RAD MS Nursing Long Exam

* Required

Questions 1 to 50
The nurse instructs a family member how to guide a visually impaired person when ambulating
by: *
a) holding the visually impaired person by his or her nondominant arm and walking side by
side.
b) holding the nondominant hand, wrapping the arm around his or her waist, and walking
side by side.
c) allowing the visually impaired person to hold the shoulder of the helper and walk slightly
behind the helper.
d) allowing the visually impaired person to hold the helper’s arm, with the helper slightly
ahead.

When educating the client about activity level, the nurse bases the information on the
knowledge that exercise affects the body’s physiologic functioning relative to glucose usage in
which of the following ways? *
a) exercise decreases the renal threshold for glucose.
b) exercise helps avoid hypoglycemia.
c) exercise increases the use of glucose by muscles.
d) exercise stimulates insulin overproduction.

Pepper then asks the nurse if it will be okay to allow his friends to autograph his cast. Which
response would be best? *
a) “Autographing or writing on the cast in any form will harm the cast.”
b) “It will be alright for your friends to autograph the cast.”
c) “Because the cast is made of plaster, autographing can weaken the cast.”
d) “If they don’t use chalk to autograph, it is okay.”

The nurse is caring for a patient with alcoholic cirrhosis. Which of the following interventions
should be implemented by the nurse to detect development of hepatic encephalopathy? *
a) measure I&O every shift
b) frequently assess for any discoloration of the skin and sclera
c) measure abdominal girth daily
d) ask to extend his arm and fingers

A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction.
Which finding by the nurse indicates that the traction is working properly? *
a) The pins are secured within the pulley.
b) The buttocks are 15° off the bed.
c) The infant no longer complains of pain.
d) The legs are suspended in the traction.

A patient with liver cirrhosis has developed hepatic encephalopathy. Which of the following
treatment regimen is specific for this condition? *
a) IV glutamic acid
 b) Neomycin (Bleomycin) IV
c) Lactulose (Duphalac)
d) Amino acid IV

Pepper, a 16-year old patient, is admitted following fiberglass cast application for a fractured
ulna. Which finding should be reported to the doctor? *
a) Pulses rapid
b) Warm fingers
c) Pain at the site
d) Paresthesia of the fingers

The nurse has been directed to position a patient for an examination of the abdomen. She
knows to place the patient in the: *
a) supine position with the knees flexed to relax the abdominal muscles.
b) reverse Trendelenburg position to facilitate the natural propulsion of intestinal contents.
c) semi-Fowler’s position with the left leg bent to minimize pressure on the abdomen.
d) prone position with pillows positioned to alleviate pressure on the abdomen.

A nurse is preparing a plan of care for a client with diabetes mellitus and plans to instruct the
client regarding the symptoms of hypoglycemia. Which symptoms below would the nurse list
on the instruction sheet that will be given to the client? *
a) Elevated pulse, shakiness, cool clammy skin
b) Slow pulse, lethargy, warm dry skin
c) Elevated pulse, lethargy, warm dry skin
d) Slow pulse, confusion, increased urine output

The nurse is caring for a patient with cirrhosis. The patient suddenly presents confusion,
agitation and asterixis. A diagnosis of Disturbed thought processes is formulated. This is due
to: *
a) increase serum ammonia
b) massive ascites formation
c) fluid volume excess
d) portal hypertension

Usually, the first symptom associated with esophageal disease is: *

a) regurgitation of food.
b) malnutrition.
c) pain.
d) dysphagia.

A nurse is assessing the Janna’s visual acuity using the Snellen chart. The visual acuity is 20/90
and interprets it as: *
a) “What the normal eyes see at distance of 20 feet, the patient’s eyes see at a distance of
90 feet.”
b) “What the normal eyes can see at a distance of 90 feet, the patient’s eye sees at a
distance of 20 feet.”
c) “To see what the normal eye sees at a distance of 20 feet, the patient’s eyes need a
90% magnification increase.”
d) “The patient’s eyes see 20% of what adults with normal vision see at 90 feet.”
Which of the following drugs is primarily used to prevent and dissolve stones formed in the
gallbladder? *
a) Ursodeoxycholic acid
b) Cholestyramine
c) Chenodeoxycholic acid
d) Amphotericin B

