mario should include
the following in his recording EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after
procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
When assessing Richard for chest percussion or chest vibration and
postural drainage, Mario would focus on the following EXCEPT:
A. Amount of food and fluid taken during the last meal before
treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s
tolerance for lying flat
Mario prepares Richard for postural drainage and percussion. Which of the
following is a special consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
, C. Client has no signs of infection
D. Time of last food and fluid intake of the client
The purpose of chest percussion and vibration is to loosen secretions in
the lungs. The difference between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped
palms while vibration gently shakes secretion loose on the
exhalation cycle
C. In both percussion and vibration the hands are on top of each
other and hand action is in tune with client’s breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration
shakes the secretions along with the inhalation of air
Situation – A 61 year old man, Mr. Regalado, is admitted to the
private ward for observation after complaints of severe chest pain.
You are assigned to take care of the client.
When doing an initial assessment, the best way for you to identify the
client’s priority problem is to:
A. Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant
questions
Nancy blames God for her situation. She is easily provoked to tears and
wants to be left alone, refusing to eat or talk to her family. A religious
person before, she now refuses to pray or go to church stating that God
has abandoned her. The nurse understands that Nancy is grieving for her
self and is in the stage of:
A. bargaining
B. denial
C. anger
D. acceptance
Which of the following ethical principles refers to the duty to do good?
Beneficence
Fidelity
Veracity
NonmaleficencE
,During which step of the nursing process does the nurse analyze data
related to the patient's health status?
A. Assessment
B. Implementation
C. Diagnosis
D. Evaluation
The basic difference between nursing diagnoses and collaborative
problems is that
A. nurses manage collaborative problems using physician-prescribed
interventions.
B. collaborative problems can be managed by independent nursing
interventions.
C. nursing diagnoses incorporate physician-prescribed interventions.
D. nursing diagnoses incorporate physiologic complications that
nurses monitor to detect change in status.
Situation – Mrs. Seva, 52 years old, asks you about possible
problems regarding her elimination now that she is in the menopausal
stage.
Instruction on health promotion regarding urinary elimination is important.
Which would you include?
A. Hold urine as long as she can before emptying the bladder to
strengthen her sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple
juice
C. After urination, wipe from anal area up towards the pubis
D. Tell client to empty the bladder at each voiding
Mrs. Seva also tells the nurse that she is often constipated. Because she is
aging, what physical changes predispose her to constipation?
A. inhibition of the parasympathetic reflex
B. weakness of sphincter muscles of anus
C. loss of tone of the smooth muscles of the colon
D. decreased ability to absorb fluids in the lower intestines
The nurse understands that one of these factors contributes to
constipation:
A. excessive exercise
, B. high fiber diet
C. no regular time for defecation daily
D. prolonged use of laxatives
You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the
length of insertion of the tubing for an adult would be:
A. tip of the nose to the base of the neck
B. the distance from the tip of the nose to the middle of the neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches
situation– Mr. Dizon, 84 years old, brought to the Emergency Room
for complaint of hypertension, flushed face, severe headache, and
nausea. You are doing the initial assessment of vital signs.
You are to measure the client’s initial blood pressure reading by doing all
of the following EXCEPT:
A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoff’s sound
C. Pump the cuff to around 50 mmHg above the point where the
pulse is obliterated
D. Observe procedures for infection control
A pulse oximeter is attached to Mr. Dizon’s finger to:
A. Determine if the client’s hemoglobin level is low and if he needs
blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertensive medications
D. Detect oxygen saturation of arterial blood before symptoms of
hypoxemia develops
In which type of shock does the patient experiences a mismatch of blood
flow to the cells?
A. Distributive
B. Cardiogenic
C. Hypovolemic
D. Septic
The preferred route of administration of medication in the most acute care
situations is which of the following routes?
OLFU
Situation – Richard has a nursing diagnosis of ineffective airway
clearance related to excessive secretions and is at risk for infection
because of retained secretions. Part of Nurse Mario’s nursing care
plan is to loosen and remove excessive secretions in the airway.
