SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Arthur rushed at the scene.

1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is

A. Stay with the person, Encourage her to remain still and Immobilize the leg while While waiting for the ambulance.
B. Leave the person for a few moments to call for help.
C. Reduce the fracture manually.
D. Move the person to a safer place.

2. Arthur suspects a hip fracture when he noticed that the old woman’s leg is

A. Lengthened, Abducted and Internally Rotated.
B. Shortened, Abducted and Externally Rotated.
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally Rotated.

3. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to

A. Infection
B. Thrombophlebitis
C. Inflammation
D. Degenerative disease

4. The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except

A. Hypothyroidism
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin.

5. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms?

A. Tachycardia and Hypotension
B. Fever and Bradycardia
C. Bradycardia and Hypertension
D. Fever and Hypertension

SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.

6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane

A. On his left hand, because his right side is weak.
B. On his left hand, because of reciprocal motion.
C. On his right hand, to support the right leg.
D. On his right hand, because only his right leg is weak.

7. You also told Mr. Rojas to hold the cane

A. 1 Inches in front of the foot.
B. 3 Inches at the lateral side of the foot.
c. 6 Inches at the lateral side of the foot.
D. 12 Inches at the lateral side of the foot.

8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him

A. Moves the cane when the right leg is moved.
B. Leans on the cane when the right leg swings through.
C. keeps the cane 6 Inches out to the side of the right foot.
D. Holds the cane on the right side.

SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood

9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as

A. PPD
B. PDP
C. PDD
D. DPP

10. The nurse would inject the solution in what route?

A. IM
B. IV
C. ID
D. SC

11. The nurse notes that a positive result for Alfred is

A. 5 mm wheal
B. 5 mm Induration
C. 10 mm Wheal
D. 10 mm Induration

12. The nurse told Alfred to come back after

A. a week
B. 48 hours
C. 1 day
D. 4 days

13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action?

A. Call the Physician
B. Notify the radiology dept. for CXR evaluation
C. Isolate the patient
D. Order for a sputum exam

14. Why is Mantoux test not routinely done in the Philippines?

A. It requires a highly skilled nurse to perform a Mantoux test
B. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions
D. Almost all Filipinos will test positive for Mantoux Test

15. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?

A. I
B. II
C. III
D. IV

16. How long is the duration of the maintenance phase of his treatment?

A. 2 months
B. 3 months
C. 4 months
D. 5 months

17. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase?

A. Rifampicin
B. Isoniazid
C. Ethambutol
D. Pyridoxine

18. According to the DOH, the most hazardous period for development of clinical disease is during the first

A. 6-12 months after
B. 3-6 months after
C. 1-2 months after
D. 2-4 weeks after

19. This is the name of the program of the DOH to control TB in the country

A. DOTS
B. National Tuberculosis Control Program
C. Short Coursed Chemotherapy
D. Expanded Program for Immunization

20. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except

A. 23 Year old athlete with diabetes insipidus
B. 23 Year old athlete taking long term Decadron therapy and anabolic steroids
C. 23 Year old athlete taking illegal drugs and abusing substances
D. Undernourished and Underweight individual who undergone gastrectomy

21. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention?

A. Primary
B. Secondary
C. Tertiary
D. Quarterly

SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.

22. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?

A. Look at the ostomy site
B. Participate with the nurse in his daily ostomy care
C. Ask for leaflets and contact numbers of ostomy support groups
D. Talk about his ostomy openly to the nurse and friends

23. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?

A. Plain NSS / Normal Saline
B. K-Y Jelly
C. Tap water
D. Irrigation sleeve

24. The nurse should insert the colostomy tube for irrigation at approximately

A. 1-2 inches
B. 3-4 inches
C. 6-8 inches
D. 12-18 inches

25. The maximum height of irrigation solution for colostomy is

A. 5 inches
B. 12 inches
C. 18 inches
D. 24 inches

26. Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?

A. Ask to defer colostomy care to another individual
B. Promises he will begin to listen the next day
C. Agrees to look at the colostomy
D. States that colostomy care is the function of the nurse while he is in the hospital

27. While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would

A. Stop the irrigation by clamping the tube
B. Slow down the irrigation
C. Tell the client that cramping will subside and is normal
D. Notify the physician

28. The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?

A. A sunken and hidden stoma
B. A dusky and bluish stoma
C. A narrow and flattened stoma
D. Protruding stoma with swollen appearance

29. Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be

A. Eat eggs
B. Eat cucumbers
C. Eat beet greens and parsley
D. Eat broccoli and spinach

30. The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?

A. Use 500 ml to 1,000 ml NSS
B. Suspend the irrigant 45 cm above the stoma
C. Insert the cone 4 cm in the stoma
D. If cramping occurs, slow the irrigation

31. The nurse knew that the normal color of Michiel’s stoma should be

A. Brick Red
B. Gray
C. Blue
D. Pale Pink

SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.

32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?

A. Hyperventilating James with 100% oxygen before and after suctioning
B. Instilling 3 to 5 ml normal saline to loosen up secretion
C. Applying suction during catheter withdrawal
D. Suction the client every hour

33. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?

A. Fr. 5
B. Fr. 10
C. Fr. 12
D. Fr. 18

34. Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?

A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 20-25 mmHg

35. If a Wall unit is used, What should be the suctioning pressure required by James?

A. 50-95 mmHg
B. 95-110 mmHg
C. 100-120 mmHg
D. 155-175 mmHg

36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?

A. New set of tracheostomy tubes and Oxygen tank
B. Theophylline and Epinephrine
C. Obturator and Kelly clamp
D. Sterile saline dressing

37. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?

A. Wilma places 2 fingers between the tie and neck
B. The tracheotomy can be pulled slightly away from the neck
C. James’ neck veins are not engorged
D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.

38. Wilma knew that James have an adequate respiratory condition if she notices that

A. James’ respiratory rate is 18
B. James’ Oxygen saturation is 91%
C. There are frank blood suction from the tube
D. There are moderate amount of tracheobronchial secretions

39. Wilma knew that the maximum time when suctioning James is

A. 10 seconds
B. 20 seconds
C. 30 seconds
D. 45 seconds

SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.

40. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma?

A. Loss of peripheral vision
B. Irreversible vision loss
C. There is an increase in IOP
D. Pain

41. Nurse jet knew that Acute close angle glaucoma is caused by

A. Sudden blockage of the anterior angle by the base of the iris
B. Obstruction in trabecular meshwork
C. Gradual increase of IOP
D. An abrupt rise in IOP from 8 to 15 mmHg

42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures

A. It measures the peripheral vision remaining on the client
B. Measures the Intra Ocular Pressure
C. Measures the Client’s Visual Acuity
D. Determines the Tone of the eye in response to the sudden increase in IOP.

43. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change?

A. IRIS
B. PUPIL
C. RODS [RETINA]
D. CONES [RETINA]

44. Nurse Jet knows that Aqueous Humor is produce where?

A. In the sub arachnoid space of the meninges
B. In the Lateral ventricles
C. In the Choroids
D. In the Ciliary Body

45. Nurse Jet knows that the normal IOP is

A. 8-21 mmHg
B. 2-7 mmHg
c. 31-35 mmHg
D. 15-30 mmHg

46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would Nurse Jet implement to measure CN II’s Acuity?

A. Slit lamp
B. Snellen’s Chart
C. Wood’s light
D. Gonioscopy

47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to

A. Contract the Ciliary muscle
B. Relax the Ciliary muscle
C. Dilate the pupils
D. Decrease production of Aqueous Humor

48. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is

A. Reduce production of CSF
B. Reduce production of Aquesous Humor
C. Constrict the pupil
D. Relaxes the Ciliary muscle

49. When caring for Mr. Batumbakal, Jet teaches the client to avoid

A. Watching large screen TVs
B. Bending at the waist
C. Reading books
D. Going out in the sun

50. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure?

A. Reading newsprint
B. Lying down
C. Watching TV
D. Listening to the music

51. If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in any case systemic toxicity occurs?

A. Atropine Sulfate
B. Pindolol [Visken]
C. Naloxone Hydrochloride [Narcan]
D. Mesoridazine Besylate [Serentil]

SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a nurse assess and analyze changes in the adult client’s health.

52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?

A. Indicates a CN VIII Dysfunction
B. Abnormal
C. Normal
D. Inconclusive

53. Ear drops are prescribed to an infant, The most appropriate method to administer the ear drops is

A. Pull the pinna up and back and direct the solution towards the eardrum
B. Pull the pinna down and back and direct the solution onto the wall of the canal
C. Pull the pinna down and back and direct the solution towards the eardrum
D. Pull the pinna up and back and direct the solution onto the wall of the canal

54. Nurse Jenny is developing a plan of care for a patient with Menieres disease. What is the priority nursing intervention in the plan of care for this particular patient?

A. Air, Breathing, Circulation
B. Love and Belongingness
C. Food, Diet and Nutrition
D. Safety

55. After mastoidectomy, Nurse John should be aware that the cranial nerve that is usually damage after this procedure is

A. CN I
B. CN II
C. CN VII
D. CN VI

56. The physician orders the following for the client with Menieres disease. Which of the following should the nurse question?

A. Dipenhydramine [Benadryl]
B. Atropine sulfate
C. Out of bed activities and ambulation
D. Diazepam [Valium]

57. Nurse Anna is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful?

A. I will try to eat foods that are low in sodium and limit my fluid intake
B. I must drink atleast 3,000 ml of fluids per day
C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
D. I will not eat turnips, red meat and raddish

58. Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect. What should be the first thing that Nurse Joemar should try to remove the insect out from peachy’s ear?

A. Use a flashlight to coax the insect out of peachy’s ear
B. Instill an antibiotic ear drops
C. Irrigate the ear
D. Pick out the insect using a sterile clean forceps

59. Following an ear surgery, which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions?

A. Activities are resumed within 5 days
B. I will make sure that I will clean my hair and face to prevent infection
C. I will use straw for drinking
D. I should avoid air travel for a while

60. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates?

A. Indicating a Cranial Nerve VIII Dysfunction
B. The test should be repeated again because the result is vague
C. This is Grossly abnormal and should be reported to the neurosurgeon
D. This indicates an intact and working vestibular branch of CN VIII

61. A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?

A. Anxiety R/T to the operation and its outcome
B. Sensory perceptual alteration R/T Lens extraction and replacement
C. Knowledge deficit R/T the pre operative and post operative self care
D. Body Image disturbance R/T the eye packing after surgery

62. Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to make?

A. He might have a sensory hearing loss in the left ear
B. Conductive hearing loss is possible in the right ear
C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
D. He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.

63. Aling myrna has Menieres disease. What typical dietary prescription would nurse Oca expect the doctor to prescribe?

A. A low sodium , high fluid intake
B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake
D. low sodium and restricted fluid intake

SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.

64. Which of the following is the appropriate nursing diagnosis?

A. Fluid volume deficit R/T furrow tongue
B. Fluid volume deficit R/T uncontrolled vomiting
C. Dehydration R/T subnormal body temperature
D. Dehydration R/T incessant vomiting

65. Approximately how much fluid is lost in acute weight loss of .5kg?

A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml

66. Postural Hypotension is

A. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
C. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting

67. Which of the following measures will not help correct the patient’s condition

A. Offer large amount of oral fluid intake to replace fluid lost
B. Give enteral or parenteral fluid
C. Frequent oral care
D. Give small volumes of fluid at frequent interval

68. After nursing intervention, you will expect the patient to have

1. Maintain body temperature at 36.5 C
2. Exhibit return of BP and Pulse to normal
3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed

A. 1,3
B. 2,4
C. 1,3,4
D. 2,3,4

SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.

69. Which of the following is a characteristic of a patient with advanced Parkinson’s disease?

A. Disturbed vision
B. Forgetfulness
C. Mask like facial expression
D. Muscle atrophy

70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by

A. Injurious chemical substances
B. Hereditary factors
C. Death of brain cells due to old age
D. Impairment of dopamine producing cells in the brain

71. The patient was prescribed with levodopa. What is the action of this drug?

A. Increase dopamine availability
B. Activates dopaminergic receptors in the basal ganglia
C. Decrease acetylcholine availability
D. Release dopamine and other catecholamine from neurological storage sites

72. You are discussing with the dietician what food to avoid with patients taking levodopa?

A. Vitamin C rich food
B. Vitamin E rich food
C. Thiamine rich food
D. Vitamin B6 rich food

73. One day, the patient complained of difficulty in walking. Your response would be

A. You will need a cane for support
B. Walk erect with eyes on horizon
C. I’ll get you a wheelchair
D. Don’t force yourself to walk

SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.

74. The nurse will assess a loss of ability in which of the following areas?

A. Balance
B. Judgment
C. Speech
D. Endurance

75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:

A. Insomnia
B. Aphraxia
C. Agnosia
D. Aphasia

76. The nurse is aware that in communicating with an elderly client, the nurse will

A. Lean and shout at the ear of the client
B. Open mouth wide while talking to the client
C. Use a low-pitched voice
D. Use a medium-pitched voice

77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?

A. I know the hallucinations are parts of the disease
B. I told her she is wrong and I explained to her what is right
C. I help her do some tasks he cannot do for himself
D. Ill turn off the TV when we go to another room

78. Which of the following is most important discharge teaching for Mr. Dela Isla

A. Emergency Numbers
B. Drug Compliance
C. Relaxation technique
D. Dietary prescription

SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.

79. What is the action of this drug?

A. Increases glandular secretion for clients affected with cystic fibrosis
B. Dissolve blockage of the urinary tract due to obstruction of cystine stones
C. Reduces secretion of the glandular organ of the body
D. Stimulate peristalsis for treatment of constipation and obstruction

80. What should the nurse caution the client when using this medication

A. Avoid hazardous activities like driving, operating machineries etc.
B. Take the drug on empty stomach
C. Take with a full glass of water in treatment of Ulcerative colitis
D. I must take double dose if I missed the previous dose

81. Which of the following drugs are not compatible when taking Probanthine?

A. Caffeine
B. NSAID
C. Acetaminophen
D. Alcohol

82. What should the nurse tell clients when taking Probanthine?

A. Avoid hot weathers to prevent heat strokes
B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a day
D. Avoid cold weathers to prevent hypothermia

83. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder?

A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
D. Glaucoma

SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.

84. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?

A. Level of awareness and response to pain
B. Papillary reflexes and response to sensory stimuli
C. Coherence and sense of hearing
D. Patency of airway and adequacy of respiration

85. Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?

A. Hand bell and extra bed linen
B. Sandbag and trochanter rolls
C. Footboard and splint
D. Suction machine and gloves

86. What is the rationale for giving Mr. Franco frequent mouth care?

A. He will be thirsty considering that he is doesn’t drink enough fluids
B. To remove dried blood when tongue is bitten during a seizure
C. The tactile stimulation during mouth care will hasten return to consciousness
D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.

87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?

A. Massage reddened areas with lotion or oils
B. Turn frequently every 2 hours
C. Use special water mattress
D. Keep skin clean and dry

88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?

A. Expressive aphasia is prominent on clients with right sided weakness
B. The affected lobe in the patient is the Right lobe
C. The client will have problems in judging distance and proprioception
D. Clients orientation to time and space will be much affected

SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.

89. Which result of the lab test will be significant to the diagnosis?

A. RBC : 4.5 TO 5 Million / cu. mm.
B. Hgb : 13 to 14 gm/dl.
C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm

90. Stat appendectomy was indicated. Pre op care would include all of the following except?

A. Consent signed by the father
B. Enema STAT
C. Skin prep of the area including the pubis
D. Remove the jewelries

91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :

A. Allay anxiety and apprehension
B. Reduce pain
C. Prevent vomiting
D. Relax abdominal muscle

92. Common anesthesia for appendectomy is

A. Spinal
B. General
C. Caudal
D. Hypnosis

93. Post op care for appendectomy include the following except

A. Early ambulation
B. Diet as tolerated after fully conscious
C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise

94. Peritonitis may occur in ruptured appendix and may cause serious problems which are

1. Hypovolemia, electrolyte imbalance
2. Elevated temperature, weakness and diaphoresis
3. Nausea and vomiting, rigidity of the abdominal wall
4. Pallor and eventually shock

A. 1 and 2
B. 2 and 3
C. 1,2,3
D. All of the above

95. If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication?

A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon

96. NGT was connected to suction. In caring for the patient with NGT, the nurse must

A. Irrigate the tube with saline as ordered
B. Use sterile technique in irrigating the tube
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips

97. When do you think the NGT tube be removed?

A. When patient requests for it
B. Abdomen is soft and patient asks for water
C. Abdomen is soft and flatus has been expelled
D. B and C only

Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.

98. What do you call a STROKE that manifests a bizarre behavior?

A. Inorganic Stroke
B. Inorganic Psychoses
C. Organic Stroke
D. Organic Psychoses

99. The main difference between chronic and organic brain syndrome is that the former

A. Occurs suddenly and reversible
B. Is progressive and reversible
C. tends to be progressive and irreversible
D. Occurs suddenly and irreversible

100. Which behavior results from organic psychoses?

A. Memory deficit
B. Disorientation
C. Impaired Judgement
D. Inappropriate affect
1. D. Move the person to a safer place.

2. D. Shortened, Adducted and Externally Rotated.

3. C. Inflammation

4. A. Hypothyroidism

5. A. Tachycardia and Hypotension

6. B. On his left hand, because of reciprocal motion.

7. c. 6 Inches at the lateral side of the foot.

8. A. Moves the cane when the right leg is moved.

9. A. PPD

10. C. ID

11. D. 10 mm Induration

12. B. 48 hours

13. A. Call the Physician

14. D. Almost all Filipinos will test positive for Mantoux Test

15. A. I

16.C. 4 months

17. C. Ethambutol

18. A. 6-12 months after

19. B. National Tuberculosis Control Program

20. A. 23 Year old athlete with diabetes insipidus

21. B. Secondary

22. B. Participate with the nurse in his daily ostomy care

23. A. Plain NSS / Normal Saline

24. B. 3-4 inches

25.C. 18 inches

26. C. Agrees to look at the colostomy

27. A. Stop the irrigation by clamping the tube

28. D. Protruding stoma with swollen appearance

29. C. Eat beet greens and parsley

30. B. Suspend the irrigant 45 cm above the stoma

31. A. Brick Red

32. D. Suction the client every hour

33. D. Fr. 18

34. C. 10-15 mmHg

35. C. 100-120 mmHg

36. C. Obturator and Kelly clamp

37. A. Wilma places 2 fingers between the tie and neck

38. A. James’ respiratory rate is 18

39. A. 10 seconds

40. D. Pain

41. A. Sudden blockage of the anterior angle by the base of the iris

42. B. Measures the Intra Ocular Pressure

43. D. CONES [RETINA]

44. D. In the Ciliary Body

45. A. 8-21 mmHg

46. B. Snellen’s Chart

47. A. Contract the Ciliary muscle

48. B. Reduce production of Aquesous Humor

49. B. Bending at the waist

50. A. Reading newsprint

51. A. Atropine Sulfate

52. C. Normal

53. B. Pull the pinna down and back and direct the solution onto the wall of the canal

54. D. Safety

55. C. CN VII

56. C. Out of bed activities and ambulation

57. A. I will try to eat foods that are low in sodium and limit my fluid intake

58. A. Use a flashlight to coax the insect out of peachy’s ear

59. D. I should avoid air travel for a while

60. D. This indicates an intact and working vestibular branch of CN VIII

61. B. Sensory perceptual alteration R/T Lens extraction and replacement

62. C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.

63. D. low sodium and restricted fluid intake

64. B. Fluid volume deficit R/T uncontrolled vomiting

65. C. 500 ml

66. B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting

67. A. Offer large amount of oral fluid intake to replace fluid lost

68. D. 2,3,4

69. C. Mask like facial expression

70. D. Impairment of dopamine producing cells in the brain

71. A. Increase dopamine availability

72. D. Vitamin B6 rich food

73. A. You will need a cane for support

74. B. Judgment

75. D. Aphasia

76. D. Use a medium-pitched voice

77. B. I told her she is wrong and I explained to her what is right

78. B. Drug Compliance

79. C. Reduces secretion of the glandular organ of the body

80. A. Avoid hazardous activities like driving, operating machineries etc.

81. D. Alcohol

82. A. Avoid hot weathers to prevent heat strokes

83. B. Peptic Ulcer Disease

84. D. Patency of airway and adequacy of respiration

85. D. Suction machine and gloves

86. D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.

87. B. Turn frequently every 2 hours

88.A. Expressive aphasia is prominent on clients with right sided weakness

89. D. WBC : 12,000 to 13,000/cu.mm

90. B. Enema STAT

91. A. Allay anxiety and apprehension

92. A. Spinal

93. B. Diet as tolerated after fully conscious

94. D. All of the above

95. B. Paralytic Ileus

96. A. Irrigate the tube with saline as ordered

97. C. Abdomen is soft and flatus has been expelled

98. D. Organic Psychoses

99.C. tends to be progressive and irreversible

100. B. Disorientation
1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has left-sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client?

a. checking stools for occult blood
b. performing range-of-motion exercises to the left side
c. keeping skin clean and dry
d. elevating the head of the bed to 30 degrees

2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:

a. destroys the odor-proof seal
b. wont affect the colostomy system
c. is appropriate for relieving the gas in a colostomy system
d. destroys the moisture barrier seal

3. When assessing the client with celiac disease, the nurse can expect to find which of the following?

a. steatorrhea
b. jaundiced sclerae
c. clay-colored stools
d. widened pulse pressure

4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because:

a. reducing sodium promotes urea nitrogen excretion
b. reducing sodium improves her glomerular filtration rate
c. reducing sodium increases potassium absorption
d. reducing sodium decreases edema

5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the:

a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe

6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect:

a. Cushing’s syndrome
b. Diabetes mellitus
c. Adrenal crisis
d. Diabetes insipidus

7. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

a. limit oral fluid intake for 1 to 2 weeks
b. report the presence of fine, sandlike particles through the nephrostomy tube.
c. Notify the physician about cloudy or foul smelling urine
d. Report bright pink urine within 24 hours after the procedure

8. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority?

a. deficient fluid volume related to osmotic diuresis
b. decreased cardiac output related to elevated heart rate
c. imbalanced nutrition: Less than body requirements related to insulin deficiency
d. ineffective thermoregulation related to dehydration

9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The nurse should expect the dose’s:

a. onset to be at 2 p.m. and its peak at 3 p.m.
b. onset to be at 2:15 p.m. and its peak at 3 p.m.
c. onset to be at 2:30 p.m. and its peak at 4 p.m.
d. onset to be at 4 p.m. and its peak at 6 p.m.

10. A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:

a. 52 mm Hg
b. 88 mm Hg
c. 48 mm Hg
d. 68 mm Hg

11. A 52 yr-old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?

a. eversion of the right nipple and a mobile mass
b. nonmobile mass with irregular edges
c. mobile mass that is oft and easily delineated
d. nonpalpable right axillary lymph nodes

12. A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?

a. Social worker
b. registered dietician
c. occupational therapist
d. enterostomal nurse therapist

13. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?

a. basilar
b. temporal
c. occipital
d. parietal

14. A male client should be taught about testicular examinations:

a. when sexual activity starts
b. after age 60
c. after age 40
d. before age 20

15. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?

A. fluid intake for the last 24 hours
B. baseline arterial blood gas (ABG) levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results

16. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women:

A. perform breast self-examination annually
B. have a mammogram annually
C. have a hormonal receptor assay annually
D. have a physician conduct a clinical evaluation every 2 years

17. When caring for a client with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:

A. esophageal perforation
B. pulmonary hypertension
C. portal hypertension
D. peptic ulcers

18. A 49-yer-old client was admitted for surgical repair of a Colles’ fracture. An external fixator was placed during surgery. The surgeon explains that this method of repair:

A. has very low complication rate
B. maintains reduction and overall hand function
C. is less bothersome than a cast
D. is best for older people

19. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction?

A. “Be sure to eat meat at every meal.”
B. “Monitor your fruit intake and eat plenty of bananas.”
C. “Restrict your salt intake.”
D. “Drink plenty of fluids.”

20. The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has tow children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?

A. Tell the client’s spouse or partner to be supportive while she recovers.
B. Encourage the client to proceed with the next phase of treatment.
C. Recommend that the client remain cheerful for the sake of her children.
D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.

21. A 21 year-old male has been seen in the clinic for a thickening in his right testicle. The physician ordered a human chorionic gonadotropin (HCG) level. The nurse’s explanation to the client should include the fact that:

A. The test will evaluate prostatic function.
B. The test was ordered to identify the site of a possible infection.
C. The test was ordered because clients who have testicular cancer has elevated levels of HCG.
D. The test was ordered to evaluate the testosterone level.

22. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:

A. A skin rash.
B. Peripheral edema.
C. A dry cough.
D. Postural hypotension.

23. Which assessment finding indicates dehydration?

A. Tenting of chest skin when pinched.
B. Rapid filling of hand veins.
C. A pulse that isn’t easily obliterated.
D. Neck vein distention

24. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.

25. For a client newly diagnosed with radiationinduced thrombocytopenia, the nurse should include which intervention in the plan of care?

A. Administer aspirin if the temperature exceeds 38.8º C.
B. Inspect the skin for petechiae once every shift.
C. Provide for frequent periods of rest.
D. Place the client in strict isolation.

26. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has:

A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure

27. For a client in addisonian crisis, it would be very risky for a nurse to administer:

A. potassium chloride
B. normal saline solution
C. hydrocortisone
D. fludrocortisone

28. The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number of immature:

A. lymphocytes
B. thrombocytes
C. reticulocytes
D. leukocytes

29. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?

A. Putting on sterile gloves then opening a container of sterile saline.
B. Cleaning the wound with a circular motion, moving from outer circles toward the center.
C. Changing the sterile field after sterile water is spilled on it.
D. Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.

30. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?

