ESI MODEL MCQ 1

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 client’s temperature?

A. Oral
B. Axillary
C. Radial
D. Heat sensitive tape

3. A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document this findings as:

A. Tachypnea
B. Hyperpyrexia
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 client’s arms and lift
B. Face the client, bend knees and place hands on client’s 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 client’s 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. Fowler’s 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. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of nursing process is being implemented here by the nurse?

A. Assessment
B. Diagnosis
C. Planning
D. Implementation

9. It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community

A. Assessment
B. Nursing Process
C. Diagnosis
D. Implementation

10. Exchange of gases takes place in which of the following organ?

A. Kidney
B. Lungs
C. Liver
D. Heart

11. The chamber of the heart that receives oxygenated blood from the lungs is the:

A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle

12. A muscular enlarges pouch or sac that lies slightly to the left which is used for temporary storage of food…

A. Gallbladder
B. Urinary bladder
C. Stomach
D. Lungs

13. 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

14. Hormones secreted by Islets of Langerhans

A. Progesterone
B. Testosterone
C. Insulin
D. Hemoglobin

15. It is a transparent membrane that focuses the light that enters the eyes to the retina.

A. Lens
B. Sclera
C. Cornea
D. Pupils

16. Which of the following is included in Orem’s theory?

A. Maintenance of a sufficient intake of air
B. Self perception
C. Love and belongingness
D. Physiologic needs

17. Which of the following cluster of data belong to Maslow’s hierarchy of needs

A. Love and belonging
B. Physiologic needs
C. Self actualization
D. All of the above

18. This is characterized by severe symptoms relatively of short duration.

A. Chronic Illness
B. Acute Illness
C. Pain
D. Syndrome

19. Which of the following is the nurse’s role in the health promotion

A. Health risk appraisal
B. Teach client to be effective health consumer
C. Worksite wellness
D. None of the above

20. It is describe as a collection of people who share some attributes of their lives.

A. Family
B. Illness
C. Community
D. Nursing

21. Five teaspoon is equivalent to how many milliliters (ml)?

A. 30 ml
B. 25 ml
C. 12 ml
D. 22 ml

22. 1800 ml is equal to how many liters?

A. 1.8
B. 18000
C. 180
D. 2800

23. Which of the following is the abbreviation of drops?

A. Gtt.
B. Gtts.
C. Dp.
D. Dr.

24. The abbreviation for micro drop is…

A. µgtt
B. gtt
C. mdr
D. mgts

25. Which of the following is the meaning of PRN?

A. When advice
B. Immediately
C. When necessary
D. Now

26. Which of the following is the appropriate meaning of CBR?

A. Cardiac Board Room
B. Complete Bathroom
C. Complete Bed Rest
D. Complete Board Room

27. One (1) tsp is equals to how many drops?

A. 15
B. 60
C. 10
D. 30

28. 20 cc is equal to how many ml?

A. 2
B. 20
C. 2000
D. 20000

29. 1 cup is equals to how many ounces?

A. 8
B. 80
C. 800
D. 8000

30. The nurse must verify the client’s identity before administration of medication. Which of the following is the safest way to identify the client?

A. Ask the client his name
B. Check the client’s identification band
C. State the client’s name aloud and have the client repeat it
D. Check the room number

31. The nurse prepares to administer buccal medication. The medicine should be placed…

A. On the client’s skin
B. Between the client’s cheeks and gums
C. Under the client’s tongue
D. On the client’s conjunctiva

32. The nurse administers cleansing enema. The common position for this procedure is…

A. Sims left lateral
B. Dorsal Recumbent
C. Supine
D. Prone

33. A client complains of difficulty of swallowing, when the nurse try to administer capsule medication. Which of the following measures the nurse should do?

