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SITUATION 1:
nursing unit.

The nurse is admitting a client with lung cancer to the

1. The nurse assesses for which most common risk factor for this type of cancer?
a. Use of chewing tobacco
c. Urban Living
b. Cigarette smoking
d. Alcohol Abuse
2. The nurse is preparing a client for surgery and notices that the client looks sad.
The client says, I am scared of having cancer. Its so horrible and I brought it on
myself. I should have quit smoking years ago. What would be the nurses BEST
response to the client?
a. Do you feel guilty because you smoked?
b. Dont be so hard on you. You dont know if your smoking caused the cancer.
c. Its normal to be scared. I would be, too. Well help you through it.
d. Its okay to be scared. What is it about cancer that youre afraid of?
3. The patient underwent a left lower lobectomy. He has been out of surgery for 48
hours. She is receiving morphine sulfate via a patient-controlled analgesia (PCA)
system. She complains of moderately severe pain in her left thorax that worsens
when she coughs. The nurse should:
a. Let the client rest, so that she is not stimulated to cough.
b. Encourage the client to take deep breaths to help control the pain.
c. Check the PCA device is functioning properly, and then reassure the client that
the machine is
working and will relieve her pain.
d. Assess the pain systematically with the hospital approved scale
4. The client asks, Why do I need to receive all these chemotherapy medicines on
the same day? The nurses response is based on the understanding that
chemotherapy given in combination:
a. Is the only way it will be paid for by insurance.
b. Achieves the greatest tumor cell kill.
c. Shortens the length of administration.
d. Decreases the chance of allergic reaction
5. Which of the following would be a major intervention to help prevent lung cancer?
a. Encourage cigarette smokers to have yearly chest radiographs.
b. Instruct people about techniques for smoking cessation.
c. Recommend that people have their houses and apartments checked for asbestos
leakage.
d. Encourage people to install central air cleaners in their homes.

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SITUATION 2: You are the nurse in the clinic and is often asked about the
prevention, screening and treatment of breast cancer.
6. A 20 year old G2P2 who breastfeeds her two months old baby worries that an
indistinct, smooth, movable, painful 2 x 1 cm mass in her left breast is cancer. No
lymph nodes are palpable. You should:
a. Tell her not to worry and reassure her it is not cancer
b. Refer to oncologist
c. Reassure her that cancer is unlikely but repeat breast examination after 1 month
d. Suggest to her to consult a surgeon to do excision biopsy.
7. Cancer is a name for a large group of diseases all of which are characterized by:
a. Cells that multiplies rapidly, invading and destroying normal tissues
b. Death in a high percentage of cases
c. A course of treatment lasting 4 5 years
d. Production of a toxin that causes a spread of abnormal tissues
8. A 45 year old client weighing 66 kilograms approached you asking you about the
significance of diet in the prevention of CA. The best response of the nurse would
be:
a. Dietary regimen does not play an important factor in developing CA
b. Incidence of CA decreases to those who practice weight control and reduces
intake of fats.
c. Increasing consumption of high caloric intake does not affect its development.
d. Age and weight is not a significant factor in the development of CA.
9. During the initial stage of adaptation to cancer and its treatment, the nurse can
facilitate the
clients adaptation by:
a. Encouraging the client to maintain her usual role
b. Facilitating family-related disagreements and conflicts
c. Supporting the client in her use of denial as a coping strategy
d. Arranging transportation and child care on treatment days
10. While being educated by the nurse about how to perform breast self-exam, a
client asks the nurse what the rationale is for moving her arms in different positions
while standing in front of a mirror. The nurse explains that these positions are used
to:
a. Increase the examiners comfort during the procedure
b. Easily diagnose any masses
c. Emphasize any change in shape or contour of the breast
d. Determine whether there is any nipple discharge with movement
SITUATION 3: Nurse Alden is in the clinic and is often asked about the
prevention, screening and treatment of different disease.
11. Nurse Alden has taught a family about then prevention of Lyme disease. Which
of the following members indicates the family understands the instructions?