A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein

31. A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which organ?

A. adrenal cortex
B. pancreas
C. adrenal medulla
D. parathyroid

32. A client has a medical history of rheumatic fever, type 1 (insulin dependent) diabetes mellitus, hypertension, pernicious anemia, and appendectomy. She’s admitted to the hospital and undergoes mitral valve replacement surgery. After discharge, the client is scheduled for a tooth extraction. Which history finding is a major risk factor for infective endocarditis?

A. appendectomy
B. pernicious anemia
C. diabetes mellitus
D. valve replacement

33. A 62 yr-old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past two years. She’s fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Test reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl, and potassium level 3.8 mEq/L. which of the following nursing diagnoses is most appropriate for this client?

A. Deficient fluid volume related to inability to conserve water
B. Imbalanced nutrition: less than body requirements related to hypermetabolic state
C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
D. Imbalanced nutrition: less than body requirements related to catabolic effects of insulin deficiency

34. A 20 yr-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb (4.5 kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment?

A. Let the client eat as desired during the hospitalization.
B. Weight the client daily.
C. Ask the client to list what she eats during a typical day.
D. Place the client on I & O status and draw blood for electrolyte levels.

35. When instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave’s disease?

A. Keep an accurate record of intake and output.
B. Use nasal desmopressin acetate DDAVP).
C. Be sure to get regulate follow-up care.
D. Be sure to exercise to improve cardiovascular fitness.

36. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time?

A. Deficient knowledge related to interventions used to treat acute illness
B. Impaired physical mobility related to complete bed rest
C. Social isolation related to restricted visiting hours in the intensive care unit
D. Anxiety related to the threat of death

37. A client is admitted to the health care facility with active tuberculosis. The nurse should include which intervention in the plan of care?

A. Putting on a mask when entering the client’s room.
B. Instructing the client to wear a mask at all times
C. Wearing a gown and gloves when providing direct care
D. Keeping the door to the client’s room open to observe the client

38. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:

A. Apply suction to the NG tube every hour.
B. Clamp the NG tube if the client complains of nausea.
C. Irrigate the NG tube gently with normal saline solution.
D. Reposition the NG tube if pulled out.

39. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?

A. administer 2 to 3 L of IV fluid rapidly
B. administer 6 L of IV fluid over the first 24 hours
C. administer a dextrose solution containing normal saline solution
D. administer IV fluid slowly to prevent circulatory overload and collapse

40. Which of the following is an adverse reaction to glipizide (Glucotrol)?

A. headache
B. constipation
C. hypotension
D. photosensitivity

41. The nurse is caring for four clients on a stepdown intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who:

A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a jejunostomy tube

42. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

A. Make inhalation longer than exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.

43. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn’t answered immediately. The most appropriate response to her would be:

A. “You seem angry. Would you like to talk about it?”
B. “Calm down. You know that stress will make your symptoms worse.”
C. “Would you like to talk about the problem with the nursing supervisor?”
D. “I can see you’re angry. I’ll come back when you’ve calmed down.”

44. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relive symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?

A. Taking daily walks.
B. Engaging in anaerobic exercise.
C. Reducing daily fat intake to less than 45% of total calories
D. Avoiding foods that increase levels of highdensity lipoproteins (HDLs)

45. A physician orders gastric decompression for a client with small bowel obstruction. The nurse should plan for the suction to be:

A. low pressure and intermittent
B. low pressure and continuous
C. high pressure and continuous
D. high pressure and intermittent

46. Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?

A. Risk for injury
B. Impaired urinary elimination
C. Ineffective breathing pattern
D. Imbalanced nutrition: less than body requirements

47. Parathyroid hormone (PTH) has which effects on the kidney?

A. Stimulation of calcium reabsorption and phosphate excretion
B. Stimulation of phosphate reabsorption and calcium excretion
C. Increased absorption of vit D and excretion of vit E
D. Increased absorption of vit E and excretion of Vit D

48. A visiting nurse is performing home assessment for a 59-yr old man recently discharged after hip replacement surgery. Which home assessment finding warrants health promotion teaching from the nurse?

A. A bathroom with grab bars for the tub and toilet
B. Items stored in the kitchen so that reaching up and bending down aren’t necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with switches to the top and bottom of the stairs

49. A client with autoimmune thrombocytopenia and a platelet count of 800/uL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery—this will go away on its own.” In considering her response to the client, the nurse must depend on the ethical principle of:

A. beneficence
B. autonomy
C. advocacy
D. justice

50. Which of the following is t he most critical intervention needed for a client with myxedema coma?

A. Administering and oral dose of levothyroxine (Synthroid)
B. Warming the client with a warming blanket
C. Measuring and recording accurate intake and output
D. Maintaining a patent airway

51. Because diet and exercise have failed to control a 63 yr-old client’s blood glucose level, the client is prescribed glipizide (Glucotrol). After oral administration, the onset of action is:

A. 15 to 30 minutes
B. 30 to 60 minutes
C. 1 to 1 ½ hours
D. 2 to 3 hours

52. A client with pneumonia is receiving supplemental oxygen, 2 L/min via nasal cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which complication may arise if the client receives a high oxygen concentration?

A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis

53. A client with type 1 diabetes mellitus has been on a regimen of multiple daily injection therapy. He’s being converted to continuous subcutaneous insulin therapy. While teaching the client bout continuous subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use of:

A. intermediate and long-acting insulins
B. short and long-acting insulins
C. short-acting only
D. short and intermediate-acting insulins

54. a client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:

A. prevent leaning
B. distribute weight away from the involved side
C. maintain stride length
D. prevent edema

55. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac stepdown unit (CSU). While giving report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should be especially observant for:

A. hypertension
B. high urine output
C. dry mucous membranes
D. pulmonary crackles

56. The nurse is caring for a client with a fractures hip. The client is combative, confused, and trying to get out of bed. The nurse should:

A. leave the client and get help
B. obtain a physician’s order to restrain the client
C. read the facility’s policy on restraints
D. order soft restraints from the storeroom

57. For the first 72 hours after thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate which of the following?

A. hypocalcemia
B. hypercalcemia
C. hypokalemia
D. Hyperkalemia

58. In a client with enteritis and frequent diarrhea, the nurse should anticipate an acidbase imbalance of:

A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis

59. When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

A. position the client in a supine position
B. elevate the head of the bed 90 degrees during meals
C. encourage the client to remove dentures
D. encourage thin liquids for dietary intake

60. A nurse is caring for a client who has a tracheostomy and temperature of 39º C. which intervention will most likely lower the client’s arterial blood oxygen saturation?

A. Endotracheal suctioning
B. Encouragement of coughing
C. Use of cooling blanket
D. Incentive spirometry

61. A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:

A. fluid resuscitation
B. infection
C. body image
D. pain management

62. Which statement is true about crackles?

A. They’re grating sounds.
B. They’re high-pitched, musical squeaks.
C. They’re low-pitched noises that sound like snoring.
D. They may be fine, medium, or course.

63. A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter. Management of her care would include:

A. scheduling her for annual tuberculin skin testing
B. placing her in quarantine until sputum cultures are negative
C. gathering a list of persons with whom she has had recent contact
D. advising her to begin prophylactic therapy with isoniazid (INH)

64. The nurse is caring for a client who ahs had an above the knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells the nurse that he doesn’t wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the client’s problem is:

A. Hopelessness
B. Powerlessness
C. Disturbed body image
D. Fear

65. A client with three children who is still I the child bearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon’s preoperative teaching when the client states:

A. “If I should become pregnant again, the child would be delivered by cesarean delivery.”
B. “If I have another child, the procedure may need to be repeated.”
C. “This surgery may render me incapable of conceiving another child.”
D. “This procedure is accomplished in two separate surgeries.”

66. A client experiences problems in body temperature regulation associated with a skin impairment. Which gland is most likely involved?

A. Eccrine
B. Sebaceous
C. Apocrine
D. Endocrine

67. A school cafeteria worker comes to the physician’s office complaining of severe scalp itching. On inspection, the nurse finds nail marks on the scalp and small light-colored round specks attached to the hair shafts close to the scalp. These findings suggest that the client suffers from:

A. scabies
B. head lice
C. tinea capitis
D. impetigo

68. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:

A. erythema
B. leukocytosis
C. pressure-like pain
D. swelling

69. A 28 yr-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially suspected. The diagnosis is confirmed if the rash appears:

A. erythematous with raised papules
B. dry and scaly with flaking skin
C. inflamed with weeping and crusting lesions
D. excoriated with multiple fissures

70. When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately?

A. Complaints of intense thirst
B. Moderate to severe pain
C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice

71. A client is admitted to the hospital following a burn injury to the left hand and arm. The client’s burn is described as white and leathery with no blisters. Which degree of severity is this burn?

A. first-degree burn
B. second-degree burn
C. third-degree burn
D. fourth-degree burn

72. The nurse is caring for client with a new donor site that was harvested to treat a new burn. The nurse position the client to:

A. allow ventilation of the site
B. make the site dependent
C. avoid pressure on the site
D. keep the site fully covered

73. a 45-yr-old auto mechanic comes to the physician’s office because an exacerbation of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The nurse should respond by:

A. Inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris
B. Suggesting he take aspirin for relief because it’s probably early rheumatoid arthritis
C. Validating his complaint but assuming it’s an adverse effect of his vocation
D. Asking him if he has been diagnosed or treated for carpal tunnel syndrome

74. The nurse is providing home care instructions to a client who has recently had a skin graft. Which instruction is most important for the client to remember?

A. Use cosmetic camouflage techniques.
B. Protect the graft from direct sunlight.
C. Continue physical therapy.
D. Apply lubricating lotion to the graft site.

75. a 28 yr-old female nurse is seen in the employee health department for mild itching and rash of both hands. Which of the following could be causing this reaction?

A. possible medication allergies
B. current life stressors she may be experiencing
C. chemicals she may be using and use of latex gloves
D. recent changes made in laundry detergent or bath soap.

76. The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for:

A. hives
B. a toxin
C. a tubercle
D. a virus

77. A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

A. scale
B. crust
C. ulcer
D. scar

78. The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?

A. Turn and reposition the client a minimum of every 8 hours.
B. Vigorously massage lotion into bony prominences.
C. Post a turning schedule at the client’s bedside.
D. Slide the client, rather than lifting when turning.

79. Following a full-thickeness (3rd degree) burn of his left arm, a client is treated with artificial skin. The client understands postoperative care of the artificial skin when he states that during the first 7 days after the procedure, he’ll restrict:

A. range of motion
B. protein intake
C. going outdoors
D. fluid ingestion

80. A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

A. 9%
B. 18%
C. 27%
D. 36%

81. The nurse is providing care for a client who has a sacral pressure ulcer with wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?

A. The wound should remain moist form the dressing.
B. The wet-to-dry dressing should be tightly packed into the wound.
C. The dressing should be allowed to dry out before removal.
D. A plastic sheet-type dressing should cover the wet dressing.

82. While in skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home with six other persons. During her visit to the clinic, she asks a staff nurse, “What should my family do?” the most accurate response from the nurse is:

A. “All family members will need to be treated.”
B. “If someone develops symptoms, tell him to see a physician right away.”
C. “Just be careful not to share linens and towels with family members.”
D. “After you’re treated, family members won’t be at risk for contracting scabies.”

83. In an industrial accident, client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?

A. A urine output consistently above 100 ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24 hours.
C. Body temperature readings all within normal limits
D. An electrocardiogram (ECG) showing no arrhythmias.

84. The nurse is reviewing the laboratory results of a client with rheumatoid arthritis. Which of the following laboratory results should the nurse expect to find?

A. Increased platelet count
B. Elevated erythrocyte sedimentation rate (ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN) and creatinine levels

85. Which nursing diagnosis takes the highest priority for a client with Parkinson’s crisis?

A. Imbalanced nutrition: less than body requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury

86. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

A. Increase the frequency of the catheterizations.
B. Insert an indwelling urinary catheter
C. Place the client on fluid restrictions
D. Use a condom catheter instead of an invasive one.

87.The nurse is caring for a client who is to undergo a lumbar puncture to assess for the presence of blood in the cerebrospinal fluid (CSF) and to measure CSF pressure. Which result would indicate n abnormality?

A. The presence of glucose in the CSF.
B. A pressure of 70 to 200 mm H2O
C. The presence of red blood cells (RBCs) in the first specimen tube
D. A pressure of 00 to 250 mmH2O

88. The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:

A. conjunctival sac
B. pupil
C. sclera
D. vitreous humor

89. A 52 yr-old married man with two adolescent children is beginning rehabilitation following a cerebrovascular accident. As the nurse is planning the client’s care, the nurse should recognize that his condition will affect:

A. only himself
B. only his wife and children
C. him and his entire family
D. no one, if he has complete recovery

90. Which action should take the highest priority when caring for a client with hemiparesis caused by a cerebrovascular accident (CVA)?

A. Perform passive range-of-motion (ROM) exercises.
B. Place the client on the affected side.
C. Use hand rolls or pillows for support.
D. Apply antiembolism stockings

91. The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic attack (TIA). Which fact should the nurse include in the teaching plan?

A. TIA symptoms may last 24 to 48 hours.
B. Most clients have residual effects after having a TIA.
C. TIA may be a warning that the client may have cerebrovascular accident (CVA)
D. The most common symptom of TIA is the inability to speak.

92. The nurse has just completed teaching about postoperative activity to a client who is going to have a cataract surgery. The nurse knows the teaching has been effective if the client:

A. coughs and deep breathes postoperatively
B. ties his own shoes
C. asks his wife to pick up his shirt from the floor after he drops it.
D. States that he doesn’t need to wear an eyepatch or guard to bed

93. The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called:

A. contusion
B. concussion
C. coup
D. contrecoup

94. When the nurse performs a neurologic assessment on Anne Jones, her pupils are dilated and don’t respond to light.

A. glaucoma
B. damage to the third cranial nerve
C. damage to the lumbar spine
D. Bell’s palsy

95. A 70 yr-old client with a diagnosis of leftsided cerebrovascular accident is admitted to the facility. To prevent the development of diffuse osteoporosis, which of the following objectives is most appropriate?

A. Maintaining protein levels.
B. Maintaining vitamin levels.
C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises

96. A client is admitted with a diagnosis of meningitis caused by Neisseria meningitides. The nurse should institute which type of isolation precautions?

A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions

97. A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, “He was unconscious briefly and then became alert and behaved as though nothing had happened.” Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client’s intracranial pressure (ICP) is increasing, the nurse would expect to observe which of the following signs first?

A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness

98. Emergency medical technicians transport a 28 yr-old iron worker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.” Which intervention by the nurse has the highest priority?

A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness

99. Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial infarction. Which nursing intervention should appear on this client’s plan of care?

A. Perform activities of daily living for the client to decease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as much as possible.

100. For a client with a head injury whose neck has been stabilized, the preferred bed position is:

A. Trendelenburg’s
B. 30-degree head elevation
C. flat
D. side-lying
1. ANS: D
Because the client’s gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client’s risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

2. ANS: A
Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas.

3. ANS: A because celiac disease destroys the absorbing surface of the intestine, fat isn’t absorbed but is passed in the stool. Steatorrhea is bulky, fatty stools that have a foul odor. Jaundiced sclerae result from elevated bilirubin levels. Clay-colored stools are seen with biliary disease when bile flow is blocked. Celiac disease doesn’t cause a widened pulse pressure.

4. ANS: D
Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which changes blood vessel permeability and allows plasma to move into interstitial tissue, causing edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake doesn’t affect the glomerular filtration rate. Potassium absorption is improved only by increasing the glomerular filtration rate; it isn’t affected by sodium intake.

5. ANS: D
The portion of the cerebrum that controls speech and hearing is the temporal lobe. Injury to the frontal lobe causes personality changes, difficulty speaking, and disturbance in memory, reasoning, and concentration. Injury to the parietal lobe causes sensory alterations and problems with spatial relationships. Damage to the occipital lobe causes vision disturbances.

6. ANS: D
Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing’s syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

7.ANS: C
The client should report the presence of foulsmelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal because of residual stone products. Hematuria is common after lithotripsy.

8.ANS: A
A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the client’s serum glucose is elevated, food isn’t a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced Nutrition: Less then body requirements isn’t appropriate. A temperature of 100.6º F isn’t life threatening, eliminating ineffective thermoregulation as the top priority.

9. ANS: C
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

10. ANS: A
CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the following formula:
MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s ICP from the MAP; in this case , 70 mmHg – 18 mmHg = 52 mmHg.

11. ANS: B
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. Nipple retraction —not eversion—may be a sign of cancer. A mobile mass that is soft and easily delineated is most often a fluid-filled benigned cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass.

12.ANS: D
An enterostomal nurse therapist is a registered nurse who has received advance education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support.

13.ANS: A
Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the dura commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done.

14. ANS: D
Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens.

15. ANS: B
Before weaning a client from mechanical ventilation, it’s most important to have a baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client’s record, and the nurse can refer to them before the weaning process begins.

16. ANS: B
According to the ACS guidelines, “Women older than age 40 should perform breast selfexamination monthly (not annually).” The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.

17.ANS: C
Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus. Bleeding associated with esophageal varices doesn’t stem from esophageal perforation, pulmonary hypertension, or peptic ulcers.

18. ANS: B
Complex intra-articular fractures are repaired with external fixators because they have a better long-term outcome than those treated with casting. This is especially true in a young client. The incidence of complications, such as pin tract infections and neuritis, is 20% to 60%. Clients must be taught how to do pin care and assess for development of neurovascular complications.

19.ANS: C
In a client with chronic renal failure, unrestricted intake of sodium, protein, potassium, and fluids may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit his intake of sodium, meat (high in Protein), bananas (high in potassium), and fluid because the kidneys can’t secrete adequate urine.

20.ANS: D
The client isn’t withdrawn or showing other signs of anxiety or depression. Therefore, the nurse can probably safely approach her about talking with others who have had similar experiences, either through Reach for Recovery or another formal support group. The nurse may educate the client’s spouse or partner to listen to concerns, but the nurse shouldn’t tell the client’s spouse what to do. The client must consult with her physician and make her own decisions about further treatment. The client needs to express her sadness, frustration, and fear. She can’t be expected to be cheerful at all times.

21. ANS: C
HCG is one of the tumor markers for testicular cancer. The HCG level won’t identify the site of an infection or evaluate prostatic function or testosterone level.

22.ANS: B
Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but the don’t indicate that therapy isn’t effective.

23. ANS: A
Tenting of chest skin when pinched indicates decreased skin elasticity due to dehydration. Hand veins fill slowly with dehydration, not rapidly. A pulse that isn’t easily obliterated and neck vein distention indicate fluid overload, not dehydration.

24. ANS: B
The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low-sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis.

25. ANS: B
Because thrombocytopenia impairs blood clotting, the nurse should assess the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it can increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

26. ANS: B
SaO2 is the degree to which hemoglobin is saturated with oxygen. It doesn’t indicate the client’s overall Hgb adequacy. Thus, an individual with a subnormal Hgb level could have normal SaO2 and still be short of breath. In this case, the nurse could assume that the client has a Hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn’t enough data to assume that the client’s problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles.

27. ANS: A
Addisonian crisis results in Hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.

28. ANS: D
Leukemia is manifested by an abnormal overpopulation of immature leukocytes in the bone marrow.

29. ANS: C
A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing microorganisms to contaminate the field. The outside of containers, such as sterile saline bottles, aren’t sterile. The containers should be opened before sterile gloves are put on and the solution poured over the sterile dressings placed in a sterile basin. Wounds should be cleaned from the most contaminated area to the least contaminated area—for example, from the center outward. The outer inch of a sterile field shouldn’t be considered sterile.

30.ANS: C
Caffeine is a stimulant, which can exacerbate palpitations and should be avoided by a client with symptomatic mitral valve prolapse. High fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps in increase cardiac output and decrease heart rate. Protein-rich foods aren’t restricted but high calorie foods are.

31. ANS: A
Excessive of aldosterone in the adrenal cortex is responsible for the client’s hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the cathecolamines—epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.

32. ANS: D
A heart valve prosthesis, such as a mitral valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, IV drug abuse, and immunosuppression. Although diabetes mellitus may predispose a person to cardiovascular disease, it isn’t a major risk factor for infective endocarditis, nor is an appendectomy or pernicious anemia.

33. ANS: A
The client has signs and symptoms of diabetes insipidus, probably caused by the failure of her renal tubules to respond to antidiuretic hormone as a consequence of pyelonephritis. The hypernatremia is secondary to her water loss. Imbalanced nutrition related to hypermetabolic state or catabolic effect of insulin deficiency is an inappropriate nursing diagnosis for the client.

34. ANS: C
When performing a nutritional assessment, one of the first things the nurse should do is to assess what the client typically eats. The client shouldn’t be permitted to eat as desired. Weighing the client daily, placing her on I & O status, and drawing blood to determine electrolyte level aren’t part of a nutritional assessment.

35. Ans. C
Regular follow-up care for the client with Grave’s disease is critical because most cases eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the client’s ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early. Intake and output is important for clients with fluid and electrolyte imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. While exercise to improve cardiovascular fitness is important, for this client the importance of regular follow-up is most critical.

36. ANS: D
Anxiety related to the threat of death is an appropriate nursing diagnosis because the client’s anxiety can adversely affect hear rate and rhythm by stimulating the autonomic nervous system. Also, because the client required resuscitation, the threat of death is a real and immediate concern. Unless anxiety is dealt with first, the client’s emotional state will impede learning. Client teaching should be limited to clear concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so the deficient knowledge would continue despite attempts teaching. Impaired physical mobility and social isolation are necessitated by the client’s critical condition; therefore, they aren’t considered problems warranting nursing diagnoses.

37. ANS: A
Because tuberculosis is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client’s room. Having the client wear a mask at all the times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client’s blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with tuberculosis should be in a room with laminar air flow, and the door should be closed at all times.

38. ANS: C
The nurse can gently irrigate the tube but must take care not to reposition it. Repositioning can cause bleeding. Suction should be applied continuously, not every hour. The NG tube shouldn’t be clamped postoperatively because secretions and gas will accumulate, stressing the suture line.

39. ANS: A
Regardless of the client’s medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly prescribed fluids include dextran (in case of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution.

40.ANS: D
Glipizide may cause adverse skin reactions, such as pruritus, and photosensitivity. It doesn’t cause headache, constipation, or hypotension.

41. ANS: B
When clients are on mechanical ventilation, the artificial airway impairs the gag and cough reflexes that help keep organisms out of the lower respiratory tract. The artificial airway also prevents the upper respiratory system from humidifying and heating air to enhance mucociliary clearance. Manipulations of the artificial airway sometimes allow secretions into the lower airways. Whit standard procedures the other choices wouldn’t be at high risk.

42. ANS: C
In chronic bronchitis, the diaphragmatic is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing—not chest breathing—increases lung expansion.

43. ANS: A
Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn’t acknowledge her feelings. Offering to get the nursing supervisor also doesn’t acknowledge the client’s feelings. Ignoring the client’s feelings suggest that the nurse has no interest in what the client has said.

44. ANS: A
Daily walks relieve symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may exacerbate these symptoms. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat foods that raise HDL levels.

45. ANS: A
Gastric decompression is typically low pressure and intermittent. High pressure and continuous gastric suctioning predisposes the gastric mucosa to injury and ulceration.

46. ANS: A
In osteoarthritis, stiffness is common in large, weight bearing joints such as the hips. This joint stiffness alters functional ability and range of motion, placing the client at risk for falling and injury. Therefore, client safety is in jeopardy. Osteoporosis doesn’t affect urinary elimination, breathing, or nutrition.

47. ANS: A
PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vit D to its active form: 1 , 25 dihydroxy vitamin D. PTH doesn’t have a role in the metabolism of Vit E.

48. ANS: C
The presence of unsecured area rugs poses a hazard in all homes, particularly in one with a resident at high risk for falls.

49. ANS: B
Autonomy ascribes the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence and justice aren’t the principles that directly relate to the situation. Advocacy is the nurse’s role in supporting the principle of autonomy.

50. ANS: D
Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Thyroid replacement will be administered IV. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldn’t be used because it may cause vasodilation and shock. Gradual warming blankets would be appropriate. Intake and output are very important but aren’t critical interventions at this time.

51. ANS: A
Glipizide begins to act in 15 to 30 minutes. The other options are incorrect.

52.ANS: A
Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don’t cause metabolic acidosis.

53. ANS: C
Continuous subcutaneous insulin regimen uses a basal rate and boluses of short-acting insulin. Multiple daily injection therapy uses a combination of short-acting and intermediate or long-acting insulins.

54. ANS: B
Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Use of a cane won’t maintain stride length or prevent edema.

55. ANS: D
High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With leftsided heart failure, pulmonary edema can develop causing pulmonary crackles. In leftsided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren’t directly associated with elevated pulmonary artery wedge pressures.

56.ANS: B
It’s mandatory in most settings to have a physician’s order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility’s policy.

57. ANS: A
The client who has undergone a thyroidectomy is t risk for developing hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek’s sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau’s sign (carpal spasm when a blood pressure cuff is inflated for few minutes). These signs aren’t present with hypercalcemia, hypokalemia, or Hyperkalemia.

58. ANS: C
Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates leading to metabolic acidosis. Diarrhea doesn’t lead to respiratory acid-base imbalances, such as respiratory acidosis and respiratory alkalosis. Loss of acid, which occurs with severe vomiting, may lead to metabolic alkalosis.

59. ANS: B
The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position—not a supine position— when lying down to reduce the risk of aspiration. Encourage the client to wear properly fitted dentures to enhance his chewing ability. Thickened liquids, not thin liquids, decrease aspiration risk.

60.ANS: A
Endotracheal suctioning secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and incentive spirometry improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn’t be affected.

61. ANS: D
With a superficial partial thickness burn such as a solar burn (sunburn), the nurse’s main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has a lower priority than pain management.