A. Dissolve the capsule in a glass of water
B. Break the capsule and give the content with an applesauce
C. Check the availability of a liquid preparation
D. Crash the capsule and place it under the tongue

34. Which of the following is the appropriate route of administration for insulin?

A. Intramuscular
B. Intradermal
C. Subcutaneous
D. Intravenous

35. The nurse is ordered to administer ampicillin capsule TID p.o. The nurse should give the medication…

A. Three times a day orally
B. Three times a day after meals
C. Two time a day by mouth
D. Two times a day before meals

36. Back Care is best described as:

A. Caring for the back by means of massage
B. Washing of the back
C. Application of cold compress at the back
D. Application of hot compress at the back

37. It refers to the preparation of the bed with a new set of linens

A. Bed bath
B. Bed making
C. Bed shampoo
D. Bed lining

38. Which of the following is the most important purpose of handwashing

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

39. What should be done in order to prevent contaminating of the environment in bed making?

A. Avoid fanning soiled linens
B. Strip all linens at the same time
C. Finished both sides at the time
D. Embrace soiled linen

40. The most important purpose of cleansing bed bath is:

A. To cleanse, refresh and give comfort to the client who must remain in bed
B. To expose the necessary parts of the body
C. To develop skills in bed bath
D. To check the body temperature of the client in bed

41. Which of the following technique involves the sense of sight?

A. Inspection
B. Palpation
C. Percussion
D. Auscultation

42. The first techniques used examining the abdomen of a client is:

A. Palpation
B. Auscultation
C. Percussion
D. Inspection

43. 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

44. An instrument used for auscultation is:

A. Percussion-hammer
B. Audiometer
C. Stethoscope
D. Sphygmomanometer

45. Resonance is best describe as:

A. Sounds created by air filled lungs
B. Short, high pitch and thudding
C. Moderately loud with musical quality
D. Drum-like

46. The best position for examining the rectum is:

A. Prone
B. Sim’s
C. Knee-chest
D. Lithotomy

47. It refers to the manner of walking

A. Gait
B. Range of motion
C. Flexion and extension
D. Hopping

48. The nurse asked the client to read the Snellen chart. Which of the following is tested:

A. Optic
B. Olfactory
C. Oculomotor
D. Trochlear

49. Another name for knee-chest position is:

A. Genu-dorsal
B. Genu-pectoral
C. Lithotomy
D. Sim’s

50. The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication

A. Use a small gauge needle
B. Apply ice on the injection site
C. Administer at a 45° angle
D. Use the Z-track technique

----------------------------------------------------------------------------------------------------------------------------

Answers and Rationale

1. Answer: D. Providing oral hygiene

Doing oral care requires the nurse to wear gloves.

2. Answer: B. Axillary

Axilla is the most accessible body part in this situation.

3. Answer: D. Tachycardia

Tachycardia means rapid heart rate. Tachypnea (Option A) refers to rapid respiratory rate. Hyperpyrexia (Option B) means increase in temperature. Arrhythmia (Option C) means irregular heart rate.

4. Answer: B. Face the client, bend knees and place hands on client’s forearm and lift

This is the proper way on supporting the client to get up in a chair that conforms to safety and proper body mechanics.

5. Answer: B. Axillary

Taking the temperature via the oral route is incorrect since the client had oral surgery. Choice C and D are unnecessary. Taking the temperature via the axilla is the most appropriate route.

6. Answer: B. Side lying

An unconscious client is best placed on his side when doing oral care to prevent aspiration.

7. Answer: C. Keep side rails up at all time

Although the other choices seem correct, they are not the best answer.

8. Answer: A. Assessment

Assessment is the first phase of the nursing process where a nurse collects information about the client. Diagnosis is the formulation of the nursing diagnosis from the information collected during the assessment. In Planning, the nurse sets achievable and measurable short and long term goals. Implementation is where nursing care is given.

9. Answer: B. Nursing Process

The statement describes the Nursing Process. The Nursing Process is the essential core of practice for the registered nurse to deliver holistic, patient-focused care.

10. Answer: B. Lungs

11. Answer: A. Left atrium

The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle. The right atrium receives blood from the veins and pumps it to the right ventricle. The right ventricle receives blood from the right atrium and pumps it to the lungs, where it is loaded with oxygen. The left ventricle (the strongest chamber) pumps oxygen-rich blood to the rest of the body, its vigorous contractions create the blood pressure.

12. Answer: C. Stomach

13. Answer: C. Immunity

14. Answer: C. Insulin

The Islets of Langerhans are the regions of the pancreas that contain its endocrine cells. Progesterone (Choice A) is produced by the ovaries. Testosterone (Choice B) is secreted by the testicles of males and ovaries of females. Hemoglobin (Choice D) is a protein molecule in the red blood cells that carries oxygen from the lungs to the body’s tissues and returns carbon dioxide.

