Medical Surgical Nursing 1 B.

“Mr, Pablo, you must be so worried, I’ll leave

you alone with your thoughts.
C. “Mr. Pablo, you’ll wear out the hospital floors
1. Following surgery, Mario complains of
and yourself at this rate.”
mild incisional pain while performing D.  “Mr. Pablo, you appear anxious to me. How
deep- breathing and coughing exercises. are you feeling about tomorrow’s surgery?”
The nurse’s best response would be: 6. After surgery, Gina returns from the
A. “Pain will become less each day.” Post-anesthesia Care Unit (Recovery
B.  “This is a normal reaction after surgery.” Room) with a nasogastric tube in place
C. “With a pillow, apply pressure against the following a gall bladder surgery. She
incision.” continues to complain of nausea. Which
D.  “I will give you the pain medication the action would the nurse take?
physician ordered.”
2. The nurse needs to carefully assess A. Call the physician immediately.
the complaint of pain of the elderly B. Administer the prescribed antiemetic.
C. Check the patency of the nasogastric tube for
because older people
any obstruction.
A. are expected to experience chronic pain D. Change the patient’s position.
B. have a decreased pain threshold 7. Mr. Perez is in continuous pain from
C. experience reduced sensory perception cancer that has metastasized to the bone.
D. have altered mental function Pain medication provides little relief and
3. Mary received AtropineSO4 as a pre- he refuses to move. The nurse should
medication 30 minutes ago and is now plan to:
complaining of dry mouth and her PR is
higher, than before the medication was A. Reassure him that the nurses will not hurt him
B. Let him perform his own activities of daily
administered. The nurse’s best
living
A. The patient is having an allergic reaction to C. Handle him gently when assisting with
the drug. required care
B. The patient needs a higher dose of this drug D. Complete A.M. care quickly as possible when
C. This is normal side-effect of AtSO4 necessary
D. The patient is anxious about upcoming 8. A client returns from the recovery room
surgery at 9AM alert and oriented, with an IV
4. Ana’s postoperative vital signs are a infusing. His pulse is 82, blood pressure
blood pressure of 80/50 mm Hg, a pulse is 120/80, respirations are 20, and all are
of 140, and respirations of 32. Suspecting within normal range. At 10 am and at 11
shock, which of the following orders am, his vital signs are stable. At noon,
would the nurse question? however, his pulse rate is 94, blood
pressure is 116/74, and respirations are
A. Put the client in modified Trendelenberg’s
position. 24. What nursing action is most
B. Administer oxygen at 100%. appropriate?
C. Monitor urine output every hour.
D. Administer Demerol 50mg IM q4h A. Notify his physician.
B. Take his vital signs again in 15 minutes.
5. Mr. Pablo, diagnosed with Bladder C.  Take his vital signs again in an hour.
Cancer, is scheduled for a cystectomy D. Place the patient in shock position.
with the creation of an ileal conduit in the 9. A 56 year old construction worker is
morning. He is wringing his hands and brought to the hospital unconscious after
pacing the floor when the nurse enters his falling from a 2-story building. When
room. What is the best approach? assessing the client, the nurse would be
A. “Good evening, Mr. Pablo. Wasn’t it a most concerned if the assessment
pleasant day, today?” revealed:
A.  Reactive pupils B. “Place one tablet under your tongue. If the
B. A depressed fontanel pain is not relieved in 15 minutes, go to the
C.  Bleeding from ears hospital.”
D.  An elevated temperature C. “Continue your activity, and if the pain does
10. Which of the ff. statements by the not go away in 10 minutes, begin taking the
client to the nurse indicates a risk factor nitro tablets one every 5 minutes for 15
minutes, then go lie down.”
for CAD?
D. “Place one Nitroglycerine tablet under the
A. “I exercise every other day.” tongue every five minutes for three doses. Go
B. “My father died of Myasthenia Gravis.” to the hospital if the pain is unrelieved.
C. “My cholesterol is 180.” 15. A client with chronic heart failure has
D. “I smoke 1 1/2 packs of cigarettes per day.” been placed on a diet restricted to
11. Mr. Braga was ordered Digoxin 0.25 2000mg. of sodium per day. The client
mg. OD. Which is poor knowledge demonstrates adequate knowledge if
regarding this drug? behaviors are evident such as not salting
food and avoidance of which food?
A. It has positive inotropic and negative
chronotropic effects A. Whole milk
B. The positive inotropic effect will decrease B. Canned sardines
urine output C. Plain nuts
C. Toxixity can occur more easily in the D. Eggs
presence of hypokalemia, liver and renal
16. A student nurse is assigned to a client
problems
D. Do not give the drug if the apical rate is less who has a diagnosis of thrombophlebitis.
than 60 beats per minute. Which action by this team member is
12. Valsalva maneuver can result in most appropriate?
bradycardia. Which of the following A. Apply a heating pad to the involved site.
activities will not stimulate Valsalva’s B. Elevate the client’s legs 90 degrees.
maneuver? C. Instruct the client about the need for bed rest.
D. Provide active range-of-motion exercises to
A. Use of stool softeners. both legs at least twice every shift.
B. Enema administration
17. A client receiving heparin sodium
C. Gagging while toothbrushing.
D. Lifting heavy objects asks the nurse how the drug works.
13. The nurse is teaching the patient Which of the following points would the
regarding his permanent artificial nurse include in the explanation to the
pacemaker. Which information given by client?
the nurse shows her knowledge deficit A. It dissolves existing thrombi.
about the artificial cardiac pacemaker? B. It prevents conversion of factors that are
needed in the formation of clots.
A. take the pulse rate once a day, in the morning C. It inactivates thrombin that forms and
upon awakening dissolves existing thrombi.
B. may be allowed to use electrical appliances D. It interferes with vitamin K absorption.
C. have regular follow up care
18. The nurse is conducting an education
D. may engage in contact sports
session for a group of smokers in a “stop
14. A patient with angina pectoris is being
smoking” class. Which finding would the
discharged home with nitroglycerine
nurse state as a common symptom of
tablets. Which of the following instructions
lung cancer? :
does the nurse include in the teaching?
A. Dyspnea on exertion
A. “When your chest pain begins, lie down, and
B. Foamy, blood-tinged sputum
place one tablet under your tongue. If the pain C. Wheezing sound on inspiration
continues, take another tablet in 5 minutes.”
D. Cough or change in a chronic cough
 19. Which is the most relevant knowledge 23. A client with COPD is being prepared
about oxygen administration to a client for discharge. The following are relevant
with COPD? instructions to the client regarding the use
of an oral inhaler EXCEPT
A. Oxygen at 1-2L/min is given to maintain the
hypoxic stimulus for breathing. A. Breath in and out as fully as possible before
B. Hypoxia stimulates the central placing the mouthpiece inside the mouth.
chemoreceptors in the medulla that makes the B. Inhale slowly through the mouth as the
client breath. canister is pressed down
C. Oxygen is administered best using a non- C. Hold his breath for about 10 seconds before
rebreathing mask exhaling
D. Blood gases are monitored using a pulse D. Slowly breath out through the mouth with
oximeter. pursed lips after inhaling the drug.
20. When suctioning mucus from a 24. A client is scheduled for a
client’s lungs, which nursing action would bronchoscopy. When teaching the client
be least appropriate? what to expect afterward, the nurse’s
A. Lubricate the catheter tip with sterile saline highest priority of information would be
before insertion. A. Food and fluids will be withheld for at least 2
B. Use sterile technique with a two-gloved hours.
approach B. Warm saline gargles will be done q 2h.
C. Suction until the client indicates to stop or no C. Coughing and deep-breathing exercises will
longer than 20 second be done q2h.
D. Hyperoxygenate the client before and after D.  Only ice chips and cold liquids will be
suctioning allowed initially.
21. Dr. Santos prescribes oral rifampin 25. The nurse enters the room of a client
(Rimactane) and isoniazid (INH) for a with chronic obstructive pulmonary
client with a positive Tuberculin skin test. disease. The client’s nasal cannula
When informing the client of this decision, oxygen is running at a rate of 6 L per
the nurse knows that the purpose of this minute, the skin color is pink, and the
choice of treatment is to respirations are 9 per minute and shallow.
A. Cause less irritation to the gastrointestinal What is the nurse’s best initial action?
tract
A. Take heart rate and blood pressure.
B. Destroy resistant organisms and promote
B. Call the physician.
proper blood levels of the drugs
C. Lower the oxygen rate.
C. Gain a more rapid systemic effect
D. Position the client in a Fowler’s position.
D. Delay resistance and increase the
tuberculostatic effect 26. The nurse is preparing her plan of
22. Mario undergoes a left thoracotomy care for her patient diagnosed with
and a partial pneumonectomy. Chest pneumonia. Which is the most
tubes are inserted, and one-bottle water- appropriate nursing diagnosis for this
seal drainage is instituted in the operating patient?
room. In the postanesthesia care unit A. Fluid volume deficit
Mario is placed in Fowler’s position on B. Decreased tissue perfusion.
either his right C. Impaired gas exchange.
side or on his back to D. Risk for infection
27. A nurse at the weight loss clinic
A. Reduce incisional pain. assesses a client who has a large
B. Facilitate ventilation of the left lung.
abdomen and a rounded face. Which
C. Equalize pressure in the pleural space.
D. Increase venous return additional assessment finding would lead
 the nurse to suspect that the client has D. “The medication will increase the synthesis of
Cushing’s syndrome rather than obesity? thyroid hormones.”
32. During the first 24 hours after thyroid
A. large thighs and upper arms surgery, the nurse should include in her
B. pendulous abdomen and large hips
care:
C. abdominal striae and ankle enlargement
D. posterior neck fat pad and thin extremities A. Checking the back and sides of the operative
28. Which statement by the client dressing
indicates understanding of the possible B. Supporting the head during mild range of
side effects of Prednisone therapy? motion exercise
C. Encouraging the client to ventilate her
A. “I should limit my potassium intake because feelings about the surgery
hyperkalemia is a side-effect of this drug.” D. Advising the client that she can resume her
B. “I must take this medicine exactly as my normal activities immediately
doctor ordered it. I shouldn’t skip doses.” 33. On discharge, the nurse teaches the
C. “This medicine will protect me from getting patient to observe for signs of surgically
any colds or infection.”
induced hypothyroidism. The nurse would
D. “My incision will heal much faster because of
this drug.” know that the patient understands the
29. A client, who is suspected of having teaching when she states she should
Pheochromocytoma, complains of notify the MD if she develops:
sweating, palpitation and headache. A. Intolerance to heat
Which assessment is essential for the B. Dry skin and fatigue
nurse to make first? C. Progressive weight gain
D. Insomnia and excitability
A. Pupil reaction 34. What is the best reason for the nurse
B. Hand grips
in instructing the client to rotate injection
C. Blood pressure
D. Blood glucose sites for insulin?
30. The nurse is attending a bridal shower A. Lipodystrophy can result and is extremely
for a friend when another guest, who painful
happens to be a diabetic, starts to tremble B. Poor rotation technique can cause superficial
and complains of dizziness. The next best hemorrhaging
C. Lipodystrophic areas can result, causing
action for the nurse to take is to:
erratic insulin absorption rates from these
A. Encourage the guest to eat some baked D. Injection sites can never be reused
macaroni 35. Which of the following would be
B. Call the guest’s personal physician inappropriate to include in a diabetic
C. Offer the guest a cup of coffee teaching plan?
D. Give the guest a glass of orange juice
31. An adult, who is newly diagnosed with A. Change position hourly to increase circulation
Graves disease, asks the nurse, “Why do B. Inspect feet and legs daily for any changes
C. Keep legs elevated on 2 pillows while
I need to take Propanolol (Inderal)?”
sleeping
Based on the nurse’s understanding of D. Keep the insulin not in use in the refrigerator
the medication and Grave’s disease, the 36. Included in the plan of care for the
best response would be: immediate post-gastroscopy period will
A. “The medication will limit thyroid hormone be:
secretion.”
A. Maintain NGT to intermittent suction
B. “The medication limit synthesis of the thyroid
B. Assess gag reflex prior to administration of
hormones.”
fluids
C. “The medication will block the cardiovascular
C. Assess for pain and medicate as ordered
symptoms of Grave’s disease.”
D. Measure abdominal girth every 4 hours
 37. Which description of pain would be 42. The husband of a client asks the
most characteristic of a duodenal ulcer? nurse about the protein-restricted diet
ordered because of advanced liver
A. Gnawing, dull, aching, hungerlike pain in the
epigastric area that is relieved by food intake disease. What statement by the nurse
B. RUQ pain that increases after meal would best explain the purpose of the
C. Sharp pain in the epigastric area that radiates diet?
to the right shoulder
D. A sensation of painful pressure in the A. “The liver cannot rid the body of ammonia
midsternal area that is made by the breakdown of protein in
the digestive system.”
38. The client underwent Billroth surgery
B. “The liver heals better with a high
for gastric ulcer. Post-operatively, the carbohydrates diet rather than protein.”
drainage from his NGT is thick and the C. “Most people have too much protein in their
volume of secretions has dramatically diets. The amount of this diet is better for liver
reduced in the last 2 hours and the client healing.”
feels like vomiting. The most appropriate D. “Because of portal hyperemesis, the blood
flows around the liver and ammonia made
nursing action is to:
from protein collects in the brain causing
A. Reposition the NGT by advancing it gently hallucinations.”
NSS 43. Which of the drug of choice for pain
B. Notify the MD of your findings controls the patient with acute
C. Irrigate the NGT with 50 cc of sterile pancreatitis?
D. Discontinue the low-intermittent suction
39. After Billroth II Surgery, the client A. Morphine
developed dumping syndrome. Which of B. NSAIDS
C. Meperidine
the following should the nurse exclude in
D. Codeine
the plan of care?
44. Immediately after cholecystectomy,
A. Sit upright for at least 30 minutes after meals the nursing action that should assume the
B. Take only sips of H2O between bites of solid highest priority is:
food
C. Eat small meals every 2-3 hours A. encouraging the client to take adequate deep
D. Reduce the amount of simple carbohydrate in breaths by mouth
the diet B. encouraging the client to cough and deep
40. The laboratory of a male patient with breathe
C. changing the dressing at least BID
Peptic ulcer revealed an elevated titer of
D. irrigate the T-tube frequently
Helicobacter pylori. Which of the following
45. A Sengstaken-Blakemore tube is
statements indicate an understanding of
inserted in the effort to stop the bleeding
this data?
esophageal varices in a patient with
A. Treatment will include Ranitidine and complicated liver cirrhosis. Upon insertion
Antibiotics of the tube, the client complains of
B. No treatment is necessary at this time difficulty of breathing. The first action of
C. This result indicates gastric cancer caused by
the nurse is to:
the organism
D. Surgical treatment is necessary A. Deflate the esophageal balloon
41. What instructions should the client be B. Monitor VS
given before undergoing a paracentesis? C. Encourage him to take deep breaths
D. Notify the MD
A. NPO 12 hours before procedure 46. The client presents with severe rectal
B. Empty bladder before procedure
bleeding, 16 diarrheal stools a day,
C. Strict bed rest following procedure
D. Empty bowel before procedure severe abdominal pain, tenesmus and
dehydration. Because of these symptoms
 the nurse should be alert for other against the incision with a pillow will help
problems associated with what disease? lessen the intra-abdominal pressure created by
coughing which causes tension on the incision
A. Chrons disease that leads to pain.
B. Ulcerative colitis 2. Answer: (C) experience reduced sensory
C. Diverticulitis perception . Degenerative changes occur in
D. Peritonitis the elderly. The response to pain in the elderly
47. A client is being evaluated for cancer maybe lessened because of reduced acuity of
of the colon. In preparing the client for touch, alterations in neural pathways and
diminished processing of sensory data.
barium enema, the nurse should:
3. Answer: (C) This is normal side-effect of
A. Give laxative the night before and a cleansing AtSO4. Atropine sulfate is a vagolytic drug
enema in the morning before the test that decreases oropharyngeal secretions and
B. Render an oil retention enema and give increases the heart rate.
laxative the night before 4. Answer: (D) Administer Demerol 50mg IM
C. Instruct the client to swallow 6 radiopaque q4h. Administering Demerol, which is a
tablets the evening before the study narcotic analgesic, can depress respiratory and
D. Place the client on CBR a day before the cardiac function and thus not given to a
study patient in shock. What is needed is promotion
48. The client has a good understanding for adequate oxygenation and perfusion. All
the other interventions can be expected to be
of the means to reduce the chances of
done by the nurse.
colon cancer when he states: 5. Answer: (D) “Mr. Pablo, you appear
A. “I will exercise daily.” anxious to me. How are you feeling about
B. “I will include more red meat in my diet.” tomorrow’s surgery?”. The client is showing
C. “I will have an annual chest x-ray.” signs of anxiety reaction to a stressful event.
D.  “I will include more fresh fruits and Recognizing the client’s anxiety conveys
vegetables in my diet.” acceptance of his behavior and will allow for
verbalization of feelings and concerns.
49. Days after abdominal surgery, the 6. Answer: (C) Check the patency of the
client’s wound dehisces. The safest nasogastric tube for any
nursing intervention when this occurs is to obstruction. Nausea is one of the common
complaints of a patient after receiving general
A. Cover the wound with sterile, moist saline anesthesia. But this complaint could be
dressing aggravated by gastric distention especially in
B. Approximate the wound edges with tapes a patient who has undergone abdominal
C. Irrigate the wound with sterile saline surgery. Insertion of the NGT helps relieve
D. Hold the abdominal contents in place with a the problem. Checking on the patency of the
sterile gloved hand NGT for any obstruction will help the nurse
50. An intravenous pyelogram reveals determine the cause of the problem and
that Paulo, age 35, has a renal calculus. institute the necessary intervention.
He is believed to have a small stone that 7. Answer: (C) Handle him gently when
will pass spontaneously. To increase the assisting with required care . Patients with
chance of the stone passing, the nurse cancer and bone metastasis experience severe
pain especially when moving. Bone tumors
would instruct the client to force fluids and weaken the bone to appoint at which normal
to activities and even position changes can lead
to fracture. During nursing care, the patient
A. Strain all urine.
needs to be supported and handled gently.
B. Ambulate.
8. Answer: (B) Take his vital signs again in 15
C. Remain on bed rest.
minutes. Monitoring the client’s vital signs
D. Ask for medications to relax him.
following surgery gives the nurse a sound
Answers and Rationales information about the client’s condition.
1. Answer: (C) “With a pillow, apply pressure Complications can occur during this period as
against the incision.” Applying pressure a result of the surgery or the anesthesia or
 both. Keeping close track of changes in the 17.Answer: (B) It prevents conversion of
VS and validating them will help the nurse factors that are needed in the formation of
initiate interventions to prevent complications clots. Heparin is an anticoagulant. It prevents
from occurring. the conversion of prothrombin to thrombin. It
9. Answer: (C) Bleeding from ears . The nurse does not dissolve a clot.
needs to perform a thorough assessment that 18.Answer: (D) Cough or change in a chronic
could indicate alterations in cerebral function, cough .Cigarette smoke is a carcinogen that
increased intracranial pressures, fractures and irritates and damages the respiratory
bleeding. Bleeding from the ears occurs only epithelium. The irritation causes the cough
with basal skull fractures that can easily which initially maybe dry, persistent and
contribute to increased intracranial pressure unproductive. As the tumor enlarges,
and brain herniation. obstruction of the airways occurs and the
10.Answer: (D) “I smoke 1 1/2 packs of cough may become productive due to
cigarettes per day.” Smoking has been infection.
considered as one of the major modifiable risk 19.Answer: (A) Oxygen at 1-2L/min is given to
factors for coronary artery disease. Exercise maintain the hypoxic stimulus for
and maintaining normal serum cholesterol breathing. COPD causes a chronic CO2
levels help in its prevention. retention that renders the medulla insensitive
11.Answer: (B) The positive inotropic effect to the CO2 stimulation for breathing. The
will decrease urine output . Inotropic effect hypoxic state of the client then becomes the
of drugs on the heart causes increase force of stimulus for breathing. Giving the
its contraction. This increases cardiac output clientoxygen in low concentrations will
that improves renal perfusion resulting in an maintain the client’s hypoxic drive.
improved urine output. 20.Answer: (C) Suction until the client
12.Answer: (A) Use of stool softeners. Straining indicates to stop or no longer than 20
or bearing down activities can cause vagal second .One hazard encountered when
stimulation that leads to bradycardia. Use of suctioning a client is the development of
stool softeners promote easy bowel hypoxia. Suctioning sucks not only the
evacuation that prevents straining or the secretions but also the gases found in the
valsalva maneuver. airways. This can be prevented by suctioning
13.Answer: (D) may engage in contact the client for an average time of 5-10 seconds
sports . The client should be advised by the and not more than 15 seconds and
nurse to avoid contact sports. This will hyperoxygenating the client before and after
prevent trauma to the area of the pacemaker suctioning.
generator. 21.Answer: (D) Delay resistance and increase
14.Answer: (D) “Place one Nitroglycerine the tuberculostatic effect . Pulmonary TB is
tablet under the tongue every five minutes treated primarily with chemotherapeutic
for three doses. Go to the hospital if the agents for 6-12 mons. A prolonged treatment
pain is unrelieved. Angina pectoris is caused duration is necessary to ensure eradication of
by myocardial ischemia related to decreased the organisms and to prevent relapse. The
coronary blood supply. Giving nitroglycerine increasing prevalence of drug resistance
will produce coronary vasodilation that points to the need to begin the treatment with
improves the coronary blood flow in 3 – 5 drugs in combination. Using drugs in
mins. If the chest pain is unrelieved, after combination can delay the drug resistance.
three tablets, there is a possibility of acute 22.Answer: (B) Facilitate ventilation of the left
coronary occlusion that requires immediate lung.  Since only a partial pneumonectomy is
medical attention. done, there is a need to promote expansion of
15.Answer: (B) Canned sardines . Canned this remaining Left lung by positioning the
foods are generally rich in sodium content as client on the opposite unoperated side.
salt is used as the main preservative. 23.Answer: (D) Slowly breath out through the
16.Answer: (C) Instruct the client about the mouth with pursed lips after inhaling the
need for bed rest. In a client with drug. If the client breathes out through the
thrombophlebitis, bedrest will prevent the mouth with pursed lips, this can easily force
dislodgment of the clot in the extremity which the just inhaled drug out of the respiratory
can lead to pulmonary embolism. tract that will lessen its effectiveness.
24.Answer: (A) Food and fluids will be 31.Answer: (C) “The medication will block the
withheld for at least 2 hours.  Prior to cardiovascular symptoms of Grave’s
bronchoscopy, the doctors sprays the back of disease.” Propranolol (Inderal) is a beta-
the throat with anesthetic to minimize the gag adrenergic blocker that controls the
reflex and thus facilitate the insertion of the cardiovascular manifestations brought about
bronchoscope. Giving the client food and by increased secretion of the thyroid hormone
drink after the procedure without checking on in Grave’s disease.
the return of the gag reflex can cause the 32.Answer: (A) Checking the back and sides
client to aspirate. The gag reflex usually of the operative dressing . Following surgery
returns after two hours. of the thyroid gland, bleeding is a potential
25.Answer: (C) Lower the oxygen rate.  The complication. This can best be assessed by
client with COPD is suffering from chronic checking the back and the sides of the
CO2 retention. The hypoxic drive is his chief operative dressing as the blood may flow
stimulus for breathing. Giving O2 inhalation towards the side and back leaving the front
at a rate that is more than 2-3L/min can make dry and clear of drainage.
the client lose his hypoxic drive which can be 33.Answer: (C) Progressive weight
assessed as decreasing RR. gain . Hypothyroidism, a decrease in thyroid
26.Answer: (C) Impaired gas exchange. hormone production, is characterized by
Pneumonia, which is an infection, causes hypometabolism that manifests itself with
lobar consolidation thus impairing gas weight gain.
exchange between the alveoli and the blood. 34.Answer: (C) Lipodystrophic areas can
Because the patient would require adequate result, causing erratic insulin absorption
hydration, this makes him prone to fluid rates from these . Lipodystrophy is the
volume excess. development of fibrofatty masses at the
27.Answer: (D) posterior neck fat pad and injection site caused by repeated use of an
thin extremities .“ Buffalo hump” is the injection site. Injecting insulin into these
accumulation of fat pads over the upper back scarred areas can cause the insulin to be
and neck. Fat may also accumulate on the poorly absorbed and lead to erratic reactions.
face. There is truncal obesity but the 35.Answer: (C) Keep legs elevated on 2 pillows
extremities are thin. All these are noted in a while sleeping . The client with DM has
client with Cushing’s syndrome. decreased peripheral circulation caused by
28.Answer: (B) “I must take this medicine microangiopathy. Keeping the legs elevated
exactly as my doctor ordered it. I shouldn’t during sleep will further cause circulatory
skip doses.”  The possible side effects of impairment.
steroid administration are hypokalemia, 36.Answer: (B) Assess gag reflex prior to
increase tendency to infection and poor administration of fluids . The client, after
wound healing. Clients on the drug must gastroscopy, has temporary impairment of the
follow strictly the doctor’s order since gag reflex due to the anesthetic that has been
skipping the drug can lower the drug level in sprayed into his throat prior to the procedure.
the blood that can trigger acute adrenal Giving fluids and food at this time can lead to
insufficiency or Addisonian Crisis aspiration.
29.Answer: (C) Blood 37.Answer: (A) Gnawing, dull, aching,
pressure . Pheochromocytoma is a tumor of hungerlike pain in the epigastric area that
the adrenal medulla that causes an increase is relieved by food intake . Duodenal ulcer is
secretion of catecholamines that can elevate related to an increase in the secretion of HCl.
the blood pressure. This can be buffered by food intake thus the
30.Answer: (D) Give the guest a glass of relief of the pain that is brought about by food
orange juice . In diabetic patients, the nurse intake.
should watch out for signs of hypoglycemia 38.Answer: (B) Notify the MD of your findings
manifested by dizziness, tremors, weakness, . The client’s feeling of vomiting and the
pallor diaphoresis and tachycardia. When this reduction in the volume of NGT drainage that
occurs in a conscious client, he should be is thick are signs of possible abdominal
given immediately carbohydrates in the form distention caused by obstruction of the NGT.
of fruit juice, hard candy, honey or, if This should be reported immediately to the
unconscious, glucagons or dextrose per IV.
 MD to prevent tension and rupture on the site is in the oropharynx causing airway
of anastomosis caused by gastric distention. obstruction
39.Answer: (A) Sit upright for at least 30 46.Answer: (B) Ulcerative colitis . Ulcerative
minutes after meals  . The dumping colitis is a chronic inflammatory condition
syndrome occurs within 30 mins after a meal producing edema and ulceration affecting the
due to rapid gastric emptying, causing entire colon. Ulcerations lead to sloughing
distention of the duodenum or jejunum that causes stools as many as 10-20 times a
produced by a bolus of food. To delay the day that is filled with blood, pus and mucus.
emptying, the client has to lie down after The other symptoms mentioned accompany
meals. Sitting up after meals will promote the the problem.
dumping syndrome. 47.Answer: (A) Give laxative the night before
40.Answer: (A) Treatment will include and a cleansing enema in the morning
Ranitidine and Antibiotics . One of the before the test .Barium enema is the
causes of peptic ulcer is H. Pylori infection. It radiologic visualization of the colon using a
releases toxin that destroys the gastric and die. To obtain accurate results in this
duodenal mucosa which decreases the gastric procedure, the bowels must be emptied of
epithelium’s resistance to acid digestion. fecal material thus the need for laxative and
Giving antibiotics will control the infection enema.
and Ranitidine, which is a histamine-2 48.Answer: (D) “I will include more fresh
blocker, will reduce acid secretion that can fruits and vegetables in my diet.”
lead to ulcer. Numerous aspects of diet and nutrition may
41.Answer: (B) Empty bladder before contribute to the development of cancer. A
procedure . Paracentesis involves the low-fiber diet, such as when fresh fruits and
removal of ascitic fluid from the peritoneal vegetables are minimal or lacking in the diet,
cavity through a puncture made below the slows transport of materials through the gut
umbilicus. The client needs to void before the which has been linked to colorectal cancer.
procedure to prevent accidental puncture of a 49.Answer: (A) Cover the wound with sterile,
distended bladder during the procedure. moist saline dressing . Dehiscence is the
42.Answer: (A) “The liver cannot rid the body partial or complete separation of the surgical
of ammonia that is made by the breakdown wound edges. When this occurs, the client is
of protein in the digestive system.”  The placed in low Fowler’s position and instructed
largest source of ammonia is the enzymatic to lie quietly. The wound should be covered to
and bacterial digestion of dietary and blood protect it from exposure and the dressing must
proteins in the GI tract. A protein-restricted be sterile to protect it from infection and moist
diet will therefore decrease ammonia to prevent the dressing from sticking to the
production. wound which can disturb the healing process.
43.Answer: (C) Meperidine . Pain in acute 50.Answer: (B) Ambulate. Free unattached
pancreatitis is caused by irritation and edema stones in the urinary tract can be passed out
of the inflamed pancreas as well as spasm due with the urine by ambulation which can
to obstruction of the pancreatic ducts. mobilize the stone and by increased fluid
Demerol is the drug of choice because it is intake which will flush out the stone during
less likely to cause spasm of the Sphincter of urination.
Oddi unlike Morphine which is spasmogenic.
44.Answer: (B) encouraging the client to
cough and deep breathe . Cholecystectomy
requires a subcostal incision. To minimize
pain, clients have a tendency to take shallow
breaths which can lead to respiratory
complications like pneumonia and atelectasis.
Deep breathing and coughing exercises can
help prevent such complications.
45.Answer: (A) Deflate the esophageal balloon
. When a client with a Sengstaken-Blakemore
tube develops difficulty of breathing, it means
the tube is displaced and the inflated balloon
 Medical Surgical Nursing 2 A. frontal lobe
B. parietal lobe
1. After a cerebrovascular accident, a 75 C. occipital lobe
yr old client is admitted to the health care D. temporal lobe
facility. The client has left-sided weakness 6. The nurse is assessing a
and an absent gag reflex. He’s postcraniotomy client and finds the urine
incontinent and has a tarry stool. His output from a catheter is 1500 ml for the
blood pressure is 90/50 mm Hg, and his 1st hour and the same for the 2nd hour.
hemoglobin is 10 g/dl. Which of the The nurse should suspect:
following is a priority for this client? A. Cushing’s syndrome
A. checking stools for occult blood B. Diabetes mellitus
B. performing range-of-motion exercises to the C. Adrenal crisis
left side D. Diabetes insipidus
C. keeping skin clean and dry 7. The nurse is providing postprocedure
D. elevating the head of the bed to 30 degrees care for a client who underwent
2. The nurse is caring for a client with a percutaneous lithotripsy. In this
colostomy. The client tells the nurse that procedure, an ultrasonic probe inserted
he makes small pin holes in the drainage through a nephrostomy tube into the renal
bag to help relieve gas. The nurse should pelvis generates ultra-high-frequency
teach him that this action: sound waves to shatter renal calculi. The
nurse should instruct the client to:
A. destroys the odor-proof seal
B. wont affect the colostomy system A. limit oral fluid intake for 1 to 2 weeks
C. is appropriate for relieving the gas in a B. report the presence of fine, sandlike particles
colostomy system through the nephrostomy tube.
D. destroys the moisture barrier seal C. Notify the physician about cloudy or foul
3. When assessing the client with celiac smelling urine
disease, the nurse can expect to find D. Report bright pink urine within 24 hours after
which of the following? the procedure
8. A client with a serum glucose level of
A. steatorrhea 618 mg/dl is admitted to the facility. He’s
B. jaundiced sclerae awake and oriented, has hot dry skin, and
C. clay-colored stools
has the following vital signs: temperature
D. widened pulse pressure
of 100.6º F (38.1º C), heart rate of 116
4. A client is hospitalized with a diagnosis
beats/minute, and blood pressure of
of chronic glomerulonephritis. The client
108/70 mm Hg. Based on these
mentions that she likes salty foods. The
assessment findings, which nursing
nurse should warn her to avoid foods
diagnosis takes the highest priority?
containing sodium because:
A. deficient fluid volume related to osmotic
A. reducing sodium promotes urea nitrogen
diuresis
excretion
B. decreased cardiac output related to elevated
B. reducing sodium improves her glomerular
heart rate
filtration rate
C. imbalanced nutrition: Less than body
C. reducing sodium increases potassium
requirements related to insulin deficiency
absorption
D. ineffective thermoregulation related to
D. reducing sodium decreases edema
dehydration
5. The nurse is caring for a client with a
9. Capillary glucose monitoring is being
cerebral injury that impaired his speech
performed every 4 hours for a client
and hearing. Most likely, the client has
diagnosed with diabetic ketoacidosis.
experienced damage to the:
Insulin is administered using a scale of
 regular insulin according to glucose C. occipital
results. At 2 p.m., the client has a D. parietal
capillary glucose level of 250 mg/dl for 14. A male client should be taught about
which he receives 8 U of regular insulin. testicular examinations:
The A. when sexual activity starts
nurse should expect the dose’s: B. after age 60
C. after age 40
A. onset to be at 2 p.m. and its peak at 3 p.m. D. before age 20
B. onset to be at 2:15 p.m. and its peak at 3 p.m.
15. Before weaning a client from a
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. ventilator, which assessment parameter is
10. A client with a head injury is being most important for the nurse to review?
monitored for increased intracranial A. fluid intake for the last 24 hours
pressure (ICP). His blood pressure is B. baseline arterial blood gas (ABG) levels
90/60 mmHG and the ICP is 18 mmHg; C. prior outcomes of weaning
therefore his cerebral perfusion pressure D. electrocardiogram (ECG) results
(CPP) is: 16. The nurse is speaking to a group of
women about early detection of breast
A. 52 mm Hg cancer. The average age of the women in
B. 88 mm Hg
the group is 47. Following the American
C. 48 mm Hg
D. 68 mm Hg Cancer Society (ACS) guidelines, the
11. A 52 yr-old female tells the nurse that nurse should recommend that the
she has found a painless lump in her right women:
breast during her monthly self- A. perform breast self-examination annually
examination. Which assessment finding B. have a mammogram annually
would strongly suggest that this client’s C. have a hormonal receptor assay annually
lump is cancerous? D. have a physician conduct a clinical evaluation
every 2 years
A. eversion of the right nipple and a mobile mass 17. When caring for a client with
B. nonmobile mass with irregular edges esophageal varices, the nurse knows that
C. mobile mass that is oft and easily delineated
bleeding in this disorder usually stems
D. nonpalpable right axillary lymph nodes
from:
12. A Client is scheduled to have a
descending colostomy. He’s very anxious A. esophageal perforation
and has many questions regarding the B. pulmonary hypertension
surgical procedure, care of stoma, and C. portal hypertension
lifestyle changes. It would be most D. peptic ulcers
appropriate for the nurse to make a 18. A 49-yer-old client was admitted for
referral to which member of the health surgical repair of a Colles’ fracture. An
care team? external fixator was placed during
surgery. The surgeon explains that this
A. Social worker method of repair:
B. registered dietician
C. occupational therapist A. has very low complication rate
D. enterostomal nurse therapist B. maintains reduction and overall hand function
13. Ottorrhea and rhinorrhea are most C. is less bothersome than a cast
commonly seen with which type of skull D. is best for older people
fracture? 19. A client is hospitalized with a
diagnosis of chronic renal failure. An
A. basilar arteriovenous fistula was created in his
B. temporal left arm for hemodialysis. When preparing
 the client for discharge, the nurse should 23. Which assessment finding indicates
reinforce which dietary instruction? dehydration?
A. “Be sure to eat meat at every meal.” A. Tenting of chest skin when pinched.
B. “Monitor your fruit intake and eat plenty of B. Rapid filling of hand veins.
bananas.” C. A pulse that isn’t easily obliterated.
C. “Restrict your salt intake.” D. Neck vein distention
D. “Drink plenty of fluids.” 24. The nurse is teaching a client with a
20. The nurse is caring for a client who history of atherosclerosis. To decrease
has just had a modified radical the risk of atherosclerosis, the nurse
mastectomy with immediate should encourage the client to:
reconstruction. She’s in her 30s and has
A. Avoid focusing on his weight.
tow children. Although she’s worried
B. Increase his activity level.
about her future, she seems to be C. Follow a regular diet.
adjusting well to her diagnosis. What D. Continue leading a high-stress lifestyle.
should the nurse do to support 25. For a client newly diagnosed with
her coping? radiationinduced thrombocytopenia, the
A. Tell the client’s spouse or partner to be nurse should include which intervention in
supportive while she recovers. the plan of care?
B. Encourage the client to proceed with the next
A. Administer aspirin if the temperature exceeds
phase of treatment.
C. Recommend that the client remain cheerful 38.8º C.
B. Inspect the skin for petechiae once every shift.
for the sake of her children.
D. Refer the client to the American Cancer C. Provide for frequent periods of rest.
D. Place the client in strict isolation.
Society’s Reach for Recovery program or
another support program. 26. A client is chronically short of breath
21. A 21 year-old male has been seen in and yet has normal lung ventilation, clear
the clinic for a thickening in his right lungs, and an arterial oxygen saturation
testicle. The physician ordered a human (SaO2) 96% or better. The client most
chorionic gonadotropin (HCG) level. The likely has:
nurse’s explanation to the client should A. poor peripheral perfusion
include the fact that: B. a possible Hematologic problem
C. a psychosomatic disorder
A. The test will evaluate prostatic function. D. left-sided heart failure
B. The test was ordered to identify the site of a
possible infection. 27. For a client in addisonian crisis, it
C. The test was ordered because clients who would be very risky for a nurse to
have testicular cancer has elevated levels of administer:
HCG.
D. The test was ordered to evaluate the A. potassium chloride
testosterone level. B. normal saline solution
C. hydrocortisone
22. A client is receiving captopril
D. fludrocortisone
(Capoten) for heart failure. The nurse
28. The nurse is reviewing the laboratory
should notify the physician that the
report of a client who underwent a bone
medication therapy is ineffective if an
marrow biopsy. The finding that would
assessment reveals:
most strongly support a diagnosis of
A. A skin rash. acute leukemia is the existence of a large
B. Peripheral edema. number of immature:
C. A dry cough.
D. Postural hypotension. A. lymphocytes
B. thrombocytes
C. reticulocytes has had five urinary tract infections over
D. leukocytes the past two years. She’s fatigued from
29. The nurse is performing wound care lack of sleep; urinates frequently, even
on a foot ulcer in a client with type 1 during the night; and has lost weight
diabetes mellitus. Which technique recently. Test reveal the following: sodium
demonstrates surgical asepsis? level 152 mEq/L, osmolarity 340 mOsm/L,
A. Putting on sterile gloves then opening a glucose level 125 mg/dl, and potassium
container of sterile saline. level 3.8 mEq/L. which of the following
B. Cleaning the wound with a circular motion, nursing diagnoses is most appropriate for
moving from outer circles toward the center. this client?
C. Changing the sterile field after sterile water is
spilled on it. A. Deficient fluid volume related to inability to
D. Placing a sterile dressing ½” (1.3 cm) from conserve water
the edge of the sterile field. B. Imbalanced nutrition: less than body
30. A client with a forceful, pounding requirements related to hypermetabolic state
heartbeat is diagnosed with mitral valve C. Deficient fluid volume related to osmotic
diuresis induced by hypernatremia
prolapse. This client should avoid which
D. Imbalanced nutrition: less than body
of the following? requirements related to catabolic effects of
A. high volumes of fluid intake insulin deficiency
B. aerobic exercise programs 34. A 20 yr-old woman has just been
C. caffeine-containing products diagnosed with Crohn’s disease. She has
D. foods rich in protein lost 10 lb (4.5 kg) and has cramps and
31. A client with a history of hypertension occasional diarrhea. The nurse should
is diagnosed with primary include which of the following when doing
hyperaldosteronism. This diagnosis a nutritional assessment?
indicates that the client’s hypertension is
A. Let the client eat as desired during the
caused by excessive hormone secretion
hospitalization.
from which organ? B. Weight the client daily.
A. adrenal cortex C. Ask the client to list what she eats during a
B. pancreas typical day.
C. adrenal medulla D. Place the client on I & O status and draw
D. parathyroid blood for electrolyte levels.
32. A client has a medical history of 35. When instructions should be included
rheumatic fever, type 1 (insulin in the discharge teaching plan for a client
dependent) diabetes mellitus, after thyroidectomy for Grave’s disease?
hypertension, pernicious anemia, and A. Keep an accurate record of intake and output.
appendectomy. She’s admitted to the B. Use nasal desmopressin acetate DDAVP).
hospital and undergoes mitral valve C. Be sure to get regulate follow-up care.
replacement surgery. After discharge, the D. Be sure to exercise to improve cardiovascular
fitness.
client is scheduled for a tooth extraction.
36. A client comes to the emergency
Which history finding is a major risk factor
department with chest pain, dyspnea, and
for infective endocarditis?
an irregular heartbeat. An
A. appendectomy electrocardiogram shows a heart rate of
B. pernicious anemia 110 beats/minute (sinus tachycardia) with
C. diabetes mellitus
frequent premature ventricular
D. valve replacement
contractions. Shortly after admission, the
33. A 62 yr-old client diagnosed with
client has ventricular tachycardia and
pyelonephritis and possible septicemia
 becomes unresponsive. After successful D. photosensitivity
resuscitation, the client is taken to the 41. The nurse is caring for four clients on
intensive care unit. Which nursing a stepdown intensive care unit. The client
diagnosis is appropriate at this time? at the highest risk for developing
nosocomial pneumonia is the one who:
A. Deficient knowledge related to interventions
used to treat acute illness A. has a respiratory infection
B. Impaired physical mobility related to B. is intubated and on a ventilator
complete bed rest C. has pleural chest tubes
C. Social isolation related to restricted visiting D. is receiving feedings through a jejunostomy
hours in the intensive care unit tube
D. Anxiety related to the threat of death 42. The nurse is teaching a client with
37. A client is admitted to the health care chronic bronchitis about breathing
facility with active tuberculosis. The nurse exercises. Which of the following should
should include which intervention in the the nurse include in the teaching?
plan of care?
A. Make inhalation longer than exhalation.
A. Putting on a mask when entering the client’s B. Exhale through an open mouth.
room. C. Use diaphragmatic breathing.
B. Instructing the client to wear a mask at all D. Use chest breathing.
times 43. A client is admitted to the hospital with
C. Wearing a gown and gloves when providing an exacerbation of her chronic systemic
direct care
lupus erythematosus (SLE). She gets
D. Keeping the door to the client’s room open to
observe the client angry when her call bell isn’t answered
38. The nurse is caring for a client who immediately. The most appropriate
underwent a subtotal gastrectomy 24 response to her would be:
hours earlier. The client has a nasogastric A. “You seem angry. Would you like to talk
(NG) tube. The nurse should: about it?”
B. “Calm down. You know that stress will make
A. Apply suction to the NG tube every hour. your symptoms worse.”
B. Clamp the NG tube if the client complains of C. “Would you like to talk about the problem
nausea. with the nursing supervisor?”
C. Irrigate the NG tube gently with normal saline D. “I can see you’re angry. I’ll come back when
solution. you’ve calmed down.”
D. Reposition the NG tube if pulled out.
44. On a routine visit to the physician, a
39. Which statement about fluid
client with chronic arterial occlusive
replacement is accurate for a client with
disease reports stopping smoking after 34
hyperosmolar hyperglycemic nonketotic
years. To relive symptoms of intermittent
syndrome (HHNS)?
claudication, a condition associated with
A. administer 2 to 3 L of IV fluid rapidly chronic arterial occlusive disease, the
B. administer 6 L of IV fluid over the first 24 nurse should recommend which
hours additional measure?
C. administer a dextrose solution containing
normal saline solution A. Taking daily walks.
D. administer IV fluid slowly to prevent B. Engaging in anaerobic exercise.
circulatory overload and collapse C. Reducing daily fat intake to less than 45% of
40. Which of the following is an adverse total calories
reaction to glipizide (Glucotrol)? D. Avoiding foods that increase levels of
highdensity lipoproteins (HDLs)
A. headache 45. A physician orders gastric
B. constipation decompression for a client with small
C. hypotension
 bowel obstruction. The nurse should plan A. beneficence
for the suction to be: B. autonomy
C. advocacy
A. low pressure and intermittent D. justice
B. low pressure and continuous 50. Which of the following is t he most
C. high pressure and continuous critical intervention needed for a client
D. high pressure and intermittent
with myxedema coma?
46. Which nursing diagnosis is most
appropriate for an elderly client with A. Administering and oral dose of levothyroxine
osteoarthritis? (Synthroid)
B. Warming the client with a warming blanket
A. Risk for injury C. Measuring and recording accurate intake and
B. Impaired urinary elimination output
C. Ineffective breathing pattern D. Maintaining a patent airway
D. Imbalanced nutrition: less than body 51. Because diet and exercise have failed
requirements to control a 63 yr-old client’s blood
47. Parathyroid hormone (PTH) has glucose level, the client is prescribed
which effects on the kidney? glipizide (Glucotrol). After oral
A. Stimulation of calcium reabsorption and administration, the onset of action is:
phosphate excretion
A. 15 to 30 minutes
B. Stimulation of phosphate reabsorption and B. 30 to 60 minutes
calcium excretion
C. 1 to 1 ½ hours
C. Increased absorption of vit D and excretion of D. 2 to 3 hours
vit E
D. Increased absorption of vit E and excretion of 52. A client with pneumonia is receiving
Vit D supplemental oxygen, 2 L/min via nasal
48. A visiting nurse is performing home cannula. The client’s history includes
assessment for a 59-yr old man recently chronic obstructive pulmonary disease
discharged after hip replacement surgery. (COPD) and coronary artery disease.
Which home assessment finding warrants Because of these findings, the nurse
health promotion teaching from the closely monitors the oxygen flow and the
nurse? client’s respiratory status. Which
complication may arise if the client
A. A bathroom with grab bars for the tub and receives a high oxygen concentration?
toilet
B. Items stored in the kitchen so that reaching up A. Apnea
and bending down aren’t necessary B. Anginal pain
C. Many small, unsecured area rugs C. Respiratory alkalosis
D. Sufficient stairwell lighting, with switches to D. Metabolic acidosis
the top and bottom of the stairs 53. A client with type 1 diabetes mellitus
49. A client with autoimmune has been on a regimen of multiple daily
thrombocytopenia and a platelet count of injection therapy. He’s being converted to
800/uL develops epistaxis and melena. continuous subcutaneous insulin therapy.
Treatment with corticosteroids and While teaching the client bout continuous
immunoglobulins has been unsuccessful, subcutaneous insulin therapy, the nurse
and the physician recommends a would be accurate in telling him the
splenectomy. The client states, “I don’t regimen includes the use of:
need surgery—this will go away on its
own.” In considering her response to the A. intermediate and long-acting insulins
B. short and long-acting insulins
client, the nurse must depend on the
C. short-acting only
ethical principle of: D. short and intermediate-acting insulins
 54. a client who recently had a 59. When caring for a client with the
cerebrovascular accident requires a cane nursing diagnosis Impaired swallowing
to ambulate. When teaching about cane related to neuromuscular impairment, the
use, the rationale for holding a cane on nurse should:
the uninvolved side is to:
A. position the client in a supine position
A. prevent leaning B. elevate the head of the bed 90 degrees during
B. distribute weight away from the involved side meals
C. maintain stride length C. encourage the client to remove dentures
D. prevent edema D. encourage thin liquids for dietary intake
55. A client with a history of an anterior 60. A nurse is caring for a client who has
wall myocardial infarction is being a tracheostomy and temperature of 39º C.
transferred from the coronary care unit which intervention will most likely lower
(CCU) to the cardiac stepdown unit the client’s arterial blood oxygen
(CSU). While giving report to the CSU saturation?
nurse, the CCU nurse says, “His A. Endotracheal suctioning
pulmonary artery wedge pressures have B. Encouragement of coughing
been in the high normal range.” The CSU C. Use of cooling blanket
nurse should be especially observant for: D. Incentive spirometry
61. A client with a solar burn of the chest,
A. hypertension
back, face, and arms is seen in urgent
B. high urine output
C. dry mucous membranes care. The nurse’s primary concern should
D. pulmonary crackles be:
56. The nurse is caring for a client with a A. fluid resuscitation
fractures hip. The client is combative, B. infection
confused, and trying to get out of bed. C. body image
The nurse should: D. pain management
62. Which statement is true about
A. leave the client and get help
crackles?
B. obtain a physician’s order to restrain the client
C. read the facility’s policy on restraints A. They’re grating sounds.
D. order soft restraints from the storeroom B. They’re high-pitched, musical squeaks.
57. For the first 72 hours after C. They’re low-pitched noises that sound like
thyroidectomy surgery, the nurse would snoring.
assess the client for Chvostek’s sign and D. They may be fine, medium, or course.
Trousseau’s sign because they indicate 63. A woman whose husband was
which of the following? recently diagnosed with active pulmonary
tuberculosis (TB) is a tuberculin skin test
A. hypocalcemia converter. Management of her care would
B. hypercalcemia
include:
C. hypokalemia
D. Hyperkalemia A. scheduling her for annual tuberculin skin
58. In a client with enteritis and frequent testing
diarrhea, the nurse should anticipate an B. placing her in quarantine until sputum cultures
acidbase imbalance of: are negative
C. gathering a list of persons with whom she has
A. respiratory acidosis had recent contact
B. respiratory alkalosis D. advising her to begin prophylactic therapy
C. metabolic acidosis with isoniazid (INH)
D. metabolic alkalosis 64. The nurse is caring for a client who
ahs had an above the knee amputation.
 The client refuses to look at the stump. warm to touch and necrotizing fasciitis is
When the nurse attempts to speak with suspected. Another manifestation that
the client about his surgery, he tells the would most suggest necrotizing fasciitis
nurse that he doesn’t wish to discuss it. is:
The client also refuses to have his family
A. erythema
visit. The nursing diagnosis that best B. leukocytosis
describes the client’s problem is: C. pressure-like pain
D. swelling
A. Hopelessness
B. Powerlessness 69. A 28 yr-old nurse has complaints of
C. Disturbed body image itching and a rash of both hands. Contact
D. Fear dermatitis is initially suspected. The
65. A client with three children who is still diagnosis is confirmed if the rash
I the child bearing years is admitted for appears:
surgical repair of a prolapsed bladder.
A. erythematous with raised papules
The nurse would find that the client B. dry and scaly with flaking skin
understood the surgeon’s preoperative C. inflamed with weeping and crusting lesions
teaching when the client states: D. excoriated with multiple fissures
70. When assessing a client with partial
A. “If I should become pregnant again, the child
would be delivered by cesarean delivery.” thickness burns over 60% of the body,
B. “If I have another child, the procedure may which of the following should the nurse
need to be repeated.” report immediately?
C. “This surgery may render me incapable of
conceiving another child.” A. Complaints of intense thirst
D. “This procedure is accomplished in two B. Moderate to severe pain
separate surgeries.” C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice
66. A client experiences problems in body
71. A client is admitted to the hospital
temperature regulation associated with a
following a burn injury to the left hand and
skin impairment. Which gland is most
arm. The client’s burn is described as
likely involved?
white and leathery with no blisters. Which
A. Eccrine degree of severity is this burn?
B. Sebaceous
C. Apocrine A. first-degree burn
D. Endocrine B. second-degree burn
67. A school cafeteria worker comes to C. third-degree burn
D. fourth-degree burn
the physician’s office complaining of
severe scalp itching. On inspection, the 72. The nurse is caring for client with a
nurse finds nail marks on the scalp and new donor site that was harvested to treat
small light-colored round specks attached a new burn. The nurse position the client
to the hair shafts close to the scalp. to:
These findings suggest that the client A. allow ventilation of the site
suffers from: B. make the site dependent
C. avoid pressure on the site
A. scabies D. keep the site fully covered
B. head lice 73. a 45-yr-old auto mechanic comes to
C. tinea capitis
D. impetigo the physician’s office because an
exacerbation of his psoriasis is making it
68. Following a small-bowel resection, a
difficult to work. He tells the nurse that his
client develops fever and anemia. The
surface surrounding the surgical wound is
 finger joints are stiff and sore in the which intervention should the nurse
morning. The nurse should respond by: include in the plan of care?
A. Inquiring further about this problem because A. Turn and reposition the client a minimum of
psoriatic arthritis can accompany psoriasis every 8 hours.
vulgaris B. Vigorously massage lotion into bony
B. Suggesting he take aspirin for relief because prominences.
it’s probably early rheumatoid arthritis C. Post a turning schedule at the client’s bedside.
C. Validating his complaint but assuming it’s an D. Slide the client, rather than lifting when
adverse effect of his vocation turning.
D. Asking him if he has been diagnosed or 79. Following a full-thickeness (3rd
treated for carpal tunnel syndrome degree) burn of his left arm, a client is
74. The nurse is providing home care treated with artificial skin. The client
instructions to a client who has recently understands postoperative care of the
had a skin graft. Which instruction is most artificial skin when he states that during
important for the client to remember? the first 7 days after the procedure, he’ll
A. Use cosmetic camouflage techniques. restrict:
B. Protect the graft from direct sunlight.
A. range of motion
C. Continue physical therapy.
B. protein intake
D. Apply lubricating lotion to the graft site.
C. going outdoors
75. a 28 yr-old female nurse is seen in the D. fluid ingestion
employee health department for mild 80. A client received burns to his entire
itching and rash of both hands. Which of back and left arm. Using the Rule of
the following could be causing this Nines, the nurse can calculate that he has
reaction? sustained burns on what percentage of
A. possible medication allergies his body?
B. current life stressors she may be experiencing
A. 9%
C. chemicals she may be using and use of latex
B. 18%
gloves
C. 27%
D. recent changes made in laundry detergent or
D. 36%
bath soap.
81. The nurse is providing care for a client
76. The nurse assesses a client with
who has a sacral pressure ulcer with wet-
urticaria. The nurse understands that
to-dry dressing. Which guideline is
urticaria is another name for:
appropriate for a wet-to-dry dressing?
A. hives
B. a toxin A. The wound should remain moist form the
C. a tubercle dressing.
D. a virus B. The wet-to-dry dressing should be tightly
packed into the wound.
77. A client with psoriasis visits the
C. The dressing should be allowed to dry out
dermatology clinic. When inspecting the before removal.
affected areas, the nurse expects to see D. A plastic sheet-type dressing should cover the
which type of secondary lesion? wet dressing.
82. While in skilled nursing facility, a client
A. scale
B. crust contracted scabies, which is diagnosed
C. ulcer the day after discharge. The client is living
D. scar at her  daughter’s home with six other
78. The nurse is caring for a bedridden, persons. During her visit to the clinic, she
elderly adult. To prevent pressure ulcers, asks a staff nurse, “What should my
 family do?” the most accurate response C. Place the client on fluid restrictions
from the nurse is: D. Use a condom catheter instead of an invasive
one.
A. “All family members will need to be treated.” 87.The nurse is caring for a client who is
B. “If someone develops symptoms, tell him to to undergo a lumbar puncture to assess
see a physician right away.”
for the presence of blood in the
C. “Just be careful not to share linens and towels
with family members.” cerebrospinal fluid (CSF) and to measure
D. “After you’re treated, family members won’t CSF pressure. Which result would
be at risk for contracting scabies.” indicate n abnormality?
83. In an industrial accident, client who
A. The presence of glucose in the CSF.
weighs 155 lb (70.3 kg) sustained full- B. A pressure of 70 to 200 mm H2O
thickness burns over 40% of his body. C. The presence of red blood cells (RBCs) in the
He’s in the burn unit receiving fluid first specimen tube
resuscitation. Which observation shows D. A pressure of 00 to 250 mmH2O
that the fluid resuscitation is benefiting the 88. The nurse is administering eyedrops
client? to a client with glaucoma. To achieve
maximum absorption, the nurse should
A. A urine output consistently above 100
instill the eyedrop into the:
ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24 hours. A. conjunctival sac
C. Body temperature readings all within normal B. pupil
limits C. sclera
D. An electrocardiogram (ECG) showing no D. vitreous humor
arrhythmias. 89. A 52 yr-old married man with two
84. The nurse is reviewing the laboratory adolescent children is beginning
results of a client with rheumatoid rehabilitation following a cerebrovascular
arthritis. Which of the following laboratory accident. As the nurse is planning the
results should the nurse expect to find? client’s care, the nurse should recognize
A. Increased platelet count that his condition will affect:
B. Elevated erythrocyte sedimentation rate (ESR)
A. only himself
C. Electrolyte imbalance
B. only his wife and children
D. Altered blood urea nitrogen (BUN) and
C. him and his entire family
creatinine levels
D. no one, if he has complete recovery
85. Which nursing diagnosis takes the
90. Which action should take the highest
highest priority for a client with
priority when caring for a client with
Parkinson’s crisis?
hemiparesis caused by a cerebrovascular
A. Imbalanced nutrition: less than body accident (CVA)?
requirements
B. Ineffective airway clearance A. Perform passive range-of-motion (ROM)
C. Impaired urinary elimination exercises.
D. Risk for injury B. Place the client on the affected side.
C. Use hand rolls or pillows for support.
86. A client with a spinal cord injury and
D. Apply antiembolism stockings
subsequent urine retention receives
91. The nurse is formulating a teaching
intermittent catheterization every 4 hours.
plan for a client who has just experienced
The average catheterized urine volume
a transient ischemic attack (TIA). Which
has been 550 ml. The nurse should plan
fact should the nurse include in the
to:
teaching plan?
A. Increase the frequency of the catheterizations.
A. TIA symptoms may last 24 to 48 hours.
B. Insert an indwelling urinary catheter
B. Most clients have residual effects after having B. Droplet precautions
a TIA. C. Airborne precautions
C. TIA may be a warning that the client may D. Standard precautions
have cerebrovascular accident (CVA) 97. A young man was running along an
D. The most common symptom of TIA is the ocean pier, tripped on an elevated area of
inability to speak.
the decking, and struck his head on the
92. The nurse has just completed
pier railing. According to his friends, “He
teaching about postoperative activity to a
was unconscious briefly and then became
client who is going to have a cataract
alert and behaved as though nothing had
surgery. The nurse knows the teaching
happened.” Shortly afterward, he began
has been effective if the client:
complaining of a headache and asked to
A. coughs and deep breathes postoperatively be taken to the emergency department. If
B. ties his own shoes the client’s intracranial pressure (ICP) is
C. asks his wife to pick up his shirt from the increasing, the nurse would expect to
floor after he drops it. observe which of the
D. States that he doesn’t need to wear an
following signs first?
eyepatch or guard to bed
93. The least serious form of brain A. pupillary asymmetry
trauma, characterized by a brief loss of B. irregular breathing pattern
consciousness and period of confusion, is C. involuntary posturing
called: D. declining level of consciousness
98. Emergency medical technicians
A. contusion transport a 28 yr-old iron worker to the
B. concussion emergency department. They tell the
C. coup
nurse, “He fell from a two-story building.
D. contrecoup
He has a large contusion on his left chest
94. When the nurse performs a
and a hematoma in the left parietal area.
neurologic assessment on Anne Jones,
He has compound fracture of his left
her pupils are dilated and don’t respond
femur and he’s comatose. We intubated
to light.
him and he’s maintaining an arterial
A. glaucoma oxygen saturation of 92% by pulse
B. damage to the third cranial nerve oximeter with a manual-resuscitation
C. damage to the lumbar spine
bag.” Which intervention by the nurse has
D. Bell’s palsy
the highest priority?
95. A 70 yr-old client with a diagnosis of
leftsided cerebrovascular accident is A. Assessing the left leg
admitted to the facility. To prevent the B. Assessing the pupils
development of diffuse osteoporosis, C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness
which of the following objectives is most
99. Alzheimer’s disease is the secondary
appropriate?
diagnosis of a client admitted with
A. Maintaining protein levels. myocardial infarction. Which nursing
B. Maintaining vitamin levels. intervention should appear on this client’s
C. Promoting weight-bearing exercises
plan of care?
D. Promoting range-of-motion (ROM) exercises
96. A client is admitted with a diagnosis of A. Perform activities of daily living for the client
meningitis caused by Neisseria to decease frustration.
meningitides. The nurse should institute B. Provide a stimulating environment.
C. Establish and maintain a routine.
which type of isolation precautions?
D. Try to reason with the client as much as
A. Contact precautions possible.
 100. For a client with a head injury whose 6. ANS: D
neck has been stabilized, the preferred Diabetes insipidus is an abrupt onset of
extreme polyuria that commonly occurs in
bed position is:
clients after brain surgery. Cushing’s
A. Trendelenburg’s syndrome is excessive glucocorticoid
B. 30-degree head elevation secretion resulting in sodium and water
C. flat retention. Diabetes mellitus is a
D. side-lying hyperglycemic state marked by polyuria,
Answers and Rationales polydipsia, and polyphagia. Adrenal crisis is
1. ANS: D undersecretion of glucocorticoids resulting in
Because the client’s gag reflex is absent, profound hypoglycemia, hypovolemia, and
elevating the head of the bed to 30 degrees hypotension.
helps minimize the client’s risk of aspiration. 7. ANS: C
Checking the stools, performing ROM The client should report the presence of
exercises, and keeping the skin clean and dry foulsmelling or cloudy urine. Unless
are important, but preventing aspiration contraindicated, the client should be instructed
through positioning is the priority. to drink large quantities of fluid each day to
2. ANS: A flush the kidneys. Sand-like debris is normal
Any hole, no matter how small, will destroy because of residual stone products. Hematuria
the odor-proof seal of a drainage bag. is common after lithotripsy.
Removing the bag or unclamping it is the only 8. ANS: A
appropriate method for relieving gas. A serum glucose level of 618 mg/dl indicates
3. ANS: A hyperglycemia, which causes polyuria and
because celiac disease destroys the absorbing deficient fluid volume. In this client,
surface of the intestine, fat isn’t absorbed but tachycardia is more likely to result from
is passed in the stool. Steatorrhea is bulky, deficient fluid volume than from decreased
fatty stools that have a foul odor. Jaundiced cardiac output because his blood pressure is
sclerae result from elevated bilirubin levels. normal. Although the client’s serum glucose
Clay-colored stools are seen with biliary is elevated, food isn’t a priority because fluids
disease when bile flow is blocked. Celiac and insulin should be administered to lower
disease doesn’t cause a widened pulse the serum glucose level. Therefore, a
pressure. diagnosis of Imbalanced Nutrition: Less then
4. ANS: D body requirements isn’t appropriate. A
Reducing sodium intake reduces fluid temperature of 100.6º F isn’t life threatening,
retention. Fluid retention increases blood eliminating ineffective thermoregulation as
volume, which changes blood vessel the top priority.
permeability and allows plasma to move into 9. ANS: C
interstitial tissue, causing edema. Urea Regular insulin, which is a short-acting
nitrogen excretion can be increased only by insulin, has an onset of 15 to 30 minutes and a
improved renal function. Sodium intake peak of 2 to 4 hours. Because the nurse gave
doesn’t affect the glomerular filtration rate. the insulin at 2 p.m., the expected onset would
Potassium absorption is improved only by be from 2:15 to 2:30 p.m. and the peak from 4
increasing the glomerular filtration rate; it p.m. to 6 p.m.
isn’t affected by sodium intake. 10.ANS: A
5. ANS: D CPP is derived by subtracting the ICP from
The portion of the cerebrum that controls the mean arterial pressure (MAP). For
speech and hearing is the temporal lobe. adequate cerebral perfusion to take place, the
Injury to the frontal lobe causes personality minimum goal is 70 mmHg. The MAP is
changes, difficulty speaking, and disturbance derived using the following formula:
in memory, reasoning, and concentration. MAP = ((diastolic blood pressure x 2) +
Injury to the parietal lobe causes sensory systolic blood pressure) / 3
alterations and problems with spatial MAP = ((60 x2) + 90) / 3
relationships. Damage to the occipital lobe MAP = 70 mmHg
causes vision disturbances. To find the CPP, subtract the client’s ICP
 from the MAP; in this case , 70 mmHg – 18 causes them to bulge, leading to rupture and
mmHg = 52 mmHg. bleeding into the lower esophagus. Bleeding
11.ANS: B associated with esophageal varices doesn’t
Breast cancer tumors are fixed, hard, and stem from esophageal perforation, pulmonary
poorly delineated with irregular edges. Nipple hypertension, or peptic ulcers.
retraction —not eversion—may be a sign of 18.ANS: B
cancer. A mobile mass that is soft and easily Complex intra-articular fractures are repaired
delineated is most often a fluid-filled with external fixators because they have a
benigned cyst. Axillary lymph nodes may or better long-term outcome than those treated
may not be palpable on initial detection of a with casting. This is especially true in a young
cancerous mass. client. The incidence of complications, such
12.ANS: D as pin tract infections and neuritis, is 20% to
An enterostomal nurse therapist is a registered 60%. Clients must be taught how to do pin
nurse who has received advance education in care and assess for development of
an accredited program to care for clients with neurovascular complications.
stomas. The enterostomal nurse therapist can 19.ANS: C
assist with selection of an appropriate stoma In a client with chronic renal failure,
site, teach about stoma care, and provide unrestricted intake of sodium, protein,
emotional support. potassium, and fluids may lead to a dangerous
13.ANS: A accumulation of electrolytes and protein
Ottorrhea and rhinorrhea are classic signs of metabolic products, such as amino acids and
basilar skull fracture. Injury to the dura ammonia. Therefore, the client must limit his
commonly occurs with this fracture, resulting intake of sodium, meat (high in Protein),
in cerebrospinal fluid (CSF) leaking through bananas (high in potassium), and fluid
the ears and nose. Any fluid suspected of because the kidneys can’t secrete adequate
being CSF should be checked for glucose or urine.
have a halo test done. 20.ANS: D
14.ANS: D The client isn’t withdrawn or showing other
Testicular cancer commonly occurs in men signs of anxiety or depression. Therefore, the
between ages 20 and 30. A male client should nurse can probably safely approach her about
be taught how to perform testicular self- talking with others who have had similar
examination before age 20, preferably when experiences, either through Reach for
he enters his teens. Recovery or another formal support group.
15.ANS: B The nurse may educate the client’s spouse or
Before weaning a client from mechanical partner to listen to concerns, but the nurse
ventilation, it’s most important to have a shouldn’t tell the client’s spouse what to do.
baseline ABG levels. During the weaning The client must consult with her physician
process, ABG levels will be checked to assess and make her own decisions
how the client is tolerating the procedure. about further treatment. The client needs to
Other assessment parameters are less critical. express her sadness, frustration, and fear. She
Measuring fluid volume intake and output is can’t be expected to be cheerful at all times.
always important when a client is being 21.ANS: C
mechanically ventilated. Prior attempts at HCG is one of the tumor markers for
weaning and ECG results are documented on testicular cancer. The HCG level won’t
the client’s record, and the nurse can refer to identify the site of an infection or evaluate
them before the weaning process begins. prostatic function or testosterone level.
16.ANS: B 22.ANS: B
According to the ACS guidelines, “Women Peripheral edema is a sign of fluid volume
older than age 40 should perform breast overload and worsening heart failure. A skin
selfexamination monthly (not annually).” The rash, dry cough, and postural hypotension are
hormonal receptor assay is done on a known adverse reactions to captopril, but the don’t
breast tumor to determine whether the tumor indicate that therapy isn’t effective.
is estrogen- or progesterone-dependent. 23.ANS: A
17.ANS: C Tenting of chest skin when pinched indicates
Increased pressure within the portal veins decreased skin elasticity due to dehydration.
 Hand veins fill slowly with dehydration, not sterile. The containers should be opened
rapidly. A pulse that isn’t easily obliterated before sterile gloves are put on and the
and neck vein distention indicate fluid solution poured over the sterile dressings
overload, not dehydration. placed in a sterile basin. Wounds should be
24.ANS: B cleaned from the most contaminated area to
The client should be encouraged to increase the least contaminated area—for example,
his activity level. Maintaining an ideal weight; from the center outward. The outer inch of a
following a low-cholesterol, low-sodium diet; sterile field shouldn’t be considered sterile.
and avoiding stress are all important factors in 30.ANS: C
decreasing the risk of atherosclerosis. Caffeine is a stimulant, which can exacerbate
25.ANS: B palpitations and should be avoided by a client
Because thrombocytopenia impairs blood with symptomatic mitral valve prolapse. High
clotting, the nurse should assess the client fluid intake helps maintain adequate preload
regularly for signs of bleeding, such as and cardiac output. Aerobic exercise helps in
petechiae, purpura, epistaxis, and bleeding increase cardiac output and decrease heart
gums. The nurse should avoid administering rate. Protein-rich foods aren’t restricted but
aspirin because it can increase the risk of high calorie foods are.
bleeding. Frequent rest periods are indicated 31.ANS: A
for clients with anemia, not Excessive of aldosterone in the adrenal cortex
thrombocytopenia. Strict isolation is indicated is responsible for the client’s hypertension.
only for clients who have highly contagious or This hormone acts on the renal tubule, where
virulent infections that are spread by air or it promotes reabsorption of sodium and
physical contact. excretion of potassium and hydrogen ions.
26.ANS: B The pancreas mainly secretes hormones
SaO2 is the degree to which hemoglobin is involved in fuel metabolism. The adrenal
saturated with oxygen. It doesn’t indicate the medulla secretes the cathecolamines—
client’s overall Hgb adequacy. Thus, an epinephrine and norepinephrine. The
individual with a subnormal Hgb level could parathyroids secrete parathyroid hormone.
have normal SaO2 and still be short of breath. 32.ANS: D
In this case, the nurse could assume that the A heart valve prosthesis, such as a mitral
client has a Hematologic problem. Poor valve replacement, is a major risk factor for
peripheral perfusion would cause subnormal infective endocarditis. Other risk factors
SaO2. There isn’t enough data to assume that include a history of heart disease (especially
the client’s problem is psychosomatic. If the mitral valve prolapse), chronic debilitating
problem were disease, IV drug abuse, and
left-sided heart failure, the client would immunosuppression. Although diabetes
exhibit pulmonary crackles. mellitus may predispose a person to
27.ANS: A cardiovascular disease, it isn’t a major risk
Addisonian crisis results in Hyperkalemia; factor for infective endocarditis, nor is an
therefore, administering potassium chloride is appendectomy or pernicious anemia.
contraindicated. Because the client will be 33.ANS: A
hyponatremic, normal saline solution is The client has signs and symptoms of diabetes
indicated. Hydrocortisone and fludrocortisone insipidus, probably caused by the failure of
are both useful in replacing deficient adrenal her renal tubules to respond to antidiuretic
cortex hormones. hormone as a consequence of pyelonephritis.
28.ANS: D The hypernatremia is secondary to her water
Leukemia is manifested by an abnormal loss. Imbalanced nutrition related to
overpopulation of immature leukocytes in the hypermetabolic state or catabolic effect of
bone marrow. insulin deficiency is an inappropriate nursing
29.ANS: C diagnosis for the client.
A sterile field is considered contaminated 34.ANS: C
when it becomes wet. Moisture can act as a When performing a nutritional assessment,
wick, allowing microorganisms to one of the first things the nurse should do is to
contaminate the field. The outside of assess what the client typically eats. The client
containers, such as sterile saline bottles, aren’t shouldn’t be permitted to eat as desired.
 Weighing the client daily, placing her on I & can cause bleeding. Suction should be applied
O status, and drawing blood to determine continuously, not every hour. The NG tube
electrolyte level aren’t part of a nutritional shouldn’t be clamped postoperatively because
assessment. secretions and gas will accumulate, stressing
35.Ans. C the suture line.
Regular follow-up care for the client with 39.ANS: A
Grave’s disease is critical because most cases Regardless of the client’s medical history,
eventually result in hypothyroidism. Annual rapid fluid resuscitation is critical for
thyroid-stimulating hormone tests and the maintaining cardiovascular integrity.
client’s ability to recognize signs and Profound intravascular depletion requires
symptoms of thyroid dysfunction will help aggressive fluid replacement. A typical fluid
detect thyroid abnormalities early. Intake and resuscitation protocol is 6 L of fluid over the
output is important for clients with fluid and first 12 hours, with more fluid to follow over
electrolyte imbalances but not thyroid the next 24 hours. Various fluids can be used,
disorders. DDAVP is used to treat diabetes depending on the degree of hypovolemia.
insipidus. While exercise to improve Commonly prescribed fluids include dextran
cardiovascular fitness is important, for this (in case of hypovolemic shock), isotonic
client the importance of regular follow-up is normal saline solution and, when the client is
most critical. stabilized, hypotonic half-normal saline
36.ANS: D solution.
Anxiety related to the threat of death is an 40.ANS: D
appropriate nursing diagnosis because the Glipizide may cause adverse skin reactions,
client’s anxiety can adversely affect hear rate such as pruritus, and photosensitivity. It
and rhythm by stimulating the autonomic doesn’t cause headache, constipation, or
nervous system. Also, because the client hypotension.
required resuscitation, the threat of death is a 41.ANS: B
real and immediate concern. Unless anxiety is When clients are on mechanical ventilation,
dealt with first, the client’s emotional state the artificial airway impairs the gag and cough
will impede learning. Client teaching should reflexes that help keep organisms out of the
be limited to clear concise explanations that lower respiratory tract. The artificial airway
reduce anxiety and promote cooperation. An also prevents the upper respiratory system
anxious client has difficulty learning, so the from humidifying and heating air to enhance
deficient knowledge would continue despite mucociliary clearance. Manipulations of the
attempts teaching. Impaired physical mobility artificial airway sometimes allow secretions
and social isolation are necessitated by the into the lower airways. Whit standard
client’s critical condition; therefore, they procedures the other choices wouldn’t be at
aren’t considered problems warranting high risk.
nursing diagnoses. 42.ANS: C
37.ANS: A In chronic bronchitis, the diaphragmatic is flat
Because tuberculosis is transmitted by droplet and weak. Diaphragmatic breathing helps to
nuclei from the respiratory tract, the nurse strengthen the diaphragm and maximizes
should put on a mask when entering the ventilation. Exhalation should longer than
client’s room. Having the client wear a mask inhalation to prevent collapse of the
at all the times would hinder sputum bronchioles. The client with chronic
expectoration and make the mask moist from bronchitis should exhale through pursed lips
respirations. If no contact with the client’s to prolong exhalation, keep the bronchioles
blood or body fluids is anticipated, the nurse from collapsing, and prevent air trapping.
need not wear a gown or gloves when Diaphragmatic breathing—not chest breathing
providing direct care. A client with —increases lung expansion.
tuberculosis should be in a room with laminar 43.ANS: A
air flow, and the door should be closed at all Verbalizing the observed behavior is a
times. therapeutic communication technique in
38.ANS: C which the nurse acknowledges what the client
The nurse can gently irrigate the tube but must is feeling. Offering to listen to the client
take care not to reposition it. Repositioning express her anger can help the nurse and the
 client understand its cause and begin to deal 50.ANS: D
with it. Although stress can exacerbate the Because respirations are depressed in
symptoms of SLE, telling the client to calm myxedema coma, maintaining a patent airway
down doesn’t acknowledge her feelings. is the most critical nursing intervention.
Offering to get the nursing supervisor also Ventilatory support is usually needed. Thyroid
doesn’t acknowledge the client’s feelings. replacement will be administered IV.
Ignoring the client’s feelings suggest that the Although myxedema coma is associated with
nurse has no interest in what the client has severe hypothermia, a warming blanket
said. shouldn’t be used because it may cause
44.ANS: A vasodilation and shock. Gradual warming
Daily walks relieve symptoms of intermittent blankets would be appropriate. Intake and
claudication, although the exact mechanism is output are very important but aren’t critical
unclear. Anaerobic exercise may exacerbate interventions at this time.
these symptoms. Clients with chronic arterial 51.ANS: A
occlusive disease must reduce daily fat intake Glipizide begins to act in 15 to 30 minutes.
to 30% or less of total calories. The client The other options are incorrect.
should limit dietary cholesterol because 52.ANS: A
hyperlipidemia is associated with Hypoxia is the main breathing stimulus for a
atherosclerosis, a known cause of arterial client with COPD. Excessive oxygen
occlusive disease. However, HDLs have the administration may lead to apnea by removing
lowest cholesterol concentration, that stimulus. Anginal pain results from a
so this client should eat foods that raise HDL reduced myocardial oxygen supply. A client
levels. with COPD may have anginal pain from
45.ANS: A generalized vasoconstriction secondary to
Gastric decompression is typically low hypoxia; however, administering oxygen at
pressure and intermittent. High pressure and any concentration dilates blood vessels, easing
continuous gastric suctioning predisposes the anginal pain. Respiratory alkalosis results
gastric mucosa to injury and ulceration. from alveolar hyperventilation, not excessive
46.ANS: A oxygen administration. In a client with COPD,
In osteoarthritis, stiffness is common in large, high oxygen concentrations decrease the
weight bearing joints such as the hips. This ventilatory drive, leading to respiratory
joint stiffness alters functional ability and acidosis, not alkalosis. High oxygen
range of motion, placing the client at risk for concentrations don’t cause metabolic acidosis.
falling and injury. Therefore, client safety is 53.ANS: C
in jeopardy. Osteoporosis doesn’t affect Continuous subcutaneous insulin regimen
urinary elimination, breathing, or nutrition. uses a basal rate and boluses of short-acting
47.ANS: A insulin. Multiple daily injection therapy uses a
PTH stimulates the kidneys to reabsorb combination of short-acting and intermediate
calcium and excrete phosphate and converts or long-acting insulins.
vit D to its active form: 1 , 25 dihydroxy 54.ANS: B
vitamin D. PTH doesn’t have a role in the Holding a cane on the uninvolved side
metabolism of Vit E. distributes weight away from the involved
48.ANS: C side. Holding the cane close to the body
The presence of unsecured area rugs poses a prevents leaning. Use of a cane won’t
hazard in all homes, particularly in one with a maintain stride length or prevent edema.
resident at high risk for falls. 55.ANS: D
49.ANS: B High pulmonary artery wedge pressures are
Autonomy ascribes the right of the individual diagnostic for left-sided heart failure. With
to make his own decisions. In this case, the leftsided heart failure, pulmonary edema can
client is capable of making his own decision develop causing pulmonary crackles. In
and the nurse should support his autonomy. leftsided heart failure, hypotension may result
Beneficence and justice aren’t the principles and urine output will decline. Dry mucous
that directly relate to the situation. Advocacy membranes aren’t directly associated with
is the nurse’s role in supporting the principle elevated pulmonary artery wedge pressures.
of autonomy.
56.ANS: B the burn extends to the dermal and
It’s mandatory in most settings to have a subcutaneous skin layers. Body image
physician’s order before restraining a client. A disturbance is a concern that has a lower
client should never be left alone while the priority than pain management.
nurse summons assistance. All staff members 62.ANS: D
require annual instruction on the use of Crackles result from air moving through
restraints, and the nurse should be familiar airways that contain fluid. Heard during
with the facility’s policy. inspiration and expiration, crackles are
57.ANS: A discrete sounds that vary in pitch and
The client who has undergone a intensity. They’re classified as fine, medium,
thyroidectomy is t risk for developing or coarse. Pleural friction rubs have a
hypocalcemia from inadvertent removal or distinctive grating sound. As the name
damage to the parathyroid gland. The client indicates, these breath sounds result when
with hypocalcemia will exhibit a positive inflamed pleurae rub together. Continuous,
Chvostek’s sign (facial muscle contraction highpitched, musical squeaks, called wheezes,
when the facial nerve in front of the ear is result when air moves rapidly through airways
tapped) and a positive Trousseau’s sign narrowed by asthma or infection or when an
(carpal spasm when a blood pressure cuff is airway is partially obstructed by a tumor or
inflated for few minutes). These signs aren’t foreign body. Wheezes, like gurgles, occur on
present with hypercalcemia, hypokalemia, or expiration and sometimes on inspiration.
Hyperkalemia. Loud, coarse, low-pitched sounds resembling
58.ANS: C snoring are called gurgles. These sounds
Diarrhea causes a bicarbonate deficit. With develop when thick secretions partially
loss of the relative alkalinity of the lower GI obstruct airflow through the large upper
tract, the relative acidity of the upper GI tract airways.
predominates leading to metabolic acidosis. 63.Ans. D
Diarrhea doesn’t lead to respiratory acid-base Individuals who are tuberculin skin test
imbalances, such as respiratory acidosis and converters should begin a 6-month regimen of
respiratory alkalosis. Loss of acid, which an antitubercular drug such as INH, and they
occurs with severe vomiting, may lead to should never have another skin test. After an
metabolic alkalosis. individual has a positive tuberculin skin test,
59.ANS: B subsequent skin tests will cause severe skin
The head of the bed must be elevated while reactions but won’t provide new information
the client is eating. The client should be about the client’s TB status. The client doesn’t
placed in a recumbent position—not a supine have active TB, so can’t transmit, or spread,
position— when lying down to reduce the risk the bacteria. Therefore, she shouldn’t be
of aspiration. Encourage the client to wear quarantined or asked for information about
properly fitted dentures to enhance his recent contacts.
chewing ability. Thickened liquids, not thin 64.ANS: C
liquids, decrease aspiration risk. Disturbed body image is a negative perception
60.ANS: A of the self that makes healthful functioning
Endotracheal suctioning secretions as well as more difficult. The defining characteristics for
gases from the airway and lowers the arterial this nursing diagnosis include undergoing a
oxygen saturation (SaO2) level. Coughing and change in body structure or function, hiding or
incentive spirometry improve oxygenation overexposing a body part, not looking at a
and should raise or maintain oxygen body part, and responding verbally or
saturation. Because of superficial nonverbally to the actual or perceived change
vasoconstriction, using a cooling blanket can in structure or function. This client may have
lower peripheral oxygen saturation readings, any of the other diagnoses, but the signs and
but SaO2 levels wouldn’t be affected. symptoms described in he case most closely
61.ANS: D match the defining characteristics for
With a superficial partial thickness burn such disturbed body image.
as a solar burn (sunburn), the nurse’s main 65.ANS: B
concern is pain management. Fluid Because the pregnant uterus exerts a lot of
resuscitation and infection become concerns if pressure on the urinary bladder, the bladder
 repair may need to be repeated. These clients with a burn injury. The client’s output is
don’t necessarily have to have a cesarean adequate.
delivery if they become pregnant, and this 71.ANS: C
procedure doesn’t render them sterile. This Third-degree burn may appear white, red, or
procedure is completed in one surgery. black and are dry and leathery with no
66.ANS: A blisters. There may be little pain because
Eccrine glands are associated with body nerve endings have been destroyed. First-
temperature regulation. Sebaceous glands degree burns are superficial and involve the
lubricate the skin and hairs, and apocrine epidermis only. There is local pain and
glands are involved in bacteria decomposition. redness but no blistering. Second-degree burn
Endocrine glands secrete hormones appear red and moist with blister formation
responsible for the regulation of body and are painful. Fourth-degree burns involve
processes, such as metabolism and glucose underlying muscle and bone tissue.
regulation. 72.ANS: C
67.ANS: B A universal concern I the care of donor sites
The light-colored spots attached to the hair for burn care is to keep the site away from
shafts are nits, which are the eggs of head lice. sources of pressure. Ventilation of the site and
They can’t be brushed off the hair shaft like keeping the site fully covered are practices in
dandruff. Scabies is a contagious dermatitis some institutions but aren’t hallmarks of
caused by the itch mite, Sacoptes scabiei, donor site care. Placing the site in a position
which lives just beneath the skin. Tinea of dependence isn’t a justified aspect of donor
capitis, or ringworm, causes patchy hair loss site care.
and circular lesions with healing centers. 73.ANS: A
Impetigo is an infection caused by Anyone with psoriasis vulgaris who reports
Staphylococcus or Sterptococcus, manifested joint pain should be evaluated for psoriaic
by vesicles or pustules that form a thick, arthritis. Approximately 15% to 20% of
honey-colored crust. individuals with psoriasis will also develop
68.ANS: C psoriatic arthritis, which can be painful and
Severe pressure-like pain out of proportion to cause deformity. It would be incorrect to
visible signs distinguishes necrotizing fasciitis assume that his pain is caused by early
from cellulites. Erythema, leukocytosis, and rheumatoid arthritis or his vocation without
swelling are present in both cellulites and asking more questions or performing
necrotizing fasciitis. diagnostic studies. Carpal tunnel syndrome
69.ANS: A causes sensory and motor changes in the
Contact dermatitis is caused by exposure to a fingers rather than localized pain in the joints.
physical or chemical allergen, such as 74.ANS: B
cleaning products, skin care products, and To avoid burning and sloughing, the client
latex gloves. Initial symptoms of itching, must protect the graft from sunlight. The other
erythema, and raised papules occur at the site three interventions are all helpful to the client
of the exposure and can begin within 1 hour and his recovery but are less important.
of exposure. Allergic reactions tend to be red 75.ANS: C
and not scaly or flaky. Weeping, crusting Because the itching and rash are localized, an
lesions are also uncommon unless the reaction environmental cause in the workplace should
is quite severe or has been present for a long be suspected. With the advent of universal
time. Excoriation is more common in skin precautions, many nurses are experiencing
disorders associated with a moist allergies to latex gloves. Allergies to
environment. medications, laundry detergents, or bath soaps
70.ANS: D or a dermatologic reaction to stress usually
Hoarseness indicate injury to the respiratory elicit a more generalized or widespread rash.
system and could indicate the need for 76.ANS: A
immediate intubation. Thirst following burns Hives and urticaria are two names for the
is expected because of the massive fluid shifts same skin lesion. Toxin is a poison. A
and resultant loss leading to dehydration. tubercle is a tiny round nodule produced by
Pain, either severe or moderate, is expected the tuberculosis bacillus. A virus is an
infectious parasite.
77.ANS: A ml/kg/hour. Thus, the expected urine output of
A scale is the characteristic secondary lesion a 155-lb client is 35 ml/hour, and a urine
occurring in psoriasis. Although crusts, ulcers, output consistently above 100 ml/hour is more
and scars also are secondary lesions in skin than adequate. Weight gain from fluid
disorders, they don’t accompany psoriasis. resuscitation isn’t a goal. In fact, a 4 lb weight
78.ANS: C gain in 24 hours suggests third spacing. Body
A turning schedule with a signing sheet will temperature readings and ECG interpretations
help ensure that the client gets turned and may demonstrate secondary benefits of fluid
thus, help prevent pressure ulcers. Turning resuscitation but aren’t primary indicators.
should occur every 1-2 hours—not every 8 84. ANS: B
hours—for clients who are in bed for The ESR test is performed to detect
prolonged periods. The nurse should apply inflammatory processes in the body. It’s a
lotion to keep the skin moist but should avoid nonspecific test, so the health care
vigorous massage, which could damage professional must view results in conjunction
capillaries. When moving the client, the nurse with physical signs and symptoms. Platelet
should lift rather than slide the client to void count, electrolytes, BUN, and creatinine levels
shearing. aren’t usually affected by the inflammatory
79.ANS: A process.
To prevent disruption of the artificial skin’s 85.ANS: B
adherence to the wound bed, the client should In Parkinson’s crisis, dopamine-related
restrict range of motion of the involved limb. symptoms are severely exacerbated, virtually
Protein intake and fluid intake are important immobilizing the client. A client who is
for healing and regeneration and shouldn’t be confined to bed during a crisis is at risk for
restricted. Going outdoors is acceptable as aspiration and pneumonia. Also, excessive
long as the left arm is protected from direct drooling increases the risk of airway
sunlight. obstruction. Because of these concerns,
80.ANS: C ineffective airway clearance is the priority
According to the Rule of Nines, the posterior diagnosis for this client. Although imbalanced
and anterior trunk, and legs each make up nutrition:less than body requirements,
18% of the total body surface. The head, neck, impaired urinary elimination and risk for
and arms each make up 9% of total body injury also are appropriate diagnoses for this
durface, and the perineum makes up 1%. In client, they aren’t immediately lifethreatening
this case, the client received burns to his back and thus are less urgent.
(18%) and one arm (9%), totaling 27%. 86.ANS: A
81.ANS: A As a rule of practice, if intermittent
A wet-to-dry saline dressing should always catheterization for urine retention typically
keep the wound moist. Tight packing or dry yields 500 ml or more, the frequency of
packing can cause tissue damage and pain. A catheterization should be increased.
dry gauze —not a plastic-sheet-type dressing Indwelling catheterization is less preferred
—should cover the wet dressing. because of the risk of urinary tract infection
82.ANS: A and the loss of bladder tone. Fluid restrictions
When someone in a group of persons sharing aren’t indicated for this case; the problem
a home contracts scabies, each individual in isn’t overhydration, rather it’s urine retention.
the same home needs prompt treatment A condom catheter doesn’t help empty the
whether he’s symptomatic or not. Towels and bladder of a client with urine retention.
linens should be washed in hot water. Scabies 87.ANS: D
can be transmitted from one person to another The normal pressure is 70 to 200 mm H2O are
before symptoms develop considered abnormal. The presence of glucose
83.ANS: A is an expected finding in CSF, and RBCs
In a client with burns, the goal of fluid typically occur in the first specimen tube from
resuscitation is to maintain a mean arterial the trauma caused by the procedure.
blood pressure that provides adequate 88.ANS: A
perfusion of vital structures. If the kidneys are The nurse should instill the eyedrop into the
adequately perfused, they will produce an conjunctival sac where absorption can best
acceptable urine output of at least 0.5 take place. The pupil permits light to enter the
 eye. The sclera maintains the eye’s shape and levels is important, but neither will prevent
size. The vitreous humor maintains the osteoporosis. ROM exercises will help
retina’s placement and the shape of the eye. prevent muscle atrophy and contractures.
89.ANS: C 96.ANS: B
According to family theory, any change in a This client requires droplet precautions
family member, such as illness, produces role because the organism can be transmitted
changes in all family members and affects the through airborne droplets when the client
entire family, even if the client eventually coughs, sneezes, or doesn’t cover his mouth.
recovers completely. Airborne precautions would be instituted for a
90.ANS: B client infected with tuberculosis. Standard
To help prevent airway obstruction and reduce precautions would be instituted for a client
the risk of aspiration, the nurse should when contact with body substances is likely.
position a client with hemiparesis on the Contact precautions would be instituted for a
affected side. Although performing ROM client infected with an organism that is
exercises, providing pillows for support, and transmitted through skin-to-skin
applying antiembolism stockings can be contact.
appropriate for a client with CVA, the first 97.ANS: D
concern is to maintain a patent airway. With a brain injury such as an epidural
91.ANS: C hematoma (a diagnosis that is most likely
TIA may be a warning that the client will based on this client’s symptoms), the initial
experience a CVA, or stroke, in the near sign of increasing ICP is a change in the level
future. TIA aymptoms last no longer than 24 of consciousness. As neurologic deterioration
hours and clients usually have complete progresses, manifestations involving pupillary
recovery after TIA. The most common symmetry, breathing patterns, and posturing
symptom of TIA is sudden, painless loss of will occur.
vision lasting up to 24 hours. 98.ANS: A
92.ANS: C In the scenario, airway and breathing are
Bending to pick up something from the floor established so the nurse’s next priority should
would increase intraocular pressure, as would be circulation. With a compound fracture of
bending to tie his shoes. The client needs to the femur, there is a high risk of profuse
wear eye protection to bed to prevent bleeding; therefore, the nurse should assess
accidental injury during sleep. the site. Neurologic assessment is a secondary
93. ANS: B concern to airway, breathing and circulation.
Concussions are considered minor with no The nurse doesn’t have enough data to
structural signs of injury. A contusion is warrant putting the client in Trendelenburg’s
bruising of the brain tissue with small position.
hemorrhages in the tissue. Coup and 99.ANS: C
contrecoup are type of injuries in which the Establishing and maintaining a routine is
damaged area on the brain forms directly essential to decreasing extraneous stimuli. The
below that site of impact (coup) or at the client should participate in daily care as much
site opposite the injury (contrecoup) due to as possible. Attempting to reason with such
movement of the brain within the skull. clients isn’t successful, because they can’t
94.ANS: B participate in abstract thinking.
The third cranial nerve (oculomotor) is 100. ANS: B
responsible for pupil constriction. When there For clients with increased intracranial
is damage to the nerve, the pupils remain pressure (ICP), the head of the bed is elevated
dilated and don’t respond to light. Glaucoma, to promote venous outflow. Trendelenburg’s
lumbar spine injury, and Bell’s palsy won’t position is contraindicated because it can raise
affect pupil constriction. ICP. Flat or neutral positioning is indicated
95.ANS: C when elevating the head of the bed would
When the mechanical stressors of weight increase the risk of neck injury or airway
bearing are absent, diffuse osteoporosis can obstruction. Sidelying isn’t specifically a
occur. Therefore, if the client does weight- therapeutic treatment for increased ICP.
bearing exercises, disuse complications can be
prevented. Maintaining protein and vitamins
 PNLE 1 A. Tachycardia and Hypotension
B. Fever and Bradycardia
SITUATION : Arthur, A registered nurse, C. Bradycardia and Hypertension
witnessed an old woman hit by a D. Fever and Hypertension
motorcycle while crossing a train railway. SITUATION: Mr. D. Rojas, An obese 35
The old woman fell at the railway. Arthur year old MS Professor of OLFU Lagro is
rushed at the scene. admitted due to pain in his weight bearing
joint. The diagnosis was Osteoarthritis.
1. As a registered nurse, Arthur knew that
the first thing that he will do at the scene 6. As a nurse, you instructed Mr. Rojas
is how to use a cane. Mr. Rojas has a
A. Stay with the person, Encourage her to remain weakness on his right leg due to self
still and Immobilize the leg while While immobilization and guarding. You plan to
waiting for the ambulance. teach Mr. Rojas to hold the cane
B. Leave the person for a few moments to call
for help. A. On his left hand, because his right side is
C. Reduce the fracture manually. weak.
D. Move the person to a safer place. B. On his left hand, because of reciprocal
motion.
2. Arthur suspects a hip fracture when he
C. On his right hand, to support the right leg.
noticed that the old woman’s leg is D. On his right hand, because only his right leg is
A. A. Lengthened, Abducted and Internally weak.
Rotated. 7. You also told Mr. Rojas to hold the
B. Shortened, Abducted and Externally Rotated. cane
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally Rotated. A. 1 Inches in front of the foot.
B. 3 Inches at the lateral side of the foot.
3. The old woman complains of pain.
C. 6 Inches at the lateral side of the foot.
John noticed that the knee is reddened, D. 12 Inches at the lateral side of the foot.
warm to touch and swollen. John 8. Mr. Rojas was discharged and 6
interprets that this signs and symptoms months later, he came back to the
are likely related to emergency room of the hospital because
A. Infection he suffered a mild stroke. The right side
B. Thrombophlebitis of the brain was affected. At the
C. Inflammation rehabilitative phase of your nursing care,
D. Degenerative disease you observe Mr. Rojas use a cane and
4. The old woman told John that she has you intervene if you see him
osteoporosis; Arthur knew that all of the
following factors would contribute to A. Moves the cane when the right leg is moved.
B. Leans on the cane when the right leg swings
osteoporosis except
through.
A. Hypothyroidism C. keeps the cane 6 Inches out to the side of the
B. End stage renal disease right foot.
C. Cushing’s Disease D. Holds the cane on the right side.
D. Taking Furosemide and Phenytoin. SITUATION: Alfred, a 40 year old
5. Martha, The old woman was now construction worker developed cough,
Immobilized and brought to the night sweats and fever. He was brought
emergency room. The X-ray shows a to the nursing unit for diagnostic studies.
fractured femur and pelvis. The ER Nurse He told the nurse he did not receive a
would carefully monitor Martha for which BCG vaccine during childhood
of the following sign and symptoms?
 9. The nurse performs a Mantoux Test. B. II
The nurse knows that Mantoux Test is C. III
D. IV
also known as
16. How long is the duration of the
A. PPD maintenance phase of his treatment?
B. PDP
C. PDD A. 2 months
D. DPP B. 3 months
10. The nurse would inject the solution in C. 4 months
D. 5 months
what route?
17. Which of the following drugs is
A. IM UNLIKELY given to Mang Alfred during
B. IV the maintenance phase?
C. ID
D. SC A. Rifampicin
11. The nurse notes that a positive result B. Isoniazid
for Alfred is C. Ethambutol
D. Pyridoxine
A. 5 mm wheal 18. According to the DOH, the most
B. 5 mm Induration hazardous period for development of
C. 10 mm Wheal
clinical disease is during the first
D. 10 mm Induration
12. The nurse told Alfred to come back A. 6-12 months after
after B. 3-6 months after
C. 1-2 months after
A. a week D. 2-4 weeks after
B. 48 hours 19. This is the name of the program of the
C. 1 day
DOH to control TB in the country
D. 4 days
13. Mang Alfred returns after the Mantoux A. DOTS
Test. The test result read POSITIVE. B. National Tuberculosis Control Program
What should be the nurse’s next action? C. Short Coursed Chemotherapy
D. Expanded Program for Immunization
A. Call the Physician 20. Susceptibility for the disease [ TB ] is
B. Notify the radiology dept. for CXR evaluation increased markedly in those with the
C. Isolate the patient
following condition except
D. Order for a sputum exam
14. Why is Mantoux test not routinely A. 23 Year old athlete with diabetes insipidus
done in the Philippines? B. 23 Year old athlete taking long term Decadron
therapy and anabolic steroids
A. It requires a highly skilled nurse to perform a C. 23 Year old athlete taking illegal drugs and
Mantoux test abusing substances
B. The sputum culture is the gold standard of D. Undernourished and Underweight individual
PTB Diagnosis and it will definitively who undergone gastrectomy
determine the extent of the cavitary lesions 21. Direct sputum examination and Chest
C. Chest X Ray Can diagnose the specific
X ray of TB symptomatic is in what level
microorganism responsible for the lesions
D. Almost all Filipinos will test positive for of prevention?
Mantoux Test A. Primary
15. Mang Alfred is now a new TB patient B. Secondary
with an active disease. What is his C. Tertiary
category according to the DOH? D. Quarterly