62. ANS: D
Crackles result from air moving through airways that contain fluid. Heard during inspiration and expiration, crackles are discrete sounds that vary in pitch and intensity. They’re classified as fine, medium, or coarse. Pleural friction rubs have a distinctive grating sound. As the name indicates, these breath sounds result when inflamed pleurae rub together. Continuous, highpitched, musical squeaks, called wheezes, result when air moves rapidly through airways narrowed by asthma or infection or when an airway is partially obstructed by a tumor or foreign body. Wheezes, like gurgles, occur on expiration and sometimes on inspiration. Loud, coarse, low-pitched sounds resembling snoring are called gurgles. These sounds develop when thick secretions partially obstruct airflow through the large upper airways.

63. Ans. D
Individuals who are tuberculin skin test converters should begin a 6-month regimen of an antitubercular drug such as INH, and they should never have another skin test. After an individual has a positive tuberculin skin test, subsequent skin tests will cause severe skin reactions but won’t provide new information about the client’s TB status. The client doesn’t have active TB, so can’t transmit, or spread, the bacteria. Therefore, she shouldn’t be quarantined or asked for information about recent contacts.

64. ANS: C
Disturbed body image is a negative perception of the self that makes healthful functioning more difficult. The defining characteristics for this nursing diagnosis include undergoing a change in body structure or function, hiding or overexposing a body part, not looking at a body part, and responding verbally or nonverbally to the actual or perceived change in structure or function. This client may have any of the other diagnoses, but the signs and symptoms described in he case most closely match the defining characteristics for disturbed body image.

65. ANS: B
Because the pregnant uterus exerts a lot of pressure on the urinary bladder, the bladder repair may need to be repeated. These clients don’t necessarily have to have a cesarean delivery if they become pregnant, and this procedure doesn’t render them sterile. This procedure is completed in one surgery.

66. ANS: A
Eccrine glands are associated with body temperature regulation. Sebaceous glands lubricate the skin and hairs, and apocrine glands are involved in bacteria decomposition. Endocrine glands secrete hormones responsible for the regulation of body processes, such as metabolism and glucose regulation.

67.ANS: B
The light-colored spots attached to the hair shafts are nits, which are the eggs of head lice. They can’t be brushed off the hair shaft like dandruff. Scabies is a contagious dermatitis caused by the itch mite, Sacoptes scabiei, which lives just beneath the skin. Tinea capitis, or ringworm, causes patchy hair loss and circular lesions with healing centers. Impetigo is an infection caused by Staphylococcus or Sterptococcus, manifested by vesicles or pustules that form a thick, honey-colored crust.

68. ANS: C
Severe pressure-like pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulites. Erythema, leukocytosis, and swelling are present in both cellulites and necrotizing fasciitis.

69. ANS: A
Contact dermatitis is caused by exposure to a physical or chemical allergen, such as cleaning products, skin care products, and latex gloves. Initial symptoms of itching, erythema, and raised papules occur at the site of the exposure and can begin within 1 hour of exposure. Allergic reactions tend to be red and not scaly or flaky. Weeping, crusting lesions are also uncommon unless the reaction is quite severe or has been present for a long time. Excoriation is more common in skin disorders associated with a moist environment.

70.ANS: D
Hoarseness indicate injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client’s output is adequate.

71. ANS: C
Third-degree burn may appear white, red, or black and are dry and leathery with no blisters. There may be little pain because nerve endings have been destroyed. First-degree burns are superficial and involve the epidermis only. There is local pain and redness but no blistering. Second-degree burn appear red and moist with blister formation and are painful. Fourth-degree burns involve underlying muscle and bone tissue.

72. ANS: C
A universal concern I the care of donor sites for burn care is to keep the site away from sources of pressure. Ventilation of the site and keeping the site fully covered are practices in some institutions but aren’t hallmarks of donor site care. Placing the site in a position of dependence isn’t a justified aspect of donor site care.

73. ANS: A
Anyone with psoriasis vulgaris who reports joint pain should be evaluated for psoriaic arthritis. Approximately 15% to 20% of individuals with psoriasis will also develop psoriatic arthritis, which can be painful and cause deformity. It would be incorrect to assume that his pain is caused by early rheumatoid arthritis or his vocation without asking more questions or performing diagnostic studies. Carpal tunnel syndrome causes sensory and motor changes in the fingers rather than localized pain in the joints.

74. ANS: B
To avoid burning and sloughing, the client must protect the graft from sunlight. The other three interventions are all helpful to the client and his recovery but are less important.

75.ANS: C
Because the itching and rash are localized, an environmental cause in the workplace should be suspected. With the advent of universal precautions, many nurses are experiencing allergies to latex gloves. Allergies to medications, laundry detergents, or bath soaps or a dermatologic reaction to stress usually elicit a more generalized or widespread rash.

76.ANS: A
Hives and urticaria are two names for the same skin lesion. Toxin is a poison. A tubercle is a tiny round nodule produced by the tuberculosis bacillus. A virus is an infectious parasite.

77. ANS: A
A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don’t accompany psoriasis.

78. ANS: C
A turning schedule with a signing sheet will help ensure that the client gets turned and thus, help prevent pressure ulcers. Turning should occur every 1-2 hours—not every 8 hours—for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift rather than slide the client to void shearing.

79.ANS: A
To prevent disruption of the artificial skin’s adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

80.ANS: C
According to the Rule of Nines, the posterior and anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body durface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27%.

81.ANS: A
A wet-to-dry saline dressing should always keep the wound moist. Tight packing or dry packing can cause tissue damage and pain. A dry gauze —not a plastic-sheet-type dressing—should cover the wet dressing.

82. ANS: A
When someone in a group of persons sharing a home contracts scabies, each individual in the same home needs prompt treatment whether he’s symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop

83.ANS: A
In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn’t a goal. In fact, a 4 lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators.

84. ANS: B
The ESR test is performed to detect inflammatory processes in the body. It’s a nonspecific test, so the health care professional must view results in conjunction with physical signs and symptoms. Platelet count, electrolytes, BUN, and creatinine levels aren’t usually affected by the inflammatory process.

85.ANS: B
In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client who is confined to bed during a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, ineffective airway clearance is the priority diagnosis for this client. Although imbalanced nutrition:less than body requirements, impaired urinary elimination and risk for injury also are appropriate diagnoses for this client, they aren’t immediately lifethreatening and thus are less urgent.

86.ANS: A
As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren’t indicated for this case; the problem isn’t overhydration, rather it’s urine retention. A condom catheter doesn’t help empty the bladder of a client with urine retention.

87.ANS: D
The normal pressure is 70 to 200 mm H2O are considered abnormal. The presence of glucose is an expected finding in CSF, and RBCs typically occur in the first specimen tube from the trauma caused by the procedure.

88. ANS: A
The nurse should instill the eyedrop into the conjunctival sac where absorption can best take place. The pupil permits light to enter the eye. The sclera maintains the eye’s shape and size. The vitreous humor maintains the retina’s placement and the shape of the eye.

89.ANS: C
According to family theory, any change in a family member, such as illness, produces role changes in all family members and affects the entire family, even if the client eventually recovers completely.

90.ANS: B
To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a client with hemiparesis on the affected side. Although performing ROM exercises, providing pillows for support, and applying antiembolism stockings can be appropriate for a client with CVA, the first concern is to maintain a patent airway.

91. ANS: C
TIA may be a warning that the client will experience a CVA, or stroke, in the near future. TIA aymptoms last no longer than 24 hours and clients usually have complete recovery after TIA. The most common symptom of TIA is sudden, painless loss of vision lasting up to 24 hours.

92. ANS: C
Bending to pick up something from the floor would increase intraocular pressure, as would bending to tie his shoes. The client needs to wear eye protection to bed to prevent accidental injury during sleep.

93. ANS: B
Concussions are considered minor with no structural signs of injury. A contusion is bruising of the brain tissue with small hemorrhages in the tissue. Coup and contrecoup are type of injuries in which the damaged area on the brain forms directly below that site of impact (coup) or at the site opposite the injury (contrecoup) due to movement of the brain within the skull.

94. ANS: B
The third cranial nerve (oculomotor) is responsible for pupil constriction. When there is damage to the nerve, the pupils remain dilated and don’t respond to light. Glaucoma, lumbar spine injury, and Bell’s palsy won’t affect pupil constriction.

95.ANS: C
When the mechanical stressors of weight bearing are absent, diffuse osteoporosis can occur. Therefore, if the client does weight-bearing exercises, disuse complications can be prevented. Maintaining protein and vitamins levels is important, but neither will prevent osteoporosis. ROM exercises will help prevent muscle atrophy and contractures.

96. ANS: B
This client requires droplet precautions because the organism can be transmitted through airborne droplets when the client coughs, sneezes, or doesn’t cover his mouth. Airborne precautions would be instituted for a client infected with tuberculosis. Standard precautions would be instituted for a client when contact with body substances is likely. Contact precautions would be instituted for a client infected with an organism that is transmitted through skin-to-skin contact. 97. ANS: D
With a brain injury such as an epidural hematoma (a diagnosis that is most likely based on this client’s symptoms), the initial sign of increasing ICP is a change in the level of consciousness. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur. 98.ANS: A
In the scenario, airway and breathing are established so the nurse’s next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Neurologic assessment is a secondary concern to airway, breathing and circulation. The nurse doesn’t have enough data to warrant putting the client in Trendelenburg’s position.

99. ANS: C
Establishing and maintaining a routine is essential to decreasing extraneous stimuli. The client should participate in daily care as much as possible. Attempting to reason with such clients isn’t successful, because they can’t participate in abstract thinking.

100. ANS: B
For clients with increased intracranial pressure (ICP), the head of the bed is elevated to promote venous outflow. Trendelenburg’s position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. Sidelying isn’t specifically a therapeutic treatment for increased ICP.

1. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be:
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs
2. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:
a. Decrease anxiety and restlessness
b. Prevents shock and relieves pain
c. Dilates coronary blood vessels
d. Helps prevent fibrillation of the heart
3. Which of the following should the nurse teach the client about the signs of digitalis toxicity?
a. Increased appetite
b. Elevated blood pressure
c. Skin rash over the chest and back
d. Visual disturbances such as seeing yellow spots
4. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help…
a. Retard rapid drug absorption
b. Excrete excessive fluids accumulated at night
c. Prevents sleep disturbances during night
d. Prevention of electrolyte imbalance
5. What would be the primary goal of therapy for a client with pulmonary edema and heart failure?
a. Enhance comfort
b. Increase cardiac output
c. Improve respiratory status
d. Peripheral edema decreased
6. Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?
a. Upper extremity flexion with lower extremity flexion
b. Upper extremity flexion with lower extremity extension
c. Extension of the extremities after a stimulus
d. Flexion of the extremities after stimulus
7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:
a. GI bleeding
b. Peptic ulcer disease
c. Abdominal cramps
d. Partial bowel obstruction
8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?
a. Monitoring urine output frequently
b. Monitoring blood pressure every 4 hours
c. Obtaining serum potassium levels daily
d. Obtaining infusion pump for the medication
9. During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome?
a. Able to perform self-care activities without pain
b. Severe chest pain
c. Can recognize the risk factors of Myocardial Infarction
d. Can Participate in cardiac rehabilitation walking program
10. A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:
a. Application of elastic stockings to prevent flaccid by muscle
b. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
c. Use a bed cradle to prevent dorsiflexion of feet
d. Do passive range of motion exercise
11. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be…
a. Hourly urine output
b. Temperature
c. Able to turn side to side
d. Able to sips clear liquid
12. A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is…..
a. To determine the existence of CHD
b. To visualize the disease process in the coronary arteries
c. To obtain the heart chambers pressure
d. To measure oxygen content of different heart chambers
13. During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to…
a. Elevate clients bed at 45°
b. Instruct the client to cough and deep breathe every 2 hours
c. Frequently monitor client’s apical pulse and blood pressure
d. Monitor clients temperature every hour
14. Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?
a. Protamine Sulfate
b. Quinidine Sulfate
c. Vitamin C
d. Coumadin
15. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of…
a. Dental floss
b. Electric toothbrush
c. Manual toothbrush
d. Irrigation device
16. Among the following signs and symptoms, which would most likely be present in a client with mitral gurgitation?
a. Altered level of consciousness
b. Exceptional Dyspnea
c. Increase creatine phospholinase concentration
d. Chest pain
17. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the…
a. Urinary meatus
b. Pain in the Labium
c. Suprapubic area
d. Right or left costovertebral angle
18. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function.
a. Blood pressure
b. Consciousness
c. Distension of the bladder
d. Pulse rate
19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?
a. Tonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Clonic seizure
20. Smoking cessation is critical strategy for the client with Burgher’s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication?
a. Paracetamol
b. Ibuprofen
c. Nitroglycerin
d. Nicotine (Nicotrol)
21. Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by:
a. Episodic vasospastic disorder of capillaries
b. Episodic vasospastic disorder of small veins
c. Episodic vasospastic disorder of the aorta
d. Episodic vasospastic disorder of the small arteries
22. Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because…
a. More accurate
b. Can be done by the client
c. It is easy to perform
d. It is not influenced by drugs
23. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost…
a. 0.3 L
b. 1.5 L
c. 2.0 L
d. 3.5 L
24. Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of:
a. Osmosis
b. Diffusion
c. Active transport
d. Filtration
25. Myrna a 52 year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking?
a. Left leg discomfort
b. Weak biceps brachii
c. Triceps muscle spasm
d. Forearm weakness
26. Which of the following statements should the nurse teach the neutropenic client and his family to avoid?
a. Performing oral hygiene after every meal
b. Using suppositories or enemas
c. Performing perineal hygiene after each bowel movement
d. Using a filter mask
27. A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in
a. Sims position
b. Supine position
c. Semi-fowlers position
d. Dorsal recumbent position
28. Which nursing intervention ensures adequate ventilating exchange after surgery?
a. Remove the airway only when client is fully conscious
b. Assess for hypoventilation by auscultating the lungs
c. Position client laterally with the neck extended
d. Maintain humidified oxygen via nasal canula
29. George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should…
a. “Strip” the chest tube catheter
b. Check the system for air leaks
c. Recognize the system is functioning correctly
d. Decrease the amount of suction pressure
30. A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that…
a. I can eat celery sticks and carrots
b. I can eat broiled scallops
c. I can eat shredded wheat cereal
d. I can eat spaghetti on rye bread
31. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased…
a. Pressure in the portal vein
b. Production of serum albumin
c. Secretion of bile salts
d. Interstitial osmotic pressure
32. A newly admitted client is diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?
a. Vital signs
b. Incision site
c. Airway
d. Level of consciousness
33. A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?
a. Systolic blood pressure less than 90mm Hg
b. Pupils unequally dilated
c. Respiratory rate of 4 breath/min
d. Pulse rate less than 60bpm
34. Nurse Lucy is planning to give pre operative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?
a. Results of the surgery will be immediately noticeable postoperatively
b. Normal saline nose drops will need to be administered preoperatively
c. After surgery, nasal packing will be in place 8 to 10 days
d. Aspirin containing medications should not be taken 14 days before surgery
35. Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem?
a. Regular insulin
b. Potassium
c. Sodium bicarbonate
d. Calcium gluconate
36. Dr. Marquez tells a client that an increase intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:
a. Fish and fruit jam
b. Oranges and grapefruit
c. Carrots and potatoes
d. Spinach and mangoes
37. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client should…
a. Rest in sitting position
b. Take a short walk
c. Drink plenty of water
d. Lie down at least 30 minutes
38. After gastroscopy, an adaptation that indicates major complication would be:
a. Nausea and vomiting
b. Abdominal distention
c. Increased GI motility
d. Difficulty in swallowing
39. A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:
a. “Most people need to eat a high protein diet for 12 months after surgery”
b. “I should not eat those foods that upset me before the surgery”
c. “I should avoid fatty foods as long as I live”
d. “Most people can tolerate regular diet after this type of surgery”
40. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is:
a. Restlessness
b. Yellow urine
c. Nausea
d. Clay- colored stools
41. Which of the following antituberculosis drugs can damage the 8th cranial nerve?
a. Isoniazid (INH)
b. Paraoaminosalicylic acid (PAS)
c. Ethambutol hydrochloride (myambutol)
d. Streptomycin
42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following:
a. Genetic defect in gastric mucosa
b. Stress
c. Diet high in fat
d. Helicobacter pylori infection
43. Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
a. Bile green
b. Bright red
c. Cloudy white
d. Dark brown
44. Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the post operative period. Which of the following is best recommended for the client?
a. Watching circus
b. Bending over
c. Watching TV
d. Lifting objects
45. A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing:
a. Fracture
b. Strain
c. Sprain
d. Contusion
46. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part of the procedure
a. Pulling the auricle backward and upward
b. Warming the solution to room temperature
c. Pacing the tip of the dropper on the edge of ear canal
d. Placing client in side lying position
47. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom?
a. Absence of drainage from the ileostomy for 6 or more hours
b. Passage of liquid stool in the stoma
c. Occasional presence of undigested food
d. A temperature of 37.6 °C
48. Jerry has diagnosed with appendicitis. He develops a fever, hypotension and tachycardia. The nurse suspects which of the following complications?
a. Intestinal obstruction
b. Peritonitis
c. Bowel ischemia
d. Deficient fluid volume
49. Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis.
a. Myocardial Infarction
b. Cirrhosis
c. Peptic ulcer
d. Pneumonia
50. Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit?
a. Watery stool
b. Yellow sclera
c. Tarry stool
d. Shortness of breath

B. Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.
 B. Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.
 D. Seeing yellow spots and colored vision are common symptoms of digitalis toxicity
 C. When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.
 B. The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergencyrequiring immediate intervention.
 C. Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury.
 C. The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea.
 D. Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.
 A. By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain
 B. The left side of the body will be affected in a right-sided brain attack.
 A. After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early.
 B. The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries.
 C. Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. Apical pulse is taken to detect dysrhythmias related to cardiac irritability.
 A. Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery.
 C. The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.
 B. Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation.
 D. Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side.
 A. Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output.
 C. Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.
 D. Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome.
 D. Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.
 A. Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure.
 C. One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L.
 A. Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.
 D. Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.
 B. Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract.
 C. Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.
 C. Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur.
 B. Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.
 C. Wheat cereal has a low sodium content.
 A. Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites.
 C. Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange.
 A. Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
 D. Aspirin containing medications should not be taken 14 days before surgery to decrease the risk of bleeding.
 A. Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem.
 D. Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives,spinach, asparagus and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots, mangoes and tomatoes.
 A. Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.
 B. Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis.
 D. It may take 4 to 6 months to eat anything, but most people can eat anything they want.
 D. Clay colored stools are indicative of hepatic obstruction
 D. Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity) is a common side effect of aminoglycosides.
 D. Most peptic ulcer is caused by Helicopter pylori which is a gram negative bacterium.
 D. 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food.
 C. Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure.
 A. Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling.
 C. The dropper should not touch any object or any part of the client’s ear.
 A. Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed.
 B. Complications of acute appendicitis are peritonitis, perforation and abscess development.
 D. A client with acute pancreatitis is prone to complications associated with respiratory system.
 B. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.
1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
a. Diuretics
b. Antihypertensive
c. Steroids
d. Anticonvulsants
2. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
a. Increase the flow of normal saline
b. Assess the pain further
c. Notify the blood bank
d. Obtain vital signs.
3. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:
a. A history of high risk sexual behaviors.
b. Positive ELISA and western blot tests
c. Identification of an associated opportunistic infection
d. Evidence of extreme weight loss and high fever
4. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
a. Raw carrots
b. Apple juice
c. Whole wheat bread
d. Cottage cheese
5. Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:
a. Flapping hand tremors
b. An elevated hematocrit level
c. Hypotension
d. Hypokalemia
6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
a. Flank pain radiating in the groin
b. Distention of the lower abdomen
c. Perineal edema
d. Urethral discharge
7. A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:
a. Assist the client with sitz bath
b. Apply war soaks in the scrotum
c. Elevate the scrotum using a soft support
d. Prepare for a possible incision and drainage.
8. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
a. Liver disease
b. Myocardial damage
c. Hypertension
d. Cancer
9. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
a. Right atrium
b. Superior vena cava
c. Aorta
d. Pulmonary
10. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
a. Ineffective health maintenance
b. Impaired skin integrity
c. Deficient fluid volume
d. Pain
11. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
a. high blood pressure
b. stomach cramps
c. headache
d. shortness of breath
12. The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
a. High levels of low density lipid (LDL) cholesterol
b. High levels of high density lipid (HDL) cholesterol
c. Low concentration triglycerides
d. Low levels of LDL cholesterol.
13. Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
a. Potential wound infection
b. Potential ineffective coping
c. Potential electrolyte balance
d. Potential alteration in renal perfusion
14. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
a. dairy products
b. vegetables
c. Grains
d. Broccoli
15. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
d. Intake and out put
16. Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be:
a. signed consent
b. vital signs
c. name band
d. empty bladder
17. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
a. 4 to 12 years.
b. 20 to 30 years
c. 40 to 50 years
d. 60 60 70 years
18. Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except
a. effects of radiation
b. chemotherapy side effects
c. meningeal irritation
d. gastric distension
19. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?
a. Administering Heparin
b. Administering Coumadin
c. Treating the underlying cause
d. Replacing depleted blood products
20. Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
a. Urine output greater than 30ml/hr
b. Respiratory rate of 21 breaths/minute
c. Diastolic blood pressure greater than 90 mmhg
d. Systolic blood pressure greater than 110 mmhg
21. Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
a. Stomatitis
b. Airway obstruction
c. Hoarseness
d. Dysphagia
22. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
a. Promotes the removal of antibodies that impair the transmission of impulses
b. Stimulates the production of acetylcholine at the neuromuscular junction.
c. Decreases the production of autoantibodies that attack the acetylcholine receptors.
d. Inhibits the breakdown of acetylcholine at the neuromuscular junction.
23. A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
a. Vital signs q4h
b. Weighing daily
c. Urine output hourly
d. Level of consciousness q4h
24. Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen like insulin delivery devices. The nurse explains that the advantages of these devices over syringes includes:
a. Accurate dose delivery
b. Shorter injection time
c. Lower cost with reusable insulin cartridges
d. Use of smaller gauge needle.
25. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
a. Swelling of the left thigh
b. Increased skin temperature of the foot
c. Prolonged reperfusion of the toes after blanching
d. Increased blood pressure
26. After a long leg cast is removed, the male client should:
a. Cleanse the leg by scrubbing with a brisk motion
b. Put leg through full range of motion twice daily
c. Report any discomfort or stiffness to the physician
d. Elevate the leg when sitting for long periods of time.
27. While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:
a. Buttocks
b. Ears
c. Face
d. Abdomen
28. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:
a. Palms of the hands and axillary regions
b. Palms of the hand
c. Axillary regions
d. Feet, which are set apart
29. Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
a. Active joint flexion and extension
b. Continued immobility until pain subsides
c. Range of motion exercises twice daily
d. Flexion exercises three times daily
30. A male client has undergone spinal surgery, the nurse should:
a. Observe the client’s bowel movement and voiding patterns
b. Log-roll the client to prone position
c. Assess the client’s feet for sensation and circulation
d. Encourage client to drink plenty of fluids
31. Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs of developing:
a. Hypovolemia
b. renal failure
c. metabolic acidosis
d. hyperkalemia
32. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
a. Protein
b. Specific gravity
c. Glucose
d. Microorganism
33. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?
a. Electrolyte imbalance
b. Head trauma
c. Epilepsy
d. Congenital defect
34. What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
a. Pupil size and papillary response
b. cholesterol level
c. Echocardiogram
d. Bowel sounds
35. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
a. “Practice using the mechanical aids that you will need when future disabilities arise”.
b. “Follow good health habits to change the course of the disease”.
c. “Keep active, use stress reduction strategies, and avoid fatigue.
d. “You will need to accept the necessity for a quiet and inactive lifestyle”.
36. The nurse is aware the early indicator of hypoxia in the unconscious client is:
a. Cyanosis
b. Increased respirations
c. Hypertension
d. Restlessness
37. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
a. Normal
b. Atonic
c. Spastic
d. Uncontrolled
38. Which of the following stage the carcinogen is irreversible?
a. Progression stage
b. Initiation stage
c. Regression stage
d. Promotion stage
39. Among the following components thorough pain assessment, which is the most significant?
a. Effect
b. Cause
c. Causing factors
d. Intensity
40. A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?
a. Sleeping in cool and humidified environment
b. Daily baths with fragrant soap
c. Using clothes made from 100% cotton
d. Increasing fluid intake
41. Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
a. A client with high blood
b. A client with bowel obstruction
c. A client with glaucoma
d. A client with U.T.I
42. Among the following clients, which among them is high risk for potential hazards from the surgical experience?
a. 67-year-old client
b. 49-year-old client
c. 33-year-old client
d. 15-year-old client
43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?
a. Headache
b. Bladder distension
c. Dizziness
d. Ability to move legs
44. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s disease except:
a. Antiemetics
b. Diuretics
c. Antihistamines
d. Glucocorticoids
45. Which of the following complications associated with tracheostomy tube?
a. Increased cardiac output
b. Acute respiratory distress syndrome (ARDS)
c. Increased blood pressure
d. Damage to laryngeal nerves
46. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules
47. An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:
a. increased capillary fragility and permeability
b. increased blood supply to the skin
c. self inflicted injury
d. elder abuse
48. Nurse Anna is aware that early adaptation of client with renal carcinoma is:
a. Nausea and vomiting
b. flank pain
c. weight gain
d. intermittent hematuria
49. A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be:
a. 1 to 3 weeks
b. 6 to 12 months
c. 3 to 5 months
d. 3 years and more
50. A client has undergone laryngectomy. The immediate nursing priority would be:
a. Keep trachea free of secretions
b. Monitor for signs of infection
c. Provide emotional support
d. Promote means of communication
1. C. Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
2. A. The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
3. B. These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
4. D. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
5. A. Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
6. B. This indicates that the bladder is distended with urine, therefore palpable.
7. C. Elevation increases lymphatic drainage, reducing edema and pain.
8. B. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
9. D. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.
10. A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
11. C. Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.
12. A. An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
13. D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
14. A. Good source of vitamin B12 are dairy products and meats.
15. C. Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
16. B. An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.
17. A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
18. D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
19. B. Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
20. A. Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
21. C. Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.
22. C. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
23. C. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
24. A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.
25. C. Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
26. D. Elevation will help control the edema that usually occurs.
27. B. Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
28. B. The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
29. A. Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
30. C. Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.
31. A. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.
32. C. The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
33. B. Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
34. A. It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
35. C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
36. D. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
37. B. In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
38. A. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
39. D. Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
40. B. The use of fragrant soap is very drying to skin hence causing the pruritus.
41. C. Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
42. A. A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
43. B. The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.
44. D. Glucocorticoids play no significant role in disease treatment.
45. D. Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
46. C. In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
47. A. Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis.
48. D. Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.
49. B. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.
50. A. Patent airway is the most priority; therefore removal of secretions is necessary. 1. A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse Patricia consults the physician about withholding which regularly scheduled medication on the day before the surgery?
a. Potassium Chloride
b. Warfarin Sodium
c. Furosemide
d. Docusate
2. A nurse is planning to assess the corneal reflex on unconscious client. Which of the following is the safest stimulus to touch the client’s cornea?
a. Cotton buds
b. Sterile glove
c. Sterile tongue depressor
d. Wisp of cotton
3. A female client develops an infection at the catheter insertion site. The nurse in charge uses the term “iatrogenic” when describing the infection because it resulted from:
a. Client’s developmental level
b. Therapeutic procedure
c. Poor hygiene
d. Inadequate dietary patterns
4. Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognize bradykinesia when the client exhibits:
a. Intentional tremor
b. Paralysis of limbs
c. Muscle spasm
d. Lack of spontaneous movement
5. A client who suffered from automobile accident complains of seeing frequent flashes of light. The nurse should expect:
a. Myopia
b. Detached retina
c. Glaucoma
d. Scleroderma
6. Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure?
a. Intermittent tachycardia
b. Polydipsia
c. Tachypnea
d. Increased restlessness
7. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure the nurse priority should be:
a. Hold the clients arms and leg firmly
b. Place the client immediately to soft surface
c. Protects the client’s head from injury
d. Attempt to insert a tongue depressor between the client’s teeth
8. A client has undergone right pneumonectomy. When turning the client, the nurse should plan to position the client either:
a. Right side-lying position or supine
b. High fowlers
c. Right or left side lying position
d. Low fowler’s position
9. Nurse Jenny should caution a female client who is sexually active in taking Isoniazid (INH) because the drug has which of the following side effects?
a. Prevents ovulation
b. Has a mutagenic effect on ova
c. Decreases the effectiveness of oral contraceptives
d. Increases the risk of vaginal infection
10. A client has undergone gastrectomy. Nurse Jovy is aware that the best position for the client is:
a. Left side lying
b. Low fowler’s
c. Prone
d. Supine
11. During the initial postoperative period of the client’s stoma. The nurse evaluates which of the following observations should be reported immediately to thephysician?
a. Stoma is dark red to purple
b. Stoma is oozes a small amount of blood
c. Stoma is lightly edematous
d. Stoma does not expel stool
12. Kate which has diagnosed with ulcerative colitis is following physician’s order for bed rest with bathroom privileges. What is the rationale for this activity restriction?
a. Prevent injury
b. Promote rest and comfort
c. Reduce intestinal peristalsis
d. Conserve energy
13. Nurse KC should regularly assess the client’s ability to metabolize the total parenteral nutrition (TPN) solution adequately by monitoring the client for which of the following signs:
a. Hyperglycemia
b. Hypoglycemia
c. Hypertension
d. Elevate blood urea nitrogen concentration
14. A female client has an acute pancreatitis. Which of the following signs and symptoms the nurse would expect to see?
a. Constipation
b. Hypertension
c. Ascites
d. Jaundice
15. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following symptoms might indicate tetany?
a. Tingling in the fingers
b. Pain in hands and feet
c. Tension on the suture lines
d. Bleeding on the back of the dressing
16. A 58 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of hypothyroidism include:
a. Diarrhea
b. Vomiting
c. Tachycardia
d. Weight gain
17. A client has undergone for an ileal conduit, the nurse in charge should closely monitor the client for occurrence of which of the following complications related to pelvic surgery?
a. Ascites
b. Thrombophlebitis
c. Inguinal hernia
d. Peritonitis
18. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice “clear”. What should be the action of the nurse?
a. Places conductive gel pads for defibrillation on the client’s chest
b. Turn off the mechanical ventilator
c. Shuts off the client’s IV infusion
d. Steps away from the bed and make sure all others have done the same
19. A client has been diagnosed with glomerulonephritis complains of thirst. The nurse should offer:
a. Juice
b. Ginger ale
c. Milk shake
d. Hard candy
20. A client with acute renal failure is aware that the most serious complication of this condition is:
a. Constipation
b. Anemia
c. Infection
d. Platelet dysfunction
21. Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic function that the client loss during the induction of anesthesia is:

a. Consciousness
b. Gag reflex
c. Respiratory movement
d. Corneal reflex
22. The nurse is assessing a client with pleural effusion. The nurse expect to find:
a. Deviation of the trachea towards the involved side
b. Reduced or absent of breath sounds at the base of the lung
c. Moist crackles at the posterior of the lungs
d. Increased resonance with percussion of the involved area
23. A client admitted with newly diagnosed with Hodgkin’s disease. Which of the following would the nurse expect the client to report?
a. Lymph node pain
b. Weight gain
c. Night sweats
d. Headache
24. A client has suffered from fall and sustained a leg injury. Which appropriate question would the nurse ask the client to help determine if the injury caused fracture?
a. “Is the pain sharp and continuous?”
b. “Is the pain dull ache?”
c. “Does the discomfort feel like a cramp?”
d. “Does the pain feel like the muscle was stretched?”
25. The Nurse is assessing the client’s casted extremity for signs of infection. Which of the following findings is indicative of infection?
a. Edema
b. Weak distal pulse
c. Coolness of the skin
d. Presence of “hot spot” on the cast
26. Nurse Rhia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia would expect to note which of the following if this disorder is present?
a. Transparent tympanic membrane
b. Thick and immobile tympanic membrane
c. Pearly colored tympanic membrane
d. Mobile tympanic membrane
27. Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low suction. Nurse Jocelyn assesses the client for symptoms of which acid-base disorder?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
28. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following values should be negative if the CSF is normal?
a. Red blood cells
b. White blood cells
c. Insulin
d. Protein
29. A client is suspected of developing diabetes insipidus. Which of the following is the most effective assessment?
a. Taking vital signs every 4 hours
b. Monitoring blood glucose
c. Assessing ABG values every other day
d. Measuring urine output hourly
30. A 58 year old client is suffering from acute phase of rheumatoid arthritis. Which of the following would the nurse in charge identify as the lowest priority of the plan of care?
a. Prevent joint deformity
b. Maintaining usual ways of accomplishing task
c. Relieving pain
d. Preserving joint function
31. Among the following, which client is autotransfusion possible?
a. Client with AIDS
b. Client with ruptured bowel
c. Client who is in danger of cardiac arrest
d. Client with wound infection
32. Which of the following is not a sign of thromboembolism?
a. Edema
b. Swelling
c. Redness
d. Coolness
33. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration?
a. Position the client on the side with head flexed forward
b. Elevate the head
c. Use tongue depressor between teeth
d. Loosen restrictive clothing
34. A client has undergone bone biopsy. Which nursing action should the nurse provide after the procedure?
a. Administer analgesics via IM
b. Monitor vital signs
c. Monitor the site for bleeding, swelling and hematoma formation
d. Keep area in neutral position
35. A client is suffering from low back pain. Which of the following exercises will strengthen the lower back muscle of the client?
a. Tennis
b. Basketball
c. Diving
d. Swimming
36. A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for:
a. (+) guaiac stool test
b. Slow, strong pulse
c. Sudden, severe abdominal pain
d. Increased bowel sounds
37. A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized?
a. Prevent an increase intraocular pressure
b. Alleviate pain
c. Maintain darkened room
d. Promote low-sodium diet
38. A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is for:
a. Constricting pupil
b. Relaxing ciliary muscle
c. Constricting intraocular vessel
d. Paralyzing ciliary muscle
39. When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion?
a. Administer diuretics
b. Administer analgesics
c. Provide hygiene
d. Hyperoxygenate before and after suctioning
40. When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching?
a. Short frequent breaths
b. Exhale with mouth open
c. Exercise twice a day
d. Place hand on the abdomen and feel it rise
41. Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:
a. Maintain room humidity below 40%
b. Place top sheet on the client
c. Limit the occurrence of drafts
d. Keep room temperature at 80 degrees
42. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because this graft will:
a. Relieve pain and promote rapid epithelialization
b. Be sutured in place for better adherence
c. Debride necrotic epithelium
d. Concurrently used with topical antimicrobials
43. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, “I can’t eat all this food”. The food that the nurse should suggest to be eaten first should be:
a. Meat loaf and coffee
b. Meat loaf and strawberries
c. Tomato soup and apple pie
d. Tomato soup and buttered bread
44. Tony returns form surgery with permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should be aware that:
a. Proper functioning of nasogastric suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery
45. When teaching a client about the signs of colorectal cancer, Nurse Trish stresses that the most common complaint of persons with colorectal cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits
46. Louis develops peritonitis and sepsis after surgical repair of ruptures diverticulum. The nurse in charge should expect an assessment of the client to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds
47. Immediately after liver biopsy, the client is placed on the right side, the nurse is aware that that this position should be maintained because it will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary ducts
c. Position with greatest comfort
d. Promote circulating blood volume
48. Tony has diagnosed with hepatitis A. The information from the health history that is most likely linked to hepatitis A is:
a. Exposed with arsenic compounds at work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants
49. Nurse Trish is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated:
a. Serum bilirubin level
b. Serum amylase level
c. Potassium level
d. Sodium level
50. Dr. Marquez orders serum electrolytes. To determine the effect of persistent vomiting, Nurse Trish should be most concerned with monitoring the:
a. Chloride and sodium levels
b. Phosphate and calcium levels
c. Protein and magnesium levels
d. Sulfate and bicarbonate levels
1. B. In preoperative period, the nurse should consult with the physician about withholding Warfarin Sodium to avoid occurrence of hemorrhage.
2. D. A client who is unconscious is at greater risk for corneal abrasion. For this reason, the safest way to test the cornel reflex is by touching the cornea lightly with a wisp of cotton.
3. B. Iatrogenic infection is caused by the heath care provider or is induced inadvertently by medical treatment or procedures.
4. D. Bradykinesia is slowing down from the initiation and execution of movement.
5. B. This symptom is caused by stimulation of retinal cells by ocular movement.
6. D. Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.
7. C. Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.
8. A. Right side lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump.
9. C. Isoniazid (INH) interferes in the effectiveness of oral contraceptives and clients of childbearing age should be counseled to use an alternative form of birth control while taking this drug.
10. B. A client who has had abdominal surgery is best placed in a low fowler’s position. This relaxes abdominal muscles and provides maximum respiratory andcardiovascular function.
11. A. Dark red to purple stoma indicates inadequate blood supply.
12. C. The rationale for activity restriction is to help reduce the hypermotility of the colon.
13. A. During Total Parenteral Nutrition (TPN) administration, the client should be monitored regularly for hyperglycemia.
14. D. Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct.
15. A. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed.
16. D. Typical signs of hypothyroidism includes weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, constipation and numbness.
17. B. After a pelvic surgery, there is an increased chance of thrombophlebitits owing to the pelvic manipulation that can interfere with circulation and promote venous stasis.
18. D. For the safety of all personnel, if the defibrillator paddles are being discharged, all personnel must stand back and be clear of all the contact with the client or the client’s bed.
19. D. Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid.
20. C. Infection is responsible for one third of the traumatic or surgically induced death of clients with renal failure as well as medical induced acute renal failure (ARF)
21. C. There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present.
22. B. Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.
23. C. Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph node, fever, malaise and night sweats.
24. A. Fractured pain is generally described as sharp, continuous, and increasing in frequency.
25. D. Signs and symptoms of infection under a casted area include odor or purulent drainage and the presence of “hot spot” which are areas on the cast that are warmer than the others.
26. B. Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick and immobile tymphanic membrane with or without perforation.
27. D. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid which is a potent acid in the body.
28. A. The adult with normal cerebrospinal fluid has no red blood cells.
29. D. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus.
30. B. The nurse should focus more on developing less stressful ways of accomplishing routine task.
31. C. Autotransfusion is acceptable for the client who is in danger of cardiac arrest.
32. D. The client with thromboembolism does not have coolness.
33. A. Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.
34. C. Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding, swelling and hematoma formation.
35. D. Walking and swimming are very helpful in strengthening back muscles for the client suffering from lower back pain.
36. C. Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the nurse maybe unable to hear bowel sounds at all.
37. A. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal.
38. A. Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased out flow of aqueous humor.
39. D. It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion.
40. D. Abdominal breathing improves lungs expansion
41. C. A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.
42. A. The graft covers the nerve endings, which reduces pain and provides framework for granulation
43. B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.
44. C. This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics.
45. D. Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common symptoms of colorectal cancer.
46. B. With increased intraabdominal pressure, the abdominal wall will become tender and rigid.
47. A. Pressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after liver biopsy.
48. B. Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus.
49. B. Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems.
50. A. Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with vomiting. Chloride, which balances cations in the extracellular compartments, is also lost with vomiting, because sodium and chloride are parallel electrolytes, hyponatremia will accompany.
1.) A client is receiving NPH insulin 20 units subq at 7:00 AM daily, at 3 PM how would the nurse finds if the client were having a hypoglycemic reaction?

A.) Feel the client and bed for dampness
B.) Observe client kussmaul respirations
C.) Smell client’s breathe for acetone odor
D.) Check client’s pupils for dilation

2.) Postoperative thyroidectomy nursing care includes which measures?

A.) Have the client speak every 5-10 mins if hoarseness is present
B.) Provide a low calcium diet to prevent hypercalcemia
C.) Check the dressing all the back of the neck for bleeding
D.) Apply a soft cervical collar to restrict neck movement

3.) What would the nurse note as typical findings on the assessment of a client with acute pancreatitis?

A.) Steatorrhea, abd. Pain, fever
B.) Fever, hypoglycemia, DHN
C.) Melena, persistent vomiting, hyperactive bowel sounds
D.) Hypoactive bowel sounds, decreased amylase and lipase levels

4.) A client is found to be comatose and hypoglycemic with a blood suger level 50 mg/dl. What nursing action is implemented first?

A.) Infuse 1000 ml of D5W over a 12-hour period
B.) Administer 50% glucose IV
C.) Check the client’s urine for the presence of sugar and acetone
D.) Encourage the client to drink orange juice with added sugar

5.) Which medication will the nurse have available for the emergency treatment of tetany in the client who has had a thyroidectomy?

A.) Calcium chloride
B.) Potassium chloride
C.) Magnesium sulfate
D.) Sodium bicarbonate

6.) What is the primary action of insulin in the body?

A.) Enhances the transport of glucose across cell walls
B.) Aids in the process of gluconeogenesis
C.) Stimulates the pancreatic beta cells
D.) Decreases the intestinal absorption of glucose

7.) What will the nurse teach the diabetic client regarding exercise in his /her treatment program?

A.) During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin
B.) With an increase in activity the body will utilize more carbohydrates; therefore more insulin will be required.
C.) The increase in activity results in an increase in the utilization of insulin; therefore the client should decrease his/her carbohydrate intake
D.) Exercise will improve pancreatic circulation and stimulate the islet of Langerhans to increase the production of intrinsic insulin

8.) The nurse is caring for a client who has exophthalmos associated with her thyroid disease. What is the cause of exophthalmos?

A.) Fluid edema in the retro-orbital tissues which force the eyes to protrude
B.) Impaired vision, which causes the client to squint in order to see
C.) Increased eye lubrication, which makes the client blink less
D.) Decrease in extraocular eye movements, which results in the “thyroid stare.”

9.) What is characteristic symptom of hypoglycemia that should alert nurse to an early insulin reaction?

A.) Diaphoresis
B.) Drowsiness
C.) Severe thirst
D.) Coma

10.) A client is scheduled for routine glycosylated hemoglobin (HbA1c) test. What is important for the nurse to tell the client before this test?

A.) Drink only water after midnight and come to the clinic early in the morning
B.) Eat a normal breakfast and be at the clinic 2 hours because of the multiple blood draws
C.) Expect to be at the clinic for several hours because of the multiple blood draws
D.) Come to the clinic at the earliest convenience to have blood drawn

11.) A client has been inhalation vasopressin therapy. What will the nurse evaluate to determine the therapeutic response to this medication?

A.) Urine specific gravity
B.) Blood glucose
C.) Vital signs
D.) Oxygen saturation levels

12.) A client with diagnosis of type 2 diabetes has been ordered a course of prednisone for her severe arthritic pain. An expected change that requires close monitoring by the nurse is;

A.) Increased blood glucose level
B.) Increased platelet aggregation
C.) Increased ceatinine clearance
D.) Increased ketone level in urine

13.) The nurse performing an assessment on a client who has been receiving long-term steroid therapy would expect to find:

A.) Jaundice
B.) Flank pain
C.) Bulging eyes
D.) Central obesity

14.) A diabetic client receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at

A.) 1200 and 1300 hours
B.) 1100 and 1700 hours
C.) 1000 and 2200 hours
D.) 0800 and 1100 hours

15.) It is important for the nurse to teach the client that metformin (Glcucophage):

A.) May cause nocturia
B.) Should be taken at night
C.) Should be taken with meals
D.) May increase the effects of aspirin

16.) A nurse assessing a client with SIADH would expect to find laboratory values of:

A.) Serum Na= 150 mEq/L and low urine osmolality
B.) Serum K= 5 mEq/L and low serum osmolality
C.) Serum Na=120 mEq/L and low serum osmolality
D.) Serum K= 3 mEq/L and high serum osmolality

17.) A priority nursing diagnostic for a client admitted to the hospital with a diagnosis of diabetes insipidus is:

A.) Sleep pattern deprivation related nocturia
B.) Activity intolerance r/t muscle weakness
C.) Fluid volume excess r/t intake greater that output
D.) Risk for impaired skin integrity r/t generalized edema

18.) A client admitted with a pheochrocytoma returns from the operating room after adrenalectomy. The nurse should carefully assess this client for:

A.) Hypokalemia
B.) Hyperglycemia
C.) Marked Na and water intake
D.) Marked fluctuations in BP

19.) When caring for client in thyroid crisis, the nurse would question an order for:

A.) IV fluid
B.) Propanolol (Inderal)
C.) Prophylthiouracil
D.) A hyperthermia blanket

20.) A client is prescribed levothyroxine (Synthroid) daily. The most important instruction to give the client for administration of this drug is:

A.) Taper dose and discontinue if mental and emotional statuses stabilize
B.) Take it at bedtime to avoid the side effects of nausea and flatus
C.) Call the M.D. immediately at the onset of palpitations or nervousness
D.) Decrease intake of juices and fruits with high potassium and calcium contents

21.) The nurse would question which medication order for a client with acute-angled glaucoma?

A.) Atropine (Atrposil) 1-2 drops in each eye now
B.) Hydrochloride (Diuril) 25 mg PO daily
C.) Propanolol (Inderal) 20 mg PO 2 times a day
D.) Carbanyl choline (Isopto carbachol) eye drops; 1 drop 2 times a day

22.) A client tells you she has heard that glaucoma may be a hereditary problem and she is concerned about her adult children. What is the best response?

A.) “There is no need for concern; glaucoma is not hereditary order.”
B.) “Screening for glaucoma should be included in an annual eye exam for everyones over 50.”
C.) “There may be a genetic factor with glaucoma and your children over 30 y/o should be screened yearly.”
D.) “Are your grandchildren complaining of any eye problems? Glaucoma generally skips a generation.”

23.) What will be important to include in the nursing care for the client with angle-closure glaucoma?

A.) Evaluation of medications to determine if any of them cause an increase in IOP is a side effect.
B.) Observation for an increase in loss of vision; it can be reversed if promptly identified.
C.) Control BP to decrease the client’s potential loss of peripheral vision.
D.) Assessment for a level of discomfort; the client may experience considerable pain until the optic nerve atrophies

24.) A child is scheduled for a myringotomy. What goal of this procedure will the nurse discuss with the parents?

A.) Promote drainage from the ear
B.) Irrigate the Eustachian tube
C.) Correct a malformation in the inner ear
D.) Equalize pressure on the tympanic membrane

25.) After a client’s eye has been anesthetized, what instructions will be important for the nurse to give the client?

A.) Do not watch TV for at least one day
B.) Do not rub the eye for 15-20 minutes
C.) Irrigate the eye every hour to prevent dryness
D.) Wear sunglasses when in direct sunlight for the next 6 hours

26.) A child diagnosed with conjunctivitis. Which statement reflects that the child understood the nurse’s teaching?

A.) “It’s okay for me to let my friends use my sunglasses while we are playing together.”
B.) “It’s okay for me to softly rub my eye, as long as I use the back of my hand.”
C.) “I can pick the crustly stuff out of my eyelashes with my fingers when I wake up in the morning.”
D.) “I will use my own washrag and towel while my eyes are sick.”

27.) What medication would the nurse anticipate giving a client with Meniere’s dse?

A.) Nifedipine
B.) Amoxicillin
C.) Propanolol
D.) Hydrochloride (Hydro DIURIL)

28.) When teaching a family and a client about the use of a hearing aid, the nurse will base the teaching on what information regarding the hearing aid?

A.) Provides mechanical transmission for damaged part of the ear
B.) Stimulates the neural network of the inner ear to amplify sound
C.) Amplifies sound but does not improve the ability to hear
D.) Tunes out extraneous noise in the lower-frequency sound spectrum

29.) What statement by the client recovering from cataract surgery would indicate to the nurse need for additional teaching?

A.) “I’ll call if I have a significant amount of pain.”
B.) “I’ll continue to take my Metamucil for another week.”
C.) “I’ll just do some laundry this afternoon instead of going to work.”
D.) “I’ll take my acetazolamide (Diamox) drops with my other morning medications

30.) A client is walking down the hall and begins to experience vertigo. What is the most important nursing action when this occurs?

A.) Have the client sit in a chair and lower his head
B.) Administer meclizine (Antivert) PO
C.) Assist the client to sit or lie down
D.) Assess if the occurrence is vertigo or dizziness

31.) Which client is at highest risk for retinal detachment?

A.) 4-year old with amblyopia
B.) 17 y/o who plays physical contact
C.) 33 y/o with severe ptosis and diplopia
D.) 72 y/o with nystagmus and Bell’s palsy

32.) To promote and maintain safety for a client after a stapedectomy. What would be included in the nursing care plan?

A.) Implement fall precautions
B.) Prevent aspirations
C.) Begin oxygen 2-4L/min via nasal cannula
D.) Change inner ear dressing when saturated

33.) The nurse would question the administration of which eye drop in a patient with increased ICP?

A.) Artificial tears
B.) Betaxolol (Betoptic)
C.) Acetazolamide (Diamox)
D.) Epinephrine HCL (Epirate)

34.) A client is being admitted for problems with Meniere’s disease. What is most important to the nurse to assess?

A.) Diet history
B.) Screening hearing test
C.) Effect on client’s activities of daily living (ADLs)
D.) Frequency and severity

35.) A client calls the nurse regarding an accident that just occurred during which an unknown chemical was splashed in his eyes. What is the most important for the nurse to tell the client to do immediately?

A.) Rinse the eye with large amount of water or saline solution
B.) Put a pad soaked in the sterile saline solution over the eye
C.) Go to the closest emergency room
D.) Have a co-worker visually checks the eye for a foreign body

36.) A 25- year old woman comes to the clinic complaining of dizziness, weakness and palpitations. What will be important for the nurse to initially evaluate when obtaining the health history?

A.) Activity and exercise patterns
B.) Nutritional patterns
C.) Family health status
D.) Coping and stress tolerance

37.) A child with leukemia is being discharged after beginning chemotherapy. What instructions will the nurse include in the teaching plan for the parents of this child?

A.) Provide a diet low in protein and high in carbohydrates
B.) Avoid fresh vegetables that are not cooked or peeled
C.) Notify the M.D. if the child’s temperature exceeds 101F (39C)
D.) Increase the use of humidifiers throughout the house

38.) Which client is most likely to have iron deficiency anemia?

A.) A client with cancer receiving radiation therapy twice a week
B.) A toddler whose primary nutritional intake is milk
C.) A client with peptic ulcer who had surgery 6 weeks ago
D.) A 15-year old client in sickle cell crisis

39.) A client has an order for one unit of whole blood. What is a correct nursing action?

A.) Initiate an IV with 5% dextrose in water (D5W) to maintain a patent access site
B.) Initiate the transfusion within 30 minutes of receiving the blood
C.) Monitor the client’s vital signs for the first 5 minutes
D.) Monitor V/S every 2 hours during the transfusion

40.) The nurse is caring for a client who is receiving a blood transfusion. The transfusion was started 30 mins ago at a rate of 100 ml/hr. The client begins to complain of low back pain and headache and is increasing restless, what is the first nursing action?

A.) Slow the infusion and evaluate the V/S and client’s history of transfusion reaction
B.) Stop the transfusion, disconnect the blood tubing and begin a primary infusion of normal saline solution
C.) Stop the infusion of blood and begin infusion of NSS from the Y connector
D.) Recheck the unit of blood for correct identification numbers and cross-match information

41.) The nurse is preparing to start an IV infusion before the administration of a unit of packed red blood cells, what fluid will the nurse select to maintain the infusion before hanging the unit of blood?

A.) D5W
B.) D5W/.45NaCl
C.) LR solution
D.) .9% Na Cl

42.) A client in sickle cell crisis is admitted to the emergency department what are the priorities of care?

A.) Nutrition, hydration, electrolyte balance
B.) Hydration, pain management, electrolyte balance
C.) Hydration, oxygenation, apin management
D.) Hydration, oxygenation, electrolyte balance

43.) A client in the ICU has been diagnosed with DIC. The nurse will anticipate administering which of the following fluids?