15. Answer: C. Cornea

The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. The cornea is like the crystal of a watch.

16. Answer: A. Maintenance of a sufficient intake of air

Dorothea Orem’s Self-Care Theory defined Nursing as “The act of assisting others in the provision and management of self-care to maintain or improve human functioning at home level of effectiveness.” Choices B, C, and D are from Abraham Maslow’s Hierarchy of Needs.

17. Answer: D. All of the above

All of the choices are part of Maslow’s Hierarchy of Needs.

18. Answer: B. Acute Illness

Chronic Illness (Choice A) are illnesses that are persistent or long-term.

19. Answer: B. Teach client to be effective health consumer

20. Answer: C. Community

Family is defined as a group consisting typically of parents and children living together in a household.

21. Answer: B. 25 ml

One teaspoon is equal to 5ml.

22. Answer: A. 1.8

23. Answer: B. Gtts.

Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized abbreviation for measurement.

24. Answer: A. µgtt

25. Answer: C. When necessary

PRN comes from the Latin “pro re nata” meaning, for an occasion that has arisen or as circumstances require.

26. Answer: C. Complete Bed Rest

CBR means complete bed rest. For more abbreviations, please see this post.

27. Answer: B. 60

One teaspoon (tsp) is equal to 60 drops (gtts).

28. Answer: B. 20

One cubic centimeter is equal to one milliliter.

29. Answer: A. 8

One cup is equal to 8 ounces.

30. Answer: B. Check the client’s identification band

The identification band is the safest way to know the identity of a patient whether he is conscious or unconscious. Ask the client his name only after you have checked his ID band.

31. Answer: B. Between the client’s cheeks and gums

32. Answer: A. Sims left lateral

This position provides comfort to the patient and an easy access to the natural curvature of the rectum.

33. Answer: C. Check the availability of a liquid preparation

The nurse should check first if the medication is available in liquid form before doing Choice A. Placing it under the tongue is not the intended way of administering an oral medication.

34. Answer: C. Subcutaneous

The subcutaneous tissue of the abdomen is preferred because absorption of the insulin is more consistent from this location than subcutaneous tissues in other locations.

35. Answer: A. Three times a day orally

TID is the Latin for “ter in die” which means three times a day. P.O. means per orem or through mouth.

36. Answer: A. Caring for the back by means of massage

37. Answer: B. Bed making

38. Answer: B. To prevent the transfer of microorganism

Hand washing is the single most effective infection control measure.

38. Answer: A. Avoid fanning soiled linens

Fanning soiled linens would scatter the lodged microorganisms and dead skin cells on the linens.

40. Answer: A. To cleanse, refresh and give comfort to the client who must remain in bed

41. Answer: A. Inspection

Palpation is a method of feeling with the fingers or hands during a physical examination. Percussion is a method of tapping on a surface to determine the underlying structure, and is used in clinical examinations to assess the condition of the thorax or abdomen. Auscultation (based on the Latin verb auscultare “to listen”) is listening to the internal sounds of the body, usually using a stethoscope.

42. Answer: D. Inspection

For abdominal exam, auscultation is performed before palpation because the act of palpation could change what was auscultated. Remember the mnemonic “I-A-Per-Pal”.

43. Answer: B. Auscultation

44. Answer: C. Stethoscope

45. Answer: A. Sounds created by air filled lungs

46. Answer: C. Knee-chest

To assume the genupectoral position the person kneels so that the weight of the body is supported by the knees and chest, with the buttocks raised. The head is turned to one side and the arms are flexed so that the upper part of the body can be supported in part by the elbows.

47. Answer: A. Gait

48. Answer: A. Optic

Cranial Nerve II or the optic nerve is tested through the use of the Snellen chart.

49. Answer: B. Genu-pectoral

50. Answer: D. Use the Z-track technique

During the procedure, skin and tissue are pulled and held firmly while a long needle is inserted into the muscle. After the medication is injected, the skin and tissue are released. The needle track that forms during this procedure takes the shape of the letter “Z,” which gives the procedure its name. This zigzag track line is what prevents medication from leaking from the muscle into surrounding tissue.