A. I
 SITUATION: Michiel, A male patient B. Slow down the irrigation
diagnosed with colon cancer was newly C. Tell the client that cramping will subside and
is normal
put in colostomy.
D. Notify the physician
22. Michiel shows the BEST adaptation 28. The next day, the nurse will assess
with the new colostomy if he shows which Michiel’s stoma. The nurse noticed that a
of the following? prolapsed stoma is evident if she sees
which of the following?
A. Look at the ostomy site
B. Participate with the nurse in his daily ostomy A. A sunken and hidden stoma
care B. A dusky and bluish stoma
C. Ask for leaflets and contact numbers of C. A narrow and flattened stoma
ostomy support groups D. Protruding stoma with swollen appearance
D. Talk about his ostomy openly to the nurse and 29. Michiel asked the nurse, what foods
friends will help lessen the odor of his colostomy.
23. The nurse plans to teach Michiel The nurse best response would be
about colostomy irrigation. As the nurse
prepares the materials needed, which of A. Eat eggs
B. Eat cucumbers
the following item indicates that the nurse
C. Eat beet greens and parsley
needs further instruction? D. Eat broccoli and spinach
A. Plain NSS / Normal Saline 30. The nurse will start to teach Michiel
B. K-Y Jelly about the techniques for colostomy
C. Tap water irrigation. Which of the following should
D. Irrigation sleeve be included in the nurse’s teaching plan?
24. The nurse should insert the colostomy
tube for irrigation at approximately A. Use 500 ml to 1,000 ml NSS
B. Suspend the irrigant 45 cm above the stoma
A. 1-2 inches C. Insert the cone 4 cm in the stoma
B. 3-4 inches D. If cramping occurs, slow the irrigation
C. 6-8 inches 31. The nurse knew that the normal color
D. 12-18 inches of Michiel’s stoma should be
25. The maximum height of irrigation
solution for colostomy is A. Brick Red
B. Gray
A. 5 inches C. Blue
B. 12 inches D. Pale Pink
C. 18 inches SITUATION: James, A 27 basketball
D. 24 inches player sustained inhalation burn that
26. Which of the following behavior of the required him to have tracheostomy due to
client indicates the best initial step in massive upper airway edema.
learning to care for his colostomy?
32. Wilma, His sister and a nurse is
A. Ask to defer colostomy care to another
suctioning the tracheostomy tube of
individual
B. Promises he will begin to listen the next day James. Which of the following, if made by
C. Agrees to look at the colostomy Wilma indicates that she is committing an
D. States that colostomy care is the function of error?
the nurse while he is in the hospital
A. Hyperventilating James with 100% oxygen
27. While irrigating the client’s colostomy,
before and after suctioning
Michiel suddenly complains of severe B. Instilling 3 to 5 ml normal saline to loosen up
cramping. Initially, the nurse would secretion
C. Applying suction during catheter withdrawal
A. Stop the irrigation by clamping the tube
D. Suction the client every hour 38. Wilma knew that James have an
33. What size of suction catheter would adequate respiratory condition if she
Wilma use for James, who is 6 feet 5 notices that
inches in height and weighing
A. James’ respiratory rate is 18
approximately 145 lbs?
B. James’ Oxygen saturation is 91%
A. Fr. 5 C. There are frank blood suction from the tube
B. Fr. 10 D. There are moderate amount of
C. Fr. 12 tracheobronchial secretions
D. Fr. 18 39. Wilma knew that the maximum time
34. Wilma is using a portable suction unit when suctioning James is
at home, What is the amount of suction
A. 10 seconds
required by James using this unit? B. 20 seconds
A. 2-5 mmHg C. 30 seconds
B. 5-10 mmHg D. 45 seconds
C. 10-15 mmHg SITUATION : Juan Miguel Lopez Zobel
D. 20-25 mmHg Ayala de Batumbakal was diagnosed with
35. If a Wall unit is used, What should be Acute Close Angle Glaucoma. He is
the suctioning pressure required by being seen by Nurse Jet.
James?
40. What specific manifestation would
A. 50-95 mmHg nurse Jet see in Acute close angle
B. 95-110 mmHg glaucoma that she would not see in an
C. 100-120 mmHg
open angle glaucoma?
D. 155-175 mmHg
36. Wilma was shocked to see that the A. Loss of peripheral vision
Tracheostomy was dislodged. Both the B. Irreversible vision loss
inner and outer cannulas was removed C. There is an increase in IOP
D. Pain
and left hanging on James’ neck. What
41. Nurse jet knew that Acute close angle
are the 2 equipment’s at james’ bedside
glaucoma is caused by
that could help Wilma deal with this
situation? A. Sudden blockage of the anterior angle by the
base of the iris
A. New set of tracheostomy tubes and Oxygen B. Obstruction in trabecular meshwork
tank C. Gradual increase of IOP
B. Theophylline and Epinephrine D. An abrupt rise in IOP from 8 to 15 mmHg
C. Obturator and Kelly clamp
D. Sterile saline dressing 42. Nurse jet performed a TONOMETRY
test to Mr. Batumbakal. What does this
37. Which of the following method if used
test measures
by Wilma will best assure that the
tracheostomy ties are not too tightly A. It measures the peripheral vision remaining on
placed? the client
B. Measures the Intra Ocular Pressure
A. Wilma places 2 fingers between the tie and C. Measures the Client’s Visual Acuity
neck D. Determines the Tone of the eye in response to
B. The tracheotomy can be pulled slightly away the sudden increase in IOP.
from the neck 43. The Nurse notices that Mr.
C. James’ neck veins are not engorged
D. Wilma measures the tie from the nose to the Batumbakal cannot anymore determine
tip of the earlobe and to the xiphoid process. RED from BLUE. The nurse knew that
which part of the eye is affected by this
change?
A. IRIS A. Reading newsprint
B. PUPIL B. Lying down
C. RODS [RETINA] C. Watching TV
D. CONES [RETINA] D. Listening to the music
44. Nurse Jet knows that Aqueous Humor 51. If Mr. Batumbakal is receiving
is produce where? pilocarpine, what drug should always be
available in any case systemic toxicity
A. In the sub arachnoid space of the meninges
B. In the Lateral ventricles occurs?
C. In the Choroids A. Atropine Sulfate
D. In the Ciliary Body B. Pindolol [Visken]
45. Nurse Jet knows that the normal IOP C. Naloxone Hydrochloride [Narcan]
is D. Mesoridazine Besylate [Serentil]
SITUATION : Wide knowledge about the
A. 8-21 mmHg
B. 2-7 mmHg human ear, it’s parts and it’s functions will
C. 31-35 mmHg help a nurse assess and analyze
D. 15-30 mmHg changes in the adult client’s health.
46. Nurse Jet wants to measure Mr.
Batumbakal’s CN II Function. What test 52. Nurse Anna is doing a caloric testing
would Nurse Jet implement to measure to his patient, Aida, a 55 year old
CN II’s Acuity? university professor who recently went
into coma after being mauled by her
A. Slit lamp
disgruntled 3rd year nursing students
B. Snellen’s Chart
C. Wood’s light whom she gave a failing mark. After
D. Gonioscopy instilling a warm water in the ear, Anna
47. The Doctor orders pilocarpine. Nurse noticed a rotary nystagmus towards the
jet knows that the action of this drug is to irrigated ear. What does this means?