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a. Applying an insect repellant to pets
b. Leaving a tick attached to the skin until examined by a healthcare provider
c. Checking for the presence of ticks after outdoor activities
d. Wearing clothing that exposes the maximum amount of skin
12. Which of the following conditions would a nurse expect when assessing a
patient who has right-sided heart failure?
a. Peripheral Edema
b. Shortness of breath
c. Decreased urinary output
d. Paroxysmal nocturnal dyspnea
13. A patient who has is admitted to the hospital with a productive cough. Which of
the following actions should a Nurse Alden carry out FIRST?
a. Obtain a sputum specimen
b. Obtain a portable chest xray
c. Administer cefoxin sodium 500 mg every 8h via IV
d. Administer guaifenesin with codeine 30 ml, po, every 4h prn
14. The teaching plan for a child who is taking long term corticosteroid therapy
would include which of the following instructions?
a. Regular appointments with a registered dietician to prevent malnutrition
b. Eye examinations yearly to assess for cataract formation
c. Regular physical therapy session to prevent muscular hypertrophy
d. Dental check up every three months to assess for gingival hyperplasia
15. Nurse Alden would expect a patient who has a cataract to report which of the
following symptoms?
a. Headache
b. Loss of peripheral vision
c. Halos around lights
d. Decrease color perception
SITUATION: The BSN 4A students just finished their lecture class on
Emergency nursing. They are getting ready for their exposure at ER the
following week.
16. A patient is brought to the ER after ingesting cocaine. During the patient
assessment, Student nurse May would expect to observe which of the following
signs?
a. Ataxia and bradycardia
b. Nystagmus and paresthesia
c. Constricted pupils and lethargy
d. Tachycardia an and chestpain
17. A patient who has undergone a thyroidectomy would be predisposed to the
development of
a. Hypermagnesia
b. Hyperkalemia
c. Hyponatremia

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d. Hypocalcemia
18. Which of the following assessment techniques should a nurse use to determine
the appropriate placement of NGT?
a. Palpating over the epigastric region
b. Auscultating for bowel sounds
c. Aspirating drainage through NGT
d. Inserting the open end of the NGT into water
19. An elderly client who lives alone is admitted to the ER he experiencing syncopal
event. Serum levels albumin are found to be 2.0 g/dL. Which of the following
nursing diagnoses is a PRIORITY for this patient?
a. Potential alteration in skin integrity
b. Potential alteration in mobility
c. Potential alteration in elimination
d. Potential alteration in comfort
20. Nurse May would advise a patient to take a diuretic
a. After lunch
b. With the evening meal
c. At bedtime
d. In the early morning
SITUATION: Nurse Bitoy is caring for a client with diabetes mellitus
admitted at Bicol Medical Hospital.
21. A patient who has type 1 diabetes experience weakness and tremors. Which of
the following action would a Nurse Bitoy take FIRST?
a. Administering the patients prn dose of insulin
b. Checking the patients most recent blood glucose level
c. Obtaining a urine specimen from the patient
d. Giving the patient a concentrated source of glucose
22. A patient who has type 1 diabetes mellitus is taking NPH insulin injection. Nurse
Bitoy should advise the patient to be alert for symptoms of hypoglycemia at which
of the following times after insulin administration?
a. Two hours
b. Four hours
c. Eight hours
d. 20 hours
23. Which of the following manifestations MOST LIKELY indicates complications in a
patient who has chronic diabetes mellitus?
a. Diminished olfactory sensation
b. Increased deep tendon reflexes
c. Decrease peripheral sensation
d. Enhanced calcium excretion

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24. A patient with diabetes mellitus had as sister who died of diabetic ketoacidosis.
Patient asks the nurse bitoy for information about her disease. Nurse bitoy should
recognize that the patient is:
a. Exhibiting readiness for learning
b. Expressing her attitudes through her behavior
c. Too upset to learn new information
d. Transferring attitudes about her disease
25. A Nurse should assess a postoperative patient for which of the following early
manifestations of hypovolemic shock
a. Hypotensiom
b. Restlesssness
c. Oliguria
d. Dyspnea
26. A Nurse would assess a patient who has undergone a lumbar laminectomy for
which of the following post-surgical complications?
a. Deep vein thrombosis
b. Urinary frequency
c. Intermittent Claudication
d. Flank pain
SITUATION: Nurse Rihanna is caring for with Acquired Immune deficiency
(AIDS).
27. Nurse Rihanna would correctly evaluate the effectiveness of megatsrol acetate
in patient with AIDS by documenting
a. Control of seizures
b. A decrease in diarrhea
c. In increase in appetite
d. Improve coordination
28. When assessing a patient who has AIDS, which of the following signs and
symptoms would be MOST indicative of AIDS dementia complex?
a. Headaches
b. Diarrhea
c. Unsteady gait
d. Bronchial infection
29. Which of the following measures would a nurse take with the newborn of a
mother who is positive for the HIV?
a. Allow rooming-in with the mother if the newborn is stable
b. Encourage the newborn to breast-feed in order to boost immunity.
c. Restrict newborn visitation to minimize the spread of infection
d. Avoid skin to skin contact with the mother until after the newborns initial bath
30. Nurse Rihanna has taught a patient who is newly diagnosed with the HIV about
the like hood for development of a acquired immune deficiency syndrome (AIDS).
Which of the following statements indicates that the patient has understood the
instruction?

