Review the concepts of Medical-Surgical Nursing with this 100-item comprehensive examination about Medical-Surgical Nursing. This is part 2 of 3.

Guidelines

• This is a 100-item examination about Medical-Surgical Nursing.
• Rationales and answers are given below.
• You are given 1 minute and 20 seconds each question. A total of 2 hours for this 100-item exam.

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

Challenge your nursing knowledge with this Medical-Surgical Nursing Examination! This is a 40-item examination that can help you improve, review and challenge your knowledge about Medical-Surgical Nursing! If you are taking the board examination or nurse licensure examination or even the NCLEX, then this practice exam is for you.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers are given below. Be sure to check your performance.

1. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

2. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

3. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?

A. The medication will be effective more quickly than if given intramuscularly.
B. It is less likely to interfere with the client’s breathing and oxygenation.
C. The danger of an overdose during fluid remobilization is reduced.
D. The client delayed gastric emptying.

4. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

5. Which client factors should alert the nurse to potential increased complications with a burn injury?

A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client’s clothing.

6. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response?

A. “To increase the urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal bloating.”
C. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”
D. “To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock.”

7. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?

A. Immediately following the injury
B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase

8. What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum

9. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?

A. The burn is full thickness rather than partial thickness.
B. The client is unable to fully pronate and supinate the extremity.
C. Capillary refill is slow in the digits and the distal pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the extremity.

10. What additional laboratory test should be performed on any African American client who sustains a serious burn injury?

A. Total protein
B. Tissue type antigens
C. Prostate specific antigen
D. Hemoglobin S electrophoresis

11. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?

A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells

12. The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action?

A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.

13. The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?

A. Raise the head of the bed.
B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.

14. Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?

A. Notify the emergency team.
B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.

15. On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?

A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning

16. Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?

A. Reposition the client onto the right side.
B. Document the finding as the only action.
C. Notify the emergency team.
D. Increase the IV flow rate.

17. Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?

A. Increased urine output, decreased urine specific gravity
B. Increased peripheral edema, decreased blood pressure
C. Decreased peripheral pulses, slow capillary refill
D. Decreased serum sodium level, increased hematocrit

18. What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm?

A. Risk for Ineffective Breathing Pattern
B. Decreased Tissue Perfusion
C. Risk for Disuse Syndrome
D. Disturbed Body Image

19. All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?

A. Serum sodium elevated to 131 mmol/L (mEq/L)
B. Serum potassium 7.5 mmol/L (mEq/L)
C. Arterial pH is 7.32
D. Hematocrit is 52%

20. The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission?

A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities

21. In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?

A. “Are you a smoker?”
B. “When was your last chest x-ray?”
C. “Have you ever had asthma or any other lung problem?”
D. “In what exact place or space were you when you were burned?”

22. Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited

23. Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited

24. The burned client’s family ask at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?

A. “When fluid remobilization has started.”
B. “When the burn wounds are closed.”
C. “When IV fluids are discontinued.”
D. “When body weight is normal.”

25. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month

26. The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?

A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.

27. Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?

A. Handwashing on entering the client’s room
B. Encouraging the client to cough and deep breathe
C. Administering the prescribed tetanus toxoid vaccine
D. Changing gloves between cleansing different burn areas

28. In reviewing the burned client’s laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis?

A. The total white blood cell count is 9000/mm3.
B. The lymphocytes outnumber the basophils.
C. The “bands” outnumber the “segs.”
D. The monocyte count is 1,800/mm3.

29. The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?

A. Place a towel roll under the client’s neck or shoulder.
B. Keep the client in a supine position without the use of pillows.
C. Have the client turn the head from side to side 90 degrees every hour while awake.
D. Keep the client in a semi-Fowler’s position and actively raise the arms above the head every hour while awake.

30. The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint?

A. Hip maintained in 30-degree flexion, no knee flexion
B. Hip flexed 90 degrees and knee flexed 90 degrees
C. Hip, knee, and ankle all at maximum flexion
D. Hip at zero flexion with leg flat

31. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds
C. Decreased white blood cell count
D. Increased serum creatinine level

32. The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action?

A. Nothing, because the findings are normal for clients during the acute phase of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.

33. Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

A. Changing gloves between wound care on different parts of the client’s body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.

34. When should ambulation be initiated in the client who has sustained a major burn?

A. When all full-thickness areas have been closed with skin grafts
B. When the client’s temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after resolution of the fluid shift

35. What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?

A. “For the first few days after surgery, the donor sites will be painful.”
B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
C. “I will have some scarring in the area when the skin is removed for grafting.”
D. “Once all grafting is completed, my risk for infection is the same as it was before I was burned.”

36. Which statement by the client indicates correct understanding of rehabilitation after burn injury?

A. “I will never be fully recovered from the burn.”
B. “I am considered fully recovered when all the wounds are closed.”
C. “I will be fully recovered when I am able to perform all the activities I did before my injury.”
D. “I will be fully recovered when I achieve the highest possible level of functioning that I can.”

37. Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment?

A. “After this treatment, my ears will not stick out.”
B. “The mask will help protect my skin from sun damage.”
C. “Using this mask will prevent scars from being permanent.”
D. “My facial scars should be less severe with the use of this mask.”

38. What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?

A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements

39. 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

40. 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

This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Medical-Surgical Nursing.  This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Note: In the actual board exams, this test is entitled as Care of Clients with Physiologic and Psychosocial Alterations Nursing. 

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

1. Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to suspect organ rejection?

a. Sudden weight loss
b. Polyuria
c. Hypertension
d. Shock

2. The immediate objective of nursing care for an overweight, mildly hypertensive male client with ureteral colic and hematuria is to decrease:

a. Pain
b. Weight
c. Hematuria
d. Hypertension

3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:

a. Decrease the total basal metabolic rate.
b. Maintain the function of the parathyroid glands.
c. Block the formation of thyroxine by the thyroid gland.
d. Decrease the size and vascularity of the thyroid gland.

4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia also can develop in the client who is diagnosed with:

a. Liver disease
b. Hypertension
c. Type 2 diabetes
d. Hyperthyroidism

5. Tracy is receiving combination chemotherapy for treatment of metastatic carcinoma. Nurse Ruby should monitor the client for the systemic side effect of:

a. Ascites
b. Nystagmus
c. Leukopenia
d. Polycythemia

6. Norma, with recent colostomy expresses concern about the inability to control the passage of gas. Nurse Oliver should suggest that the client plan to:

a. Eliminate foods high in cellulose.
b. Decrease fluid intake at meal times.
c. Avoid foods that in the past caused flatus.
d. Adhere to a bland diet prior to social events.

7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, “I should:

a. Lie on my left side while instilling the irrigating solution.”
b. Keep the irrigating container less than 18 inches above the stoma.”
c. Instill a minimum of 1200 ml of irrigating solution to stimulate
evacuation of the bowel.”
d. Insert the irrigating catheter deeper into the stoma if cramping
occurs during the procedure.”

8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and electrolyte imbalances. The client is somewhat confused and complains of nausea and muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance, the nurse would expect to:

a. Administer Kayexalate
b. Restrict foods high in protein
c. Increase oral intake of cheese and milk.
d. Administer large amounts of normal saline via I.V.

9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:

a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min

10.Terence suffered form burn injury. Using the rule of nines, which has the largest percent of burns?

a. Face and neck
b. Right upper arm and penis
c. Right thigh and penis
d. Upper trunk

11. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:

a. Reactive pupils
b. A depressed fontanel
c. Bleeding from ears
d. An elevated temperature

12. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?

a. take the pulse rate once a day, in the morning upon awakening
b. May be allowed to use electrical appliances
c. Have regular follow up care
d. May engage in contact sports

13.The nurse is ware that the most relevant knowledge about oxygen administration to a male client with COPD is

a. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
c. Oxygen is administered best using a non-rebreathing mask
d. Blood gases are monitored using a pulse oximeter.

14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Tonny is placed in Fowler’s position on either his right side or on his back. The nurse is aware that this position:

a. Reduce incisional pain.
b. Facilitate ventilation of the left lung.
c. Equalize pressure in the pleural space.
d. Increase venous return

15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect afterward, the nurse’s highest priority of information would be:

a. Food and fluids will be withheld for at least 2 hours.
b. Warm saline gargles will be done q 2h.
c. Coughing and deep-breathing exercises will be done q2h.
d. Only ice chips and cold liquids will be allowed initially.

16.Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

a. hypernatremia.
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.

17.Ms. X has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
b. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
c. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
d. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.

18.Maritess was recently diagnosed with a genitourinary problem and is being examined in the emergency department. When palpating the her kidneys, the nurse should keep which anatomical fact in mind?

a. The left kidney usually is slightly higher than the right one.
b. The kidneys are situated just above the adrenal glands.
c. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾” to 1-1/8″) wide.
d. The kidneys lie between the 10th and 12th thoracic vertebrae.

19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is aware that the diagnostic test are consistent with CRF if the result is:

a. Increased pH with decreased hydrogen ions.
b. Increased serum levels of potassium, magnesium, and calcium.
c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.

20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?

a. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin.
b. Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
c. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found.
d. Alteration in the size, shape, and organization of differentiated cells.

21. During a routine checkup, Nurse Mariane assesses a male client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

a. Squamous cell carcinoma
b. Multiple myeloma
c. Leukemia
d. Kaposi’s sarcoma

22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist’s instructions. Why does the client require special positioning for this type of anesthesia?

a. To prevent confusion
b. To prevent seizures
c. To prevent cerebrospinal fluid (CSF) leakage
d. To prevent cardiac arrhythmias

23.A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

a. Auscultate bowel sounds.
b. Palpate the abdomen.
c. Change the client’s position.
d. Insert a rectal tube.

24.Wilfredo with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse Patricia position the client for this test initially?

a. Lying on the right side with legs straight
b. Lying on the left side with knees bent
c. Prone with the torso elevated
d. Bent over with hands touching the floor

25.A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the nurse interpret this finding?

a. Blood supply to the stoma has been interrupted.
b. This is a normal finding 1 day after surgery.
c. The ostomy bag should be adjusted.
d. An intestinal obstruction has occurred.

26.Anthony suffers burns on the legs, which nursing intervention helps prevent contractures?

a. Applying knee splints
b. Elevating the foot of the bed
c. Hyperextending the client’s palms
d. Performing shoulder range-of-motion exercises

27.Nurse Ron is assessing a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
b. Urine output of 20 ml/hour.
c. White pulmonary secretions.
d. Rectal temperature of 100.6° F (38° C).

28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, Nurse Celia should:

a. Turn him frequently.
b. Perform passive range-of-motion (ROM) exercises.
c. Reduce the client’s fluid intake.
d. Encourage the client to use a footboard.

29.Nurse Maria plans to administer dexamethasone cream to a female client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?

a. With a circular motion, to enhance absorption.
b. With an upward motion, to increase blood supply to the affected area
c. In long, even, outward, and downward strokes in the direction of hair growth
d. In long, even, outward, and upward strokes in the direction opposite hair growth

30.Nurse Kate is aware that one of the following classes of medication protect the ischemic myocardium by blocking catecholamines and
sympathetic nerve stimulation is:

a. Beta -adrenergic blockers
b. Calcium channel blocker
c. Narcotics
d. Nitrates

31.A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?

a. High Fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position

32.The nurse is aware that one of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?

a. Beta-adrenergic blockers
b. Calcium channel blocker
c. Diuretics
d. Inotropic agents

33.A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated low-density lipoprotein (LDL) level. Which of the following dietary modifications is not appropriate for this client?

a. Fiber intake of 25 to 30 g daily
b. Less than 30% of calories form fat
c. Cholesterol intake of less than 300 mg daily
d. Less than 10% of calories from saturated fat

34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?

a. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
b. The CCU nurse notifies the on-call physician about a change in the client’s condition
c. The emergency department nurse calls up the latest electrocardiogram results to check the client’s progress.
d. At the client’s request, the CCU nurse updates the client’s wife on his condition

35. A male client arriving in the emergency department is receiving cardiopulmonary resuscitation from paramedics who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a palpable pulse. Which of the following actions
should the nurse take first?

a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.
b. Check endotracheal tube placement.
c. Obtain an arterial blood gas (ABG) sample.
d. Administer atropine, 1 mg L.V.

36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina determines that mean arterial pressure (MAP) is which of the following?

a. 46 mm Hg
b. 80 mm Hg
c. 95 mm Hg
d. 90 mm Hg

37. A female client arrives at the emergency department with chest and stomach pain and a report of black tarry stool for several months. Which of the following order should the nurse Oliver anticipate?

a. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels
b. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.
c. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum metabolic panel.
d. Electroencephalogram, alkaline phosphatase and aspartate aminotransferase levels, basic serum metabolic panel

38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the following conditions is suspected by the nurse when a decrease in platelet count from 230,000 ul to 5,000 ul is noted?

a. Pancytopenia
b. Idiopathic thrombocytopemic purpura (ITP)
c. Disseminated intravascular coagulation (DIC)
d. Heparin-associated thrombosis and thrombocytopenia (HATT)

39. Which of the following drugs would be ordered by the physician to improve the platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?

a. Acetylsalicylic acid (ASA)
b. Corticosteroids
c. Methotrezate
d. Vitamin K

40. A female client is scheduled to receive a heart valve replacement with a porcine valve. Which of the following types of transplant is this?

a. Allogeneic
b. Autologous
c. Syngeneic
d. Xenogeneic

41. Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway?

a. Release of Calcium
b. Release of tissue thromboplastin
c. Conversion of factors XII to factor XIIa
d. Conversion of factor VIII to factor VIIIa

42. Instructions for a client with systemic lupus erythematosus (SLE) would include information about which of the following blood dyscrasias?

a. Dressler’s syndrome
b. Polycythemia
c. Essential thrombocytopenia
d. Von Willebrand’s disease

43. The nurse is aware that the following symptoms is most commonly an early indication of stage 1 Hodgkin’s disease?

a. Pericarditis
b. Night sweat
c. Splenomegaly
d. Persistent hypothermia

44. Francis with leukemia has neutropenia. Which of the following functions must frequently assessed?

a. Blood pressure
b. Bowel sounds
c. Heart sounds
d. Breath sounds

45. The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?

a. Brain
b. Muscle spasm
c. Renal dysfunction
d. Myocardial irritability

46. Nurse Patricia is aware that the average length of time from human immunodeficiency virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?

a. Less than 5 years
b. 5 to 7 years
c. 10 years
d. More than 10 years

47. An 18-year-old male client admitted with heat stroke begins to show signs of disseminated intravascular coagulation (DIC). Which of the following laboratory findings is most consistent with DIC?

a. Low platelet count
b. Elevated fibrinogen levels
c. Low levels of fibrin degradation products
d. Reduced prothrombin time

48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained weight loss over the past 3 months. Physical examination reveals a single enlarged supraclavicular lymph node. Which of the following is the most probable diagnosis?

a. Influenza
b. Sickle cell anemia
c. Leukemia
d. Hodgkin’s disease

49. A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive?

a. AB Rh-positive
b. A Rh-positive
c. A Rh-negative
d. O Rh-positive

Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.