A client with type 2 diabetes mellitus has blood glucose greater than 600 mg/dL and is
complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the
physician’s documentation and expects to note which of the following diagnoses? *
a) Diabetic ketoacidosis (DKA)
b) Hyperglycemic hyperosmolar non-ketotic syndrome
c) Pheochromocytoma
d) Hypoglycemia or Insulin shock

To maintain Bryant’s traction, the nurse must make certain that the child’s: *
a) Hips are slightly elevated above the bed and the legs are suspended at a right angle to
the bed
b) Hips are elevated above the level of the body on a pillow and the legs are suspended
parallel to the bed
c) Hips are resting on the bed, with the legs suspended at a right angle to the bed
d) Hips and legs are flat on the bed, with the traction positioned at the foot of the bed

Excessive eating experienced by the diabetic client is due to which of the following reasons? *
a) Increased loss of body water due to polyuria
b) Increased metabolic rate
c) Decrease production of ADH
d) Unavailability of glucose to the cells

The dumping syndrome occurs when high-carbohydrate foods are administered over a period of
less than 20 minutes. A nursing measure to prevent or minimize the dumping syndrome is to
administer the feeding: *
a) with about 100 mL of fluid to dilute the high carbohydrate concentration.
b) with the patient in semi-Fowler’s position to decrease transit time influenced by gravity.
c) by bolus to prevent continuous intestinal distension.
d) at a warm temperature to decrease peristalsis.

The physician orders oral neomycin as well as a neomycin enema for a client with cirrhosis. The
nurse understands that the purpose of this therapy is to: *
a) reduce bleeding within the intestine
b) block ammonia formation
c) prevent straining during defecation
d) reduce abdominal pressure

The nursing management of the patient with cholecystitis associated with cholelithiasis is
based on the knowledge that *
a) Meperidine (Demerol) is used in the management of colic pain.
b) gallstones once removed tend not to recur.
 c) the disorder can be successfully treated with oral bile salts that dissolve gallstones in
just a week.
d) a low-fat diet is recommended.

Which patient education is important to include about insulin administration? *

a) Draw up clear insulin first when mixing 2 types of insulin in one syringe
b) “Administer insulin straight from the refrigerator.”
c) Shake the vial of insulin vigorously before withdrawing the medication.
d) “Administer insulin after the first meal of the day.”

An emergency room nurse is reviewing the laboratory results of a client suspected of having
diabetic ketoacidosis. Which of the following laboratory results would the nurse expect to note
in this disorder? *
a) Blood pH of 7.5
b) Serum bicarbonate of 27 mEq/L
c) No ketones in the urine
d) Blood glucose level of 500 mg/dL

The patient undergoing a Weber test says that the sound is louder in her left ear. This means
that: *
a) there is a conductive hearing loss in the left ear.
b) there is a blocked ear canal in the right ear.
c) the patient has nerve damage from listening to loud music.
d) the patient has normal hearing.

Changes in the ear that occur with aging may include the following, EXCEPT: *
a) Degeneration of cells at the base of the cochlea.
b) Destruction of the cranial nerve that innervates the hearing organ.
c) Diminished ability to hear high frequency sound waves.
d) Atrophy of the tympanic membrane.

A patient who was sent home after being diagnosed of Meniere’s had a sudden attack of
vertigo. The family understood the discharge teaching if they did which of the following? *
a) Turned on the radio to divert the attention of the patient.
b) Allowed the patient to go to the washroom alone.
c) Gave the patient alcohol to put him to sleep
d) Enforced bed rest and provided a dimly lit room.

The site that provides the fastest absorption rate for regular insulin is believed to be the: *
a) Anterior thigh
b) Deltoid area
c) Gluteal site
d) Abdominal area

Which action by the nurse would best assist client with frequent hypoglycemic episodes? *
a) Examine factors with the client that may be causing frequent hypoglycemic episodes
b) Contact the local employment office to help him find another job
c) Ask the client what he does to treat his hypoglycemia
d) Ask the client if he indeed has been drinking at work
The nurse is testing the coordinated functioning of the eyes’ cranial nerves. To do this correctly,
the nurse would test the: *
a) Pupil response to light
b) Pupil response to light and accommodation
c) Corneal reflex
d) Six cardinal fields of gaze