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a. I can expect to develop AIDS in a short time
b. I can expect to remain healthy for a number years
c. Can expect that I will recover fully from this infection
d. Can expect that the course of AIDS will be predictable
31. When teaching a patient who has recently tested positive for the HIV, a nurse
would emphasize the importance of
a. Separating the patients utensils from those others
b. Avoiding unprotected sexual encounters
c. Minimizing exposure to sunlight
d. Limiting close contact with children
SITUATION: Nurse Audrey is caring for a client name Jerome Ching with a
sucking stab wound of the left thorax.
32. Nurse Audrey should position the Client
a. On the left side with head elevated
b. In a high-fowlers position with the left side supported
c. On the back with the feet elevated
d. On the right sides flat in bed with a pillow supporting the left arm
33. When assessing to Jerome, Nurse Audrey should be concerned PRIMARILY with
the
a. Blood Pressure and pupillary response
b. Degree and level of pain
c. Quality and depth of respirations
d. Amount of serosanguineous drainage
34. Jerome Ching with a sucking chest wound has a large pressure dressing over the
site. Nurse Audrey recognizes the purpose of this dressing is to:
a. Seal off major vessels
b. Prevent additional contamination
c. Protect the Pleura
d. Maintain negative intrathoracic pressure
35. Jerome are encouraged to perform deep breathing exercises after surgery. The
reason for this is that deep breathing exercises help to:
a. Increase blood volume
b. Expand the residual volume
c. Counteract respiratory acidosis
d. Decrease partial pressure of oxygen
36. Jerome complains of severe pain 2 days following surgery. Nurse Audrey initials
action SHOULD be:
a. Administer prn analgesic
b. Have the client rest
c. Determine when the last analgesic was given
d. Take the clients vital signs

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SITUATION: Nurse Bornok is caring for Ms. Urzula Bokbokova admitted

with sudden chest pain.
37. Ms. Bokbokova with a coronary occlusion is experiencing chest pain and
distress. Nurse bornok should administer oxygen:
a. To prevent dyspnea
b. To prevent cyanosis
c. To increase oxygen concentration to heart cells
d. To increase oxygen tension in the circulating blood
38. Nurse Bornok realizes that the pain associated with coronary occlusion is cause
by primarily by:
a. Arterial spasm
b. Ischemia of the heart muscle
c. Blocking of the coronary veins
d. Irritation of nerve endings in the cardiac plexus
39. Ms. Bokbokova asks Nurse Bornok When I get chest pain at home, how I will I
know if I should call my doctor? Nurse Bornok should teach the client to call
physician if the pain:
a. Occurs after moderate exercise
b. If is not relieved by rest or by Nitroglycerin
c. Is accompanies by mild diaphoresis
d. Radiates to the arms, neck, or jaw
40. When obtaining consent for surgery, initially Nurse Bornok should:
a. Explain the risk involved in the surgery
b. Evaluate if the clients knowledge level is sufficient to give consent
c. Witness the signature, since this is what the nurses signatures documents
d. Explain that obtaining the signature is routine for any surgery
41. Ms. Bokbokova asks nurse Bornok about the benefits that can be derived from
coronary bypass surgery. Nurse Bornok bases a response on the knowledge that:
a. Studies have consistently shown that this surgery increases an individuals life
span
b. Surgery will improve the chances of returning to gainful employment
c. This surgery significantly decreases symptoms in a large percentage of
individuals
d. Evidence substantiates that surgery can prevent progression of coronary artery
disease.
SITUATION: Ryan Cabacab, an adolescent with diabetes is brought to the
emergency room in ketoacidosis. He admits to not adhering to the diabetic
regimen.
42. As a FIRST step in attempting to help Ryan develop some understanding of the
importance of a diabetic regimen, the nurse SHOULD:

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a. Provide printed material about diabetes in teenagers
b. Allow the client to express feelings about having diabetes
c. Assume that the client has not been properly taught about diabetes
d. Impress on the parents that it is their responsibility to demonstrate
understanding
43. A need for COGNITIVE LEARNING becomes apparent when Ryan asks:
a. How do I give myself an injection?
b. What is diabetes?
c. Can I still be a cheerleader?
d. When do I test my blood for glucose?
44. When planning a menu for Ryan whose height and weight are average, the
nurse considers a meal pattern that:
a. Avoid potatoes, bread and cereal
b. Discourages substitutions on the menu pattern
c. Allows for normal growth and developmental needs
d. Limits calories to prevent weight gain
45. When teaching Ryan about diabetes and self-administration of insulin, the FIRST
step for the nurse should be to:
a. begin the teaching program at the clients level of understanding
b. Find out what the client knows about the health problem
c. Set specific and realistic short-long-term goals
d. Collect all the equipment needed to demonstrate giving an injection
46. A nurse plans an evening snack of milk, crackers, and cheese for Ryan who
requires NPH insulin. This snack provides:
a. Encouragement to stay on the diet
b. Added calories to promote weight gain
c. High-carbohydrates nourishment for immediate use
d. Nourishment to counteract late insulin activity
SITUATION: Jerico has a permanent gastrostomy tube because of the
inability to ingest food.
47. To maintain the pleasure of eating, the nurse Kristine should advise Jerico
should:
a. Chew the food prior to using it for feeding
b. Chew gum during gastrostomy tube feeding
c. Use blender to puree favorite foods
d. Feed via tube at normal mealtimes
48. When teaching self-administration of a gastrostomy tube feeding, Nurse Kristine
should advise Jerico to:
a. Maintain a supine position the entire time
b. Heat the feeding 10% above body temperature
c. Finish the feeding with water
d. Instill fluid prior to feeding to ensure that the tube is in the stomach

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49. During a tube feeding, the observation that indicates that Jerico is unable to
tolerate a continuation of the feeding would be:
a. A passage of flatus
b. A rise of formula in the tube
c. The rapid flow of the feeding
d. Epigastric tenderness
50. The advantage of gastrostomy tube feeding over a nasogastric tube feeding is
that:
a. More tube feeding mixture can be given each time
b. There is less chance of aspiration
c. The client can self-administer the feeding
d. The procedure does not require gravity
51. Nurse Kristine can prevent a major reaction to total parenteral nutrition
infusions by:
a. The slow administration of the fluid
b. Checking the vital signs every 4 hours
c. Changing the site every 24 hours
d. Recording the intake and output
52. Nurse Kristine understands that edema can caused by inadequate nutrition is
result of the:
a. ADH mechanism
b. Nitrogen balance mechanism
c. Aldosterone mechanism
d. Capillary fluid shift mechanism
SITUATION: Nurse Vhong, is caring Billy who is receiving peritoneal
dialysis.
53. Once instated in the acute care setting, peritoneal dialysis:
a. Should be discontinued if the client complains of abdominal discomfort
b. Is largely a nursing responsibility
c. May be maintained for 12 to 48 hours
d. Requires checking of vital signs every 15 minutes
54. The purpose of peritoneal dialysis:
a. Provide fluid for intracellular
b. Remove toxins and metabolic wastes
c. Clean the peritoneal membrane
d. Reestablish kidney function
55. When receiving peritoneal dialysis, Nurse Vhong should:
a. Position the client from side to side if fluids are not draining properly
b. Remove the cannula at the end of the procedure and apply a dry, sterile dressing
c. Maintain the client in a flat, supine position during the entire procedure
d. Notify the physician if there is a deficit of 200 ml in the drainage fluid

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56. Billy complains of severe respiratory difficulty, the MOST immediate nursing
action should be to:
a. Change the clients position
b. Notify the Physician
c. Drain fluid from the peritoneal cavity
d. Discontinue the treatment