A. Contract the Ciliary muscle A. Indicates a CN VIII Dysfunction

B. Relax the Ciliary muscle B. Abnormal
C. Dilate the pupils C. Normal
D. Decrease production of Aqueous Humor D. Inconclusive
48. The doctor orders timolol [timoptic]. 53. Ear drops are prescribed to an infant,
Nurse jet knows that the action of this The most appropriate method to
drug is administer the ear drops is

A. Reduce production of CSF A. Pull the pinna up and back and direct the
B. Reduce production of Aquesous Humor solution towards the eardrum
C. Constrict the pupil B. Pull the pinna down and back and direct the
D. Relaxes the Ciliary muscle solution onto the wall of the canal
49. When caring for Mr. Batumbakal, Jet C. Pull the pinna down and back and direct the
solution towards the eardrum
teaches the client to avoid
D. Pull the pinna up and back and direct the
A. Watching large screen TVs solution onto the wall of the canal
B. Bending at the waist 54. Nurse Jenny is developing a plan of
C. Reading books care for a patient with Menieres disease.
D. Going out in the sun What is the priority nursing intervention in
50. Mr. Batumbakal has undergone eye the plan of care for this particular patient?
angiography using an Intravenous dye
and fluoroscopy. What activity is A. Air, Breathing, Circulation
B. Love and Belongingness
contraindicated immediately after
C. Food, Diet and Nutrition
procedure?
D. Safety C. I will use straw for drinking
55. After mastoidectomy, Nurse John D. I should avoid air travel for a while
should be aware that the cranial nerve 60. Nurse Oca will do a caloric testing to
that is usually damage after this a client who sustained a blunt injury in the
procedure is head. He instilled a cold water in the
client’s right ear and he noticed that
A. CN I
nystagmus occurred towards the left ear.
B. CN II
C. CN VII What does this finding indicates?
D. CN VI A. Indicating a Cranial Nerve VIII Dysfunction
56. The physician orders the following for B. The test should be repeated again because the
the client with Menieres disease. Which of result is vague
the following should the nurse question? C. This is Grossly abnormal and should be
reported to the neurosurgeon
A. Dipenhydramine [Benadryl] D. This indicates an intact and working
B. Atropine sulfate vestibular branch of CN VIII
C. Out of bed activities and ambulation 61. A client with Cataract is about to
D. Diazepam [Valium]
undergo surgery. Nurse Oca is preparing
57. Nurse Anna is giving dietary
plan of care. Which of the following
instruction to a client with Menieres
nursing diagnosis is most appropriate to
disease. Which statement if made by the
address the long term need of this type of
client indicates that the teaching has been
patient?
successful?
A. Anxiety R/T to the operation and its outcome
A. I will try to eat foods that are low in sodium B. Sensory perceptual alteration R/T Lens
and limit my fluid intake extraction and replacement
B. I must drink atleast 3,000 ml of fluids per day C. Knowledge deficit R/T the pre operative and
C. I will try to follow a 50% carbohydrate, 30% post operative self care
fat and 20% protein diet D. Body Image disturbance R/T the eye packing
D. I will not eat turnips, red meat and raddish after surgery
58. Peachy was rushed by his father, 62. Nurse Joseph is performing a
Steven into the hospital admission. WEBERS TEST. He placed the tuning
Peachy is complaining of something fork in the patients forehead after tapping
buzzing into her ears. Nurse Joemar it onto his knee. The client states that the
assessed peachy and found out It was an fork is louder in the LEFT EAR. Which of
insect. What should be the first thing that the following is a correct conclusion for
Nurse Joemar should try to remove the nurse Josph to make?
insect out from peachy’s ear?
A. He might have a sensory hearing loss in the
A. Use a flashlight to coax the insect out of left ear
peachy’s ear B. Conductive hearing loss is possible in the
B. Instill an antibiotic ear drops right ear
C. Irrigate the ear C. He might have a sensory hearing loss in the
D. Pick out the insect using a sterile clean right hear, and/or a conductive hearing loss in
forceps the left ear.
59. Following an ear surgery, which D. He might have a conductive hearing loss in
statement if heard by Nurse Oca from the the right ear, and/or a sensory hearing loss in
patient indicates a correct understanding the left ear.
of the post operative instructions? 63. Aling myrna has Menieres disease.
What typical dietary prescription would
A. Activities are resumed within 5 days nurse Oca expect the doctor to prescribe?
B. I will make sure that I will clean my hair and
face to prevent infection A. A low sodium , high fluid intake
B. A high calorie, high protein dietary intake D. Give small volumes of fluid at frequent
C. low fat, low sodium and high calorie intake interval
D. low sodium and restricted fluid intake 68. After nursing intervention, you will
SITUATION : [ From DEC 1991 NLE ] A expect the patient to have
45 year old male construction worker was
1. Maintain body temperature at 36.5 C
admitted to a tertiary hospital for
2. Exhibit return of BP and Pulse to normal
incessant vomiting. Assessment 3. Manifest normal skin turgor of skin and
disclosed: weak rapid pulse, acute weight tongue
loss of .5kg, furrows in his tongue, slow 4. Drinks fluids as prescribed
flattening of the skin was noted when the A. 1,3
nurse released her pinch. B. 2,4
Temperature: 35.8 C , BUN Creatinine C. 1,3,4
D. 2,3,4
ratio : 10 : 1, He also complains for
SITUATION: A 65 year old woman was
postural hypotension. There was no
admitted for Parkinson’s Disease. The
infection.
charge nurse is going to make an initial
assessment.
64. Which of the following is the
appropriate nursing diagnosis? 69. Which of the following is a
A. Fluid volume deficit R/T furrow tongue characteristic of a patient with advanced
B. Fluid volume deficit R/T uncontrolled Parkinson’s disease?
vomiting
A. Disturbed vision
C. Dehydration R/T subnormal body temperature
B. Forgetfulness
D. Dehydration R/T incessant vomiting
C. Mask like facial expression
65. Approximately how much fluid is lost D. Muscle atrophy
in acute weight loss of .5kg? 70. The onset of Parkinson’s disease is
A. 50 ml between 50-60 years old. This disorder is
B. 750 ml caused by
C. 500 ml
D. 75 ml A. Injurious chemical substances
B. Hereditary factors
66. Postural Hypotension is
C. Death of brain cells due to old age
A. A drop in systolic pressure less than 10 D. Impairment of dopamine producing cells in
mmHg when patient changes position from the brain
lying to sitting. 71. The patient was prescribed with
B. A drop in systolic pressure greater than 10 levodopa. What is the action of this drug?
mmHg when patient changes position from
lying to sitting A. Increase dopamine availability
C. A drop in diastolic pressure less than 10 B. Activates dopaminergic receptors in the basal
mmHg when patient changes position from ganglia
lying to sitting C. Decrease acetylcholine availability
D. A drop in diastolic pressure greater than 10 D. Release dopamine and other catecholamine
mmHg when patient changes position from from neurological storage sites
lying to sitting 72. You are discussing with the dietician
67. Which of the following measures will what food to avoid with patients taking
not help correct the patient’s condition levodopa?

A. Offer large amount of oral fluid intake to A. Vitamin C rich food

replace fluid lost B. Vitamin E rich food
B. Give enteral or parenteral fluid C. Thiamine rich food
C. Frequent oral care D. Vitamin B6 rich food
 73. One day, the patient complained of C. Relaxation technique
difficulty in walking. Your response would D. Dietary prescription
be SITUATION : Knowledge of the drug
PROPANTHELINE BROMIDE
A. You will need a cane for support [Probanthine] Is necessary in treatment of
B. Walk erect with eyes on horizon
various disorders.
C. I’ll get you a wheelchair
D. Don’t force yourself to walk 79. What is the action of this drug?
SITUATION: Mr. Dela Isla, a client with
early Dementia exhibits thought process A. Increases glandular secretion for clients
affected with cystic fibrosis
disturbances.
B. Dissolve blockage of the urinary tract due to
74. The nurse will assess a loss of ability obstruction of cystine stones
C. Reduces secretion of the glandular organ of
in which of the following areas?
the body
A. Balance D. Stimulate peristalsis for treatment of
B. Judgment constipation and obstruction
C. Speech 80. What should the nurse caution the
D. Endurance client when using this medication
75. Mr. Dela Isla said he cannot
A. Avoid hazardous activities like driving,
comprehend what the nurse was saying.
operating machineries etc.
He suffers from: B. Take the drug on empty stomach
A. Insomnia C. Take with a full glass of water in treatment of
B. Aphraxia Ulcerative colitis
C. Agnosia D. I must take double dose if I missed the
D. Aphasia previous dose
76. The nurse is aware that in 81. Which of the following drugs are not
communicating with an elderly client, the compatible when taking Probanthine?
nurse will A. Caffeine
B. NSAID
A. Lean and shout at the ear of the client
C. Acetaminophen
B. Open mouth wide while talking to the client
D. Alcohol
C. Use a low-pitched voice
D. Use a medium-pitched voice 82. What should the nurse tell clients
77. As the nurse talks to the daughter of when taking Probanthine?
Mr. Dela Isla, which of the following A. Avoid hot weathers to prevent heat strokes
statement of the daughter will require the B. Never swim on a chlorinated pool
nurse to give further teaching? C. Make sure you limit your fluid intake to 1L a
day
A. I know the hallucinations are parts of the D. Avoid cold weathers to prevent hypothermia
disease 83. Which of the following disease would
B. I told her she is wrong and I explained to her
Probanthine exert the much needed
what is right
C. I help her do some tasks he cannot do for action for control or treatment of the
himself disorder?
D. Ill turn off the TV when we go to another
A. Urinary retention
room
B. Peptic Ulcer Disease
78. Which of the following is most C. Ulcerative Colitis
important discharge teaching for Mr. Dela D. Glaucoma
Isla SITUATION : Mr. Franco, 70 years old,
A. Emergency Numbers suddenly could not lift his spoons nor
B. Drug Compliance speak at breakfast. He was rushed to the
 hospital unconscious. His diagnosis was SITUATION : a 20 year old college
CVA. student was rushed to the ER of PGH
after he fainted during their ROTC drill.
84. Which of the following is the most
Complained of severe right iliac pain.
important assessment during the acute
Upon palpation of his abdomen, Ernie
stage of an unconscious patient like Mr.
jerks even on slight pressure. Blood test
Franco?
was ordered. Diagnosis is acute
A. Level of awareness and response to pain appendicitis.
B. Papillary reflexes and response to sensory
stimuli 89. Which result of the lab test will be
C. Coherence and sense of hearing significant to the diagnosis?
D. Patency of airway and adequacy of respiration
85. Considering Mr. Franco’s conditions, A. RBC : 4.5 TO 5 Million / cu. mm.
which of the following is most important to B. Hgb : 13 to 14 gm/dl.
include in preparing Franco’s bedside C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm
equipment?
90. Stat appendectomy was indicated.
A. Hand bell and extra bed linen Pre op care would include all of the
B. Sandbag and trochanter rolls following except?
C. Footboard and splint
D. Suction machine and gloves A. Consent signed by the father
86. What is the rationale for giving Mr. B. Enema STAT
Franco frequent mouth care? C. Skin prep of the area including the pubis
D. Remove the jewelries
A. He will be thirsty considering that he is 91. Pre-anesthetic med of Demerol and
doesn’t drink enough fluids atrophine sulfate were ordered to :
B. To remove dried blood when tongue is bitten
during a seizure A. Allay anxiety and apprehension
C. The tactile stimulation during mouth care will B. Reduce pain
hasten return to consciousness C. Prevent vomiting
D. Mouth breathing is used by comatose patient D. Relax abdominal muscle
and it’ll cause oral mucosa dying and 92. Common anesthesia for
cracking. appendectomy is
87. One of the complications of prolonged
bed rest is decubitus ulcer. Which of the A. Spinal
B. General
following can best prevent its occurrence?
C. Caudal
A. Massage reddened areas with lotion or oils D. Hypnosis
B. Turn frequently every 2 hours 93. Post op care for appendectomy
C. Use special water mattress include the following except
D. Keep skin clean and dry
88. If Mr. Franco’s Right side is weak, A. Early ambulation
B. Diet as tolerated after fully conscious
What should be the most accurate
C. Nasogastric tube connect to suction
analysis by the nurse? D. Deep breathing and leg exercise
A. Expressive aphasia is prominent on clients 94. Peritonitis may occur in ruptured
with right sided weakness appendix and may cause serious
B. The affected lobe in the patient is the Right problems which are
lobe
C. The client will have problems in judging 1. Hypovolemia, electrolyte imbalance
distance and proprioception 2. Elevated temperature, weakness and
D. Clients orientation to time and space will be diaphoresis
much affected
3. Nausea and vomiting, rigidity of the D. Occurs suddenly and irreversible
abdominal wall 100. Which behavior results from organic
4. Pallor and eventually shock psychoses?
A. 1 and 2
B. 2 and 3 A. Memory deficit
C. 1,2,3 B. Disorientation
D. All of the above C. Impaired Judgement
95. If after surgery the patient’s abdomen D. Inappropriate affect
becomes distended and no bowel sounds Answers
appreciated, what would be the most 1. D. Move the person to a safer place.
suspected complication? 2. D. Shortened, Adducted and Externally
Rotated.
A. Intussusception 3. C. Inflammation
B. Paralytic Ileus 4. A. Hypothyroidism
C. Hemorrhage 5. A. Tachycardia and Hypotension
D. Ruptured colon 6. B. On his left hand, because of reciprocal
96. NGT was connected to suction. In motion.
caring for the patient with NGT, the nurse 7. c. 6 Inches at the lateral side of the foot.
8. A. Moves the cane when the right leg is
must moved.
A. Irrigate the tube with saline as ordered 9. A. PPD
B. Use sterile technique in irrigating the tube 10.C. ID
C. advance the tube every hour to avoid kinks 11.D. 10 mm Induration
D. Offer some ice chips to wet lips 12.B. 48 hours
13.A. Call the Physician
97. When do you think the NGT tube be
14.D. Almost all Filipinos will test positive for
removed? Mantoux Test
A. When patient requests for it 15.A. I
B. Abdomen is soft and patient asks for water 16.C. 4 months
C. Abdomen is soft and flatus has been expelled 17.C. Ethambutol
D. B and C only 18.A. 6-12 months after
19.B. National Tuberculosis Control Program
Situation: Amanda is suffering from
20.A. 23 Year old athlete with diabetes
chronic arteriosclerosis Brain syndrome insipidus
she fell while getting out of the bed one 21.B. Secondary
morning and was brought to the hospital, 22.B. Participate with the nurse in his daily
and she was diagnosed to have ostomy care
cerebrovascular thrombosis thus 23.A. Plain NSS / Normal Saline
24.B. 3-4 inches
transferred to a nursing home.
25.C. 18 inches
98. What do you call a STROKE that 26.C. Agrees to look at the colostomy
27.A. Stop the irrigation by clamping the tube
manifests a bizarre behavior?
28.D. Protruding stoma with swollen
A. Inorganic Stroke appearance
B. Inorganic Psychoses 29.C. Eat beet greens and parsley
C. Organic Stroke 30.B. Suspend the irrigant 45 cm above the
D. Organic Psychoses stoma
99. The main difference between chronic 31.A. Brick Red
32.D. Suction the client every hour
and organic brain syndrome is that the
33.D. Fr. 18
former 34.C. 10-15 mmHg
A. Occurs suddenly and reversible 35.C. 100-120 mmHg
B. Is progressive and reversible 36.C. Obturator and Kelly clamp
C. tends to be progressive and irreversible 37.A. Wilma places 2 fingers between the tie
and neck
38.A. James’ respiratory rate is 18 79.C. Reduces secretion of the glandular
39.A. 10 seconds organ of the body
40.D. Pain 80.A. Avoid hazardous activities like driving,
41.A. Sudden blockage of the anterior angle operating machineries etc.
by the base of the iris 81.D. Alcohol
42.B. Measures the Intra Ocular Pressure 82.A. Avoid hot weathers to prevent heat
43.D. CONES [RETINA] strokes
44.D. In the Ciliary Body 83.B. Peptic Ulcer Disease
45.A. 8-21 mmHg 84.D. Patency of airway and adequacy of
46.B. Snellen’s Chart respiration
47.A. Contract the Ciliary muscle 85.D. Suction machine and gloves
48.B. Reduce production of Aquesous Humor 86.D. Mouth breathing is used by comatose
49.B. Bending at the waist patient and it’ll cause oral mucosa dying
50.A. Reading newsprint and cracking.
51.A. Atropine Sulfate 87.B. Turn frequently every 2 hours
52.C. Normal 88.A. Expressive aphasia is prominent on
53.B. Pull the pinna down and back and direct clients with right sided weakness
the solution onto the wall of the canal 89.D. WBC : 12,000 to 13,000/cu.mm
54.D. Safety 90.B. Enema STAT
55.C. CN VII 91.A. Allay anxiety and apprehension
56.C. Out of bed activities and ambulation 92.A. Spinal
57.A. I will try to eat foods that are low in 93.B. Diet as tolerated after fully conscious
sodium and limit my fluid intake 94.D. All of the above
58.A. Use a flashlight to coax the insect out of 95.B. Paralytic Ileus
peachy’s ear 96.A. Irrigate the tube with saline as ordered
59.D. I should avoid air travel for a while 97.C. Abdomen is soft and flatus has been
60.D. This indicates an intact and working expelled
vestibular branch of CN VIII 98.D. Organic Psychoses
61.B. Sensory perceptual alteration R/T Lens 99.C. tends to be progressive and irreversible
extraction and replacement 100. B. Disorientation
62.C. He might have a sensory hearing loss in
the right hear, and/or a conductive hearing
loss in the left ear.
63.D. low sodium and restricted fluid intake
64.B. Fluid volume deficit R/T uncontrolled
vomiting
65.C. 500 ml
66.B. A drop in systolic pressure greater than
10 mmHg when patient changes position
from lying to sitting
67.A. Offer large amount of oral fluid intake
to replace fluid lost
68.D. 2,3,4
69.C. Mask like facial expression
70.D. Impairment of dopamine producing cells
in the brain
71.A. Increase dopamine availability
72.D. Vitamin B6 rich food
73.A. You will need a cane for support
74.B. Judgment
75.D. Aphasia
76.D. Use a medium-pitched voice
77.B. I told her she is wrong and I explained to
her what is right
78.B. Drug Compliance
 PNLE 3 6. A client is admitted to the hospital with
1. Marco who was diagnosed with brain benign prostatic hyperplasia, the nurse
tumor was scheduled for craniotomy. In most relevant assessment would be:
preventing the development of cerebral A. Flank pain radiating in the groin
edema after surgery, the nurse should B. Distention of the lower abdomen
expect the use of: C. Perineal edema
D. Urethral discharge
A. Diuretics 7. A client has undergone with penile
B. Antihypertensive
implant. After 24 hrs of surgery, the
C. Steroids
D. Anticonvulsants client’s scrotum was edematous and
2. Halfway through the administration of painful. The nurse should:
blood, the female client complains of A. Assist the client with sitz bath
lumbar pain. After stopping the infusion B. Apply war soaks in the scrotum
Nurse Hazel should: C. Elevate the scrotum using a soft support
D. Prepare for a possible incision and drainage.
A. Increase the flow of normal saline 8. Nurse hazel receives emergency
B. Assess the pain further
laboratory results for a client with chest
C. Notify the blood bank
D. Obtain vital signs. pain and immediately informs the
3. Nurse Maureen knows that the positive physician. An increased myoglobin level
diagnosis for HIV infection is made based suggests which of the following?
on which of the following: A. Liver disease
B. Myocardial damage
A. A history of high risk sexual behaviors.
C. Hypertension
B. Positive ELISA and western blot tests
D. Cancer
C. Identification of an associated opportunistic
infection 9. Nurse Maureen would expect the a
D. Evidence of extreme weight loss and high client with mitral stenosis would
fever demonstrate symptoms associated with
4. Nurse Maureen is aware that a client congestion in the:
who has been diagnosed with chronic
A. Right atrium
renal failure recognizes an adequate B. Superior vena cava
amount of high-biologic-value protein C. Aorta
when the food the client selected from the D. Pulmonary
menu was: 10. A client has been diagnosed with
hypertension. The nurse priority nursing
A. Raw carrots
B. Apple juice diagnosis would be:
C. Whole wheat bread A. Ineffective health maintenance
D. Cottage cheese
B. Impaired skin integrity
5. Kenneth who has diagnosed with C. Deficient fluid volume
uremic syndrome has the potential to D. Pain
develop complications. Which among the 11. Nurse Hazel teaches the client with
following complications should the nurse angina about common expected side
anticipates: effects of nitroglycerin including:
A. Flapping hand tremors A. high blood pressure
B. An elevated hematocrit level B. stomach cramps
C. Hypotension C. headache
D. Hypokalemia D. shortness of breath
 12. The following are lipid abnormalities. 18. Marie with acute lymphocytic
Which of the following is a risk factor for leukemia suffers from nausea and
the development of atherosclerosis and headache. These clinical manifestations
PVD? may indicate all of the following except
A. High levels of low density lipid (LDL) A. effects of radiation
cholesterol B. chemotherapy side effects
B. High levels of high density lipid (HDL) C. meningeal irritation
cholesterol D. gastric distension
C. Low concentration triglycerides 19. A client has been diagnosed with
D. Low levels of LDL cholesterol. Disseminated Intravascular Coagulation
13. Which of the following represents a (DIC). Which of the following is
significant risk immediately after surgery contraindicated with the client?
for repair of aortic aneurysm?
A. Administering Heparin
A. Potential wound infection B. Administering Coumadin
B. Potential ineffective coping C. Treating the underlying cause
C. Potential electrolyte balance D. Replacing depleted blood products
D. Potential alteration in renal perfusion 20. Which of the following findings is the
14. Nurse Josie should instruct the client best indication that fluid replacement for
to eat which of the following foods to the client with hypovolemic shock is
obtain the best supply of Vitamin B12? adequate?
A. dairy products A. Urine output greater than 30ml/hr
B. vegetables B. Respiratory rate of 21 breaths/minute
C. Grains C. Diastolic blood pressure greater than 90
D. Broccoli mmhg
15. Karen has been diagnosed with D. Systolic blood pressure greater than 110
aplastic anemia. The nurse monitors for mmhg
changes in which of the following 21. Which of the following signs and
physiologic functions? symptoms would Nurse Maureen include
in teaching plan as an early manifestation
A. Bowel function
B. Peripheral sensation of laryngeal cancer?
C. Bleeding tendencies A. Stomatitis
D. Intake and out put B. Airway obstruction
16. Lydia is scheduled for elective C. Hoarseness
splenectomy. Before the clients goes to D. Dysphagia
surgery, the nurse in charge final 22. Karina a client with myasthenia gravis
assessment would be: is to receive immunosuppressive therapy.
The nurse understands that this therapy
A. signed consent
B. vital signs is effective because it:
C. name band A. Promotes the removal of antibodies that
D. empty bladder impair the transmission of impulses
17. What is the peak age range in B. Stimulates the production of acetylcholine at
acquiring acute lymphocytic leukemia the neuromuscular junction.
(ALL)? C. Decreases the production of autoantibodies
that attack the acetylcholine receptors.
A. 4 to 12 years. D. Inhibits the breakdown of acetylcholine at the
B. 20 to 30 years neuromuscular junction.
C. 40 to 50 years
D. 60 60 70 years
 23. A female client is receiving IV 28. Nurse Katrina would recognize that
Mannitol. An assessment specific to safe the demonstration of crutch walking with
administration of the said drug is: tripod gait was understood when the
client places weight on the:
A. Vital signs q4h
B. Weighing daily A. Palms of the hands and axillary regions
C. Urine output hourly B. Palms of the hand
D. Level of consciousness q4h C. Axillary regions
24. Patricia a 20 year old college student D. Feet, which are set apart
with diabetes mellitus requests additional 29. Mang Jose with rheumatoid arthritis
information about the advantages of using states, “the only time I am without pain is
a pen like insulin when I lie in bed perfectly still”. During the
delivery devices. The nurse explains that convalescent stage, the nurse in charge
the advantages of these devices over with Mang Jose should encourage:
syringes includes:
A. Active joint flexion and extension
A. Accurate dose delivery B. Continued immobility until pain subsides
B. Shorter injection time C. Range of motion exercises twice daily
C. Lower cost with reusable insulin cartridges D. Flexion exercises three times daily
D. Use of smaller gauge needle. 30. A male client has undergone spinal
25. A male client’s left tibia is fractures in surgery, the nurse should:
an automobile accident, and a cast is
A. Observe the client’s bowel movement and
applied. To assess for damage to major voiding patterns
blood vessels from the fracture tibia, the B. Log-roll the client to prone position
nurse in charge should monitor the client C. Assess the client’s feet for sensation and
for: circulation
D. Encourage client to drink plenty of fluids
A. Swelling of the left thigh 31. Marina with acute renal failure moves
B. Increased skin temperature of the foot
into the diuretic phase after one week of
C. Prolonged reperfusion of the toes after
blanching therapy. During this phase the client must
D. Increased blood pressure be assessed for signs of developing:
26. After a long leg cast is removed, the A. Hypovolemia
male client should: B. renal failure
C. metabolic acidosis
A. Cleanse the leg by scrubbing with a brisk
D. hyperkalemia
motion
B. Put leg through full range of motion twice 32. Nurse Judith obtains a specimen of
daily clear nasal drainage from a client with a
C. Report any discomfort or stiffness to the head injury. Which of the following tests
physician differentiates mucus from cerebrospinal
D. Elevate the leg when sitting for long periods fluid (CSF)?
of time.
27. While performing a physical A. Protein
assessment of a male client with gout of B. Specific gravity
C. Glucose
the great toe, NurseVivian should assess
D. Microorganism
for additional tophi (urate deposits) on
33. A 22 year old client suffered from his
the:
first tonic-clonic seizure. Upon awakening
A. Buttocks the client asks the nurse, “What caused
B. Ears me to have a seizure? Which of the
C. Face following would the nurse include in the
D. Abdomen
 primary cause of tonic clonic seizures in 39. Among the following components
adults more the 20 years? thorough pain assessment, which is the
most significant?
A. Electrolyte imbalance
B. Head trauma A. Effect
C. Epilepsy B. Cause
D. Congenital defect C. Causing factors
34. What is the priority nursing D. Intensity
assessment in the first 24 hours after 40. A 65 year old female is experiencing
admission of the client with thrombotic flare up of pruritus. Which of the client’s
CVA? action could aggravate the cause of flare
ups?
A. Pupil size and papillary response
B. cholesterol level A. Sleeping in cool and humidified environment
C. Echocardiogram B. Daily baths with fragrant soap
D. Bowel sounds C. Using clothes made from 100% cotton
35. Nurse Linda is preparing a client with D. Increasing fluid intake
multiple sclerosis for discharge from the 41. Atropine sulfate (Atropine) is
hospital to home. Which of the following contraindicated in all but one of the
instruction is most appropriate? following client?
A. “Practice using the mechanical aids that you A. A client with high blood
will need when future disabilities arise”. B. A client with bowel obstruction
B. “Follow good health habits to change the C. A client with glaucoma
course of the disease”. D. A client with U.T.I
C. “Keep active, use stress reduction strategies, 42. Among the following clients, which
and avoid fatigue. among them is high risk for potential
D. “You will need to accept the necessity for a
hazards from the surgical experience?
quiet and inactive lifestyle”.
36. The nurse is aware the early indicator A. 67-year-old client
of hypoxia in the unconscious client is: B. 49-year-old client
C. 33-year-old client
A. Cyanosis D. 15-year-old client
B. Increased respirations 43. Nurse Jon assesses vital signs on a
C. Hypertension
client undergone epidural anesthesia.
D. Restlessness
Which of the following would the nurse
37. A client is experiencing spinal shock.
assess next?
Nurse Myrna should expect the function
of the bladder to be which of the A. Headache
following? B. Bladder distension
C. Dizziness
A. Normal D. Ability to move legs
B. Atonic 44. Nurse Katrina should anticipate that
C. Spastic
all of the following drugs may be used in
D. Uncontrolled
the attempt to control the symptoms of
38. Which of the following stage the
Meniere’s disease except:
carcinogen is irreversible?
A. Antiemetics
A. Progression stage
B. Diuretics
B. Initiation stage
C. Antihistamines
C. Regression stage
D. Glucocorticoids
D. Promotion stage
45. Which of the following complications
associated with tracheostomy tube?
A. Increased cardiac output presence of the human immunodeficiency
B. Acute respiratory distress syndrome (ARDS) virus (HIV).
C. Increased blood pressure 4. D . One cup of cottage cheese contains
D. Damage to laryngeal nerves approximately 225 calories, 27 g of protein, 9
46. Nurse Faith should recognize that g of fat, 30 mg cholesterol, and 6 g of
fluid shift in an client with burn injury carbohydrate. Proteins of high biologic value
(HBV) contain optimal levels of amino acids
results from increase in the:
essential for life.
A. Total volume of circulating whole blood 5. A . Elevation of uremic waste products causes
B. Total volume of intravascular plasma irritation of the nerves, resulting in flapping
C. Permeability of capillary walls hand tremors.
D. Permeability of kidney tubules 6. B . This indicates that the bladder is distended
47. An 83-year-old woman has several with urine, therefore palpable.
7. C . Elevation increases lymphatic drainage,
ecchymotic areas on her right arm. The
reducing edema and pain.
bruises are probably caused by: 8. B . Detection of myoglobin is a diagnostic
A. increased capillary fragility and permeability tool to determine whether myocardial damage
B. increased blood supply to the skin has occurred.
C. self inflicted injury 9. D . When mitral stenosis is present, the left
D. elder abuse atrium has difficulty emptying its contents
into the left ventricle because there is no valve
48. Nurse Anna is aware that early
to prevent back ward flow into the pulmonary
adaptation of client with renal carcinoma vein, the pulmonary circulation is under
is: pressure.
10.A . Managing hypertension is the priority for
A. Nausea and vomiting the client with hypertension. Clients with
B. flank pain hypertension frequently do not experience
C. weight gain pain, deficient volume, or impaired skin
D. intermittent hematuria integrity. It is the asymptomatic nature of
49. A male client with tuberculosis asks hypertension that makes it so difficult to treat.
Nurse Brian how long the chemotherapy 11.C . Because of its widespread vasodilating
must be continued. Nurse Brian’s effects, nitroglycerin often produces side
accurate reply would be: effects such as headache, hypotension and
dizziness.
A. 1 to 3 weeks 12.A. An increased in LDL cholesterol
B. 6 to 12 months concentration has been documented at risk
C. 3 to 5 months factor for the development of atherosclerosis.
D. 3 years and more LDL cholesterol is not broken down into the
50. A client has undergone laryngectomy. liver but is deposited into the wall of the
The immediate nursing priority would be: blood vessels.
13.D . There is a potential alteration in renal
A. Keep trachea free of secretions perfusion manifested by decreased urine
B. Monitor for signs of infection output. The altered renal perfusion may be
C. Provide emotional support related to renal artery embolism, prolonged
D. Promote means of communication hypotension, or prolonged aortic cross-
Answers and Rationales clamping during the surgery.
1. C . Glucocorticoids (steroids) are used for 14.A . Good source of vitamin B12 are dairy
their anti-inflammatory action, products and meats.
which decreases the development of edema. 15.C . Aplastic anemia decreases the bone
2. A . The blood must be stopped at once, and marrow production of RBC’s, white blood
then normal saline should be infused to keep cells, and platelets. The client is at risk for
the line patent and maintain blood volume. bruising and bleeding tendencies.
3. B . These tests confirm the presence of HIV 16.B . An elective procedure is scheduled in
antibodies that occur in response to the advance so that all preparations can be
completed ahead of time. The vital signs are
 the final check that must be completed before 30.C . Alteration in sensation and circulation
the client leaves the room so that continuity of indicates damage to the spinal cord, if these
care and assessment is provided for. occurs notify physician immediately.
17.A . The peak incidence of Acute Lymphocytic 31.A . In the diuretic phase fluid retained during
Leukemia (ALL) is 4 years of age. It is the oliguric phase is excreted and may reach 3
uncommon after 15 years of age. to 5 liters daily, hypovolemia may occur and
18.D . Acute Lymphocytic Leukemia (ALL) does fluids should be replaced.
not cause gastric distention. It does invade the 32.C . The constituents of CSF are similar to
central nervous system, and clients experience those of blood plasma. An examination for
headaches and vomiting from meningeal glucose content is done to determine whether
irritation. a body fluid is a mucus or a CSF. A CSF
19.B . Disseminated Intravascular Coagulation normally contains glucose.
(DIC) has not been found to respond to oral 33.B . Trauma is one of the primary cause of
anticoagulants such as Coumadin. brain damage and seizure activity in adults.
20.A . Urine output provides the most sensitive Other common causes of seizure activity in
indication of the client’s response to therapy adults include neoplasms, withdrawal from
for hypovolemic shock. Urine output should drugs and alcohol, and vascular disease.
be consistently greater than 30 to 35 mL/hr. 34.A . It is crucial to monitor the pupil size and
21.C . Early warning signs of laryngeal cancer papillary response to indicate changes around
can vary depending on tumor location. the cranial nerves.
Hoarseness lasting 2 weeks should be 35.C . The nurse most positive approach is to
evaluated because it is one of the most encourage the client with multiple sclerosis to
common warning signs. stay active, use stress reduction techniques
22.C . Steroids decrease the body’s immune and avoid fatigue because it is important to
response thus decreasing the production of support the immune system while remaining
antibodies that attack the acetylcholine active.
receptors at the neuromuscular junction 36.D . Restlessness is an early indicator of
23.C . The osmotic diuretic mannitol is hypoxia. The nurse should suspect hypoxia in
contraindicated in the presence of inadequate unconscious client who suddenly becomes
renal function or heart failure because it restless.
increases the intravascular volume that must 37.B . In spinal shock, the bladder becomes
be filtered and excreted by the kidney. completely atonic and will continue to fill
24.A . These devices are more accurate because unless the client is catheterized.
they are easily to used and have improved 38.A . Progression stage is the change of tumor
adherence in insulin regimens by young from the preneoplastic state or low degree of
people because the medication can be malignancy to a fast growing tumor that
administered discreetly. cannot be reversed.
25.C . Damage to blood vessels may decrease the 39.D . Intensity is the major indicative of severity
circulatory perfusion of the toes, this would of pain and it is important for the evaluation
indicate the lack of blood supply to the of the treatment.
extremity. 40.B . The use of fragrant soap is very drying to
26.D . Elevation will help control the edema that skin hence causing the pruritus.
usually occurs. 41.C . Atropine sulfate is contraindicated with
27.B . Uric acid has a low solubility, it tends to glaucoma patients because it increases
precipitate and form deposits at various sites intraocular pressure.
where blood flow is least active, including 42.A . A 67 year old client is greater risk because
cartilaginous tissue such as the ears. the older adult client is more likely to have a
28.B . The palms should bear the client’s weight less-effective immune system.
to avoid damage to the nerves in the axilla. 43.B . The last area to return sensation is in the
29.A . Active exercises, alternating extension, perineal area, and the nurse in charge should
flexion, abduction, and adduction, mobilize monitor the client for distended bladder.
exudates in the joints relieves stiffness and 44.D . Glucocorticoids play no significant role in
pain. disease treatment.
45.D . Tracheostomy tube has several potential
complications including bleeding, infection
and laryngeal nerve damage.
46.C . In burn, the capillaries and small vessels
dilate, and cell damage cause the release of a
histamine-like substance. The substance
causes the capillary walls to become more
permeable and significant quantities of fluid
are lost.
47.A . Aging process involves increased capillary
fragility and permeability. Older adults have a
decreased amount of subcutaneous fat and
cause an increased incidence of bruise like
lesions caused by collection of extravascular
blood inloosely structured dermis.
48.D . Intermittent pain is the classic sign of
renal carcinoma. It is primarily due
to capillary erosion by the cancerous growth.
49.B . Tubercle bacillus is a drug resistant
organism and takes a long time to
be eradicated. Usually a combination of three
drugs is used for minimum of 6 months and at
least six months beyond culture conversion.
50.A . Patent airway is the most priority;
therefore removal of secretions is necessary.
 PNLE Exam 1 D. “Joining a support group of parents who are
coping with this problem can be quite helpful.
1. A 10 year old who has sustained a
5. To check for wound hemorrhage after a
head injury is brought to the emergency
client has had a surgery for the removal
department by his mother. A diagnosis of
of a tumor in the neck, nurse grace
a mild concussion is made. At the time of
should:
discharge, nurse Ron should instruct the
mother to: A. Loosen an edge of the dressing and lift it to
see the wound
A. Withhold food and fluids for 24 hours. B. Observe the dressing at the back of the neck
B. Allow him to play outdoors with his friends. for the presence of blood
C. Arrange for a follow up visit with the child’s C. Outline the blood as it appears on the dressing
primary care provider in one week. to observe any progression
D. Check for any change in responsiveness every D. Press gently around the incision to express
two hours until the follow-up visit. accumulated blood from the wound
2. A male client has suffered a motor 6. A 16-year-old primigravida arrives at
accident and is now suffering from the labor and birthing unit in her 38th
hypovolemic shock. Nurse Helen should week of gestation and states that she is
frequency assess the client’s vital signs labor. To verify that the client is in true
during the compensatory stage of shock, labor nurse Trina should:
because:
A. Obtain sides for a fern test
A. Arteriolar constriction occurs B. Time any uterine contractions
B. The cardiac workload decreases C. Prepare her for a pelvic examination
C. Decreased contractility of the heart occurs D. Apply nitrazine paper to moist vaginal tissue
D. The parasympathetic nervous system is 7. As part of the diagnostic workup for
triggered pulmonic stenosis, a child has cardiac
3. A paranoid male client with catheterization. Nurse Julius is aware that
schizophrenia is losing weight, reluctant children with pulmonic stenosis have
to eat, and voicing concerns about being increased pressure:
poisoned. The best intervention by nurse
Dina would be to: A. In the pulmonary vein
B. In the pulmonary artery
A. Allow the client to open canned or pre- C. On the left side of the heart
packaged food D. On the right side of the heart
B. Restrict the client to his room until 2 lbs are 8. An obese client asks nurse Julius how
gained to lose weight. Before answering, the
C. Have a staff member personally taste all of the
nurse should remember that long-term
client’s food
D. Tell the client the food has been x-rayed by weight loss occurs best when:
the staff and is safe
A. Eating patterns are altered
4. One day the mother of a young adult B. Fats are limited in the diet
confides to nurse Frida that she is very C. Carbohydrates are regulated
troubled by he child’s emotional illness. D. Exercise is a major component
The nurse’s most therapeutic initial 9. As a very anxious female client is
response would be: talking to the nurse May, she starts
crying. She appears to be upset that she
A. “You may be able to lessen your feelings of
cannot control her crying. The most
guilt by seeking counseling”
B. “It would be helpful if you become involved appropriate response by the nurse would
in volunteer work at this time” be:
C. “I recognize it’s hard to deal with this, but try
to remember that this too shall pass” A. “Is talking about your problem upsetting
you?”
B. “It is Ok to cry; I’ll just stay with you for A. Change the maternal position
now” B. Prepare for an immediate birth
C. “You look upset; lets talk about why you are C. Call the physician immediately
crying.” D. Obtain the client’s blood pressure
D. “Sometimes it helps to get it out of your 15. A male client receiving prolonged
system.” steroid therapy complains of always being
10. A patient has partial-thickness burns thirsty and urinating frequently. The best
to both legs and portions of his trunk. initial action by the nurse would be to:
Which of the following I.V. fluids is given
first? A. Perform a finger stick to test the client’s blood
glucose level
A. Albumin B. Have the physician assess the client for an
B. D5W enlarged prostate
C. Lactated Ringer’s solution C. Obtain a urine specimen from the client for
D. 0.9% sodium chloride solution with 2 mEq of screening purposes
potassium per 100 ml D. Assess the client’s lower extremities for the
11. During the first 48 hours after a presence of pitting edema
severe burn of 40% of the clients body 16. Nurse Bea recognizes that a
surface, the nurse’s assessment should pacemaker is indicated when a client is
include observations for water experiencing:
intoxication. Associated adaptations A. Angina
include: B. Chest pain
C. Heart block
A. Sooty-colored sputum
D. Tachycardia
B. Frothy pink-tinged sputum
C. Twitching and disorientation 17. When administering pancrelipase
D. Urine output below 30ml per hour (Pancreases capsules) to child with cystic
12. After a muscle biopsy, nurse Willy fibrosis, nurse Faith knows they should be
should teach the client to: given:

A. Change the dressing as needed A. With meals and snacks

B. Resume the usual diet as soon as desired B. Every three hours while awake
C. Bathe or shower according to preference C. On awakening, following meals, and at
D. Expect a rise in body temperature for 48 hours bedtime
13. Before a client whose left hand has D. After each bowel movement and after postural
draianage
been amputated can be fitted for a
18. A preterm neonate is receiving
prosthesis, nurse Joy is aware that:
oxygen by an overhead hood. During the
A. Arm and shoulder muscles must be developed time the infant is under the hood, it would
B. Shrinkage of the residual limb must be be appropriate for nurse Gian to:
completed
C. Dexterity in the other extremity must be A. Hydrate the infant q15 min
achieved B. Put a hat on the infant’s head
D. Full adjustment to the altered body image C. Keep the oxygen concentration consistent
must have occurred D. Remove the infant q15 min for stimulation
14. Nurse Cathy applies a fetal monitor to 19. A client’s sputum smears for acid fast
the abdomen of a client in active labor. bacilli (AFB) are positive, and
When the client has contractions, the transmission-based airborne precautions
nurse notes a 15 beat per minute are ordered. Nurse Kyle should instruct
deceleration of the fetal heart rate below visitors to:
the baseline lasting 15 seconds. Nurse
A. Limit contact with non-exposed family
Cathy should: members
B. Avoid contact with any objects present in the 24. After a laryngectomy, the most
client’s room important equipment to place at the
C. Wear an Ultra-Filter mask when they are in
client’s bedside would be:
the client’s room
D. Put on a gown and gloves before going into A. Suction equipment
the client’s room B. Humidified oxygen
20. A client with a head injury has a fixed, C. A nonelectric call bell
dilated right pupil; responds only to D. A cold-stream vaporizer
painful stimuli; and exhibits decorticate 25. Nurse Oliver interviews a young
posturing. Nurse Kate should recognize female client with anorexia nervosa to
that these are signs of: obtain information for the nursing history.
The client’s history is likely to reveal a:
A. Meningeal irritation
B. Subdural hemorrhage A. Strong desire to improve her body image
C. Medullary compression B. Close, supportive mother-daughter
D. Cerebral cortex compression relationship
21. After a lateral crushing chest injury, C. Satisfaction with and desire to maintain her
obvious right-sided paradoxic motion of present weight
D. Low level of achievement in school, with little
the client’s chest demonstrates multiple
concerns for grades
rib fraactures, resulting in a flail chest. 26. Nurse Bea should plan to assist a client
The complication the nurse should with an obsessive-compulsive disorder to
carefully observe for would be: control the use of ritualistic behavior by:
A. Providing repetitive activities that require
A. Mediastinal shift little thought
B. Tracheal laceration B. Attempting to reduce or limit situations that
C. Open pneumothorax increase anxiety
D. Pericardial tamponade C. Getting the client involved with activities that
22. When planning care for a client at 30- will provide distraction
weeks gestation, admitted to the hospital D. Suggesting that the client perform menial
after vaginal bleeding secondary to tasks to expiate feelings of guilt
placenta previa, the nurse’s primary 27. A 2 ½ year old child undergoes a
objective would be: ventriculoperitoneal shunt revision. Before
discharge, nurse John, knowing the expected
A. Provide a calm, quiet environment developmental behaviors for this age group,
B. Prepare the client for an immediate cesarean should tell the parents to call the physician if
birth the child:
C. Prevent situations that may stimulate the A. Tries to copy all the father’s mannerisms
cervix or uterus B. Talks incessantly regardless of the presence of
D. Ensure that the client has regular cervical others
examinations assess for labor C. Becomes fussy when frustrated and displays a
23. When planning discharge teaching for shortened attention span
D. Frequently starts arguments with playmates
a young female client who has had a
by claiming all toys are “mine”
pneumothorax, it is important that the
28. A urinary tract infection is a potential
nurse include the signs and symptoms of
danger with an indwelling catheter. Nurse
a pneumothorax and teach the client to
Gina can best plan to avoid this
seek medical assistance if she
complication by:
experiences:
A. Assessing urine specific gravity
A. Substernal chest pain B. Maintaining the ordered hydration
B. Episodes of palpitation C. Collecting a weekly urine specimen
C. Severe shortness of breath D. Emptying the drainage bag frequently
D. Dizziness when standing up
 29. A client has sustained a fractured adaptation to extrauterine life would be
right femur in a fall on stairs. Nurse Troy indicated by:
with the emergency response team
A. flexed extremities
assess for signs of circulatory impairment B. Cyanotic lips and face
by: C. A heart rate of 130 beats per minute
D. A respiratory rate of 40 breath per minute
A. Turning the client to side lying position
B. Asking the client to cough and deep breathe 35. The laboratory calls to state that a
C. Taking the client’s pedal pulse in the affected client’s lithium level is 1.9 mEq/L after 10
limb days of lithium therapy. Nurse Reese
D. Instructing the client to wiggle the toes of the should:
right foot
30. To assess orientation to place in a A. Notify the physician of the findings because
the level is dangerously high
client suspected of having dementia of
B. Monitor the client closely because the level of
the alzheimers type, nurse Chris should lithium in the blood is slightly elevated
ask: C. Continue to administer the medication as
ordered because the level is within the
A. “Where are you?”
therapeutic range
B. “Who brought you here?”
D. Report the findings to the physician so the
C. “Do you know where you are?”
dosage can be increased because the level is
D. “How long have you been there?”
below therapeutic range
31. Nurse Mary assesses a postpartum
36. A client has a regular 30-day
client who had an abruption placentae
menstrual cycles. When teaching about
and suspects that disseminated
the rhythm method, Which the client and
intravascular coagulation (DIC) is
her husband have chosen to use for
occurring when assessments
family planning, nurse Dianne should
demonstrate:
emphasize that the client’s most fertile
A. A boggy uterus days are:
B. Multiple vaginal clots
C. Hypotension and tachycardia A. Days 9 to 11
D. Bleeding from the venipuncture site B. Days 12 to 14
C. Days 15 to 17
32. When a client on labor experiences
D. Days 18 to 20
the urge to push a 9cm dilation, the
37. Before an amniocentesis, nurse
breathing pattern that nurse Rhea should
Alexandra should:
instruct the client to use is the:
A. Initiate the intravenous therapy as ordered by
A. Expulsion pattern the physiscian
B. Slow paced pattern B. Inform the client that the procedure could
C. Shallow chest pattern precipitate an infection
D. blowing pattern C. Assure that informed consent has been
33. Nurse Ronald should explain that the obtained from the client
most beneficial between-meal snack for a D. Perform a vaginal examination on the client to
client who is recovering from the full- assess cervical dilation
thickness burns would be a: 38. While a client is on intravenous
magnesium sulfate therapy for
A. Cheeseburger and a malted
preeclampsia, it is essential for nurse
B. Piece of blueberry pie and milk
C. Bacon and tomato sandwich and tea Amy to monitor the client’s deep tendon
D. Chicken salad sandwich and soft drink reflexes to:
34. Nurse Wilma recognizes that failure of A. Determine her level of consciousness
a newborn to make the appropriate B. Evaluate the mobility of the extremities
C. Determine her response to painful stimuli C. Eat the last of three meals daily by 8pm
D. Prevent development of respiratory distress D. Suck a peppermint candy after each meal
39. A preschooler is admitted to the 44. After a mastectomy or hysterectomy,
hospital with a diagnosis of acute clients may feel incomplete as women.
glomerulonephritis. The child’s history The statement that should alert nurse
reveals a 5-pound weight gain in one Gina to this feeling would be:
week and peritoneal edema. For the most
A. “I can’t wait to see all my friends again”
accurate information on the status of the B. “I feel washed out; there isn’t much left”
child’s edema, nursing intervention should C. “I can’t wait to get home to see my
include: grandchild”
D. “My husband plans for me to recuperate at our
A. Obtaining the child’s daily weight daughter’s home”
B. Doing a visual inspection of the child
45. A client with obstruction of the
C. Measuring the child’s intake and output
D. Monitoring the child’s electrolyte values common bile duct may show a prolonged
40. Nurse Mickey is administering bleeding and clotting time because:
dexamethasome (Decadron) for the early A. Vitamin K is not absorbed
management of a client’s cerebral edema. B. The ionized calcium levels falls
This treatment is effective because: C. The extrinsic factor is not absorbed
D. Bilirubin accumulates in the plasma
A. Acts as hyperosmotic diuretic 46. Realizing that the hypokalemia is a
B. Increases tissue resistance to infection
side effect of steroid therapy, nurse
C. Reduces the inflammatory response of tissues
D. Decreases the information of cerebrospinal Monette should monitor a client taking
fluid steroid medication for:
41. During newborn nursing assessment, A. Hyperactive reflexes
a positive Ortolani’s sign would be B. An increased pulse rate
indicated by: C. Nausea, vomiting, and diarrhea
D. Leg weakness with muscle cramps
A. A unilateral droop of hip
47. When assessing a newborn
B. A broadening of the perineum
C. An apparent shortening of one leg suspected of having Down syndrome,
D. An audible click on hip manipulation nurse Rey would expect to observe:
42. When caring for a dying client who is A. long thin fingers
in the denial stage of grief, the best B. Large, protruding ears
nursing approach would be to: C. Hypertonic neck muscles
D. Simian lines on the hands
A. Agree and encourage the client’s denial
48. A 10 year old girl is admitted to the
B. Allow the denial but be available to discuss
death pediatric unit for recurrent pain and
C. Reassure the client that everything will be OK swelling of her joints, particularly her
D. Leave the client alone to confront the feelings knees and ankles. Her diagnosis is
of impending loss juvenile rheumatoid arthritis. Nurse Janah
43. To decrease the symptoms of recognizes that besides joint
gastroesophageal reflux disease (GERD), inflammation, a unique manifestation of
the physician orders dietary and the rheumatoid process involves the:
medication management. Nurse Helen
A. Ears
should teach the client that the meal
B. Eyes
alteration that would be most appropriate C. Liver
would be: D. Brain
A. Ingest foods while they are hot
B. Divide food into four to six meals a day
 49. A disturbed client is scheduled to A. Provide frequent saline mouthwashes
begin group therapy. The client refuses to B. Use karaya powder to decrease irritation
C. Increase fluid intake to compensate for the
attend. Nurse Lolit should:
diarrhea
A. Accept the client’s decision without D. Provide meticulous skin care of the abdomen
discussion with Betadine
B. Have another client to ask the client to 54. During a group therapy session, one
consider of the clients ask a male client with the
C. Tell the client that attendance at the meeting is diagnosis of antisocial personality
required
disorder why he is in the hospital.
D. Insist that the client join the group to help the
socialization process Considering this client’s type of
50. Because a severely depressed client personality disorder, the nurse might
has not responded to any of the expect him to respond:
antidepressant medications, the A. “I need a lot of help with my troubles”
psychiatrist decides to try B. “Society makes people react in old ways”
electroconvulsive therapy (ECT). Before C. “I decided that it’s time I own up to my
the treatment the nurse should: problems”
D. “My life needs straightening out and this
A. Have the client speak with other clients might help”
receiving ECT 55. A child visits the clinic for a 6-week
B. Give the client a detailed explanation of the checkup after a tonsillectomy and
entire procedure
adenoidectomy. In addition to assessing
C. Limit the client’s intake to a light breakfast on
the days of the treatment hearing, the nurse should include an
D. Provide a simple explanation of the procedure assessment of the child’s:
and continue to reassure the client
A. Taste and smell
51. Nurse Vicky is aware that teaching B. Taste and speech
about colostomy care is understood when C. Swallowing and smell
the client states, “I will contact my D. Swallowing and speech
physician and report ____”: 56. A client is diagnosed with cancer of
the jaw. A course of radiation therapy is to
A. If I notice a loss of sensation to touch in the
stoma tissue” be followed by surgery. The client is
B. When mucus is passed from the stoma concerned about the side effects related
between irrigations” to the radiation treaments. Nurse Ria
C. The expulsion of flatus while the irrigating should explain that the major side effects
fluid is running out” that will experienced is:
D. If I have difficulty in inserting the irrigating
tube into the stoma” A. Fatigue
52. The client’s history that alerts nurse B. Alopecia
Henry to assess closely for signs of C. Vomiting
D. Leucopenia
postpartum infection would be:
57. Nurse Katrina prepares an older-adult
A. Three spontaneous abortions client for sleep, actions are taken to help
B. negative maternal blood type reduce the likelihood of a fall during the
C. Blood loss of 850 ml after a vaginal birth night. Targeting the most frequent cause
D. Maternal temperature of 99.9° F 12 hours
of falls, the nurse should:
after delivery
53. A client is experiencing stomatitis as a A. Offer the client assistance to the bathroom
result of chemotherapy. An appropriate B. Move the bedside table closer to the client’s
nursing intervention related to this bed
condition would be to:
C. Encourage the client to take an available 62. The central problem the nurse might
sedative face with a disturbed schizophrenic client
D. Assist the client to telephone the spouse to say
is the client’s:
“goodnight”
58. When evaluating a growth and A. Suspicious feelings
development of a 6 month old infant, B. Continuous pacing
nurse Patty would expect the infant to be C. Relationship with the family
D. Concern about working with others
able to:
63. When planning care with a client
A. Sit alone, display pincer grasp, wave bye bye during the postoperative recovery period
B. Pull self to a standing position, release a toy following an abdominal hysterectomy and
by choice, play peek-a-boo
bilateral salpingo-oophorectomy, nurse
C. Crawl, transfer toy from one hand to the other,
display of fear of strangers Frida should include the explanation that:
D. Turn completely over, sit momentarily A. Surgical menopause will occur
without support, reach to be picked up B. Urinary retention is a common problem
59. A breastfeeding mother asks the C. Weight gain is expected, and dietary plan are
nurse what she can do to ease the needed
discomfort caused by a cracked nipple. D. Depression is normal and should be expected
Nurse Tina should instruct the client to: 64. An adolescent client with anorexia
nervosa refuses to eat, stating, “I’ll get too
A. Manually express milk and feed it to the baby
fat.” Nurse Andrea can best respond to
in a bottle
B. Stop breastfeeding for two days to allow the this behavior initially by:
nipple to heal A. Not talking about the fact that the client is not
C. Use a breast shield to keep the baby from eating
direct contact with the nipple B. Stopping all of the client’s priviledges until
D. Feed the baby on the unaffected breast first food is eaten
until the affected breast heals C. Telling the client that tube feeding will
60. Nurse Sandy observes that there is eventually be necessary
blood coming from the client’s ear after D. Pointing out to the client that death can occur
head injury. Nurse Sandy should: with malnutrition.
65. A pain scale is used to assess the
A. Turn the client to the unaffected side
degree of pain. The client rates the pain
B. Cleanse the client’s ear with sterile gauze
C. Test the drainage from the client’s ear with as an 8 on a scale of 10 before
Dextrostix medication and a 7 on a scale of 10 after
D. Place sterile cotton loosely in the external ear being medicated. Nurse Glenda
of the client determines that the:
61. Nurse Gio plans a long term care for
A. Client has a low pain tolerance
parents of children with sickle-cell
B. Medication is not adequately effective
anemia, which includes periodic group C. Medication has sufficiently decreased the pain
conferences. Some of the discussions level
should be directed towards: D. Client needs more education about the use of
the pain scale
A. Finding special school facilities for the child
66. To enhance a neonate’s behavioral
B. Making plans for moving to a more
therapeutic climate development, therapeutic nursing
C. Choosing a means of birth control to avoid measures should include:
future pregnancies
A. Keeping the baby awake for longer periods of
D. Airing their feelings regarding the
time before each feeding
transmission of the disease to the child
B. Assisting the parents to stimulate their baby
through touch, sound, and sight.
C. Encouraging parental contact for at least one A. For people to attain their birthrights of health
15-minute period every four hours. and longevity
D. Touching and talking to the baby at least B. For promotion of health and prevention of
hourly, beginning within two to four hours disease
after birth C. For people to have access to basic health
67. Before formulating a plan of care for a services
6 year old boy with attention deficit D. For people to be organized in their health
efforts
hyperactivity disorder (ADHD), nurse Kyla
72. What other statistic may be used to
is aware that the initial aim of therapy is to
determine attainment of longevity?
help the client to:
A. Age-specific mortality rate
A. Develop language skills
B. Proportionate mortality rate
B. Avoid his own regressive behavior
C. Swaroop’s index
C. Mainstream into a regular class in school
D. Case fatality rate
D. Recognize himself as an independent person
of worth 73. Which of the following is the most
68. Nurse Wally knows that the most prominent feature of public health
important aspect of the preoperative care nursing?
for a child with Wilms’ tumor would be: A. It involves providing home care to sick people
who are not confined in the hospital
A. Checking the size of the child’s liver
B. Services are provided free of charge to people
B. Monitoring the child’s blood pressure
within the catchment area.
C. Maintaining the child in a prone position
C. The public health nurse functions as part of a
D. Collecting the child’s urine for culture and
team providing a public health nursing
sensitivity
services.
69. At 11:00 pm the count of hydrocodone D. Public health nursing focuses on preventive,
(Vicodin) is incorrect. After several not curative, services.
minutes of searching the medication cart 74. Which of the following is the mission
and medication administration records, no of the Department of Health?
explanation can be found. The primary
nurse should notify the: A. Health for all Filipinos
B. Ensure the accessibility and quality of health
A. Nursing unit manager care
B. Hospital administrator C. Improve the general health status of the
C. Quality control manager population
D. Physician ordering the medication D. Health in the hands of the Filipino people by
70. When caring for the a client with a the year 2020
pneumothorax, who has a chest tube in 75. Nurse Pauline determines whether
place, nurse Kate should plan to: resources were maximized in
implementing Ligtas Tigdas, she is
A. Administer cough suppressants at appropriate evaluating:
intervals as ordered
B. Empty and measure the drainage in the A. Effectiveness
collection chamber each shift B. Efficiency
C. Apply clamps below the insertion site when C. Adequacy
ever getting the client out of bed D. Appropriateness
D. Encourage coughing, deep breathing, and 76. Lissa is a B.S.N. graduate. She want
range of motion to the arm on the affected to become a Public Health Nurse. Where
side
will she apply?
71. According to C.E.Winslow, which of
the following is the goal of Public Health? A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit 82. Nurse Cathy learns that some leaders
77. As an epidemiologist, Nurse Celeste are transactional leaders. Which of the
is responsible for reporting cases of following does NOT characterize a
notifiable diseases. What law mandates transactional leader?
reporting of cases of notifiable diseases?
A. Focuses on management tasks
A. Act 3573 B. Is a caretaker
B. R.A. 3753 C. Uses trade-offs to meet goals
C. R.A. 1054 D. Inspires others with vision
D. R.A. 1082 83. Functional nursing has some
78. Nurse Fay is aware that isolation of a advantages, which one is an
child with measles belongs to what level EXCEPTION?
of prevention?
A. Psychological and sociological needs are
A. Primary emphasized.
B. Secondary B. Great control of work activities.
C. Intermediate C. Most economical way of delivering nursing
D. Tertiary services.
79. Nurse Gina is aware that the following D. Workers feel secure in dependent role
is an advantage of a home visit? 84. Which of the following is the best
guarantee that the patient’s priority needs
A. It allows the nurse to provide nursing care to a
are met?
greater number of people.
B. It provides an opportunity to do first hand A. Checking with the relative of the patient
appraisal of the home situation. B. Preparing a nursing care plan in collaboration
C. It allows sharing of experiences among people with the patient
with similar health problems. C. Consulting with the physician
D. It develops the family’s initiative in providing D. Coordinating with other members of the team
for health needs of its members. 85. Nurse Tony stresses the need for all
80. The PHN bag is an important tool in the employees to follow orders and
providing nursing care during a home instructions from him and not from
visit. The most important principle of bag anyone else. Which of the following
technique states that it: principles does he refer to?
A. Should save time and effort. A. Scalar chain
B. Should minimize if not totally prevent the B. Discipline
spread of infection. C. Unity of command
C. Should not overshadow concern for the D. Order
patient and his family.
86. Nurse Joey discusses the goal of the
D. May be done in a variety of ways depending
on the home situation, etc. department. Which of the following
81. Nurse Willy reads about Path Goal statements is a goal?
theory. Which of the following behaviors A. Increase the patient satisfaction rate
is manifested by the leader who uses this B. Eliminate the incidence of delayed
theory? administration of medications
C. Establish rapport with patients
A. Recognizes staff for going beyond D. Reduce response time to two minutes
expectations by giving them citations 87. Nurse Lou considers shifting to
B. Challenges the staff to take individual
transformational leadership. Which of the
accountability for their own practice
C. Admonishes staff for being laggards following statements best describes this
D. Reminds staff about the sanctions for non type of leadership?
performance
A. Uses visioning as the essence of leadership
B. Serves the followers rather than being served 93. Which procedure or practice requires
C. Maintains full trust and confidence in the surgical asepsis?
subordinates
D. Possesses innate charisma that makes others A. Hand washing
feel good in his presence. B. Nasogastric tube irrigation
88. Nurse Mae tells one of the staff, “I C. I.V. cannula insertion
don’t have time to discuss the matter with D. Colostomy irrigation
you now. See me in my office later” when 94. The nurse is performing wound care
the latter asks if they can talk about an using surgical asepsis. Which of the
issue. Which of the following conflict following practices violates surgical
resolution strategies did she use? asepsis?

A. Smoothing A. Holding sterile objects above the waist

B. Compromise B. Pouring solution onto a sterile field cloth
C. Avoidance C. Considering a 1″ (2.5-cm) edge around the
D. Restriction sterile field contaminated
D. Opening the outermost flap of a sterile
89. Nurse Bea plans of assigning
package away from the body
competent people to fill the roles
95. On admission, a client has the
designed in the hierarchy. Which process
following arterial blood gas (ABG) values:
refers to this?
PaO2, 50 mm Hg; PaCO2, 70 mm Hg;
A. Staffing pH, 7.20; HCO3–, 28 mEq/L. Based on
B. Scheduling these values,
C. Recruitment the nurse should formulate which nursing
D. Induction
diagnosis for this client?
90. Nurse Linda tries to design an
organizational structure that allows A. Risk for deficient fluid volume
communication to flow in all directions B. Deficient fluid volume
C. Impaired gas exchange
and involve workers in decision making.
D. Metabolic acidosis
Which form of organizational structure is
96. The use of larvivorous fish in malaria
this?
control is the basis for which strategy of
A. Centralized malaria control?
B. Decentralized
C. Matrix A. Stream seeding
D. Informal B. Stream clearing
C. Destruction of breeding places
91. When documenting information in a
D. Zooprophylaxis
client’s medical record, the nurse should:
97. In Integrated Management of
A. erase any errors. Childhood Illness, severe conditions
B. use a #2 pencil. generally require urgent referral to a
C. leave one line blank before each new entry. hospital. Which of the following severe
D. end each entry with the nurse’s signature and
conditions DOES NOT always require
title.
urgent referral to a hospital?
92. Which of the following factors are
major components of a client’s general A. Mastoiditis
background drug history? B. Severe dehydration
C. Severe pneumonia
A. Allergies and socioeconomic status D. Severe febrile disease
B. Urine output and allergies 98. A mother brought her daughter, 4
C. Gastric reflex and age
years old, to the RHU because of cough
D. Bowel habits and allergies
and colds. Following the IMCI
 assessment guide, which of the following 6. C. Prepare her for a pelvic
is a danger sign that indicates the need examination. Pelvic examination would
reveal dilation and effacement
for urgent referral to a hospital?
7. D. On the right side of the heart. Pulmonic
A. Inability to drink stenosis increases resistance to blood flow,
B. High grade fever causing right ventricular hyperthropy; with
C. Signs of severe dehydration right ventricular failure there is an increase in
D. Cough for more than 30 days pressure on the right side of the heart.
99. Food fortification is one of the 8. A. Eating patterns are altered. A new
dietary regimen, with a balance of foods from
strategies to prevent micronutrient
the food pyramid, must be established and
deficiency conditions. R.A. 8976 continued for weight reduction to occur and
mandates fortification of certain food be maintained.
items. Which of the following is among 9. B. “It is Ok to cry; I’ll just stay with you
these food items? for now”. This portrays a nonjudgmental
attitude that recognizes the client’s needs.
A. Sugar 10.C. Lactated Ringer’s solution. Lactated
B. Bread Ringer’s solution replaces lost sodium and
C. Margarine corrects metabolic acidosis, both of which
D. Filled milk commonly occur following a burn. Albumin is
100. The major sign of iron deficiency used as adjunct therapy, not primary fluid
anemia is pallor. What part is best replacement. Dextrose isn’t given to burn
examined for pallor? patients during the first 24 hours because it
can cause pseudodiabetes. The patient is
A. Palms hyperkalemic from the potassium shift from
B. Nailbeds the intracellular space to the plasma, so
C. Around the lips potassium would be detrimental.
D. Lower conjunctival sac 11.C. Twitching and disorientation. Excess
Answers and Rationales extracellular fluid moves into cells (water
1. C. Check for any change in responsiveness intoxication); intracellular fluid excess in
every two hours until the follow-up sensitive brain cells causes altered mental
visit. Signs of an epidural hematoma in status; other signs include anorexia nervosa,
children usually do not appear for 24 hours or nausea, vomiting, twitching, sleepiness, and
more hours; a follow-up visit usually is convulsions.
arranged for one to two days after the injury. 12.B. Resume the usual diet as soon as
2. A. Arteriolar constriction occurs.The early desired. As long as the client has no nausea or
compensation of shock is cardiovascular and vomiting, there are no dietary restriction.
is seen in changes in pulse, BP, and pulse 13.B. Shrinkage of the residual limb must be
pressure; blood is shunted to vital centers, completed. Shrinkage of the residual limb,
particularly heart and brain. resulting from reduction of subcutaneous fat
3. A. Allow the client to open canned or pre- and interstitial fluid, must occur for an
packaged food. The client’s comfort, safety, adequate fit between the limb and the
and nutritional status are the priorities; the prosthesis.
client may feel comfortable to eat if the food 14.A. Change the maternal
has been sealed before reaching the mental position. Stimulation of the sympathetic
health facility. nervous system is an initial response to mild
4. D. “Joining a support group of parents who hypoxia that accompanies partial cord
are coping with this problem can be quite compression (umbilical vein) during
helpful. Taking with others in similar contractions; changing the maternal position
circumstances provides support and allows for can alleviate the compression.
sharing of experiences. 15.A. Perform a finger stick to test the client’s
5. B. Observe the dressing at the back of the blood glucose level. The client has signs of
neck for the presence of blood. Drainage diabetes, which may result from steroid
flows by gravity. therapy, testing the blood glucose level is a
 method of screening for diabetes, thus 28.B. Maintaining the ordered
gathering more data. hydration. Promoting hydration maintains
16.C. Heart block. This is the primary indication urine production at a higher rate, which
for a pacemaker because there is an interfere flushes the bladder and prevents urinary stasis
with the electrical conduction system of the and possible infection.
heart. 29.C. Taking the client’s pedal pulse in the
17.A. With meals and snacks. Pancreases affected limb. Monitoring a pedal pulse will
capsules must be taken with food and snacks assess circulation to the foot.
because it acts on the nutrients and readies 30.A.  “Where are you?”. “Where are you?” is
them for absorption. the best question to elicit information about
18.B. Put a hat on the infant’s head. Oxygen the client’s orientation to place because it
has cooling effect, and the baby should be encourages a response that can be assessed.
kept warm so that metabolic activity and 31.D. Bleeding from the venipuncture
oxygen demands are not increased. site. This indicates a fibrinogenemia; massive
19.C. Wear an Ultra-Filter mask when they clotting in the area of the separation has
are in the client’s room. Tubercle bacilli are resulted in a lowered circulating fibrinogen.
transmitted through air currents; therefore 32.D. blowing pattern. Clients should use a
personal protective equipment such as an blowing pattern to overcome the premature
Ultra-Filter mask is necessary. urge to push.
20.D. Cerebral cortex compression. Cerebral 33.A. Cheeseburger and a malted. Of the
compression affects pyramidal tracts, selections offered, this is the highest in
resulting in decorticate rigidity and cranial calories and protein, which are needed for
nerve injury, which cause pupil dilation. increased basal metabolic rate and for tissue
21.A.Mediastinal shift. Mediastinal structures repair.
move toward the uninjured lung, reducing 34.B. Cyanotic lips and face. Central cyanosis
oxygenation and venous return. (blue lips and face) indicates lowered
22.C. Prevent situations that may stimulate oxygenation of the blood, caused by either
the cervix or uterus. Stimulation of the decreased lung expansion or right to left
cervix or uterus may cause bleeding or shunting of blood.
hemorrhage and should be avoided. 35.A. Notify the physician of the findings
23.C. Severe shortness of breath. This could because the level is dangerously
indicate a recurrence of the pneumothorax as high. Levels close to 2 mEq/L are
one side of the lung is inadequate to meet the dangerously close to the toxic level;
oxygen demands of the body. immediate action must be taken.
24.A. Suction equipment. Respiratory 36.C. Days 15 to 17. Ovulation occurs
complications can occur because of edema of approximately 14 days before the next
the glottis or injury to the recurrent laryngeal menses, about the 16th day in 30 day cycle;
nerve. the 15th to 17th days would be the best time
25.A. Strong desire to improve her body to avoid sexual intercourse.
image. Clients with anorexia nervosa have a 37.C. Assure that informed consent has been
disturbed self image and always see obtained from the client. An invasive
themselves as fat and needing further procedure such as amniocentesis requires
reducing. informed consent.
26.B. Attempting to reduce or limit situations 38.D. Prevent development of respiratory
that increase anxiety. Persons with high distress. Respiratory distress or arrest may
anxiety levels develop various behaviors to occur when the serum level of magnesium
relieve their anxiety; by reducing anxiety, the sulfate reaches 12 to 15 mg/dl; deep tendon
need for these obsessive-compulsive action is reflexes disappear when the serum level is 10
reduced. to 12 mg/dl; the drug is withheld in the
27.C. Becomes fussy when frustrated and absence of deep tendon reflexes; the
displays a shortened attention therapeutic serum level is 5 to 8 mg/dl.
span. Shortened attention span and fussy 39.A. Obtaining the child’s daily
behavior may indicate a change in intracranial weight. Weight monitoring is the most useful
pressure and/or shunt malfunction. means of assessing fluid balance and changes
 in the edematous state; 1 liter of fluid weighs 53.A. Provide frequent saline
about 2.2 pounds. mouthwashes. This is soothing to the oral
40.C. Reduces the inflammatory response of mucosa and helps prevent infection.
tissues. Corticosteroids act to decrease 54.B. “Society makes people react in old
inflammation which decreases edema. ways”. The client is incapable of accepting
41.D. An audible click on hip responsibility for self-created problems and
manipulation. With specific manipulation, an blames society for the behavior.
audible click may be heard of felt as he 55.A. Taste and smell. Swelling can obstruct
femoral head slips into the acetabulum. nasal breathing, interfering with the senses of
42.B. Allow the denial but be available to taste and smell.
discuss death. This does not remove client’s 56.A. Fatigue. Fatigue is a major problem
only way of coping, and it permits future caused by an increase in waste products
movement through the grieving process when because of catabolic processes.
the client is ready. 57.A. Offer the client assistance to the
43.B. Divide food into four to six meals a bathroom. Statistics indicate that the most
day. The volume of food in the stomach frequent cause of falls by hospitalized clients
should be kept small to limit pressure on the is getting up or attempting to get up to the
cardiac sphincter. bathroom unassisted.
44.B. “I feel washed out; there isn’t much 58.D. Turn completely over, sit momentarily
left”. The client’s statement infers an without support, reach to be picked
emptiness with an associated loss. up. These abilities are age-appropriate for the
45.A. Vitamin K is not absorbed. Vitamin K, a 6 month old child.
fat soluble vitamin, is not absorbed from the 59.D. Feed the baby on the unaffected breast
GI tract in the absence of bile; bile enters the first until the affected breast heals. The
duodenum via the common bile duct. most vigorous sucking will occur during the
46.D. Leg weakness with muscle first few minutes of breastfeeding when the
cramps. Impulse conduction of skeletal infant would be on the unaffected breast; later
muscle is impaired with decreased potassium suckling is less traumatic.
levels, muscular weakness and cramps may 60.D. Place sterile cotton loosely in the
occur with hypokalemia. external ear of the client. This would absorb
47.D. Simian lines on the hands. This is the drainage without causing further trauma.
characteristic finding in newborns with Down 61.D. Airing their feelings regarding the
syndrome. transmission of the disease to the
48.B. Eyes. Rheumatoid arthritis can cause child. Discussion with parents who have
inflammation of the iris and ciliary body of children with similar problems helps to reduce
the eyes which may lead to blindness. some of their discomfort and guilt.
49.A. Accept the client’s decision without 62.A. Suspicious feelings. The nurse must deal
discussion. This is all the nurse can do until with these feelings and establish basic trust to
trust is established; facing the client to attend promote a therapeutic milieu.
will disrupt the group. 63.A. Surgical menopause will occur. When a
50.D. Provide a simple explanation of the bilateral oophorectomy is performed, both
procedure and continue to reassure the ovaries are excised, eliminating ovarian
client. The nurse should offer support and use hormones and initiating response.
clear, simple terms to allay client’s anxiety. 64.D. Pointing out to the client that death can
51.D. If I have difficulty in inserting the occur with malnutrition. The client expects
irrigating tube into the stoma”. This occurs the nurse to focus on eating, but the emphasis
with stenosis of the stoma; forcing insertion of should be placed on feelings rather than
the tube could cause injury. actions.
52.C. Blood loss of 850 ml after a vaginal 65.B. Medication is not adequately
birth. Excessive blood loss predisposes the effective. The expected effect should be more
client to an increased risk of infection because than a one point decrease in the pain level.
of decreased maternal resistance; they 66.B. Assisting the parents to stimulate their
expected blood loss is 350 to 500 ml. baby through touch, sound, and
sight. Stimuli are provided via all the senses;
since the infant’s behavioral development is
 enhanced through parent-infant interactions, those who are not sick (specific disease
these interactions should be encouraged. prevention).
67.D. Recognize himself as an independent 79.B. It provides an opportunity to do first
person of worth. Academic deficits, an hand appraisal of the home
inability to function within constraints situation. Choice A is not correct since a
required of certain settings, and negative peer home visit requires that the nurse spend so
attitudes often lead to low self-esteem. much time with the family. Choice C is an
68.B. Monitoring the child’s blood advantage of a group conference, while choice
pressure. Because the tumor is of renal D is true of a clinic consultation.
origin, the rennin angiotensin mechanism can 80.B. Should minimize if not totally prevent
be involved, and blood pressure monitoring is the spread of infection. Bag technique is
important. performed before and after handling a client
69.A. Nursing unit manager. Controlled in the home to prevent transmission of
substance issues for a particular nursing unit infection to and from the client.
are the responsibility of that unit’s nurse 81.A. Recognizes staff for going beyond
manager. expectations by giving them citations. Path
70.D. Encourage coughing, deep breathing, Goal theory according to House and
and range of motion to the arm on the associates rewards good performance so that
affected side. All these interventions promote others would do the same.
aeration of the re-expanding lung and 82.D. Inspires others with vision. Inspires
maintenance of function in the arm and others with a vision is characteristic of a
shoulder on the affected side. transformational leader. He is focused more
71.A. For people to attain their birthrights of on the day-to-day operations of the
health and longevity. According to Winslow, department/unit.
all public health efforts are for people to 83.A. Psychological and sociological needs are
realize their birthrights of health and emphasized. When the functional method is
longevity. used, the psychological and sociological needs
72.C. Swaroop’s index. Swaroop’s index is the of the patients are neglected; the patients are
percentage of the deaths aged 50 years or regarded as ‘tasks to be done”
older. Its inverse represents the percentage of 84.B. Preparing a nursing care plan in
untimely deaths (those who died younger than collaboration with the patient. The best
50 years). source of information about the priority needs
73.D. Public health nursing focuses on of the patient is the patient himself. Hence
preventive, not curative, services.. The using a nursing care plan based on his
catchment area in PHN consists of a expressed priority needs would ensure
residential community, many of whom are meeting his needs effectively.
well individuals who have greater need for 85.C. Unity of command. The principle of unity
preventive rather than curative services. of command means that employees should
74.B. Ensure the accessibility and quality of receive orders coming from only one manager
health care. Ensuring the accessibility and and not from two managers. This averts the
quality of health care is the primary mission possibility of sowing confusion among the
of DOH. members of the organization.
75.B. Efficiency. Efficiency is determining 86.A. Increase the patient satisfaction
whether the goals were attained at the least rate. Goal is a desired result towards which
possible cost. efforts are directed. Options AB, C and D are
76.D. Rural Health Unit. R.A. 7160 devolved all objectives which are aimed at specific end.
basic health services to local government units 87.A. Uses visioning as the essence of
(LGU’s ). The public health nurse is an leadership. Transformational leadership relies
employee of the LGU. heavily on visioning as the core of leadership.
77.A. Act 3573. Act 3573, the Law on Reporting 88.C. Avoidance. This strategy shuns discussing
of Communicable Diseases, enacted in 1929, the issue head-on and prefers to postpone it to
mandated the reporting of diseases listed in a later time. In effect the problem remains
the law to the nearest health station. unsolved and both parties are in a lose-lose
78.A. Primary. The purpose of isolating a client situation.
with a communicable disease is to protect
89.A. Staffing. Staffing is a management diagnosis of Impaired gas exchange. ABG
function involving putting the best people to values can’t indicate a diagnosis of Fluid
accomplish tasks and activities to attain the volume deficit (or excess) or Risk for
goals of the organization. deficient fluid volume. Metabolic acidosis is a
90.B. Decentralized. Decentralized structures medical, not nursing, diagnosis; in any event,
allow the staff to make decisions on matters these ABG values indicate respiratory, not
pertaining to their practice and communicate metabolic, acidosis.
in downward, upward, lateral and diagonal 96.A. Stream seeding. Stream seeding is done
flow. by putting tilapia fry in streams or other
91.D. end each entry with the nurse’s bodies of water identified as breeding places
signature and title. The end of each entry of the Anopheles mosquito.
should include the nurse’s signature and title; 97.B. Severe dehydration. The order of priority
the signature holds the nurse accountable for in the management of severe dehydration is as
the recorded information. Erasing errors in follows: intravenous fluid therapy, referral to
documentation on a legal document such as a a facility where IV fluids can be initiated
client’s chart isn’t permitted by law. Because within 30 minutes, Oresol/nasogastric tube,
a client’s medical record is considered a legal Oresol/orem. When the foregoing measures
document, the nurse should make all entries in are not possible or effective, tehn urgent
ink. The nurse is accountable for the referral to the hospital is done.
information recorded and therefore shouldn’t 98.A. Inability to drink. A sick child aged 2
leave any blank lines in which another health months to 5 years must be referred urgently to
care worker could make additions. a hospital if he/she has one or more of the
92.A. Allergies and socioeconomic following signs: not able to feed or drink,
status. General background data consist of vomits everything, convulsions, abnormally
such components as allergies, medical history, sleepy or difficult to awaken.
habits, socioeconomic status, lifestyle, beliefs, 99.A. Sugar. R.A. 8976 mandates fortification of
and sensory deficits. Urine output, gastric rice, wheat flour, sugar and cooking oil with
reflex, and bowel habits are significant only if Vitamin A, iron and/or iodine.
a disease affecting these functions is present. 100. A. Palms. The anatomic characteristics
93.C. I.V. cannula insertion. Caregivers must of the palms allow a reliable and convenient
use surgical asepsis when performing wound basis for examination for pallor.
care or any procedure in which a sterile body
cavity is entered or skin integrity is broken.
To achieve surgical asepsis, objects must be
rendered or kept free of all pathogens.
Inserting an I.V. cannula requires surgical
asepsis because it disrupts skin integrity and
involves entry into a sterile cavity (a vein).
The other options are used to ensure medical
asepsis or clean technique to prevent the
spread of infection. The GI tract isn’t sterile;
therefore, irrigating a nasogastric tube or a
colostomy requires only clean technique.
94.B. Pouring solution onto a sterile field
cloth. Pouring solution onto a sterile field
cloth violates surgical asepsis because
moisture penetrating the cloth can carry
microorganisms to the sterile field via
capillary action. The other options are
practices that help ensure surgical asepsis.
95.C. Impaired gas exchange. The client has a
below-normal value for the partial pressure of
arterial oxygen (PaO2) and an above-normal
value for the partial pressure of arterial carbon
dioxide (PaCO2), supporting the nursing
 PNLE: Medical Surgical Nursing 4 5. Assessment of a client with possible
1. A patient is admitted to the medical thrombophlebitis to the left leg and a deep
surgical unit following surgery. Four days vein thrombosis is done by pulling up on
after surgery, the patient spikes a 38.9 the toes while gently holding down on the
degrees C oral temperature and exhibits knee. The client complains of extreme
a wet, productive cough. The nurse pain in the calf. This should be
assesses the patient with understanding documented as:
that an infection that is acquired during A. positive tourniquet test
hospitalization is known as: B. positive homan’s sign
C. negative homan’s sign
A. a community acquired infection D. negative tourniquet test
B. an iatrogenic infection
6. Thomas Elison is a 79 year old man
C. a nosocomial infection
D. an opportunistic infection who is admitted with diagnosis of
2. A client with anemia has a hemoglobin dementia. The doctor orders a series of
of 6.5 g/dL. The client is experiencing laboratory tests to determine whether Mr.
symptoms of cerebral tissue hypoxia. Elison’s dementia is treatable. The nurse
Which of the following nursing understands that the most common cause
interventions would be most important in of dementia in this population is:
providing care? A. AIDS
B. Alzheimer’s disease
A. Providing rest periods throughout the day
C. Brain tumors
B. Instituting energy conservation techniques
D. Vascular disease
C. Assisting in ambulation to the bathroom
D. Checking temperature of water prior to 7. Which of the following nursing
bathing interventions is contraindicated in the
3. A client was involved in a motor care of a client with acute osteomyelitis?
vehicular accident in which the seat belt A. Apply heat compress to the affected area
was not worn. The client is exhibiting B. Immobilize the affected area
crepitus, decrease breath sounds on the C. Administer narcotic analgesics for pain
left, complains of shortness of breath, and D. Administer OTC analgesics for pain
has a respiratory rate of 34 breaths per 8. A client with congestive heart failure
minute. Which of the following has digoxin (Lanoxin) ordered everyday.
assessment findings would concern the Prior to giving the medication, the nurse
nurse most? checks the digoxin level which is
therapeutic and ausculates an apical
A. Temperature of 102 degrees F and productive
pulse. The apical pulse is 63 bpm for 1
cough
B. ABG with PaO2 of 92 and PaCO2 of 40 full minute. The nurse should:
mmHg
A. Hold the Lanoxin
C. Trachea deviating to the right B. Give the half dose now, wait an hour and give
D. Barrel-chested appearance
the other half
4. The proper way to open an envelop- C. Call the physician
wrapped sterile package after removing D. Give the Lanoxin as ordered
the outer package or tape is to open the 9. Nurse Marian is caring for a client with
first position of the wrapper: haital hernia, which of the following
should be included in her teaching plan
A. away from the body
B. to the left of the body regarding causes:
C. to the right of the body
A. To avoid heavy lifting
D. toward the body B. A dietary plan based on soft foods
C. Its prevalence in young adults 16. Nurse Edward is performing
D. Its prevalence in fair-skinned individuals discharge teaching for a newly diagnosed
10. Joseph has been diagnosed with diabetic patient scheduled for a fasting
hepatic encephalopathy. The nurse blood glucose test. The nurse explains to
observes flapping tremors. The nurse the patient that hyperglycemia is defined
understands that flapping tremors as a blood glucose level above:
associated with hepatic encephalopathy
are also known as: A. 100 mg/dl
B. 120 mg/dl
A. aphasia C. 130 mg/dl
B. ascites D. 150 mg/dl
C. astacia 17. Mang Edison is on bed rest has
D. asterixis developed an ulcer that is full thickness
11. Hyperkalemia can be treated with and is penetrating the subcutaneous
administration of 50% dextrose and tissue. The nurse documents that this
insulin. The 50% dextrose: ulcer is in which of the following stages?
A. causes potassium to be excreted A. Stage 1
B. causes potassium to move into the cell B. Stage 2
C. causes potassium to move into the serum C. Stage 3
D. counteracts the effects of insulin D. Stage 4
12. Which of the following findings would 18. A 24 year old male patient comes to
strongly indicate the possibility of the clinic after contracting genital herpes.
cirrhosis? Which of the following intervention would
A. dry skin be most appropriate?
B. hepatomegaly
A. Encourage him to maintain bed rest for
C. peripheral edema
several days
D. pruritus
B. Monitor temperature every 4 hours
13. Aling Puring has just been diagnosed C. Instruct him to avoid sexual contact during
with close-angle (narrow-angle) acute phases of illness
glaucoma. The nurse assesses the client D. Encourage him to use antifungal agents
for which of the following common regularly
presenting symptoms of the disorder? 19. An 8 year old boy is brought to the
trauma unit with a chemical burn to the
A. halo vision
face. Priority assessment would include
B. dull eye pain
C. severe eye and face pain which of the following?
D. impaired night vision A. Skin integrity
14. Chvostek’s sign is associated with B. BP and pulse
which electrolyte impabalnce? C. Patency of airway
D. Amount of pain
A. hypoclacemia
20. A client with anemia due to
B. hypokalemia
C. hyponatremia chemotherapy has a hemoglobin of 7.0
D. hypophosphatenia g/dL. Which of the following complaints
15. What laboratory test is a common would be indicative of tissue hypoxia
measure of the renal function? related to anemia?

A. CBC A. dizziness
B. BUN/Crea B. fatigue relieved by rest
C. Glucose C. skin that is warm and dry to the touch
D. Alanine amino transferase (ALT) D. apathy
 21. Hazel Murray, 32 years old complains by medical therapy. And an opportunistic
of abrupt onset of chest and back pain infection affects a compromised host.
2. C. Assisting in ambulation to the
and loss of radial pulses. The nurse
bathroom. Cerebral tissue hypoxia is
suspects that Mrs. Murray may have: commonly associated with dizziness. The
A. Acute MI greatest potential risk to the client with
B. CVA dizziness is injury, especially with changes in
C. Dissecting abdominal aorta position. Planning for periods of rest and
D. Dissecting thoracic aneurysm conserving energy are important with
someone with anemia because of his or her
22. Nurse Alexandra is establishing a
fatigue level but most important is safety.
plan of care for a client newly admitted 3. C. Trachea deviating to the right. A
with SIADH. The priority diagnosis for this mediastinal shift is indicative of a tension
client would be which of the following? pneumothorax along with the other symptoms
in the question. Since the individual was
A. Fluid volume deficit involved in a MVA, assessment would be
B. Anxiety related to disease process targeted at acute traumatic injuries to the
C. Fluid volume excess lungs, heart or chest wall rather than other
D. Risk for injury conditions indicated in the other answers.
23. Nursing management of the client Option A is common with pneumonia; values
with a UTI should include: in option B are not alarming; and option D is
typical of someone with COPD.
A. Taking medication until feeling better 4. A. away from the body. When opening an
B. Restricting fluids envelop-wrapped sterile package, reaching
C. Decreasing caffeine drinks and alcohol across the package and using the first motion
D. Douching daily to open the top cover away from the body
24. Felicia Gomez is 1 day postoperative eliminates the need to later reach across the
from coronary artery bypass surgery. The steri9le field while opening the package. To
nurse understands that a postoperative remove equipment from the package, opening
patient who’s maintained on bed rest is at the first portion of the package toward, to the
left, or to the right of the body would require
high risk for developing:
reaching across a sterile field.
A. angina 5. B. positive homan’s sign. Pain in the calf
B. arterial bleeding while pulling up on the toes is abnormal and
C. deep vein thrombosis (DVT) indicates a positive test. If the client feels
D. dehiscence of the wound nothing or just feels like the calf muscle is
25. Which of the following statement is stretching, it is considered negative. A
tourniquet test is used to measure for varicose
true regarding the visual changes veins.
associated with cataracts? 6. B. Alzheimer’s disease. Alzheimer’s disease
is the most common cause of dementia in the
A. Both eyes typically cataracts at the same time
elderly population. AIDS, brain tumors and
B. The loss of vision is experienced as a painless,
vascular disease are all less common causes of
gradual blurring
progressive loss of mental function in elderly
C. The patient is suddenly blind
patients.
D. The patient is typically experiences a painful,
7. A. Apply heat compress to the affected
sudden blurring of vision.
area. Options B, C and D are appropriate
Answers and Rationales nursing interventions when caring for a client
1. C. a nosocomial infection. Nosocomial, or diagnosed with osteomyelitis. The application
hospital-acquired are infections acquired of heat can increase edema and pain in the
during hospitalization for which the patient affected area and spread bacteria through
isn’t being primarily treated. Community vasodilation.
acquired or opportunistic infections may not 8. D. Give the Lanoxin as ordered. The
be acquired during hospitalization. An Lanoxin should be held for a pulse of 60 bpm.
iatrogenic infection is caused by the doctor or Nurses cannot arbitrarily give half of a dose
 without a physician’s order. Unless specific 16.B. 120 mg/dl. Hyperglycemia is defined as a
parameters are given concerning pulse rate, blood glucose level greater than 120 mg/dl.
most resources identify 60 as the reference Blood glucose levels of 120 mg/dl, 130 mg/dl
pulse. and 150 mg/dl are considered hyperglycemic.
9. A. To avoid heavy lifting. Heavy lifting is A blood glucose of 100 mg/dl is normal.
one factor that leads to development of a 17.C. Stage 3. A stage 3 ulcer is full thickness
hiatal hernia. Dietary factors involve limiting involving the subcutaneous tissue. A stage 1
fat intake, not restricting client to soft foods. It ulcer has a defined area of persistent redness
is more prevalent in individuals who are in lightly pigmented skin. A stage 2 ulcer
middle-aged or older. Fair-skinned individuals involves partial thickness skin loss. Stage 4
are not prone to this condition. ulcers extend through the skin and exhibit
10.D. asterixis. Flapping tremors associated with tissue necrosis and muscle or bone
hepatic encephalophaty are asterixis. Aphasia involvement.
is the inability to speak. Ascites is an 18.C. Instruct him to avoid sexual contact
accumulation of fluid in the peritoneal cavity. during acute phases of illness. Herpes is a
Astacia is the inability to stand or sit still. virus and is spread through direct contact. An
11.D. counteracts the effects of insulin. The antifungal would not be useful; bed rest and
50% dextrose is given to counteract the temperature measurement are usually not
effects of insulin. Insulin drives the potassium necessary.
into the cell, thereby lowering the serum 19.C. Patency of airway. A burn face, neck or
potassium levels. The dextrose doesn’t chest may cause airway closure because of the
directly cause potassium excretion or any edema that occurs within hours. Remember
movement of potassium. the ABC’s: airway, breathing and circulation.
12.B. hepatomegaly. Although option D is Airway always comes first, even before pain.
correct, it is not a strong indicator of cirrhosis. The nurse will also assess options B and D,
Pruritus can occur for many reasons. Options but these are not the highest priority
A and C are incorrect, fluid accumulations is assessments.
usually in the form of ascites in the abdomen. 20.A. dizziness. Central tissue hypoxia is
Hepatomegaly is an enlarged liver, which is commonly associated with dizziness.
correct. The spleen may also be enlarged. Recognition of cerebral hypoxia is critical
13.C. severe eye and face pain. Narrow-angle since the body will attempt to shunt
glaucoma develops abruptly and manifests oxygenated blood to vital organs.
with acute face and eye pain and is a medial 21.D. Dissecting thoracic aneurysm. A
emergency. Halo vision, dull eye pain and dissecting thoracic aneurysm may cause loss
impaired night vision are symptoms of radical pulses and severe chest and back
associated with open-angle glaucoma. pain. An MI typically doesn’t cause loss of
14.A. hypoclacemia. Chvostek’s sign is a spasm radial pulses or severe back pain. CVA and
of the facial muscles elicited by tapping the dissecting abdominal aneurysm are incorrect
facial nerve and is associated with responses.
hypocalcemia. Clinical signs of hypokalemia 22.C. Fluid volume excess. SIADH results in
are muscle weakness, leg cramps, fatigue, fluid retention and hyponatremia. Correction
nausea and vomiting. Muscle cramps, is aimed at restoring fluid and electrolyte
anorexia, nausea and vomiting are clinical balance. Anxiety and risk for injury should be
signs of hyponatremia. Clinical manifestations addressed following fluid volume excess.
associated with hypophosphatemia include 23.C. Decreasing caffeine drinks and
muscle pain, confusion, seizures and coma. alcohol. Caffeine and alcohol can increase
15.B. BUN/Crea. The BUN is primarily used as bladder spasms and mucosal irritation, thus
indicator of kidney function because most increase the signs and symptoms of UTI. All
renal diseases interfere with its excretion and antibiotics should be taken completely to
cause blood vessels to rise. Creatinine is prevent resistant strains of organisms.
produced in relatively constant amounts, 24.C. deep vein thrombosis (DVT). DVT, is the
according to the amount of muscle mass and most probable complication for postoperative
is excreted entirely by the kidneys making it a patients on bed rest. Options A, B and D
good indicator of renal function. aren’t likely complications of the post
operative period.
25.B. The loss of vision is experienced as a
painless, gradual blurring. Typically, a
patient with cataracts experiences painless,
gradual loss of vision. Although both eyes
may develop at different rates.
 Medical Surgical Nursing 6 A. Pruritic lesions
B. Multiple petechiae
1. A client with myasthenia gravis ask the C. Shiny, scaly lesions
nurse why the disease has occurred. The D. Erythematous macules
nurse bases the reply on the knowledge 7. A urine specimen for ketones should
that there is: be removed from a client’s retention
A. A genetic in the production acetylcholine catheter by:
B. A reduced amount of neurotransmitter A. Disconnecting the catheter and draining it into
acetylcholine a clean container
C. A decreased number of functioning B. Cleansing the drainage valve and removing it
acetylcholine receptor sites from the catheter bag
D. An inhibition of the enzyme ACHE leaving C. Wiping the catheter with alcohol and draining
the end plates folded it into a sterile test tube
2. A client with an inflamed sciatic nerve D. Using a sterile syringe to remove it from
is to have a conventional transcutaneous clamped, cleansed catheter
electrical nerve stimulation (TENS) device 8. Following an abdominal
applied to the painful nerve pathway. cholecystectomy, the nurse should
When operating the TENS unit the nurse assess for signs of respiratory
should complications because the:
A. Maintain the same dial setting everyday A. Incision is in close proximity to the
B. Turn the machine several times a day for 10 to diaphragm
20 minutes B. Length of time required for surgery is
C. Adjust the TENS dial until the client prolonged
perceives pain relief and comfort C. Client’s resistance is lowered because of bile
D. Apply the color-coded electrodes anywhere it in the blood
is comfortable for the client D. Bloodstream is invaded by microorganisms
3. Although no cause has been from the biliary tract
determined for scleroderma, it is thought 9. The nurse assess the client with
to be caused by: cholecystitis for the development of
obstructive jaundice, which would be
A. Autoimmunity
evidenced by:
B. Ocular motility
C. Increased amino acid metabolism A. Inadequate absorption of fat-soluble K
D. Defective sebaceous gland formation B. Light amber urine, dark brown stools, yellow
4. The nurse must help the client with skin
pemphigus vulgaris deal with the C. Dark-colored urine, clay colored stools, itchy
resulting: skin
D. Straw-colored urine, putty-colored stools,
A. Infertility yellow sclerae
B. Paralysis 10. A client with cholelithiasis experience
C. Skin lesions discomfort after ingesting fatty foods
D. Impaired digestion
because.
5. The nurse should explain to the client
with psoriasis that treatment usually A. Fatty foods are hard to digest
involves: B. Bile flow into the intestine is obstructed
C. The liver is manufacturing inadequate bile
A. Avoiding exposure to the sum D. There is inadequate closure of the Ampulla of
B. Topical application of steroids Vater
C. Potassium permanganate baths 11. The chief complaint in a client with
D. Debridement of necrotic plaques Vincent’s Angina is:
6. The nurses should assess a client with
psoriasis A. Chest pain
B. Shortness of breath D. Separation of the edges of the non-adherent
C. Shoulder discomfort dressing
D. Bleeding oral ulcerations 18. During peritoneal dialysis the nurse
12. Clients with fractured mandibles observes that drainage of dialysate from
usually have them immobilized with wires. the peritoneal cavity has ceased before
The life-threatening problem that can the required amount has drained out The
develop postoperatively is: nurse should assist the client to:
A. Infection A. Turn from side to side
B. Vomiting B. Drink 8 ounces of water
C. Osteomyelitis C. Deep breathe and cough
D. Bronchospasm D. Periodically rotate the catheter
13. As a result of fractured ribs, the client 19. A client has ear surgery. An early
may develop: response that may be associated with
A. Scoliosis possible damage to the motor branch of
B. Paradoxical respiration the facial nerve is:
C. Obstructive lung-disease
A. A bitter metallic state
D. Hernation of the diaphragm
B. Dryness of the lips and mouth
14. A client has a bone marrow aspiration C. A sensation of pain behind the ear
performed, immediately after the D. An inability to wrinkle the forehead
procedure, the nurse should: 20. After a prostatectomy, a client
A. Position the client on the affected side complains of painful bladder spasms. To
B. Begin frequent monitoring of vital signs limit these spasms the nurse should:
C. Cleanse the site with an antiseptic solution
A. Administer a narcotic every 4 hours
D. Briefly apply pressure over the aspiration site
B. Irrigate the Foley catheter with 60 ml of
15. Following a bilateral lumbar normal saline
sympathectomy a client has a sudden C. Encourage the client not to contract his
drop in blood pressure but no. evidence muscles as if he were voiding
of bleeding. The nurse recognizes that D. Advance the catheter to relieve the pressure
this is most likely caused by: against the prostatic fossa
21. After 1 week a client with acute renal
A. An inadequate fluid intake failure moves, into the diuretic phase.
B. The after effects of anesthesia
During this phase the client must be
C. A reallocation of the blood supply
D. An increased level of epinephrine carefully assessed for signs of:
16. The occurrence of chronic illness is A. Hypovolemia
greatest in: B. Hyperkalemia
C. Metabolic acidosis
A. Older adult D. Chronic renal failure
B. Adolescents
22. The nurse checks for hypocalcemia
C. Young children
D. Middle-aged adults by placing a blood pressure cuff on a
17. A client with full-thickness burns on client’s arm and inflating it. After about 3
the chest has a skin graft. During the minutes the client develops carpopedial
1s124 hours after a skin graft, care of the spasm. The nurse records this finding as
donor site includes immediately reporting. a positive:

A. Small amount of yellowish green oozing A. Homan’s sign

B. A moderate area of serosanguinous oozing B. Romberg sign
C. Epithelialization under the non-adherent C. Chvostek’s skin
dressing D. Trosseau’s sign
 23. A client is scheduled for a below-the- 28. A female nurse is assigned to obtain a
knee amputation of the right leg. Legally, history from & client with a urinary tract
the client may not sign the operative problem an sexual dysfunction. Which of
consent if: the following statements might place the
client more at ease and willing to give a.
A. Ambivalent feelings regarding operation are
present history of his problem?
B. Any sedative type of medication has recently A. “When dud you first notice this problem?
been administration B. “Why do you think you have a problem?”
C. A discussion of alternative with 2 physicians C. “Do you think you sexual dysfunction is
have not been performed and recorded psychological?”
D. A complete history and physical have not D. “Does your sexual dysfunction seem to be
been performed related to your urinary tract problem?”
24. The nurse is assigned to check a 29. A client is scheduled for an ultrasound
client’s continuous bladder irrigation. examination of the prostate. To describe
Which one of the following solution is the procedure to the client, the nurse
normally used for continuous or should plan to relate that:
intermittent bladder and catheter
irrigations? A. The procedure is performed using a
cystoscope
A. Hydrogen peroxide B. A probe will be inserted into the rectum
B. Bacteriostatic water C. A flat disk is placed on the abdomen
C. Sterile normal saline D. This procedure uses x-rays to produce a visual
D. Plain water image
25. When continuous bladder irrigation is 30. To effectively teach men the
used following prostate surgery, the rate importance of testicular self-examination,
of flow is adjusted: the nurse should know that testicular
carcinoma:
A. To run at 60 drops per minutes
B. According to the client’s oral intake A. Rarely metastasizes
C. To maintain an output of 500 ml every 8 B. Has a high incidence of early metastasis
hours C. Cannot be detected by laboratory tests
D. To keep the drainage to light pink D. Must first be biopsied to confirm the
26. The nurse is assigned to teach a diagnosis
class in health behaviors to young man. 31. A nurse is assigned to instruct a client
Which of the following can be stated as a in the method of testicular self-
probably cause of cancer of the penis? examination. The instruction should
include mention that the best time to
A. A diet high in acidic foods
B. Poor personal hygiene perform this task is:
C. Exercise A. Immediately after getting out of bed in the
D. Circumcision morning
27. The nurse is assigned to give perineal B. Immediately before going to bed
care to an uncircumcised male client. C. In the morning after breakfast
Which of the following is correct? D. After a warm bath or shower
32. Mr. Dorn has vasectomy. He asks the
A. The anal area is washed at a separate time
nurse why he just use a method of birth
B. The foreskin is retracted and the area beneath
the foreskin is cleansed control because today he, had a
C. The foreskin should not be retracted except by sterilization procedure. The most correct
a physician answer is:
D. The scrotum is carefully washed with sterile
normal saline A. The sperm count will not be negative until his
testosterone level decrease
B. Some minor surgery usually is necessary to Barrows. Which one of the following is a
ensure sterilization usual sign and symptoms of this
C. Some live sperm will be present in the
infection?
ejaculatory fluid for a period of time
D. Even though a vasectomy is performed, a A. Pain high in the abdomen
condom is still recommended for 1 to 2 years B. Intensive vaginal and perineal itching
33. A client is scheduled for a cystectomy C. Decrease in urinary output
and asks the nurse what the physician will D. High fever
be able to see during the procedure. The 38. The nurse prepares to give Ms.
most correct reply is the: Edwards a vaginal suppository, which is
inserted by means of a special applicator
A. Kidney and ureters
supplied with the drug. Which one of the
B. Bladder and rectum
C. Prostate and ureters following is correct?
D. Urethra and bladder A. Ask the client to void prior to inserting the
34. A client is scheduled for a cystectomy suppository
and asks the nurse what the physician will B. Lubricate the tip of the suppository with
be able to see during the procedure. The petroleum jelly
most correct reply is the: C. Insert the applicator tip gently and with an
upward and forward motion
A. Kidney and ureters D. Insert the applicator approximately ½ inch
B. Bladder and rectum and depress the plunger
C. Prostate and ureters 39. The nurse is assigned to give Ms.
D. Urethra and bladder Milton perineal care. When cleansing the
35. Nurse assistant attending a nursing perineum, the cotton ball or wash cloth is
conference hears that one of her clients gently directed:
has hydrocele. She asks the nurse how
this condition is treated. The most A. Side to side across the labia majora
B. Downward from the pubic area to the anus
common response is:
C. Upward from the anus to the pubic area
A. Usually the problem requires more medical or D. Prom the urinary meatus to the vagina
surgical intervention 40. The nurse is assigned to administer a
B. Surgery may be necessary to correct the vaginal irrigation (douche). Which of the
problem following is correct?
C. Wearing a scrotal support usually corrects She
problem A. The irrigation is best administered with the
D. Drug therapy usually helps control the client standing in a bathtub
collection of fluid B. Before inserting, the nozzle is lubricated with
36. The nurse is participating in a health petroleum jelly
class for young women. One subject is C. The temperature of the solution should be
between 80°F and 84°F
cancer of the ovary. Which of the
D. The nozzle is inserted downward and
following statements is correct? backward within the vagina
A. Early symptoms of cancer of the ovary are 41. The nurse is assigned to teach health-
vague seeking behaviors to young women. One
B. This type of cancer has a high cure rate topic the nurse plans to includes is the
C. Chemotherapy is not used for treating ovarian importance of the Pap test, which is used
cancer
mainly to detect:
D. The most prominent early symptoms is an
irregular menstrual cycle A. Ovarian cyst
37. The nurse is asked to discuss the B. Patency of the fallopian tube
signs and symptoms of vaginitis caused C. Cervical cancer
by the fungus candida albicans with Ms. D. Uterine infections
 42. The physician asks the nurse to B. Help to change positions to achieve comfort
position a client for a vaginal examination. C. Ambulate with him at frequent intervals
D. Encourage quadriceps setting exercises
Which of the following position is normally
47. If Ms. Drake tells the nurse her feet
used for this type of examination?
are cold. Which of the following nursing
A. Lithotomy position action would be best
B. Sim’s position
C. Dorsal recumbent position A. Apply a hot water bottle
D. Left lateral position B. Use an electric heating pad
43. Ms. Hull has had an C. Wrap them in a warm blanket
D. Elevate her feet on a stool
electrocauterization of her cervix for
48. Which of the following would indicate
chronic cervicitis. Following the procedure
to the nurse that the stationary thrombus
the nurse should instruct Ms. Hull to:
in Ms. Fleming suddenly develops?
A. Douche the next day to remove debris and
blood cloth A. Chest pains
B. Avoid straining and heavy lifting until the B. Leg cramps
physician permits this activity C. Numbness in the foot
C. Stay in bed for the next 5 days D. Swelling of the knee
D. Return in bed for the next 5 days 49. Following a total abdominal
44. The nursing assistant is assigned to hysterectomy Ms. Sara Fleming develops
give Ms. Bailey, who has had an a slightly elevated temperature and
abdominal hysterectomy, a sitz bath. She swelling in the right call of her leg. The
is instructed to use the special sitz bath physician prescribes warm moist
tub. She asks the nurse why the regular compresses for the client’s affected leg.
bath tub cannot be used. The most Which of the following nursing actions is
correct reply is based on the fact that a correct when applying the warm moist
regular bath tab: compress? The nurse:

A. Is more slippery and is dangerous when used A. Heats the water to 120°F
for surgical clients B. Uses a sterile technique
B. Cannot supply water that is of the desired C. Inspect the skin every 4 hours
temperature for this procedure D. Covers the wet gauze with a towel
C. Applies heat to the legs and alters the desired 50. Ms. Betty Lynch, age 29, holes that
effect of heat directed to the pelvic region she has recently developed a skin
D. Cannot be kept as clean as a special sitz bath problem and makes an appointment to be
tub
seen in a clinic specializing diagnosis of
45. Which of the following solutions would
psoriasis is made by the physician. When
be best for the nurse to use when
examining Mr. Lynch’s skin for areas of
cleaning the inner cannula of a
psoriasis, the nurse should look for:
tracheostomy tube?
A. Weeping lesions on the trunk of the body
A. IsopropyI alcohol B. Patches of redness covered with silvery scales
B. Sodium hydrochloride C. Areas of redness surrounded by crusts
C. Hydrogen peroxide D. A rash characterized by raised, pus-filled
D. Providone-iodine lesions
46. The nurse observes that the client’s Answers
knee is swollen and painful. 1. C. A decreased number of functioning
Consequently; which one of the following acetylcholine receptor sites
nursing measures should be carried out? 2. C. Adjust the TENS dial until the client
perceives pain relief and comfort
A. Perform passive range of motion during each 3. A. Autoimmunity
shift
4. C. Skin lesions 44.C. Applies heat to the legs and alters the
5. B. Topical application of steroids desired effect of heat directed to the pelvic
6. C. Shiny, scaly lesions region
7. D. Using a sterile syringe to remove it from 45.C. Hydrogen peroxide
clamped, cleansed catheter 46.B. Help to change positions to achieve
8. A. Incision is in close proximity to the comfort
diaphragm 47.C. Wrap them in a warm blanket
9. B. Light amber urine, dark brown stools, 48.B. Leg cramps
yellow skin 49.D. Covers the wet gauze with a towel
10.B. Bile flow into the intestine is obstructed 50.B. Patches of redness covered with silvery
11.D. Bleeding oral ulcerations scales
12.B. Vomiting
13.B. Paradoxical respiration
14.D. Briefly apply pressure over the
aspiration site
15.C. A reallocation of the blood supply
16.A. Older adult
17.A. Small amount of yellowish green oozing
18.A. Turn from side to side
19.D. An inability to wrinkle the forehead
20.C. Encourage the client not to contract his
muscles as if he were voiding
21.A. Hypovolemia
22.D. Trosseau’s sign
23.B. Any sedative type of medication has
recently been administration
24.C. Sterile normal saline
25.D. To keep the drainage to light pink
26.B. Poor personal hygiene
27.B. The foreskin is retracted and the area
beneath the foreskin is cleansed
28.A. “When dud you first notice this
problem?
29.B. A probe will be inserted into the rectum
30.B. Has a high incidence of early metastasis
31.D. After a warm bath or shower
32.C. Some live sperm will be present in the
ejaculatory fluid for a period of time
33.D. Urethra and bladder
34.D. Urethra and bladder
35.B. Surgery may be necessary to correct the
problem
36.A. Early symptoms of cancer of the ovary
are vague
37.B. Intensive vaginal and perineal itching
38.A. Ask the client to void prior to inserting
the suppository
39.B. Downward from the pubic area to the
anus
40.D. The nozzle is inserted downward and
backward within the vagina
41.B. Patency of the fallopian tube
42.A. Lithotomy position
43.B. Avoid straining and heavy lifting until
the physician permits this activity
 Medical Surgical Nursing 7 C. Reflex (neurogenic) incontinence
Neurogenic incontinence is associated with a
1. During which stage of pressure ulcer spinal cord lesion.
development does the ulcer extend into D. Functional incontinence
the subcutaneous tissue? Functional incontinence refers to incontinence
in patients with intact urinary physiology who
A. Stage III experience mobility impairment,
Clinically, a deep crater with or without environmental barriers, or cognitive problems.
undermining of adjacent tissues is noted.
4. Ageism refers to
B. Stage IV
A stage IV pressure ulcer extends into the A. Bias against older people based solely on
underlying structure, including the muscle and chronological age
possibly the bone. Individuals demonstrating ageism base their
C. Stage II beliefs and attitudes about older people based
A stage II ulcer exhibits a break in the skin upon chronological age without consideration
through the epidermis or dermis. of functional capacity.
D. Stage I B. fear of old age.
A stage I pressure ulcer is an area of Fear of aging and the inability of many to
nonblanchable erythema, tissue swelling, and confront their own aging process may trigger
congestion, and the patient complains of ageist beliefs.
discomfort. C. loss of memory.
2. During which stage of pressure ulcer Age-related loss of memory occurs more with
development does the ulcer extend into short-term and recent memory.
the underlying structures, including the D. benign senescent forgetfulness.
muscle and possibly the bone? Benign senescent forgetfulness refers to the
age-related loss of memory in the absence of a
A. Stage IV pathologic process.
A stage IV pressure ulcer extends into the 5. When assessing the older adult, the
underlying structure, including the muscle and nurse anticipates increase in which of the
possibly the bone. follow components of respiratory status?
B. Stage III
A stage III ulcer extends into the A. Residual lung volume
subcutaneous tissue. As a result, patient experience fatigue and
C. Stage II breathlessness with sustained activity.
A stage II ulcer exhibits a break in the skin B. Vital capacity
through the epidermis or dermis. The nurse anticipates decreased vital capacity.
D. Stage I C. Gas exchange and diffusing capacity
A stage I pressure ulcer is an area of The nurse anticipates decreased gas exchange
nonblanchable erythema, tissue swelling, and and diffusing capacity resulting in impaired
congestion, and the patient complains of healing of tissues due to decreased
discomfort. oxygenation.
3. Which type of incontinence is D. Cough efficiency
associated with weakened perineal The nurse anticipates difficulty coughing up
muscles that permit leakage of urine secretions due to decreased cough efficiency.
when intra-abdominal pressure is 6. According to the classification of
increased? hypertension diagnosed in the older adult,
hypertension that can be attributed to an
A. Stress incontinence underlying cause is termed
Stress incontinence may occur with coughing
or sneezing. A. secondary.
B. Urge incontinence Secondary hypertension may be caused by a
Urge incontinence is involuntary elimination tumor of the adrenal gland (e.g.,
of urine associated with a strong perceived pheochromacytoma).
need to void.
B. primary. increasing dose requirements to maintain the
Primary hypertension has no known same level of pain relief.
underlying cause. B. addiction.
C. essential. Addiction refers to a behavioral pattern of
Essential hypertension has no known substance use characterized by a compulsion
underlying cause. to take the drug primarily to experience its
D. isolated systolic. psychic effects.
Isolated systolic hypertension is demonstrated C. dependence.
by readings in which the systolic pressure Dependence occurs when a patient who has
exceeds 140 mm Hg and the diastolic been taking opioids experiences a withdrawal
measurement is normal or near normal (less syndrome when the opioids are discontinued.
than 90 mm Hg). D. balanced analgesia.
7. Which of the following terms refers to Balanced analgesia occurs when the patient is
the decrease in lens flexibility that occurs using more than one form of analgesia
concurrently to obtain more pain relief with
with age, resulting in the near point of
fewer side effects.
focus getting farther away?
10. Prostaglandins are chemical
A. Presbyopia substances thought to
Presbyopia usually begins in the fifth decade
of life, when reading glasses are required to A. increase sensitivity of pain receptors.
magnify objects. Prostaglandins are believed to increase
B. Presbycusis sensitivity to pain receptors by enhancing the
Presbycusis refers to age-related hearing loss. pain-provoking effect of bradykinin.
C. Cataract B. reduce the perception of pain.
Cataract is the development of opacity of the Endorphins and enkephalins reduce or inhibit
lens of the eye. transmission or perception of pain.
D. Glaucoma C. inhibit the transmission of pain.
Glaucoma is a disease characterized by Endorphins and enkephalins reduce or inhibit
increased intraocular pressure. transmission or perception of pain.
D. inhibit the transmission of noxious stimuli.
8. Which of the following states is
Morphine and other opioid medications
characterized by a decline in intellectual inhibit the transmission of noxious stimuli by
functioning? mimicking enkephalin and endorphin.
A. Dementia 11. Which of the following principles or
Dementia is an acquired syndrome in which guidelines accurately informs the nurse
progressive deterioration in global intellectual regarding placebos?
abilities is of such severity that it interferes
with the person’s customary occupational and A. Placebos should never be used to test the
social performance. person’s truthfulness about pain.
B. Depression Perception of pain is highly individualized.
Depression is a mood disorder that disrupts B. A placebo effect is an indication that the
quality of life. person does not have pain.
C. Delirium A placebo effect is a true physiologic
Delirium is often called acute confusional response.
state. C. A placebo should be used as the first line of
D. Delusion treatment for the patient.
Delusion is a symptom of psychoses. A placebo should never be used as a first line
of treatment.
9. When a person who has been taking
D. A positive response to a placebo indicates that
opioids becomes less sensitive to their the person’s pain is not real.
analgesic properties, that person is said Reduction in pain as a response to placebo
to have developed a (an) should never be interpreted as an indication
that the person’s pain is not real.
A. tolerance.
12. Regarding tolerance and addiction,
Tolerance is characterized by the need for
the nurse understands that
A. although patients may need increasing levels B. Chloride
of opioids, they are not addicted. Chloride is an anion.
Physical tolerance usually occurs in the C. Bicarbonate
absence of addiction. Bicarbonate is an anion.
B. tolerance to opioids is uncommon. D. Phosphate
Tolerance to opioids is common. Phosphate is an anion.
C. addiction to opioids commonly develops. 16. Which of the following electrolytes is a
Addiction to opioids is rare. major anion in body fluid?
D. the nurse must be primarily concerned about
development of addiction by the patient in A. Chloride
pain. Chloride is a major anion found in
Addiction is rare and should never be the extracellular fluid.
primary concern for a patient in pain. B. Potassium
13. The preferred route of administration Potassium is a cation.
of medication in the most acute care C. Sodium
Sodium is a cation.
situations is which of the following routes?
D. Calcium
A. Intravenous Calcium is a cation.
The IV route is the preferred parenteral route 17. Oncotic pressure refers to
in most acute care situations because it is
much more comfortable for the patient, and A. the osmotic pressure exerted by proteins.
peak serum levels and pain relief occur more Oncotic pressure is a pulling pressure exerted
rapidly and reliably. by proteins, such as albumin.
B. Epidural B. the number of dissolved particles contained in
Epidural administration is used to control a unit of fluid.
postoperative and chronic pain. Osmolality refers to the number of dissolved
C. Subcutaneous particles contained in a unit of fluid.
Subcutaneous administration results in slow C. the excretion of substances such as glucose
absorption of medication. through increased urine output.
D. Intramuscular Osmotic diuresis occurs when the urine output
Intramuscular administration of medication is increases due to excretion of substances such
absorbed more slowly than intravenously as glucose.
administered medication. D. the amount of pressure needed to stop flow of
water by osmosis.
14. Mu opioids have which of the
Osmotic pressure is the amount of pressure
following effects on respiratory rate: needed to stop the flow of water by osmosis.
A. Stimulation, then depression 18. Which of the following solutions is
Mu opioids also cause bradycardia, hypotonic?
hypothermia, and constipation.
B. No change A. 0.45% NaCl.
Kappa opioids result in no change in Half-strength saline is hypotonic
respiratory rate. B. Lactated Ringer’s solution.
C. Stimulation, only Lactated Ringer’s is isotonic.
Delta opioids result in stimulation of C. 0.9% NaCl.
respiratory rate. Normal saline (0.9% NaCl) is isotonic.
D. Depression, only D. 5% NaCl.
Neither mu, nor kappa, nor delta opoids A solution that is 5% NaCl is hypertonic.
depress respiratory rate as its only effect upon 19. The normal serum value for
respiratory rate. potassium is
15. Which of the following electrolytes is a
A. 3.5-5.5 mEq/L.
major cation in body fluid?
Serum potassium must be within normal
A. Potassium limits to prevent cardiac dysrhythmias.
Potassium is a major cation that affects B. 135-145 mEq/L.
cardiac muscle functioning. Normal serum sodium is 135-145 mEq/L.
C. 96-106 mEq/L. the patient is demonstrating which stage
Normal serum chloride is 96-106 mEq/L. of shock?
D. 8.5-10.5 mg/dL.
Normal total serum calcium is 8.5-10.5mg/dL. A. Compensatory
20. In which type of shock does the In compensatory shock, the patient’s blood
patient experiences a mismatch of blood pressure is normal, respirations are above 20,
and heart rate is above 100 but below 150.
flow to the cells?
B. Progressive
A. Distributive In progressive shock, the patient’s skin
Distributive or vasogenic shock results from appears mottled and mentation demonstrates
displacement of blood volume, creating a lethargy.
relative hypovolemia. C. Refractory
B. Cardiogenic In refractory or irreversible shock, the patient
Cardiogenic shock results from the failure of a requires complete mechanical and
heart as a pump. pharmacologic support.
C. Hypovolemic D. Irreversible
In hypovolemic shock, there is a decrease in In refractory or irreversible shock, the patient
the intravascular volume. requires complete mechanical and
D. Septic pharmacologic support.
In septic shock, overwhelming infection 23. Which of the following vasoactive
results in a relative hypovolemia. drugs used in treating shock results in
21. Which stage of shock is best reduced preload and afterload, reducing
described as that stage when the oxygen demand of the heart?
mechanisms that regulate blood pressure
A. Nitroprusside (Nipride)
fail to sustain a systolic pressure above
A disadvantage of nitroprusside is that it
90 mm Hg? causes hypotension.
A. Progressive B. Dopamine (Intropin)
In the progressive stage of shock, the Dopamine improves contractility, increases
mechanisms that regulate blood pressure can stroke volume, and increases cardiac output.
no longer compensate, and the mean arterial C. Epinephrine (adrenaline)
pressure falls below normal limits. Epinephrine improves contractility, increases
B. Refractory stroke volume, and increases cardiac output.
The refractory or irreversible stage of shock D. Methoxamine (Vasoxyl)
represents the point at which organ damage is Methoxamine increases blood pressure by
so severe that the patient does not respond to vasoconstriction.
treatment and cannot survive. 24. The nurse anticipates that the
C. Compensatory immunosuppressed patient is at greatest
In the compensatory state, the patient’s blood risk for which type of shock?
pressure remains within normal limits due to
vasoconstriction, increased heart rate, and A. Septic
increased contractility of the heart. Septic shock is associated with
D. Irreversible immunosuppression, extremes of age,
The refractory or irreversible stage of shock malnourishment, chronic illness, and invasive
represents the point at which organ damage is procedures.
so severe that the patient does not respond to B. Neurogenic
treatment and cannot survive. Neurogenic shock is associated with spinal
22. When the nurse observes that the cord injury and anesthesia.
C. Cardiogenic
patient’s systolic blood pressure is less
Cardiogenic shock is associated with disease
than 80–90 mm Hg, respirations are rapid of the heart.
and shallow, heart rate is over 150 beats D. Anaphylactic
per minute, and urine output is less than Anaphylactic shock is associated with
30 cc per hour, the nurse recognizes that hypersensitivity reactions.
 25. Which of the following colloids is point of white blood cell depression after
expensive but rapidly expands plasma therapy that has toxic effects on the bone
marrow.
volume?
28. During which step of cellular
A. Albumin carcinogenesis do cellular changes
Albumin is a colloid that requires human exhibit increased malignant behavior?
donors, is limited in supply, and can cause
congestive heart failure. A. Progression
B. Dextran During this third step, cells show a propensity
Dextran is a colloid, synthetic plasma to invade adjacent tissues and metastasize.
expander that interferes with platelet B. Promotion
aggregation and is not recommended for During promotion, repeated exposure to
hemorrhagic shock. promoting agents causes the expression of
C. Lactated Ringers abnormal genetic information even after long
Lactated ringers is a crystalloid, not a colloid. latency periods.
D. Hypertonic Saline C. Initiation
Hypertonic saline is a crystalloid, not a During this first step, initiators such as
colloid. chemicals, physical factors, and biologic
26. Which of the following terms refers to agents escape normal enzymatic mechanisms
cells that lack normal cellular and alter the genetic structure of cellular
DNA.
characteristics and differ in shape and
D. Prolongation
organization with respect to their cells of No stage of cellular carcinogenesis is termed
origin? prolongation.
A. Anaplasia 29. The drug, Interleukin-2, is an example
Usually, anaplastic cells are malignant. of which type of biologic response
B. Neoplasia modifier?
Neoplasia refers to uncontrolled cell growth
that follows no physiologic demand. A. Cytokine
C. Dysplasia Other cytokines include interferon alfa and
Dysplasia refers to bizarre cell growth filgrastim.
resulting in cells that differ in size, shape, or B. Monoclonal antibodies
arrangement from other cells of the same type Monoclonal antibodies include rituximab,
of tissue. trastuzumab, and gemtuzumab.
D. Hyperplasia C. Retinoids
Hyperplasia refers to an increase in the Retinoic acid is an example of a retinoid.
number of cells of a tissue, most often D. Antimetabolites
associated with a period of rapid body growth. Antimetabolites are cell cycle-specific
antineoplastic agents.
27. Palliation refers to
30. Of the following terms, which is used
A. relief of symptoms associated with cancer. to refer to the period of time during which
Palliation is the goal for care in terminal mourning a loss takes place?
cancer patients.
B. hair loss. A. Bereavement
Alopecia is the term that refers to hair loss. Bereavement is the period of time during
C. the spread of cancer cells from the primary which mourning a loss takes place.
tumor to distant sites. B. Grief
Metastasis is the term that refers to the spread Grief is the personal feelings that accompany
of cancer cells from the primary tumor to an anticipated or actual loss
distant sites. C. Mourning
D. the lowest point of white blood cell Mourning is the individual, family, group and
depression after therapy that has toxic effects cultural expressions of grief and associated
on the bone marrow. behaviors
Nadir is the term that refers to the lowest
D. Hospice                                                             authorization of another individual to make
Hospice is a coordinated program of medical decisions on behalf of the person who
interdisciplinary care and services provided created an advance directive when he/she is
primarily in the home to terminally ill patients no loner able to speak for him/herself.
and   their families. C. Health care power of attorney
31. Which of the following “awareness Health care power of attorney is a legal
contexts” is characterized by the patient, document that enables the signer to designate
another individual to make health care
the family, and the health care
decisions on his/her behalf when he/she is
professionals being aware that the patient unable to do so.
is dying but all pretend otherwise? D. Durable power of attorney for health
A durable power of attorney for health care is
A. Mutual pretense awareness
a legal document that enables the signer to
In mutual pretense awareness, the patient, the
designate another individual to make health
family and the health care professionals are
care decisions on his/her behalf when he/she
aware that the patient is dying but all pretend
is unable to do so.
otherwise.
B. Closed awareness 34. A malignant tumor
In closed awareness, the patient is unaware of A. gains access to the blood and lymphatic
his terminality in a context where others are channels.
aware. By this mechanism, the tumor metastasizes to
C. Suspected awareness other areas of the body.
In suspected awareness, the patient suspects B. demonstrates cells that are well-differentiated.
what others know and attempts to find it out. Cells of malignant tumors are
D. Open awareness undifferentiated.
In open awareness, all are aware that the C. is usually slow growing.
patient is dying and are able to openly Malignant tumors demonstrate variable rate of
acknowledge that reality. growth; however, the more anaplastic the
32. For individuals known to be dying by tumor, the faster its growth.
virtue of age and/or diagnoses, which of D. grows by expansion.
the following signs indicate approaching A malignant tumor grows at the periphery and
death: sends out processes that infiltrate and destroy
surrounding tissues.
A. Increased restlessness 35. Which of the following classes of
As the oxygen supply to the brain decreases, antineoplastic agents is cell–cycle-
the patient may become restless.
specific?
B. Increased wakefulness
As the body weakens, the patient will sleep A. Antimetabolites (5-FU)
more and begin to detach from the Antimetabolites are cell–cycle-specific (S
environment. phase).
C. Increased eating B. Antitumor antibiotics (bleomycin)
For many patients, refusal of food is an Antitumor antibiotics are cell-cycle
indication that they are ready to die. nonspecific.
D. Increased urinary output C. Alkylating agents (cisplatin)
Based upon decreased intake, urinary output Alkylating agents are cell-cycle nonspecific.
generally decreases in amount and frequency. D. Nitrosureas (carmustine)
33. Which of the following terms best Nitrosureas are cell-cycle nonspecific.
describes a living will? 36. Regarding the surgical patient, which
of the following terms refers to the period
A. Medical directive
The living will is a type of advance medical of time that constitutes the surgical
directive in which the individual of sound experience?
mind documents treatment preferences.
A. Perioperative phase
B. Proxy directive
Perioperative period includes the
A proxy directive is the appointment and
 preoperative, intraoperative, and postoperative Onset of symptoms depends upon time of last
phases. consumption of alcohol.
B. Preoperative phase D. Up to 24 hours after alcohol withdrawal
Preoperative phase is the period of time from Twenty-four hours is too short a time frame to
when the decision for surgical intervention is consider alcohol withdrawal delirium no
made to when the patient is transferred to the longer a threat to a chronic alcoholic.
operating room table. 39. Which of the following categories of
C. Intraoperative phase medications may result in seizure activity
Intraoperataive phase is the period of time
if withdrawn suddenly?
from when the patient is transferred to the
operating room table to when he or she is A. Tranquilizers
admitted to the postanesthesia care unit. Abrupt withdrawal of tranquilizers may result
D. Postoperative phase in anxiety, tension, and even seizures if
Postoperative phase is the period of time that withdrawn suddenly.
begins with the admission of the patient to the B. Adrenal corticosteroids
postanesthesia care unit and ends after a Abrupt withdrawal of steroids may precipitate
follow-up evaluation in the clinical setting or cardiovascular collapse.
home. C. Antidepressants
37. When the indication for surgery is Monoamine oxidase inhibitors increase the
without delay, the nurse recognizes that hypotensive effects of anesthetics.
the surgery will be classified as D. Diuretics
Thiazide diuretics may cause excessive
A. emergency. respiratory depression during anesthesia due
Emergency surgery means that the patient to an associated electrolyte imbalance.
requires immediate attention and the disorder 40. When the patient is encouraged to
may be life-threatening. concentrate on a pleasant experience or
B. urgent.
restful scene, the cognitive coping
Urgent surgery means that the patient requires
prompt attention within 24-30 hours. strategy being employed by the nurse is
C. required. A. imagery.
Required surgery means that the patient needs Imagery has proven effective for oncology
to have surgery, and it should be planned patients.
within a few weeks or months. B. optimistic self-recitation.
D. elective. Optimistic self-recitation is practiced when
Elective surgery means that there is an the patient is encouraged to recite optimistic
indication for surgery, but failure to have thoughts such as “I know all will go well.”
surgery will not be catastrophic. C. distraction.
38. When a person with a history of Distraction is employed when the patient is
chronic alcoholism is admitted to the encouraged to think of an enjoyable story or
hospital for surgery, the nurse anticipates recite a favorite poem.
that the patient may show signs of alcohol D. progressive muscular relaxation.                      
Progressive muscular relaxation requires
withdrawal delirium during which time
contracting and relaxing muscle groups and is
period? a physical coping strategy as opposed to
A. Up to 72 hours after alcohol withdrawal cognitive.
Alcohol withdrawal delirium is associated 41. According to the American Society of
with a significant mortality rate when it Anesthesiology Physical Status
occurs postoperatively. Classification System, a patient with
B. Immediately upon admission severe systemic disease that is not
Onset of symptoms depends upon time of last
incapacitating is noted to have physical
consumption of alcohol.
C. Upon awakening in the post-anesthesia care status classification
unit A. P3
Classification P3 patients are those who have
 compensated heart failure, cirrhosis, or poorly B. Hypotension
controlled diabetes, for example. Hypotension is a later sign of malignant
B. P4 hyperthermia.
Classification P4 patients have an C. Elevated temperature
incapacitating systemic disease that is a The rise in temperature is actually a late sign
constant threat to life. that develops rapidly.
C. P1 D. Oliguria
Classification P1 refers to a normal healthy Scant urinary output is a later sign of
patient malignant hyperthermia.
D. P2 45. Which of the following terms is used
Classification P2 reflects a patient with mild to refer to protrusion of abdominal organs
systemic disease
through the surgical incision?
42. Which stage of anesthesia is termed
surgical anesthesia? A. Evisceration
Evisceration is a surgical emergency.
A. III B. Hernia
With proper administration of the anesthetic, A hernia is a weakness in the abdominal wall.
this stage may be maintained for hours. C. Dehiscence
B. I Dehiscence refers to partial or complete
Stage I is beginning anesthesia, as the patient separation of wound edges.
breathes in the anesthetic mixture and D. Erythema
experiences warmth, dizziness, and a feeling Erythema refers to redness of tissue.
of detachment. 46. When the method of wound healing is
C. II
one in which wound edges are not
Stage II is the excitement stage, which may be
characterized by struggling, singing, laughing, surgically approximated and
or crying. integumentary continuity is restored by
D. IV granulations, the wound healing is termed
Stage IV is a stage of medullary depression
and is reached when too much anesthesia has A. second intention healing.
been administered. When wounds dehisce, they will be allowed to
heal by secondary intention.
43. Fentanyl (Sublimaze) is categorized
B. primary intention healing.
as which type of intravenous anesthetic Primary or first intention healing is the
agent? method of healing in which wound edges are
surgically approximated and integumentary
A. Neuroleptanalgesic
continuity is restored without granulating.
Fentanyl is 75-100 times more potent than
C. first intention healing.
morphine and has about 25% of the duration
Primary or first intention healing is the
of morphine (IV).
method of healing in which wound edges are
B. Tranquilizer
surgically approximated and integumentary
Examples of tranquilizers include midazolam
continuity is restored without granulating.
(Versed) and diazepam (Valium).
D. third intention healing.
C. Opioid
Third intention healing is a method of healing
Opioids include morphine and meperidine
in which surgical approximation of wound
hydrochloride (Demerol).
edges is delayed and integumentary continuity
D. Dissociative agent
is restored by bringing apposing granulations
Ketamine is a dissociative agent.
together.
44. Which of the following manifestations
47. The nurse recognizes which of the
is often the earliest sign of malignant
following signs as typical of the patient in
hyperthermia?
shock?
A. Tachycardia (heart rate above 150 beats per
A. Rapid, weak, thready pulse
minute)
Pulse increases as the body tries to
Tachycardia is often the earliest sign of
compensate.
malignant hyperthermia.
B. Flushed face A. Orthopnea
Pallor is an indicator of shock. Patients with orthopnea are placed in a high
C. Warm, dry skin Fowler’s position to facilitate breathing.
Skin is generally cool and moist in shock. B. Dyspnea
D. Increased urine output Dyspnea refers to labored breathing or
Usually, a low blood pressure and shortness of breath.
concentrated urine are observed in the patient C. Hemoptysis
in shock. Hemoptysis refers to expectoration of blood
48. When the nurse observes that the from the respiratory tract.
postoperative patient demonstrates a D. Hypoxemia                                                      
Hypoxemia refers to low oxygen levels in the
constant low level of oxygen saturation,
blood.
although the patient’s breathing appears
normal, the nurse identifies that the
patient may be suffering which type of
hypoxemia?
A. Subacute
Supplemental oxygen may be indicated.
B. Hypoxic
Hypoxic hypoxemia results from inadequate
breathing.
C. Episodic
Episodic hypoxemia develops suddenly, and
the patient may be at risk for myocardial
ischemia, cerebral dysfunction, and cardiac
arrest.
D. Anemic
Anemic hypoxemia results from blood loss
during surgery.
49. When the surgeon performs an
appendectomy, the nurse recognizes that
the surgical category will be identified as
A. clean contaminated.
Clean-contaminated cases are those with a
potential, limited source for infection, the
exposure to which, to a large extent, can be
controlled.
B. clean.
Clean cases are those with no apparent source
of potential infection.
C. contaminated.
Contaminated cases are those that contain an
open and obvious source of potential
infection.
D. dirty.
A traumatic wound with foreign bodies, fecal
contamination, or purulent drainage would be
considered a dirty case.
50. Which of the following terms is used
to describe inability to breathe easily
except in an upright position?
 Medical Surgical Nursing 18 for hours to weeks but occasionally for
months or years.
1. Which of the following conditions of the C. BPPV is caused by tympanic membrane
inner ear is associated with normal infection.
hearing? BPPV is speculated to be caused by the
disruption of debris within the semi circular
A. Vestibular neuronitis canal. This debris is formed from small
Vestibular neuronitis is a disorder of the crystals of calcium carbonate from the inner
vestibular nerve characterized by severe ear structure, the utricle.
vertigo with normal hearing. D. BPPV is stimulated by the use of certain
B. Meniere’s disease medication such as acetaminophen.
Meniere’s disease is associated with BPPV is frequently stimulated by head
progressive sensorineural hearing loss. trauma, infection, or other events.
C. Labyrinthitis
4. Nursing management of the patient
Labyrinthitis is associated with varying
degrees of hearing loss. with acute symptoms of benign
D. Endolymphatic hydrops paroxysmal positional vertigo includes
Endolymphatic hydrops refers to dilation in which of the following?
the endolymmphatic space associated with
Meniere’s disease. A. Bed rest
Bed rest is recommended for patients with
2. Of the following terms, which refers to
acute symptoms. Canalith repositioning
the progressive hearing loss associated procedures (CRP) may be used to provide
with aging? resolution of vertigo, and patients with acute
vertigo may be medicated with meclizine for
A. Presbycusis
1-2 weeks.
Both middle and inner ear age-related changes
B. The Epley repositioning procedure
result in hearing loss.
The Epley procedure is not recommended for
B. Exostoses
patients with acute vertigo.
Exostoses refers to small, hard, bony
C. Meclizine for 2-4 weeks
protrusions in the lower posterior bony
Patients with acute vertigo may be medicated
portion of the ear canal.
with meclizine for 1-2 weeks.
C. Otalgia
D. The Dix-Hallpike procedure.
Otalgia refers to a sensation of fullness or pain
The Dix-Hallpike test is an assessment test
in the ear.
used to evaluate for BPPV.
D. Sensorineural hearing loss
Sensorineural hearing loss is loss of hearing 5. Which of the following terms refers to
related to damage of the end organ for hearing the inability to recognize objects through
and/or cranial nerve VIII. a particular sensory system?
3. Which of the following statements
A. Agnosia
describes benign paroxysmal positional Agnosia may be visual, auditory, or tactile.
vertigo (BPPV)? B. Dementia
Dementia refers to organic loss of intellectual
A. The vertigo is usually accompanied by nausea
function.
and vomiting; however hearing impairment
C. Ataxia
does not generally occur.
Ataxia refers to the inability to coordinate
BPPV is a brief period of incapacitating
muscle movements.
vertigo that occurs when the position of the
D. Aphasia
patient’s head is changed with respect to
Aphasia refers to loss of the ability to express
gravity. The vertigo is usually accompanied
oneself or to understand language.
by nausea and vomiting; however hearing
impairment does not generally occur. 6. Which of the following terms refers to
B. The onset of BPPV is gradual. weakness of both legs and the lower part
The onset of BPPV is sudden and followed by of the trunk?
a predisposition for positional vertigo, usually
A. Paraparesis A. frontal
Paraparesis is a frequent manifestation of The frontal lobe also controls information
degenerative neurologic disorders. storage or memory and motor function.
B. Hemiplegia B. temporal
Hemiplegia refers to paralysis of one side of The temporal lobe contains the auditory
the body or a part of it due to an injury to the receptive area.
motor areas of the brain. C. parietal
C. Quadriparesis The parietal lobe contains the primary sensory
Quadriparesis refers to weakness that involves cortex, which analyzes sensory information
all four extremities. and relays interpretation to the thalamus and
D. Paraplegia other cortical areas.
Paraplegia refers to paralysis of both legs and D. occipital
the lower trunk. The occipital lobe is responsible for visual
7. Of the following neurotransmitters, interpretation.
which demonstrates inhibitory action, 10. Which of the following terms is used
helps control mood and sleep, and to describe the fibrous connective tissue
inhibits pain pathways? that covers the brain and spinal cord?

A. Serotonin A. Meninges
The sources of serotonin are the brain stem, The meninges have three layers, the dura
hypothalamus, and dorsal horn of the spinal mater, arachnoid mater, and pia mater.
cord. B. Dura mater
B. Enkephalin The dura mater is the outmost layer of the
Enkephalin is excitatory and associated with protective covering of the brain and spinal
pleasurable sensations. cord.
C. Norepinephrine C. Arachnoid mater
Norepinephrine is usually excitatory and The arachnoid is the middle membrane of the
affects mood and overall activity. protective covering of the brain and spinal
D. Acetylcholine cord.
Acetylcholine is usually excitatory, but the D. Pia mater                                                          
parasympathetic effects are sometimes The pia mater is the innermost membrane of
inhibitory. the protective covering of the brain and spinal
8. The lobe of the brain that contains the cord.
auditory receptive areas is the 11. The cranial nerve that is responsible
____________ lobe. for salivation, tearing, taste, and
sensation in the ear is the
A. temporal _____________________ nerve.
The temporal lobe plays the most dominant
role of any area of the cortex in cerebration. A. vestibulocochlear
B. frontal The vestibulocochlear (VII) cranial nerve is
The frontal lobe, the largest lobe, controls responsible for hearing and equilibrium.
concentration, abstract thought, information B. oculomotor
storage or memory, and motor function. The oculomotor (III) cranial nerve is
C. parietal responsible for the muscles that move the eye
The parietal lobe contains the primary sensory and lid, pupillary constriction, and lens
cortex, which analyzes sensory information accommodation.
and relays interpretation to the thalamus and C. trigeminal
other cortical areas. The trigeminal (V) cranial nerve is
D. occipital responsible for facial sensation, corneal
The occipital lobe is responsible for visual reflex, and mastication.
interpretation. D. facial
9. The lobe of the brain that is the largest The facial (VII) nerve controls facial
and controls abstract thought is the expression and muscle movement.
____________ lobe.
 12. The cranial nerve that is responsible A. flaccid muscle paralysis.
for muscles that move the eye and lid is Lower motor neuron lesions cause flaccid
muscle paralysis, muscle atrophy, decreased
the _____________________ nerve.
muscle tone, and loss of voluntary control.
A. oculomotor B. increased muscle tone.
The oculomotor (III) cranial nerve is also Upper motor neuron lesions cause increased
responsible for pupillary constriction and lens muscle tone.
accommodation. C. no muscle atrophy.
B. trigeminal Upper motor neuron lesions cause no muscle
The trigeminal (V) cranial nerve is atrophy.
responsible for facial sensation, corneal D. hyperactive and abnormal reflexes.
reflex, and mastication. Upper motor neuron lesions cause hyperactive
C. vestibulocochlear and abnormal reflexes.
The vestibulocochlear (VII) cranial nerve is 16. The percentage of patients over the
responsible for hearing and equilibrium. age of 70 admitted to the hospital with
D. facial delirium is about
The facial (VII) nerve is responsible for
salivation, tearing, taste, and sensation in the A. 25%.
ear. About 25% of patients over the age of 70
13. The cranial nerve that is responsible admitted to the hospital have delirium. The
for facial sensation and corneal reflex is cause is often reversible and treatable (as in
drug toxicity, vitamin B12 deficiency or
the _____________________ nerve.
thyroid disease) or chronic and irreversible.
A. trigeminal Depression may produce impairment of
The trigeminal (V) cranial nerve is also attention and memory.
responsible for mastication. B. 10%.
B. oculomotor About 25% of patients over the age of 70
The oculomotor (III) cranial nerve is admitted to the hospital have delirium.
responsible for the muscles that move the eye C. 40%.
and lid, pupillary constriction, and lens About 25% of patients over the age of 70
accommodation. admitted to the hospital have delirium.
C. vestibulocochlear D. 50%.
The vestibulocochlear (VII) cranial nerve is About 25% of patients over the age of 70
responsible for hearing and equilibrium. admitted to the hospital have delirium.
D. facial 17. Structural and motor changes related
The facial nerve is responsible for salivation, to aging that may be assessed in geriatric
tearing, taste, and sensation in the ear. patients during an examination of
14. Upper motor neuron lesions cause neurologic function include which of the
A. no muscle atrophy. following?
Upper motor neuron lesions do not cause
A. Decreased or absent deep tendon reflexes
muscle atrophy but do cause loss of voluntary Structural and motor changes related to aging
control.
that may be assessed in geriatric patients
B. decreased muscle tone. include decreased or absent deep tendon
Lower motor neuron lesions cause decreased
reflexes.
muscle tone. B. Increased pupillary responses
C. flaccid paralysis.
Pupillary responses are reduced or may not
Lower motor neuron lesions cause flaccid appear at all in the presence of cataracts
paralysis.
C. Increased autonomic nervous system
D. absent or decreased reflexes. responses.
Lower motor neuron lesions cause absent or
There is an overall slowing of autonomic
decreased reflexes. nervous system responses
15. Lower motor neuron lesions cause
D. Enhanced reaction and movement times D. Electrogastrography
Strength and agility are diminished and Electrogastrography is an electrophysiologic
reaction and movement times are decreased. study performed to assess gastric motility
18. What safety actions does the nurse disturbances.
need to take for a patient on oxygen 20. Which of the following are
therapy who is undergoing magnetic sympathetic effects of the nervous
resonance imaging (MRI)? system?

A. Ensure that no patient care equipment A. Dilated pupils

containing metal enters the room where the Dilated pupils are a sympathetic effect of the
MRI is located. nervous system. Constricted pupils are a
For patient safety the nurse must make sure no parasympathetic effect.
patient care equipment (e.g., portable oxygen B. Decreased blood pressure
tanks) that contains metal or metal parts enters Decreased blood pressure is a
the room where the MRI is located. The parasympathetic effect. Increased blood
magnetic field generated by the unit is so pressure is a sympathetic effect.
strong that any metal-containing items will be C. Increased peristalsis
strongly attracted and can literally be pulled Increased peristalsis is a parasympathetic
away with such great force that they can fly effect. Decreased peristalsis is a sympathetic
like projectiles towards the magnet. effect.
B. Securely fasten the patient’s portable oxygen D. Decreased respiratory rate                                
tank to the bottom of the MRI table after the Decreased respiratory rate is a
patient has been positioned on the top of the parasympathetic effect. Increased respiratory
MRI table. rate is a sympathetic effect.
For patient safety the nurse must make sure no 21. Lesions in the temporal lobe may
patient care equipment (e.g., portable oxygen result in which of the following types of
tanks) that contains metal or metal parts enters agnosia?
the room where the MRI is located.
C. Check the patient’s oxygen saturation level A. Auditory
using a pulse oximeter after the patient has Lesions in the temporal lobe (lateral and
been placed on the MRI table. superior portions) may result in auditory
For patient safety the nurse must make sure no agnosia.
patient care equipment (e.g., portable oxygen B. Visual
tanks) that contains metal or metal parts enters Lesions in the occipital lobe may result in
the room where the MRI is located. visual agnosia.
D. No special safety actions need to be taken. C. Tactile
For patient safety the nurse must make sure no Lesions in the parietal lobe may result in
patient care equipment (e.g., portable oxygen tactile agnosia.
tanks) that contains metal or metal parts enters D. Relationship
the room where the MRI is located. Lesions in the parietal lobe (posteroinferior
19. Which of the following terms refer to a regions) may result in relationship and body
method of recording, in graphic form, the part agnosia.
electrical activity of the muscle? 22. When the nurse observes that the
patient has extension and external
A. Electromyogram rotation of the arms and wrists and
Electromyogram is a method of recording, in
extension, plantar flexion, and internal
graphic form, the electrical activity of the
muscle. rotation of the feet, she records the
B. Electroencephalogram patient’s posturing as
Electroencephalogram is a method of
A. decerebrate.
recording, in graphic form, the electrical
Decerebrate posturing is the result of lesions
activity of the brain.
at the midbrain and is more ominous than
C. Electrocardiography
decorticate posturing.
Electrocardiography is performed to assess
the electrical activity of the heart.
B. normal. 25. An osmotic diuretic, such as Mannitol,
The described posturing results from cerebral is given to the patient with increased
trauma and is not normal.
intracranial pressure (IICP) in order to
C. flaccid.
The patient has no motor function, is limp, A. dehydrate the brain and reduce cerebral
and lacks motor tone with flaccid posturing. edema.
D. decorticate. Osmotic diuretics draw water across intact
In decorticate posturing, the patient has membranes, thereby reducing the volume of
flexion and internal rotation of the arms and brain and extracellular fluid.
wrists and extension, internal rotation, and B. control fever.
plantar flexion of the feet. Antipyretics and a cooling blanket are used to
23. Monro-Kellie hypothesis refers to control fever in the patient with IICP.
C. control shivering.
A. the dynamic equilibrium of cranial contents. Chloropromazine (Thorazine) may be
The hypothesis states that because of the prescribed to control shivering in the patient
limited space for expansion within the skull, with IICP.
an increase in any one of the cranial contents D. reduce cellular metabolic demands.
(brain tissue, blood, or cerebrospinal fluid) Medications such as barbiturates are given to
causes a change in the volume of the others. the patient with IICP to reduce cellular
B. unresponsiveness to the environment. metabolic demands.
Akinetic mutism is the phrase used to refer to
26. Which of the following positions are
unresponsiveness to the environment.
C. the brain’s attempt to restore blood flow by employed to help reduce intracranial
increasing arterial pressure to overcome the pressure (ICP)?
increased intracranial pressure.
A. Avoiding flexion of the neck with use of a
Cushing’s response is the phrase used to refer
cervical collar
to the brain’s attempt to restore blood flow by
Use of a cervical collar promotes venous
increasing arterial pressure to overcome the
drainage and prevents jugular vein distortion
increased intracranial pressure.
that will increase ICP.
D. a condition in which the patient is wakeful but
B. Keeping the head flat with use of no pillow
devoid of conscious content, without
Slight elevation of the head is maintained to
cognitive or affective mental function.
aid in venous drainage unless otherwise
Persistent vegetative state is the phrase used
prescribed.
to describe a condition in which the patient is
C. Rotating the neck to the far right with neck
wakeful but devoid of conscious content,
support
without cognitive or affective mental function.
Extreme rotation of the neck is avoided
24. A patient who demonstrates an because compression or distortion of the
obtunded level of consciousness jugular veins increases ICP.
D. Extreme hip flexion supported by pillows
A. sleeps almost constantly but can be aroused
Extreme hip flexion is avoided because this
and can follow simple commands.
position causes an increase in intra-abdominal
An obtunded patient stays awake only with
pressure and intrathoracic pressure, which can
persistent stimulation.
produce a rise in ICP.
B. has difficulty following commands, and may
be agitated or irritable. 27. Which of the following insults or
A confused patient has difficulty following abnormalities most commonly causes
commands, and may be agitated or irritable. ischemic stroke?
C. sleeps often and shows slowed speech and
thought processes. A. Cocaine use
A patient who sleeps often and shows slowed Cocaine is a potent vasoconstrictor and may
speech and thought processes is described as result in a life-threatening reaction, even with
lethargic. the individual’s first unprescribed use of the
D. does not respond to environmental stimuli. drug.
A comatose patient does not respond to
environmental stimuli.
B. Arteriovenous malformation A. Agnosia
Arteriovenous malformations are associated Auditory agnosia is failure to recognize
with hemorrhagic strokes. significance of sounds.
C. Trauma B. Agraphia
Trauma is associated with hemorrhagic Agraphia refers to disturbances in writing
strokes. intelligible words.
D. Intracerebral aneurysm rupture C. Apraxia
Intracerebral aneurysm rupture is associated Apraxia refers to inability to perform
with hemorrhagic strokes. previously learned purposeful motor acts on a
28. When the patient is diagnosed as voluntary basis.
having global aphasia, the nurse D. Perseveration                                                    
Perseveration is the continued and automatic
recognizes that the patient will
repetition of an activity, word, or phrase that
A. be unable to form words that are is no longer appropriate.
understandable or comprehend the spoken 31. Which of the following terms related to
word. aphasia refers to difficulty reading?
Global aphasia is a combination of expressive
and receptive aphasia and presents A. Alexia
tremendous challenge to the nurse to Alexia or dyslexia may occur in the absence
effectively communicate with the patient. of aphasia.
B. be unable to comprehend the spoken word. B. Agnosia
In receptive aphasia, the patient is unable to Agnosia is failure to recognize familiar
form words that are understandable. objects perceived by the senses.
C. be unable to form words that are C. Agraphia
understandable. Agraphia refers to disturbances in writing
In expressive aphasia, the patient is unable to intelligible words.
form words that are understandable. D. Perseveration
D. be unable to speak at all. Perseveration is the continued and automatic
The patient who is unable to speak at all is repetition of an activity, word, or phrase that
referred to as mute. is no longer appropriate.
29. Which of the following terms related to 32. Which of the following terms related to
aphasia refers to the inability to perform aphasia refers to difficulty in selecting
previously learned purposeful motor acts appropriate words, particularly nouns?
on a voluntary basis? A. Anomia
A. Apraxia Anomia is also termed dysnomia.
Verbal apraxia refers to difficulty in forming B. Acalculia
and organizing intelligible words although the Acalculia refers to difficulty in dealing with
musculature is intact. mathematical processes or numerical symbols
B. Agnosia in general.
Agnosia is failure to recognize familiar C. Dysarthria
objects perceived by the senses. Dysarthria refers to defects of articulation due
C. Agraphia to neurologic causes.
Agraphia refers to disturbances in writing D. Paraphasia
intelligible words. Paraphasia refers to using wrong words, word
D. Perseveration substitutions, and faults in word usage in both
Perseveration is the continued and automatic oral and written language.
repetition of an activity or word or phrase that 33. A patient has had neurologic deficits
is no longer appropriate. lasting for more than 24 hours, and now
30. Which of the following terms related to the symptoms are resolving. The nurse
aphasia refers to the failure to recognize concludes that the patient has had which
familiar objects perceived by the senses? type of stroke?
A. Reversible ischemic neurologic deficit B. have no drug-drug interactions and therefore
With a reversible ischemic neurologic deficit, may be taken together.
the patient has more pronounced signs and Garlic and warfarin taken together can greatly
symptoms that last more than 24 hours; increase the INR, increasing the risk of
symptoms resolve in a matter of days without bleeding.
any permanent neurologic deficit. C. can cause platelet aggregation and therefore
B. Transient ischemic attack (TIA) increase the risk of blood clotting.
With a TIA, the patient has a temporary Garlic and warfarin taken together can greatly
episode of neurologic dysfunction that may increase the INR, increasing the risk of
last a few seconds or minutes but not longer bleeding.
than 24 hours. D. may increase cerebral blood flow causing
C. Stroke in evolution migraine headaches.
With a stroke in evolution the patient Garlic and warfarin taken together can greatly
experiences a worsening of neurological signs increase the INR, increasing the risk of
and symptoms over several minutes or hours; bleeding.
it is a progressing stroke. 36. Later signs of increased intracranial
D. Completed stroke pressure (ICP) later include which of the
With a completed stroke, the patient’s
following?
neurological signs and symptoms have
stabilized with no indication of further A. Projectile vomiting
progression of the hypoxic insult to the brain. Projectile vomiting may occur with increased
34. Which of the following is a modifiable pressure on the reflex center in the medulla.
risk factor for transient ischemic attacks B. Increased pulse rate
and ischemic strokes? As ICP increases, the pulse rate decreases.
C. Decreased blood pressure
A. History of smoking. As ICP increases, the blood pressure
Modifiable risk factors for TIAs and ischemic increases.
stroke include hypertension, Type 1 diabetes, D. Narrowed pulse pressure
cardiac disease, history of smoking, and As ICP increases, the pulse pressure (the
chronic alcoholism. difference between the systolic and the
B. Thyroid disease diastolic pressure) widens.
Hypertension, Type 1 diabetes, and cardiac 37. Bleeding between the dura mater and
disease are modifiable risk factors for TIAs arachnoid membrane is termed
and ischemic stroke.
C. Social drinking A. subdural hematoma.
Chronic alcoholism is a modifiable risk factor A subdural hematoma is bleeding between the
for TIAs and ischemic stroke. dura mater and arachnoid membrane.
D. Advanced age B. intracerebral hemorrhage.
Advanced age, gender, and race are non- Intracerebral hemorrhage is bleeding in the
modifiable risk factors for stroke. brain or the cerebral tissue with displacement
35. A patient who has had a previous of surrounding structures.
stroke and is taking warfarin tells the C. epidural hematoma.
An epidural hematoma is bleeding between
nurse that he started taking garlic to help
the inner skull and the dura, compressing the
reduce his blood pressure. The nurse brain underneath.
knows that garlic when taken together D. extradural hematoma.
with warfarin An extradural hematoma is another name for
an epidural hematoma.
A. can greatly increase the international
38. Which of the following statements
normalization ratio (INR) and therefore
increase the risk of bleeding. reflect nursing management of the patient
Garlic and warfarin taken together can greatly with expressive aphasia?
increase the INR, increasing the risk of
bleeding. A. Encourage the patient to repeat sounds of the
alphabet.
Nursing management of the patient with
 expressive aphasia includes encouraging the A. vomits.
patient to repeat sounds of the alphabet. Vomiting is a sign of increasing intracranial
B. Speak clearly and in simple sentences; use pressure and should be reported immediately.
gestures or pictures when able. B. complains of headache.
Nursing management of the patient with In general, the finding of headache in the
global aphasia includes speaking clearly and patient with a concussion is an expected
in simple sentences and using gestures or abnormal observation. However, severe
pictures when able. headache should be reported or treated
C. Speak slowly and clearly to assist the patient immediately.
in forming the sounds. C. complains of generalized weakness.
Nursing management of the patient with Weakness of one side of the body should be
receptive aphasia includes speaking slowing reported or treated immediately.
and clearly to assist the patient in forming the D. sleeps for short periods of time.                      
sounds. Difficulty in waking the patient should be
D. Frequently reorient the patient to time, place, reported or treated immediately.
and situation. 41. When the nurse reviews the
Nursing management of the patient with physician’s progress notes for the patient
cognitive deficits, such as memory loss,
who has sustained a head injury and sees
includes frequently reorienting the patient to
time, place, and situation. that the physician observed Battle’s sign
39. Health promotion efforts to decrease when the patient was in the Emergency
the risk for ischemic stroke involve Department, the nurse knows that the
encouraging a healthy lifestyle including physician observed