Mr. Portier has been ordered to undergo endoscopic retrograde cholangiopancreatography

(ERCP). Which of the following organs does this diagnostic test not inspect? *
a) The liver
b) The pancreas
c) The gallbladder
d) The thymus

A nurse who is investigating a patient’s statement about duodenal pain should assess the: *
a) left lower quadrant.
b) periumbilical area, followed by right lower quadrant.
c) epigastric area and consider possible radiation of pain to the right subscapular region
d) hypogastrium in the right or left lower quadrant

On examination of a patient’s stool, the nurse suspects the presence of an upper

gastrointestinal bleed when she observes a stool that is: *
a) threaded with mucus.
b) greasy and foamy.
c) tarry and black.
d) clay-colored

Consequences of diarrhea include all of the following, except: *

a) Hyperkalemia
b) Electrolyte imbalance
c) Decreased bicarbonate
d) Acidosis

A hiatal hernia involves: *

a) an extension of the esophagus through an opening in the diaphragm.
b) a twisting of the duodenum through an opening in the diaphragm.
c) a protrusion of the upper stomach into the lower portion of the thorax.
d) an involution of the esophagus, which causes a severe stricture.

Ms. Jenkins’ physician presented surgical options for her condition and Ms. Jenkins prefers the
most radical approach because her right ear is causing her too much problem. Which of the
following surgeries is considered to be the most radical? *
a) Selective resection of the vestibular nerve.
b) Removal of the entire inner ear structures.
c) Pharmacological ablation of the vestibular hair cells.
d) Shunting of endolymphatic fluid.
A nurse is assessing the learning readiness of a client newly diagnosed with diabetes mellitus.
Which client behavior indicates to the nurse that the client is not ready to learn? *
a) The client asks if the spouse can attend the teaching session.
b) The client asks appropriate questions about what will be taught
c) The client asks for written materials about diabetes mellitus before class.
d) The client complains of fatigue whenever the nurse plans a teaching session.

Mr. Victorini has hepatitis A. Which of the following is true of this disorder? *
a) It is blood borne, causes fatigue, and has an incubation time of two to three weeks.
b) It usually is not associated with jaundice, is a DNA virus, is transmitted through blood
and body fluids, and is often caused by sharing needles during illicit drug use.
c) It is life-threatening, irreversible, and debilitating.
d) It is an RNA virus, often spread by food handlers infected with the virus, and has an
incubation time of 15 to 50 days.

Patient with celiac disease asks why malnutrition is usually accompanied by his condition. The
nurse would respond based on the knowledge that: *
a) gluten competes with the absorption of other nutrients.
b) gluten pulls water excessively from the intravascular to the gut lumen, increasing
nutrients excretion.
c) gluten attaches in the intestinal wall and damages the villi characterized by atrophy.
d) gluten-rich foods interfere with proper absorption of other vitamins and minerals.

The patient tells you that he has to hold his paper farther and farther away from his face to
read it. It has become a joke in his family about how far away he needs to hold reading
material. You tell the patient: *
a) “You may have astigmatism, and your eyes will get used to the problem.”
b) “You have myopia. Glasses will help you read.”
c) “You have presbyopia, which is a normal age-related change. Reading glasses will help
you.”
d) “You may have an eye infection that is affecting your vision. You will need an antibiotic
ointment to instill into your eyes.”

A client is taking NPH insulin daily every morning. The nurse instructs the client that the most
likely time for a hypoglycemic reaction is: *
a) 6-8 hours after injection
b) 18-24 hours after injection.
c) 2-4 hours after injection
d) 1-2 hours after injection

The liver has many complicated functions. Which of the following is the definition of
gluconeogenesis? *
a) It is the production of amino acids and bile.
b) It is the conversion of glucose to glycogen, which can be stored in preparation for times
of fasting.
c) It is the synthesis of glucose from amino acids during times of fasting.
d) It is the conversion of stored glycogen into usable glucose to meet the immediate
energy needs of the body.
The nurse performing the eye irrigation would: *
a) place the irrigating syringe directly onto the corner of the eye and allow the fluid to
move across the eye
b) have the patient tip her head up and run the irrigation fluid over the open eye.
c) not allow the patient to blink.
d) direct the irrigating fluid from the inner to the outer canthus.