57. To control uremia, Nurse Vhong should teach Billy to limit the intake of:
a. Potassium
b. Protein
c. Fluid
d. Sodium
SITUATION: Nurse Pestilyas in the Barangay of Maquito is having her
health teaching to her clients.
58. Amanda works as a keypunch operator. This would necessarily have implications
for her plan of care during pregnancy. Nurse Pestilyas should recommend that
Amanda:
a. Ask for time in the morning and afternoon to elevate her legs
b. Try to walk about every few hours during the work day
c. Tell her employer she cannot work beyond the second trimester
d. Ask for time in the morning and afternoon to obtain nourishment
59. While teaching a young primigravida about labor, Nurse Pestilyas should tell her
to come to the hospital when:
a. She has bloody show and back pressure
b. Membranes rupture or contractions are 5 to 8 minutes apart
c. Contractions are 10 to 15 minutes apart
d. Contractions are 2 to 3 minutes apart and she cannot walk about.
60. Abby is in her fourth month pregnancy. Abby asks Nurse Pestilyas how the
babys heartbeat rapid it is, Nurse Pestilyas should respond:
a. The babys heartbeat rate is normally very rapid so you neednt worry
b. The babys heart rate is usually twice the mothers pulse rate
c. The babys heartbeat is rapid to accommodate the nutritional needs
d. It is far better that the heart rate is rapid; when it is slow, there is need to worry
61. Rosana asks Nurse Pestilyas, Is it true the doctor will do an internal
examination during her first prenatal visit? Nurse Pestilyas should respond:
a. Yes an internal is done on all mothers, but it is only slightly uncomfortable
b. Are you fearful of having an internal examination done?
c. Yes, Have you ever had an internal examination done before?
d. Yes an internal examination is done on all mothers on the first visit
62. Diana asks the nurse Pestilyas when she may expect her baby. She tells the
nurse her las menstrual period was March 15. Her expected date of delivery would
be:

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a. December 24
b. January 24
c. November 24
d. October 24

SITUATION: Treatment modalities can be simply defined as methods of

treatment. These are ways in which a physician would go about treating a
condition. All of which may be brought to bear for the benefit of a client.
63. Ann is schedules for an occupational therapy group. While listening to
instructions for the group project, Ann experiences the feeling of weakness and is
unable to over the right arm. After a check of pulse and respirations, the nurse BET
response would be:
a. Exactly when did the weakness begin?
b. Is this similar to what you usually experience?
c. What emotion were you feeling before you felt the weakness?
d. Would you like to leave the group for a while?
64. The occurrence of a pattern behavior that uses physical symptoms in response
to stress can be reduced if the nurse:
a. Decrease anxiety by limiting discussion of problems with the client
b. Provides client teaching regarding medical care
c. Teaches the family how to decrease stress at home
d. Assists the client in developing new coping mechanisms
65. During a group therapy session some members accuse a client of
intellectualizing to avoid discussing feelings. The client asks if the nurse agrees with
the others. The nurse BEST response would be:
a. It seems that way to me, too
b. What is your perception of my behavior?
c. You seem to need my opinion
d. Id rather not give my personal opinion
66. Activities that would be MOST therapeutic for the hyperactive client that the
nurse should encourage include:
a. Sanding and varnishing wooden bookends
b. Carving figures out of wood
c. Lacing tooled leather wallets
d. Stenciling designs on copper sheeting
67. Which of the following patients would be benefit MOST from group therapy?
a. A patient in the second stage of dementia
b. A patient in the manic phase of a bipolar disorder
c. A patient who has positive schizophrenia
d. A patient in the working phase of major depression
SITUATION: Three day old Baby Al-en is diagnosed as having congenital hip
dysplasia is caring by Nurse May