A. a low fat, low cholesterol diet, and increasing A. an area of bruising over the mastoid bone.
exercise. Battle‘s sign may indicate skull fracture.
Health promotion efforts to decrease the risk B. a bloodstain surrounded by a yellowish stain
for ischemic stroke involve encouraging a on the head dressing.
healthy lifestyle including a low fat, low A bloodstain surrounded by a yellowish stain
cholesterol diet, and increasing exercise. on the head dressing is referred to as a halo
B. eating fish no more than once a month. sign and is highly suggestive of a
Recent evidence suggests that eating fish two cerebrospinal fluid leak.
or more times per week reduces the risk of C. escape of cerebrospinal fluid (CSF) from the
thrombotic stroke for women patient’s ear.
C. a high protein diet and increasing weight- Escape of CSF from the patient’s ear is
bearing exercise. termed otorrhea.
Health promotion efforts to decrease the risk D. escape of cerebrospinal fluid (CSF) from the
for ischemic stroke involve encouraging a patient’s nose.
healthy lifestyle including a low fat, low Escape of CSF from the patient’s nose is
cholesterol diet, and increasing exercise. termed rhinorrhea.
D. a low cholesterol, low protein diet, and 42. Which of the following findings in the
decreasing aerobic exercise. patient who has sustained a head injury
Health promotion efforts to decrease the risk indicate increasing intracranial pressure
for ischemic stroke involve encouraging a (ICP)?
healthy lifestyle including a low fat, low
cholesterol diet, and increasing exercise. A. Widened pulse pressure
40. Before the patient diagnosed with a Additional signs of increasing ICP include
concussion is released from the increasing systolic blood pressure,
bradycardia, rapid respirations, and rapid rise
Emergency Department, the nurse
in body temperature.
teaches the family or friends who will be B. Increased pulse
tending to the patient to contact the Bradycardia, slowing of the pulse, is an
physician or return to the ED if the patient indication of increasing ICP in the head-
injured patient.
C. Decreased respirations following a head injury include which of
Rapid respiration is an indication of the following?
increasing ICP in the head-injured patient.
D. Decreased body temperature A. Age over 65 years
A rapid rise in body temperature is regarded Risk factors that increase the likelihood of
as unfavorable because hyperthermia may post-traumatic seizures following a head
indicate brain stem damage, a poor prognostic injury include brain contusion with subdural
sign. hematoma, skull fracture, loss of
43. Which of the following nursing consciousness or amnesia of 1 day or more,
interventions is appropriate when caring and age over 65 years.
B. Loss of consciousness for less than 1 day
for the awake and oriented head injury
Loss of consciousness or amnesia of 1 day or
patient? more is a risk factor that increases the
A. Supply oxygen therapy to keep blood gas likelihood of post-traumatic seizures
values within normal range. following a head injury
The goal is to keep blood gas values within C. Glasgow Coma Scale (GCS) score less than
normal range to ensure adequate cerebral 10
circulation. The GCS assesses level of consciousness; a
B. Do not elevate the head of the bed. score of 10 or less indicates the need for
In general, the head of the bed is elevated emergency attention. It is not a risk factor for
about 30 degrees to decrease intracranial post-traumatic seizures.
venous pressure. D. Epidural hematoma
C. Encourage the patient to cough every 2 hours. Brain contusion with subdural hematoma is a
Coughing should not be encouraged because it risk factor that increases the likelihood of
increases intracranial pressure. post-traumatic seizures following a head
D. Use restraints if the patient becomes agitated. injury
Restraints should be avoided because 46. A post-traumatic seizure classified as
straining against them can increase early occurs
intracranial pressure. Use of padded side rails
and application of mitts are the appropriate A. within 1-7 days of injury.
interventions in the agitated head-injured Posttraumatic seizures are classified as
patient. immediate (occurring within 24 hours of
injury), early, (occurring within 1-7 days of
44. Of the following stimuli, which is
injury) or late, occurring more than 7 days
known to trigger an episode of autonomic following injury.
hyperreflexia in the patient who has B. within 4 hours of injury.
suffered a spinal cord injury? Posttraumatic seizures are classified as
immediate (occurring within 24 hours of
A. Applying a blanket over the patient injury), early, (occurring within 1-7 days of
An object on the skin or skin pressure may injury) or late, occurring more than 7 days
precipitate an autonomic hyperreflexic following injury.
episode. C. within 24 hours of injury.
B. Diarrhea Posttraumatic seizures occurring within 24
In general, constipation or fecal impaction hours of injury are classified as immediate
triggers autonomic hyperreflexia. seizures.
C. Placing the patient in a sitting position D. more than 7 days following surgery.
When the patient is observed to be Posttraumatic seizures occurring more than 7
demonstrating signs of autonomic days following surgery are classified as late
hyperreflexia, he is placed in a sitting position seizures.
immediately to lower blood pressure.
47. The nurse assesses the dressing of a
D. Voiding
The most common cause of autonomic patient with a basal skull fracture and
hyperreflexia is a distended bladder. sees the halo sign – a blood stain
45. Risk factors that increase the surrounded by a yellowish stain. The
likelihood of post-traumatic seizures nurse knows that this sign
A. is highly suggestive of a cerebrospinal fluid A. Homonymous hemianopsia
(CSF) leak. Homonymous hemianopsia occurs with
The halo sign – a blood stain surrounded by a occipital lobe tumors.
yellowish stain is highly suggestive of a B. Scotoma
cerebrospinal fluid (CSF) leak. Scotoma refers to a defect in vision in a
B. may indicate a subdural hematoma.. specific area in one or both eyes.
The halo sign is highly suggestive of a C. Diplopia
cerebrospinal fluid (CSF) leak. Diplopia refers to double vision or the
C. is highly suggestive of a cerebral contusion. awareness of two images of the same object
The halo sign is highly suggestive of a occurring in one or both eyes.
cerebrospinal fluid (CSF) leak. D. Nystagmus                                                        
D. normally occurs within 24 hours following a Nystagmus refers to rhythmic, involuntary
basal skull fracture. movements or oscillations of the eyes.
The halo sign is highly suggestive of a
cerebrospinal fluid (CSF) leak.
48. A Glasgow Coma Scale (GCS) score
of 7 or less is generally interpreted as
A. coma.
The Glasgow Coma Scale (GCS) is a tool for
assessing a patient’s response to stimuli. A
score of 7 or less is generally interpreted as
coma.
B. a need for emergency attention.
A GCS score of 10 or less indicates a need for
emergency attention.
C. least responsive.
A GCS score of 3 is interpreted as least
responsive.
D. most responsive.
A GCS score of 15 is interpreted as most
responsive.
49. Which of the following terms refers to
muscular hypertonicity with increased
resistance to stretch?
A. Spasticity
Spasticity is often associated with weakness,
increased deep tendon reflexes, and
diminished superficial reflexes.
B. Akathesia
Akathesia refers to a restless, urgent need to
move around and agitation.
C. Ataxia
Ataxia refers to impaired ability to coordinate
movement.
D. Myclonus
Myoclonus refers to spasm of a single muscle
or group of muscles.
50. Of the following terms, which refers to
blindness in the right or left halves of the
visual fields of both eyes?
 Medical Surgical Nursing 17 B. Anaphylactoid (anaphylaxis-like) reactions
are commonly fatal.
1. When the nurse observes diffuse Although possibly severe, anaphylactoid
swelling involving the deeper skin layers reactions are rarely fatal.
in the patient who has experienced an C. The most common food item causing
allergic reaction, the nurse records the anaphylaxis is chocolate.
finding as Food items that are common causes of
anaphylaxis include peanuts, tree nuts,
A. angioneurotic edema. shellfish, fish, milk, eggs, soy and wheat.
The area of skin demonstrating angioneurotic D. Systemic reactions include urticaria and
edema may appear normal but often has a angioedema
reddish hue and does not pit. Local reactions usually involve urticaria and
B. urticaria. angioedema at the site of the antigen
Urticaria (hives) is characterized as exposure. Systemic reactions occur within
edematous skin elevations that vary in size about 30 minutes of exposure involving
and shape, itch, and cause local discomfort. cardiovascular, respiratory, gastrointestinal,
C. contact dermatitis. and integumentary organ systems.
Contact dermatitis refers to inflammation of 4. Which of the following statements
the skin caused by contact with an allergenic describes the clinical manifestations of a
substance, such as poison ivy.
delayed hypersensitivity (type IV) allergic
D. pitting edema.
Pitting edema is the result of increased reaction to latex?
interstitial fluid and associated with disorders A. Signs and symptoms are localized to the area
such as congestive heart failure. of exposure, usually the back of the hands.
2. Atopic allergic disorders are Clinical manifestations of a delayed
characterized by hypersensitivity reaction are localized to the
area of exposure.
A. a hereditary predisposition. B. Signs and symptoms can be eliminated by
Atopic allergic disorders are characterized by changing glove brands or using powder-free
a hereditary predisposition and production of gloves.
a local reaction to IgE antibodies produced in Clinical manifestations of an irritant contact
response to common environmental allergens. dermatitis can be eliminated by changing
B. an IgA-mediated reaction. glove brands or using powder-free gloves.
Atopic and nonatopic allergic disorders are C. Signs and symptoms may worsen when hand
IgE-mediated allergic reactions. lotion is applied before donning latex gloves.
C. production of a systemic reaction. With an irritant contact dermatitis, avoid use
Atopic allergic disorders are characterized by of hand lotion before donning gloves as this
a hereditary predisposition and production of may worsen symptoms as lotions may leach
a local reaction to IgE antibodies produced in latex proteins from the gloves.
response to common environmental allergens. D. Signs and symptoms occur within minutes
D. a response to physiologic allergens. after exposure to latex.
Atopic allergic disorders are characterized by Described as a latex allergy, when clinical
a hereditary predisposition and production of manifestations occur within minutes after
a local reaction to IgE antibodies produced in exposure to latex, an immediate
response to common environmental allergens. hypersensitivity (type I) allergic reaction has
3. The nurse teaches the patient with occurred.
allergies about anaphylaxis including 5. Which of the following terms refers to
which of the following statements? fixation or immobility of a joint?
A. The most common cause of anaphylaxis is A. Ankylosis
penicillin. Ankylosis may result from disease or scarring
The most common cause of anaphylaxis, due to trauma.
accounting for about 75% of fatal B. Hemarthrosis
anaphylactic reactions in the U.S., is Hemarthrosis refers to bleeding into the joint.
penicillin.
C. Diarthrodial B. Rheumatoid arthritis
Diarthrodial refers to a joint with two freely Rheumatoid arthritis results from an
moveable parts. autoimmune response in the synovial tissue
D. Arthroplasty with damage taking place in body joints.
Arthroplasty refers to replacement of a joint. C. Systemic lupus erythematosus
6. Accumulation of crystalline depositions SLE is an immunoregulatory disturbance that
in articular surfaces, bones, soft tissue, results in increased autoantibody production.
D. Polymyalgia rheumatic
and cartilage is referred to as
In polymyalgia rheumatic, immunoglobulin is
A. tophi. deposited in the walls of inflamed temporal
Tophi, when problematic, are surgically arteries.
excised. 9. Osteoarthritis is known as a disease
B. subchondral bone. that
Subchondral bone refers to a bony plate that
supports the articular cartilage. A. is the most common and frequently disabling
C. pannus. of joint disorders.
Pannus refers to newly formed synovial tissue The functional impact of osteoarthritis on
infiltrated with inflammatory cells. quality of life, especially for elderly patients,
D. joint effusion. is often ignored.
Joint effusion refers to the escape of fluid B. affects young males.
from the blood vessels or lymphatics into the Reiter’s syndrome is a spondyloarthropathy
joint cavity. that affects young adult males and is
7. Passive range-of-motion exercises are characterized primarily by urethritis, arthritis,
and conjunctivitis.
indicated during which stage of rheumatic
C. requires early treatment because most of the
disease? damage appears to occur early in the course of
A. Acute the disease.
Passive range of motion is indicated because Psoriatic arthritis, characterized by synovitis,
the patient is unable to perform exercises polyarthritis, and spondylitis requires early
alone during an acute stage of rheumatic treatment because of early damage caused by
disease. disease.
B. Subacute D. affects the cartilaginous joints of the spine and
Active assistive or active range of motion is surrounding tissues.
recommended during the subacute stage of Ankylosing spondylitis causes the described
rheumatic diseases. problem and is usually diagnosed in the
C. Inactive second or third decade of life.
Active range of motion and isometrics are 10. Which of the following newer
recommended during the inactive stage of pharmacological therapies used for the
rheumatic diseases. treatment of osteoarthritis is thought to
D. Remission improve cartilage function and retard
Active range of motion and isometrics are
degradation as well as have some anti-
recommended during the remission stage of
rheumatic diseases. inflammatory effects?
8. Which of the following connective A. Viscosupplementation
tissue disorders is characterized by Viscosupplementation, the intraarticular
insoluble collagen being formed and injection of hyaluronic acid, is thought to
accumulating excessively in the tissues? improve cartilage function and retard
degradation. It may also have some anti-
A. Scleroderma inflammatory effects.
Scleroderma occurs initially in the skin but B. Glucosamine
also occurs in blood vessels, major organs, Glucosamine and chondroitin are thought to
and body systems, potentially resulting in improve tissue function and retard breakdown
death. of cartilage.
C. Chondroitin D. usually lasts for less than two weeks,
Chondroitin and glucosamine are thought to Fibromyalgia, is a common condition that
improve tissue function and retard breakdown involves chronic fatigue, generalized muscle
of cartilage. aching, and stiffness. It is very typical for
D. Capsaicin                                                           patients to have endured their symptoms for a
Capsaicin is a topical analgesic. long period of time.
11. Which of the following statements 13. Which of the following terms refers to
reflect nursing interventions in the care of a condition characterized by destruction
the patient with osteoarthritis? of the melanocytes in circumscribed
areas of the skin?
A. Encourage weight loss and an increase in
aerobic activity. A. Vitiligo
Weight loss and an increase in aerobic activity Vitiligo results in the development of white
such as walking, with special attention to patches that may be localized or widespread.
quadriceps strengthening are important B. Hirsutism
approaches to pain management. Hirsutism is the condition of having excessive
B. Provide an analgesic after exercise. hair growth.
Patients should be assisted to plan their daily C. Lichenification
exercise at a time when the pain is least Lichenification refers to a leathery thickening
severe, or plan to use an analgesic, if of the skin.
appropriate, prior to their exercise session. D. Telangiectases
C. Assess for the gastrointestinal complications Telangiectases refers to red marks on the skin
associated with COX-2 inhibitors. caused by stretching of the superficial blood
Gastrointestinal complications, especially GI vessels.
bleeding, are associated with the use of 14. Of the following types of cells, which
nonsteroidal anti-inflammatory drugs
are believed to play a significant role in
(NSAIDs).
D. Avoid the use of topical analgesics. cutaneous immune system reactions?
Topical analgesics such as capsaicin and A. Langerhans’ cells
methylsalicylate may be used for pain Langerhans’ cells are common to the
management. epidermis and are accessory cells of the
12. Fibromyalgia is a common condition afferent immune system process.
that B. Merkel’s cells
Merkel’s cells are the receptor cells in the
A. involves chronic fatigue, generalized muscle epidermis that transmit stimuli to the axon via
aching and stiffness. a chemical response.
Fibromyalgia, is a common condition that C. Melanocytes
involves chronic fatigue, generalized muscle Melanocytes are special cells of the epidermis
aching, and stiffness. that are primarily involved in producing
B. is caused by a virus. melanin, which colors the hair and skin.
The cause is unknown and no pathological D. Phagocytes
characteristics have been identified that are Phagocytes are white blood cells that engulf
specific for the condition and destroy foreign materials.
C. is treated by diet, exercise, and physical
15. When the nurse assesses the patient
therapy.
Treatment consists of attention to the specific and observes blue-red and dark brown
symptoms reported by the patient. NSAIDs plaques and nodules, she recognizes that
may be used to treat the diffuse muscle aching these manifestations are associated with
and stiffness. Tricyclic antidepressants are
used to improve or restore normal sleep A. Kaposi’s sarcoma.
patterns and individualized programs of Kaposi’s sarcoma is a frequent comorbidity of
exercise are used to decrease muscle the patient with AIDS.
weakness and discomfort and to improve the B. platelet disorders.
general de-conditioning that occurs in these With platelet disorders, the nurse observes
individuals
 ecchymoses (bruising) and purpura (bleeding A. Furuncle
into the skin). Furuncles occur anywhere on the body, but
C. allergic reactions. are most prevalent in areas subjected to
Urticaria (wheals or hives) is the irritation, pressure friction, and excessive
manifestation of allergic reactions. perspiration, such as the back of the neck, the
D. syphilis. axillae, or the buttocks.
A painless chancre or ulcerated lesion is a B. Carbuncle
typical finding in the patient with syphilis. A carbuncle is a localized skin infection
16. The nurse reading the physician’s involving several hair follicles.
report of an elderly patient’s physical C. Chelitis.
Chelitis refers to dry cracking at the corners of
examination knows a notation that the
the mouth.
patient demonstrates xanthelasma refers D. Comedone.
to Comedones are the primary lesions of acne,
caused by sebum blockage in the hair follicle.
A. yellowish waxy deposits on upper eyelids.
The change is a common, benign 19. The nurse recommends which of the
manifestation of aging skin or it can following types of therapeutic baths for its
sometimes signal hyperlipidemia. antipruritic action?
B. liver spots.
Solar lentigo is the term that refers to liver A. Colloidal (Aveeno, oatmeal)
spots. Aveeno or oatmeal baths are recommended to
C. dark discoloration of the skin. decrease itching associated with a
Melasma is the term that refers to dark dermatologic disorder.
discoloration of the skin. B. Sodium bicarbonate (baking soda)
D. bright red moles. Baking soda baths are cooling but dangerous.
Cherry angioma is the term that is used to The tub gets very slippery and a bath mat
describe a bright red mole. must be used in the tub.
C. Water
17. The nurse notes that the patient
Water baths have the same effect as wet
demonstrates generalized pallor and dressings, not known to counteract itching.
recognizes that this finding may be D. Saline
indicative of Saline baths have the same effects as saline
dressings, not known to counteract itching.
A. anemia.
20. Which of the following materials
In the light-skinned individual, generalized
pallor is a manifestation of anemia. In brown- consists of a powder in water?
and black-skinned individuals, anemia is A. Suspension
demonstrated as a dull skin appearance. A suspension requires shaking before
B. albinism. application, exemplified by calamine lotion.
Albinism is a condition of total absence of B. Hygroscopic agent
pigment in which the skin appears whitish A hygroscopic agent is a powder that acts to
pink. absorb and retain moisture from the air and to
C. vitiligo. reduce friction between surfaces.
Vitiligo is a condition characterized by the C. Paste
destruction of the melanocytes in A paste is a mixture of powder and ointment.
circumscribed areas of skin, resulting in D. Linament                                                          
patchy, milky white spots. A linament is a lotion with oil added to
D. local arterial insufficiency. prevent crusting.
Local arterial insufficiency is characterized by
21. Which of the following skin conditions
marked localized pallor.
is caused by staphylococci, streptococci,
18. Which of the following terms refers
or multiple bacteria?
most precisely to a localized skin infection
of a single hair follicle? A. Impetigo
Impetigo is seen at all ages, but is particularly
 common among children living under poor higher incidence of development of malignant
hygienic conditions. melanoma.
B. Scabies 24. When caring for a patient receiving
Scabies is caused by the itch mite. autolytic debridement therapy, the nurse
C. Pediculosis capitis
Pediculosis capitis is caused by head lice. A. advises the patient about the foul odor that
D. Poison ivy will occur during therapy.
Poison ivy is a contact dermatitis caused by During autolytic debridement therapy a foul
the oleoresin given off by a particular form of odor will be produced by the breakdown of
ivy. cellular debris. This odor does not indicate
22. The nurse teaches the patient who that the wound is infected.
demonstrates herpes zoster (shingles) B. ensures that the dressing is kept dry at all
times.
that
During autolytic debridement therapy the
A. the infection results from reactivation of the wound is kept moist.
chickenpox virus. C. ensures that the wound is kept open to the air
It is assumed that herpes zoster represents a for at least six hours per day.
reactivation of latent varicella (chickenpox) During autolytic debridement therapy the
virus and reflects lowered immunity. wound is covered with an occlusive dressing.
B. once a patient has had shingles, they will not D. Uses an enzymatic debriding agent such as
have it a second time. Pancrease.
It is believed that the varicella zoster virus lies Commercially available enzymatic debriding
dormant inside nerve cells near the brain and agents include Accuzyme, Clooagenase,
spinal cord and is reactivated with weakened Granulex, and Zymase.
immune systems and cancers. 25. Which of the following reflect the
C. a person who has had chickenpox can contract pathophysiology of cutaneous signs of
it again upon exposure to a person with HIV disease?
shingles.
A person who has had chickenpox is immune A. Immune function deterioration
and, therefore, not at risk of infection after Cutaneous signs may be the first
exposure to patients with herpes zoster. manifestations of HIV, appearing in more
D. There are no known medications that affect than 90 per cent of HIV infected patients as
the course of shingles. the immune function deteriorates. Common
There is some evidence that infection is complaints include pruritis, folliculitis, and
arrested if oral antiviral agents are chronic actinic dermatitis.
administered within 24 hours of the initial B. High CD4 count
eruption. Cutaneous signs of HIV disease correlate to
23. Development of malignant melanoma low CD4 counts.
is associated with which of the following C. Genetic predisposition
Cutaneous signs of HIV disease appear as
risk factors?
immune function deteriorates.
A. Individuals with a history of severe sunburn D. Decrease in normal skin flora
Ultraviolet rays are strongly suspected as the Cutaneous signs of HIV disease appear as
etiology of malignant melanoma. immune function deteriorates.
B. African-American heritage 26. Most skin conditions related to HIV
Fair-skinned, blue-eyed, light-haired people of disease may be helped primarily by
Celtic or Scandinavian origin are at higher
risk for development of malignant melanoma. A. highly active antiretroviral therapy (HAART).
C. People who tan easily The goals of all HIV-related conditions
People who burn and do not tan are at risk for include improvement of CD4 count and
development of malignant melanoma. lowering of viral load. Initiation of HAART
D. Elderly individuals residing in the Northeast (highly active antiretroviral therapy) will help
Elderly individuals who retire to the improve most skin conditions related to HIV
southwestern United States appear to have a disease. Symptomatic relief will be required
until the skin condition improves.
B. symptomatic therapies. D. Superficial
Initiation of HAART (highly active Injury from a flash flame is not associated
antiretroviral therapy) will help improve most with a burn that is limited to the epidermis.
skin conditions related to HIV disease. 29. Regarding emergency procedures at
Symptomatic relief will be required until the the burn scene, the nurse teaches which
skin condition improves.
of the following guidelines?
C. low potency topical corticosteroid therapy.
High-potency, not low-potency, topical A. Never wrap burn victims in ice.
corticosteroid therapy may be helpful for Such procedure may worsen the tissue
some skin conditions. damage and lead to hypothermia in patients
D. improvement of the patient’s nutritional with large burns.
status. B. Apply ice directly to a burn area.
Improvement of the patient’s nutritional status Ice must never be applied directly to a burn
is beneficial for the overall treatment of HIV because it may worsen the tissue damage.
disease; it is not specific for treatment of skin C. Never apply water to a chemical burn.
conditions. Chemical burns resulting from contact with a
27. Which of the following terms refers to corrosive material are irrigated immediately.
a graft derived from one part of a patient’s D. Maintain cold dressings on a burn site at all
body and used on another part of that times.
Such procedures may worsen the tissue
same patient’s body?
damage and lead to hypothermia in patients
A. Autograft with large burns.
Autografts of full-thickness and pedicle flaps 30. The first dressing change for an
are commonly used for reconstructive surgery, autografted area is performed
months or years after the initial injury.
B. Allograft A. as soon as foul odor or purulent drainage is
An allograft is a graft transferred from one noted, or 3-5 days after surgery.
human (living or cadaveric) to another human. A foul odor or purulent infection may indicate
C. Homograft infection and should be reported to the
A homograft is a graft transferred from one surgeon immediately.
human (living or cadaveric) to another human. B. within 12 hours after surgery.
D. Heterograft The first dressing change usually occurs 3-5
A heterograft is a graft obtained from an days after surgery.
animal of a species other than that of the C. within 24 hours after surgery.
recipient. The first dressing change usually occurs 3-5
28. When the emergency nurse learns days after surgery.
D. as soon as sanguineous drainage is noted.        
that the patient suffered injury from a
Sanguineous drainage on a dressing covering
flash flame, the nurse anticipates which an autograft is an anticipated abnormal
depth of burn? observation postoperatively.
A. Deep partial thickness 31. Which of the following observations in
A deep partial thickness burn is similar to a the patient who has undergone allograft
second-degree burn and is associated with for treatment of burn site must be
scalds and flash flames. reported to the physician immediately?
B. Superficial partial thickness
Superficial partial thickness burns are similar A. Crackles in the lungs
to first-degree burns and are associated with Crackles in the lungs may indicate a fluid
sunburns. buildup indicative of congestive heart failure
C. Full thickness and pulmonary edema.
Full thickness burns are similar to third- B. Pain at the allograft donor site
degree burns and are associated with direct Pain at the allograft donor site is anticipated,
flame, electric current, and chemical contact. since the nerve endings have been stimulated.
C. Sanguineous drainage at the allograft donor
site
 Sanguineous drainage at the allograft donor TransCyte indeterminate or between
site is anticipated, since upper layers of tissue superficial and deep partial thickness in depth.
have been removed. B. partial-thickness burns.
D. Decreased pain at the allograft recipient site is a temporary biosynthetic?BCG Matrix
Decreased pain at the recipient site is wound covering intended for use with partial-
anticipated since the wound has been thickness burns and donor sites
protected by the graft. C. superficial burns.
32. Which of the following factors are is used to treat burns in which?TransCyte the
associated with increased fluid depth is indeterminate or between superficial
and deep partial thickness in depth.
requirements in the management of
D. donor sites.
patients with burn injury? is a temporary biosynthetic wound?BCG
A. Inhalation injuries Matrix covering intended for use with partial-
Factors associated with increased fluid thickness burns and donor sites
requirements include inhalation injuries, 35. Which of the following statements
delayed resuscitation, scald burn injuries, reflect current research regarding the
high-voltage electrical injuries, utilization of non-pharmacological
hyperglycemia, alcohol intoxification and measures in the management of burn
chronic diuretic therapy.
pain?
B. Chemical burn injuries
Chemical burn injuries are not associated with A. Music therapy may provide reality orientation,
increased fluid requirements. distraction, and sensory stimulation.
C. Low-voltage electrical injuries Researchers have found that music affects
Low-voltage electrical injuries are not both the physiologic and psychological
associated with increased fluid requirements. aspects of the pain experience. Music diverts
D. Hypoglycemia the patient’s attention away from the painful
Hypoglycemia is not associated with stimulus. Music may also provide reality
increased fluid requirements. orientation, distraction, and sensory
33. Antimicrobial barrier?Acticoat stimulation. It also allows for patient self-
dressings used in the treatment of burn expression.
wounds can be left in place for five days. B. Music therapy diverts the patient’s attention
toward painful stimulus.
Antimicrobial barrier dressings can be left
Music diverts the patient’s attention away
in place for? from, not toward, the painful stimulus.
A. Acticoat up to five days C. Humor therapy has not proven effective in the
thus helping to decrease discomfort to the management of burn pain.
patient, decrease costs of dressing supplies, Humor therapy has proven effective in the
and decrease nursing time involved in burn management of burn pain.
dressing changes. D. Pet therapy has proven effective in the
B. seven to ten days. management of burn pain.
antimicrobial barrier dressings?Acticoat can Pet therapy has not proven effective in the
be left in place for up to five days. management of burn pain.
C. three days. 36. The most important intervention in the
Acticoat antimicrobial barrier dressings can nutritional support of a patient with a burn
be left in place for up to five days. injury is to provide adequate nutrition and
D. two days. calories to:
antimicrobial barrier dressings can be left in?
Acticoat place for up to five days. A. decrease catabolism.
34. A new biosynthetic dressing used , is The most important intervention in the
used to treat?in the treatment of burns, nutritional support of a patient with a burn
injury is to provide adequate nutrition and
TransCyte
calories to decrease catabolism. Nutritional
A. burns of indeterminate depth support with optimized protein intake can
is used to treat burns in which the depth is?
 decrease the protein losses by approximately B. sees an object from 200 feet away that a
50%. person with normal vision sees from 20 feet
B. increase metabolic rate. away.
A marked increase in metabolic rate is seen Most people, positioned 20 feet from the eye
after a burn injury; interventions are instituted chart, can see the letters designated as 20/20
to decrease metabolic rate and catabolism. from a distance of 20 feet.
C. increase glucose demands. C. sees an object from 20 feet away that a person
A marked increase in glucose demands are with normal vision sees from 20 feet away.
seen after a burn injury; interventions are The standard of normal vision, 20/20 means
instituted to decrease glucose demands and that the patient can read the 20/20 line from a
catabolism. distance of 20 feet.
D. increase skeletal muscle breakdown. D. sees an object from 200 feet away that a
Rapid skeletal muscle breakdown with amino person with normal vision sees from 200 feet
acids serving as the energy source is seen after away.
a burn injury; interventions are instituted to In order to read the 20/20 line, the person of
decrease catabolism. normal vision will be standing at a distance of
37. Which of the following terms refers to 20 feet from the chart.
the absence of the natural lens? 40. Which type of glaucoma presents an
ocular emergency?
A. Aphakia
When a cataract is extracted, and an A. Acute angle-closure glaucoma
intraocular lens implant is not used, the Acute angle-closure glaucoma results in rapid
patient demonstrates aphakia. progressive visual impairment.
B. Scotoma B. Normal tension glaucoma
Scotoma refers to a blind or partially blind Normal tension glaucoma is treated with
area in the visual field. topical medication.
C. Keratoconus C. Ocular hypertension
Keratoconus refers to a cone-shaped Ocular hypertension is treated with topical
deformity of the cornea. medication.
D. Hyphema D. Chronic open-angle glaucoma                          
Hyphema refers to blood in the anterior Chronic open-angle glaucoma is treated
chamber of the eye. initially with topical medications, with oral
38. Edema of the conjunctiva is termed medications added at a later time.
41. Which of the following categories of
A. chemosis.
medications increases aqueous fluid
Chemosis is a common manifestation of pink-
eye. outflow in the patient with glaucoma?
B. papilledema. A. Cholinergics
Papilledema refers to swelling of the optic Cholinergics increase aqueous fluid outflow
disk due to increased intracranial pressure. by contracting the ciliary muscle, causing
C. proptosis. miosis, and opening the trabecular meshwork.
Proptosis is the downward displacement of the B. Beta-blockers
eyeball. Beta-blockers decrease aqueous humor
D. strabismus. production.
Strabismus is a condition in which there is a C. Alpha-adrenergic agonists
deviation from perfect ocular alignment. Alpha-adrenergic agonists decrease aqueous
39. When the patient tells the nurse that humor production.
his vision is 20/200, and asks what that D. Carbonic anhydrase inhibitors
means, the nurse informs the patient that Carbonic anhydrase inhibitors decrease
a person with 20/200 vision aqueous humor production.
42. Which of the following statements
A. sees an object from 20 feet away that a person describe refractive surgery?
with normal vision sees from 200 feet away.
The fraction 20/20 is considered the standard A. Refractive surgery is an elective, cosmetic
of normal vision. surgery performed to reshape the cornea.
 Refractive surgery is an elective procedure exposure to strong light, such as sunlight or
and is considered a cosmetic procedure (to bright lights. Ordinary indoor light is not a
achieve clear vision without the aid of problem. The patient should be counseled to
prosthetic devices). It is performed to reshape wear protective clothing, such as long-sleeved
the cornea for the purpose of correction of all shirts, sunglasses, and wide-brimmed hats, if
refractive errors. the patient has to go outdoors during daylight
B. Refractive surgery will alter the normal aging hours in the first five days post-treatment.
of the eye. Inadvertent sunlight exposure can lead to
Refractive surgery will not alter the normal severe blistering of the skin and sunburn.
aging process of the eye. B. the first 24 hours after the procedure.
C. Refractive surgery may be performed on all The patient should avoid exposure to direct
patients, even if they have underlying health sunlight or bright lights for the first five days
conditions. post-treatment.
Patients with conditions that are likely to C. two weeks after the procedure.
adversely affect corneal wound healing The patient should avoid exposure to direct
(corticosteroid use, immunosuppression, sunlight or bright lights for the first five days
elevated IOP) are not good candidates for the post-treatment.
procedure. D. the first month after the procedure.
D. Refractive surgery may be performed on The patient should avoid exposure to direct
patients with an abnormal corneal structure as sunlight or bright lights for the first five days
long as they have a stable refractive error. post-treatment.
The corneal structure must be normal and 45. Retinoblastoma is the most common
refractive error stable. eye tumor of childhood; it is hereditary in
43. The nurse knows that a postoperative
vision-threatening complication of LASIK A. 30-40% of cases.
Retinoblastoma can be hereditary or
refractive surgery, diffuse lamellar
nonhereditary. It is hereditary in 30-40% of
keratitis (DLK) occurs cases. All bilateral cases are hereditary.
A. in the first week after surgery. B. 10-20% of cases.
DLK is a peculiar, non-infectious, Retinoblastoma is hereditary in 30-40% of
inflammatory reaction in the lamellar cases.
interface after LASIK. It is characterized by a C. 25-50% of cases.
white granular, diffuse culture-negative Retinoblastoma is hereditary in 30-40% of
lamellar keratitis occurring in the first week cases.
after surgery. Studies suggest that since no D. 50-75% of cases.
single agent appears to be solely the cause of Retinoblastoma is hereditary in 30-40% of
DLK, a multifactorial etiology is likely. cases.
B. 1 month after surgery. 46. Which of the following terms refers to
DLK occurs in the first week after surgery. altered sensation of orientation in space?
C. 2-3 months after surgery.
DLK occurs in the first week after surgery. A. Dizziness
D. 6 months after surgery. Dizziness may be associated with inner ear
DLK occurs in the first week after surgery. disturbances.
B. Vertigo
44. The nurse advises the patient
Vertigo is the illusion of movement where the
undergoing photodynamic therapy (PDT) individual or the surroundings are sensed as
for macular degeneration to avoid moving.
exposure to direct sunlight or bright lights C. Tinnitus
for Tinnitus refers to a subjective perception of
sound with internal origin.
A. the first five days after the procedure. D. Nystagmus
Photodynamic therapy includes the use of Nystagmus refers to involuntary rhythmic eye
verteporfin, a light-activated dye. The dye movement.
within the blood vessels near the surface of 47. Of the following terms, which
the skin could become activated with
describes a condition characterized by
 abnormal spongy bone formation around A. Rinne’s
the stapes? In the Rinne’s test, the examiner shifts the
stem of a vibrating tuning fork between two
A. Otosclerosis positions to test air conduction of sound and
Otosclerosis is more common in females than bone conduction of sound.
males and is frequently hereditary. B. Whisper
B. Middle ear effusion The whisper test involves covering the
A middle ear effusion is denoted by fluid in untested ear and, whispering from a distance
the middle ear without evidence of infection. of 1 or 2 feet from the unoccluded ear, and the
C. Chronic otitis media ability of the patient to repeat what was
Chronic otitis media is defined as repeated whispered.
episodes of acute otitis media causing C. Watch tick
irreversible tissue damage and persistent The watch tick test relies on the ability of the
tympanic membrane perforation. patient to perceive the high-pitched sound
D. Otitis externa made by a watch held at the patient’s auricle.
Otitis externa refers to inflammation of the D. Weber’s                                                            
external auditory canal. The Weber’s test uses bone conduction to test
48. Ossiculoplasty is defined as lateralization of sound.