Mario listens to Richard’s bilateral sounds and finds that congestion is in
the upper lobes of the lungs. The appropriate position to drain the anterior
and posterior apical segments of the lungs when Mario does percussion
would be:
A. Client lying on his back then flat on his abdomen on
Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in
sitting position then flat on his back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
When documenting outcome of Richard’s treatment Mario should include
the following in his recording EXCEPT:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after
procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
When assessing Richard for chest percussion or chest vibration and
postural drainage, Mario would focus on the following EXCEPT:
A. Amount of food and fluid taken during the last meal before
treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s
tolerance for lying flat
Mario prepares Richard for postural drainage and percussion. Which of the
following is a special consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
, C. Client has no signs of infection
D. Time of last food and fluid intake of the client
The purpose of chest percussion and vibration is to loosen secretions in
the lungs. The difference between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped
palms while vibration gently shakes secretion loose on the
exhalation cycle
C. In both percussion and vibration the hands are on top of each
other and hand action is in tune with client’s breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration
shakes the secretions along with the inhalation of air
Situation – A 61 year old man, Mr. Regalado, is admitted to the
private ward for observation after complaints of severe chest pain.
You are assigned to take care of the client.
When doing an initial assessment, the best way for you to identify the
client’s priority problem is to:
A. Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant
questions
Nancy blames God for her situation. She is easily provoked to tears and
wants to be left alone, refusing to eat or talk to her family. A religious
person before, she now refuses to pray or go to church stating that God
has abandoned her. The nurse understands that Nancy is grieving for her
self and is in the stage of:
A. bargaining
B. denial
C. anger
D. acceptance
Which of the following ethical principles refers to the duty to do good?
Beneficence
Fidelity
Veracity
NonmaleficencE
,During which step of the nursing process does the nurse analyze data
related to the patient's health status?
A. Assessment
B. Implementation
C. Diagnosis
D. Evaluation
The basic difference between nursing diagnoses and collaborative
problems is that
A. nurses manage collaborative problems using physician-prescribed
interventions.
B. collaborative problems can be managed by independent nursing
interventions.
C. nursing diagnoses incorporate physician-prescribed interventions.
D. nursing diagnoses incorporate physiologic complications that
nurses monitor to detect change in status.
Situation – Mrs. Seva, 52 years old, asks you about possible
problems regarding her elimination now that she is in the menopausal
stage.
Instruction on health promotion regarding urinary elimination is important.
Which would you include?
A. Hold urine as long as she can before emptying the bladder to
strengthen her sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple
juice
C. After urination, wipe from anal area up towards the pubis
D. Tell client to empty the bladder at each voiding
Mrs. Seva also tells the nurse that she is often constipated. Because she is
aging, what physical changes predispose her to constipation?
A. inhibition of the parasympathetic reflex
B. weakness of sphincter muscles of anus
C. loss of tone of the smooth muscles of the colon
D. decreased ability to absorb fluids in the lower intestines
The nurse understands that one of these factors contributes to
constipation:
A. excessive exercise
, B. high fiber diet
C. no regular time for defecation daily
D. prolonged use of laxatives
You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the
length of insertion of the tubing for an adult would be:
A. tip of the nose to the base of the neck
B. the distance from the tip of the nose to the middle of the neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches
situation– Mr. Dizon, 84 years old, brought to the Emergency Room
for complaint of hypertension, flushed face, severe headache, and
nausea. You are doing the initial assessment of vital signs.
You are to measure the client’s initial blood pressure reading by doing all
of the following EXCEPT:
A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoff’s sound
C. Pump the cuff to around 50 mmHg above the point where the
pulse is obliterated
D. Observe procedures for infection control
A pulse oximeter is attached to Mr. Dizon’s finger to:
A. Determine if the client’s hemoglobin level is low and if he needs
blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertensive medications
D. Detect oxygen saturation of arterial blood before symptoms of
hypoxemia develops
In which type of shock does the patient experiences a mismatch of blood
flow to the cells?
A. Distributive
B. Cardiogenic
C. Hypovolemic
D. Septic
The preferred route of administration of medication in the most acute care
situations is which of the following routes?