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68. Congenital hip dysplasia is often discovered by the nurse in the newborn
nursery when the infants assessment reveals a:
a. Limitation in adduction of the leg
b. Shortening of the leg on the unaffected side
c. Depressed dance reflex
d. Asymmetry of the gluteal folds
69. Baby Al-en has spica cast applied from below the axilla to below the knee. To
prevent a serious complication that often occurs in infants in a spica cast, nurse
May teaches Baby Al-ens parents to:
a. Feed Al-en a low-calorie diet
b. Limit movement to prevent cast damage
c. Seek immediate medical care if Al-en develops a cough
d. Change Al-en a low calorie diet
70. When elevating Baby Al-ens head, Nurse May is aware that it is important to:
a. Limit position to 1 hour at a maximum
b. Raise the entire mattress and spring at the head of the bed
c. Use at least two pillows under her shoulders
d. Place folded diapers at edge of the cast
SITUATION: Manilyn Masagca, a 64 year old homemaker, is admitted
because of possible intestinal obstruction. A Cantor Tube has been
inserted and attached to suction.
71. A serious danger to which Mrs. Masagca is exposed because of intestinal suction
is excessive loss of:
a. Protein enzymes
b. Energy carbohydrates
c. Water and electrolytes
c. Vitamins and Minerals
72. Critical assessment of Mrs. Masagca includes observation for:
a. Dehydration
b. Excessive salivation
c. Edema
d. Belching
73. Mrs. Masagca is schedules for a colostomy. Her anxiety is overt and realistic.
The most effective way to help Mrs. Masagca at this point is to:
a. Encourage her to express her feelings
b. Reassure her that many people cope with this problem
c. Explain the procedure and postoperative course
d. Administer a sedative and tell her to rest
74. The primary step toward long-range goals in Mrs. Masagcas rehabilitation is
her:
a. Mastery of techniques of colostomy care
b. Knowledge of the necessary dietary modifications

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c. readiness to accept her altered body function
d. Awareness of available community resources

SITUATION: Arci Muniz an actress underwent a cholecystectomy.

75. When changing Ms. Munizs dressing the Nurse Pablo is careful not to introduce
microorganism into the surgical incision. This is an example of:
a. Surgical Asepsis
b. Wound Asepsis
c. Concurrent Asepsis
d. Medical Asepsis
76. To promote healing the large incision, Ms.Munizs physician would order daily
doses of:
a. Ascorbic acid
b. Vitamin A
c. Mephyton
d. Vitamin b12 complex
77. Following a cholecystectomy, Nurse Pablo assess for signs of respiratory
complications because the:
a. Clients resistance is lowered due to bile in the blood
b. Bloodstream is invaded by microorganisms from the biliary tract
c. Incision is in close proximity to the diaphragm
d. Length of time required for surgery is prolonged
SITUATION: Two month old Paul Lara is brought to the clinic and a
diagnosis of colic is made. Mrs. Lara appears exhausted.
78. The nurse realizes that Mrs. Lara needs helping coping with Paul and suggests
that she:
a. Provide Paul warm sweetened tea when he begins to cry
b. Arrange for some time away from Paul each day to rest
c. Sit comfortably in a quit darkened room to hold Paul when he cries
d. Give Paul a warm bath to calm him down
79. The behavior of an infant with colic is usually suggestive of:
a. Paroxysmal abdominal pain due to excessive gas
b. Inadequate peristalsis resulting in constipation
c. An allergic response to certain proteins in milk
d. A protective mechanism designed to rid the GI tract of foreign proteins
SITUATION: Nurse Celine, is caring Kenneth with trigeminal neuralgia (Tic
douloureux).
80. In planning the nursing care to Pacoi with trigeminal neuralgia, Nurse Celine
should specifically:
a. Emphasize the importance of brushing the teeth

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b. Apply iced compress to the affected area
c. Initiate of the jaw and facial muscles
d. Be alert to prevent dehydration or starvation
81. To prevent precipitating a painful attack of Pacoi with Tic douloureux Nurse
Celine should
a. Discontinue oral hygiene temporarily
b. Massage both sides of the face frequently
c. Keep the client in the prone position
d. Avoid walking swiftly past the client
82. Nurse Celine would expect a client with tic douloureux
a. Uncontrollable tremors of the eyelid
b. Unilateral muscle weakness
c. Excruciating facial and head pain
d. Multiple petechiae
83. Surgery with severing of the nerve, is performed. An unusual occurrence after
surgery would be the:
a. Development of herpes simplex
b. Loss of muscle power in the area
c. Development of crawling or tingling sensation in the area
d. Recurrence of the pain which will gradually decrease over time.
84. Nurse Celine would expect to Pacoi to demonstrate :
a. Exhaustion and fatigue due to extreme pain
b. Excessive talkativeness due to apprehension
c. Prolonged periods of sleep due to anxiety
d. Hyperactivity due to medications received
85. In discharge planning for Pacoi, Nurse Celine should counsel Pacoi to:
a. Chew food on the affected side
b. Avoid stressful situations
c. Have regular dental checkups
d. Preform facial exercises
SITUATION: Rosita a 76 year old woman is admitted to the rehabilitation
unit following a stroke. She is bedridden and aphasic. The morning after
her admission the physician orders an indwelling catheter, since she has
been incontinent during the night.
86. It is learned from the daughter that her mother had not been incontinent while
at home, and she insisted that the nurse had failed to communicate with her mother
or get consent. This is an example of:
a. A catheter inserted for the clients benefit
b. Treatment without consent of the client which is an invasion of rights
c. Inability to obtain consent for treatment because the client was aphasic
d. A treatment that does not need special consent
87. Ms. Rosita emotional responses to her illness would be MOST influenced by:

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a. Her premorbid personality
b. The location of her lesion
c. The care she is receiving
d. Her ability to understand her illness
88. In aiding Ms. Rosita to develop independence the nurse should:
a. Demonstrate ways she can regain, independence in activities
b. Establish long-range goals for the client
c. Point out her errors in performance
d. Reinforce success in tasks accomplished
89. For optimum nutrition the nurse may find that Ms. Rosita needs assistance with
her eating. To accomplish this goal, the nurse should:
a. Encourage her to participate in the feeding process
b. Request that her food be pureed
c. Have her daughter feed her every meal
d. Feed Ms. Rosita to conserve her energy

SITUATION: Nurse Betilda caring for a client who has traceheostomy tube.
90. Nurse Betilda must be sure to check the cuff of the tracheostomy tube which:
a. Must be inflated during suctioning
b. Should allow only deflated a slight air leak at the height of inspiration
c. Should create a tight seal between the trachea and the tube
d. Must remain deflated for 10 minutes every hour
91. When performing deep tracheal suctioning for a client with a tracheostomy,
Nurse Betilda should:
a. Be sure the cuff of the tracheostomy is inflated during suctioning
b. Instill Mucomyst into the tracheostomy prior to suctioning to loosen secretions
c. Hyperoxygenate the client before suctioning
d. Apply negative pressure as the catheter is being inserted
92 When a client has tracheostomy Nurse Betilda must be aware that a drug that
would be contraindicated for this person
a. Atropine
b. Chloral hydarte
c. Nalorphine
d. Pyrvinium pamoate (Povan)
93. When cleaning a tracheostomy tube that has an inner cannula Nurse Betilda
should plan to remove the inner cannula:
a. And use sterile applications to cleanse the outer cannula
b. After high volume, low pressure cuff is deflated
c. And replace it with a sterile obturator
d. In order to cleanse it with hydrogen peroxide

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94. When performing tracheostomy care, Nurse Betilda MUST:
a. Use sterile gloves during procedure
b. Place the client in the semi-fowlers position
c. Use Betadine to clean the inner cannula when it is removed
d. Monitor the clients temperature after the procedure

SITUATION: William Halosjos is admitted to the St. Joseph Hospital with a

diagnosis of bronchial asthma.
95. William experiencing difficulty of breathing because of:
a. A too rapid expulsion of air
b. An increase in the vital capacity of the lungs
c. Hyperventilation due to an anxiety reaction
d. Spasm of the bronchi which trap the air
96. Nursing Management for a client with acute episode of bronchial asthma should
be directed toward:
a. Raising mucus secretions from the chest
b. Limiting pulmonary secretions by decreasing fluid intake
c. Curing the condition permanently
d. Convincing the client that the condition is emotionally based
97. The nurse administers aminophylline via suppository to William. The purpose of
this therapy is to promote
a. Relaxation of bronchial muscles
b. Reduction of respiratory bacteria
c. evacuation of the lower bowel
d. Rest and relaxation
98. William has an IV infusion to keep vein open for emergency medications, if the
IV infiltrates the nurse should FIRST
a. Elevate the IV site
b. Attempt to flush the tube
c. Discontinue the infusion
d. Apply warm, moist soaks
99. The nurse understands that wheeze associated with asthma is thought to be:
a. Dilation of the bronchi
b. An unexpressed call for help
c. An impairment of cardiovascular function
d. An expression of hypochondriasis
100. The Physician orders daily sputum specimens to be collected from a client. It is
MOST appropriate for the nurse to collect this specimen:

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a. Before meal
b. On awakening
c. Before a respiratory treatment
d. After activity

Prepared by: JayMC