A gastric analysis with stimulation that results in an excess of gastric acid being secreted could
be diagnostic of: *
a) chronic atrophic gastritis.
b) pernicious anemia.
c) gastric carcinoma.
d) duodenal ulcer.

Preparation for an appendectomy includes the following, except: *

a) Salicylates to lower an elevated temperature.
b) An intravenous infusion.
c) Prophylactic antibiotic therapy.
d) All of the above.

Increased intraocular pressure may occur as a result of: *

a) increased production of aqueous humor by the ciliary body.
b) blockage of the lacrimal canals and ducts.
c) dilation of the retinal arterioles.
d) edema of the corneal stroma.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds
heard in less than 30 seconds. She documents that the patient’s bowel sounds are: *
a) hyperactive.
b) normal.
c) none of the above.
d) hypoactive.

A patient with pancreatic cancer is admitted to the hospital for evaluation for treatment. The
patient asks the nurse to explain the Whipple procedure the surgeon has described. The
nurse’s explanation includes the information that a Whipple procedure involves: *
a) radical removal of the pancreas, duodenum, and spleen, and attaching the stomach to
the jejunum, which requires oral supplementation of pancreatic digestive enzymes and
insulin replacement therapy.
b) resection of the entire pancreas and the distal portion of the stomach, with anastomosis
of the common bile duct and stomach into the duodenum.
c) removal of part of the pancreas, part of the stomach, the duodenum, and the
gallbladder, with joining of the pancreatic duct, common bile duct, and stomach into the
jejunum.
d) creating a bypass around the obstruction caused by the tumor by joining the gallbladder
to the jejunum.

A client with diabetes mellitus has been given instructions about foot care. The client’s
statement indicate an understanding of the nurse’s instructions would be: *
 a) “I will check my feet using a mirror once a week.”
b) “I will always keep my feet dry especially in between toes.”
c) “I can go to the beach and walk along the shore barefoot.”
d) “I will soak my feet daily for 1 hour.”

Which statement is true regarding balanced skeletal traction? Balanced skeletal traction: *
a) Is used primarily to heal the fractured hips
b) Utilizes Kirschner wires
c) Requires that both legs be secured
d) Uses a Steinman pin

The nurse suspects that a patient who presents with the symptom of food “sticking” in the
lower portion of the esophagus may have the motility disorder known as: *
a) hiatal hernia.
b) achalasia.
c) gastroesophageal reflux disease.
d) diffuse spasm.

A client is suspected of having hepatitis. Which diagnostic test results will assist in confirming
this diagnosis? *
a) Elevated hemoglobin
b) Elevated serum bilirubin
c) Elevated blood urea nitrogen
d) Decreased erythrocyte sedimentation rate

The most common symptom that patients with gastrointestinal reflux disease (GERD) mention
is: *
a) odynophagia.
b) dyspepsia.
c) regurgitation
d) pyrosis.

Back

RAD MS Nursing Long Exam

* Required

Questions 51 to 100
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To
determine whether the problem is currently active, the nurse would assess the client for which
of the following most frequent symptom(s) of duodenal ulcer? *
a) Pain that is relieved by food intake
b) Weight loss
c) Nausea and vomiting
d) Pain that radiated down the right arm
The nurse is aware that the teaching about myasthenic and cholinergic crises is understood
when a client who has been diagnosed with myasthenia gravis states that a symptom common
to both is: *
a) difficulty breathing
b) diarrhea
c) salivation
d) abdominal cramping

Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is
the preferred method of feeding for your patient? *
a) Total Parenteral Nutrition
b) Nasogastric Feeding
c) Oral Liquid Supplementation
d) Partial Parenteral Nutrition

The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-
rays, the nurse should instruct the client to: *
a) administer an enema
b) take an antiemetic
c) take a laxative
d) follow a clear liquid diet

The nurse would monitor for which of the following adverse reactions to aluminum-containing
antacids such as aluminum hydroxide (Amphojel)? *
a) Fluid retention
b) Constipation
c) Diarrhea
d) GI upset

You assess a patient with Cushing’s disease. For which finding will you notify the physician
immediately? *
a) Weight gain of 1 pound since the previous day
b) +1 dependent edema in ankles and calves
c) Purple striae present on abdomen and thighs
d) Crackles bilaterally in lower lobes of lungs