50. Stacy is discharged from the hospital following her chemotherapy treatments. Which statement of Stacy’s mother indicated that she understands when she will contact the physician?

a. “I should contact the physician if Stacy has difficulty in sleeping”.
b. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
c. “My physician should be called if Stacy is irritable and unhappy”.
d. “Should Stacy have continued hair loss, I need to call the doctor”.

51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:

a. “Stacy looks very nice wearing a hat”.
b. “You should not worry about her hair, just be glad that she is alive”.
c. “Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”.
d. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in texture”.

52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge should:

a. Provide frequent mouthwash with normal saline.
b. Apply viscous Lidocaine to oral ulcers as needed.
c. Use lemon glycerine swabs every 2 hours.
d. Rinse mouth with Hydrogen Peroxide.

53. During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take is:

a. Notify the physician
b. Flush the IV line with saline solution
c. Immediately discontinue the infusion
d. Apply an ice pack to the site, followed by warm compress.

54. The term “blue bloater” refers to a male client which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

55. The term “pink puffer” refers to the female client with which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

56. Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?

a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg

57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following conditions?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respirator y alkalosis

58. Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?

a. Asthma attack
b. Pulmonary embolism
c. Respiratory failure
d. Rheumatoid arthritis

Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:

59. Which laboratory test indicates liver cirrhosis?

a. Decreased red blood cell count
b. Decreased serum acid phosphate level
c. Elevated white blood cell count
d. Elevated serum aminotransferase

60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:

a. Impaired clotting mechanism
b. Varix formation
c. Inadequate nutrition
d. Trauma of invasive procedure

61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?

a. Increased urine output
b. Altered level of consciousness
c. Decreased tendon reflex
d. Hypotension

62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:

a. “I’ll see if your physician is in the hospital”.
b. “Maybe your reacting to the drug; I will withhold the next dose”.
c. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
d. “Frequently, bowel movements are needed to reduce sodium level”.

63. Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm?

a. Lower back pain, increased blood pressure, decreased re blood cell (RBC) count, increased white blood (WBC) count.
b. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
c. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count.
d. Intermitted lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.

64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?

a. Call for help.
b. Obtain vital signs
c. Ask the client to “lift up”
d. Apply gloves and assess the groin site

65. Which of the following treatment is a suitable surgical intervention for a client with unstable angina?

a. Cardiac catheterization
b. Echocardiogram
c. Nitroglycerin
d. Percutaneous transluminal coronary angioplasty (PTCA)

66. The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:

a. Anaphylactic shock
b. Cardiogenic shock
c. Distributive shock
d. Myocardial infarction (MI)

67. A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?

a. Kidneys’ excretion to sodium only.
b. Kidneys’ retention of sodium and water
c. Kidneys’ excretion of sodium and water
d. Kidneys’ retention of sodium and excretion of water

68. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:

a. It dilates peripheral blood vessels.
b. It decreases sympathetic cardioacceleration.
c. It inhibits the angiotensin-coverting enzymes
d. It inhibits reabsorption of sodium and water in the loop of Henle.

69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:

a. Elavated serum complement level
b. Thrombocytosis, elevated sedimentation rate
c. Pancytopenia, elevated antinuclear antibody (ANA) titer
d. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels

70. Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate?

a. “Your son had a mild concussion, acetaminophen is strong enough.”
b. “Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.”
c. “Narcotics are avoided after a head injury because they may hide a worsening condition.”
d. Stronger medications may lead to vomiting, which increases the intracarnial pressure (ICP).”

71. When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?

a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)
b. Emergent; the client is poorly oxygenated
c. Normal
d. Significant; the client has alveolar hypoventilation

72. When prioritizing care, which of the following clients should the nurse Olivia assess first?

a. A 17-year-old clients 24-hours postappendectomy
b. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
c. A 50-year-old client 3 days postmyocardial infarction
d. A 50-year-old client with diverticulitis

73. JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?

a. Replaces estrogen
b. Decreases infection
c. Decreases inflammation
d. Decreases bone demineralization

74. Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct?

a. Osteoarthritis is rarely debilitating
b. Osteoarthritis is a rare form of arthritis
c. Osteoarthritis is the most common form of arthritis
d. Osteoarthritis afflicts people over 60

75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following lifethreatening complications?

a. Exophthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema

76. Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately?

a. Pitting edema of the legs
b. An irregular apical pulse
c. Dry mucous membranes
d. Frequent urination

77. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?

a. Above-normal urine and serum osmolality levels
b. Below-normal urine and serum osmolality levels
c. Above-normal urine osmolality level, below-normal serum osmolality level
d. Below-normal urine osmolality level, above-normal serum osmolality level

78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?

a. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
b. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar.”
c. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly elevated.”
d. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”

79. A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?

a. Diabetes mellitus
b. Diabetes insipidus
c. Hypoparathyroidism
d. Hyperparathyroidism

80. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

a. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
b. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
c. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
d. “I’ll take the entire dose at bedtime.”

81. Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?

a. High corticotropin and low cortisol levels
b. Low corticotropin and high cortisol levels
c. High corticotropin and high cortisol levels
d. Low corticotropin and low cortisol levels

82. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?

a. Testing for ketones in the urine
b. Testing urine specific gravity
c. Checking temperature every 4 hours
d. Performing capillary glucose testing every 4 hours

83. 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. Nurse Mariner should expect the dose’s:

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

84. The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

a. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
b. A decreased TSH level
c. An increase in the TSH level after 30 minutes during the TSH stimulation test
d. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay

85. Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

a. “Inject insulin into healthy tissue with large blood vessels and nerves.”
b. “Rotate injection sites within the same anatomic region, not among different regions.”
c. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
d. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”

86. Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

a. Elevated serum acetone level
b. Serum ketone bodies
c. Serum alkalosis
d. Below-normal serum potassium level

87. For a client with Graves’ disease, which nursing intervention promotes comfort?

a. Restricting intake of oral fluids
b. Placing extra blankets on the client’s bed
c. Limiting intake of high-carbohydrate foods
d. Maintaining room temperature in the low-normal range

88. Patrick is treated in the emergency department for a Colles’ fracture sustained during a fall. What is a Colles’ fracture?

a. Fracture of the distal radius
b. Fracture of the olecranon
c. Fracture of the humerus
d. Fracture of the carpal scaphoid

89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?

a. Calcium and sodium
b. Calcium and phosphorous
c. Phosphorous and potassium
d. Potassium and sodium

90. Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Atelectasis
c. Bronchitis
d. Pneumonia

91. A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?

a. Asthma attack
b. Atelectasis
c. Bronchitis
d. Fat embolism

92. A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?

a. Acute asthma
b. Chronic bronchitis
c. Pneumonia
d. Spontaneous pneumothorax

93. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?

a. Bronchitis
b. Pneumonia
c. Pneumothorax
d. Tuberculosis (TB)

94. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?

a. The space remains filled with air only
b. The surgeon fills the space with a gel
c. Serous fluids fills the space and consolidates the region
d. The tissue from the other lung grows over to the other side

95. Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?

a. Alveolar damage in the infracted area
b. Involvement of major blood vessels in the occluded area
c. Loss of lung parenchyma
d. Loss of lung tissue

96. Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

97. After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?

a. Air leak
b. Adequate suction
c. Inadequate suction
d. Kinked chest tube

98. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?

a. 18
b. 21
c. 35
d. 40

99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?

a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml

100. Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?

a. “I will wear the stockings until the physician tells me to remove them.”
b. “I should wear the stockings even when I am sleep.”
c. “Every four hours I should remove the stockings for a half hour.”
d. “I should put on the stockings before getting out of bed in the morning.”

This is a preboard examination which can help you sharpen your nursing knowledge for the coming board examinations. This is a 100-item examination about Medical-Surgical Nursing.  This examination is good for 2 hours, that’s 1 minute and 20 seconds per question. Situational questions are also included.

Note: In the actual board exams, this test is entitled as Care of Clients with Physiologic and Psychosocial Alterations Nursing. 

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance

1. Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is:

a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed

2. Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia?

a. On the client’s right side
b. On the client’s left side
c. Directly in front of the client
d. Where the client like

3. A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?

a. Check respiration, circulation, neurological response.
b. Align the spine, check pupils, and check for hemorrhage.
c. Check respirations, stabilize spine, and check circulation.
d. Assess level of consciousness and circulation.

4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and relieves angina by:

a. Increasing contractility and slowing heart rate.
b. Increasing AV conduction and heart rate.
c. Decreasing contractility and oxygen consumption.
d. Decreasing venous return through vasodilation.

5. Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?

a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the precordium, and check the pulse.
d. Administer two quick blows.

6. Nurse Monett is caring for a client recovering from gastro-intestinal bleeding. The nurse should:

a. Plan care so the client can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the client takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.

7. A male client was on warfarin (Coumadin) before admission, and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?

a. Stop the I.V. infusion of heparin and notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.

8. A client undergone ileostomy, when should the drainage appliance be applied to the stoma?

a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the client is able to begin self-care procedures.

9. A client undergone spinal anesthetic, it will be important that the nurse immediately position the client in:

a. On the side, to prevent obstruction of airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.

10.While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure?

a. Blood pressure is decreased from 160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an occasional skipped beat.
c. The client is oriented when aroused from sleep, and goes back to sleep immediately.
d. The client refuses dinner because of anorexia.

11.Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first?

a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough

12. A male client has active tuberculosis (TB). Which of the following symptoms will be exhibit?

a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104°F (40°C) and nausea
d. Headache and photophobia

13. Mark, a 7-year-old client is brought to the emergency department. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has
a nonproductive cough. He recently had a cold. Form this history; the client may have which of the following conditions?

a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema

14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have
which of the following reactions?

a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own

15. A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging?

a. Increased elastic recoil of the lungs
b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity

16. Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to administration of this medication?

a. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter.
b. Increase in systemic blood pressure.
c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
d. Increase in intracranial pressure (ICP).

17. Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to:

a. Report incidents of diarrhea.
b. Avoid foods high in vitamin K
c. Use a straight razor when shaving.
d. Take aspirin to pain relief.

18. Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:

a. Leaving the hair intact
b. Shaving the area
c. Clipping the hair in the area
d. Removing the hair with a depilatory.

19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication:

a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump

20. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the purpose of performing the examination is to discover:

a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses

21. When caring for a female client who is being treated for hyperthyroidism, it is important to:

a. Provide extra blankets and clothing to keep the client warm.
b. Monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.
c. Balance the client’s periods of activity and rest.
d. Encourage the client to be active to prevent constipation.

22. Nurse Kris is teaching a client with 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.

23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:

a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.

24. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following?

a. Avoid lifting objects weighing more than 5 lb (2.25 kg).
b. Lie on your abdomen when in bed
c. Keep rooms brightly lit.
d. Avoiding straining during bowel movement or bending at the waist.

25. George should be taught about testicular examinations during:

a. when sexual activity starts
b. After age 69
c. After age 40
d. Before age 20.

26. A male client undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. Nurse Trish first response is to:

a. Call the physician
b. Place a saline-soaked sterile dressing on the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.

27. Nurse Audrey is caring for a client who has suffered a severe cerebrovascular accident. During routine assessment, the nurse notices Cheyne- Strokes respirations. Cheyne-strokes respirations are:

a. A progressively deeper breaths followed by shallower breaths with apneic periods.
b. Rapid, deep breathing with abrupt pauses between each breath.
c. Rapid, deep breathing and irregular breathing without pauses.
d. Shallow breathing with an increased respiratory rate.

28. Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:

a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs

29. The nurse is caring for Kenneth experiencing an acute asthma attack. The client stops wheezing and breath sounds aren’t audible. The reason for this
change is that:

a. The attack is over.
b. The airways are so swollen that no air cannot get through.
c. The swelling has decreased.
d. Crackles have replaced wheezes.

30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:

a. Place the client on his back remove dangerous objects, and insert a bite block.
b. Place the client on his side, remove dangerous objects, and insert a bite block.
c. Place the client o his back, remove dangerous objects, and hold down his arms.
d. Place the client on his side, remove dangerous objects, and protect his head.

31. After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

a. Infection of the lung.
b. Kinked or obstructed chest tube
c. Excessive water in the water-seal chamber
d. Excessive chest tube drainage

32. Nurse Maureen is talking to a male client, the client begins choking on his lunch. He’s coughing forcefully. The nurse should:

a. Stand him up and perform the abdominal thrust maneuver from behind.
b. Lay him down, straddle him, and perform the abdominal thrust maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this time.

33. Nurse Ron is taking a health history of an 84 year old client. Which information will be most useful to the nurse for planning care?

a. General health for the last 10 years.
b. Current health promotion activities.
c. Family history of diseases.
d. Marital status.

34. When performing oral care on a comatose client, Nurse Krina should:

a. Apply lemon glycerin to the client’s lips at least every 2 hours.
b. Brush the teeth with client lying supine.
c. Place the client in a side lying position, with the head of the bed lowered.
d. Clean the client’s mouth with hydrogen peroxide.

35. A 77-year-old male client is admitted with a diagnosis of dehydration and change in mental status. He’s being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F (39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this client may have which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis

36. Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today most likely to have TB?

a. A 16-year-old female high school student
b. A 33-year-old day-care worker
c. A 43-yesr-old homeless man with a history of alcoholism
d. A 54-year-old businessman

37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?

a. To confirm the diagnosis
b. To determine if a repeat skin test is needed
c. To determine the extent of lesions
d. To determine if this is a primary or secondary infection

38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated with which of the following classes of medication right away?

a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids

39. Mr. Vasquez 56-year-old client with a 40-year history of smoking one to two packs of cigarettes per day has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.

40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone marrow transplantation is not correct?

a. The patient is under local anesthesia during the procedure
b. The aspirated bone marrow is mixed with heparin.
c. The aspiration site is the posterior or anterior iliac crest.
d. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before the procedure.

41. After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:

a. Call the physician
b. Document the patient’s status in his charts.
c. Prepare oxygen treatment
d. Raise the side rails

42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my white blood cell production?” The nurse in-charge best response would be that the increased number of white blood cells (WBC) is:

a. Crowd red blood cells
b. Are not responsible for the anemia.
c. Uses nutrients from other cells
d. Have an abnormally short life span of cells.