A. surgical reconstruction of the middle ear

bones.
Ossiculoplasty is performed to restore
hearing.
B. surgical repair of the eardrum.
Surgical repair of the eardrum is termed
tympanoplasty.
C. incision into the tympanic membrane.
Tympanotomy or myringotomy is the term
used to refer to incision into the tympanic
membrane.
D. incision into the eardrum.
Tympanotomy or myringotomy is the term
used to refer to incision into the tympanic
membrane.
49. Which of the following terms refers to
surgical repair of the tympanic
membrane?
A. Tympanoplasty
Tympanoplasty may be necessary to repair a
scarred eardrum.
B. Tympanotomy
A tympanotomy is an incision into the
tympanic membrane.
C. Myringotomy
A myringotomy is an incision into the
tympanic membrane.
D. Ossiculoplasty
An ossiculoplasty is a surgical reconstruction
of the middle ear bones to restore hearing.
50. Of the following tests, which uses a
tuning fork between two positions to
assess hearing?
 Medical Surgical Nursing 19 patches of demyelination in the brain and
1. Which of the following terms is used to spinal cord?
describe rapid, jerky, involuntary, A. Multiple sclerosis
purposeless movements of the The cause of MS is not known and the disease
extremities? affects twice as many women as men.
B. Parkinson’s disease
A. Chorea Parkinson’s disease is associated with
Choreiform movements, such as grimacing, decreased levels of dopamine caused by
may also be observed in the face. destruction of pigmented neuronal cells in the
B. Bradykinesia substantia nigra in the basal ganglia of the
Bradykinesia refers to very slow voluntary brain.
movements and speech. C. Huntington’s disease
C. Dyskinesia Huntington’s disease is a chronic, progressive,
Dyskinesia refers to impaired ability to hereditary disease of the nervous system that
execute voluntary movements. results in progressive involuntary dance-like
D. Spondylosis movement and dementia.
Spondylosis refers to degenerative arthritis of D. Creutzfeldt-Jakob’s disease
the cervical or lumbar vertebrae. Creutzfeldt-Jakob’s disease is a rare,
2. Which of the phases of a migraine transmissible, progressive fatal disease of the
headache usually lasts less than an hour? central nervous system characterized by
spongiform degeneration of the gray matter of
A. Aura the brain.
The aura phase occurs in about 20% of 5. Which of the following diseases is
patients who have migraines and may be
associated with decreased levels of
characterized by focal neurological
symptoms. dopamine due to destruction of
B. Prodrome pigmented neuronal cells in the
The prodrome phase occurs hours to days substantia nigra in the basal ganglia of
before a migraine headache. the brain?
C. Headache
The headache phase lasts from 4 to 72 hours. A. Parkinson’s disease
D. Recovery In some patients, Parkinson’s disease can be
During the post-headache phase, patients may controlled; however, it cannot be cured.
sleep for extended periods. B. Multiple sclerosis
3. The most common type of brain Multiple sclerosis is a chronic, degenerative,
progressive disease of the CNS characterized
neoplasm is the
by the occurrence of small patches of
A. glioma. demyelination in the brain and spinal cord.
Gliomas are the most common brain C. Huntington’s disease
neoplasms, accounting for about 45% of all Huntington’s disease is a chronic, progressive,
brain tumors. hereditary disease of the nervous system that
B. angioma. results in progressive involuntary dance-like
Angiomas account for approximately 4% of movement and dementia.
brain tumors. D. Creutzfeldt-Jakob’s disease
C. meningioma. Creutzfeldt-Jakob’s disease is a rare,
Meningiomas account for 15-20% of all brain transmissible, progressive fatal disease of the
tumors. central nervous system characterized by
D. neuroma. spongiform degeneration of the gray matter of
Neuromas account for 7% of all brain tumors. the brain.
4. Which of the following diseases is a 6. Which of the following diseases is a
chronic, degenerative, progressive chronic, progressive, hereditary disease
disease of the central nervous system of the nervous system that results in
characterized by the occurrence of small progressive involuntary dance-like
movement and dementia?
A. Huntington’s disease B. Trigeminal (V)
Because it is transmitted as an autosomal Trigeminal neuralgia is a disorder of the
dominant genetic disorder, each child of a trigeminal nerve and causes facial pain.
parent with HD has a 50% risk of inheriting C. Vestibulocochlear (VIII)
the illness. Meniere’s syndrome is a disorder of the
B. Multiple sclerosis vestibulocochlear nerve.
Multiple sclerosis is a chronic, degenerative, D. Vagus (X)
progressive disease of the CNS characterized Guillain-Barre syndrome is a disorder of the
by the occurrence of small patches of vagus nerve.
demyelination in the brain and spinal cord. 9. The most common cause of acute
C. Parkinson’s disease encephalitis in the United States is
Parkinson’s disease is associated with
decreased levels of dopamine due to A. Herpes Simplex Virus (HSV).
destruction of pigmented neuronal cells in the Viral infection is the most common cause of
substantia nigra in the basal ganglia of the encephalitis. HSV is the most common cause
brain. of acute encephalitis in the U.S.
D. Creutzfeldt-Jakob’s disease B. Cryptococcus neoformans.
Creutzfeldt-Jakob’s disease is a rare, C. neoformans is one of several fungi that
transmissible, progressive fatal disease of the may cause fungal encephalitis. Fungal
central nervous system characterized by infections of the central nervous system occur
spongiform degeneration of the gray matter of rarely in healthy people.
the brain. C. Western equine bacteria.
7. Which of the following diseases is a The Western equine encephalitis virus is one
rare, transmissible, progressive fatal of four types of arboviral encephalitis that
occur in North America.
disease of the central nervous system
D. Candida albicans.
characterized by spongiform C. albicans is one of several fungi that may
degeneration of the gray matter of the cause fungal encephalitis. Fungal infections of
brain? the central nervous system occur rarely in
healthy people.
A. Creutzfeldt-Jakob’s disease
10. Which of the following reflects basic
The disease causes severe dementia and
myoclonus. nursing measures in the care of the
B. Multiple sclerosis patient with viral encephalitis?
Multiple sclerosis is a chronic, degenerative,
A. Providing comfort measures
progressive disease of the CNS characterized
by the occurrence of small patches of Providing comfort measures directed at the
headache, include dimmed lights, limited
demyelination in the brain and spinal cord.
C. Parkinson’s disease noise, and analgesics are the basic nursing
measures in the care of the patient with a viral
Parkinson’s disease is associated with
decreased levels of dopamine due to encephalitis.
B. Administering narcotic analgesics
destruction of pigmented neuronal cells in the
substantia nigra in the basal ganglia of the Narcotic analgesics may mask neurologic
symptoms; therefore, they are used cautiously.
brain.
D. Huntington’s disease C. Administering amphotericin B.
With viral encephalitis, acyclovir therapy is
Huntington’s disease is a chronic, progressive,
hereditary disease of the nervous system that commonly prescribed; Amphotericin B is
used in the treatment of fungal encephalitis.
results in progressive involuntary dance-like
movement and dementia. D. Monitoring cardiac output
Nursing management of the patient with viral
8. Bell’s palsy is a disorder of which encephalitis includes monitoring of blood
cranial nerve? chemistry test results and urinary output to
alert the nurse to the presence of renal
A. Facial (VII)
complications related to acyclovir therapy.
Bell’s palsy is characterized by facial
dysfunction, weakness, and paralysis
 11. Nursing management of the patient A. psychosis, disorientation, delirium, insomnia,
with new variant Creutzfeldt-Jakob and hallucinations.
Korsakoff’s syndrome is a personality
Disease (nvCJD) includes
disorder characterized by psychosis,
A. providing supportive care. disorientation, delirium, insomnia, and
The nvCJD is a progressive fatal disease with hallucinations.
no treatment available. Due to the fatal B. severe dementia and myocLonus.
outcome of nvCJD, nursing care is primarily Creutzefeldt-Jacob disease results in severe
supportive. dementia and myoclonus.
B. initiating isolation procedures. C. tremor, rigidity, and bradykinesia.
Prevention of disease transmission is an The three cardinal signs of Parkinson’s
important part of providing nursing care. disease are tremor, rigidity, and bradykinesia.
Although patient isolation is not necessary, D. choreiform movement and dementia.
use of standard precautions is important. Huntington’s disease results in progressive
Institutional protocols are followed for blood involuntary choreiform (dancelike) movement
and body fluid exposure and decontamination and dementia.
of equipment. 14. The primary North American vector
C. preparing for organ donation. transmitting arthropod-borne virus
Organ donation is not an option because of the encephalitis is the
risk for disease transmission.
D. administering amphotericin B. A. mosquito
Amphotericin B is used in the treatment of Arthropod vectors transmit several types of
fungal encephalitis; no treatment is available viruses that cause encephalitis. The primary
for nvCJD. vector in North America is the mosquito.
12.Three medications referred to as the B. tick.
‘ABC drugs’ are currently the main The primary vector in North America is the
mosquito.
pharmacological therapy for multiple
C. horse.
sclerosis. Which of the following The primary vector in North America is the
statements reflects information to be mosquito.
included in patient teaching? D. flea.
The primary vector in North America is the
A. Flu-like symptoms can be controlled with mosquito.
nonsteroidal anti-inflammatory drugs
15. The initial symptoms of new variant
(NSAIDs) and usually resolve after a few
months of therapy. Creutzfeldt-Jakob Disease (nvCJD) are
Seventy-five percent of patients taking one of A. anxiety, depression, and behavioral changes.
the interferons experience flu-like symptoms Anxiety, depression, and behavioral changes
that can be controlled with NSAIDS and are the initial symptoms of nvCJD
usually resolve after a few months of therapy. B. memory and cognitive impairment.
B. Take interferon beta-la (Avonex) with food or Memory and cognitive impairment occur late
milk. in the course of nvCJD
Interferon beta-la is given by intramuscular C. diplopia and bradykinesia.
injection once a week. Anxiety, depression and behavioral changes
C. Take interferon beta-1b (Betaseron) at night are the initial symptoms of nvCJD
before bedtime for best effects. D. akathisia and dysphagia.
Interferon beta-1b is administered Anxiety, depression and behavioral changes
subcutaneously once a week. are the initial symptoms of nvCJD
D. Take glatiramer acetate (Copaxone) on an
16. A patient with fungal encephalitis
empty stomach.
Glatiramer acetate is administed by receiving amphotericin B complaints of
intramuscular injection once a week. fever, chills, and body aches. The nurse
13. Korsakoff’s syndrome is characterized knows that these symptoms
by
A. may be controlled by the administration of Monitoring of blood chemistry test results and
diphenhydramine (Benedryl) and urinary output will alert the nurse to the
acetaminophen (Tylenol) approximately 30 presence of renal complications related to
minutes prior to administration of the acyclovir therapy.
amphotericin. 18. Medical management of arthropod-
Administration of amphotericin B may cause borne virus (arboviral) encephalitis is
fever, chills and body aches. The
aimed at
administration of diphenhydramine
(Benedryl) and acetaminophen (Tylenol) A. controlling seizures and increased
approximately 30 minutes prior to the intracranical pressure.
administration of amphotericin B may prevent There is no specific medication for arboviral
these side effects. encephalitis. Medical management is aimed at
B. indicate renal toxicity and a worsening of the controlling seizures and increased intracranial
patient’s condition. pressure.
Renal toxicity due to amphotericin B is dose B. preventing renal insufficiency.
limiting. Monitoring the serum creatinine and Medical management is aimed at controlling
blood urea nitrogen levels may alert the nurse seizures and increased intracranial pressure.
to thedevelopment of renal insufficiency and C. maintaining hemodynamic stability and
the need to address the patients’ renal status. adequate cardiac output.
C. are primarily associated with infection with Medical management is aimed at controlling
Coccidioides immitis and Aspergillus. seizures and increased intracranial pressure.
Vascular changes are associated with C. D. preventing muscular atrophy.
immitis and Aspergillus Manifestations of Medical management is aimed at controlling
vascular change may include arteritis or seizures and increased intracranial pressure.
cerebral infarction. 19. The patient receiving mitoxantrone
D. indicate the need for immediate blood and
(Novantrone) for treatment of secondary
cerebral spinal fluid (CSF) cultures.
Blood and CSF cultures help diagnosis fungal progressive multiple sclerosis (MS) is
encephalitis. closely monitored for
17. The patient with Herpes Simplex Virus A. leukopenia and cardiac toxicity.
(HSV) encephalitis is receiving acyclovir Mitoxantrone is an antineoplastic agent used
(Zovirax). The nurse monitors blood primarily to treat leukemia and lyphoma but is
chemistry test results and urinary output also used to treat secondary progressive MS.
for Patients need to have laboratory tests ordered
and the results closely monitored due to the
A. renal complications related to acyclovir potential for leukopenia and cardiac toxicity.
therapy. B. mood changes and fluid and electrolyte
Monitoring of blood chemistry test results and alterations.
urinary output will alert the nurse to the Patients receiving corticosteroids are
presence of renal complications related to monitored for side effects related to
acyclovir therapy. corticosteroids such as mood changes and
B. signs and symptoms of cardiac insufficiency. fluid and electrolyte alterations.
Monitoring of blood chemistry test results and C. renal insufficiency.
urinary output will alert the nurse to the Patients receiving mitoxantrone are closely
presence of renal complications related to monitored for leukopenia and cardiac toxicity.
acyclovir therapy. D. hypoxia.
C. signs of relapse. Patients receiving mitoxantrone are closely
Monitoring of blood chemistry test results and monitored for leukopenia and cardiac toxicity.
urinary output will alert the nurse to the 20. What percentage of patients who
presence of renal complications related to survived the polio epidemic of the 1950s
acyclovir therapy. To prevent relapse
are now estimated to have developed
treatment with acyclovir should continue for
up to 3 weeks. post-polio syndrome?
D. signs of improvement in the patient’s
condition.
A. 60-80% No specific medical or surgical treatment is
Patients who survived the polio epidemic of available for this syndrome and therefore
the 1950s, many now elderly, are developing nursing plays a pivotal role in the team
new symptoms of weakness, fatigue and approach to assisting patients and families in
musculoskeletalpain. It is estimated that dealing with the symptoms of progressive loss
between 60% and 80% of the 640,000 polio of muscle strength and significant fatigue.
survivors are experiencing the phenomenon Nursing interventions are aimed at slowing
known as post-polio syndrome. the loss of strength and maintaining the
B. 50% physical, psychological and social well being
It is estimated that between 60 and 80% of of the patient.
patients who survived the polio epidemic of B. Administering antiretroviral agents.
the 1950s are now experiencing post-polio No specific medical or surgical treatment is
syndrome. available for this syndrome.
C. 25-30% C. Planning activities for evening hours rather
It is estimated that between 60 and 80% of then morning hours.
patients who survived the polio epidemic of Patients need to plan and coordinate activities
the 1950s are now experiencing post-polio to conserve energy and reduce fatigue.
syndrome. Important activities should be planned for the
D. 10%                                                                   morning as fatigue often increases in the
It is estimated that between 60 and 80% of afternoon and evening.
patients who survived the polio epidemic of D. Avoiding the use of heat applications in the
the 1950s are now experiencing post-polio treatment of muscle and joint pain.
syndrome. Pain in muscles and joints may be a problem.
21. Which of the following statements Nonpharmacologic techniques such as the
describe the pathophysiology of post- application of heat and cold are most
appropriate because these patients tend to
polio syndrome?
have strong reactions to medications.
A. The exact cause is unknown, but aging or 23. Which of the following terms is used
muscle overuse is suspected. to describe edema of the optic nerve?
The exact cause of post-polio syndrome is not
known but researchers suspect that with aging A. Papilledema
or muscle overuse the neurons not destroyed Papilledema is edema of the optic nerve.
originally by the poliovirus are unable to B. Scotoma
continue generating axon sprouts. Scotoma is a defect in vision in a specific area
B. The exact cause is unknown, but latent in one or both eyes.
poliovirus is suspected. C. Lymphedema
The exact cause of post-polio syndrome is not Lymphedema is the chronic swelling of an
known. extremity due to interrupted lymphatic
C. Post-polio syndrome is caused by an ciruclation, typically from an axillary
autoimmune response. dissection.
The exact cause of post-polio syndrome is not D. Angioneurotic edema
known. Angioneurotic edema is a condition
D. Post-polio syndrome is caused by long-term characterized by urticaria and diffuse swelling
intake of a low-protein, high-fat diet in polio of the deeper layers of the skin.
survivors. 24. Degenerative neurologic disorders
The exact cause of post-polio syndrome is not include which of the following?
known.
22. Which of the following statements A. Huntington’s disease
Huntington’s disease is a chronic, progressive,
reflect nursing interventions of a patient
degenerative neurologic hereditary disease of
with post-polio syndrome? the nervous system that results in progressive
A. Providing care aimed at slowing the loss of involuntary choreiform movement and
strength and maintaining the physical, dementia.
psychological and social well being of the B. Paget’s disease
patient. Paget’s disease is a musculoskeletal disorder,
 characterized by localized rapid bone 28. Which of the following terms refers to
turnover, most commonly affecting the skull, the shaft of the long bone?
femur, tibia, pelvic bones, and vertebrae.
C. Osteomyelitis A. Diaphysis
Osteomyelitis is an infection of the bone. The diaphysis is primarily cortical bone.
D. Glioma B. Epiphysis
Malignant glioma is the most common type of An epiphysis is an end of a long bone.
brain tumor. C. Lordosis
25. Bone density testing in patients with Lordosis refers to an increase in lumbar
post-polio syndrome has demonstrated curvature of spine.
D. Scoliosis
A. low bone mass and osteoporosis. Scoliosis refers to lateral curving of the spine.
Bone density testing in patients with post- 29. Paresthesia is the term used to refer
polio syndrome has demonstrated low bone to
mass and osteoporosis. Thus, the importance
of identifying risks, preventing falls, and A. abnormal sensations.
treating osteoporosis must be discussed with Abnormal sensations, such as burning,
patients and their families. tingling, and numbness, are referred to as
B. osteoarthritis. paresthesias.
Bone density testing in patients with post- B. absence of muscle movement suggesting
polio syndrome has demonstrated low bone nerve damage.
mass and osteoporosis. The absence of muscle tone suggesting nerve
C. calcification of long bones. damage is referred to as paralysis.
Bone density testing in patients with post- C. involuntary twitch of muscle fibers.
polio syndrome has demonstrated low bone Involuntary twitch of muscle fibers is referred
mass and osteoporosis. to as fasciculation.
D. no significant findings. D. absence of muscle tone.
Bone density testing in patients with post- A muscle which holds no tone is termed
polio syndrome has demonstrated low bone flaccid.
mass and osteoporosis. 30. Which of the following terms refers to
26. Which of the following terms refers to a grating or crackling sound or sensation?
mature compact bone structures that form
concentric rings of bone matrix? A. Crepitus
Crepitus may occur with movement of ends of
A. Lamellae a broken bone or irregular joint surface.
Lamellae are mineralized bone matrix. B. Callus
B. Endosteum Callus is fibrous tissue that forms at the
Endosteum refers to the marrow cavity lining fracture site.
of hollow bone. C. Clonus
C. Trabecula Clonus refers to rhythmic contraction of
Trabecula refers to lattice-like bone structure. muscle.
D. Cancellous bone D. Fasciculation
Cancellous bone refers to spongy, lattice-like Fasciculation refers to involuntary twitch of
bone structure. muscle fibers.
27. An osteon is defined as a 31. Which of the following terms refers to
muscle tension being unchanged with
A. microscopic functional bone unit.
muscle shortening and joint motion?
The center of an osteon contains a capillary.
B. bone-forming cell. A. Isotonic contraction
An osteoblast is a bone-forming cell. Exercises such as swimming and bicycling are
C. bone resorption cell. isotonic.
An osteoclast is a bone resorption cell. B. Isometric contraction
D. mature bone cell. Isometric contraction is characterized by
An osteocyte is a mature bone cell. increased muscle tension, unchanged muscle
length, and no joint motion.
C. Contracture B. Peroneal
Contracture refers to abnormal shortening of The peroneal nerve is assessed by asking the
muscle, joint, or both. patient to dorsiflex the ankle and extend the
D. Fasciculation toes.
Fasciculation refers to involuntary twitch of C. Radial
muscle fibers. The radial nerve is assessed by asking the
32. During which stage or phase of bone patient to stretch out the thumb, then the wrist,
healing after fracture does callus and then the fingers at the metacarpal joints.
D. Median
formation occur?
The median nerve is assessed by asking the
A. Reparative patient to touch the thumb to the little finger.
Callus formation occurs during the reparative 35. Which nerve is assessed when the
stage but is disrupted by excessive motion at nurse asks the patient to dorsiflex the
the fracture site ankle and extend the toes?
B. Remodeling
Remodeling is the final stage of fracture A. Peroneal
repair during which the new bone is The motor function of the peroneal nerve is
reorganized into the bone’s former structural assessed by asking the patient to dorsiflex the
arrangement. ankle and extend the toes while the sensory
C. Inflammation function is assessed by pricking the skin
During inflammation, macrophages invade between the great and center toes.
and debride the fracture area. B. Radial
D. Revascularization The radial nerve is assessed by asking the
Revascularization occurs within about 5 days patient to stretch out the thumb, then the wrist,
after the fracture. and then the fingers at the metacarpal joints.
33. During which stage or phase of bone C. Median
healing after fracture is devitalized tissue The median nerve is assessed by asking the
patient to touch the thumb to the little finger.
removed and new bone reorganized into
D. Ulnar
its former structural arrangement? Asking the patient to spread all fingers allows
A. Remodeling the nurse to assess motor function affected by
Remodeling is the final stage of fracture ulnar innervation.
repair. 36. Which of the following statements
B. Inflammation reflect the progress of bone healing?
During inflammation, macrophages invade
and debride the fracture area. A. Serial x-rays are used to monitor the progress
C. Revascularization of bone healing.
Revascularization occurs within about 5 days Serial x-rays are used to monitor the progress
after the fracture. of bone healing.
D. Reparative B. All fracture healing takes place at the same
Callus formation occurs during the reparative rate no matter the type of bone fractured.
stage but is disrupted by excessive motion at The type of bone fractured, the adequacy of
the fracture site. blood supply, the surface contact of the
fragments, and the general health of the
34. Which nerve is assessed when the
person influence the rate of fracture healing.
nurse asks the patient to spread all C. The age of the patient influences the rate of
fingers? fracture healing.
The type of bone fractured, the adequacy of
A. Ulnar
blood supply, the surface contact of the
Asking the patient to spread all fingers allows
fragments, and the general health of the
the nurse to assess motor function affected by
person influence the rate of fracture healing.
ulnar innervation while pricking the fat pad at
D. Adequate immobilization is essential until
the top of the small finger allows assessment
there is ultrasound evidence of bone formation
of the sensory function affected by the ulnar
with ossification.
nerve.
Adequate immobilization is essential until
 there is x-ray evidence of bone formation with is fibrous tissue that covers, supports, and
ossification. separates muscles.
37. Diminished range of motion, loss of 39. Which of the following is an indicator
flexibility, stiffness, and loss of height are of neurovascular compromise?
history and physical findings associated
A. Capillary refill more than 3 seconds
with age-related changes of the Capillary refill more than 3 seconds is an
A. joints. indicator of neurovascular compromise. Other
History and physical findings associated with indicators include cool skin temperature, pale
age-related changes of the joints include or cyanotic color, weakness, paralysis,
diminished range of motion, loss of flexibility, paresthesia, unrelenting pain, pain on passive
stiffness, and loss of height. stretch, and absence of feeling.
B. bones. B. Warm skin temperature
History and physical findings associated with Cool skin temperature is an indicator of
age-related changes of bones include loss of neurovascular compromise.
height, posture changes, kyphosis, flexion of C. Diminished pain
hips and knees, back pain, osteoporosis, and Unrelenting pain is an indicator of
fracture. neurovascular compromise.
C. muscles. D. Pain on active stretch.
History and physical findings associated with Pain on passive stretch is an indicator of
age-related changes of muscles include loss of neurovascular compromise.
strength, diminished agility, decreased 40. Which of the following terms refers to
endurance, prolonged response time moving away from midline?
(diminished reaction time), diminished tone, a
broad base of support, and a history of falls. A. Abduction
D. ligaments. Abduction is moving away from midline.
History and physical findings associated with B. Adduction
age-related changes of ligaments include joint Adduction is moving toward midline.
pain on motion that resolves with rest, C. Inversion
crepitus, joint swelling/enlargement, and Inversion is turning inward.
degenerative joint disease (osteoarthritis). D. Eversion
Eversion is turning outward.
38. Fracture healing occurs in four areas,
including the 41. Surgical fusion of a joint is termed
A. arthrodesis.
A. external soft tissue.
Fracture healing occurs in four areas, Arthrodesis of a joint is created surgically to
treat chronic pain.
including the bone marrow, bone cortex,
periosteum, and the external soft tissue, where B. open reduction with internal fixation (ORIF).
ORIF refers to surgery to repair and stabilize a
a bridging callus (fibrous tissue) stabilizes the
fracture. fracture.
C. heterotrophic ossification.
B. cartilage.
Fracture healing occurs in four areas, Heterotrophic ossification refers to formation
of bone in the periprosthetic space.
including the bone marrow, bone cortex,
periosteum, and the external soft tissue. D. arthroplasty.
Arthroplasty refers to surgical repair of a joint
Cartilage is special tissue at the ends of bone.
C. bursae. or joint replacement.
Fracture healing occurs in four areas, 42. Which of the following devices is
including the bone marrow, bone cortex, designed specifically to support and
periosteum, and the external soft tissue. The immobilize a body part in a desired
bursae is a fluid-filled sac found in connective position?
tissue, usually in the area of joints.
D. fascia. A. Splint
Fracture healing occurs in four areas, A splint may be applied to a fractured
including the bone marrow, bone cortex, extremity initially until swelling subsides.
periosteum, and the external soft tissue. Fascia
B. Brace C. Avoid placing a pillow between the legs when
A brace is an externally applied device to sleeping.
support a body part, control movement, and The patient should be taught to put a pillow
prevent injury. between the legs when sleeping.
C. Continuous passive motion (CPM) device D. Bend forward only when seated in a chair.
A CPM device is an instrument that moves a The patient should be taught to avoid bending
body part to promote healing and circulation. forward when seated in a chair.
D. Trapeze 46. Injury to the ______ nerve as a result
A trapeze is an overhead patient-helping of pressure is a cause of footdrop.
device to promote patient mobility in bed.
43. When caring for the patient in traction, A. Peroneal
the nurse is guided by which of the Injury to the peroneal nerve as a result of
pressure is a cause of footdrop.
following principles?
B. Sciatic
A. Skeletal traction is never interrupted. Injury to the peroneal nerve as a result of
Skeletal traction is applied directly to the bone pressure is a cause of footdrop.
and is never interrupted. C. Femoral
B. Weights should rest on the bed. Injury to the peroneal nerve as a result of
In order to be effective, weights must hang pressure is a cause of footdrop.
freely and not rest on the bed or floor. D. Achilles
C. Knots in the ropes should touch the pulley. Injury to the peroneal nerve as a result of
Knots in the rope or the footplate must not pressure is a cause of footdrop.
touch the pulley or the foot of the bed. 47. The nurse teaching the patient with a
D. Weights are removed routinely. cast about home care includes which of
Traction must be continuous to be effective in the following instructions?
reducing and immobilizing fractures.
44. Meniscectomy refers to the A. Dry a wet fiberglass cast thoroughly using a
hair dryer on a cool setting to avoid skin
A. replacement of one of the articular surfaces of problems.
a joint. Instruct the patient to keep the cast dry and to
The most common site for meniscectomy is dry a wet fiberglass cast thoroughly using a
the knee. hair dryer on a cool setting to avoid skin
B. incision and diversion of the muscle fascia. problems; do not cover it with plastic or
Fasciotomy refers to the incision and rubber.
diversion of the muscle fascia to relieve B. Cover the cast with plastic or rubber.
muscle constriction. A cast should be kept dry; do not cover it with
C. excision of damaged joint fibrocartilage. plastic or rubber because this causes
Hemiarthroplsty refers to the replacement of condensation, which dampens the cast and
one of the articular surfaces of a joint. skin.
D. removal of a body part. C. Keep the cast below heart level.
Amputation refers to the removal of a body A casted extremitiy should be elevated
part. frequently to heart level to prevent swelling.
45. In order to avoid hip dislocation after D. Fix a broken cast by applying tape.
replacement surgery, the nurse teaches A broken cast should be reported to the
the patient which of the following physician; the patient should not attempt to fix
it.
guidelines?
48. A continuous passive motion (CPM)
A. Never cross the affected leg when seated. device applied after knee surgery
Crossing the affected leg may result in
dislocation of the hip joint after total hip A. promotes healing by increasing circulation
replacement. and movement of the knee joint.
B. Keep the knees together at all times. A CPM device applied after knee surgery
The patient should be taught to keep the knees promotes healing by increasing circulation
apart at all times. and movement of the knee joint.
B. provides active range of motion.
A CPM device provides passive range of
motion.
C. promotes healing by immobilizing the knee
joint.
A CPM device applied after knee surgery
promotes healing by increasing circulation
and movement of the knee joint.
D. prevents infection and controls edema and
bleeding.
A CPM device applied after knee surgery
promotes healing by increasing circulation
and movement of the knee joint.
49. Which of the following terms refers to
disease of a nerve root?
A. Radiculopathy
When the patient reports radiating pain down
the leg, he is describing radiculopathy.
B. Involucrum
Involucrum refers to new bone growth around
the sequestrum.
C. Sequestrum
Sequestrum refers to dead bone in an abscess
cavity.
D. Contracture
Contracture refers to abnormal shortening of
muscle or fibrosis of joint structures.
50. Of the following common problems of
the upper extremities, which results from
entrapment of the median nerve at the
wrist?
A. Carpal tunnel syndrome
Carpal tunnel syndrome is commonly due to
repetitive hand activities.
B. Ganglion
A ganglion, a collection of gelatinous material
near the tendon sheaths and joints, appears as
a round, firm, cystic swelling, usually on the
dorsum of the wrist.
C. Dupuytren’s contracture
Dupuytren’s contracture is a slowly
progressive contracture of the palmar fascia.
D. Impingement syndrome
Impingement syndrome is associated with the
shoulder and may progress to a rotator cuff
tear.
 PNLE: Medical Surgical Nursing Exam 2 A. frontal lobe
B. parietal lobe
1. After a cerebrovascular accident, a 75 C. occipital lobe
yr old client is admitted to the health care D. temporal lobe
facility. The client has left-sided weakness 6. The nurse is assessing a
and an absent gag reflex. He’s postcraniotomy client and finds the urine
incontinent and has a tarry stool. His output from a catheter is 1500 ml for the
blood pressure is 90/50 mm Hg, and his 1st hour and the same for the 2nd hour.
hemoglobin is 10 g/dl. Which of the The nurse should suspect:
following is a priority for this client?
A. Cushing’s syndrome
A. checking stools for occult blood B. Diabetes mellitus
B. performing range-of-motion exercises to the C. Adrenal crisis
left side D. Diabetes insipidus
C. keeping skin clean and dry 7. The nurse is providing postprocedure
D. elevating the head of the bed to 30 degrees care for a client who underwent
2. The nurse is caring for a client with a percutaneous lithotripsy. In this
colostomy. The client tells the nurse that procedure, an ultrasonic probe inserted
he makes small pin holes in the drainage through a nephrostomy tube into the renal
bag to help relieve gas. The nurse should pelvis generates ultra-high-frequency
teach him that this action: sound waves to shatter renal calculi. The
A. destroys the odor-proof seal nurse should instruct the client to:
B. wont affect the colostomy system
A. limit oral fluid intake for 1 to 2 weeks
C. is appropriate for relieving the gas in a
B. report the presence of fine, sandlike particles
colostomy system
through the nephrostomy tube.
D. destroys the moisture barrier seal
C. Notify the physician about cloudy or foul
3. When assessing the client with celiac smelling urine
disease, the nurse can expect to find D. Report bright pink urine within 24 hours after
which of the following? the procedure
8. A client with a serum glucose level of
A. steatorrhea
B. jaundiced sclerae 618 mg/dl is admitted to the facility. He’s
C. clay-colored stools awake and oriented, has hot dry skin, and
D. widened pulse pressure has the following vital signs: temperature
4. A client is hospitalized with a diagnosis of 100.6º F (38.1º C), heart rate of 116
of chronic glomerulonephritis. The client beats/minute, and blood pressure of
mentions that she likes salty foods. The 108/70 mm Hg. Based on these
nurse should warn her to avoid foods assessment findings, which nursing
containing sodium because: diagnosis takes the highest priority?