A.) Packed RBC
B.) Fresh Frozen plasma (FFP)
C.) Volume expanders, such as D10W
D.) Whole blood

44.) The nurse is assessing a client who has been given a diagnosis of polycythemia vera. What characteristics will the nurse anticipate finding when assessing this client?

A.) Increased fatigue and bleeding tendencies
B.) Hemoglobin below 13 mg/dl
C.) Headaches, dyspnea, claudication
D.) Back pain, ecchymosis, and joint tenderness

45.) A client has been diagnosed with pernicious anemia what will the nurse teach this client regarding medication he will need to take after he goes home?

A.) Monthly Vit. B12 injections will be necessary
B.) Ferrous sulfate PO daily will be prescribed
C.) Coagulation studies are important to evaluate medications
D.) Decrease intake of leafy green vegetables because of increased Vit. K

46.) First postop day after a right lower lobe (RLL) lobectomy, the client breathes and coughs but has difficulty raising mucus. What indicates that the client is not adequately clearing secretions?

A.) Chest x-ray film shows right sided pleural fluid
B.) A few scattered crackles on RLL on auscultation
C.) PCO2 increases from 35-45 mm Hg
D.) Decrease in forced vital capacity

47.) What nursing observations indicate that the cuff on an endotracheal tube is leaking?

A.) An increase in peak pressure on the ventilator
B.) Client is able to speak
C.) Increased swallowing efforts by client
D.) Increased crackles (rales) over left lung field

48.) The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home?

A.) Because of his need for oxygen, the client will have to limit activity at home
B.) The use of oxygen will eliminate the client’s shortness of breath
C.) Precautions are necessary because oxygen can spontaneously ignite and explode
D.) Use oxygen during activity to relieve the strain on the client’s heart

49.) The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information?

A.) “You should avoid emotional situations that increase his shortness of breathe.”
B.) “Help your husband arrange activities so that he does as little walking as possible.”
C.) “Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening.”
D.) “Your husband will be no more short of breath when he walks but that will not hurt him.”

50.) Which statement correctly describes suctioning through an endotracheal tube

A.) The catheter is inserted into the endotracheal tube; intermittent suction is applied until no further secretions are retrieved; the catheter is then withdrawn.
B.) The catheter is inserted through the nose, and the upper airway is suctioned; the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway
C.) With suction applied, the catheter is inserted into the endotracheal tube; when resistance is met, the catheter is slowly withdrawn
D.) The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.
 A
 C
 A
 B
 A
 A
 A
 A
 A
 D
 A
 A
 D
 B
 C
 C
 B
 D
 D
 C
 A
 C
 A
 A
 B
 D
 D
 C
 C
 C
 B
 A
 D
 D
 A
 B
 B
 B
 B
 B
 D
 C
 B
 C
 A
 C
 B
 A
 C
 D
1. A 42-year-old client admitted with an acute myocardial infarction asks to see his chart. What should the nurse do first?

a. Allow the client to view his chart
b. Contact the supervisor and physician for approval
c. Ask the client if he has concerns about his care
d. Tell the client that he isn't permitted to view his chart.

2. A registered nurse who works in the preoperative area of the operating room notices that a client is scheduled for a partial mastectomy and axillary lymph node removal the following week. The nurse should make sure, that the client is well educated about her surgery by:

a. taking with the nursing staff at the physician's office to find out what the client has been taught and her level of understanding
b. making sure that the post-anesthesia recovery unit nurses know what to teach the patient before discharge
c. providing all of the preoperative teaching before surgery
d. having the post-operative nurses teach the patient because she'll be too anxious before surgery

3. A male client brings a list of his prescribed medications to the clinic. During the initial assessment, he tells the nurse that he has been experiencing delayed ejaculation. Which drug class is associated with this problem?

a. Anticoagulants
b. Antibiotics
c.Antihypertens ive
d. Steroids

Situation: Larry was admitted at Manila Doctor's Hospital because of a second-degree burn wound.

4. Before debriding a second-degree burn wound in the left lower leg, the nurse should do which of the following?

a. Apply Lindane (Kwell) to the affected area
b. Medicate the client with narcotic analgesic
c. Administer acylovir (Zovirax) IV
d. Apply a topical antimicrobial ointment

5. Larry’s anterior trunk, both front upper extremities, both lower extremities sustained second and third degree burn. Estimate the total percentage of body surface area burned using the Rule of Nines.

a. 60%
b.63%
c. 62%
d. 61%

Situation . Hearing, impairment appears to be common among elderly patients. But also occurs among children.

6. To assess the degree of hearing impairment of a 70-year-old client. Which communication approach would you initiate?

a. Use verbal communication and observe the response
b. Give message to client in writing
c. Asks a family member about the client's
d. Post a sign "Patient deaf"

7. While you are mating your routine rounds you were told that there is a client in the 1CU who is in respirator and who lip- reads. To establish relationship with him, communication is best accomplished by:

a. Speaking slowly but aloud
b. Writing messages
c. Gesturing while speaking
d. Using simple "charade" approach or strategy

8. One of your client's has just undergone an ear surgery. Which of the following would be inappropriate in planning for his care?

a. Administration of anti-emetics and analgesics as ordered
b. Daily irrigation of the ear canal
c. Walking with assistance at least 24 hours after operation
d. Teaching the patient to avoid sneezing, coughing and nose blowing

9. Which of the following conditions would an irrigation of the ear canal be appropriate intervention?

a. Foreign body in the ear canal
b. Serious otitis
c. Impacted cerumen
d. Tympanic membrane perforation

10. Children who have undetected hearing loss are likely to exhibit which of the following:

a. Indifference and lack of interest in the environment
b. Hyperactivity
c. An increased interest in reading
d. Hand gestures while speaking

Situation . One of the main fools of the nursing profession is the use of therapeutic communication. The following situation would require you of your communication skills.

11. A patient who is diagnosed to have terminal illness tells you. "I’m really scared. Am I dying?" What could be your most appropriate response?

a. "Tell me about what you think."
b. "I'm sure you are scared; other clients in your situation feel the same way."
c. "You should be careful not to let your family know you're scared"
d. "Why are you scared?"

12. The nurse assessing a male client who has been admitted for treatment of alcoholism. Which question by the nurse is least appropriate?

a. "How much do you think?"
b. "What other drugs do you use?" .
c. "How is your general health?"
d. "Why do you drink so much?"

13. A 58-year-old male client tells the office nurse that his wife does not let him change his colostomy bag himself. Which response by the nurse indicates as understanding of the situation?

a. "Your wife's need to help you is a reality you should accept"
b. "Do you think your wife might benefit from counseling?"
c. "You feel you need privacy when changing your colostomy?"
d. "Have you discussed the situation with your doctor?"

14. An 87 year old widow was hospitalized for treatment of chronic renal disease. She lives with her daughter and son-in- law and their family, who are very supportive. She is now ready for discharge. The doctor has ordered high carbohydrates, low-protein, low sodium diet for her and the family has asked for assistance in planning low-sodium diet meals. Which of the following choices best reflects the pre-discharge information the nurse should provide for the client's family regarding low-sodium diet?

a. Avoid canned and processed foods, do not use salt replacements substitute herbs and replaces for salt in cooking and when seasoning foods, call a dietitian for help.
b. Use potassium salts in place of table salt when coking and seasoning foods, read the labels on packaged foods to determine sodium content, and avoid snacks food
c. Limit milk and dairy products, cook separate meals that are low in sodium and encourage increased fluid intake
d. Avoid eating in a restaurant, soak vegetables well before cooking to remove sodium, omit all canned foods, and remove salt shakes from table.

15. You are encouraging your patient for major cancer operation to verbalize her fears. She remarked," I am afraid to do". Your appropriate response is

a. "I know how you feel about your condition".
b. "Don't worry, you are in good hands."
c. "Let me call a chaplain to see you."
d. "Let us asks your doctor about your operation."

16. The nurse is caring for a client whose arterial blood gases indicate metabolic acidosis. The nurse knows that of the following, the least likely to cause metabolic acidosis is:

a. cardiac arrest
b. Diabetic ketoacidosis
c. decreased serum potassium level
d. renal failure

17. The nurse is caring for a client who is receiving IV fluids, Which observation the nurse makes best indicates that the IV has infiltrated?

a. Pain at the site
b. A change in flow rate
c. Coldness around the insertion site
d. Redness around the insertion site

18 A 27 y.o adult is admitted for treatment of Crohn's disease. Which information is most significant when the nurse assesses nurtritional health?

a. Anthropometric measurements
b. bleeding gums
c. dry skin
d. facial rubor

19. ASA (aspirin) is being administered to a client. The nurse understands that the most common mechanism of action for nonnarcotic analgesic is their ability to:

a. Inhibit prostaglandin systhesis
b. After pain perception in the cerebellum
c. Directly affect the central nervous system
d. Target the pain-producing effect of kinins

20. The nurse caring for an adult client who is receiving TPN will need to be monitored for which of the following metabolic complications?

a. Hypoglycemia and Hypercalcemia
b. Hyperglycemia and Hypokalemia
c. Hyperglycemia and Kyperkalemia
d. Hyperkalemia and Hypercalcemia

21. Total parenteral nutrition is ordered for an adult. Which nutrient is not likely to be in the solution?

a. Dextrose 10%
b. Trace minerals
c. Amino acids
d. Non of the above

22. A man has sprained his ankle. The physician would order cold applied to the injured area to.

a. Reduce the body's temperature
b. Increase circulation to the area
c. Aid in absorbing the edema
d. Relieve pain and control bleeding.

23. An adult is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water?

a. 65 F
b. 90 F
c. 110 F
d. 105 F

24. An adult has chronic lower back pain and receives hot pack three times a week. The nurse knows that the treatment is given for which of the following reasons?

a. To help remove debris from the wound
b. To keep the client warm and raise his temperature
c. To improve the client's general circulation
d. To relieve muscle spasm and promote muscle relaxation

25. A patient classification system where patients minimal therapy and less frequent observation

a. minimal care (category 1)
b. moderate care (category 2)
c. maximum care (category 3)
d. intensive care (category 4)

26. The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressing is best?

a. Dry gauze dressing
b. wet gauze dressing
c. wet to dry dressing
d. moisture vapor permeable dressing

27. The client has been placed in the trendelenburg position. The nurse knows the effects of this position to the client include which of the following.

a. increase blood flow to the feet
b. decrease blood pressure
c. increase pressure on the diaphragm
d. decrease intracranial pressure

28. A man who has been in an MVA is going into shock. Before placing the client in a modified trendelenburg position, the nurse should assess the client for:

a. long bone fracture
b. air embolus
c. head injury
d. thrombophlebitis

29. The nurse enter a room and finds a fire. Which is the best initial action?

a. Evacuate any people in the room, beginning with the most ambultory and ending with the least mobile
b. activating the fire alarm or call the operator, depending on the institutions system
c. get a fire extinguisher and put out the fire
d. close all the windows and doors and turn off any oxygen or electricity appliance.

30. The nurse is to open a sterile package from central supply. Which is the correct direction to open the first lap?

a. Toward the nurse
b. Away from the nurse
c. To the nurse's left or right hand
d. It does not matter as long as the nurse touches only the outside edge

31. The nurse knows which of the following is the proper technique for medical asepsis?

a. gloving for all the client contact
b. changing hospital linens weekly
c. using your hands to turn off the faucet after handwashing
d. gowning to care for a 1 year old child w/ infections diarrhea

32. An adult ha a left, above the knee amputation two weeks ago. The nurse places him in a prone position tree times a day because:

a. Prevents pressure ulcer on the sacrum
b. helps the prosthesis to fit correctly
c. prevents flexion constractures
d. allow better blood flow to the heart

33. A woman is to have a pelvic exam. Which of the following should the nurse have the client do first?

a. Remove all her clothes and her socks and shoes
b. go to the bahtroom and void saving a sample
c. assume a lithotomy position on the exam table
d. assemble all the equipments needed for the examination

34. An adult is supine. Which of the ff. can the nurse to to prevent external rotation of the legs?

a. put a pillow under the clients lower legs
b. place a pillow directly under the client knee
c. use a trochanter rool alongside the client's upper thighs
d. lower the client's legs so that they ae below hips.

35. The nurse prepares to palpate a clients maxillary sinues. For this procedure, where should the nurse place the hands?

a. On the bridge of the nose
b. below the eyebrows
c. below the cheekbones
d. over the temporal area

36. A client who receives general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?

a. Pain related to the surgery
b. Fluid volume deficit related to fluid and blood loss from surgery
c. Impared physical mobility related to surgery
d. Risk for aspiration related to anesthesia

37. After a client receives an IM injection, he complains of a burning pain in the injection site. Which nursing action whould be best to take at this time?

a. apply a cold compress to decrease swelling
b. apply a warm compress to dilate the blood vessels
c. Massage the area to promote absorption of the drug
d. Instruct the client to tighten his gluteal muscles to enhance absorption of the drug

38. A patient classification system where patients need close attention and complete care in most activities and requires frequent and complex treatments and medications:

a. Minimal Care (category 1)
b. Moderate Care (category 2)
c. Maximum Care (category 3)
d. Intensive Care (category 4)

39. An observation consistent with complete-airway obstruction is:

a. Loud crowing when attempting to speak
b. Inability to cough
c. Wheezes on auscultation
d. Gradual

40. The nurse assesses the client's home environment for the safe use crutches. Which one of the following would pose the greatest hazard to the client's safe use of crutches at home?

a. A 4-year old cocker spaniel
b. Scatter rugs
c. Snack tables
d. Diet high in fat

41. A patient who has kaposis sarcoma has all of the following nursing diagnoses. To which one should the nurse give priority?

a. Altered thought processes related to lesions
b. Altered with maintenance related to non compliance
c. Defensive coping related to loss of boundaries
d. Hopelessness, related to inability to control disease process

42. Which of the following statements, if made by a patient who has had a basal cell carcinoma removed, would indicate to the nurse the need for further instruction?

a. "I will use sunscreen with at least a sun protection factor (SPF) of 15.”
b. "I will use tanning booths rather than sunbathing from now on."
c. "I will stay out of the sun between 10:00 AM and 2:00 PM"
d. "I will wear a broad - brimmed heat when I am in the sun"

43. A patient who has a diagnosis is metastatic cancer of the kidney is told by the physician that the kidney needs to be removed. The patient asks the nurse. "What should I do?"Which of the following responses by the nurse would be most therapeutic?

a. "Let's talk about your options."
b. "You need to follow the doctor's advice."
c. "What does your family want you to do."
d. "I wouldn't have the surgery done without a second opinion.

44. Which of the following conditions, reported to a nurse by a 20 year old male patient, would indicate a risk for development of testicular cancer?

a. Genital Herpes
b. Undescended testicle
c. Measles
d. Hydrocele

45. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to:

a. Limit fluid intake for 24 hours
b. Teach muscle tightening exercises
c. Teach the procedure for irrigation of the stoma
d. Provide cleansing enemas and laxatives as ordered

46. To gain access to a vein and an artery, an external shunt may be used for clients who require hemodialysis. The most serious problem with an external shunt is.

a. Septicemia
b. Clot-formation
c. Exsanguination
d. Sclerosis of vessels

47. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to:

a. Limit fluid intake for 24 hours
b. Teach the procedure for irrigation of the stoma
c. Teach muscle-tightening exercises
d. Provide cleansing enemas and laxatives as ordered

48. Intramedullary nailing is used in the treatment of:

a. Slipped epiphysis of the femur
b. Fracture of shaft of the femur
c. Fracture of the neck of the femur
d. Intertrochanteric fracture of the femur

49. The nurse should know that, following a fracture of the neck of the femur, the desirable position for the

a. Internal rotation with extension of the knee
b. Internal rotation with flexion of the knee and hip
c. External rotation with flexion of the knee and hip
d. External rotation with extension of the knee and hip

50. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by:

a. Stimulating the cerebral cortex
b. Blocking the action of cholinesterase
c. Replacing deficient neurotransmitters
d. Accelerating transmission along neural swaths 1. C. Ask the client if he has concerns about his care 2. A. taking with the nursing staff at the physician's office to find out what the client has been taught and her level of understanding 3. C. Antihypertensive 4. B. Medicate the client with narcotic analgesic 5. B. 63% 6. A. Use verbal communication and observe the response 7. A. Speaking slowly but aloud 8. D. Teaching the patient to avoid sneezing, coughing and nose blowing 9. C. Impacted cerumen 10. A. Indifference and lack of interest in the environment 11. A. "Tell me about what you think." 12. D. "Why do you drink so much?" 13. C. "You feel you need privacy when changing your colostomy?" 14. A. Avoid canned and processed foods, do not use salt replacements substitute herbs and replaces for salt in cooking and when seasoning foods, call a dietitian for help. 15. A. "I know how you feel about your condition". 16. C. decreased serum potassium level 17. C. Coldness around the insertion site 18. A. Anthropometric measurements 19. A. Inhibit prostaglandin systhesis 20. B. Hyperglycemia and Hypokalemia 21. D. Non of the above 22. D. Relieve pain and control bleeding. 23. B. 90 F 24. D. To relieve muscle spasm and promote muscle relaxation 25. A. minimal care (category 1) 26. D. moisture vapor permeable dressing 27. C. increase pressure on the diaphragm 28. C. head injury 29. A. Evacuate any people in the room, beginning with the most ambultory and ending with the least mobile 30. B. Away from the nurse 31. D. gowning to care for a 1 year old child w/ infections diarrhea 32. C. prevents flexion constractures 33. B. go to the bahtroom and void saving a sample 34. C. use a trochanter rool alongside the client's upper thighs 35. C. below the cheekbones 36. D. Risk for aspiration related to anesthesia 37. B. apply a warm compress to dilate the blood vessels 38. D. Intensive Care (category 4) 39. B. Inability to cough 40. B. Scatter rugs 41. D. Hopelessness, related to inability to control disease process 42. B. "I will use tanning booths rather than sunbathing from now on." 43. A. "Let's talk about your options." 44. B. Undescended testicle 45. D. Provide cleansing enemas and laxatives as ordered 46. C. Exsanguination 47. D. Provide cleansing enemas and laxatives as ordered 48. B. Fracture of shaft of the femur 49. A. Internal rotation with extension of the knee 50. B. Blocking the action of cholinesterase
1. A client with myasthenia gravis ask the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

a. A genetic in the production acetylcholine
b. A reduced amount of neurotransmitter acetylcholine
c. A decreased number of functioning acetylcholine receptor sites
d. An inhibition of the enzyme ACHE leaving the end plates folded

2. A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit the nurse should

a. Maintain the same dial setting everyday
b. Turn the machine several times a day for 10 to 20 minutes
c. Adjust the TENS dial until the client perceives pain relief and comfort
d. Apply the color-coded electrodes anywhere it is comfortable for the client

3. Although no cause has been determined for scleroderma, it is thought to be caused by:

a. Autoimmunity
b. Ocular motility
c. Increased amino acid metabolism
d. Defective sebaceous gland formation

4. The nurse must help the client with pemphigus vulgaris deal with the resulting:

a. Infertility
b. Paralysis
c. Skin lesions
d. Impaired digestion

5. The nurse should explain to the client with psoriasis that treatment usually involves:

a. Avoiding exposure to the sum
b. Topical application of steroids
c. Potassium permanganate baths
d. Debridement of necrotic plaques

6. The nurses should assess a client with psoriasis

a. Pruritic lesions
b. Multiple petechiae
c. Shiny, scaly lesions
d. Erythematous macules

7. A urine specimen for ketones should be removed from a client's retention catheter by:

a. Disconnecting the catheter and draining it into a clean container
b. Cleansing the drainage valve and removing it from the catheter bag
c. Wiping the catheter with alcohol and draining it into a sterile test tube
d. Using a sterile syringe to remove it from clamped, cleansed catheter

8. Following an abdominal cholecystectomy, the nurse should assess for signs of respiratory complications because the:

a. Incision is in close proximity to the diaphragm
b. Length of time required for surgery is prolonged
c. Client's resistance is lowered because of bile in the blood
d. Bloodstream is invaded by microorganisms from the biliary tract

9. The nurse assess the client with cholecystitis for the development of obstructive jaundice, which would be evidenced by:

a. Inadequate absorption of fat-soluble K
b. Light amber urine, dark brown stools, yellow skin
c. Dark-colored urine, clay colored stools, itchy skin
d. Straw-colored urine, putty-colored stools, yellow sclerae

10. A client with cholelithiasis experience discomfort after ingesting fatty foods because.

a. Fatty foods are hard to digest
b. Bile flow into the intestine is obstructed
c. The liver is manufacturing inadequate bile
d. There is inadequate closure of the Ampulla of Vater

11. The chief complaint in a client with Vincent's Angina is:

a. Chest pain
b. Shortness of breath
c. Shoulder discomfort
d. Bleeding oral ulcerations
12. Clients with fractured mandibles usually have them immobilized with wires. The life-threatening problem that can develop postoperatively is:

a. Infection
b. Vomiting
c. Osteomyelitis
d. Bronchospasm

13. As a result of fractured ribs, the client may develop:

a. Scoliosis
b. Paradoxical respiration
c. Obstructive lung-disease
d. Hernation of the diaphragm

14. A client has a bone marrow aspiration performed, immediately after the procedure, the nurse should:

a. Position the client on the affected side
b. Begin frequent monitoring of vital signs
c. Cleanse the site with an antiseptic solution
d. Briefly apply pressure over the aspiration site

15. Following a bilateral lumbar sympathectomy a client has a sudden drop in blood pressure but no. evidence of bleeding. The nurse recognizes that this is most likely caused by:

a. An inadequate fluid intake
b. The after effects of anesthesia
c. A reallocation of the blood supply
d. An increased level of epinephrine

16. The occurrence of chronic illness is greatest in:

a. Older adult
b. Adolescents
c. Young children
d. Middle-aged adults

17. A client with full-thickness burns on the chest has a skin graft. During the 1s124 hours after a skin graft, care of the donor site includes immediately reporting.

a. Small amount of yellowish green oozing
b. A moderate area of serosanguinous oozing
c. Epithelialization under the non-adherent dressing
d. Separation of the edges of the non-adherent dressing

18. During peritoneal dialysis the nurse observes that drainage of dialysate from the peritoneal cavity has ceased before the required amount has drained out The nurse should assist the client to:

a. Turn from side to side
b. Drink 8 ounces of water
c. Deep breathe and cough
d. Periodically rotate the catheter

19. A client has ear surgery. An early response that may be associated with possible damage to the motor branch of the facial nerve is:

a. A bitter metallic state
b. Dryness of the lips and mouth
c. A sensation of pain behind the ear
d. An inability to wrinkle the forehead

20. After a prostatectomy, a client complains of painful bladder spasms. To limit these spasms the nurse should:

a. Administer a narcotic every 4 hours
b. irrigate the Foley catheter with 60 ml of normal saline
c. Encourage the client not to contract his muscles as if he were voiding
d. Advance the catheter to relieve the pressure against the prostatic fossa

21. After 1 week a client with acute renal failure moves, into the diuretic phase. During this phase the client must be carefully assessed for signs of:

a. Hypovolemia
b. Hyperkalemia
c. Metabolic acidosis
d. Chronic renal failure

22. The nurse checks for hypocalcemia by placing a blood pressure cuff on a client's arm and inflating it. After about 3 minutes the client develops carpopedial spasm. The nurse records this finding as a positive:

a. Homan's sign
b. Romberg sign
c. Chvostek's skin
d. Trosseau's sign

23. A client is scheduled for a below-the-knee amputation of the right leg. Legally, the client may not sign the operative consent if:

a. Ambivalent feelings regarding operation are present
b. Any sedative type of medication has recently been administration
c. A discussion of alternative with 2 physicians have not been performed and recorded
d. A complete history and physical have not been performed

24. The nurse is assigned to check a client's continuous bladder irrigation. Which one of the following solution is normally used for continuous or intermittent bladder and catheter irrigations?

a. Hydrogen peroxide
b. Bacteriostatic water
c. Sterile normal saline
d. Plain water

25. When continuous bladder irrigation is used following prostate surgery, the rate of flow is adjusted:

a. To run at 60 drops per minutes
b. According to the client's oral intake
c. To maintain an output of 500 ml every 8 hours
d. To keep the drainage to light pink

26. The nurse is assigned to teach a class in health behaviors to young man. Which of the following can be stated as a probably cause of cancer of the penis?

a. A diet high in acidic foods
b. Poor personal hygiene
c. Exercise
d. Circumcision

27. The nurse is assigned to give perineal care to an uncircumcised male client. Which of the following is correct?

a. The anal area is washed at a separate time
b. The foreskin is retracted and the area beneath the foreskin is cleansed
c. The foreskin should not be retracted except by a physician
d. The scrotum is carefully washed with sterile normal saline

28. A female nurse is assigned to obtain a history from & client with a urinary tract problem an sexual dysfunction. Which of the following statements might place the client more at ease and willing to give a. history of his problem?

a. "When dud you first notice this problem?
b. "Why do you think you have a problem?"
c. "Do you think you sexual dysfunction is psychological?"
d. "Does your sexual dysfunction seem to be related to your urinary tract problem?"