A 20 year old college student was rushed to the ER of VSMMC after he fainted during their
ROTC drill. He complained of severe right iliac pain. Upon palpation of his abdomen, the
student jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Pre-anesthetic med of Demerol and atropine sulfate were ordered to : *
a) Allay anxiety and apprehension
b) Prevent vomiting
c) Reduce pain
d) Relax abdominal muscle

A 20 year old college student was rushed to the ER of VSMMC after he fainted during their
ROTC drill. He complained of severe right iliac pain. Upon palpation of his abdomen, the
student jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.
Stat appendectomy was indicated. Pre op care would include all of the following except? *
a) Skin prep of the area including the pubis
b) Remove the jewelries
c) Enema STAT
d) Consent signed by the father

When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a
nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is
the rationale for choosing this nursing diagnosis? *
a) Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation,
and rupture of the appendix.
b) The appendix may develop gangrene and rupture, especially in a middle-aged client.
c) Infection of the appendix diminishes necrotic arterial blood flow and increases venous
drainage.
d) Obstruction of the appendix may increase venous drainage and cause the appendix to
rupture.

A female adult client with a history of chronic hyperparathyroidism admits to being

noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis
of Risk for injury. To complete the nursing diagnosis statement for this client, which “related-to”
phrase should the nurse add? *
a) Related to tetany secondary to a decreased serum calcium level
b) Related to bone demineralization resulting in pathologic fractures
c) Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
d) Related to exhaustion secondary to an accelerated metabolic rate

A 38 year old woman returns from a subtotal thyroidectomy for the treatment of
hyperthyroidism. Upon assessment, the immediate priority that the nurse would include is: *
a) Assess for neurological status
b) Assess for respiratory distress
c) Assess fluid volume status
d) Assess for pain

A client who has had a retinal detachment has a scleral buckling procedure to attempt to
reattach the retina. Before the client is discharged home, the nurse should: *
a) Explain to the client that reading will help strengthen the eye muscles.
b) Reassure the client that the glasses worn before surgery can still be worn.
c) Tell the client that usual activities can be resumed within two weks.
d) Instruct the client to wear dark glasses after the patch is removed.

Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is 7.5g/dl
and HCT is 27%. Her doctor determines that surgical intervention is necessary and she
undergoes partial gastrectomy. Postoperative nursing care includes: *
a) Flushing the NG tube with sterile water.
b) Positioning her in high Fowler’s position.
c) Giving pain medication Q6H.
 d) Keeping her NPO until the return of peristalsis.

Which of the following are considered as the risk factors of irritable bowel syndrome? Select all
that apply. *
o Stress
o Gastric resection
o Spicy foods
o Smoking
o Enteritis
o Celiac disease

Which assessment data indicate to the nurse the clients gastric ulcer has perforated? *
a) Rigid, board-like abdomen with rebound tenderness
b) Complaints of vague abdominal pain in the right upper quadrant
c) Frequent, clay-colored, liquid stool
d) Complaints of sudden, sharp, substernal pain

A client with irritable bowel syndrome is being prepared for discharge. Which of the following
meal plans should the nurse give the client? *
a) Low fiber, low-fat
b) High fiber, low-fat
c) High-fiber, high-fat
d) Low fiber, high-fat

Hyperphosphatemia and hypocalcemia are indicative of which of the following disorders? *

a) Hypoparathyroidism
b) Cushing’s Syndrome
c) Grave’s Disease
d) Hyperparathyroidism

While caring for a client with peptic ulcer disease, the client reports that he has been
nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these
findings, which nursing actions would be most appropriate for the nurse to take? Select all that
apply. *
a) Notifying the physician of the client’s symptoms
b) Monitoring the client’s vital signs
c) Initiating oxygen therapy
d) Reassessing the client on an hour
e) Administering an antacid hourly until nausea subsides.

Nursing suggestions to help a person break the constipation habit include all of the following
except: *
a) Establishing a regular schedule of exercise.
b) A low-residue, bland diet.
c) A fluid intake of at least 2 L/day.
d) Establishing a regular time for daily elimination.