43. Diagnostic assessment of Francis would probably not reveal:

a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts

44. Robert, a 57-year-old client with acute arterial occlusion of the left leg undergoes an emergency embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound. The nurse immediately notifies the physician, and asks her to prepare the client for surgery. As the nurse enters the client’s room to prepare him, he states that he won’t have any more surgery. Which of the following is the best initial response by the nurse?

a. Explain the risks of not having the surgery
b. Notifying the physician immediately
c. Notifying the nursing supervisor
d. Recording the client’s refusal in the nurses’ notes

45. During the endorsement, which of the following clients should the on-duty nurse assess first?

a. The 58-year-old client who was admitted 2 days ago with heart failure, blood pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute.
b. The 89-year-old client with end-stage right-sided heart failure, blood pressure of 78/50 mm Hg, and a “do not resuscitate” order
c. The 62-year-old client who was admitted 1 day ago with thrombophlebitis and is receiving L.V. heparin
d. The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. dilitiazem (Cardizem)

46. Honey, a 23-year old client complains of substernal chest pain and states that her heart feels like “it’s racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the client about using?

a. Barbiturates
b. Opioids
c. Cocaine
d. Benzodiazepines

47. A 51-year-old female client tells the nurse in-charge 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 mobile mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily delineated
d. Nonpalpable right axillary lymph nodes

48. A 35-year-old client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?

a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy

49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

a. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
c. Can’t assess tumor or regional lymph nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis

50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

a. “Keep the stoma uncovered.”
b. “Keep the stoma dry.”
c. “Have a family member perform stoma care initially until you get used to the procedure.”
d. “Keep the stoma moist.”

51. A 37-year-old client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?

a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer

52. Antonio with lung cancer develops Horner’s syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:

a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected side.
d. hoarseness and dysphagia.

53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:

a. prostate-specific antigen, which is used to screen for prostate cancer.
b. protein serum antigen, which is used to determine protein levels.
c. pneumococcal strep antigen, which is a bacteria that causes pneumonia.
d. Papanicolaou-specific antigen, which is used to screen for cervical cancer.

54. What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?

a. “Avoid drinking liquids until the gag reflex returns.”
b. “Avoid eating milk products for 24 hours.”
c. “Notify a nurse if you experience blood in your urine.”
d. “Remain supine for the time specified by the physician.”

55. A male client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT) scan

56. During a breast examination, which finding most strongly suggests that the Luz has breast cancer?

a. Slight asymmetry of the breasts.
b. A fixed nodular mass with dimpling of the overlying skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable masses that change with the menstrual cycle

57. A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?

a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)

58. Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?

a. The client lies still.
b. The client asks questions.
c. The client hears thumping sounds.
d. The client wears a watch and wedding band.

59. Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?

a. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
b. To avoid fractures, the client should avoid strenuous exercise.
c. The recommended daily allowance of calcium may be found in a wide variety of foods.
d. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for contraindications for this procedure. Which finding is a contraindication?

a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness

61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?

a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis

62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old client with stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should be given?

a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour

63. A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke?

a. Elbow contracture secondary to spasticity
b. Loss of muscle contraction decreasing venous return
c. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus

64. Heberden’s nodes are a common sign of osteoarthritis. Which of the following statement is correct about this deformity?

a. It appears only in men
b. It appears on the distal interphalangeal joint
c. It appears on the proximal interphalangeal joint
d. It appears on the dorsolateral aspect of the interphalangeal joint.

65. Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis?

a. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
b. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
d. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t

66. Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true about a cane or other assistive devices?

a. A walker is a better choice than a cane.
b. The cane should be used on the affected side
c. The cane should be used on the unaffected side
d. A client with osteoarthritis should be encouraged to ambulate without the cane

67. A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
b. 21 U regular insulin and 9 U NPH.
c. 10 U regular insulin and 20 U NPH.
d. 20 U regular insulin and 10 U NPH.

68. Nurse Len should expect to administer which medication to a client with gout?

a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)

69. Mr. Domingo 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 of the following glands?

a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid

70. For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wetto- dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?

a. They contain exudate and provide a moist wound environment.
b. They protect the wound from mechanical trauma and promote healing.
c. They debride the wound and promote healing by secondary intention.
d. They prevent the entrance of microorganisms and minimize wound discomfort.

71. Nurse Zeny is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?

a. Hyperkalemia
b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia

72. A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids as ordered

73. A female client tells nurse Nikki that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:

a. urine glucose level.
b. fasting blood glucose level.
c. serum fructosamine level.
d. glycosylated hemoglobin level.

74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?

a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm

75. The adrenal cortex is responsible for producing which substances?

a. Glucocorticoids and androgens
b. Catecholamines and epinephrine
c. Mineralocorticoids and catecholamines
d. Norepinephrine and epinephrine

76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia

77. Which laboratory test value is elevated in clients who smoke and can’t be used as a general indicator of cancer?

a. Acid phosphatase level
b. Serum calcitonin level
c. Alkaline phosphatase level
d. Carcinoembryonic antigen level

78. Francis with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?

a. Nights sweats, weight loss, and diarrhea
b. Dyspnea, tachycardia, and pallor
c. Nausea, vomiting, and anorexia
d. Itching, rash, and jaundice

79. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:

a. The baby can get the virus from my placenta.”
b. “I’m planning on starting on birth control pills.”
c. “Not everyone who has the virus gives birth to a baby who has the virus.”
d. “I’ll need to have a C-section if I become pregnant and have a baby.”

80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the home, the nurse should be sure to include which instruction?

a. “Put on disposable gloves before bathing.”
b. “Sterilize all plates and utensils in boiling water.”
c. “Avoid sharing such articles as toothbrushes and razors.”
d. “Avoid eating foods from serving dishes shared by other family members.”

81. Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the
client?

a. Pallor, bradycardia, and reduced pulse pressure
b. Pallor, tachycardia, and a sore tongue
c. Sore tongue, dyspnea, and weight gain
d. Angina, double vision, and anorexia

82. After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?

a. Page an anesthesiologist immediately and prepare to intubate the client.
b. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary.
c. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs.
d. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.

83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

a. weight gain.
b. fine motor tremors.
c. respiratory acidosis.
d. bilateral hearing loss.

84. A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provided by which type of white blood cell?

a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte

85. In an individual with Sjögren’s syndrome, nursing care should focus on:

a. moisture replacement.
b. electrolyte balance.
c. nutritional supplementation.
d. arrhythmia management.

86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:

a. enzyme-linked immunosuppressant assay (ELISA) test.
b. electrolyte panel and hemogram.
c. stool for Clostridium difficile test.
d. flat plate X-ray of the abdomen.

87. A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:

a. E-rosette immunofluorescence.
b. quantification of T-lymphocytes.
c. enzyme-linked immunosorbent assay (ELISA).
d. Western blot test with ELISA.

88. A complete blood count is commonly performed before a Joe goes into surgery. What does this test seek to identify?

a. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
b. Low levels of urine constituents normally excreted in the urine
c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
d. Electrolyte imbalance that could affect the blood’s ability to coagulate properly

89. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?

a. Platelet count, prothrombin time, and partial thromboplastin time
b. Platelet count, blood glucose levels, and white blood cell (WBC) count
c. Thrombin time, calcium levels, and potassium levels
d. Fibrinogen level, WBC, and platelet count

90. When taking a dietary history from a newly admitted female client, Nurse Len should remember that which of the following foods is a common allergen?

a. Bread
b. Carrots
c. Orange
d. Strawberries

91. Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?

a. A client with hepatitis A who states, “My arms and legs are itching.”
b. A client with cast on the right leg who states, “I have a funny feeling in my right leg.”
c. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.”
d. A client with rheumatoid arthritis who states, “I am having trouble sleeping.”

92. Nurse Sarah is caring for clients on the surgical floor and has just received report from the previous shift. Which of the following clients should the nurse see first?

a. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.
b. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
c. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
d. A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.

93. Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?

a. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.
b. The client supports his head and neck when turning his head to the right.
c. The client spontaneously flexes his wrist when the blood pressure is obtained.
d. The client is drowsy and complains of sore throat.

94. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?

a. Encourage the client to change positions frequently in bed.
b. Administer Demerol 50 mg IM q 4 hours and PRN.
c. Apply warmth to the abdomen with a heating pad.
d. Use comfort measures and pillows to position the client.

95. Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?

a. Assess for a bruit and a thrill.
b. Warm the dialysate solution.
c. Position the client on the left side.
d. Insert a Foley catheter

96. Nurse Jannah teaches an elderly client with right-sided weakness how to use cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective?

a. The client holds the cane with his right hand, moves the can forward followed by the right leg, and then moves the left leg.
b. The client holds the cane with his right hand, moves the cane forward followed by his left leg, and then moves the right leg.
c. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then moves the left leg.
d. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.

97. An elderly client is admitted to the nursing home setting. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?

a. Ask the woman’s family to provide personal items such as photos or mementos.
b. Select a room with a bed by the door so the woman can look down the hall.
c. Suggest the woman eat her meals in the room with her roommate.
d. Encourage the woman to ambulate in the halls twice a day.

98. Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse’s teaching was effective?

a. The client slowly pushes the walker forward 12 inches, then takes small steps forward while leaning on the walker.
b. The client lifts the walker, moves it forward 10 inches, and then takes several small steps forward.
c. The client supports his weight on the walker while advancing it forward, then takes small steps while balancing on the walker.
d. The client slides the walker 18 inches forward, then takes small steps while holding onto the walker for balance.

99. Nurse Deric is supervising a group of elderly clients in a residential home setting. The nurse knows that the elderly are at greater risk of developing sensory deprivation for what reason?

a. Increased sensitivity to the side effects of medications.
b. Decreased visual, auditory, and gustatory abilities.
c. Isolation from their families and familiar surroundings.
d. Decrease musculoskeletal function and mobility.

100. A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?

a. Encourage the client to perform pursed lip breathing.
b. Check the client’s temperature.
c. Assess the client’s potassium level.
d. Increase the client’s oxygen flow rate.

Challenge your nursing knowledge with this Medical-Surgical Nursing Examination with the topic of: Cardiovascular Nursing! This is a 60-item examination that can help you improve, review and challenge your knowledge about Medical-Surgical Nursing! If you are taking the board examination or nurse licensure examination or even the NCLEX, then this practice exam is for you.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers are given below. Be sure to check your performance.

1. Which of the following arteries primarily feeds the anterior wall of the heart?

a. Circumflex artery
b. Internal mammary artery
c. Left anterior descending artery
d. Right coronary artery

2. When do coronary arteries primarily receive blood flow?

a. During inspiration
b. During diastole
c. During expiration
d. During systole

3. Which of the following illnesses is the leading cause of death in the US?

a. Cancer
b. Coronary artery disease
c. Liver failure
d. Renal failure

4. Which of the following conditions most commonly results in CAD?

a. Atherosclerosis
b. DM
c. MI
d. Renal failure

5. Atherosclerosis impedes coronary blood flow by which of the following mechanisms?

a. Plaques obstruct the vein
b. Plaques obstruct the artery
c. Blood clots form outside the vessel wall
d. Hardened vessels dilate to allow the blood to flow through

6. Which of the following risk factors for coronary artery disease cannot be corrected?

a. Cigarette smoking
b. DM
c. Heredity
d. HPN

7. Exceeding which of the following serum cholesterol levels significantly increases the risk of coronary artery disease?

a. 100 mg/dl
b. 150 mg/dl
c. 175 mg/dl
d. 200 mg/dl

8. Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease?

a. Decrease anxiety
b. Enhance myocardial oxygenation
c. Administer sublignual nitroglycerin
d. Educate the client about his symptoms

9. Medical treatment of coronary artery disease includes which of the following procedures?

a. Cardiac catheterization
b. Coronary artery bypass surgery
c. Oral medication administration
d. Percutaneous transluminal coronary angioplasty

10. Prolonged occlusion of the right coronary artery produces an infarction in which of he following areas of the heart?

a. Anterior
b. Apical
c. Inferior
d. Lateral

11. Which of the following is the most common symptom of myocardial infarction?

a. Chest pain
b. Dyspnea
c. Edema
d. Palpitations

12. Which of the following landmarks is the corect one for obtaining an apical pulse?

a. Left intercostal space, midaxillary line
b. Left fifth intercostal space, midclavicular line
c. Left second intercostal space, midclavicular line
d. Left seventh intercostal space, midclavicular line

13. Which of the following systems is the most likely origin of pain the client describes as knifelike chest pain that increases in intensity with inspiration?

a. Cardiac
b. Gastrointestinal
c. Musculoskeletal
d. Pulmonary

14. A murmur is heard at the second left intercostal space along the left sternal border. Which valve area is this?

a. Aortic
b. Mitral
c. Pulmonic
d. Tricuspid

15. Which of the following blood tests is most indicative of cardiac damage?

a. Lactate dehydrogenase
b. Complete blood count
c. Troponin I
d. Creatine kinase

16. What is the primary reason for administering morphine to a client with myocardial infarction?

a. To sedate the client
b. To decrease the client’s pain
c. To decrease the client’s anxiety
d. To decrease oxygen demand on the client’s heart

17. Which of the followng conditions is most commonly responsible for myocardial infarction?

a. Aneurysm
b. Heart failure
c. Coronary artery thrombosis
d. Renal failure

18. What supplemental medication is most frequently ordered in conjuction with furosemide (Lasix)?

a. Chloride
b. Digoxin
c. Potassium
d. Sodium

19. After myocardial infarction, serum glucose levels and free fatty acids are both increase. What type of physiologic changes are these?

a. Electrophysiologic
b. Hematologic
c. Mechanical
d. Metabolic

20. Which of the following complications is indicated by a third heart sound (S3)?

a. Ventricular dilation
b. Systemic hypertension
c. Aortic valve malfunction
d. Increased atrial contractions

21. After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?

a. Left-sided heart failure
b. Pulmonic valve malfunction
c. Right-sided heart failure
d. Tricuspid valve malfunction

22. Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage?

a. Cardiac catheterization
b. Cardiac enzymes
c. Echocardiogram
d. Electrocardiogram

23. What is the first intervention for a client experiencing myocardial infarction?

a. Administer morphine
b. Administer oxygen
c. Administer sublingual nitroglycerin
d. Obtain an electrocardiogram

24. What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying?

a. “Tell me about your feeling right now.”
b. “When the doctor arrives, everything will be fine.”
c. “This is a bad situation, but you’ll feel better soon.”
d. “Please be assured we’re doing everything we can to make you feel better.”

25. Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?

a. Beta-adrenergic blockers
b. Calcium channel blockers
c. Narcotics
d. Nitrates

26. What is the most common complication of a myocardial infarction?

a. Cardiogenic shock
b. Heart failure
c. Arrhythmias
d. Pericarditis

27. With which of the following disorders is jugular vein distention most prominent?

a. Abdominal aortic aneurysm
b. Heart failure
c. Myocardial infarction
d. Pneumothorax

28. What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention?

a. High-fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position

29. Which of the following parameters should be checked before administering digoxin?

a. Apical pulse
b. Blood pressure
c. Radial pulse
d. Respiratory rate

30. Toxicity from which of the following medications may cause a client to see a green halo around lights?

a. Digoxin
b. Furosemide
c. Metoprolol
d. Enalapril

31. Which ofthe following symptoms is most commonly associated with left-sided heart failure?

a. Crackles
b. Arrhythmias
c. Hepatic engorgement
d. Hypotension

32. In which of the following disorders would the nurse expect to assess sacral eddema in bedridden client?

a. DM
b. Pulmonary emboli
c. Renal failure
d. Right-sided heart failure

33. Which of the following symptoms might a client with right-sided heart failure exhibit?

a. Adequate urine output
b. Polyuria
c. Oliguria
d. Polydipsia

34. Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility?

a. Beta-adrenergic blockers
b. Calcium channel blockers
c. Diuretics
d. Inotropic agents

35. Stimulation of the sympathetic nervous system produces which of the following responses?

a. Bradycardia
b. Tachycardia
c. Hypotension
d. Decreased myocardial contractility

36. Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output?

a. Angina pectoris
b. Cardiomyopathy
c. Left-sided heart failure
d. Right-sided heart failure

37. What is the most common cause of abdominal aortic aneurysm?

a. Atherosclerosis
b. DM
c. HPN
d. Syphilis

38. In which of the following areas is an abdominal aortic aneurysm most commonly located?

a. Distal to the iliac arteries
b. Distal to the renal arteries
c. Adjacent to the aortic branch
d. Proximal to the renal arteries

39. A pulsating abdominal mass usually indicates which of the following conditions?

a. Abdominal aortic aneurysm
b. Enlarged spleen
c. Gastic distention
d. Gastritis

40. What is the most common symptom in a client with abdominal aortic aneurysm?

a. Abdominal pain
b. Diaphoresis
c. Headache
d. Upper back pain

41. Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?

a. Abdominal pain
b. Absent pedal pulses
c. Angina
d. Lower back pain

42. What is the definitive test used to diagnose an abdominal aortic aneurysm?

a. Abdominal X-ray
b. Arteriogram
c. CT scan
d. Ultrasound

43. Which of the following complications is of greatest concern when caring for a preoperative abdominal aneurysm client?

a. HPN
b. Aneurysm rupture
c. Cardiac arrythmias
d. Diminished pedal pulses

44. Which of the following blood vessel layers may be damaged in a client with an aneurysm?

a. Externa
b. Interna
c. Media
d. Interna and Media

45. When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most commonly palpated?

a. Right upper quadrant
b. Directly over the umbilicus
c. Middle lower abdomen to the left of the midline
d. Midline lower abdomen to the right of the midline

46. Which of the following conditions is linked to more than 50% of clients with abdominal aortic aneurysms?

a. DM
b. HPN
c. PVD
d. Syphilis

47. Which of the following sounds is distinctly heard on auscultation over the abdominal region of an abdominal aortic aneurysm client?

a. Bruit
b. Crackles
c. Dullness
d. Friction rubs

48. Which of the following groups of symptoms indicated a ruptured abdominal aneurysm?

a. Lower back pain, increased BP, decreased RBC, increased WBC
b. Severe lower back pain, decreased BP, decreased RBC, increased WBC
c. Severe lower back pain, decreased BP, decreased RBC, decreased WBC
d. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC

49. Which of the following complications of an abdominal aortic repair is indicated by detection of a hematoma in the perineal area?

a. Hernia
b. Stage 1 pressure ulcer
c. Retroperitoneal rupture at the repair site
d. Rapid expansion of the aneurysm

50. Which hereditary disease is most closely linked to aneurysm?

a. Cystic fibrosis
b. Lupus erythematosus
c. Marfan’s syndrome
d. Myocardial infarction

51. Which of the following treatments is the definitive one for a ruptured aneurysm?

a. Antihypertensive medication administration
b. Aortogram
c. Beta-adrenergic blocker administration
d. Surgical intervention

52. Which of the following heart muscle diseases is unrelated to other cardiovascular disease?

a. Cardiomyopathy
b. Coronary artery disease
c. Myocardial infarction
d. Pericardial Effusion

53. Which of the following types of cardiomyopathy can be associated with childbirth?

a. Dilated
b. Hypertrophic
c. Myocarditis
d. Restrictive

54. Septal involvement occurs in which type of cardiomyopathy?

a. Congestive
b. Dilated
c. Hypertrophic
d. Restrictive

55. Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?

a. Heart failure
b. DM
c. MI
d. Pericardial effusion

56. What is the term used to describe an enlargement of the heart muscle?

a. Cardiomegaly
b. Cardiomyopathy
c. Myocarditis
d. Pericarditis

57. Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?

a. Pericarditis
b. Hypertension
c. Obliterative
d. Restricitive

58. Which of the following types of cardiomyopathy does not affect cardiac output?

a. Dilated
b. Hypertrophic
c. Restrictive
d. Obliterative

59. Which of the following cardiac conditions does a fourth heart sound (S4) indicate?

a. Dilated aorta
b. Normally functioning heart
c. Decreased myocardial contractility
d. Failure of the ventricle to eject all the blood during systole

60. Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy?

a. Antihypertensive
b. Beta-adrenergic blockers
c. Calcium channel blockers
d. Nitrates

This is a free examination about the concepts of Gastrointestinal Nursing! This 60-item medical-surgical nursing exam will help you review and challenge your nursing knowledge about Gastrointestinal Nursing. If you are taking the board examination or nurse licensure examination or even the NCLEX, then this practice exam is just right for you!

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers are given below. Be sure to check your performance.

1. Which of the following arteries primarily feeds the anterior wall of the heart?

a. Circumflex artery
b. Internal mammary artery
c. Left anterior descending artery
d. Right coronary artery

2. When do coronary arteries primarily receive blood flow?

a. During inspiration
b. During diastole
c. During expiration
d. During systole

3. Which of the following illnesses is the leading cause of death in the US?

a. Cancer
b. Coronary artery disease
c. Liver failure
d. Renal failure

4. Which of the following conditions most commonly results in CAD?

a. Atherosclerosis
b. DM
c. MI
d. Renal failure

5. Atherosclerosis impedes coronary blood flow by which of the following mechanisms?

a. Plaques obstruct the vein
b. Plaques obstruct the artery
c. Blood clots form outside the vessel wall
d. Hardened vessels dilate to allow the blood to flow through

6. Which of the following risk factors for coronary artery disease cannot be corrected?

a. Cigarette smoking
b. DM
c. Heredity
d. HPN

7. Exceeding which of the following serum cholesterol levels significantly increases the risk of coronary artery disease?

a. 100 mg/dl
b. 150 mg/dl
c. 175 mg/dl
d. 200 mg/dl

8. Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease?

a. Decrease anxiety
b. Enhance myocardial oxygenation
c. Administer sublignual nitroglycerin
d. Educate the client about his symptoms

9. Medical treatment of coronary artery disease includes which of the following procedures?

a. Cardiac catheterization
b. Coronary artery bypass surgery
c. Oral medication administration
d. Percutaneous transluminal coronary angioplasty

10. Prolonged occlusion of the right coronary artery produces an infarction in which of he following areas of the heart?

a. Anterior
b. Apical
c. Inferior
d. Lateral

11. Which of the following is the most common symptom of myocardial infarction?

a. Chest pain
b. Dyspnea
c. Edema
d. Palpitations

12. Which of the following landmarks is the corect one for obtaining an apical pulse?

a. Left intercostal space, midaxillary line
b. Left fifth intercostal space, midclavicular line
c. Left second intercostal space, midclavicular line
d. Left seventh intercostal space, midclavicular line

13. Which of the following systems is the most likely origin of pain the client describes as knifelike chest pain that increases in intensity with inspiration?

a. Cardiac
b. Gastrointestinal
c. Musculoskeletal
d. Pulmonary

14. A murmur is heard at the second left intercostal space along the left sternal border. Which valve area is this?

a. Aortic
b. Mitral
c. Pulmonic
d. Tricuspid

15. Which of the following blood tests is most indicative of cardiac damage?

a. Lactate dehydrogenase
b. Complete blood count
c. Troponin I
d. Creatine kinase

16. What is the primary reason for administering morphine to a client with myocardial infarction?

a. To sedate the client
b. To decrease the client’s pain
c. To decrease the client’s anxiety
d. To decrease oxygen demand on the client’s heart

17. Which of the followng conditions is most commonly responsible for myocardial infarction?

a. Aneurysm
b. Heart failure
c. Coronary artery thrombosis
d. Renal failure

18. What supplemental medication is most frequently ordered in conjuction with furosemide (Lasix)?

a. Chloride
b. Digoxin
c. Potassium
d. Sodium

19. After myocardial infarction, serum glucose levels and free fatty acids are both increase. What type of physiologic changes are these?

a. Electrophysiologic
b. Hematologic
c. Mechanical
d. Metabolic

20. Which of the following complications is indicated by a third heart sound (S3)?

a. Ventricular dilation
b. Systemic hypertension
c. Aortic valve malfunction
d. Increased atrial contractions

21. After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?

a. Left-sided heart failure
b. Pulmonic valve malfunction
c. Right-sided heart failure
d. Tricuspid valve malfunction

22. Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage?

a. Cardiac catheterization
b. Cardiac enzymes
c. Echocardiogram
d. Electrocardiogram

23. What is the first intervention for a client experiencing myocardial infarction?

a. Administer morphine
b. Administer oxygen
c. Administer sublingual nitroglycerin
d. Obtain an electrocardiogram

24. What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying?

a. “Tell me about your feeling right now.”
b. “When the doctor arrives, everything will be fine.”
c. “This is a bad situation, but you’ll feel better soon.”
d. “Please be assured we’re doing everything we can to make you feel better.”

25. Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?

a. Beta-adrenergic blockers
b. Calcium channel blockers
c. Narcotics
d. Nitrates

26. What is the most common complication of a myocardial infarction?

a. Cardiogenic shock
b. Heart failure
c. Arrhythmias
d. Pericarditis

27. With which of the following disorders is jugular vein distention most prominent?

a. Abdominal aortic aneurysm
b. Heart failure
c. Myocardial infarction
d. Pneumothorax

28. What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention?

a. High-fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position

29. Which of the following parameters should be checked before administering digoxin?

a. Apical pulse
b. Blood pressure
c. Radial pulse
d. Respiratory rate

30. Toxicity from which of the following medications may cause a client to see a green halo around lights?

a. Digoxin
b. Furosemide
c. Metoprolol
d. Enalapril

31. Which of the following symptoms is most commonly associated with left-sided heart failure?

a. Crackles
b. Arrhythmias
c. Hepatic engorgement
d. Hypotension

32. In which of the following disorders would the nurse expect to assess sacral eddema in bedridden client?

a. DM
b. Pulmonary emboli
c. Renal failure
d. Right-sided heart failure

33. Which of the following symptoms might a client with right-sided heart failure exhibit?

a. Adequate urine output
b. Polyuria
c. Oliguria
d. Polydipsia

34. Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility?

a. Beta-adrenergic blockers
b. Calcium channel blockers
c. Diuretics
d. Inotropic agents

35. Stimulation of the sympathetic nervous system produces which of the following responses?

a. Bradycardia
b. Tachycardia
c. Hypotension
d. Decreased myocardial contractility

36. Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output?

a. Angina pectoris
b. Cardiomyopathy
c. Left-sided heart failure
d. Right-sided heart failure

37. What is the most common cause of abdominal aortic aneurysm?

a. Atherosclerosis
b. DM
c. HPN
d. Syphilis

38. In which of the following areas is an abdominal aortic aneurysm most commonly located?

a. Distal to the iliac arteries
b. Distal to the renal arteries
c. Adjacent to the aortic branch
d. Proximal to the renal arteries

39. A pulsating abdominal mass usually indicates which of the following conditions?

a. Abdominal aortic aneurysm
b. Enlarged spleen
c. Gastic distention
d. Gastritis

40. What is the most common symptom in a client with abdominal aortic aneurysm?

a. Abdominal pain
b. Diaphoresis
c. Headache
d. Upper back pain

41. Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?

a. Abdominal pain
b. Absent pedal pulses
c. Angina
d. Lower back pain

42. What is the definitive test used to diagnose an abdominal aortic aneurysm?

a. Abdominal X-ray
b. Arteriogram
c. CT scan
d. Ultrasound

43. Which of the following complications is of greatest concern when caring for a preoperative abdominal aneurysm client?

a. HPN
b. Aneurysm rupture
c. Cardiac arrythmias
d. Diminished pedal pulses

44. Which of the following blood vessel layers may be damaged in a client with an aneurysm?

a. Externa
b. Interna
c. Media
d. Interna and Media

45. When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most commonly palpated?

a. Right upper quadrant
b. Directly over the umbilicus
c. Middle lower abdomen to the left of the midline
d. Midline lower abdomen to the right of the midline

46. Which of the following conditions is linked to more than 50% of clients with abdominal aortic aneurysms?

a. DM
b. HPN
c. PVD
d. Syphilis

47. Which of the following sounds is distinctly heard on auscultation over the abdominal region of an abdominal aortic aneurysm client?

a. Bruit
b. Crackles
c. Dullness
d. Friction rubs

48. Which of the following groups of symptoms indicated a ruptured abdominal aneurysm?

a. Lower back pain, increased BP, decreased RBC, increased WBC
b. Severe lower back pain, decreased BP, decreased RBC, increased WBC
c. Severe lower back pain, decreased BP, decreased RBC, decreased WBC
d. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC

49. Which of the following complications of an abdominal aortic repair is indicated by detection of a hematoma in the perineal area?

a. Hernia
b. Stage 1 pressure ulcer
c. Retroperitoneal rupture at the repair site
d. Rapid expansion of the aneurysm

50. Which hereditary disease is most closely linked to aneurysm?

a. Cystic fibrosis
b. Lupus erythematosus
c. Marfan’s syndrome
d. Myocardial infarction

51. Which of the following treatments is the definitive one for a ruptured aneurysm?

a. Antihypertensive medication administration
b. Aortogram
c. Beta-adrenergic blocker administration
d. Surgical intervention

52. Which of the following heart muscle diseases is unrelated to other cardiovascular disease?

a. Cardiomyopathy
b. Coronary artery disease
c. Myocardial infarction
d. Pericardial Effusion

53. Which of the following types of cardiomyopathy can be associated with childbirth?

a. Dilated
b. Hypertrophic
c. Myocarditis
d. Restrictive

54. Septal involvement occurs in which type of cardiomyopathy?

a. Congestive
b. Dilated
c. Hypertrophic
d. Restrictive

55. Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?

a. Heart failure
b. DM
c. MI
d. Pericardial effusion

56. What is the term used to describe an enlargement of the heart muscle?

a. Cardiomegaly
b. Cardiomyopathy
c. Myocarditis
d. Pericarditis

57. Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?

a. Pericarditis
b. Hypertension
c. Obliterative
d. Restricitive

58. Which of the following types of cardiomyopathy does not affect cardiac output?

a. Dilated
b. Hypertrophic
c. Restrictive
d. Obliterative

59. Which of the following cardiac conditions does a fourth heart sound (S4) indicate?

a. Dilated aorta
b. Normally functioning heart
c. Decreased myocardial contractility
d. Failure of the ventricle to eject all the blood during systole

60. Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy?

a. Antihypertensive
b. Beta-adrenergic blockers
c. Calcium channel blockers
d. Nitrates

This is a comprehensive examination which you can use for your Nurse Licensure Examination (NLE). This comprehensive exam ranges all topics of nursing.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers & Rationale are given below. Be sure to read them!