29. A client is scheduled for an ultrasound examination of the prostate. To describe the procedure to the client, the nurse should plan to relate that:

a. The procedure is performed using a cystoscope
b. A probe will be inserted into the rectum
c. A flat disk is placed on the abdomen
d. This procedure uses x-rays to produce a visual image

30. To effectively teach men the importance of testicular self-examination, the nurse should know that testicular carcinoma:

a. Rarely metastasizes
b. Has a high incidence of early metastasis
c. Cannot be detected by laboratory tests
d. Must first be biopsied to confirm the diagnosis

31. A nurse is assigned to instruct a client in the method of testicular self-examination. The instruction should include mention that the best time to perform this task is:

a. Immediately after getting out of bed in the morning
b. Immediately before going to bed
c. In the morning after breakfast
d. After a warm bath or shower

32. Mr. Dorn has vasectomy. He asks the nurse why he just use a method of birth control because today he, had a sterilization procedure. The most correct answer is:

a. The sperm count will not be negative until his testosterone level decrease
b. Some minor surgery usually is necessary to ensure sterilization
c. Some live sperm will be present in the ejaculatory fluid for a period of time
d. Even though a vasectomy is performed, a condom is still recommended for 1 to 2 years

33. A client is scheduled for a cystectomy and asks the nurse what the physician will be able to see during the procedure. The most correct reply is the:

a. Kidney and ureters
b. Bladder and rectum
c. Prostate and ureters
d. Urethra and bladder

34. A client is scheduled for a cystectomy and asks the nurse what the physician will be able to see during the procedure. The most correct reply is the:

a. Kidney and ureters
b. Bladder and rectum
c. Prostate and ureters
d. Urethra and bladder

35. Nurse assistant attending a nursing conference hears that one of her clients has hydrocele. She asks the nurse how this condition is treated. The most common response is:

a. Usually the problem requires more medical or surgical intervention
b. Surgery may be necessary to correct the problem
c. Wearing a scrotal support usually corrects She problem
d. Drug therapy usually helps control the collection of fluid

36. The nurse is participating in a health class for young women. One subject is cancer of the ovary. Which of the following statements is correct?

a. Early symptoms of cancer of the ovary are vague
b. This type of cancer has a high cure rate
c. Chemotherapy is not used for treating ovarian cancer
d. The most prominent early symptoms is an irregular menstrual cycle

37. The nurse is asked to discuss the signs and symptoms of vaginitis caused by the fungus candida albicans with Ms. Barrows. Which one of the following is a usual sign and symptoms of this infection?

a. Pain high in the abdomen
b. Intensive vaginal and perineal itching
c. Decrease in urinary output
d. High fever

38. The nurse prepares to give Ms. Edwards a vaginal suppository, which is inserted by means of a special applicator supplied with the drug. Which one of the following is correct?

a. Ask the client to void prior to inserting the suppository
b. Lubricate the tip of the suppository with petroleum jelly
c. Insert the applicator tip gently and with an upward and forward motion
d. Insert the applicator approximately ½ inch and depress the plunger

39. The nurse is assigned to give Ms. Milton perineal care. When cleansing the perineum, the cotton ball or wash cloth is gently directed:

a. Side to side across the labia majora
b. Downward from the pubic area to the anus
c. Upward from the anus to the pubic area
d. Prom the urinary meatus to the vagina

40. The nurse is assigned to administer a vaginal irrigation (douche). Which of the following is correct?

a. The irrigation is best administered with the client standing in a bathtub
b. Before inserting, the nozzle is lubricated with petroleum jelly
c. The temperature of the solution should be between 80°F and 84°F
d. The nozzle is inserted downward and backward within the vagina

41. The nurse is assigned to teach health-seeking behaviors to young women. One topic the nurse plans to includes is the importance of the Pap test, which is used mainly to detect:

a. Ovarian cyst
b. Patency of the fallopian tube
c. Cervical cancer
d. Uterine infections

42. The physician asks the nurse to position a client for a vaginal examination. Which of the following position is normally used for this type of examination?

a. Lithotomy position
b. Sim's position
c. Dorsal recumbent position
d. Left lateral position

43. Ms. Hull has had an electrocauterization of her cervix for chronic cervicitis. Following the procedure the nurse should instruct Ms. Hull to:

a. Douche the next day to remove debris and blood cloth
b. Avoid straining and heavy lifting until the physician permits this activity
c. Stay in bed for the next 5 days
d. Return in bed for the next 5 days

44. The nursing assistant is assigned to give Ms. Bailey, who has had an abdominal hysterectomy, a sitz bath. She is instructed to use the special sitz bath tub. She asks the nurse why the regular bath tub cannot be used. The most correct reply is based on the fact that a regular bath tab:

a. Is more slippery and is dangerous when used for surgical clients
b. Cannot supply water that is of the desired temperature for this procedure
c. Applies heat to the legs and alters the desired effect of heat directed to the pelvic region
d. Cannot be kept as clean as a special sitz bath tub
45. Which of the following solutions would be best for the nurse to use when cleaning the inner cannula of a tracheostomy tube?

a. IsopropyI alcohol
b. Sodium hydrochloride
c. Hydrogen peroxide
d. Providone-iodine

46. The nurse observes that the client's knee is swollen and painful. Consequently; which one of the following nursing measures should be carried out?

a. Perform passive range of motion during each shift
b. Help to change positions to achieve comfort
c. Ambulate with him at frequent intervals
d. Encourage quadriceps setting exercises

47. If Ms. Drake tells the nurse her feet are cold. Which of the following nursing action would be best

a. Apply a hot water bottle b Use an electric heating pad
c. Wrap them in a warm blanket
d. Elevate her feet on a stool

48. Which of the following would indicate to the nurse that the stationary thrombus in Ms. Fleming suddenly develops?
a. Chest pains
b. Leg cramps
c. Numbness in the foot
d. Swelling of the knee

49. Following a total abdominal hysterectomy Ms. Sara Fleming develops a slightly elevated temperature and swelling in the right call of her leg. The physician prescribes warm moist compresses for the client's affected leg. Which of the following nursing actions is correct when applying the warm moist compress? The nurse:

a. Heats the water to 120°F
b. Uses a sterile technique
c. Inspect the skin every 4 hours
d. Covers the wet gauze with a towel

50. Ms. Betty Lynch, age 29, holes that she has recently developed a skin problem and makes an appointment to be seen in a clinic specializing diagnosis of psoriasis is made by the physician. When examining Mr. Lynch's skin for areas of psoriasis, the nurse should look for:

a. Weeping lesions on the trunk of the body
b. Patches of redness covered with silvery scales
c. Areas of redness surrounded by crusts
d. A rash characterized by raised, pus-filled lesions
1. Before being discharged, Mr. Heywood must be taught principles f good body mechanics. The nurse would be correct in telling Mr. Heywood that when he picks up something, he should:

a. Flex both his knees
b. Keep his feet together
c. Lift with arms extended
d. Bend from the waist

2. The nurse applies a commercially made hot moist pack, called a hydrocollator, to the client's lower back. To reduce the potential for a thermal injury the nurse should plan to:

a. Wrap the pack in several thick towels
b. Rub skin lotion over the back area
c. Place a pillow between hint and the back
d. Position the client on rubber ring

3. Which one of the following observations would most indicate to the nurse that the skin over Mr. Heywood's coccyx is becoming impaired? The skin:

a. Looks shiny over boy prominences
b. Appears red when pressure in relieved
c. Feels cool and clammy
d. Is moist and warm

4. Before turning Mr. Heywood to wash his back, which instruction should the nurse provide to minimize his discomfort?

a. "Hold your breath as you are turning."
b. "Move your upper body first then legs."
c. "Curl up in a ball before you move."
d. "Avoid twisting your body while moving."

5. Which of the following should the nurse use to provide support to Mr. Heywood's spine?

a. A sheep skin pad
b. An air mattress
c. A bed board
d. A foam square

6. Mr. Heywood is to remain in bed for the time being. Which position would the nurse find gives Mr. Heywood the most comfort?

a. On his back with the head and knees elevated
b. On his side with hips and legs straight
c. On his abdomen with his head to the side
d. On his back with his head and knees straight

7. Mr. Heywood is receiving 10 mg of Diazepam (Vatium) orally t.i.d. Besides diminishing anxiety, the nurse explains that this medication is also used to:

a. Reduce emotional depression
b. Relax skeletal muscles
c. Promote restful sleep
d. Relieve inflammation

8. Mr. Barry Heywood, a construction worker, has been experiencing periodic bouts of law back pain. Now, in addition to the pain that radiates into his buttocks, he has some numbness and tingling in his legs. The physician suspects that Mr. Heywood has a herniated intervertebral disk in the lumbar spine. While assessing the disk to indicate that the pain is increased when:

a. Eating
b. Sneezing
c. Resting
d. Urinating

9. Mr. Rumsey, who has not regained consciousness, rushed to surgery where his arm is amputated above the elbow. When Mr. Rumsey reacts from the anesthesia, he sees that his forearm is missing. He screams obscenities and sobs uncontrollably. Which of the following is the best action the nurse can take at this time?

a. Leave the room until he has worked through his anger
b. Stay with him quietly in the room at his bedside
c. Tell him to get control of himself
d. Call the hospital chaplain for him

10. In what position should the nurse place Mr. Rumsey while continuing with his assessment and care?

a. Prone
b. Supine extended
c. On his back with his legs elevated
d. On his side with his neck

11. During a farming accident Mr. Steve Rumsey's arm gets caught in a corn auger. His lower left arm and band are crushed. Which of the following assessments would the nurse typically find when the paramedics bring Mr. Rumsey to the hospital in shock? The client would have:

a. Decreased heart rate
b. Decreasing blood pressure
c. Increasing bowel sounds
d. Increasing urine output

12. Ms. Angela Freeman has acute low back pain. She' has pelvic-belt traction, which she uses intermittently throughout the day. When the nurse helps Ms. Freeman apply the pelvic traction, it would be best to place the top of the belt:

a. Just below the ribcage
b. Even with her waistline
c. Level with the iliac crest
d. Where it is most comfortable

13. Ms. Rizal has acute rheumatoid arthritis. Her hands and spine are involved. When the nurse admits Ms. Rizal is most likely to tell the nurse that the first symptoms that caused her to seek health care was:

a. Stiff, sore joints
b. Generalized fatigue
c. Stabbing hand pain
d. Disuse of fingers

14. Before Ms. Elkins leaves the emergency department, the nurse demonstrates hew to apply the roller bandage. She is told to remove it for approximately 20 minutes and re-apply it three times a day. It is essential that the nurse tells Ms. Elkins to loosen-the bandage if:

a. Her toes feel fairly warm
b. Her ankle feels painful
c. Her toes appear swollen
d. She wears a cotton sock

15. The x-ray reveals that the bones are intact. The physician tells Ms. Elkins that she has severely sprained ankle. The physician directs the nurse to wrap Ms. Elkins foot with an elastic roller bandage referred to by some as an Ace bandage. Where should the nurse begin applying the bandage?

a. Below the knee
b. Above the knee
c. Across the phalanges
d. At the metatarsals

16. Following an injury in which Ms. Leona Elkins while climbing stairs, she experiencing immediate swelling of her ankle and pain on movement. Her physician has sent her to the hospital for x-ray. Which on of the following nursing measures would be most helpful for relieving the swelling while preparing to obtain the x-ray of Ms. Elkin's lower leg?

a. Dangle the foot
b. Elevate the foot
c. Exercise the foot
d. Immobilize the foot

SITUATION: Mr. Ramos was barbecuing outdoors when the gas tank exploded. He sustained second degree and third degree burns of the anterior portion of BOTH arms, the upper half of his anterior trunk and the anterior and posterior portions of his left lower extremity.

17. The BEST initial management of burns that can be employed at the scene is generally which of the following:

a. Pour cold water over the burned areas
b. Apply clean dressing to the affected area
c. Rinse the area with mild soap and water
d. Apply tomato juice and ointment over the area

18. At the emergency room, the nurse assessed the extent of the burn on the patient's body. Based on the rules of nine. Which of the following is the BEST estimate of the burn?

a. 36%
b. 45%
c. 27%
d. 54%

19. Which one of the following .blood value determinations is most likely be useful to evaluate the adequacy of the fluid replacement?

a. Creatinine levels
b. Blood urea nitrogen
c. Hematocrit level
d. C02 tension

20. The nurse is administering the prescribed IVF. When she evaluated the patient, she suspected fluid overload because of which finding?

a. Dark and scant urine output
b. Moist rates
c. Bradycardia and hypotension
d. Facial flushing and twitching

21. The doctor orders MAFENIDE for application over the bum area. The nurse understands that one disadvantage of this drug is that:

a. It causes lactic acidosis
b. It must be constantly applied
c. It has minimal eschar penetration
d. It is bacteriostatic

SITUATION: MARK Lester had been diagnosed with Stage 1 bronchogenic cancer. He had undergone lobectomy on the left lower lung. A two-bottle drainage system is inserted.

22. The patient is placed on bed post-operatively in what position?

a. Prone
b. Trendelenburg
c. Right side
d. Left side

23 Water-seal chest drainage involves attaching the chest tube to a:

a. Suction machine directly
b. Rubber tube/glass tube that is submerged underwater
c. Rubber tube that is left open to air
d. A closed drainage bottle with sterile water and no external opening

24. If the nurse sees fluid moving up and down during inspiration and expiration on the water seal bottle, she should:

a. Do nothing as this is expected
b. Immediately check the bottle for leaks
c. Call the physician immediately and damp the chest tube
d. Cover the wound with wet sterile gauze and send someone to calf the physician

25. If the nurse sees vigorous and continuous bubbling in the second bottle, she should:

a. Momentarily clamp the tube to note for air leak
b. Administer oxygen to the patient
c. Attempt to change a new bottle
d. Pull the chest tube out to remove the air leak
Mr. Duffy is admitted to the CCU with a diagnosis of R/O MI. He presented in the ER with a typical description of pain associated with an MI, and is now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is complaining of chest pain. Oxygen therapy has not been started, and he is not on the monitor. He is frightened.

1. The nurse is aware of several important tasks that should all be done immediately in order to give Mr. Duffy the care he needs. Which of the following nursing interventions will relieve his current myocardial ischemia?
a. stool softeners, rest
b. O2 therapy, analgesia
c. Reassurance, cardiac monitoring
d. Adequate fluid intake, low-fat diet

2. During the first three days that Mr. Duffy is in the CCU, a number of diagnostic blood tests are obtained. Which of the following patterns of cardiac enzyme elevation are most common following an MI?
a. SGOT, CK, and LDH are all elevated immediately.
b. SGOT rises 4-6 hours after infarction with CK and LDH rising slowly 24 hours later.
c. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36 hours) and then the LDH (peaks 3-4 days).
d. CK peaks first and remains elevated for 1 to 2 weeks.

3. On his second day in CCU Mr. Duffy suffers a life-threatening cardiac arrhythmia. Considering his diagnosis, which is the most probable arrhythmia?
a. atrial tachycardia
b. ventricular fibrillation
c. atrial fibrillation
d. heart block

4. Mr. Duffy is placed on digitalis on discharge from the hospital. The nurse planning with him for his discharge should educate him as to the purpose and actions of his new medication. What should she or he teach Mr. Duffy to do at home to monitor his reaction to this medication?

a. take his blood pressure
b. take his radial pulse for one minute
c. check his serum potassium (K) level
d. weigh himself everyday

5. You decide to discuss glaucoma prevention. Which of the following diagnostic tests should these clients request from their care provider?
a. fluorescein stain
b. snellen’s test
c. tonometry
d. slit lamp

6. You also explain common eye changes associated with aging. One of these is presbyopia, which is:
a. Refractive error that prevents light rays from coming to a single focus on the retina.
b. Poor distant vision
c. Poor near vision
d. A gradual lessening of the power of accommodation

7. Some of the diabetic clients are interested in understanding what is visualized during funduscopic examination. During your discussion you describe the macular area as:
a. Head of the optic nerve, seen on the nasal side of the field, lighter in color than the retina.
b. The area of central vision, seen on the temporal side of the optic disc, which is quite avascular.
c. Area where the central retinal artery and vein appear on the retina.
d. Reddish orange in color, sometimes stippled.

8. One of the clients has noted a raised yellow plaque on the nasal side of the conjunctiva. You explain that this is called:
a. a pinguecula, which is normal slightly raised fatty structure under the conjunctiva that may gradually increase with age.
b. Icterus, which may be due to liver disease.
c. A pterygium, which will interfere with vision.
d. Ciliary flush caused by congestion of the ciliary artery.

9. You know that all but one of the following may eventually result in uremia. Which option is not implicated?
a. glomerular disease
b. uncontrolled hypertension
c. renal disease secondary to drugs, toxins, infections, or radiations
d. all of the above

10. You did the initial assessment on Mr. Kaplan when he came to your unit. What classical signs and symptoms did you note?
a. fruity- smelling breath.
b. Weakness, anorexia, pruritus
c. Polyuria, polydipsia, polyphagia
d. Ruddy complexion

11. Numerous drugs have been used on Mr. Kaplan in an attempt to stabilize him. Regarding his diagnosis and management of his drugs, you know that:
a. The half-life of many drugs is decreased in uremia; thus dosage may have to be increased to be effective.
b. Drug toxicity is a major concern in uremia; individualization of therapy and often a decrease in dose is essential.
c. Drug therapy is not usually affected by this diagnosis
d. Precautions should be taken with prescription drugs, but most OTC medications are safe for him to use.

12. The point of maximum impulse (PMI) is an important landmark in the cardiac exam. Which statement best describes the location of the PMI in the healthy adult?
a. Base of the heart, 5th intercostal space, 7-9 cm to the left of the midsternal line.
b. Base of the heart, 7th intercostal space, 7-9 cm to the left of the midsternal line.
c. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
d. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.

13. During the physical examination of the well adult client, the health care provider auscultates the heart. When the stethoscope is placed on the 5th intercostal space along the left sternal border, which valve closure is best evaluated?
a. Tricuspid
b. Pulmonic
c. Aortic
d. Mitral

14. The pulmonic component of which heart sound is best heard at the 2nd LICS at the LSB?
a. S1
b. S2
c. S3
d. S4

15. The coronary arteries furnish blood supply to the myocardium. Which of the following is a true statement relative to the coronary circulation?
a. the right and left coronary arteries are the first of many branches off the ascending aorta
b. blood enters the right and left coronary arteries during systole only
c. the right coronary artery forms almost a complete circle around the heart, yet supplies only the right ventricle
d. the left coronary artery has two main branches, the left anterior descending and left circumflex: both supply the left ventricle

Sally Baker, a 40-year-old woman, is admitted to the hospital with an established diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve.

16. Ms. Baker has decided to have surgical correction of her stenosed valve at this time because her subjective complaints of dyspnea, hemoptysis, orthopnea, and paroxysmal nocturnal dyspnea have become unmanageable. These complaints are probably due to:
a. thickening of the pericardium
b. right heart failure
c. pulmonary hypertension
d. left ventricular hypertrophy

17. On physical exam of Ms. Baker, several abnormal findings can be observed. Which of the following is not one of the usual objective findings associated with mitral stenosis?
a. low-pitched rumbling diastolic murmur, precordial thrill, and parasternal lift
b. small crepitant rales at the bases of the lungs
c. weak, irregular pulse, and peripheral and facial cyanosis in severe disease
d. chest x-ray shows left ventricular hypertrophy

18. You are seeing more clients with diagnoses of mitral valve prolapse. You know those mitral valve prolapse is usually a benign cardiac condition, but may be associated with atypical chest pain. This chest pain is probably caused by:
a. ventricular ischemia
b. dysfunction of the left ventricle
c. papillary muscle ischemia and dysfunction
d. cardiac arrythmias

19. The most common lethal cancer in males between their fifth and seventh decades is:
a. cancer of the prostate
b. cancer of the lung
c. cancer of the pancreas
d. cancer of the bowel

20. Of the four basic cell types of lung cancer listed below, which is always associated with smoking?
a. adenocarcinoma
b. squamous cell carcinoma (epidermoid)
c. undifferenciated carcinoma
d. bronchoalveolar carcinoma

21. Chemotherapy may be used in combination with surgery in the treatment of lung cancer. Special nursing considerations with chemotherapy include all but which of the following?
a. Helping the client deal with depression secondary to the diagnosis and its treatment
b. Explaining that the reactions to chemotherapy are minimal
c. Careful observation of the IV site of the administration of the drugs
d. Careful attention to blood count results

22. Which of the following operative procedures of the thorax is paired with the correct definition?
a. Pneumonectomy: removal of the entire lung
b. Wedge resection: removal of one or more lobes of a lung
c. Decortication: removal of the reibs or sections of ribs
d. Thoracoplasty: removal of fibrous membrane that develops over visceral pleura as a result of emphysema

Mr. Liberatore, age 76, is admitted to your unit. He has a past medical history of hypertension, DM, hyperlipidemia. Recently he has had several episodes where he stops talking in midsentence and stares into space. Today the episode lasted for 15 minutes. The admission diagnosis is impending CVA.

23. The episodes Mr. Liberatore has been experiencing are probably:
a. small cerebral hemorrhages
b. TIA’s or transient ischemic attacks
c. Secondary to hypoglycemia
d. Secondary to hyperglycemia

24. Mr. Liberatore suffers a left sided CVA. He is right handed. The nurse should expect:
a. left-sided paralysis
b. visual loss
c. no alterations in speech
d. no impairment of bladder function

25. Upper motor neuron disease may be manifested in which of the following clinical signs?
a. spastic paralysis, hyperreflexia, presence of babinski reflex
b. flaccid paralysis, hyporeflexia
c. muscle atrophy, fasciculations
d. decreased or absent voluntary movement

26. During your assessment of Julie she tells you all visual symptoms are gone but that she now has a severe pounding headache over her left eye. You suspect Julie may have:
a. a tension headache
b. the aura and headache of migraine
c. a brain tumor
d. a conversion reaction

27. You explain to Julie and her mother that migraine headaches are caused by:
a. an allergic response triggered by stress
b. dilation of cerebral arteries
c. persistent contraction of the muscles of the head, neck and face
d. increased intracranial pressure

28. A thorough history reveals that hormonal changes associated with menstruation may have triggered Julie’s migraine attack. In investigating Julie’s history what factors would be least significant in migraine?
a. seasonal allergies
b. trigger foods such as alcohol, MSG, chocolate
c. family history of migraine
d. warning sign of onset, or aura

29. A client with muscle contraction headache will exhibit a pattern different for Julie’s. Which of the following is more compatible with tension headache?
a. severe aching pain behind both eyes
b. headache worse when bending over
c. a bandlike burning around the neck
d. feeling of tightness bitemporally, occipitally, or in the neck

Mr. Snyder is admitted to your unit with a brain tumor. The type of tumor he has is currently unknown. You begin to think about the way brain tumors are classified.

30. Glioma is an intracranial tumor. Which of the following statements about gliomas do you know to be false?
a. 50% of all intracranial tumors are gliomas
b. gliomas are usually benign
c. they grow rapidly and often cannot be totally excised from the surrounding tissue
d. most glioma victims die within a year after diagnosis

31. Acoustic neuromas produce symptoms of progressive nerve deafness, tinnitus, and vertigo due to pressure and eventual destruction of:
a. CN5
b. CN7
c. CN8
d. The ossicles

32. Whether Mr Snyder’s tumor is benign or malignant, it will eventually cause increased intracranial pressure. Signs and symptoms of increasing intracranial pressure may include all of the following except:
a. headache, nausea, and vomiting
b. papilledema, dizziness, mental status changes
c. obvious motor deficits
d. increased pulse rate, drop in blood pressure

33. Mr Snyder is scheduled for surgery in the morning, and you are surprised to find out that there is no order for an enema. You assess the situation and conclude that the reason for this is:
a. Mr. Snyder has had some mental changes due to the tumor and would find an enema terribly traumatic
b. Straining to evacuate the enema might increase the intracranial pressure
c. Mr. Snyder had been on clear liquids and then was NPO for several days, so an enema is not necessary
d. An oversight and you call the physician to obtain the order

34. Postoperatively Mr. Snyder needs vigilant nursing care including all of the following except:
a. Keeping his head flat
b. Assessments q ½ hour of LOC, VS, papillary responses, and mental status
c. Helping him avoid straining at stool, vomiting, or coughing
d. Providing a caring, supportive atmosphere for him and his family

35. Potential postintracranial surgery problems include all but which of the following?
a. increased ICP
b. extracranial hemorrhage
c. seizures
d. leakage of cerebrospinal fluid

Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy.

36. You are responsible for teaching Mrs. Hogan deep breathing and coughing exercises. Why are these exercises especially important for Mrs. Hogan?
a. they prevent postoperative atelectasis and pneumonia
b. the incision in gallbladder surgery is in the subcostal area, which makes the client reluctant to take a deep breath and cough
c. because she is probably overweight and will be less willing to breathe, cough, and move postoperatively

37. On the morning of Mrs. Hogan’s planned cholecystectomy she awakens with a pain in her right scapular area and thinks she slept in poor position. While doing the preop check list you note that on her routine CB report her WBC is 15,000. Your responsibility at this point is:
a. to notify the surgeon at once; this is an elevated WBC indicating an inflammatory reaction
b. to record this finding in a prominent place on the preop checklist and in your preop notes
c. to call the laboratory for a STAT repeat WBC
d. none. This is not an unusual finding

38. Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM and Demerol 50 mg IM one hour preoperatively. Which nursing actions follow the giving of the preop medication?
a. have her void soon after receiving the medication
b. allow her family to be with her before the medication takes effect
c. bring her valuables to the nursing station
d. reinforce preop teaching

39. Mrs. Hogan is transported to the recovery room following her cholecystectomy. As you continue to check her vital signs you note a continuing trend in Mrs. Hogan’s status: her BP is gradually dropping and her pulse rate is increasing. Your most appropriate nursing action is to:
a. order whole blood for Mrs. Hogan from the lab
b. increase IV fluid rate of infusion and place in trendelenburg position
c. immediately report signs of shock to the head nurse and/or surgeon and monitor VS closely
d. place in lateral sims position to facilitate breathing

40. Mrs. Hogan returns to your clinical unit following discharge from the recovery room. Her vital signs are stable and her family is with her. Postoperative leg exercises should be inititated:
a. after the physician writes the order
b. after the family leaves
c. if Mrs. Hogan will not be ambulated early
d. stat

41. An oropharyngeal airway may:
a. Not be used in a conscious patient.
b. Cause airway obstruction.
c. Prevent a patient from biting and occluding an ET tube.
d. Be inserted "upside down" into the mouth opening and then rotated into the proper orientation as it is advanced into the mouth.
e. All of the above.