After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system should
include which of the following nursing interventions? *
 a) Irrigate the tube with 30 ml of sterile water every hour, if needed.
b) Reposition the tube if it is not draining well
c) Monitor the client for nausea and vomiting, and abdominal distention
d) Turn the machine to high suction of the drainage is sluggish on low suction.

The most significant initial nursing observations that should be made about a client who is
suspected of having myasthenia gravis , include the: *
a) Degree of anxiety and concern about the suspected diagnosis
b) Ability to chew and speak distinctly
c) Capacity to smile and close the eyelids.
d) Effectiveness of respiratory exchange and ability to swallow.

Alvin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this
indicate? *
a) He has fresh, active upper GI bleeding.
b) His gastric bleeding occurred 2 hours earlier.
c) He needs a transfusion of packed RBC’s.
d) He needs immediate saline gastric lavage.

In a client with diarrhea, which outcome indicates that fluid resuscitation is successful? *
a) The client no longer experiences perianal burning.
b) The client reports a decrease in stool frequency and liquidity
c) The client exhibits firm skin turgor
d) The client passes formed stools at regular intervals

Trent has been diagnosed with appendicitis. He develops a fever, hypotension and tachycardia.
The nurse suspects which of the following complications? *
a) Intestinal obstruction
b) Peritonitis
c) Deficient fluid volume
d) Bowel ischemia

The nurse is aware that a client with a spinal cord injury is developing autonomic dysreflexia
when the client has: *
a) Absence of sweating and pyrexia
b) Escalating tachycardia and shock
c) Paroxysmal hypertension and bradycardia.
d) Flaccid paralysis and numbness.

A male client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb)
test result. In discussing the result with the client, the nurse would be most accurate in
stating: *
a) “Your insulin regimen needs to be altered significantly.”
b) “It tells us about your sugar control for the last 3 months.”
c) “It looks like you aren’t following the prescribed diabetic diet.”
d) “The test needs to be repeated following a 12-hour fast.”
A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is
obtained for analysis. A nurse reviews the results of the CSF analysis and determines that
which of the following results would verify the diagnosis? *
a) Clear CSF, decreased pressure, and elevated protein
b) Cloudy CSF, decreased protein, and decreased glucose
c) Cloudy CSF, elevated protein, and decreased glucose
d) Clear CSF, elevated protein, and decreased glucose

While assessing a client with Parkinson's disease , the nurse identifies bradykinesia when the
client exhibits: *
a) Paralysis of the limbs
b) An intention tremor
c) A lack of spontaneous movement
d) Muscle flaccidity

A client whose vertebral column at the level of T6 and T7 was completely crushed and whose
left leg was traumatically amputated above the knee is admitted to the ICU . When performing
an assessment, the nurse would expect to find that the client was experiencing: *
a) Spastic paralysis of the arms and legs.
b) Pain at the level of compression
c) Difficulty breathing
d) Pain in the residual limb

A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The
client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal
pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and
the bowel sounds are diminished. Which of the following is the most appropriate nursing
intervention? *
a) Notify the physician
b) Reposition the client and apply a heating pad on a warm setting to the client’s
abdomen.
c) Administer Dilaudid
d) Call and ask the operating room team to perform the surgery as soon as possible

A client who has Guillain-Barre syndrome asks, "Will I ever got better?" The most appropriate
answer by the nurse would be: *
a) "We are doing everything we can to provide the best care."
b) "You'll notice your strength will improve each day."
c) "Your chances for recovery are very good but recovery is slow".
d) "You seem concerned about getting better. What do you think?"

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) Most clients have residual effects after having a TIA.
b) TIA symptoms may last 24 to 48 hours.
c) The most common symptom of TIA is the inability to speak.
d) TIA may be a warning that the client may have cerebrovascular accident (CVA)
Which of the following best describes the method of action of medications, such as ranitidine
(Zantac), which are used in the treatment of peptic ulcer disease? *
a) Reduce gastric acid secretions
b) Protect the mucosal barrier
c) Stimulate gastrin release
d) Neutralize gastric acid

When obtaining the nursing history from a client who has open-angle (chronic) glaucoma, a
complaint that the nurse should expect is: *
a) Loss of peripheral vision
b) Seeing floating specks
c) Intolerance to light
d) Flashes of light