1. A 10 year old who has sustained a head injury is brought to the emergency department by his mother. A diagnosis of a mild concussion is made. At the time of discharge, nurse Ron should instruct the mother to:

A. Withhold food and fluids for 24 hours.
B. Allow him to play outdoors with his friends.
C. Arrange for a follow up visit with the child’s primary care provider in one week.
C. Check for any change in responsiveness every two hours until the follow-up visit.

2. A male client has suffered a motor accident and is now suffering from hypovolemic shock. Nurse Helen should frequency assess the client’s vital signs during the compensatory stage of shock, because:

A. Arteriolar constriction occurs
B. The cardiac workload decreases
C. Decreased contractility of the heart occurs
D. The parasympathetic nervous system is triggered

3. A paranoid male client with schizophrenia is losing weight, reluctant to eat, and voicing concerns about being poisoned. The best intervention by nurse Dina would be to:

A. Allow the client to open canned or pre-packaged food
B. Restrict the client to his room until 2 lbs are gained
C. Have a staff member personally taste all of the client’s food
D. Tell the client the food has been x-rayed by the staff and is safe

4. One day the mother of a young adult confides to nurse Frida that she is very troubled by he child’s emotional illness. The nurse’s most therapeutic initial response would be:

A. “You may be able to lessen your feelings of guilt by seeking counseling”
B. “It would be helpful if you become involved in volunteer work at this time”
C. “I recognize it’s hard to deal with this, but try to remember that this too shall pass”
D. “Joining a support group of parents who are coping with this problem can be quite helpful.

5. To check for wound hemorrhage after a client has had a surgery for the removal of a tumor in the neck, nurse grace should:

A. Loosen an edge of the dressing and lift it to see the wound
B. Observe the dressing at the back of the neck for the presence of blood
C. Outline the blood as it appears on the dressing to observe any progression
D. Press gently around the incision to express accumulated blood from the wound

6. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor. To verify that the client is in true labor nurse Trina should:

A. Obtain sides for a fern test
B. Time any uterine contractions
C. Prepare her for a pelvic examination
D. Apply nitrazine paper to moist vaginal tissue

7. As part of the diagnostic workup for pulmonic stenosis, a child has cardiac catheterization. Nurse Julius is aware that children with pulmonic stenosis have increased pressure:

A. In the pulmonary vein
B. In the pulmonary artery
C. On the left side of the heart
D. On the right side of the heart

8. An obese client asks nurse Julius how to lose weight. Before answering, the nurse should remember that long-term weight loss occurs best when:

A. Eating patterns are altered
B. Fats are limited in the diet
C. Carbohydrates are regulated
D. Exercise is a major component

9. As a very anxious female client is talking to the nurse May, she starts crying. She appears to be upset that she cannot control her crying. The most appropriate response by the nurse would be:

A. “Is talking about your problem upsetting you?”
B. “It is Ok to cry; I’ll just stay with you for now”
C. “You look upset; lets talk about why you are crying.”
D. “Sometimes it helps to get it out of your system.”

10. A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids is given first?

A. Albumin
B. D5W
C. Lactated Ringer’s solution
D. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml

11. During the first 48 hours after a severe burn of 40% of the clients body surface, the nurse’s assessment should include observations for water intoxication. Associated adaptations include:

A. Sooty-colored sputum
B. Frothy pink-tinged sputum
C. Twitching and disorientation
D. Urine output below 30ml per hour

12. After a muscle biopsy, nurse Willy should teach the client to:

A. Change the dressing as needed
B. Resume the usual diet as soon as desired
C. Bathe or shower according to preference
D. Expect a rise in body temperature for 48 hours

13. Before a client whose left hand has been amputated can be fitted for a prosthesis, nurse Joy is aware that:

A. Arm and shoulder muscles must be developed
B. Shrinkage of the residual limb must be completed
C. Dexterity in the other extremity must be achieved
D. Full adjustment to the altered body image must have occurred

14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse Cathy should:

A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the client’s blood pressure

15. A male client receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. The best initial action by the nurse would be to:

A. Perform a finger stick to test the client’s blood glucose level
B. Have the physician assess the client for an enlarged prostate
C. Obtain a urine specimen from the client for screening purposes
D. Assess the client’s lower extremities for the presence of pitting edema

16. Nurse Bea recognizes that a pacemaker is indicated when a client is experiencing:

A. Angina
B. Chest pain
C. Heart block
D. Tachycardia

17. When administering pancrelipase (Pancreases capsules) to child with cystic fibrosis, nurse Faith knows they should be given:

A. With meals and snacks
B. Every three hours while awake
C. On awakening, following meals, and at bedtime
C. After each bowel movement and after postural draianage

18. A preterm neonate is receiving oxygen by an overhead hood. During the time the infant is under the hood, it would be appropriate for nurse Gian to:

A. Hydrate the infant q15 min
B. Put a hat on the infant’s head
C. Keep the oxygen concentration consistent
D. Remove the infant q15 min for stimulation

19. A client’s sputum smears for acid fast bacilli (AFB) are positive, and transmission-based airborne precautions are ordered. Nurse Kyle should instruct visitors to:

A.Limit contact with non-exposed family members
B. Avoid contact with any objects present in the client’s room
C. Wear an Ultra-Filter mask when they are in the client’s room
D. Put on a gown and gloves before going into the client’s room

20. A client with a head injury has a fixed, dilated right pupil; responds only to painful stimuli; and exhibits decorticate posturing. Nurse Kate should recognize that these are signs of:

A. Meningeal irritation
B. Subdural hemorrhage
C. Medullary compression
D. Cerebral cortex compression

21. After a lateral crushing chest injury, obvious right-sided paradoxic motion of the client’s chest demonstrates multiple rib fraactures, resulting in a flail chest. The complication the nurse should carefully observe for would be:

A. Mediastinal shift
B. Tracheal laceration
C. Open pneumothorax
D. Pericardial tamponade

22. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding secondary to placenta previa, the nurse’s primary objective would be:

A. Provide a calm, quiet environment
B. Prepare the client for an immediate cesarean birth
C. Prevent situations that may stimulate the cervix or uterus
D. Ensure that the client has regular cervical examinations assess for labor

23. When planning discharge teaching for a young female client who has had a pneumothorax, it is important that the nurse include the signs and symptoms of a pneumothorax and teach the client to seek medical assistance if she experiences:

A. Substernal chest pain
B. Episodes of palpitation
C. Severe shortness of breath
D. Dizziness when standing up

24. After a laryngectomy, the most important equipment to place at the client’s bedside would be:

A. Suction equipment
B. Humidified oxygen
C. A nonelectric call bell
D. A cold-stream vaporizer

25. Nurse Oliver interviews a young female client with anorexia nervosa to obtain information for the nursing history. The client’s history is likely to reveal a:

A. Strong desire to improve her body image
B. Close, supportive mother-daughter relationship
C. Satisfaction with and desire to maintain her present weight
D. Low level of achievement in school, with little concerns for grades

26. Nurse Bea should plan to assist a client with an obsessive-compulsive disorder to control the use of ritualistic behavior by:

A. Providing repetitive activities that require little thought
B. Attempting to reduce or limit situations that increase anxiety
C. Getting the client involved with activities that will provide distraction
D. Suggesting that the client perform menial tasks to expiate feelings of guilt

27. A 2 ½ year old child undergoes a ventriculoperitoneal shunt revision. Before discharge, nurse John, knowing the expected developmental behaviors for this age group, should tell the parents to call the physician if the child:

A. Tries to copy all the father’s mannerisms
B. Talks incessantly regardless of the presence of others
C. Becomes fussy when frustrated and displays a shortened attention span
D. Frequently starts arguments with playmates by claiming all toys are “mine”

28. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to avoid this complication by:

A. Assessing urine specific gravity
B. Maintaining the ordered hydration
C. Collecting a weekly urine specimen
D. Emptying the drainage bag frequently

29. A client has sustained a fractured right femur in a fall on stairs. Nurse Troy with the emergency response team assess for signs of circulatory impairment by:

A. Turning the client to side lying position
B. Asking the client to cough and deep breathe
C. Taking the client’s pedal pulse in the affected limb
D. Instructing the client to wiggle the toes of the right foot

30. To assess orientation to place in a client suspected of having dementia of the alzheimers type, nurse Chris should ask:

A. “Where are you?”
B. “Who brought you here?”
C. “Do you know where you are?”
D. “How long have you been there?”

31. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated intravascular coagulation (DIC) is occurring when assessments demonstrate:

A. A boggy uterus
B. Multiple vaginal clots
C. Hypotension and tachycardia
D. Bleeding from the venipuncture site

32. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should instruct the client to use is the:

A. Expulsion pattern
B. Slow paced pattern
C. Shallow chest pattern
D. blowing pattern

33. Nurse Ronald should explain that the most beneficial between-meal snack for a client who is recovering from the full-thickness burns would be a:

A. Cheeseburger and a malted
B. Piece of blueberry pie and milk
C. Bacon and tomato sandwich and tea
D. Chicken salad sandwich and soft drink

34. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would be indicated by:

A. flexed extremities
B. Cyanotic lips and face
C. A heart rate of 130 beats per minute
D. A respiratory rate of 40 breath per minute

35. The laboratory calls to state that a client’s lithium level is 1.9 mEq/L after 10 days of lithium therapy. Nurse Reese should:

A. Notify the physician of the findings because the level is dangerously high
B. Monitor the client closely because the level of lithium in the blood is slightly elevated
C. Continue to administer the medication as ordered because the level is within the therapeutic range
D. Report the findings to the physician so the dosage can be increased because the level is below therapeutic range

36. A client has a regular 30-day menstrual cycles. When teaching about the rhythm method, Which the client and her husband have chosen to use for family planning, nurse Dianne should emphasize that the client’s most fertile days are:

A. Days 9 to 11
B. Days 12 to 14
C. Days 15 to 17
D. Days 18 to 20

37. Before an amniocentesis, nurse Alexandra should:

A. Initiate the intravenous therapy as ordered by the physiscian
B. Inform the client that the procedure could precipitate an infection
C. Assure that informed consent has been obtained from the client
D. Perform a vaginal examination on the client to assess cervical dilation

38. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to monitor the client’s deep tendon reflexes to:

A. Determine her level of consciousness
B. Evaluate the mobility of the extremities
C. Determine her response to painful stimuli
D. Prevent development of respiratory distress

39. A preschooler is admitted to the hospital with a diagnosis of acute glomerulonephritis. The child’s history reveals a 5-pound weight gain in one week and peritoneal edema. For the most accurate information on the status of the child’s edema, nursing intervention should include:

A. Obtaining the child’s daily weight
B. Doing a visual inspection of the child
C. Measuring the child’s intake and output
D. Monitoring the child’s electrolyte values

40. Nurse Mickey is administering dexamethasome (Decadron) for the early management of a client’s cerebral edema. This treatment is effective because:

A. Acts as hyperosmotic diuretic
B. Increases tissue resistance to infection
C. Reduces the inflammatory response of tissues
D. Decreases the information of cerebrospinal fluid

41. During newborn nursing assessment, a positive Ortolani’s sign would be indicated by:

A. A unilateral droop of hip
B. A broadening of the perineum
C. An apparent shortening of one leg
D. An audible click on hip manipulation

42. When caring for a dying client who is in the denial stage of grief, the best nursing approach would be to:

A. Agree and encourage the client’s denial
B. Allow the denial but be available to discuss death
C. Reassure the client that everything will be OK
D. Leave the client alone to confront the feelings of impending loss

43. To decrease the symptoms of gastroesophageal reflux disease (GERD), the physician orders dietary and medication management. Nurse Helen should teach the client that the meal alteration that would be most appropriate would be:

A. Ingest foods while they are hot
B. Divide food into four to six meals a day
C.Eat the last of three meals daily by 8pm
D. Suck a peppermint candy after each meal

44. After a mastectomy or hysterectomy, clients may feel incomplete as women. The statement that should alert nurse Gina to this feeling would be:

A. “I can’t wait to see all my friends again”
B. “I feel washed out; there isn’t much left”
C. “I can’t wait to get home to see my grandchild”
D. “My husband plans for me to recuperate at our daughter’s home”

45. A client with obstruction of the common bile duct may show a prolonged bleeding and clotting time because:

A. Vitamin K is not absorbed
B. The ionized calcium levels falls
C. The extrinsic factor is not absorbed
D. Bilirubin accumulates in the plasma

46. Realizing that the hypokalemia is a side effect of steroid therapy, nurse Monette should monitor a client taking steroid medication for:

A. Hyperactive reflexes
B. An increased pulse rate
C. Nausea, vomiting, and diarrhea
D. Leg weakness with muscle cramps

47. When assessing a newborn suspected of having Down syndrome, nurse Rey would expect to observe:

A. long thin fingers
B. Large, protruding ears
C. Hypertonic neck muscles
D. Simian lines on the hands

48. A 10 year old girl is admitted to the pediatric unit for recurrent pain and swelling of her joints, particularly her knees and ankles. Her diagnosis is juvenile rheumatoid arthritis. Nurse Janah recognizes that besides joint inflammation, a unique manifestation of the rheumatoid process involves the:

A. Ears
B. Eyes
C. Liver
D. Brain

49. A disturbed client is scheduled to begin group therapy. The client refuses to attend. Nurse Lolit should:

A. Accept the client’s decision without discussion
B. Have another client to ask the client to consider
C. Tell the client that attendance at the meeting is required
D. Insist that the client join the group to help the socialization process

50. Because a severely depressed client has not responded to any of the antidepressant medications, the psychiatrist decides to try electroconvulsive therapy (ECT). Before the treatment the nurse should:

A. Have the client speak with other clients receiving ECT
B. Give the client a detailed explanation of the entire procedure
C. Limit the client’s intake to a light breakfast on the days of the treatment
D. Provide a simple explanation of the procedure and continue to reassure the client

51. Nurse Vicky is aware that teaching about colostomy care is understood when the client states, “I will contact my physician and report ____”:

A. If I notice a loss of sensation to touch in the stoma tissue”
B. When mucus is passed from the stoma between irrigations”
C. The expulsion of flatus while the irrigating fluid is running out”
D. If I have difficulty in inserting the irrigating tube into the stoma”

52. The client’s history that alerts nurse Henry to assess closely for signs of postpartum infection would be:

A. Three spontaneous abortions
B. negative maternal blood type
C. Blood loss of 850 ml after a vaginal birth
D. Maternal temperature of 99.9° F 12 hours after delivery

53. A client is experiencing stomatitis as a result of chemotherapy. An appropriate nursing intervention related to this condition would be to:

A. Provide frequent saline mouthwashes
B. Use karaya powder to decrease irritation
C. Increase fluid intake to compensate for the diarrhea
D. Provide meticulous skin care of the abdomen with Betadine

54. During a group therapy session, one of the clients ask a male client with the diagnosis of antisocial personality disorder why he is in the hospital. Considering this client’s type of personality disorder, the nurse might expect him to respond:

A. “I need a lot of help with my troubles”
B. “Society makes people react in old ways”
C. “I decided that it’s time I own up to my problems”
D. “My life needs straightening out and this might help”

55. A child visits the clinic for a 6-week checkup after a tonsillectomy and adenoidectomy. In addition to assessing hearing, the nurse should include an assessment of the child’s:

A. Taste and smell
B. Taste and speech
C. Swallowing and smell
D. Swallowing and speech

56. A client is diagnosed with cancer of the jaw. A course of radiation therapy is to be followed by surgery. The client is concerned about the side effects related to the radiation treaments. Nurse Ria should explain that the major side effects that will experienced is:

A. Fatigue
B. Alopecia
C. Vomiting
D. Leucopenia

57. Nurse Katrina prepares an older-adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. Targeting the most frequent cause of falls, the nurse should:

A. Offer the client assistance to the bathroom
B. Move the bedside table closer to the client’s bed
C. Encourage the client to take an available sedative
D. Assist the client to telephone the spouse to say “goodnight”

58. When evaluating a growth and development of a 6 month old infant, nurse Patty would expect the infant to be able to:

A. Sit alone, display pincer grasp, wave bye bye
B. Pull self to a standing position, release a toy by choice, play peek-a-boo
C. Crawl, transfer toy from one hand to the other, display of fear of strangers
D. Turn completely over, sit momentarily without support, reach to be picked up

59. A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. Nurse Tina should instruct the client to:

A. Manually express milk and feed it to the baby in a bottle
B. Stop breastfeeding for two days to allow the nipple to heal
C. Use a breast shield to keep the baby from direct contact with the nipple
D. Feed the baby on the unaffected breast first until the affected breast heals

60. Nurse Sandy observes that there is blood coming from the client’s ear after head injury. Nurse Sandy should:

A. Turn the client to the unaffected side
B. Cleanse the client’s ear with sterile gauze
C. Test the drainage from the client’s ear with Dextrostix
D. Place sterile cotton loosely in the external ear of the client

61. Nurse Gio plans a long term care for parents of children with sickle-cell anemia, which includes periodic group conferences. Some of the discussions should be directed towards:

A. Finding special school facilities for the child
B. Making plans for moving to a more therapeutic climate
C. Choosing a means of birth control to avoid future pregnancies
D. Airing their feelings regarding the transmission of the disease to the child

62. The central problem the nurse might face with a disturbed schizophrenic client is the client’s:

A. Suspicious feelings
B. Continuous pacing
C. Relationship with the family
D. Concern about working with others

63. When planning care with a client during the postoperative recovery period following an abdominal hysterectomy and bilateral salpingo-oophorectomy, nurse Frida should include the explanation that:

A. Surgical menopause will occur
B. Urinary retention is a common problem
C. Weight gain is expected, and dietary plan are needed
D. Depression is normal and should be expected

64. An adolescent client with anorexia nervosa refuses to eat, stating, “I’ll get too fat.” Nurse Andrea can best respond to this behavior initially by:

A. Not talking about the fact that the client is not eating
B. Stopping all of the client’s priviledges until food is eaten
C. Telling the client that tube feeding will eventually be necessary
D. Pointing out to the client that death can occur with malnutrition.

65. A pain scale is used to assess the degree of pain. The client rates the pain as an 8 on a scale of 10 before medication and a 7 on a scale of 10 after being medicated. Nurse Glenda determines that the:

A. Client has a low pain tolerance
B. Medication is not adequately effective
C. Medication has sufficiently decreased the pain level
D. Client needs more education about the use of the pain scale

66. To enhance a neonate’s behavioral development, therapeutic nursing measures should include:

A. Keeping the baby awake for longer periods of time before each feeding
B. Assisting the parents to stimulate their baby through touch, sound, and sight.
C. Encouraging parental contact for at least one 15-minute period every four hours.
D. Touching and talking to the baby at least hourly, beginning within two to four hours after birth

67. Before formulating a plan of care for a 6 year old boy with attention deficit hyperactivity disorder (ADHD), nurse Kyla is aware that the initial aim of therapy is to help the client to:

A. Develop language skills
B. Avoid his own regressive behavior
C. Mainstream into a regular class in school
D. Recognize himself as an independent person of worth

68. Nurse Wally knows that the most important aspect of the preoperative care for a child with Wilms’ tumor would be:

A. Checking the size of the child’s liver
B. Monitoring the child’s blood pressure
C. Maintaining the child in a prone position
D. Collecting the child’s urine for culture and sensitivity

69. At 11:00 pm the count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and medication administration records, no explanation can be found. The primary nurse should notify the:

A. Nursing unit manager
B. Hospital administrator
C. Quality control manager
D. Physician ordering the medication

70. When caring for the a client with a pneumothorax, who has a chest tube in place, nurse Kate should plan to:

A. Administer cough suppressants at appropriate intervals as ordered
B. Empty and measure the drainage in the collection chamber each shift
C. Apply clamps below the insertion site when ever getting the client out of bed
D. Encourage coughing, deep breathing, and range of motion to the arm on the affected side

71. According to C.E.Winslow, which of the following is the goal of Public Health?

A. For people to attain their birthrights of health and longevity
B. For promotion of health and prevention of disease
C. For people to have access to basic health services
D. For people to be organized in their health efforts

72. What other statistic may be used to determine attainment of longevity?

A. Age-specific mortality rate
B. Proportionate mortality rate
C. Swaroop’s index
D. Case fatality rate

73. Which of the following is the most prominent feature of public health nursing?

A. It involves providing home care to sick people who are not confined in the hospital
B. Services are provided free of charge to people within the catchment area.
C. The public health nurse functions as part of a team providing a public health nursing services.
D. Public health nursing focuses on preventive, not curative, services.

74. Which of the following is the mission of the Department of Health?

A. Health for all Filipinos
B. Ensure the accessibility and quality of health care
C. Improve the general health status of the population
D. Health in the hands of the Filipino people by the year 2020

75. Nurse Pauline determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating:

A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness

76. Lissa is a B.S.N. graduate. She want to become a Public Health Nurse. Where will she apply?

A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit

77. As an epidemiologist, Nurse Celeste is responsible for reporting cases of notifiable diseases. What law mandates reporting of cases of notifiable diseases?

A. Act 3573
B. R.A. 3753
C. R.A. 1054
D. R.A. 1082

78. Nurse Fay is aware that isolation of a child with measles belongs to what level of prevention?

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

79. Nurse Gina is aware that the following is an advantage of a home visit?

A. It allows the nurse to provide nursing care to a greater number of people.
B. It provides an opportunity to do first hand appraisal of the home situation.
C. It allows sharing of experiences among people with similar health problems.
D. It develops the family’s initiative in providing for health needs of its members.

80. The PHN bag is an important tool in providing nursing care during a home visit. The most important principle of bag technique states that it:

A. Should save time and effort.
B. Should minimize if not totally prevent the spread of infection.
C. Should not overshadow concern for the patient and his family.
D. May be done in a variety of ways depending on the home situation, etc.

81. Nurse Willy reads about Path Goal theory. Which of the following behaviors is manifested by the leader who uses this theory?

A. Recognizes staff for going beyond expectations by giving them citations
B. Challenges the staff to take individual accountability for their own practice
C. Admonishes staff for being laggards
D. Reminds staff about the sanctions for non performance

82. Nurse Cathy learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader?

A. Focuses on management tasks
B. Is a caretaker
C. Uses trade-offs to meet goals
D. Inspires others with vision

83. Functional nursing has some advantages, which one is an EXCEPTION?

A. Psychological and sociological needs are emphasized.
B. Great control of work activities.
C. Most economical way of delivering nursing services.
D. Workers feel secure in dependent role

84. Which of the following is the best guarantee that the patient’s priority needs are met?

A. Checking with the relative of the patient
B. Preparing a nursing care plan in collaboration with the patient
C. Consulting with the physician
D. Coordinating with other members of the team

85. Nurse Tony stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to?

A. Scalar chain
B. Discipline
C. Unity of command
D. Order

86. Nurse Joey discusses the goal of the department. Which of the following statements is a goal?

A. Increase the patient satisfaction rate
B. Eliminate the incidence of delayed administration of medications
C. Establish rapport with patients
D. Reduce response time to two minutes

87. Nurse Lou considers shifting to transformational leadership. Which of the following statements best describes this type of leadership?

A. Uses visioning as the essence of leadership
B. Serves the followers rather than being served
C. Maintains full trust and confidence in the subordinates
D. Possesses innate charisma that makes others feel good in his presence.

88. Nurse Mae tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my office later” when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use?

A. Smoothing
B. Compromise
C. Avoidance
D. Restriction

89. Nurse Bea plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?

A. Staffing
B. Scheduling
C. Recruitment
D. Induction

90. Nurse Linda tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?

A. Centralized
B. Decentralized
C. Matrix
D. Informal

91. When documenting information in a client’s medical record, the nurse should:

A. erase any errors.
B. use a #2 pencil.
C. leave one line blank before each new entry.
D. end each entry with the nurse’s signature and title.

92. Which of the following factors are major components of a client’s general background drug history?

A. Allergies and socioeconomic status
B. Urine output and allergies
C. Gastric reflex and age
D. Bowel habits and allergies

93. Which procedure or practice requires surgical asepsis?

A. Hand washing
B. Nasogastric tube irrigation
C. I.V. cannula insertion
D. Colostomy irrigation

94. The nurse is performing wound care using surgical asepsis. Which of the following practices violates surgical asepsis?

A. Holding sterile objects above the waist
B. Pouring solution onto a sterile field cloth
C. Considering a 1″ (2.5-cm) edge around the sterile field contaminated
D. Opening the outermost flap of a sterile package away from the body

95. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values,
the nurse should formulate which nursing diagnosis for this client?

A. Risk for deficient fluid volume
B. Deficient fluid volume
C. Impaired gas exchange
D. Metabolic acidosis

96. The use of larvivorous fish in malaria control is the basis for which strategy of malaria control?

A. Stream seeding
B. Stream clearing
C. Destruction of breeding places
D. Zooprophylaxis

97. In Integrated Management of Childhood Illness, severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital?

A. Mastoiditis
B. Severe dehydration
C. Severe pneumonia
D. Severe febrile disease

98. A mother brought her daughter, 4 years old, to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?

A. Inability to drink
B. High grade fever
C. Signs of severe dehydration
D. Cough for more than 30 days

99. Food fortification is one of the strategies to prevent micronutrient deficiency conditions. R.A. 8976 mandates fortification of certain food items. Which of the following is among these food items?

A. Sugar
B. Bread
C. Margarine
D. Filled milk

100. The major sign of iron deficiency anemia is pallor. What part is best examined for pallor?

A. Palms
B. Nailbeds
C. Around the lips
D. Lower conjunctival sac

This is a comprehensive examination which you can use for your Nurse Licensure Examination (NLE). This comprehensive exam ranges all topics of nursing.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers & Rationale are given below. Be sure to read them!

1. A woman in a child bearing age receives a rubella vaccination. Nurse Joy would give her which of the following instructions?

a. Refrain from eating eggs or egg products for 24 hours

b. Avoid having sexual intercourse

c. Don’t get pregnant at least 3 months

d. Avoid exposure to sun

2. Jonas who is diagnosed with encephalitis is under the treatment of Mannitol. Which of the following patient outcomes indicate to Nurse Ronald that the treatment of Mannitol has been effective for a patient that has increased intracranial pressure?

a. Increased urinary output

b. Decreased RR

c. Slowed papillary response

d. Decreased level of consciousness

3. Mary asked Nurse Maureen about the incubation period of rabies. Which statement by the Nurse Maureen is appropriate?

a. Incubation period is 6 months

b. Incubation period is 1 week

c. Incubation period is 1 month

d. Incubation period varies depending on the site of the bite

4. Which of the following should Nurse Cherry do first in taking care of a male client with rabies?

a. Encourage the patient to take a bath

b. Cover IV bottle with brown paper bag

c. Place the patient near the comfort room

d. Place the patient near the door

5. Which of the following is the screening test for dengue hemorrhagic fever?

a. Complete blood count

b. ELISA

c. Rumpel-leede test

d. Sedimentation rate

6. Mr. Dela Rosa is suspected to have malaria after a business trip in Palawan. The most important diagnostic test in malaria is:

a. WBC count

b. Urinalysis

c. ELISA

d. Peripheral blood smear

7. The Nurse supervisor is planning for patient’s assignment for the AM shift. The nurse supervisor avoids assigning which of the following staff members to a client with herpes zoster?

a. Nurse who never had chicken pox

b. Nurse who never had roseola

c. Nurse who never had german measles

d. Nurse who never had mumps

8. Clarissa is 7 weeks pregnant. Further examination revealed that she is susceptible to rubella. When would be the most appropriate for her to receive rubella immunization?

a. At once

b. During 2nd trimester

c. During 3rd trimester

d. After the delivery of the baby

9. A female child with rubella should be isolated from a:

a. 21 year old male cousin living in the same house

b. 18 year old sister who recently got married

c. 11 year old sister who had rubeola during childhood

d. 4 year old girl who lives next door

10. What is the primary prevention of leprosy?

a. Nutrition

b. Vitamins

c. BCG vaccination

d. DPT vaccination

11. A bacteria which causes diphtheria is also known as?

a. Amoeba

b. Cholera

c. Klebs-loeffler bacillus

d. Spirochete

12. Nurse Ron performed mantoux skin test today (Monday) to a male adult client. Which statement by the client indicates that he understood the instruction well?