42. Endotracheal intubation:
a. Can be attempted for up to 2 minutes before you need to stop and ventilate the patient.
b. Reduces the risk of aspiration of gastric contents.
c. Should be performed with the neck flexed forward making the chin touch the chest.
d. Should be performed after a patient is found to be not breathing and two breaths have been given but before checking for a pulse.

43. When giving bag-valve mask ventilations:
a. Rapid and forceful ventilations are desirable so that adequate ventilation will be assured
b. Effective ventilations can always be given by one person.
c. Cricoid pressure may prevent gastric inflation during ventilations.
d. Tidal volumes will always be larger than when giving mouth to pocket mask ventilations.

44. If breath sounds are only heard on the right side after intubation:
a. Extubate, ventilate for 30 seconds then try again.
b. The patient probably only has one lung, the right.
c. You have intubated the stomach.
d. Pull the tube back and listen again.

45. An esophageal obturator airway (EOA):
a. Can be inserted by any person trained in ACLS.
b. Requires visualization of the trachea before insertion.
c. Never causes regurgitation.
d. Should not be used with a conscious person, pediatric patients, or patients who have swallowed caustic substances.

46. During an acute myocardial infarct (MI):
a. A patient may have a normal appearing ECG.
b. Chest pain will always be present.
c. A targeted history is rarely useful in making the diagnosis of MI.
d. The chest pain is rarely described as crushing, pressing, or heavy.

47. The most common lethal arrhythmia in the first hour of an MI is:
a. Pulseless Ventricular Tachycardia
b. Asystole
c. Ventricular fibrillation
d. First degree heart block.

48. Which of the following is true about verapamil?
a. It is used for wide-complex tachycardia.
b. It may cause a drop in blood pressure.
c. It is a first line drug for Pulseless Electrical Activity.
d. It is useful for treatment of severe hypotension.

49. Atropine:
a. Is always given for a heart rate less than 60 bpm.
b. Cannot be given via ET tube.
c. Has a maximum total dosage of 0.03-0.04 mg/kg IV in the setting of cardiac arrest.
d. When given IV, should always be given slowly.

50. Asystole should not be "defibrillated."
a. True
b. False
1. b. O2 therapy, analgesia
All the nursing interventions listed are important in the care of Mr. Duffy. However relief of his pain will be best achieved by increasing the O2 content of the blood to his heart, and relieving the spasm of coronary vessels.

2. c. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36 hours) and then the LDH (peaks 3-4 days).
Although the timing of initial elevation, peak elevation, and duration of elevation vary with sources, current literature favors option letter c.

3. b. ventricular fibrillation
Ventricular irritability is common in the early post-MI period, which predisposes the client to ventricular arrhythmias. Heart block and atrial arrhythmias may also be seen post-MI but ventricular arrhythmias are more common.

4. b. take his radial pulse for one minute
All options have some validity. However, option B relates best to the action of digitalis. If the pulse rate drops below 60 or is markedly irregular, the digitalis should be held and the physician consulted. Serum potassium levles should be monitored periodically in clients on digitalis and diuretics, as potassium balance is essential for prevention of arrhythmias. However the client cannot do this at home. Daily weights may make the client alert to fluid accumulation, an early sign of CHF. Blood pressure measurement is also helpful; providing the client has the right size cuff and he or she and/or significant other understand the technique and can interpret the results meaningfully.

5. c. tonometry
Option A is most often used to detect corneal lesions; B is a test for visual acuity using snellen’s chart; D is used to focus on layers of the cornea and lens looking for opacities and inflammation.

6. d. A gradual lessening of the power of accommodation
Option A defines astigmatism, B is myopia, and C is hyperopia

7. b. The area of central vision, seen on the temporal side of the optic disc, which is quite avascular.
Options A and C refer to the optic disc, D describes the color of the retina.

8. a. a pinguecula, which is normal slightly raised fatty structure under the conjunctiva that may gradually increase with age.
Correct by definition.

9. d. all of the above
Options A, B and C are potential causes of renal damage and eventual renal failure. Individuals can live very well with only one healthy kidney.

10. b. Weakness, anorexia, pruritus
Weakness and anorexia are due to progressive renal damage; pruritus is secondary to presence of urea in the perspiration. Fruity smelling breath is found in diabetic ketoacidosis. Polyuria, polydipsia, polyphagia are signs of DM and early diabetic ketoacidosis. Oliguria is seen in chronic renal failure. The skin is more sallow or brown as renal failure continues.

11. b. Drug toxicity is a major concern in uremia; individualization of therapy and often a decrease in dose is essential.
Metabolic changes and alterations in excretion put the client with uremia at risk for development of toxicity to any drug. Thus alteration in drug schedule and dosage is necessary for safe care.

12. c. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.
The PMI is the impulse at the apex of the heart caused by the beginning of ventricular systole. It is generally located in the 5th left ICS, 7-9 cm from the MSL or at, or just medial to, the MCL.

13. a. Tricuspid
The sound created by closure of the tricuspid valve is heard at the 5th LICS at the LSB. Pulmonic closure is best heard at the 2nd LICS, LSB. Aortic closure is best heard at the 2nd RICS, RSB. Mitral valve closure is best heard at the PMI landmark (apex)

14. b. S2
S1 is caused by mitral and tricuspid valve closure, S2 is caused by the aortic and pulmonic valve closure; S3 and S4 are generally considered abnormal heat sounds in adults and are best heard at the apex.

15. d. the left coronary artery has two main branches, the left anterior descending and left circumflex: both supply the left ventricle
The right and left coronary arteries are the only branches off the ascending aorta; blood enters these arteries mainly during diastole; the right coronary artery also often supplies a small portion of the left ventricle.

16. c. pulmonary hypertension
Pulmonary congestion secondary to left atrial hypertrophy causes these symptoms. The left ventricle does not hypertrophy in mitral stenosis; right heart failure would cause abdominal discomfort and peripheral edema; pericardial thickening does not occur.

17. d. chest x-ray shows left ventricular hypertrophy
Evidence of left atrial enlargement may be seen on chest x-ray and ECG. The other objective findings may be seen in chronic mitral stenosis with episodes of atrial fibrillation and right heart failure.

18. c. papillary muscle ischemia and dysfunction
Ventricular ischemia does not occur with prolapsed mitral valve; options B and D are not painful conditions in themselves.

19. b. cancer of the lung
The incidence of lung cancer is also rapidly rising in women.

20. b. squamous cell carcinoma (epidermoid)
Textbooks of medicine and nursing classify primary pulmonary carcinoma somewhat differently. However most agree that sqaumous cell or epidermoid carcinoma is always associated with cigarette smoking.

21. b. Explaining that the reactions to chemotherapy are minimal
There ar enumerous severe reactions to chemotherapy such as stomatitis, alopecia, bone marrow depression, nausea and vomiting. Options A, B and D are important nursing considerations.

22. a. Pneumonectomy: removal of the entire lung
Wedge resection is removal of part of a segment of the lung; decortication is the removal of a fibrous membrane that develops over the visceral pleura; and thoracoplasty is the removal of ribs or sections of ribs.

23. b. TIA’s or transient ischemic attacks
A TIA is a temporary reduction in blood flow to the brain, manifesting itself in symptoms like those Mr. Liberatore experiences. Although hypo- and hyperglycemia can cause some drowsiness and/or disorientation, the episodes Mr. Liberatore experiences fit the pattern of TIA because of his quick recovery with no sequelae and no treatment.

24. b. visual loss
Visual field loss is a common side effect of CVA. In right-handed persons the speech center (Broca’s area) is most commonly in the left brain; because of the crossover of the motor fibers, a CVA in the left brain will produce a right-sided hemiplegia. Thus, Mr. Liberatore will probably have some speech disturbance and right-sided paralysis. Often bladder control is diminished following CVA.

25. a. spastic paralysis, hyperreflexia, presence of babinski reflex
Options B, C and D describe lower motor neuron disease.

26. b. the aura and headache of migraine
The warning sign or aura is associated with migraine although not everyone with migrane has an aura. Migraine is usually unilateral and described as pounding. Julie’s symptoms are most compatible with migraine.

27. b. dilation of cerebral arteries
The vascular theory best explains migraine and often diagnosis is confirmed through a trial of ergotamine, which constricts the dilated, pulsating vesels.

28. a. seasonal allergies
Sinus headache often accompanies seasonal allergies. Many factors may contribute to migraine. Usually the client comes from a family that has migrated, which may have been called “sick headache” due to accompanying nausea and vomiting. Often there is an aura. Stress, diet, hormonal changes, and fatigue may all be implicated in migraine.

29. d. feeling of tightness bitemporally, occipitally, or in the neck
Options A and B describe sinus headache; option A may also be compatible with headache secondary to eyestrain; option B is also compatible with migraine; option C would be correct if stated a bandlike “tightness” around the head instead of “burning”

30. b. gliomas are usually benign
Gliomas are malignant tumors.

31. c. CN8
CN8, the acoustic nerve or vestibulocochlear nerve, is the most commonly affected CN in acoustic neuroma although as the tumor progresses CN5 and CN7 can be affected.

32. d. increased pulse rate, drop in blood pressure
As ICP increases, the pulse rate decreases and the BP rise. However, as ICP continues to rise, vital signs may vary considerably.

33. b. Straining to evacuate the enema might increase the intracranial pressure
Any activity that increases ICP could possibly cause brain herniation. Straining to expel an enema is one example of how the increased ICP can be further aggravated.

34. a. Keeping his head flat
Postoperatively clients who have undergone craniotomy usually have their heads elevated to decrease local edema and also decrease ICP.

35. b. extracranial hemorrhage
Hemorrhage is predominantly intracranial, although there may be some bloody drainage on external dressings. Increased ICP may result from hemorrhage or edema. CSF leakage may result in meningitis. Seizures are another postoperative concern.

36. b. the incision in gallbladder surgery is in the subcostal area, which makes the client reluctant to take a deep breath and cough
Option A is true: the rationale for deep breathing and coughing is to prevent postoperative pulmonary complications such as pneumonia and atelectasis. However, the risk of pulmonary problems is somewhat increased in clients with biliary tract surgery because of their high abdominal incisions. Option C assumes the stereotype of the person with gallbladder disease – fair, fat and fory – which is not necessarily the case. Splinting the incision with the hands or a pillow is very helpful in controlling the pain during coughing.

37. a. to notify the surgeon at once; this is an elevated WBC indicating an inflammatory reaction
A WBC count of 15,000 probably indicates acute cholecystitis, especially considering Mrs. Hogan’s new pain. The surgeon should be called as he/she may treat the acute attack medically and delay the surgery for several days, weeks, or months.

38. b. allow her family to be with her before the medication takes effect
Options A, C and D should all take place prior to administration of the drugs. The family may also be involved earlier but certainly should have that time immediately after the medication is given and before it takes full effect to be with their loved ones. Good planning of nursing care can facilitate this.

39. c. immediately report signs of shock to the head nurse and/or surgeon and monitor VS closely
These are signs of impending shock, which may be true shock or a reaction to anesthesia. Your most appropriate action is to report your findings quickly and accurately and to continue to monitor Mrs. Hogan carefully.

40. d. stat
Leg exercises, deep breathing and coughing, moving, and turning should begin as soon as the client’s condition is stable. The family can be extremely helpful in encouraging the client to do them, in supporting the incision, etc. a doctor’s oreder is not necessary – this is a nursing responsibility.

41. e. All of the above.
An oropharyngeal airway should be used in an unconscious patient. In a conscious or semiconscious patient its use may cause laryngospasm or vomiting. An oropharyngeal airway that is too long may push the epiglottis into a position that obstructs the airway. It is often use with an ETT to prevent biting and occlusion. It is usually inserted upside down and then rotated into the correct orientation as it approaches full insertion.

42. b. Reduces the risk of aspiration of gastric contents.
Letter A is wrong because an attempt should not last no longer than 30 seconds. Unless injury is suspected the neck should be slightly flexed and the head extended.. the ‘sniffing position’. After securing an airway and successfully ventilating the patient with two breaths you should then check for a pulse. If there is no pulse begin chest compressions. Intubation is part of the secondary survey ABC’s.

43. c. Cricoid pressure may prevent gastric inflation during ventilations.
Cricoid pressure may prevent gastric inflation during ventilations and may also prevent regurgitation by compressing the esophagus. Letter A may cause gastric insufflation thus increasing the risk for regurgitation and aspiration. With adults breaths should be delivered slowly and steadily over 2 seconds. Effective ventilation using bag-valve mask usually requires at least two well trained rescuers. A frequent problem with bag-valve mask ventilations is the inability to provide adequate tidal volumes.

44. d. Pull the tube back and listen again.
Most likely you have a right main stem bronchus intubation. Pulling the tube back a few centimeters may be all you need to do.

45. d. Should not be used with a conscious person, pediatric patients, or patients who have swallowed caustic substances.
EOA insertion should only be attempted by persons highly proficient in their use. Moreover, since visualization is not required the EOA may be very useful in patient’s when intubation is contraindicated or not possible. Vomiting and aspiration are possible complications of insertion and removal of an EOA.

46. a. A patient may have a normal appearing ECG.
Which is why a normal ECG alone cannot be relied upon to rule out an MI. Chest pain does not always accompany an MI. This is especially true of patients with diabetes. A targeted history is often crucial in making the diagnosis of acute MI. The chest pain associated with an acute MI is often described as heavy, crushing pressure, 'like an elephant sitting on my chest.'

47. c. Ventricular fibrillation
Moreover, ventricular fibrillation is 15 times more likely to occur during the first hour of an acute MI than the following twelve hours which is why it is vital to decrease the delay between onset of chest pain and arrival at a medical facility. First degree heart block is not a lethal arrhythmia.

48. b. It may cause a drop in blood pressure.
Verapamil usually decreases blood pressure, which is why it is sometimes used as an antihypertensive agent. Verapamil may be lethal if given to a patient with V-tach, therefore it should not be given to a tachycardic patient with a wide complex QRS. Verapamil is a calcium channel blocker and may actually cause PEA if given too fast intravenously or if given in excessive amounts. The specific antidote for overdose from verapamil, or any other calcium channel blocker, is calcium. Verapamil may cause hypotension.

49. c. Has a maximum total dosage of 0.03-0.04 mg/kg IV in the setting of cardiac arrest.
Only give atropine for symptomatic bradycardias. Many physically fit people have resting heart rates less than 60 bpm. Atropine may be given via an endotracheal tube. Administering atropine slowly may cause paradoxical bradycardia.

50. a. True
Asystole is not amenable to correction by defibrillation. But there is a school of thought that holds that asystole should be treated like V-fib, i.e... defibrillate it. The thinking is that human error or equipment malfunction may result in misidentifying V-fib as asystole. Missing V- fib can have deadly consequences for the patient because V-fib is highly amenable to correction by defibrillation.
1. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
A)Chronic vessel plaque formation
B)Pulmonary embolism
C)Occlusions at the vessel bifurcations
D)Coronary artery aneurysms

2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
A)"I cannot give this medication as it is written. I have no idea of what you mean."
B)"Would you please clarify what you have written so I am sure I am reading it correctly?"
C)"I am having difficulty reading your handwriting. It would save me time if you would be more careful."
D)"Please print in the future so I do not have to spend extra time attempting to read your writing."

3. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?
A)Reprimand the child and give a 15 minute "time out"
B)Maintain a permissive attitude for this behavior
C)Use patience and a sense of humor to deal with this behavior
D)Assert authority over the child through limit setting

4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A)"Have you had a recent heart attack?"
B)"Do you become short of breath during your normal daily activities?"
C)"How many pillows do you use at night to sleep comfortably?"
D)"Do you smoke?"

5. The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate? A)Fluid restriction 1000cc per day
B)Ambulate in hallway 4 times a day
C)Administer analgesic therapy as ordered
D)Encourage increased caloric intake

6. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
A)Sexual promiscuity
B)Poor body image
C)Dropping out of school
D)Drug experimentation

7. A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
A)Pre-interaction
B)Orientation
C)Working
D)Termination

8. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to
A)Begin mouth to mouth resuscitation
B)Give the child water to help in swallowing
C)Perform 5 abdominal thrusts
D)Call for the emergency response team

9. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?
A)"Do not worry. Epilepsy can be treated with medications."
B)"The seizure may or may not mean your child has epilepsy."
C)"Since this was the first convulsion, it may not happen again."
D)"Long term treatment will prevent future seizures."

10. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
A)Gestational age assessment suggested growth retardation
B)Meconium was cleared from the airway at delivery
C)Phototherapy was used to treat Rh incompatibility
D)The infant received mechanical ventilation for 2 weeks

11. Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?
A)Cereal
B)Eggs
C)Meat
D)Juice

12. A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing?
A)Fear
B)Helplessness
C)Self-blame
D)Rejection

13. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory?
A)"Name the year." "What season is this?" (pause for answer after each question)
B)"Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number."
C)"I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."
D)"What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

14. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
A) Venturi mask
B) Partial rebreather mask
C) Non-rebreather mask
D) Simple face mask

15. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?
A) Capillary refill of fingers on right hand is 3 seconds
B) Skin warm to touch and normally colored
C) Client reports prickling sensation in the right hand
D) Slight swelling of fingers of right hand

16. Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
A) Liver function
B) Kidney function
C) Blood sugar
D) Cardiac enzymes

17. Which client is at highest risk for developing a pressure ulcer?
A) 23 year-old in traction for fractured femur
B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C) 75 year-old with left sided paresthesia and is incontinent of urine and stool
D) 30 year-old who is comatose following a ruptured aneurysm

18. Which contraindication should the nurse assess for prior to giving a child immunization?
A) Mild cold symptoms
B) Chronic asthma
C) Depressed immune system
D) Allergy to eggs

19. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
A) Neurotoxicity
B) Hepatomegaly
C) Nephrotoxicity
D) Ototoxicity

20. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
A) Protect the eyes of the neonate from the heat lamp
B) Monitor the neonate’s temperature
C) Warm all medications and liquids before giving
D) Avoid touching the neonate with cold hands

21. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
A) "I give my insulin to myself in my thighs."
B) "Sometimes when I put my shoes on I don't know where my toes are."
C) "Here are my up and down glucose readings that I wrote on my calendar."
D) "If I bathe more than once a week my skin feels too dry."

22. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first? A) Place the child in the nearest bed
B) Administer IV medication to slow down the seizure
C) Place a padded tongue blade in the child's mouth
D) Remove the child's toys from the immediate area

23. The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information? A) "I usually avoid driving at night since lights sometimes seem to make things blur."
B) "I take half of the usual dose for my sinuses to maintain my blood pressure."
C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."
D) "I take extra fiber and drink lots of water to avoid getting constipated.”

24. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
A) Irritability
B) Slight edema at site
C) Local tenderness
D) Temperature of 102.5 F

25. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering
A) Pulmonary embolectomy
B) Vena caval interruption
C) Increasing the coumadin therapy to an INR of 3-4
D) Thrombolytic therapy

26. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
A) Drink small amounts of liquids frequently
B) Eat the evening meal just before retiring
C) Take sodium bicarbonate after each meal
D) Sleep with head propped on several pillows

27. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching? A) "I'm going to try feeding my baby some rice cereal."
B) "When he wakes at night for a bottle, I feed him."
C) "I dip his pacifier in honey so he'll take it."
D) "I keep formula in the refrigerator for 24 hours."

28. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
A) Institute seizure precautions
B) Weigh the child twice per shift
C) Encourage the child to eat protein-rich foods
D) Relieve boredom through physical activity

29. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
A) "This action of my lips helps to keep my airway open."
B) "I can expel more when I pucker up my lips to breathe out."
C) "My mouth doesn't get as dry when I breathe with pursed lips."
D) "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse."

30. A 57 year-old male client has hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
A) Ask the client if he has noticed any bleeding or dark stools
B) Tell the client to call 911 and go to the emergency department immediately
C) Schedule a repeat Hemoglobin and Hematocrit in 1 month
D) Tell the client to schedule an appointment with a hematologist

31. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?

A) "Addiction usually causes people to feel guilty. Don’t worry, it is a typical response due to your drinking behavior."
B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"
C) "Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs."
D) "You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done."

32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?
A) Review the client's weight pattern over the year
B) Ask the mother to record her diet for the last 24 hours
C) Encourage her to talk about her view of herself
D) Give her several pamphlets on postpartum nutrition

33. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis?
A) Use only cloth diapers that are rinsed in bleach
B) Do not use occlusive ointments on the rash
C) Use commercial baby wipes with each diaper change
D) Discontinue a new food that was added to the infant's diet just prior to the rash

34. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is
A) Progressive failure to adapt
B) Feelings of anger or hostility
C) Reunion wish or fantasy
D) Feelings of alienation or isolation

35. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
A) Trust
B) Initiative
C) Independence
D) Self-esteem

36. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous
Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 microdrops/cc. What rate would deliver 4 mgm of Lidocaine/minute?
A) 60 microdrops/minute
B) 20 microdrops/minute
C) 30 microdrops/minute
D) 40 microdrops/minute

37. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
A) Norplant is safe and may be removed easily
B) Oral contraceptives should not be used by smokers
C) Depo-Provera is convenient with few side effects
D) The IUD gives protection from pregnancy and infection

38. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
A) Confusion
B) Loss of half of visual field
C) Shallow respirations
D) Tonic-clonic seizures

39. A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?
A) "Nursing will help contract the uterus and reduce your risk of bleeding."
B) "Breastfeeding twins will take too much energy after the hemorrhage."
C) "The blood transfusion may increase the risks to you and the babies."
D) "Lactation should be delayed until the "real milk" is secreted."

40. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane).
What is the nurse’s best explanation of these findings?
A) These side effects are common and should subside in a few days
B) The client is probably having an allergic reaction and should discontinue the drug
C) Taking the lithium on an empty stomach should decrease these symptoms
D) Decreasing dietary intake of sodium and fluids should minimize the side effects

41. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
A) Place pillows under the knees
B) Use elastic stockings continuously
C) Encourage range of motion and ambulation
D) Massage the legs twice daily

42. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that
A) Circumcision is delayed so the foreskin can be used for the surgical repair
B) This procedure is contraindicated because of the permanent defect
C) There is no medical indication for performing a circumcision on any child
D) The procedure should be performed as soon as the infant is stable

43. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
A) Loss of consciousness
B) Feeding problems
C) Poor weight gain
D) Fatigue with crying

44. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?
A) Double the birth weight
B) Triple the birth weight
C) Gain 6 ounces each week
D) Add 2 pounds each month

45. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
A) Raise the head of the bed at least 30 degrees
B) Encourage ambulation within 24 hours
C) Maintain in a flat position, logrolling as needed
D) Encourage leg contraction and relaxation after 48 hours

46. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
A) "Focus on your sons' needs during the first days at home."
B) "Tell each child what he can do to help with the baby."
C) "Suggest that your husband spend more time with the boys."
D) "Ask the children what they would like to do for the newborn."

47. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
A) A cerebral vascular accident
B) Postoperative meningitis
C) Medication reaction
D) Metabolic alkalosis

48. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect?
A) Oculogyric crisis
B) Tardive dyskinesia
C) Nystagmus
D) Dysphagia

49. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
A) A social worker from the local hospital
B) An occupational therapist from the community center
C) A physical therapist from the rehabilitation agency
D) Another client with diabetes mellitus and takes insulin

50. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
A) Convince the client that the hospital staff is trying to help
B) Help the client to enter into group recreational activities
C) Provide interactions to help the client learn to trust staff
D) Arrange the environment to limit the client’s contact with other clients

51. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
A) Surgical repair of a diseased coronary artery
B) Placement of an automatic internal cardiac defibrillator
C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
D) Non-invasive radiographic examination of the heart

52. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
A) They can expect the child will be mentally retarded
B) Administration of thyroid hormone will prevent problems
C) This rare problem is always hereditary
D) Physical growth/development will be delayed

53. A priority goal of involuntary hospitalization of the severely mentally ill client is
A) Re-orientation to reality
B) Elimination of symptoms
C) Protection from harm to self or others
D) Return to independent functioning

54. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?
A) "I don't remember anything about what happened to me."
B) "I'd rather not talk about it right now."
C) "It's the other entire guy's fault! He was going too fast."
D) "My mother is heartbroken about this."

55. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
A) Altered tissue perfusion
B) Risk for fluid volume deficit
C) High risk for hemorrhage
D) Risk for infection

56. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
A) Expose the cast to air and turn the child frequently
B) Use a heat lamp to reduce the drying time
C) Handle the cast with the abductor bar
D) Turn the child as little as possible

57. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
A) Instruct the client to maintain a regular diet the day prior to the examination
B) Restrict the client's fluid intake 4 hours prior to the examination
C) Administer a laxative to the client the evening before the examination
D) Inform the client that only 1 x-ray of his abdomen is necessary

58. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse's response is based on an understanding that
A) AGN is a streptococcal infection that involves the kidney tubules
B) The disease is easily transmissible in schools and camps
C) The illness is usually associated with chronic respiratory infections
D) It is not "caught" but is a response to a previous B-hemolytic strep infection

59. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?
A) 3 episodes of vomiting in 1 hour
B) Periodic crying and irritability
C) Vigorous sucking on a pacifier
D) No measurable voiding in 4 hours

60. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
A) Check vital signs
B) Massage the fundus
C) Offer a bedpan
D) Check for perineal lacerations

61. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
A) Unequal leg length
B) Limited adduction
C) Diminished femoral pulses
D) Symmetrical gluteal folds

62. To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would
A) Assist the client to use the bedside commode
B) Administer stool softeners every day as ordered
C) Administer antidysrhythmics prn as ordered
D) Maintain the client on strict bed rest

63. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to
A) Give the client orientation materials and review the unit rules and regulations
B) Introduce him/her and accompany the client to the client’s room
C) Take the client to the day room and introduce her to the other clients
D) Ask the nursing assistant to get the client’s vital signs and complete the admission search

64. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
A) "I have constant blurred vision."
B) "I can't see on my left side."
C) "I have to turn my head to see my room."
D) "I have specks floating in my eyes."

65. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
A) Has increased airway obstruction
B) Has improved airway obstruction
C) Needs to be suctioned
D) Exhibits hyperventilation

66. Which behavioral characteristic describes the domestic abuser?
A) Alcoholic
B) Over confident
C) High tolerance for frustrations
D) Low self-esteem

67. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend
A) Isometric
B) Range of motion
C) Aerobic
D) Isotonic

68. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
A) Counsel the woman to consent to HIV screening
B) Perform tests for sexually transmitted diseases
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic

69. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
A) Arrange to change client care assignments
B) Explain that this behavior is expected
C) Discuss the appropriate use of "time-out"
D) Explain that the child needs extra attention

70. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
D) Unfamiliar toys and games

71. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
C) Interpretation of events originate from their own perspective
D) Conclusions are based on previous experiences

72. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a prioriy nursing diagnosis?
A) Nutrition
B) Elimination
C) Activity
D) Safety

73. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
A) Sports and games with rules
B) Finger paints and water play
C) "Dress-up" clothes and props
D) Chess and television programs

74. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
A) High Fowler's
B) Supine
C) Left lateral
D) Low Fowler's

75. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
A) Urinary output of 30 ml per hour
B) No complaints of thirst
C) Increased hematocrit
D) Good skin turgor around burn
1. D: Coronary artery aneurysms
Kawasaki Disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms.

2. The correct answer is B: "Would you please clarify what you have written so I am sure I am reading it correctly?"
Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.

3. The correct answer is C: Use patience and a sense of humor to deal with this behavior
The nurse should help the parents see the negativism as a normal growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.

4. The correct answer is B: "Do you become short of breath during your normal daily activities?"
These are the symptoms of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess both associated with right-sided heart failure.

5. The correct answer is C: Administer analgesic therapy as ordered
The main general objectives in the treatment of a sickle cell crisis is bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement and antibiotics to treat any existing infection.

6. The correct answer is B: Poor body image
As the adolescent gains weight, there is a lessening sense of self esteem and poor body image.

7. The correct answer is C: Working
During the working phase alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior.

8. The correct answer is C: Perform 5 abdominal thrusts
At this age, the most effective way to clear the airway of food is to perform abdominal thrusts.

9. The correct answer is B: "The seizure may or may not mean your child has epilepsy."
There are many possible causes for a childhood seizure. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown).

10. The correct answer is D: The infant received mechanical ventilation for 2 weeks
Bronchopulmonary dysplasia is an iatrogenic disease caused by therapies such as use of positive-pressure ventilation used to treat lung disease.

11. The correct answer is A: Cereal
The guidelines of the American Academy of Pediatrics recommend that one new food be introduced at a time, beginning with strained cereal.

12.The correct answer is C: Self-blame
Domestic violence victims may be immobilized by a variety of affective responses, one being self-blame. The victim believes that a change in their behavior will cause the abuser to become nonviolent, which is a myth.

13. The correct answer is C: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."

14. The correct answer is C:
The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of oxygen is available.

15. The correct answer is C:
Prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

16. The correct answer is A: INH can cause hepatocellular injury and hepatitis.
This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

17. The correct answer is C:
Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

18. The correct answer is C:
Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.

19. The correct answer is C:
Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.

20. The correct answer is B:
When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the infant it does not pose a safety risk.

21. The correct answer is B:
Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients do not feel pressure and/or pain and are at high risk for skin impairment.

22. The correct answer is D:
Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child''s mouth and they should not be moved. Of the choices given, first priority would be for safety.

23.The correct answer is D:
Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.

24. The correct answer is D:
An adverse reaction of a fever should be reported immediately. Other reactions that should be reported include crying for > 3 hours, seizure activity, and tender, swollen, reddened areas.

25. The correct answer is B:
Clients with contraindications to heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.

26. The correct answer is D:
Heartburn is a burning sensation caused by regurgitation of gastric contents that is best relieved by sleeping position, eating small meals, and not eating before bedtime.

27. The correct answer is C:
Honey has been associated with infant botulism and should be avoided. Older children and adults have digestive enzymes that kill the botulism spores.

28. The correct answer is A: Institute seizure precautions
The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications and anticipatory preparation such as seizure precautions are needed.

29. The correct answer is D: "By prolonging breathing out with pursed lips my little areas in my lungs don''t collapse."
Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of the weak alveolar walls from the disease process . Alveolar collapse can be avoided with the use of pursed-lip breathing. This is the major reason to use it. The other options are secondary effects of purse-lip breathing.

30. The correct answer is A: Ask the client if he has noticed any bleeding or dark stools
Normal hemoglobin for males is 13.0 - 18 g/100 ml. Normal hemotocrit for males is 42 - 52%. These values are below normal and indicate mild anemia. The first thing the nurse should do is ask the client if he''s noticed any bleeding or change in stools that could indicate bleeding from the GI tract.

31. The correct answer is B: "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"
This response encourages the client to get in touch with their feelings and utilize problem solving steps to reduce guilt feelings.

32. The correct answer is C: Encourage her to talk about her view of herself
To an adolescent, body image is very important. The nurse must acknowledge this before assessment and teaching.

33. The correct answer is D: Discontinue a new food that was added to the infant''s diet just prior to the rash
The addition of new foods to the infant''s diet may be a cause of diaper dermatitis.

34. The correct answer is D: Feelings of alienation or isolation
The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self imposed or can occur as a result of the inability to express feelings. At this stage of development it is important to achieve a sense of identity and peer acceptance.

35. The correct answer is C: Independence
In Erikson’s theory of development, toddlers struggle to assert independence. They often use the word “no” even when they mean yes. This stage is called autonomy versus shame and doubt.

36. The correct answer is A: 60 microdrops/minute
2 gm=2000 mgm
2000 mgm/500 cc = 4 mgm/x cc
2000x = 2000 x= 2000/2000 = 1 cc of IV solution/minute
CC x 60 microdrops = 60 microdrops/minute

37. The correct answer is B: Oral contraceptives should not be used by smokers
The use of oral contraceptives in a pregnant woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.

38. The correct answer is C: Shallow respirations
A.L.S. is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective.

39. The correct answer is A: "Nursing will help contract the uterus and reduce your risk of bleeding."
Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage.

40. The correct answer is A: These side effects are common and should subside in a few days
Nausea, metallic taste and fine hand tremors are common side effects that usually subside within days.

41. The correct answer is C: Encourage range of motion and ambulation
Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk.

42. The correct answer is A: Circumcision is delayed so the foreskin can be used for the surgical repair
Even if mild hypospadias is suspected, circumcision is not done in order to save the foreskin for surgical repair, if needed.

43. The correct answer is A: Loss of consciousness
While parents should report any of the observations, they need to call the health care provider immediately if the level of alertness changes. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages.

44. The correct answer is A: Double the birth weight
Although growth rates vary, infants normally double their birth weight by 6 months.

45. The correct answer is C: Maintain in a flat position, logrolling as needed
The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn for the client while on bed rest.

46. The correct answer is A: "Focus on your sons'' needs during the first days at home."
In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.

47.The correct answer is A: A cerebral vascular accident
Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.

48. The correct answer is A: Oculogyric crisis
This refers to involuntary muscles spasm of the eye.

49.The correct answer is B: An occupational therapist from the community center
An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.

50. The correct answer is C: Provide interactions to help the client learn to trust staff
This establishes trust, facilitates a therapeutic alliance between staff and client.

51. The correct answer is C:
Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass Graft is the surgical procedure to repair a diseased coronary artery.

52. The correct answer is B: Administration of thyroid hormone will prevent problems
Early identification and continued treatment with hormone replacement corrects this condition.

53. The correct answer is C: Protection from self-harm and harm to others
Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.

54. The correct answer is A: "I don''t remember anything about what happened to me."
Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion "voluntary forgetting" is generally used to protect one’s own self esteem.

55. The correct answer is D: Risk for infection
Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn.

56. The correct answer is A: Expose the cast to air and turn the child frequently
The child should be turned every 2 hours, with surface exposed to the air.

57. The correct answer is C: Administer a laxative to the client the evening before the examination
Bowel prep is important because it will allow greater visualization of the bladder and ureters.

58.The correct answer is D: It is not "caught" but is a response to a previous B-hemolytic strep infection
AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior, and is considered as a noninfectious renal disease.

59. The correct answer is D: No measurable voiding in 4 hours
The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.

60. The correct answer is B: Massage the fundus
The nurse’s first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery.

61. The correct answer is A: Unequal leg length
Shortening of a leg is a sign of developmental dysplasia of the hip.

62. The correct answer is B: Administer stool softeners every day as ordered
Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate.

63. The correct answer is B: Introduce him/herself and accompany the client to the client’s room
Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.

64.The correct answer is C: "I have to turn my head to see my room."
Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabeculae meshwork. If left untreated or undetected blindness results in the affected eye.

65. The correct answer is A: Has increased airway obstruction
The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions no support exists to indicate the need for suctioning.

66. The correct answer is D: Low self-esteem
Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, have a low self-esteem, and have a great need to exercise control or power-over partner.

67. The correct answer is A: Isometric
The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals.

68. The correct answer is A: Counsel the woman to consent to HIV screening
The client''s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.

69. The correct answer is B: Explain that this behavior is expected
During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parent, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool.

70. The correct answer is B: Separation from parents
Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.

71. The correct answer is B: Think logically in organizing facts
The child in the concrete operations stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects.

72. The correct answer is D: Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan.

73. The correct answer is A: Sports and games with rules
The purpose of play for the 7 year-old is cooperation. Rules are very important. Logical reasoning and social skills are developed through play.

74. The correct answer is A: High Fowler''s
Sitting in a chair or resting in a bed in high Fowler''s position decreases the cardiac workload and facilitates breathing.

75. The correct answer is A: Urinary output of 30 ml per hour
For a child of this age, this is adequate output, yet does not suggest overload.

1. The nurse would evaluate that the client understands his home care instructions after scleral buckling for a detached retina if he says his activity should include:

a. Avoiding abrupt movements of the head
b. Exercising the eye muscles each day
c. Turning the entire head rather than just the eyes for sight
d. Avoiding activities requiring good depth perception

2. Lomotil has been prescribed to treat a client’s diarrhea. The nurse should teach the client to report which of the following common side effects?

a. Urinary retention
b. Diaphoresis
c. Hypotension
d. Lethargy

3. Nitroglycerin is also available in ointment or paste form. Before applying nitroglycerin ointment, the nurse should:

a. Cleanse the skin with alcohol where the ointment will be placed.
b. Obtain the client’s pulse rate and rhythm
c. Remove the ointment previously applied
d. Instruct the client to expect pain relief in the next 15 minutes

4. While a client with hypertension is being assessed, he says to the nurse, “I really don’t know why I am here. I feel fine and haven’t had any symptoms.” The nurse would explain to the client that symptoms of hypertension:

a. Are often not present
b. Signify a high risk of stroke
c. Occur only with malignant hypertension
d. Appear after irreversible kidney damage has occurred

5. For a neurologically injured client, the nurse would best assess motor strength by:

a. Comparing equality of hand grasps
b. Observing spontaneous movements
c. Observing the client feed himself
d. Asking him to signal if he feels pressure applied to his feet

6. Morphine 8 mg IM has been ordered for a client. The ampule label reads 15 mg/mL. How many milliliters will the nurse give?

a. 0.45 mL
b. 0.53 mL
c. 0.66 mL
d. 0.75 mL

7. The correct procedure for auscultating the client’s abdomen for bowel sounds would include:

a. Palpating the abdomen first to determine correct stethoscope placement
b. Encouraging the client to cough to stimulate movement of fluid and air through the abdomen
c. Placing the client on the left side to aid auscultation
d. Listening for 5minutes in all four quadrants to confirm absence of bowel sound

8. A client is admitted to the hospital with a diagnosis of a right hip fracture. She complains of right hip pain and cannot move her right leg. Which of the following assessments made by the nurse indicates that the client has a typical sign of hip fracture? The client’s right leg is:

a. Rotated internally
b. Held in a flexed position
c. Adducted
d. Shorter than the leg on the unaffected side

9. The nurse assesses the client’s understanding of the relationship between body position and gastroesophageal reflux. Which response would indicate that the client understands measures to avoid problems with reflux while sleeping?

a. I can elevate the foot of the bed 4 to 6 inches
b. I can sleep on my stomach with my head turned to the left
c. I can sleep on my back without a pillow under my head
d. I can elevate the head of the bed 4 to 6 inches

10. Which of the following would be an appropriate nursing diagnosis for a hospitalized client with bacterial pneumonia and shortness of breath?

a. Ineffective cardiopulmonary tissue perfusion related to myocardial damage
b. Risk for self-care deficit related to fatigue
c. Deficient fluid volume related to nausea and vomiting
d. Disturbed thought processes related to inadequate relief of chest pain

11. Theophylline ethylenediamide is administered to a client with COPD to:

a. Reduce bronchial secretions
b. Relax bronchial smooth muscle
c. Strengthen myocardial contractions
d. Decrease alveolar elasticity

12. Which of the following lab results would be unexpected in a client with chronic renal failure?

a. Serum potassium 6.0 mEq/L
b. Serum creatinine 9 mg/dL
c. BUN 15 mg/dL
d. Serum phosphate 5.2 mg/dL.

13. Which of the following criteria are acceptable for a rescuer to discontinue CPR?

a. When it is obvious that the victim will not survive
b. When the rescuer is exhausted
c. After 30 minutes of CPR without a pulse rate
d. When the family requests discontinuation

14. A client is scheduled to undergo an abdominal perineal resection with a permanent colostomy. Which of the following measures would be an anticipated part of the client’s preoperative care?

a. Keep the client NPO for 24 hrs before surgery
b. Administer neomycin sulfate the evening before surgery
c. Inform the client that total parenteral nutrition will likely be implemented after surgery
d. Advise the client to limit physical activity

15. The nurse notes that the client’s urinary appliance contains yellow urine with large amounts of mucus. How would the nurse best interpret these data?

a. The client is developing an infection of the urinary tract
b. The mucus is caused by elevated levels of glucose in the urine
c. These findings are normal for a client with an ileal conduit
d. There is irritation of the stoma

16. Which of the following assessments would be important for the nurse to make to determine whether or not a client is recovering as expected from spinal anesthesia?

a. Level of consciousness
b. Rate and depth of respirations
c. Rate of capillary refill in the toes
d. Degree of response to pinpricks in the legs and toes

17. A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client’s understanding of how to take this drug. Which of the following statements indicates the client has adequate knowledge?

a. I can use antidiarrheal drugs if I develop diarrhea
b. I will report any black stools to the physician
c. I will check my gums for any bleeding
d. I will dilute the medication and drink it with a straw

18. The nurse has instructed the client about the correct positioning of his leg and hip following hip replacement surgery. Which of the following statements indicate that the client has understood these instructions?

a. I may cross my legs as long as I keep my knees extended
b. I should avoid bending over to tie my shoes
c. I can sit in any chair that I find comfortable
d. I should avoid any unnecessary walking for about 3 months after my surgery

19. Clients with diabetes mellitus require frequent vision assessment. The nurse should instruct the client about which of the following eye problems most likely to be associated with diabetes mellitus?

a. Cataracts
b. Retinopathy
c. Astigmatism
d. Glaucoma

20. An autograft is taken from the client’s left leg. The nurse should care for the donor site by:

a. Covering it with an occlusive dry dressing
b. Keeping the site clean and dry
c. Applying a pressure dressing
d. Wrapping the extremity with an elastic bandage

21. Which of the following categories of medications would the nurse anticipate being included in the conservative management of a client with a herniated lumbar disk?

a. Muscle relaxant
b. Sedatives
c. Tranquilizers
d. Parenteral analgesics

22. The client has a nursing diagnosis of Constipation related to decreased mobility secondary to traction. A care plan that incorporates which of the following breakfasts would be most helpful in reestablishing a normal bowel routine?

a. Eggs and bacon, buttered white toast, orange juice and coffee
b. Corn flakes with sliced banana, milk and English muffin with jelly
c. Orange juice, breakfast pastries (doughnut and Danish) and coffee
d. An orange, raisin bran and milk, and wheat toast with butter

23. A client has been placed on levodopa to treat Parkinson’s disease. Which of the following is a common side effects of levodopa that the nurse should include in the client’s teaching plan?

a. Pancytopenia
b. Peptic ulcer
c. Postural hypotension
d. Weight loss

24. The client would be experiencing a typical symptom of Meniere’s disease if, before an attack, he experienced:

a. A severe headache
b. Blurred vision
c. Nausea
d. A feeling of inner ear fullness

25. Which of the following observations should the postanesthesia care unit (PACU) nurse plan to make first when the client who has had a modified radical mastectomy returns from the operating room?

a. Obtaining and recording vital signs
b. Observing that drainage tubes are patent and functioning
c. Ensuring that the client’s airway is free of obstruction
d. Checking the client’s dressings for drainage

26. The classic signs and symptoms of rheumatoid arthritis include which of the following?

a. Pain on weight-bearing, rash and low-grade fever
b. Joint swelling, joint stiffness in the morning and bilateral joint movement
c. Crepitus, development of Heberden’s nodes and anemia
d. Fatigue, leucopenia and joint pain

27. Nursing measures for the client who has had an MI include helping the client to avoid activity that results in Valsalva’s maneuver. Valsalva’s maneuver may cause cardiac dysrhythmias, increased venous pressure, increased intrathoracic pressure and thrombi dislodgement. Which of the following actions would help prevent Valsalva’s maneuver? Have the client:

a. Assume a side-lying position
b. Clench her teeth while moving in bed
c. Drink fluids through a straw
d. Avoid holding her breath during activity

28. A client is scheduled for radical neck surgery and a total laryngectomy. During the preoperative teaching, the nurse should prepare the client for which of the following postoperative possibilities?

a. Endotracheal intubation
b. Insertion of laryngectomy tube
c. Immediate speech therapy
d. Gastrostomy tube

29. The client is being taught to self-administer insulin. Learning goals most likely will be attained when they are established by the:

a. Nurse and client because both need to be responsible for teaching
b. Physician and client because the physician is the manager of care and the client is the main participant
c. Client because the client is best able to identify his or her own needs and how to meet those needs
d. Client, nurse and physician so the client can participate in planning care with the nurse and physician

30. Which statement by the client with rheumatoid arthritis would indicate that she needs additional teaching to safely receive the maximum benefit of her aspirin therapy?

a. I always take aspirin with food to protect my stomach
b. Once I learned to take aspirin with meals, I was able to start using the inexpensive generic brand
c. I always watch for bleeding gums or blood in my stool
d. I try to take aspirin only on days when the pain seems particularly bad

31. A client has stress incontinence has been given a pamphlet that describes Kegel exercises. Which of the following statements indicates to the nurse that the client has understood the instructions contained in the pamphlet?

a. I should perform these exercises every evening
b. It will probably take a year before the exercises are effective
c. I can do these exercises sitting up, lying down or standing
d. I need to tighten my abdominal muscles to do these exercises correctly

32. The development of laryngeal cancer is most clearly linked to which of the following factors?

a. High-fat, low-fiber diet
b. Alcohol and tobacco use
c. Low socioeconomic status
d. Overuse of artificial sweeteners

33. Oxtriphylline (Choledyl SA) 0.2 g has been ordered. Available tablets are 100mg. How many tablets should be given?

a. 0.5 tablets
b. 2.0 tablets
c. 2.5 tablets
d. 5.0 tablets

34. The most common causes of megaloblastic, macrocytic anemias are:

a. Folate or vitamin B deficiency
b. Chronic disease
c. Iron deficiency
d. Infection

35. Which of the following nutrients provides a little over half of the energy needed during sleep?

a. Protein
b. Carbohydrate
c. Fat
d. Water

36. An anticipated outcome for the client after cataract removal surgery would include which of the following?

a. The client states her vision is clear
b. The client states her infection is under control
c. The client describes methods to prevent an increase in intraocular pressure
d. The client states she is able to administer parenteral pain medication 37. The nurse understands that Hodgkin’s disease is suspected when a client presents with a painless, swollen lymph node. Hodgkin’s disease typically affects people in which age group?

a. Children (ages 6-12 years)
b. Teenagers (ages 13-20 years)
c. Young adults (ages 21-40 years)
d. Older adults (ages 41-50 years)

38. The nurse notes the following assessment findings regarding the client’s peripheral vascular status: cramping leg pain relieved by rest; cool, pale feet; and delayed capillary refilling. Based on these data, the nurse would make a nursing diagnosis of:

a. Impaired skin integrity
b. Impaired gas exchange
c. Ineffective peripheral tissue perfusion
d. Impaired physical mobility

39. The client with urinary tract infection is given a prescription for trimethoprim (Bactrim-DS) for her infection. Which of the following statements would indicate that she understands the principles of antibiotic therapy?

a. I’ll take the pills until I feel better and keep the rest for recurrences
b. I’ll take all the pills then return to my doctor
c. I’ll take the pills until the symptoms go away then reduce the dose to one pill a day
d. I’ll take all the pills then have the prescription renewed once

40. Which of the following clients would the nurse expect to be at highest risk for developing a urinary tract infection?

a. Woman who has delivered two children vaginally
b. Man with an indwelling urinary catheter for incontinence
c. Man with a past medical history of renal calculi
d. Woman with well-controlled diabetes mellitus

41. When bandaging the burned client’s hand, the nurse should make certain that:

a. The bandage is free of elastic
b. The hand and finger surfaces do not touch
c. The hand and fingers are not elevated above heart level
d. The bandage material is moistened with sterile normal saline solution

42. The nurse is caring for a client who has a history of aplastic anemia. Which of the following data from the nursing history indicates that the anemia is not being managed effectively?

a. Pallor of skin and mucous membranes
b. Heart rate of 68 bpm, bounding pulse
c. Blood pressure of 146/90 mm Hg
d. Poor skin turgor

43. A client is learning about caring for her ileostomy. Which of the following statements would indicate that she understands how to care for her ileostomy pouch?

a. I’ll empty my pouch when it’s about one-third full
b. I can take my pouch off at night
c. I should change my pouch immediately after lunch
d. I must apply a new pouch system every day

44. A client’s laboratory tests indicate that the client has hypocalcemia. Which of the following symptoms should the nurse look for in the client?

a. Flushed skin
b. Depressed reflexes
c. Tingling in extremities
d. Diarrhea

45. Which of the following symptoms would the nurse most likely observe in a client with cholecystitis from cholelithiasis?

a. Black stools
b. Nausea after ingestion of high fat foods
c. Elevated temperature of 103 F (39.4 C)
d. Decreased WBC count

46. Pain control is an important nursing goal for the client with pancreatitis. Which of the following medications would the nurse plan to administer in this situation?

a. Meperidine hydrochloride (Demerol)
b. Cimetidine (Tagamet)
c. Morphine sulfate
d. Codeine sulfate

47. A client is recovering from a gastric resection for peptic ulcer disease. Which of the following outcomes indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery?

a. Increases food intake and tolerance gradually
b. Experiences occasional episodes of nausea and vomiting
c. Drinks 2000 mL/day of water
d. Experiences a rapid weight gain within 1 week

48. What would be the most important nursing intervention in caring for the client’s residual limb during the first 24 hrs after amputation of the left leg?

a. Keeping the residual limb flat on the bed
b. Abducting the residual limb on a scheduled basis
c. Applying traction to the residual limb
d. Elevating the residual limb on a pillow

49. After the client returns from surgery for a deviated nasal septum, the nurse would anticipate placing her in what position?

a. Supine
b. Left side-lying
c. Semi-Fowler’s
d. Reverse Trendelenburg’s

50. While suctioning a client’s laryngectomy tube, the nurse insert the catheter:

a. About 1-2 inches
b. As the client exhales
c. Until resistance is met, then withdraw it 1-2 cm
d. Until the client begins coughing

1. a. Avoiding abrupt movements of the head

2. a. Urinary retention

3. c. Remove the ointment previously applied

4. a. Are often not present

5. a. Comparing equality of hand grasps

6. b. 0.53 mL

7. d. Listening for 5minutes in all four quadrants to confirm absence of bowel sound

8. d. Shorter than the leg on the unaffected side

9. d. I can elevate the head of the bed 4 to 6 inches

10. b. Risk for self-care deficit related to fatigue

11. b. Relax bronchial smooth muscle

12. c. BUN 15 mg/dL

13. b. When the rescuer is exhausted

14. b. Administer neomycin sulfate the evening before surgery

15. c. These findings are normal for a client with an ileal conduit

16. d. Degree of response to pinpricks in the legs and toes

17. d. I will dilute the medication and drink it with a straw

18. b. I should avoid bending over to tie my shoes

19. b. Retinopathy

20. b. Keeping the site clean and dry

21. a. Muscle relaxant

22. d. An orange, raisin bran and milk, and wheat toast with butter

23. c. Postural hypotension

24. d. A feeling of inner ear fullness

25. c. Ensuring that the client’s airway is free of obstruction

26. b. Joint swelling, joint stiffness in the morning and bilateral joint movement

27. d. Avoid holding her breath during activity

28. b. Insertion of laryngectomy tube

29. d. Client, nurse and physician so the client can participate in planning care with the nurse and physician

30. d. I try to take aspirin only on days when the pain seems particularly bad

31. c. I can do these exercises sitting up, lying down or standing

32. b. Alcohol and tobacco use

33. b. 2.0 tablets

34. a. Folate or vitamin B deficiency

35. c. Fat

36. c. The client describes methods to prevent an increase in intraocular pressure

37. c. Young adults (ages 21-40 years)

38. c. Ineffective peripheral tissue perfusion

39. b. I’ll take all the pills then return to my doctor

40. b. Man with an indwelling urinary catheter for incontinence

41. b. The hand and finger surfaces do not touch

42. a. Pallor of skin and mucous membranes

43. a. I’ll empty my pouch when it’s about one-third full

44. b. Depressed reflexes

45. b. Nausea after ingestion of high fat foods

46. a. Meperidine hydrochloride (Demerol)

47. a. Increases food intake and tolerance gradually

48. d. Elevating the residual limb on a pillow

49. c. Semi-Fowler’s

50. c. Until resistance is met, then withdraw it 1-2 cm