Angelo is being admitted to a hospital unit complaining of severe pain in the lower abdomen.
Admission vital signs reveal an oral temperature of 38 C. Signs and symptoms include pain in
the RLQ of the abdomen that may be localize at McBurney’s point. To relieve pain, Angelo
should assume which position? *
Sitting
Supine, stretched out
Prone
Lying with legs drawn up

A client with gout is encouraged to increase fluid intake. Which of the following statements best
explains why increased fluids are encouraged for gout? *
a) Fluids provide a cushion for weakened bones.
b) .Fluids promote the excretion of uric acid.
c) Fluids decrease inflammation.
d) .Fluids increase calcium absorption.

The nurse might expect a client with multiple sclerosis to complain about the most common
initial symptom, which is: *
a) Headaches
b) Visual disturbances
c) Skin infections
d) Diarrhea

A nurse in the emergency department is observing a 4-year-old child for signs of increased
intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following
signs or symptoms would be cause for concern? *
a) Bulging anterior fontanel.
b) Inability to read short words from a distance of 18 inches.
c) Repeated vomiting.
d) Signs of sleepiness at 10 PM.

An older adult has cataracts in both eyes. The left cataract is scheduled to be extracted in
several days. The nurse should plan to instruct the client that: *
 a) "At night you will be wearing a hard patch over your operated eye for a month or so."
b) "You may have to remain on bed rest for three to four days after your surgery."
c) "You must remember to take deep breaths and cough several times an hour."
d) "Both eyes will be bandaged for 24 hours after surgery."

The nurse is providing discharge instructions to a male client following gastrectomy and
instructs the client to take which measure to assist in preventing dumping syndrome? *
a) Eat high carbohydrate foods
b) Ambulate following a meal
c) Limit the fluid taken with meal
d) Sit in a high-Fowler’s position during meals

After a left cataract extraction, a client complains of severe discomfort in the operated eye. The
nurse recognizes that this is a problem that may be caused by: *
a) Expected postoperative discomfort
b) Pressure on the eye from the protective shield
c) Hemorrhage into the eye.
d) Isolation related to sensory deprivation

A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How
should the nurse position the client for this test initially? *
a) Prone with the torso elevated
b) Bent over with hands touching the floor
c) Lying on the right side with legs straight
d) Lying on the left side with knees bent

A client who has had a retinal detachment has a scleral buckling procedure to attempt to
reattach the retina. Before the client is discharged home, the nurse should: *
a) Reassure the client that the glasses worn before surgery can still be worn.
b) Tell the client that usual activities can be resumed within two weeks.
c) Explain to the client that reading will help strengthen the eye muscles.
d) Instruct the client to wear dark glasses after the patch is removed.

Which expected outcome should the nurse include for a client diagnosed with peptic ulcer
disease? *
a) The client maintains lifestyle modifications
b) The client take s antacids with each meal
c) The client has no signs and symptoms of hemoptysis
d) The clients pain is controlled with the use of NSAIDs

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) Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as
detected by radioimmunoassay
b) An increase in the TSH level after 30 minutes during the TSH stimulation test
c) No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the
TSH stimulation test
d) A decreased TSH level
When assisting the family to help an aphasic member regain as much speech function as
possible, the nurse should instruct them to: *
a) Give positive reinforcement for correct communication
b) Encourage the client to speak while being patient with all attempts.
c) Speak louder than usual during visits.
d) Tell the client to use the correct words when speaking

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

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental
confusion. The priority intervention for this client is: *
a) Encourage increased fluid intake
b) Measure the urinary output
c) Weigh the client
d) Check the vital signs

A 70-year-old client visits the clinic and complains of minor soiling with occasional urgency and
loss of control. Further assessment reveals that the client has poor control of flatus. Based on
the presenting symptoms, you suspect that the client may have: *
a) Peptic ulcer disease
b) Constipation
c) Irritable bowel syndrome
d) Fecal incontinence

A female client with a suspected brain tumor is scheduled for computed tomography (CT).
What should the nurse do when preparing the client for this test? *
a) Place a cap on the client’s head.
b) Administer a sedative as ordered.
c) Immobilize the neck before the client is moved onto a stretcher.
d) Determine whether the client is allergic to iodine, contrast dyes, or shellfish.