a. I will come back later

b. I will come back next month

c. I will come back on Friday

d. I will come back on Wednesday, same time, to read the result

13. A male client had undergone Mantoux skin test. Nurse Ronald notes an 8mm area of indurations at the site of the skin test. The nurse interprets the result as:

a. Negative

b. Uncertain and needs to be repeated

c. Positive

d. Inconclusive

14. Tony will start a 6 month therapy with Isoniazid (INH). Nurse Trish plans to teach the client to:

a. Use alcohol moderately

b. Avoid vitamin supplements while o therapy

c. Incomplete intake of dairy products

d. May be discontinued if symptoms subsides

15. Which is the primary characteristic lesion of syphilis?

a. Sore eyes

b. Sore throat

c. Chancroid

d. Chancre

16. What is the fast breathing of Jana who is 3 weeks old?

a. 60 breaths per minute

b. 40 breaths per minute

c. 10 breaths per minute

d. 20 breaths per minute

17. Which of the following signs and symptoms indicate some dehydration?

a. Drinks eagerly

b. Restless and irritable

c. Unconscious

d. A and B

18. What is the first line for dysentery?

a. Amoxicillin

b. Tetracycline

c. Cefalexin

d. Cotrimoxazole

19. In home made oresol, what is the ratio of salt and sugar if you want to prepare with 1 liter of water?

a. 1 tbsp. salt and 8 tbsp. sugar

b. 1 tbsp. salt and 8 tsp. sugar

c. 1 tsp. salt and 8 tsp. sugar

d. 8 tsp. salt and 8 tsp. sugar

20. Gentian Violet is used for:

a. Wound

b. Umbilical infections

c. Ear infections

d. Burn

21. Which of the following is a live attenuated bacterial vaccine?

a. BCG

b. OPV

c. Measles

d. None of the above

22. EPI is based on?

a. Basic health services

b. Scope of community affected

c. Epidemiological situation

d. Research studies

23. TT? provides how many percentage of protection against tetanus?

a. 100

b. 99

c. 80

d. 90

24. Temperature of refrigerator to maintain potency of measles and OPV vaccine is:

a. -3c to -8c

b. -15c to -25c

c. +15c to +25c

d. +3c to +8c

25. Diptheria is a:

a. Bacterial toxin

b. Killed bacteria

c. Live attenuated

d. Plasma derivatives

26. Budgeting is under in which part of management process?

a. Directing

b. Controlling

c. Organizing

d. Planning

27. Time table showing planned work days and shifts of nursing personnel is:

a. Staffing

b. Schedule

c. Scheduling

d. Planning

28. A force within an individual that influences the strength of behavior?

a. Motivation

b. Envy

c. Reward

d. Self-esteem

29. “To be the leading hospital in the Philippines” is best illustrate in:

a. Mission

b. Philosophy

c. Vision

d. Objective

30. It is the professionally desired norms against which a staff performance will be compared?

a. Job descriptions

b. Survey

c. Flow chart

d. Standards

31. Reprimanding a staff nurse for work that is done incorrectly is an example of what type of reinforcement?

a. Feedback

b. Positive reinforcement

c. Performance appraisal

d. Negative reinforcement

32. Questions that are answerable only by choosing an option from a set of given alternatives are known as?

a. Survey

b. Close ended

c. Questionnaire

d. Demographic

33. A researcher that makes a generalization based on observations of an individuals behavior is said to be which type of reasoning:

a. Inductive

b. Logical

c. Illogical

d. Deductive

34. The balance of a research’s benefit vs. its risks to the subject is:

a. Analysis

b. Risk-benefit ratio

c. Percentile

d. Maximum risk

35. An individual/object that belongs to a general population is a/an:

a. Element

b. Subject

c. Respondent

d. Author

36. An illustration that shows how the members of an organization are connected:

a. Flowchart

b. Bar graph

c. Organizational chart

d. Line graph

37. The first college of nursing that was established in the Philippines is:

a. Fatima University

b. Far Eastern University

c. University of the East

d. University of Sto. Tomas

38. Florence nightingale is born on:

a. France

b. Britain

c. U.S

d. Italy

39. Objective data is also called:

a. Covert

b. Overt

c. Inference

d. Evaluation

40. An example of subjective data is:

a. Size of wounds

b. VS

c. Lethargy

d. The statement of patient “My hand is painful”

41. What is the best position in palpating the breast?

a. Trendelenburg

b. Side lying

c. Supine

d. Lithotomy

42. When is the best time in performing breast self examination?

a. 7 days after menstrual period

b. 7 days before menstrual period

c. 5 days after menstrual period

d. 5 days before menstrual period

43. Which of the following should be given the highest priority before performing physical examination to a patient?

a. Preparation of the room

b. Preparation of the patient

c. Preparation of the nurse

d. Preparation of environment

44. It is a flip over card usually kept in portable file at nursing station.

a. Nursing care plan

b. Medicine and treatment record

c. Kardex

d. TPR sheet

45. Jose has undergone thoracentesis. The nurse in charge is aware that the best position for Jose is:

a. Semi fowlers

b. Low fowlers

c. Side lying, unaffected side

d. Side lying, affected side

46. The degree of patients abdominal distension may be determined by:

a. Auscultation

b. Palpation

c. Inspection

d. Percussion

47. A male client is addicted with hallucinogen. Which physiologic effect should the nurse expect?

a. Bradyprea

b. Bradycardia

c. Constricted pupils

d. Dilated pupils

48. Tristan a 4 year old boy has suffered from full thickness burns of the face, chest and neck. What will be the priority nursing diagnosis?

a. Ineffective airway clearance related to edema

b. Impaired mobility related to pain

c. Impaired urinary elimination related to fluid loss

d. Risk for infection related to epidermal disruption

49. In assessing a client’s incision 1 day after the surgery, Nurse Betty expect to see which of the following as signs of a local inflammatory response?

a. Greenish discharge

b. Brown exudates at incision edges

c. Pallor around sutures

d. Redness and warmth

50. Nurse Ronald is aware that the amiotic fluid in the third trimester weighs approximately:

a. 2 kilograms

b. 1 kilograms

c. 100 grams

d. 1.5 kilograms

51. After delivery of a baby girl. Nurse Gina examines the umbilical cord and expects to find a cord to:

a. Two arteries and two veins

b. One artery and one vein

c. Two arteries and one vein

d. One artery and two veins

52. Myrna a pregnant client reports that her last menstrual cycle is July 11, her expected date of birth is

a. November 4

b. November 11

c. April 4

d. April 18

53. Which of the following is not a good source of iron?

a. Butter

b. Pechay

c. Grains

d. Beef

54. Maureen is admitted with a diagnosis of ectopic pregnancy. Which of the following would you anticipate?

a. NPO

b. Bed rest

c. Immediate surgery

d. Enema

55. Gina a postpartum client is diagnosed with endometritis. Which position would you expect to place her based on this diagnosis?

a. Supine

b. Left side lying

c. Trendelinburg

d. Semi-fowlers

56. Nurse Hazel knows that Myrna understands her condition well when she remarks that urinary frequency is caused by:

a. Pressure caused by the ascending uterus

b. Water intake of 3L a day

c. Effect of cold weather

d. Increase intake of fruits and vegetables

57. How many ml of blood is loss during the first 24 hours post delivery of Myrna?

a. 100

b. 500

c. 200

d. 400

58. Which of the following hormones stimulates the secretion of milk?

a. Progesterone

b. Prolactin

c. Oxytocin

d. Estrogen

59. Nurse Carla is aware that Myla’s second stage of labor is beginning when the following assessment is noted:

a. Bay of water is broken

b. Contractions are regular

c. Cervix is completely dilated

d. Presence of bloody show

60. The leaking fluid is tested with nitrazine paper. Nurse Kelly confirms that the client’s membrane have ruptures when the paper turns into a:

a. Pink

b. Violet

c. Green

d. Blue

61. After amniotomy, the priority nursing action is:

a. Document the color and consistency of amniotic fluid

b. Listen the fetal heart tone

c. Position the mother in her left side

d. Let the mother rest

62. Which is the most frequent reason for postpartum hemorrhage?

a. Perineal lacerations

b. Frequent internal examination (IE)

c. CS

d. Uterine atomy

63. On 2nd postpartum day, which height would you expect to find the fundus in a woman who has had a caesarian birth?

a. 1 finger above umbilicus

b. 2 fingers above umbilicus

c. 2 fingers below umbilicus

d. 1 finger below umbilicus

64. Which of the following criteria allows Nurse Kris to perform home deliveries?

a. Normal findings during assessment

b. Previous CS

c. Diabetes history

d. Hypertensive history

65. Nurse Carla is aware that one of the following vaccines is done by intramuscular (IM) injection?

a. Measles

b. OPV

c. BCG

d. Tetanus toxoid

66. Asin law is on which legal basis:

a. RA 8860

b. RA 2777

c. RI 8172

d. RR 6610

67. Nurse John is aware that the herbal medicine appropriate for urolithiasis is:

a. Akapulco

b. Sambong

c. Tsaang gubat

d. Bayabas

68. Community/Public health bag is defined as:

a. An essential and indispensable equipment of the community health nurse during home visit

b. It contains drugs and equipment used by the community health nurse

c. Is a requirement in the health center and for home visit

d. It is a tool used by the community health nurse in rendering effective procedures during home visit

69. TT4 provides how many percentage of protection against tetanus?

a. 70

b. 80

c. 90

d. 99

70. Third postpartum visit must be done by public health nurse:

a. Within 24 hours after delivery

b. After 2-4 weeks

c. Within 1 week

d. After 2 months

71. Nurse Candy is aware that the family planning method that may give 98% protection to another pregnancy to women

a. Pills

b. Tubal ligation

c. Lactational Amenorrhea method (LAM)

d. IUD

72. Which of the following is not a part of IMCI case management process

a. Counsel the mother

b. Identify the illness

c. Assess the child

d. Treat the child

73. If a young child has pneumonia when should the mother bring him back for follow up?

a. After 2 days

b. In the afternoon

c. After 4 days

d. After 5 days

74. It is the certification recognition program that develop and promotes standard for health facilities:

a. Formula

b. Tutok gamutan

c. Sentrong program movement

d. Sentrong sigla movement

75. Baby Marie was born May 23, 1984. Nurse John will expect finger thumb opposition on:

a. April 1985

b. February 1985

c. March 1985

d. June 1985

76. Baby Reese is a 12 month old child. Nurse Oliver would anticipate how many teeth?

a. 9

b. 7

c. 8

d. 6

77. Which of the following is the primary antidote for Tylenol poisoning?

a. Narcan

b. Digoxin

c. Acetylcysteine

d. Flumazenil

78. A male child has an intelligence quotient of approximately 40. Which kind of environment and interdisciplinary program most likely to benefit this child would be best described as:

a. Habit training

b. Sheltered workshop

c. Custodial

d. Educational

79. Nurse Judy is aware that following condition would reflect presence of congenital G.I anomaly?

a. Cord prolapse

b. Polyhydramios

c. Placenta previa

d. Oligohydramios

80. Nurse Christine provides health teaching for the parents of a child diagnosed with celiac disease. Nurse Christine teaches the parents to include which of the following food items in the child’s diet:

a. Rye toast

b. Oatmeal

c. White bread

d. Rice

81. Nurse Randy is planning to administer oral medication to a 3 year old child. Nurse Randy is aware that the best way to proceed is by:

a. “Would you like to drink your medicine?”

b. “If you take your medicine now, I’ll give you lollipop”

c. “See the other boy took his medicine? Now it’s your turn.”

d. “Here’s your medicine. Would you like a mango or orange juice?”

82. At what age a child can brush her teeth without help?

a. 6 years

b. 7 years

c. 5 years

d. 8 years

83. Ribivarin (Virazole) is prescribed for a female hospitalized child with RSV. Nurse Judy prepare this medication via which route?

a. Intra venous

b. Oral

c. Oxygen tent

d. Subcutaneous

84. The present chairman of the Board of Nursing in the Philippines is:

a. Maria Joanna Cervantes

b. Carmencita Abaquin

c. Leonor Rosero

d. Primitiva Paquic

85. The obligation to maintain efficient ethical standards in the practice of nursing belong to this body:

a. BON

b. ANSAP

c. PNA

d. RN

86. A male nurse was found guilty of negligence. His license was revoked. Re-issuance of revoked certificates is after how many years?

a. 1 year

b. 2 years

c. 3 years

d. 4 years

87. Which of the following information cannot be seen in the PRC identification card?

a. Registration Date

b. License Number

c. Date of Application

d. Signature of PRC chairperson

88. Breastfeeding is being enforced by milk code or:

a. EO 51

b. R.A. 7600

c. R.A. 6700

d. P.D. 996

89. Self governance, ability to choose or carry out decision without undue pressure or coercion from anyone:

a. Veracity

b. Autonomy

c. Fidelity

d. Beneficence

90. A male patient complained because his scheduled surgery was cancelled because of earthquake. The hospital personnel may be excused because of:

a. Governance

b. Respondent superior

c. Force majeure

d. Res ipsa loquitor

91. Being on time, meeting deadlines and completing all scheduled duties is what virtue?

a. Fidelity

b. Autonomy

c. Veracity

d. Confidentiality

92. This quality is being demonstrated by Nurse Ron who raises the side rails of a confused and disoriented patient?

a. Responsibility

b. Resourcefulness

c. Autonomy

d. Prudence

93. Which of the following is formal continuing education?

a. Conference

b. Enrollment in graduate school

c. Refresher course

d. Seminar

94. The BSN curriculum prepares the graduates to become?

a. Nurse generalist

b. Nurse specialist

c. Primary health nurse

d. Clinical instructor

95. Disposal of medical records in government hospital/institutions must be done in close coordination with what agency?

a. Department of Health

b. Records Management Archives Office

c. Metro Manila Development Authority

d. Bureau of Internal Revenue

96. Nurse Jolina must see to it that the written consent of mentally ill patients must be taken from:

a. Nurse

b. Priest

c. Family lawyer

d. Parents/legal guardians

97. When Nurse Clarence respects the client’s self-disclosure, this is a gauge for the nurses’

a. Respectfulness

b. Loyalty

c. Trustworthiness

d. Professionalism

98. The Nurse is aware that the following tasks can be safely delegated by the nurse to a non-nurse health worker except:

a. Taking vital signs

b. Change IV infusions

c. Transferring the client from bed to chair

d. Irrigation of NGT

99. During the evening round Nurse Tina saw Mr. Toralba meditating and afterwards started singing prayerful hymns. What would be the best response of Nurse Tina?

a. Call the attention of the client and encourage to sleep

b. Report the incidence to head nurse

c. Respect the client’s action

d. Document the situation

100. In caring for a dying client, you should perform which of the following activities

a. Do not resuscitate

b. Assist client to perform ADL

c. Encourage to exercise

d. Assist client towards a peaceful death

101. The Nurse is aware that the ability to enter into the life of another person and perceive his current feelings and their meaning is known:

a. Belongingness

b. Genuineness

c. Empathy

d. Respect

102. The termination phase of the NPR is best described one of the following:

a. Review progress of therapy and attainment of goals

b. Exploring the client’s thoughts, feelings and concerns

c. Identifying and solving patients problem

d. Establishing rapport

103. During the process of cocaine withdrawal, the physician orders which of the following:

a. Haloperidol (Haldol)

b. Imipramine (Tofranil)

c. Benztropine (Cogentin)

d. Diazepam (Valium)

104. The nurse is aware that cocaine is classified as:

a. Hallucinogen

b. Psycho stimulant

c. Anxiolytic

d. Narcotic

105. In community health nursing, it is the most important risk factor in the development of mental illness?

a. Separation of parents

b. Political problems

c. Poverty

d. Sexual abuse

106. All of the following are characteristics of crisis except

a. The client may become resistive and active in stopping the crisis

b. It is self-limiting for 4-6 weeks

c. It is unique in every individual

d. It may also affect the family of the client

107. Freud states that temper tantrums is observed in which of the following:

a. Oral

b. Anal

c. Phallic

d. Latency

108. The nurse is aware that ego development begins during:

a. Toddler period

b. Preschool age

c. School age

d. Infancy

109. Situation: A 19 year old nursing student has lost 36 lbs for 4 weeks. Her parents brought her to the hospital for medical evaluation. The diagnosis was ANOREXIA NERVOSA. The Primary gain of a client with anorexia nervosa is:

a. Weight loss

b. Weight gain

c. Reduce anxiety

d. Attractive appearance

110. The nurse is aware that the primary nursing diagnosis for the client is:

a. Altered nutrition : less than body requirement

b. Altered nutrition : more than body requirement

c. Impaired tissue integrity

d. Risk for malnutrition

111. After 14 days in the hospital, which finding indicates that her condition in improving?

a. She tells the nurse that she had no idea that she is thin

b. She arrives earlier than scheduled time of group therapy

c. She tells the nurse that she eat 3 times or more in a day

d. She gained 4 lbs in two weeks

112. The nurse is aware that ataractics or psychic energizers are also known as:

a. Anti manic

b. Anti depressants

c. Antipsychotics

d. Anti anxiety

113. Known as mood elevators:

a. Anti depressants

b. Antipsychotics

c. Anti manic

d. Anti anxiety

114. The priority of care for a client with Alzheimer’s disease is

a. Help client develop coping mechanism

b. Encourage to learn new hobbies and interest

c. Provide him stimulating environment

d. Simplify the environment to eliminate the need to make chores

115. Autism is diagnosed at:

a. Infancy

b. 3 years old

c. 5 years old

d. School age

116. The common characteristic of autism child is:

a. Impulsitivity

b. Self destructiveness

c. Hostility

d. Withdrawal

117. The nurse is aware that the most common indication in using ECT is:

a. Schizophrenia

b. Bipolar

c. Anorexia Nervosa

d. Depression

118. A therapy that focuses on here and now principle to promote self-acceptance?

a. Gestalt therapy

b. Cognitive therapy

c. Behavior therapy

d. Personality therapy

119. A client has many irrational thoughts. The goal of therapy is to change her:

a. Personality

b. Communication

c. Behavior

d. Cognition

120. The appropriate nutrition for Bipolar I disorder, in manic phase is:

a. Low fat, low sodium

b. Low calorie, high fat

c. Finger foods, high in calorie

d. Small frequent feedings

121. Which of the following activity would be best for a depressed client?

a. Chess

b. Basketball

c. Swimming

d. Finger painting

122. The nurse is aware that clients with severe depression, possess which defense mechanism:

a. Introjection

b. Suppression

c. Repression

d. Projection

123. Nurse John is aware that self mutilation among Bipolar disorder patients is a means of:

a. Overcoming fear of failure

b. Overcoming feeling of insecurity

c. Relieving depression

d. Relieving anxiety

124. Which of the following may cause an increase in the cystitis symptoms?

a. Water

b. Orange juice

c. Coffee

d. Mango juice

125. In caring for clients with renal calculi, which is the priority nursing intervention?

a. Record vital signs

b. Strain urine

c. Limit fluids

d. Administer analgesics as prescribed

126. In patient with renal failure, the diet should be:

a. Low protein, low sodium, low potassium

b. Low protein, high potassium

c. High carbohydrate, low protein

d. High calcium, high protein

127. Which of the following cannot be corrected by dialysis?

a. Hypernatremia

b. Hyperkalemia

c. Elevated creatinine

d. Decreased hemoglobin

128. Tony with infection is receiving antibiotic therapy. Later the client complaints of ringing in the ears. This ototoxicity is damage to:

a. 4th CN

b. 8th CN

c. 7th CN

d. 9th CN

129. Nurse Emma provides teaching to a patient with recurrent urinary tract infection includes the following:

a. Increase intake of tea, coffee and colas

b. Void every 6 hours per day

c. Void immediately after intercourse

d. Take tub bath everyday

130. Which assessment finding indicates circulatory constriction in a male client with a newly applied long leg cast?

a. Blanching or cyanosis of legs

b. Complaints of pressure or tightness

c. Inability to move toes

d. Numbness of toes

131. During acute gout attack, the nurse administer which of the following drug:

a. Prednisone (Deltasone)

b. Colchicines

c. Aspirin

d. Allopurinol (Zyloprim)

132. Information in the patients chart is inadmissible in court as evidence when:

a. The client objects to its use

b. Handwriting is not legible

c. It has too many unofficial abbreviations

d. The clients parents refuses to use it

133. Nurse Karen is revising a client plan of care. During which step of the nursing process does such revision take place?

a. Planning

b. Implementation

c. Diagnosing

d. Evaluation

134. When examining a client with abdominal pain, Nurse Hazel should assess:

a. Symptomatic quadrant either second or first

b. The symptomatic quadrant last

c. The symptomatic quadrant first

d. Any quadrant

135. How long will nurse John obtain an accurate reading of temperature via oral route?

a. 3 minutes

b. 1 minute

c. 8 minutes

d. 15 minutes

136. The one filing the criminal care against an accused party is said to be the?

a. Guilty

b. Accused

c. Plaintiff

d. Witness

137. A male client has a standing DNR order. He then suddenly stopped breathing and you are at his bedside. You would:

a. Call the physician

b. Stay with the client and do nothing

c. Call another nurse

d. Call the family

138. The ANA recognized nursing informatics heralding its establishment as a new field in nursing during what year?

a. 1994

b. 1992

c. 2000

d. 2001

139. When is the first certification of nursing informatics given?

a. 1990-1993

b. 2001-2002

c. 1994-1996

d. 2005-2008

140. The nurse is assessing a female client with possible diagnosis of osteoarthritis. The most significant risk factor for osteoarthritis is:

a. Obesity

b. Race

c. Job

d. Age

141. A male client complains of vertigo. Nurse Bea anticipates that the client may have a problem with which portion of the ear?

a. Tymphanic membranes

b. Inner ear

c. Auricle

d. External ear

142. When performing Weber’s test, Nurse Rosean expects that this client will hear

a. On unaffected side

b. Longer through bone than air conduction

c. On affected side by bone conduction

d. By neither bone or air conduction

143. Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by:

a. Kernigs sign

b. Brudzinski’s sign

c. A positive sweat chloride test

d. A positive edrophonium (Tensilon) test

144. A male client is hospitalized with Guillain-Barre Syndrome. Which assessment finding is the most significant?

a. Even, unlabored respirations

b. Soft, non distended abdomen

c. Urine output of 50 ml/hr

d. Warm skin

145. For a female client with suspected intracranial pressure (ICP), a most appropriate respiratory goal is:

a. Maintain partial pressure of arterial oxygen (Pa O2) above 80mmHg

b. Promote elimination of carbon dioxide

c. Lower the PH

d. Prevent respiratory alkalosis

146. Which nursing assessment would identify the earliest sign of ICP?

a. Change in level of consciousness

b. Temperature of over 103°F

c. Widening pulse pressure

d. Unequal pupils

147. The greatest danger of an uncorrected atrial fibrillation for a male patient will be which of the following:

a. Pulmonary embolism

b. Cardiac arrest

c. Thrombus formation

d. Myocardial infarction

148. Linda, A 30 year old post hysterectomy client has visited the health center. She inquired about BSE and asked the nurse when BSE should be performed. You answered that the BSE is best performed:

a. 7 days after menstruation

b. At the same day each month

c. During menstruation

d. Before menstruation

149. An infant is ordered to recive 500 ml of D5NSS for 24 hours. The Intravenous drip is running at 60 gtts/min. How many drops per minute should the flow rate be?

a. 60 gtts/min.

b. 21 gtts/min

c. 30 gtts/min

d. 15 gtts/min

150. Mr. Gutierrez is to receive 1 liter of D5RL to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately how many drops per minutes should the IV be regulated?

a. 13-14 drops

b. 17-18 drops

c. 10-12 drops

d. 15-16 drops

NURSING DIAGNOSIS: Cardiac Output, decreased

May be related to

• Altered myocardial contractility/inotropic changes
• Alterations in rate, rhythm, electrical conduction
• Structural changes (e.g., valvular defects, ventricular aneurysm)

Possibly evidenced by

• Increased heart rate (tachycardia), dysrhythmias, ECG changes
• Changes in BP (hypotension/hypertension)
• Extra heart sounds (S₃, S₄)
• Decreased urine output
• Diminished peripheral pulses
• Cool, ashen skin; diaphoresis
• Orthopnea, crackles, JVD, liver engorgement, edema
• Chest pain

Desired Outcomes

Cardiac Pump Effectiveness (NOC)

• Display vital signs within acceptable limits, dysrhythmias absent/controlled,and no symptoms of failure (e.g., hemodynamic parameters within acceptable limits, urinary output adequate).
• Report decreased episodes of dyspnea, angina.
• Participate in activities that reduce cardiac workload.

Decreased Cardiac Output — Heart Failure (CHF) Nursing Care Plan (NCP): Nursing Interventions & Rationale

This post contains 6 Heart Failure Nursing Care Plan (NCP) (NCPs). These Nursing Care Plan (NCP) are free to use and are suited for patients with Heart Failure.

Failure of the left and/or right chambers of the heart results in insufficient output to meet tissue needs and causes pulmonary and systemic vascular congestion. This disease condition is termedheart failure (HF). Despite diagnostic and therapeutic advances, HF continues to be associated with high morbidity and mortality.  This is a nursing care plan for Heart Failure.

Heart Failure Nursing Priorities

1. Improve myocardial contractility/systemic perfusion.
2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

Heart Failure Discharge Goals

1. Cardiac output adequate for individual needs.
2. Complications prevented/resolved.
3. Optimum level of activity/functioning attained.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

6 Heart Failure Nursing Care Plan (NCP)

1. Decreased Cardiac Output — Heart Failure (CHF) Nursing Care Plan (NCP)
2. Activity Intolerance — Heart Failure (CHF) Nursing Care Plan (NCP)
3. Excess Fluid Volume — Heart Failure (CHF) Nursing Care Plan (NCP)
4. Impaired Gas Exchange — Heart Failure (CHF) Nursing Care Plan (NCP)
5. Impaired Skin Integrity — Heart Failure (CHF) Nursing Care Plan (NCP)
6. Knowledge Deficit — Heart Failure (CHF) Nursing Care Plan (NCP)

Other Nursing Care Plan (NCP) for Heart Failure

1. Activity intolerance—poor cardiac reserve, side effects of medication, generalized weakness.
2. Fluid Volume excess or deficient—changes in glomerular filtration rate, diuretic use, individual fluid/salt intake.
3. Skin Integrity, impaired—decreased activity level, prolonged sitting, presence of edema, altered circulation.
4. Therapeutic Regimen: ineffective management—complexity of regimen, economic limitations.
5. Home Maintenance, impaired—chronic/debilitating condition, insufficient finances, inadequate support systems.
6. Self-Care deficit—decreased strength/endurance, depression.

Diagnostic Studies

• ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias, e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular contractions (PVCs) may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present.
• Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may suggest ventricular aneurysm.
• Sonograms (echocardiogram, Doppler and transesophageal echocardiogram): May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
• Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion.
• Exercise or pharmacological stress myocardial perfusion (e.g., Persantine or Thallium scan):Determines presence of myocardial ischemia and wall motion abnormalities.
• Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium.
• Cardiac catheterization: Abnormal pressures are indicative and help differentiate right- versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected into the ventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsy may be useful in some patients to determine the underlying disorder, such as myocarditis or amylodosis.
• Liver enzymes: Elevated in liver congestion/failure.
• Digoxin and other cardiac drug levels: Determine therapeutic range and correlate with patient response.
• Bleeding and clotting times: Determine therapeutic range; identify those at risk for excessive clot formation.
• Electrolytes: May be altered because of fluid shifts/decreased renal function, diuretic therapy.
• Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.
• Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased Pco₂ (late).
• BUN/creatinine: Elevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is indicative of renal failure.
• Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis in congested liver.
• Complete blood count (CBC): May reveal anemia, polycythemia, or dilutional changes indicating water retention. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.
• ESR: May be elevated, indicating acute inflammatory reaction.
• Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF.

Review the concepts of Medical-Surgical Nursing with this 100-item comprehensive examination about Medical-Surgical Nursing. This is part 1 of 3.

Guidelines

• This is a 100-item examination about Medical-Surgical Nursing.
• Rationales and answers are given below.
• You are given 1 minute and 20 seconds each question. A total of 2 hours for this 100-item exam.

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

1. As a registered nurse, Devon 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. Devon 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. Devon noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to

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

4. The old woman told Devon that she has osteoporosis; Devon 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. 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 the old woman 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. Roxas, an obese 35 year old MS Professor is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.

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

A. one (1) inches in front of the foot.
B. three (3) inches at the lateral side of the foot.
c. six (6) inches at the lateral side of the foot.
D. twelve (12) inches at the lateral side of the foot.

8. Mr. Roxas 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 observed that Mr. Roxas uses 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 tuberculosis 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: Marvin, A male patient diagnosed with colon cancer was newly put in colostomy.

22. Marvin 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 Marvin 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, Marvin 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 Marvin’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. Marvin 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 Marvin 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 Marvin’s stoma should be

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

SITUATION: John Lloyd, 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 John Lloyd. Which of the following, if made by Wilma indicates that she is committing an error?

A. Hyperventilating John Lloyd 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 John Lloyd, 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 John Lloyd 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 John Lloyd?

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 John Lloyd’ neck. What are the two (2) equipments at John Lloyd’s 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. John Lloyd’ 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 John Lloyd have an adequate respiratory condition if she notices that

A. John Lloyd’ respiratory rate is 18
B. John Lloyd’ 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 John Lloyd is

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

SITUATION : John Smith 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. Smith. 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. Smith 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. Smith’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. Smith, 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. Smith 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. Smith 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 :  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 0.5kg, 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 0.5kg?

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 prophantheline 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. Francisco, 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. Francisco?

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. Francisco’s conditions, which of the following is most important to include in preparing Francisco’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. Francisco 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. Francisco’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