A. reducing sodium promotes urea nitrogen A. deficient fluid volume related to osmotic
excretion diuresis
B. reducing sodium improves her glomerular B. decreased cardiac output related to elevated
filtration rate heart rate
C. reducing sodium increases potassium C. imbalanced nutrition: Less than body
absorption requirements related to insulin deficiency
D. reducing sodium decreases edema D. ineffective thermoregulation related to
5. The nurse is caring for a client with a dehydration
cerebral injury that impaired his speech 9. Capillary glucose monitoring is being
and hearing. Most likely, the client has performed every 4 hours for a client
experienced damage to the: diagnosed with diabetic ketoacidosis.
Insulin is administered using a scale of
 regular insulin according to glucose C. occipital
results. At 2 p.m., the client has a D. parietal
capillary glucose level of 250 mg/dl for 14. A male client should be taught about
which he receives 8 U of regular insulin. testicular examinations:
The A. when sexual activity starts
nurse should expect the dose’s: B. after age 60
C. after age 40
A. onset to be at 2 p.m. and its peak at 3 p.m. D. before age 20
B. onset to be at 2:15 p.m. and its peak at 3 p.m.
15. Before weaning a client from a
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. ventilator, which assessment parameter is
10. A client with a head injury is being most important for the nurse to review?
monitored for increased intracranial A. fluid intake for the last 24 hours
pressure (ICP). His blood pressure is B. baseline arterial blood gas (ABG) levels
90/60 mmHG and the ICP is 18 mmHg; C. prior outcomes of weaning
therefore his cerebral perfusion pressure D. electrocardiogram (ECG) results
(CPP) is: 16. The nurse is speaking to a group of
women about early detection of breast
A. 52 mm Hg cancer. The average age of the women in
B. 88 mm Hg
the group is 47. Following the American
C. 48 mm Hg
D. 68 mm Hg Cancer Society (ACS) guidelines, the
11. A 52 yr-old female tells the nurse that nurse should recommend that the
she has found a painless lump in her right women:
breast during her monthly self- A. perform breast self-examination annually
examination. Which assessment finding B. have a mammogram annually
would strongly suggest that this client’s C. have a hormonal receptor assay annually
lump is cancerous? D. have a physician conduct a clinical evaluation
every 2 years
A. eversion of the right nipple and a mobile mass 17. When caring for a client with
B. nonmobile mass with irregular edges esophageal varices, the nurse knows that
C. mobile mass that is oft and easily delineated
bleeding in this disorder usually stems
D. nonpalpable right axillary lymph nodes
from:
12. A Client is scheduled to have a
descending colostomy. He’s very anxious A. esophageal perforation
and has many questions regarding the B. pulmonary hypertension
surgical procedure, care of stoma, and C. portal hypertension
lifestyle changes. It would be most D. peptic ulcers
appropriate for the nurse to make a 18. A 49-yer-old client was admitted for
referral to which member of the health surgical repair of a Colles’ fracture. An
care team? external fixator was placed during
surgery. The surgeon explains that this
A. Social worker method of repair:
B. registered dietician
C. occupational therapist A. has very low complication rate
D. enterostomal nurse therapist B. maintains reduction and overall hand function
13. Ottorrhea and rhinorrhea are most C. is less bothersome than a cast
commonly seen with which type of skull D. is best for older people
fracture? 19. A client is hospitalized with a
diagnosis of chronic renal failure. An
A. basilar arteriovenous fistula was created in his
B. temporal left arm for hemodialysis. When preparing
 the client for discharge, the nurse should 23. Which assessment finding indicates
reinforce which dietary instruction? dehydration?
A. “Be sure to eat meat at every meal.” A. Tenting of chest skin when pinched.
B. “Monitor your fruit intake and eat plenty of B. Rapid filling of hand veins.
bananas.” C. A pulse that isn’t easily obliterated.
C. “Restrict your salt intake.” D. Neck vein distention
D. “Drink plenty of fluids.” 24. The nurse is teaching a client with a
20. The nurse is caring for a client who history of atherosclerosis. To decrease
has just had a modified radical the risk of atherosclerosis, the nurse
mastectomy with immediate should encourage the client to:
reconstruction. She’s in her 30s and has
A. Avoid focusing on his weight.
tow children. Although she’s worried
B. Increase his activity level.
about her future, she seems to be C. Follow a regular diet.
adjusting well to her diagnosis. What D. Continue leading a high-stress lifestyle.
should the nurse do to support 25. For a client newly diagnosed with
her coping? radiationinduced thrombocytopenia, the
A. Tell the client’s spouse or partner to be nurse should include which intervention in
supportive while she recovers. the plan of care?
B. Encourage the client to proceed with the next
A. Administer aspirin if the temperature exceeds
phase of treatment.
C. Recommend that the client remain cheerful 38.8º C.
B. Inspect the skin for petechiae once every shift.
for the sake of her children.
D. Refer the client to the American Cancer C. Provide for frequent periods of rest.
D. Place the client in strict isolation.
Society’s Reach for Recovery program or
another support program. 26. A client is chronically short of breath
21. A 21 year-old male has been seen in and yet has normal lung ventilation, clear
the clinic for a thickening in his right lungs, and an arterial oxygen saturation
testicle. The physician ordered a human (SaO2) 96% or better. The client most
chorionic gonadotropin (HCG) level. The likely has:
nurse’s explanation to the client should A. poor peripheral perfusion
include the fact that: B. a possible Hematologic problem
C. a psychosomatic disorder
A. The test will evaluate prostatic function. D. left-sided heart failure
B. The test was ordered to identify the site of a
possible infection. 27. For a client in addisonian crisis, it
C. The test was ordered because clients who would be very risky for a nurse to
have testicular cancer has elevated levels of administer:
HCG.
D. The test was ordered to evaluate the A. potassium chloride
testosterone level. B. normal saline solution
C. hydrocortisone
22. A client is receiving captopril
D. fludrocortisone
(Capoten) for heart failure. The nurse
28. The nurse is reviewing the laboratory
should notify the physician that the
report of a client who underwent a bone
medication therapy is ineffective if an
marrow biopsy. The finding that would
assessment reveals:
most strongly support a diagnosis of
A. A skin rash. acute leukemia is the existence of a large
B. Peripheral edema. number of immature:
C. A dry cough.
D. Postural hypotension. A. lymphocytes
B. thrombocytes
C. reticulocytes has had five urinary tract infections over
D. leukocytes the past two years. She’s fatigued from
29. The nurse is performing wound care lack of sleep; urinates frequently, even
on a foot ulcer in a client with type 1 during the night; and has lost weight
diabetes mellitus. Which technique recently. Test reveal the following: sodium
demonstrates surgical asepsis? level 152 mEq/L, osmolarity 340 mOsm/L,
A. Putting on sterile gloves then opening a glucose level 125 mg/dl, and potassium
container of sterile saline. level 3.8 mEq/L. which of the following
B. Cleaning the wound with a circular motion, nursing diagnoses is most appropriate for
moving from outer circles toward the center. this client?
C. Changing the sterile field after sterile water is
spilled on it. A. Deficient fluid volume related to inability to
D. Placing a sterile dressing ½” (1.3 cm) from conserve water
the edge of the sterile field. B. Imbalanced nutrition: less than body
30. A client with a forceful, pounding requirements related to hypermetabolic state
heartbeat is diagnosed with mitral valve C. Deficient fluid volume related to osmotic
diuresis induced by hypernatremia
prolapse. This client should avoid which
D. Imbalanced nutrition: less than body
of the following? requirements related to catabolic effects of
A. high volumes of fluid intake insulin deficiency
B. aerobic exercise programs 34. A 20 yr-old woman has just been
C. caffeine-containing products diagnosed with Crohn’s disease. She has
D. foods rich in protein lost 10 lb (4.5 kg) and has cramps and
31. A client with a history of hypertension occasional diarrhea. The nurse should
is diagnosed with primary include which of the following when doing
hyperaldosteronism. This diagnosis a nutritional assessment?
indicates that the client’s hypertension is
A. Let the client eat as desired during the
caused by excessive hormone secretion
hospitalization.
from which organ? B. Weight the client daily.
A. adrenal cortex C. Ask the client to list what she eats during a
B. pancreas typical day.
C. adrenal medulla D. Place the client on I & O status and draw
D. parathyroid blood for electrolyte levels.
32. A client has a medical history of 35. When instructions should be included
rheumatic fever, type 1 (insulin in the discharge teaching plan for a client
dependent) diabetes mellitus, after thyroidectomy for Grave’s disease?
hypertension, pernicious anemia, and A. Keep an accurate record of intake and output.
appendectomy. She’s admitted to the B. Use nasal desmopressin acetate DDAVP).
hospital and undergoes mitral valve C. Be sure to get regulate follow-up care.
replacement surgery. After discharge, the D. Be sure to exercise to improve cardiovascular
fitness.
client is scheduled for a tooth extraction.
36. A client comes to the emergency
Which history finding is a major risk factor
department with chest pain, dyspnea, and
for infective endocarditis?
an irregular heartbeat. An
A. appendectomy electrocardiogram shows a heart rate of
B. pernicious anemia 110 beats/minute (sinus tachycardia) with
C. diabetes mellitus
frequent premature ventricular
D. valve replacement
contractions. Shortly after admission, the
33. A 62 yr-old client diagnosed with
client has ventricular tachycardia and
pyelonephritis and possible septicemia
 becomes unresponsive. After successful D. photosensitivity
resuscitation, the client is taken to the 41. The nurse is caring for four clients on
intensive care unit. Which nursing a stepdown intensive care unit. The client
diagnosis is appropriate at this time? at the highest risk for developing
nosocomial pneumonia is the one who:
A. Deficient knowledge related to interventions
used to treat acute illness A. has a respiratory infection
B. Impaired physical mobility related to B. is intubated and on a ventilator
complete bed rest C. has pleural chest tubes
C. Social isolation related to restricted visiting D. is receiving feedings through a jejunostomy
hours in the intensive care unit tube
D. Anxiety related to the threat of death 42. The nurse is teaching a client with
37. A client is admitted to the health care chronic bronchitis about breathing
facility with active tuberculosis. The nurse exercises. Which of the following should
should include which intervention in the the nurse include in the teaching?
plan of care?
A. Make inhalation longer than exhalation.
A. Putting on a mask when entering the client’s B. Exhale through an open mouth.
room. C. Use diaphragmatic breathing.
B. Instructing the client to wear a mask at all D. Use chest breathing.
times 43. A client is admitted to the hospital with
C. Wearing a gown and gloves when providing an exacerbation of her chronic systemic
direct care
lupus erythematosus (SLE). She gets
D. Keeping the door to the client’s room open to
observe the client angry when her call bell isn’t answered
38. The nurse is caring for a client who immediately. The most appropriate
underwent a subtotal gastrectomy 24 response to her would be:
hours earlier. The client has a nasogastric A. “You seem angry. Would you like to talk
(NG) tube. The nurse should: about it?”
B. “Calm down. You know that stress will make
A. Apply suction to the NG tube every hour. your symptoms worse.”
B. Clamp the NG tube if the client complains of C. “Would you like to talk about the problem
nausea. with the nursing supervisor?”
C. Irrigate the NG tube gently with normal saline D. “I can see you’re angry. I’ll come back when
solution. you’ve calmed down.”
D. Reposition the NG tube if pulled out.
44. On a routine visit to the physician, a
39. Which statement about fluid
client with chronic arterial occlusive
replacement is accurate for a client with
disease reports stopping smoking after 34
hyperosmolar hyperglycemic nonketotic
years. To relive symptoms of intermittent
syndrome (HHNS)?
claudication, a condition associated with
A. administer 2 to 3 L of IV fluid rapidly chronic arterial occlusive disease, the
B. administer 6 L of IV fluid over the first 24 nurse should recommend which
hours additional measure?
C. administer a dextrose solution containing
normal saline solution A. Taking daily walks.
D. administer IV fluid slowly to prevent B. Engaging in anaerobic exercise.
circulatory overload and collapse C. Reducing daily fat intake to less than 45% of
40. Which of the following is an adverse total calories
reaction to glipizide (Glucotrol)? D. Avoiding foods that increase levels of
highdensity lipoproteins (HDLs)
A. headache 45. A physician orders gastric
B. constipation decompression for a client with small
C. hypotension
 bowel obstruction. The nurse should plan A. beneficence
for the suction to be: B. autonomy
C. advocacy
A. low pressure and intermittent D. justice
B. low pressure and continuous 50. Which of the following is t he most
C. high pressure and continuous critical intervention needed for a client
D. high pressure and intermittent
with myxedema coma?
46. Which nursing diagnosis is most
appropriate for an elderly client with A. Administering and oral dose of levothyroxine
osteoarthritis? (Synthroid)
B. Warming the client with a warming blanket
A. Risk for injury C. Measuring and recording accurate intake and
B. Impaired urinary elimination output
C. Ineffective breathing pattern D. Maintaining a patent airway
D. Imbalanced nutrition: less than body 51. Because diet and exercise have failed
requirements to control a 63 yr-old client’s blood
47. Parathyroid hormone (PTH) has glucose level, the client is prescribed
which effects on the kidney? glipizide (Glucotrol). After oral
A. Stimulation of calcium reabsorption and administration, the onset of action is:
phosphate excretion
A. 15 to 30 minutes
B. Stimulation of phosphate reabsorption and B. 30 to 60 minutes
calcium excretion
C. 1 to 1 ½ hours
C. Increased absorption of vit D and excretion of D. 2 to 3 hours
vit E
D. Increased absorption of vit E and excretion of 52. A client with pneumonia is receiving
Vit D supplemental oxygen, 2 L/min via nasal
48. A visiting nurse is performing home cannula. The client’s history includes
assessment for a 59-yr old man recently chronic obstructive pulmonary disease
discharged after hip replacement surgery. (COPD) and coronary artery disease.
Which home assessment finding warrants Because of these findings, the nurse
health promotion teaching from the closely monitors the oxygen flow and the
nurse? client’s respiratory status. Which
complication may arise if the client
A. A bathroom with grab bars for the tub and receives a high oxygen concentration?
toilet
B. Items stored in the kitchen so that reaching up A. Apnea
and bending down aren’t necessary B. Anginal pain
C. Many small, unsecured area rugs C. Respiratory alkalosis
D. Sufficient stairwell lighting, with switches to D. Metabolic acidosis
the top and bottom of the stairs 53. A client with type 1 diabetes mellitus
49. A client with autoimmune has been on a regimen of multiple daily
thrombocytopenia and a platelet count of injection therapy. He’s being converted to
800/uL develops epistaxis and melena. continuous subcutaneous insulin therapy.
Treatment with corticosteroids and While teaching the client bout continuous
immunoglobulins has been unsuccessful, subcutaneous insulin therapy, the nurse
and the physician recommends a would be accurate in telling him the
splenectomy. The client states, “I don’t regimen includes the use of:
need surgery—this will go away on its
own.” In considering her response to the A. intermediate and long-acting insulins
B. short and long-acting insulins
client, the nurse must depend on the
C. short-acting only
ethical principle of: D. short and intermediate-acting insulins
 54. a client who recently had a 59. When caring for a client with the
cerebrovascular accident requires a cane nursing diagnosis Impaired swallowing
to ambulate. When teaching about cane related to neuromuscular impairment, the
use, the rationale for holding a cane on nurse should:
the uninvolved side is to:
A. position the client in a supine position
A. prevent leaning B. elevate the head of the bed 90 degrees during
B. distribute weight away from the involved side meals
C. maintain stride length C. encourage the client to remove dentures
D. prevent edema D. encourage thin liquids for dietary intake
55. A client with a history of an anterior 60. A nurse is caring for a client who has
wall myocardial infarction is being a tracheostomy and temperature of 39º C.
transferred from the coronary care unit which intervention will most likely lower
(CCU) to the cardiac stepdown unit the client’s arterial blood oxygen
(CSU). While giving report to the CSU saturation?
nurse, the CCU nurse says, “His A. Endotracheal suctioning
pulmonary artery wedge pressures have B. Encouragement of coughing
been in the high normal range.” The CSU C. Use of cooling blanket
nurse should be especially observant for: D. Incentive spirometry
61. A client with a solar burn of the chest,
A. hypertension
back, face, and arms is seen in urgent
B. high urine output
C. dry mucous membranes care. The nurse’s primary concern should
D. pulmonary crackles be:
56. The nurse is caring for a client with a A. fluid resuscitation
fractures hip. The client is combative, B. infection
confused, and trying to get out of bed. C. body image
The nurse should: D. pain management
62. Which statement is true about
A. leave the client and get help
crackles?
B. obtain a physician’s order to restrain the client
C. read the facility’s policy on restraints A. They’re grating sounds.
D. order soft restraints from the storeroom B. They’re high-pitched, musical squeaks.
57. For the first 72 hours after C. They’re low-pitched noises that sound like
thyroidectomy surgery, the nurse would snoring.
assess the client for Chvostek’s sign and D. They may be fine, medium, or course.
Trousseau’s sign because they indicate 63. A woman whose husband was
which of the following? recently diagnosed with active pulmonary
tuberculosis (TB) is a tuberculin skin test
A. hypocalcemia converter. Management of her care would
B. hypercalcemia
include:
C. hypokalemia
D. Hyperkalemia A. scheduling her for annual tuberculin skin
58. In a client with enteritis and frequent testing
diarrhea, the nurse should anticipate an B. placing her in quarantine until sputum cultures
acidbase imbalance of: are negative
C. gathering a list of persons with whom she has
A. respiratory acidosis had recent contact
B. respiratory alkalosis D. advising her to begin prophylactic therapy
C. metabolic acidosis with isoniazid (INH)
D. metabolic alkalosis 64. The nurse is caring for a client who
ahs had an above the knee amputation.
 The client refuses to look at the stump. warm to touch and necrotizing fasciitis is
When the nurse attempts to speak with suspected. Another manifestation that
the client about his surgery, he tells the would most suggest necrotizing fasciitis
nurse that he doesn’t wish to discuss it. is:
The client also refuses to have his family
A. erythema
visit. The nursing diagnosis that best B. leukocytosis
describes the client’s problem is: C. pressure-like pain
D. swelling
A. Hopelessness
B. Powerlessness 69. A 28 yr-old nurse has complaints of
C. Disturbed body image itching and a rash of both hands. Contact
D. Fear dermatitis is initially suspected. The
65. A client with three children who is still diagnosis is confirmed if the rash
I the child bearing years is admitted for appears:
surgical repair of a prolapsed bladder.
A. erythematous with raised papules
The nurse would find that the client B. dry and scaly with flaking skin
understood the surgeon’s preoperative C. inflamed with weeping and crusting lesions
teaching when the client states: D. excoriated with multiple fissures
70. When assessing a client with partial
A. “If I should become pregnant again, the child
would be delivered by cesarean delivery.” thickness burns over 60% of the body,
B. “If I have another child, the procedure may which of the following should the nurse
need to be repeated.” report immediately?
C. “This surgery may render me incapable of
conceiving another child.” A. Complaints of intense thirst
D. “This procedure is accomplished in two B. Moderate to severe pain
separate surgeries.” C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice
66. A client experiences problems in body
71. A client is admitted to the hospital
temperature regulation associated with a
following a burn injury to the left hand and
skin impairment. Which gland is most
arm. The client’s burn is described as
likely involved?
white and leathery with no blisters. Which
A. Eccrine degree of severity is this burn?
B. Sebaceous
C. Apocrine A. first-degree burn
D. Endocrine B. second-degree burn
67. A school cafeteria worker comes to C. third-degree burn
D. fourth-degree burn
the physician’s office complaining of
severe scalp itching. On inspection, the 72. The nurse is caring for client with a
nurse finds nail marks on the scalp and new donor site that was harvested to treat
small light-colored round specks attached a new burn. The nurse position the client
to the hair shafts close to the scalp. to:
These findings suggest that the client A. allow ventilation of the site
suffers from: B. make the site dependent
C. avoid pressure on the site
A. scabies D. keep the site fully covered
B. head lice 73. a 45-yr-old auto mechanic comes to
C. tinea capitis
D. impetigo the physician’s office because an
exacerbation of his psoriasis is making it
68. Following a small-bowel resection, a
difficult to work. He tells the nurse that his
client develops fever and anemia. The
surface surrounding the surgical wound is
 finger joints are stiff and sore in the which intervention should the nurse
morning. The nurse should respond by: include in the plan of care?
A. Inquiring further about this problem because A. Turn and reposition the client a minimum of
psoriatic arthritis can accompany psoriasis every 8 hours.
vulgaris B. Vigorously massage lotion into bony
B. Suggesting he take aspirin for relief because prominences.
it’s probably early rheumatoid arthritis C. Post a turning schedule at the client’s bedside.
C. Validating his complaint but assuming it’s an D. Slide the client, rather than lifting when
adverse effect of his vocation turning.
D. Asking him if he has been diagnosed or 79. Following a full-thickeness (3rd
treated for carpal tunnel syndrome degree) burn of his left arm, a client is
74. The nurse is providing home care treated with artificial skin. The client
instructions to a client who has recently understands postoperative care of the
had a skin graft. Which instruction is most artificial skin when he states that during
important for the client to remember? the first 7 days after the procedure, he’ll
A. Use cosmetic camouflage techniques. restrict:
B. Protect the graft from direct sunlight.
A. range of motion
C. Continue physical therapy.
B. protein intake
D. Apply lubricating lotion to the graft site.
C. going outdoors
75. a 28 yr-old female nurse is seen in the D. fluid ingestion
employee health department for mild 80. A client received burns to his entire
itching and rash of both hands. Which of back and left arm. Using the Rule of
the following could be causing this Nines, the nurse can calculate that he has
reaction? sustained burns on what percentage of
A. possible medication allergies his body?
B. current life stressors she may be experiencing
A. 9%
C. chemicals she may be using and use of latex
B. 18%
gloves
C. 27%
D. recent changes made in laundry detergent or
D. 36%
bath soap.
81. The nurse is providing care for a client
76. The nurse assesses a client with
who has a sacral pressure ulcer with wet-
urticaria. The nurse understands that
to-dry dressing. Which guideline is
urticaria is another name for:
appropriate for a wet-to-dry dressing?
A. hives
B. a toxin A. The wound should remain moist form the
C. a tubercle dressing.
D. a virus B. The wet-to-dry dressing should be tightly
packed into the wound.
77. A client with psoriasis visits the
C. The dressing should be allowed to dry out
dermatology clinic. When inspecting the before removal.
affected areas, the nurse expects to see D. A plastic sheet-type dressing should cover the
which type of secondary lesion? wet dressing.
82. While in skilled nursing facility, a client
A. scale
B. crust contracted scabies, which is diagnosed
C. ulcer the day after discharge. The client is living
D. scar at her  daughter’s home with six other
78. The nurse is caring for a bedridden, persons. During her visit to the clinic, she
elderly adult. To prevent pressure ulcers, asks a staff nurse, “What should my
 family do?” the most accurate response C. Place the client on fluid restrictions
from the nurse is: D. Use a condom catheter instead of an invasive
one.
A. “All family members will need to be treated.” 87.The nurse is caring for a client who is
B. “If someone develops symptoms, tell him to to undergo a lumbar puncture to assess
see a physician right away.”
for the presence of blood in the
C. “Just be careful not to share linens and towels
with family members.” cerebrospinal fluid (CSF) and to measure
D. “After you’re treated, family members won’t CSF pressure. Which result would
be at risk for contracting scabies.” indicate n abnormality?
83. In an industrial accident, client who
A. The presence of glucose in the CSF.
weighs 155 lb (70.3 kg) sustained full- B. A pressure of 70 to 200 mm H2O
thickness burns over 40% of his body. C. The presence of red blood cells (RBCs) in the
He’s in the burn unit receiving fluid first specimen tube
resuscitation. Which observation shows D. A pressure of 00 to 250 mmH2O
that the fluid resuscitation is benefiting the 88. The nurse is administering eyedrops
client? to a client with glaucoma. To achieve
maximum absorption, the nurse should
A. A urine output consistently above 100
instill the eyedrop into the:
ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24 hours. A. conjunctival sac
C. Body temperature readings all within normal B. pupil
limits C. sclera
D. An electrocardiogram (ECG) showing no D. vitreous humor
arrhythmias. 89. A 52 yr-old married man with two
84. The nurse is reviewing the laboratory adolescent children is beginning
results of a client with rheumatoid rehabilitation following a cerebrovascular
arthritis. Which of the following laboratory accident. As the nurse is planning the
results should the nurse expect to find? client’s care, the nurse should recognize
A. Increased platelet count that his condition will affect:
B. Elevated erythrocyte sedimentation rate (ESR)
A. only himself
C. Electrolyte imbalance
B. only his wife and children
D. Altered blood urea nitrogen (BUN) and
C. him and his entire family
creatinine levels
D. no one, if he has complete recovery
85. Which nursing diagnosis takes the
90. Which action should take the highest
highest priority for a client with
priority when caring for a client with
Parkinson’s crisis?
hemiparesis caused by a cerebrovascular
A. Imbalanced nutrition: less than body accident (CVA)?
requirements
B. Ineffective airway clearance A. Perform passive range-of-motion (ROM)
C. Impaired urinary elimination exercises.
D. Risk for injury B. Place the client on the affected side.
C. Use hand rolls or pillows for support.
86. A client with a spinal cord injury and
D. Apply antiembolism stockings
subsequent urine retention receives
91. The nurse is formulating a teaching
intermittent catheterization every 4 hours.
plan for a client who has just experienced
The average catheterized urine volume
a transient ischemic attack (TIA). Which
has been 550 ml. The nurse should plan
fact should the nurse include in the
to:
teaching plan?
A. Increase the frequency of the catheterizations.
A. TIA symptoms may last 24 to 48 hours.
B. Insert an indwelling urinary catheter
B. Most clients have residual effects after having B. Droplet precautions
a TIA. C. Airborne precautions
C. TIA may be a warning that the client may D. Standard precautions
have cerebrovascular accident (CVA) 97. A young man was running along an
D. The most common symptom of TIA is the ocean pier, tripped on an elevated area of
inability to speak.
the decking, and struck his head on the
92. The nurse has just completed
pier railing. According to his friends, “He
teaching about postoperative activity to a
was unconscious briefly and then became
client who is going to have a cataract
alert and behaved as though nothing had
surgery. The nurse knows the teaching
happened.” Shortly afterward, he began
has been effective if the client:
complaining of a headache and asked to
A. coughs and deep breathes postoperatively be taken to the emergency department. If
B. ties his own shoes the client’s intracranial pressure (ICP) is
C. asks his wife to pick up his shirt from the increasing, the nurse would expect to
floor after he drops it. observe which of the
D. States that he doesn’t need to wear an
following signs first?
eyepatch or guard to bed
93. The least serious form of brain A. pupillary asymmetry
trauma, characterized by a brief loss of B. irregular breathing pattern
consciousness and period of confusion, is C. involuntary posturing
called: D. declining level of consciousness
98. Emergency medical technicians
A. contusion transport a 28 yr-old iron worker to the
B. concussion emergency department. They tell the
C. coup
nurse, “He fell from a two-story building.
D. contrecoup
He has a large contusion on his left chest
94. When the nurse performs a
and a hematoma in the left parietal area.
neurologic assessment on Anne Jones,
He has compound fracture of his left
her pupils are dilated and don’t respond
femur and he’s comatose. We intubated
to light.
him and he’s maintaining an arterial
A. glaucoma oxygen saturation of 92% by pulse
B. damage to the third cranial nerve oximeter with a manual-resuscitation
C. damage to the lumbar spine
bag.” Which intervention by the nurse has
D. Bell’s palsy
the highest priority?
95. A 70 yr-old client with a diagnosis of
leftsided cerebrovascular accident is A. Assessing the left leg
admitted to the facility. To prevent the B. Assessing the pupils
development of diffuse osteoporosis, C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness
which of the following objectives is most
99. Alzheimer’s disease is the secondary
appropriate?
diagnosis of a client admitted with
A. Maintaining protein levels. myocardial infarction. Which nursing
B. Maintaining vitamin levels. intervention should appear on this client’s
C. Promoting weight-bearing exercises
plan of care?
D. Promoting range-of-motion (ROM) exercises
96. A client is admitted with a diagnosis of A. Perform activities of daily living for the client
meningitis caused by Neisseria to decease frustration.
meningitides. The nurse should institute B. Provide a stimulating environment.
C. Establish and maintain a routine.
which type of isolation precautions?
D. Try to reason with the client as much as
A. Contact precautions possible.
 100. For a client with a head injury whose 6. ANS: D
neck has been stabilized, the preferred Diabetes insipidus is an abrupt onset of
extreme polyuria that commonly occurs in
bed position is:
clients after brain surgery. Cushing’s
A. Trendelenburg’s syndrome is excessive glucocorticoid
B. 30-degree head elevation secretion resulting in sodium and water
C. flat retention. Diabetes mellitus is a
D. side-lying hyperglycemic state marked by polyuria,
Answers and Rationales polydipsia, and polyphagia. Adrenal crisis is
1. ANS: D undersecretion of glucocorticoids resulting in
Because the client’s gag reflex is absent, profound hypoglycemia, hypovolemia, and
elevating the head of the bed to 30 degrees hypotension.
helps minimize the client’s risk of aspiration. 7. ANS: C
Checking the stools, performing ROM The client should report the presence of
exercises, and keeping the skin clean and dry foulsmelling or cloudy urine. Unless
are important, but preventing aspiration contraindicated, the client should be instructed
through positioning is the priority. to drink large quantities of fluid each day to
2. ANS: A flush the kidneys. Sand-like debris is normal
Any hole, no matter how small, will destroy because of residual stone products. Hematuria
the odor-proof seal of a drainage bag. is common after lithotripsy.
Removing the bag or unclamping it is the only 8. ANS: A
appropriate method for relieving gas. A serum glucose level of 618 mg/dl indicates
3. ANS: A hyperglycemia, which causes polyuria and
because celiac disease destroys the absorbing deficient fluid volume. In this client,
surface of the intestine, fat isn’t absorbed but tachycardia is more likely to result from
is passed in the stool. Steatorrhea is bulky, deficient fluid volume than from decreased
fatty stools that have a foul odor. Jaundiced cardiac output because his blood pressure is
sclerae result from elevated bilirubin levels. normal. Although the client’s serum glucose
Clay-colored stools are seen with biliary is elevated, food isn’t a priority because fluids
disease when bile flow is blocked. Celiac and insulin should be administered to lower
disease doesn’t cause a widened pulse the serum glucose level. Therefore, a
pressure. diagnosis of Imbalanced Nutrition: Less then
4. ANS: D body requirements isn’t appropriate. A
Reducing sodium intake reduces fluid temperature of 100.6º F isn’t life threatening,
retention. Fluid retention increases blood eliminating ineffective thermoregulation as
volume, which changes blood vessel the top priority.
permeability and allows plasma to move into 9. ANS: C
interstitial tissue, causing edema. Urea Regular insulin, which is a short-acting
nitrogen excretion can be increased only by insulin, has an onset of 15 to 30 minutes and a
improved renal function. Sodium intake peak of 2 to 4 hours. Because the nurse gave
doesn’t affect the glomerular filtration rate. the insulin at 2 p.m., the expected onset would
Potassium absorption is improved only by be from 2:15 to 2:30 p.m. and the peak from 4
increasing the glomerular filtration rate; it p.m. to 6 p.m.
isn’t affected by sodium intake. 10.ANS: A
5. ANS: D CPP is derived by subtracting the ICP from
The portion of the cerebrum that controls the mean arterial pressure (MAP). For
speech and hearing is the temporal lobe. adequate cerebral perfusion to take place, the
Injury to the frontal lobe causes personality minimum goal is 70 mmHg. The MAP is
changes, difficulty speaking, and disturbance derived using the following formula:
in memory, reasoning, and concentration. MAP = ((diastolic blood pressure x 2) +
Injury to the parietal lobe causes sensory systolic blood pressure) / 3
alterations and problems with spatial MAP = ((60 x2) + 90) / 3
relationships. Damage to the occipital lobe MAP = 70 mmHg
causes vision disturbances. To find the CPP, subtract the client’s ICP
 from the MAP; in this case , 70 mmHg – 18 causes them to bulge, leading to rupture and
mmHg = 52 mmHg. bleeding into the lower esophagus. Bleeding
11.ANS: B associated with esophageal varices doesn’t
Breast cancer tumors are fixed, hard, and stem from esophageal perforation, pulmonary
poorly delineated with irregular edges. Nipple hypertension, or peptic ulcers.
retraction —not eversion—may be a sign of 18.ANS: B
cancer. A mobile mass that is soft and easily Complex intra-articular fractures are repaired
delineated is most often a fluid-filled with external fixators because they have a
benigned cyst. Axillary lymph nodes may or better long-term outcome than those treated
may not be palpable on initial detection of a with casting. This is especially true in a young
cancerous mass. client. The incidence of complications, such
12.ANS: D as pin tract infections and neuritis, is 20% to
An enterostomal nurse therapist is a registered 60%. Clients must be taught how to do pin
nurse who has received advance education in care and assess for development of
an accredited program to care for clients with neurovascular complications.
stomas. The enterostomal nurse therapist can 19.ANS: C
assist with selection of an appropriate stoma In a client with chronic renal failure,
site, teach about stoma care, and provide unrestricted intake of sodium, protein,
emotional support. potassium, and fluids may lead to a dangerous
13.ANS: A accumulation of electrolytes and protein
Ottorrhea and rhinorrhea are classic signs of metabolic products, such as amino acids and
basilar skull fracture. Injury to the dura ammonia. Therefore, the client must limit his
commonly occurs with this fracture, resulting intake of sodium, meat (high in Protein),
in cerebrospinal fluid (CSF) leaking through bananas (high in potassium), and fluid
the ears and nose. Any fluid suspected of because the kidneys can’t secrete adequate
being CSF should be checked for glucose or urine.
have a halo test done. 20.ANS: D
14.ANS: D The client isn’t withdrawn or showing other
Testicular cancer commonly occurs in men signs of anxiety or depression. Therefore, the
between ages 20 and 30. A male client should nurse can probably safely approach her about
be taught how to perform testicular self- talking with others who have had similar
examination before age 20, preferably when experiences, either through Reach for
he enters his teens. Recovery or another formal support group.
15.ANS: B The nurse may educate the client’s spouse or
Before weaning a client from mechanical partner to listen to concerns, but the nurse
ventilation, it’s most important to have a shouldn’t tell the client’s spouse what to do.
baseline ABG levels. During the weaning The client must consult with her physician
process, ABG levels will be checked to assess and make her own decisions
how the client is tolerating the procedure. about further treatment. The client needs to
Other assessment parameters are less critical. express her sadness, frustration, and fear. She
Measuring fluid volume intake and output is can’t be expected to be cheerful at all times.
always important when a client is being 21.ANS: C
mechanically ventilated. Prior attempts at HCG is one of the tumor markers for
weaning and ECG results are documented on testicular cancer. The HCG level won’t
the client’s record, and the nurse can refer to identify the site of an infection or evaluate
them before the weaning process begins. prostatic function or testosterone level.
16.ANS: B 22.ANS: B
According to the ACS guidelines, “Women Peripheral edema is a sign of fluid volume
older than age 40 should perform breast overload and worsening heart failure. A skin
selfexamination monthly (not annually).” The rash, dry cough, and postural hypotension are
hormonal receptor assay is done on a known adverse reactions to captopril, but the don’t
breast tumor to determine whether the tumor indicate that therapy isn’t effective.
is estrogen- or progesterone-dependent. 23.ANS: A
17.ANS: C Tenting of chest skin when pinched indicates
Increased pressure within the portal veins decreased skin elasticity due to dehydration.
 Hand veins fill slowly with dehydration, not sterile. The containers should be opened
rapidly. A pulse that isn’t easily obliterated before sterile gloves are put on and the
and neck vein distention indicate fluid solution poured over the sterile dressings
overload, not dehydration. placed in a sterile basin. Wounds should be
24.ANS: B cleaned from the most contaminated area to
The client should be encouraged to increase the least contaminated area—for example,
his activity level. Maintaining an ideal weight; from the center outward. The outer inch of a
following a low-cholesterol, low-sodium diet; sterile field shouldn’t be considered sterile.
and avoiding stress are all important factors in 30.ANS: C
decreasing the risk of atherosclerosis. Caffeine is a stimulant, which can exacerbate
25.ANS: B palpitations and should be avoided by a client
Because thrombocytopenia impairs blood with symptomatic mitral valve prolapse. High
clotting, the nurse should assess the client fluid intake helps maintain adequate preload
regularly for signs of bleeding, such as and cardiac output. Aerobic exercise helps in
petechiae, purpura, epistaxis, and bleeding increase cardiac output and decrease heart
gums. The nurse should avoid administering rate. Protein-rich foods aren’t restricted but
aspirin because it can increase the risk of high calorie foods are.
bleeding. Frequent rest periods are indicated 31.ANS: A
for clients with anemia, not Excessive of aldosterone in the adrenal cortex
thrombocytopenia. Strict isolation is indicated is responsible for the client’s hypertension.
only for clients who have highly contagious or This hormone acts on the renal tubule, where
virulent infections that are spread by air or it promotes reabsorption of sodium and
physical contact. excretion of potassium and hydrogen ions.
26.ANS: B The pancreas mainly secretes hormones
SaO2 is the degree to which hemoglobin is involved in fuel metabolism. The adrenal
saturated with oxygen. It doesn’t indicate the medulla secretes the cathecolamines—
client’s overall Hgb adequacy. Thus, an epinephrine and norepinephrine. The
individual with a subnormal Hgb level could parathyroids secrete parathyroid hormone.
have normal SaO2 and still be short of breath. 32.ANS: D
In this case, the nurse could assume that the A heart valve prosthesis, such as a mitral
client has a Hematologic problem. Poor valve replacement, is a major risk factor for
peripheral perfusion would cause subnormal infective endocarditis. Other risk factors
SaO2. There isn’t enough data to assume that include a history of heart disease (especially
the client’s problem is psychosomatic. If the mitral valve prolapse), chronic debilitating
problem were disease, IV drug abuse, and
left-sided heart failure, the client would immunosuppression. Although diabetes
exhibit pulmonary crackles. mellitus may predispose a person to
27.ANS: A cardiovascular disease, it isn’t a major risk
Addisonian crisis results in Hyperkalemia; factor for infective endocarditis, nor is an
therefore, administering potassium chloride is appendectomy or pernicious anemia.
contraindicated. Because the client will be 33.ANS: A
hyponatremic, normal saline solution is The client has signs and symptoms of diabetes
indicated. Hydrocortisone and fludrocortisone insipidus, probably caused by the failure of
are both useful in replacing deficient adrenal her renal tubules to respond to antidiuretic
cortex hormones. hormone as a consequence of pyelonephritis.
28.ANS: D The hypernatremia is secondary to her water
Leukemia is manifested by an abnormal loss. Imbalanced nutrition related to
overpopulation of immature leukocytes in the hypermetabolic state or catabolic effect of
bone marrow. insulin deficiency is an inappropriate nursing
29.ANS: C diagnosis for the client.
A sterile field is considered contaminated 34.ANS: C
when it becomes wet. Moisture can act as a When performing a nutritional assessment,
wick, allowing microorganisms to one of the first things the nurse should do is to
contaminate the field. The outside of assess what the client typically eats. The client
containers, such as sterile saline bottles, aren’t shouldn’t be permitted to eat as desired.
 Weighing the client daily, placing her on I & can cause bleeding. Suction should be applied
O status, and drawing blood to determine continuously, not every hour. The NG tube
electrolyte level aren’t part of a nutritional shouldn’t be clamped postoperatively because
assessment. secretions and gas will accumulate, stressing
35.Ans. C the suture line.
Regular follow-up care for the client with 39.ANS: A
Grave’s disease is critical because most cases Regardless of the client’s medical history,
eventually result in hypothyroidism. Annual rapid fluid resuscitation is critical for
thyroid-stimulating hormone tests and the maintaining cardiovascular integrity.
client’s ability to recognize signs and Profound intravascular depletion requires
symptoms of thyroid dysfunction will help aggressive fluid replacement. A typical fluid
detect thyroid abnormalities early. Intake and resuscitation protocol is 6 L of fluid over the
output is important for clients with fluid and first 12 hours, with more fluid to follow over
electrolyte imbalances but not thyroid the next 24 hours. Various fluids can be used,
disorders. DDAVP is used to treat diabetes depending on the degree of hypovolemia.
insipidus. While exercise to improve Commonly prescribed fluids include dextran
cardiovascular fitness is important, for this (in case of hypovolemic shock), isotonic
client the importance of regular follow-up is normal saline solution and, when the client is
most critical. stabilized, hypotonic half-normal saline
36.ANS: D solution.
Anxiety related to the threat of death is an 40.ANS: D
appropriate nursing diagnosis because the Glipizide may cause adverse skin reactions,
client’s anxiety can adversely affect hear rate such as pruritus, and photosensitivity. It
and rhythm by stimulating the autonomic doesn’t cause headache, constipation, or
nervous system. Also, because the client hypotension.
required resuscitation, the threat of death is a 41.ANS: B
real and immediate concern. Unless anxiety is When clients are on mechanical ventilation,
dealt with first, the client’s emotional state the artificial airway impairs the gag and cough
will impede learning. Client teaching should reflexes that help keep organisms out of the
be limited to clear concise explanations that lower respiratory tract. The artificial airway
reduce anxiety and promote cooperation. An also prevents the upper respiratory system
anxious client has difficulty learning, so the from humidifying and heating air to enhance
deficient knowledge would continue despite mucociliary clearance. Manipulations of the
attempts teaching. Impaired physical mobility artificial airway sometimes allow secretions
and social isolation are necessitated by the into the lower airways. Whit standard
client’s critical condition; therefore, they procedures the other choices wouldn’t be at
aren’t considered problems warranting high risk.
nursing diagnoses. 42.ANS: C
37.ANS: A In chronic bronchitis, the diaphragmatic is flat
Because tuberculosis is transmitted by droplet and weak. Diaphragmatic breathing helps to
nuclei from the respiratory tract, the nurse strengthen the diaphragm and maximizes
should put on a mask when entering the ventilation. Exhalation should longer than
client’s room. Having the client wear a mask inhalation to prevent collapse of the
at all the times would hinder sputum bronchioles. The client with chronic
expectoration and make the mask moist from bronchitis should exhale through pursed lips
respirations. If no contact with the client’s to prolong exhalation, keep the bronchioles
blood or body fluids is anticipated, the nurse from collapsing, and prevent air trapping.
need not wear a gown or gloves when Diaphragmatic breathing—not chest breathing
providing direct care. A client with —increases lung expansion.
tuberculosis should be in a room with laminar 43.ANS: A
air flow, and the door should be closed at all Verbalizing the observed behavior is a
times. therapeutic communication technique in
38.ANS: C which the nurse acknowledges what the client
The nurse can gently irrigate the tube but must is feeling. Offering to listen to the client
take care not to reposition it. Repositioning express her anger can help the nurse and the
 client understand its cause and begin to deal 50.ANS: D
with it. Although stress can exacerbate the Because respirations are depressed in
symptoms of SLE, telling the client to calm myxedema coma, maintaining a patent airway
down doesn’t acknowledge her feelings. is the most critical nursing intervention.
Offering to get the nursing supervisor also Ventilatory support is usually needed. Thyroid
doesn’t acknowledge the client’s feelings. replacement will be administered IV.
Ignoring the client’s feelings suggest that the Although myxedema coma is associated with
nurse has no interest in what the client has severe hypothermia, a warming blanket
said. shouldn’t be used because it may cause
44.ANS: A vasodilation and shock. Gradual warming
Daily walks relieve symptoms of intermittent blankets would be appropriate. Intake and
claudication, although the exact mechanism is output are very important but aren’t critical
unclear. Anaerobic exercise may exacerbate interventions at this time.
these symptoms. Clients with chronic arterial 51.ANS: A
occlusive disease must reduce daily fat intake Glipizide begins to act in 15 to 30 minutes.
to 30% or less of total calories. The client The other options are incorrect.
should limit dietary cholesterol because 52.ANS: A
hyperlipidemia is associated with Hypoxia is the main breathing stimulus for a
atherosclerosis, a known cause of arterial client with COPD. Excessive oxygen
occlusive disease. However, HDLs have the administration may lead to apnea by removing
lowest cholesterol concentration, that stimulus. Anginal pain results from a
so this client should eat foods that raise HDL reduced myocardial oxygen supply. A client
levels. with COPD may have anginal pain from
45.ANS: A generalized vasoconstriction secondary to
Gastric decompression is typically low hypoxia; however, administering oxygen at
pressure and intermittent. High pressure and any concentration dilates blood vessels, easing
continuous gastric suctioning predisposes the anginal pain. Respiratory alkalosis results
gastric mucosa to injury and ulceration. from alveolar hyperventilation, not excessive
46.ANS: A oxygen administration. In a client with COPD,
In osteoarthritis, stiffness is common in large, high oxygen concentrations decrease the
weight bearing joints such as the hips. This ventilatory drive, leading to respiratory
joint stiffness alters functional ability and acidosis, not alkalosis. High oxygen
range of motion, placing the client at risk for concentrations don’t cause metabolic acidosis.
falling and injury. Therefore, client safety is 53.ANS: C
in jeopardy. Osteoporosis doesn’t affect Continuous subcutaneous insulin regimen
urinary elimination, breathing, or nutrition. uses a basal rate and boluses of short-acting
47.ANS: A insulin. Multiple daily injection therapy uses a
PTH stimulates the kidneys to reabsorb combination of short-acting and intermediate
calcium and excrete phosphate and converts or long-acting insulins.
vit D to its active form: 1 , 25 dihydroxy 54.ANS: B
vitamin D. PTH doesn’t have a role in the Holding a cane on the uninvolved side
metabolism of Vit E. distributes weight away from the involved
48.ANS: C side. Holding the cane close to the body
The presence of unsecured area rugs poses a prevents leaning. Use of a cane won’t
hazard in all homes, particularly in one with a maintain stride length or prevent edema.
resident at high risk for falls. 55.ANS: D
49.ANS: B High pulmonary artery wedge pressures are
Autonomy ascribes the right of the individual diagnostic for left-sided heart failure. With
to make his own decisions. In this case, the leftsided heart failure, pulmonary edema can
client is capable of making his own decision develop causing pulmonary crackles. In
and the nurse should support his autonomy. leftsided heart failure, hypotension may result
Beneficence and justice aren’t the principles and urine output will decline. Dry mucous
that directly relate to the situation. Advocacy membranes aren’t directly associated with
is the nurse’s role in supporting the principle elevated pulmonary artery wedge pressures.
of autonomy.
56.ANS: B the burn extends to the dermal and
It’s mandatory in most settings to have a subcutaneous skin layers. Body image
physician’s order before restraining a client. A disturbance is a concern that has a lower
client should never be left alone while the priority than pain management.
nurse summons assistance. All staff members 62.ANS: D
require annual instruction on the use of Crackles result from air moving through
restraints, and the nurse should be familiar airways that contain fluid. Heard during
with the facility’s policy. inspiration and expiration, crackles are
57.ANS: A discrete sounds that vary in pitch and
The client who has undergone a intensity. They’re classified as fine, medium,
thyroidectomy is t risk for developing or coarse. Pleural friction rubs have a
hypocalcemia from inadvertent removal or distinctive grating sound. As the name
damage to the parathyroid gland. The client indicates, these breath sounds result when
with hypocalcemia will exhibit a positive inflamed pleurae rub together. Continuous,
Chvostek’s sign (facial muscle contraction highpitched, musical squeaks, called wheezes,
when the facial nerve in front of the ear is result when air moves rapidly through airways
tapped) and a positive Trousseau’s sign narrowed by asthma or infection or when an
(carpal spasm when a blood pressure cuff is airway is partially obstructed by a tumor or
inflated for few minutes). These signs aren’t foreign body. Wheezes, like gurgles, occur on
present with hypercalcemia, hypokalemia, or expiration and sometimes on inspiration.
Hyperkalemia. Loud, coarse, low-pitched sounds resembling
58.ANS: C snoring are called gurgles. These sounds
Diarrhea causes a bicarbonate deficit. With develop when thick secretions partially
loss of the relative alkalinity of the lower GI obstruct airflow through the large upper
tract, the relative acidity of the upper GI tract airways.
predominates leading to metabolic acidosis. 63.Ans. D
Diarrhea doesn’t lead to respiratory acid-base Individuals who are tuberculin skin test
imbalances, such as respiratory acidosis and converters should begin a 6-month regimen of
respiratory alkalosis. Loss of acid, which an antitubercular drug such as INH, and they
occurs with severe vomiting, may lead to should never have another skin test. After an
metabolic alkalosis. individual has a positive tuberculin skin test,
59.ANS: B subsequent skin tests will cause severe skin
The head of the bed must be elevated while reactions but won’t provide new information
the client is eating. The client should be about the client’s TB status. The client doesn’t
placed in a recumbent position—not a supine have active TB, so can’t transmit, or spread,
position— when lying down to reduce the risk the bacteria. Therefore, she shouldn’t be
of aspiration. Encourage the client to wear quarantined or asked for information about
properly fitted dentures to enhance his recent contacts.
chewing ability. Thickened liquids, not thin 64.ANS: C
liquids, decrease aspiration risk. Disturbed body image is a negative perception
60.ANS: A of the self that makes healthful functioning
Endotracheal suctioning secretions as well as more difficult. The defining characteristics for
gases from the airway and lowers the arterial this nursing diagnosis include undergoing a
oxygen saturation (SaO2) level. Coughing and change in body structure or function, hiding or
incentive spirometry improve oxygenation overexposing a body part, not looking at a
and should raise or maintain oxygen body part, and responding verbally or
saturation. Because of superficial nonverbally to the actual or perceived change
vasoconstriction, using a cooling blanket can in structure or function. This client may have
lower peripheral oxygen saturation readings, any of the other diagnoses, but the signs and
but SaO2 levels wouldn’t be affected. symptoms described in he case most closely
61.ANS: D match the defining characteristics for
With a superficial partial thickness burn such disturbed body image.
as a solar burn (sunburn), the nurse’s main 65.ANS: B
concern is pain management. Fluid Because the pregnant uterus exerts a lot of
resuscitation and infection become concerns if pressure on the urinary bladder, the bladder
 repair may need to be repeated. These clients with a burn injury. The client’s output is
don’t necessarily have to have a cesarean adequate.
delivery if they become pregnant, and this 71.ANS: C
procedure doesn’t render them sterile. This Third-degree burn may appear white, red, or
procedure is completed in one surgery. black and are dry and leathery with no
66.ANS: A blisters. There may be little pain because
Eccrine glands are associated with body nerve endings have been destroyed. First-
temperature regulation. Sebaceous glands degree burns are superficial and involve the
lubricate the skin and hairs, and apocrine epidermis only. There is local pain and
glands are involved in bacteria decomposition. redness but no blistering. Second-degree burn
Endocrine glands secrete hormones appear red and moist with blister formation
responsible for the regulation of body and are painful. Fourth-degree burns involve
processes, such as metabolism and glucose underlying muscle and bone tissue.
regulation. 72.ANS: C
67.ANS: B A universal concern I the care of donor sites
The light-colored spots attached to the hair for burn care is to keep the site away from
shafts are nits, which are the eggs of head lice. sources of pressure. Ventilation of the site and
They can’t be brushed off the hair shaft like keeping the site fully covered are practices in
dandruff. Scabies is a contagious dermatitis some institutions but aren’t hallmarks of
caused by the itch mite, Sacoptes scabiei, donor site care. Placing the site in a position
which lives just beneath the skin. Tinea of dependence isn’t a justified aspect of donor
capitis, or ringworm, causes patchy hair loss site care.
and circular lesions with healing centers. 73.ANS: A
Impetigo is an infection caused by Anyone with psoriasis vulgaris who reports
Staphylococcus or Sterptococcus, manifested joint pain should be evaluated for psoriaic
by vesicles or pustules that form a thick, arthritis. Approximately 15% to 20% of
honey-colored crust. individuals with psoriasis will also develop
68.ANS: C psoriatic arthritis, which can be painful and
Severe pressure-like pain out of proportion to cause deformity. It would be incorrect to
visible signs distinguishes necrotizing fasciitis assume that his pain is caused by early
from cellulites. Erythema, leukocytosis, and rheumatoid arthritis or his vocation without
swelling are present in both cellulites and asking more questions or performing
necrotizing fasciitis. diagnostic studies. Carpal tunnel syndrome
69.ANS: A causes sensory and motor changes in the
Contact dermatitis is caused by exposure to a fingers rather than localized pain in the joints.
physical or chemical allergen, such as 74.ANS: B
cleaning products, skin care products, and To avoid burning and sloughing, the client
latex gloves. Initial symptoms of itching, must protect the graft from sunlight. The other
erythema, and raised papules occur at the site three interventions are all helpful to the client
of the exposure and can begin within 1 hour and his recovery but are less important.
of exposure. Allergic reactions tend to be red 75.ANS: C
and not scaly or flaky. Weeping, crusting Because the itching and rash are localized, an
lesions are also uncommon unless the reaction environmental cause in the workplace should
is quite severe or has been present for a long be suspected. With the advent of universal
time. Excoriation is more common in skin precautions, many nurses are experiencing
disorders associated with a moist allergies to latex gloves. Allergies to
environment. medications, laundry detergents, or bath soaps
70.ANS: D or a dermatologic reaction to stress usually
Hoarseness indicate injury to the respiratory elicit a more generalized or widespread rash.
system and could indicate the need for 76.ANS: A
immediate intubation. Thirst following burns Hives and urticaria are two names for the
is expected because of the massive fluid shifts same skin lesion. Toxin is a poison. A
and resultant loss leading to dehydration. tubercle is a tiny round nodule produced by
Pain, either severe or moderate, is expected the tuberculosis bacillus. A virus is an
infectious parasite.
77.ANS: A ml/kg/hour. Thus, the expected urine output of
A scale is the characteristic secondary lesion a 155-lb client is 35 ml/hour, and a urine
occurring in psoriasis. Although crusts, ulcers, output consistently above 100 ml/hour is more
and scars also are secondary lesions in skin than adequate. Weight gain from fluid
disorders, they don’t accompany psoriasis. resuscitation isn’t a goal. In fact, a 4 lb weight
78.ANS: C gain in 24 hours suggests third spacing. Body
A turning schedule with a signing sheet will temperature readings and ECG interpretations
help ensure that the client gets turned and may demonstrate secondary benefits of fluid
thus, help prevent pressure ulcers. Turning resuscitation but aren’t primary indicators.
should occur every 1-2 hours—not every 8 84. ANS: B
hours—for clients who are in bed for The ESR test is performed to detect
prolonged periods. The nurse should apply inflammatory processes in the body. It’s a
lotion to keep the skin moist but should avoid nonspecific test, so the health care
vigorous massage, which could damage professional must view results in conjunction
capillaries. When moving the client, the nurse with physical signs and symptoms. Platelet
should lift rather than slide the client to void count, electrolytes, BUN, and creatinine levels
shearing. aren’t usually affected by the inflammatory
79.ANS: A process.
To prevent disruption of the artificial skin’s 85.ANS: B
adherence to the wound bed, the client should In Parkinson’s crisis, dopamine-related
restrict range of motion of the involved limb. symptoms are severely exacerbated, virtually
Protein intake and fluid intake are important immobilizing the client. A client who is
for healing and regeneration and shouldn’t be confined to bed during a crisis is at risk for
restricted. Going outdoors is acceptable as aspiration and pneumonia. Also, excessive
long as the left arm is protected from direct drooling increases the risk of airway
sunlight. obstruction. Because of these concerns,
80.ANS: C ineffective airway clearance is the priority
According to the Rule of Nines, the posterior diagnosis for this client. Although imbalanced
and anterior trunk, and legs each make up nutrition:less than body requirements,
18% of the total body surface. The head, neck, impaired urinary elimination and risk for
and arms each make up 9% of total body injury also are appropriate diagnoses for this
durface, and the perineum makes up 1%. In client, they aren’t immediately lifethreatening
this case, the client received burns to his back and thus are less urgent.
(18%) and one arm (9%), totaling 27%. 86.ANS: A
81.ANS: A As a rule of practice, if intermittent
A wet-to-dry saline dressing should always catheterization for urine retention typically
keep the wound moist. Tight packing or dry yields 500 ml or more, the frequency of
packing can cause tissue damage and pain. A catheterization should be increased.
dry gauze —not a plastic-sheet-type dressing Indwelling catheterization is less preferred
—should cover the wet dressing. because of the risk of urinary tract infection
82.ANS: A and the loss of bladder tone. Fluid restrictions
When someone in a group of persons sharing aren’t indicated for this case; the problem
a home contracts scabies, each individual in isn’t overhydration, rather it’s urine retention.
the same home needs prompt treatment A condom catheter doesn’t help empty the
whether he’s symptomatic or not. Towels and bladder of a client with urine retention.
linens should be washed in hot water. Scabies 87.ANS: D
can be transmitted from one person to another The normal pressure is 70 to 200 mm H2O are
before symptoms develop considered abnormal. The presence of glucose
83.ANS: A is an expected finding in CSF, and RBCs
In a client with burns, the goal of fluid typically occur in the first specimen tube from
resuscitation is to maintain a mean arterial the trauma caused by the procedure.
blood pressure that provides adequate 88.ANS: A
perfusion of vital structures. If the kidneys are The nurse should instill the eyedrop into the
adequately perfused, they will produce an conjunctival sac where absorption can best
acceptable urine output of at least 0.5 take place. The pupil permits light to enter the
 eye. The sclera maintains the eye’s shape and levels is important, but neither will prevent
size. The vitreous humor maintains the osteoporosis. ROM exercises will help
retina’s placement and the shape of the eye. prevent muscle atrophy and contractures.
89.ANS: C 96.ANS: B
According to family theory, any change in a This client requires droplet precautions
family member, such as illness, produces role because the organism can be transmitted
changes in all family members and affects the through airborne droplets when the client
entire family, even if the client eventually coughs, sneezes, or doesn’t cover his mouth.
recovers completely. Airborne precautions would be instituted for a
90.ANS: B client infected with tuberculosis. Standard
To help prevent airway obstruction and reduce precautions would be instituted for a client
the risk of aspiration, the nurse should when contact with body substances is likely.
position a client with hemiparesis on the Contact precautions would be instituted for a
affected side. Although performing ROM client infected with an organism that is
exercises, providing pillows for support, and transmitted through skin-to-skin
applying antiembolism stockings can be contact.
appropriate for a client with CVA, the first 97.ANS: D
concern is to maintain a patent airway. With a brain injury such as an epidural
91.ANS: C hematoma (a diagnosis that is most likely
TIA may be a warning that the client will based on this client’s symptoms), the initial
experience a CVA, or stroke, in the near sign of increasing ICP is a change in the level
future. TIA aymptoms last no longer than 24 of consciousness. As neurologic deterioration
hours and clients usually have complete progresses, manifestations involving pupillary
recovery after TIA. The most common symmetry, breathing patterns, and posturing
symptom of TIA is sudden, painless loss of will
vision lasting up to 24 hours. occur.
92.ANS: C 98.ANS: A
Bending to pick up something from the floor In the scenario, airway and breathing are
would increase intraocular pressure, as would established so the nurse’s next priority should
bending to tie his shoes. The client needs to be circulation. With a compound fracture of
wear eye protection to bed to prevent the femur, there is a high risk of profuse
accidental injury during sleep. bleeding; therefore, the nurse should assess
93. ANS: B the site. Neurologic assessment is a secondary
Concussions are considered minor with no concern to airway, breathing and circulation.
structural signs of injury. A contusion is The nurse doesn’t have enough data to
bruising of the brain tissue with small warrant putting the client in Trendelenburg’s
hemorrhages in the tissue. Coup and position.
contrecoup are type of injuries in which the 99.ANS: C
damaged area on the brain forms directly Establishing and maintaining a routine is
below that site of impact (coup) or at the essential to decreasing extraneous stimuli. The
site opposite the injury (contrecoup) due to client should participate in daily care as much
movement of the brain within the skull. as possible. Attempting to reason with such
94.ANS: B clients isn’t successful, because they can’t
The third cranial nerve (oculomotor) is participate in abstract thinking.
responsible for pupil constriction. When there 100. ANS: B
is damage to the nerve, the pupils remain For clients with increased intracranial
dilated and don’t respond to light. Glaucoma, pressure (ICP), the head of the bed is elevated
lumbar spine injury, and Bell’s palsy won’t to promote venous outflow. Trendelenburg’s
affect pupil constriction. position is contraindicated because it can raise
95.ANS: C ICP. Flat or neutral positioning is indicated
When the mechanical stressors of weight when elevating the head of the bed would
bearing are absent, diffuse osteoporosis can increase the risk of neck injury or airway
occur. Therefore, if the client does weight- obstruction. Sidelying isn’t specifically a
bearing exercises, disuse complications can be therapeutic treatment for increased ICP.
prevented. Maintaining protein and vitamins
 Medical Surgical Nursing Exam 16 C. chronic rejection.
Chronic rejection occurs after many years.
1. The nurse who provides teaching to the D. simple rejection.
female patient regarding prevention of The term simple is not used in the
recurrent urinary tract infections includes categorization of types of rejection of kidney
which of the following statements? transplants.
4. When caring for a patient with an
A. Void immediately after sexual intercourse.
uncomplicated, mild urinary tract infection
Voiding will serve to flush the urethra,
expelling contaminants. (UTI), the nurse knows that recent studies
B. Take tub baths instead of showers. have shown which of the following drugs
Showers are encouraged rather than tub baths to be a good choice for short-course (e.g.
because bacteria in the bath water may enter 3-day) therapy?
the urethra.
C. Increase intake of coffee, tea, and colas. A. Levofloxacin (Levaquin)
Coffee, tea, colas, alcohol, and other fluids Levofloxacin, a floroquinolone, is a good
that are urinary tract irritants should be choice for short-course therapy of
avoided. uncomplicated, mild to moderate UTI.
D. Void every 5 hours during the day. Clinical trial data show high patient
The patient should be encouraged to void compliance with the 3-day regimen (95.6%)
every 2-3 hours during the day and and a high eradication rate for all pathogens
completely empty the bladder. (96.4%).
2. A history of infection specifically B. Trimethoprim sulfamethoxazole (TMP-SMZ,
Bactrim, Septra)
caused by group A beta-hemolytic
Trimethoprim sulfamethoxazole is a
streptococci is associated with which of commonly used medication for treatment of a
the following disorders? complicated UTI, such as pyelonephritis.
C. Nitrofurantoin (Macrodantin, Furadantin)
A. Acute glomerulonephritis
Nitrofurantoin is a commonly used
Acute glomerulonephritis is also associated
medication for treatment of a complicated
with varicella zoster virus, hepatitis B, and
UTI, such as pyelonephritis.
Epstein-Barr virus.
D. Ciprofloxacin (Cipro)
B. Acute renal failure
Ciprofloxacin is a good choice for treatment
Acute renal failure is associated with
of a complicated UTI. Recent studies have
hypoperfusion to the kidney, parenchymal
found ciprofloxacin to be significantly more
damage to the glomeruli or tubules, and
effective than TMP-SMX in community-
obstruction at a point distal to the kidney.
based patients and in nursing home residents.
C. Chronic renal failure
Chronic renal failure may be caused by 5. Which of the following terms refers to
systemic disease, hereditary lesions, difficult or painful sexual intercourse?
medications, toxic agents, infections, and
A. Dyspareunia
medications.
Dyspareunia is a common problem of the
D. Nephrotic syndrome
aged female.
Nephrotic syndrome is caused by disorders
B. Amenorrhea
such as chronic glomerulonephritis, systemic
Amenorrhea refers to absence of menstrual
lupus erythematosus, multiple myeloma, and
flow.
renal vein thrombosis.
C. Dysmenorrhea
3. Rejection of a transplanted kidney Dysmenorrhea refers to painful menstruation.
within 24 hours after transplant is termed D. Endometriosis
Endometriosis is a condition in which
A. hyperacute rejection.
endometrial tissue seeds in other areas of the
Hyperacute rejection may require removal of
pelvis.
the transplanted kidney.
B. acute rejection. 6. The opening into the vagina on the
Acute rejection occurs within 3-14 days of perineum is termed the
transplantation.
A. introitus. B. Mammography
The introitus is the vaginal orifice. Mammography is recommended for health
B. adnexa. screening for women aged 40 years and older.
Adnexa is a term used to describe the C. Cholesterol and lipid profile
fallopian tubes and ovaries together. Cholesterol and lipid profile is recommended
C. cervix. for women aged 40 years and older.
The cervix is the bottom (interior) part of the D. Bone mineral density testing
uterus that is located in the vagina. Bone mineral density testing is recommended
hymen. for women aged 40 years and older.
D. The hymen is a tissue that may cover the 10. Which of the following statements
vaginal opening partially or completely before reflects nursing care of the woman with
vaginal penetration.
mild to moderate ovarian hyperstimulation
7. Which of the following hormones is
syndrome (OHSS)?
primarily responsible for stimulating the
production of progesterone? A. Advise the patient to decrease her activity,
monitor her urine output and to return for
A. Luteinizing hormone frequent office visits.
Luteinizing hormone is released by the Management in mild and moderate cases of
pituitary gland. OHSS consists of decreased activity,
B. Follicle-stimulating hormone monitoring of urine output and frequent office
Follicle-stimulating hormone is responsible visits as designated by the reproductive
for stimulating the ovaries to secrete estrogen. endocrinologist.
C. Estrogen B. Advise the patient to measure her weight and
Estrogens are responsible for developing and abdominal circumference daily.
maintaining the female reproductive tract. Treatment of severe, not mild to moderate,
D. Androgen OHSS includes daily measurements of weight
Androgens, secreted in small amounts by the and abdominal circumference.
ovaries, are involved in early development of C. Advise the patient to monitor her heart rate
the follicle and also affect the female libido. and to report if her pulse falls below 60 beats
8. When the results of a Pap smear are per minute.
reported as class 5, the nurse recognizes Symptoms of OHSS include abdominal
that the common interpretation is discomfort, distention, weight gain and
ovarian enlargement.
A. malignant. D. Prepare the patient for immediate
A class 5 Pap smear, according to the hospitalization.                                                
Bethesda Classification, indicates squamous The patient with severe OHSS is hospitalized
cell carcinoma. for monitoring and treatment.
B. normal. 11. Which of the following terms is used
A class 1 Pap smear is interpreted as normal. to describe a procedure in which cervical
C. probably normal.
tissue is removed as result of detection of
A class 2 Pap smear is interpreted as probably
normal. abnormal cells?
D. suspicious. A. Conization
A class 3 Pap smear is interpreted as The procedure is also called a cone biopsy.
suspicious. B. Colporrhaphy
9. For women aged 19-39 years, Colporrhaphy refers to repair of the vagina.
recommended health screening C. Cryotherapy
diagnostic testing includes which of the Cryotherapy refers to destruction of tissue by
following? freezing.
D. Perineorrhaphy
A. Pap smear Perineorrhaphy refers to sutural repair of
A Pap smear is recommended for women perineal lacerations.
aged 19-39 years, as well as for women aged
40 and older.
 12. Of the following terms, which is used C. Transmission occurs only when the carrier has
to refer to a type of gestational symptoms.
Transmission is possible even when the
trophoblastic neoplasm?
carrier does not have symptoms.
A. Hydatidiform mole D. The virus is very difficult to kill.
Hydatidiform mole occurs in 1 in 1000 Usually, the virus is killed at room
pregnancies. temperature by drying.
B. Dermoid cyst 15. An opening between the bladder and
A dermoid cyst is an ovarian tumor of the vagina is called a
undefined origin that consists of
undifferentiated embryonal cells. A. vesicovaginal fistula.
C. Doderlein’s bacilli A vesicovaginal fistula may occur because of
Doderlein’s bacilli is one component of tissue injury sustained during surgery, vaginal
normal vaginal flora. delivery, or a disease process.
D. Bartholin’s cyst B. cystocele.
Bartholin’s cyst is a cyst in a paired vestibular A cystocele is a downward displacement of
gland in the vulva. the bladder toward the vaginal orifice.
13. When the female client reports a C. rectocele.
A rectocele is a bulging of the rectum into the
frothy yellow-brown vaginal discharge, the
vagina.
nurse suspects the client has a vaginal D. rectovaginal fistula.
infection caused by A rectovaginal fistula is an opening between
the rectum and the vagina.
A. trichomonas vaginalis.
Trichomonas vaginalis causes a frothy 16. Which of the following statements
yellow-white or yellow-brown vaginal defines laparoscopic myomectomy—an
discharge. alternative to hysterectomy for the
B. candida albicans. treatment of excessive bleeding due to
Candidiasis causes a white, cheeselike fibroids?
discharge clinging to the vaginal epithelium.
C. gardnerella vaginalis. A. Removal of fibroids through a laparoscope
Gardnerella vaginalis causes a gray-white to inserted through a small abdominal incision.
yellow-white discharge clinging to the Laparoscopic myomectomy is the removal of
external vulva and vaginal walls. fibroids through a laparoscope inserted
D. chlamydia. through a small abdominal incision.
Chlamydia causes a profuse purulent B. Cauterization and shrinking of fibroids using a
discharge. laser or electrical needles.
14. The nurse providing education Laparoscopic myolysis is the procedure in
regarding sexually transmitted diseases which a laser or electrial needles are used to
cauterize and shrink the fibroid.
includes which of the following statements
C. Coagulation of the fibroids using electrical
regarding herpes virus 2(herpes current.
genitalis)? Laparoscopic cryomyolysis is the procedure
in which electric current is used to coagulate
A. In pregnant women with active herpes virus,
the fibroids.
babies delivered vaginally may become
D. Resection of the fibroids using a laser through
infected with the virus.
a hyserscope passed through the cervix.
Therefore, a cesarean delivery may be
Hysteroscopic resection of myomas is the
performed if the virus recurs near the time of
procedure in which a laser is used through a
delivery.
hyserscope passed through the cervix; no
B. Transmission of the virus requires sexual
incision or overnight stay is needed.
contact.
Asexual transmission by contact with wet 17. Stage 3 of breast development,
surfaces or self-transmission (i.e., touching a according to Tanner, occurs when
cold sore and then touching the genital area)
can occur.
A. the areola (a darker tissue ring around the retention problems noticed by women in
nipple) develops. relation to onset of menses generally continue
Stage 3 also involves further enlargement of through menses, BSE is not recommended
breast tissue. during that time.
B. breast budding begins. D. any time during the month.
Breast budding is the first sign of puberty in a Because most women notice increased
female. tenderness, lumpiness, and fluid retention
C. the areola and nipple form a secondary mound before their menstrual period, BSE is best
on top of breast tissue. performed when the time for menses is taken
In stage 4, the nipple and areola form a into account.
secondary mound on top of breast tissue. 20. Which type of biopsy is used for
D. the breast develops into a single contour nonpalpable lesions found on
In stage 5, the female demonstrates continued
mammography?
development of a larger breast with a single
contour. A. Stereotactic
18. When the female patient Stereotactic biopsy utilizes computer location
demonstrates thickening, scaling, and of the suspicious area found on biopsy,
erosion of the nipple and areola, the followed by core needle insertion and
sampling of tissue for pathologic examination.
nurse recognizes that the patient is
B. Excisional
exhibiting signs of Excisional biopsy is the usual procedure for
A. Paget’s disease. any palpable breast mass.
Paget’s disease is a malignancy of mammary C. Incisional
ducts with early signs of erythema of nipple Incisional biopsy is performed on a palpable
and areola. mass when tissue sampling alone is required.
B. acute mastitis. D. Tru-Cut core                                                    
Acute mastitis is demonstrated by nipple Tru-Cut core biopsy is used when a tumor is
cracks or abrasions along with reddened and relatively large and close to the skin surface.
warm breast skin and tenderness. 21. The nurse recognizes which of the
C. fibroadenoma. following statements as accurately
Fibroadenoma is characterized as the reflecting a risk factor for breast cancer?
occurrence of a single, nontender mass that is
firm, mobile, and not fixed to breast tissue or A. Mother affected by cancer before 60 years of
chest wall. age
D. peau d’orange (edema). Risk for breast cancer increases twofold if
Peau d’orange is associated with the breast first-degree female relatives (sister, mother, or
and demonstrates an orange peel apearance of daughter) had breast cancer.
breast skin with enlargement of skin pores. B. Onset of menses before 14 years of age
19. The nurse teaches the female patient Increased risk is associated with early
menarche (i.e., menses beginning before 12
who is premenopausal to perform breast
years of age).
self-examination (BSE) C. Multiparity
A. on day 5 to day 7, counting the first day of Nulliparity and later maternal age for first
menses as day 1. birth are associated with increased risk for
BSE is best performed after menses, when breast cancer.
less fluid is retained. D. No alcohol consumption
B. with the onset of menstruation Alcohol use remains controversial; however, a
Because most women notice increased slightly increased risk is found in women who
tenderness, lumpiness, and fluid retention consume even one drink daily and doubles
before their menstrual period, BSE is not among women drinking three drinks daily.
recommended with the onset of menses. 22. Which of the following terms is used
C. on day 2 to day 4, counting the first day of to describe removal of the breast tissue
menses as day 1. and an axillary lymph node dissection
Because the tenderness, lumpiness, and fluid
 leaving muscular structure intact as the option of systemic chemotherapy, not just
surgical treatment of breast cancer? women whose tumors are greater than 1 cm in
size.
A. Modified radical mastectomy B. 75%
A modified radical mastectomy leaves the All women (100%) with invasive breast
pectoralis major and minor muscles intact. cancer should consider the option of systemic
B. Segmental mastectomy chemotherapy, not just women whose tumors
In a segmental mastectomy, varying amounts are greater than 1 cm in size.
of breast tissue are removed, including the C. 50%
malignant tissue and some surrounding tissue All women (100%) with invasive breast
to ensure clear margins. cancer should consider the option of systemic
C. Total mastectomy chemotherapy, not just women whose tumors
In a total mastectomy, breast tissue only is are greater than 1 cm in size.
removed. D. 25%
D. Radical mastectomy All women (100%) with invasive breast
Radical mastectomy includes removal of the cancer should consider the option of systemic
pectoralis major and minor muscles in chemotherapy, not just women whose tumors
addition to breast tissue and axillary lymph are greater than 1 cm in size.
node dissection. 25. Which of the following terms refers to
23. Ductal lavage is used for surgical removal of one of the testes?
A. women at higher risk for benign proliferative A. Orchiectomy
breast disease. Orchiectomy is required when the testicle has
Performed in the doctor’s office, a been damaged.
microcatheter is inserted through the nipple B. Circumcision
while instilling saline and retrieving the fluid Circumcision is excision of the foreskin, or
for analysis. It has been shown to identify prepuce, of the glans penis.
atypical cells in this population and has been C. Vasectomy
found to be adept at detecting cellular changes Vasectomy is the ligation and transection of
within the breast tissue. part of the vas deferens to prevent the passage
B. women at low risk for breast cancer. of the sperm from the testes.
Ductal lavage is used for women at higher D. Hydrocelectomy
risk, not low risk, for benign proliferative Hydrocelectomy describes the surgical repair
breast disease. of a hydrocele, a collection of fluid in the
C. screening women over age 65. tunica vaginalis.
Ductal lavage is used for women at higher risk 26. The term or disease associated with
for benign proliferative breast disease; it is not
buildup of fibrous plaques in the sheath of
used as a screening tool.
D. women with breast implants. the corpus cavernosum causing curvature
Ductal lavage is used for women at higher risk of the penis when it is erect is known as
for benign proliferative breast disease; it is not
A. Peyronie’s disease.
specific for women with breast implants.
Peyronie’s disease may require surgical
24. The 2000 NIH Consensus removal of the plaques when the disease
Development Conference Statement makes sexual intercourse painful, difficult, or
states that what percentage of women impossible.
with invasive breast cancer should B. Bowen’s disease
consider the option of systemic Bowen’s disease refers to a form of squamous
cell carcinoma in situ of the penile shaft.
chemotherapy, not just women whose
C. phimosis.
tumors are greater than 1cm in size? Phimosis refers to the condition in which the
A. 100% (all) foreskin is constricted so that it cannot be
The 2000 Consensus Development retracted over the glans.
Conference Statement states that all women D. priapism.
with invasive breast cancer should consider Priapism refers to an uncontrolled, persistent
 erection of the penis occurring from either B. prostatitis.
neural or vascular causes. Prostatitis is an inflammation of the prostate
27. Which of the following terms is used gland.
to describe the opening of the urethra on C. prostaglandin.
Prostaglandins are physiologically active
the dorsum of the penis?
substances present in tissues with vasodilator
A. Epispadias properties.
Epispadias is a congenital anomaly in which D. prostatectomy.
the urethral opening is on the dorsum of the Prostatectomy refers to the surgical removal
penis and is usually repaired through plastic of the prostate gland.
surgery when the boy is very young. 30. Proteins formed when cells are
B. Hypospadias exposed to viral or foreign agents that are
Hypospadias is a congenital anomaly in which capable of activating other components of
the urethral opening is on the underside of the
the immune system are referred to as
penis and is usually repaired through plastic
surgery when the boy is very young. A. interferons.
C. Urethral stricture Interferons are biologic response modifiers
Urethral stricture is a condition in which a with nonspecific viricidal proteins.
section of urethra is narrowed. B. antibodies.
D. Urethritis Antibodies are protein substances developed
Urethritis refers to inflammation of the urethra by the body in response to and interacting
and is commonly associated with sexually with a specific foreign substance.
transmitted disease. C. antigens.
28. The nurse teaches the patient who Antigens are substances that induce formation
has been prescribed Viagra which of the of antibodies.
following guidelines? D. complements.                                                  
Complement refers to a series of enzymatic
A. Do not take more than one tablet per day of proteins in the serum that, when activated,
your prescribed dose. destroy bacteria and other cells.
Taking Viagra more than once a day will not 31. Cytotoxic T cells
improve its effects and the patient may
experience back and leg aches as well as A. lyse cells infected with virus.
nausea and vomiting. Cytotoxic T cells play a role in graft rejection.
B. Viagra should be taken immediately before B. are important in producing circulating
intercourse. antibodies.
Viagra should be taken one hour before B cells are lymphocytes important in
intercourse. producing circulating antibodies.
C. Viagra will result in erection formation. C. attack foreign invaders (antigens) directly.
Viagra will not create the erection; the Helper T cells are lymphocytes that attack
erection must be created by sexual antigens directly.
stimulation. D. decrease B cell activity to a level at which the
D. Viagra will restore sex drive. immune system is compatible with life.
Viagra will not restore desire or sex drive. Suppressor T cells are lymphocytes that
29. The obstructive and irritative symptom decrease B-cell activity to a level at which the
immune system is compatible with life.
complex caused by benign prostatic
32. During which stage of the immune
hypertrophy is termed
response does the circulating lymphocyte
A. prostatism. containing the antigenic message return
Symptoms of prostatism include increased to the nearest lymph node?
frequency of urination, nocturia, urgency,
dribbling, and a sensation that the bladder has A. Proliferation
not completely emptied. Once in the node, the sensitized lymphocyte
stimulates some of the resident dormant T and
 B lymphocytes to enlarge, divide, and supply of both red and white cells. Stem cells
proliferate. comprise only a small portion of all types of
B. Recognition bone marrow cells.
In the recognition stage, the immune system B. Stem cell transplantation can restore immune
distinguishes an invader as foreign, or non- system functioning.
self. Research conducted with mouse models has
C. Response demonstrated that once the immune system
In the response stage, the changed has been destroyed experimentally, it can be
lymphocytes function either in a humoral or completely restored with the implantation of
cellular fashion. just a few purified stem cells.
D. Effector C. Stem cell transplantion has been performed in
In the effector stage, either the antibody of the the laboratory only.
humoral response or the cytotoxic T cell of Stem cell transplantation has been carried out
the cellular response reaches and couples with in human subjects with certain types of
the antigen on the surface of the foreign immune dysfunction such as severe combined
invader. immunodeficiency (SCID).
33. Which of the following responses D. Clinical trials are underway in patients with
identifies a role of T lymphocytes? acquired immune deficiencies only.
Clinical trails are underway in patients with a
A. Transplant rejection variety of disorders with an autoimmune
Transplant rejection and graft-versus-host component including systemic lupus
disease are cellular response roles of T cells. erythematosus,rheumatoid arthritis,
B. Anaphylaxis scleroderma, and multiple sclerosis.
Anaphylaxis is a humoral response role of B- 36. The nurse’s base knowledge of
lymphocytes. primary immunodeficiencies includes
C. Allergic hay fever and asthma
which of the following statements?
Allergic hay fever and asthma are humoral
response roles of B-lymphocytes. Primary immunodeficiencies
D. Bacterial phagocytosis and lysis A. develop early in life after protection from
Bacterial phagocytosis and lysis are humoral maternal antibodies decreases.
response roles of B-lymphocytes. These disorders may involve one or more
34. Of the following classifications of components of the immune system.
medications, which is known to inhibit B. occur most commonly in the aged population.
prostaglandin synthesis or release? Primary immunodeficiencies are seen
primarily in infants and young children.
A. Nonsteroidal anti-inflammatory drugs C. develop as a result of treatment with
(NSAIDs) in large doses antineoplastic agents.
NSAIDs include aspirin and ibuprofen. Primary immunodeficiencies are rare
B. Antibiotics (in large doses) disorders with genetic origins.
Antibiotics in large doses are known to cause D. disappear with age.
bone marrow suppression. Without treatment, infants and children with
C. Adrenal corticosteroids these disorders seldom survive to adulthood.
Adrenal corticosteroids are known to cause 37. Agammaglobulinemia is also known
immunosuppression.
as
D. Antineoplastic agents
Antineoplastic agents are known to cause A. Bruton’s disease.
immunosuppression. Bruton’s disease is a sex-linked disease that
35. Which of the following statements results in infants born with the disorder
reflect current stem cell research? suffering severe infections soon after birth
B. Nezelof syndrome.
A. The stem cell is known as a precursor cell that Nezelof syndrome is a disorder involving lack
continually replenishes the body’s entire of a thymus gland.
supply of both red and white cells. C. Wiskott-Aldrich syndrome.
The stem cell is known as a precursor cell that Wiskott-Aldrich syndrome involves the
continually replenishes the body’s entire
 absence of T cells and B cells and the C. Mycobacterium avium
presence of thrombocytopenia. Mycobacterium avium is an acid-fast bacillus
D. Common variable immunodeficiency (CVID) that commonly causes a respiratory illness.
CVID is another term for D. Pneumocystic carinii                                        
hypogammaglobulinemia. Pneumocystic carinii is an organism that is
38. When the nurse administers thought to be protozoan but believed to be a
intravenous gamma-globulin infusion, she fungus based on its structure.
recognizes that which of the following 41. Of the following blood tests, which
complaints, if reported by the patient, may confirms the presence of antibodies to
indicate an adverse effect of the infusion? HIV?

A. Tightness in the chest A. Enzyme-linked immunoabsorbant assay

Flank pain, tightness in the chest, or (ELISA)
hypotension indicates adverse effects of ELISA, as well as Western blot assay,
gamma-globulin infusion. identifies and confirms the presence of
B. Nasal stuffiness antibodies to HIV.
Nasal stuffiness is not recognized as an B. Erythrocyte sedimentation rate (ESR)
adverse effect of gamma-globulin infusion. The ESR is an indicator of the presence of
C. Increased thirst inflammation in the body.
Increased thirst is not recognized as an C. p24 antigen
adverse effect of gamma-globulin infusion. The p24 antigen is a blood test that measures
D. Burning urination viral core protein.
Burning urination is a sign of urinary tract D. Reverse transcriptase
infection, not an adverse effect of gamma- Reverse transcriptase is not a blood test.
globulin infusion. Rather, it is an enzyme that transforms single-
stranded RNA into a double-stranded DNA.
39. Ataxia is the term that refers to
42. When assisting the patient to interpret
A. uncoordinated muscle movement. a negative HIV test result, the nurse
Ataxia-telangiectasia is an autosomal informs the patient that the results mean
recessive disorder affecting both T-cell and B-
cell immunity. A. his body has not produced antibodies to the
B. vascular lesions caused by dilated blood AIDS virus.
vessels. A negative test result indicates that antibodies
Telangiectasia is the term that refers to to the AIDS virus are not present in the blood
vascular lesions caused by dilated blood at the time the blood sample for the test is
vessels. drawn.
C. inability to understand the spoken word. B. he has not been infected with HIV.
Receptive aphasia is an inability to understand A negative test result should be interpreted as
the spoken word. demonstrating that if infected, the body has
D. difficulty swallowing. not produced antibodies (which take from 3
Dysphagia refers to difficulty swallowing. weeks to 6 months or longer). Therefore,
40. Which of the following subsequent testing of an at-risk patient must
microorganisms is known to cause be encouraged.
C. he is immune to the AIDS virus.
retinitis in people with HIV/AIDS?
The test result does not mean that the patient
A. Cytomegalovirus is immune to the virus, nor does it mean that
Cytomegalovirus is a species-specific herpes the patient is not infected. It just means that
virus. the body may not have produced antibodies
B. Cryptococcus neoformans yet.
Cryptococcus neoformans is a fungus that D. antibodies to the AIDS virus are in his blood.
causes an opportunistic infection in patients When antibodies to the AIDS virus are
with HIV/AIDS. detected in the blood, the test is interpreted as
positive.
 43. Which of the following substances 46. Which of the following statements
may be used to lubricate a condom? reflect the treatment of HIV infection?
A. K-Y jelly A. Treatment of HIV infection for an individual
K-Y jelly is water-based and will provide patient is based on the clinical condition of the
lubrication while not damaging the condom. patient, CD4 T cell count level, and HIV RNA
B. Skin lotion (viral load).
The oil in skin lotion will cause the condom to Although specific therapies vary, treatment of
break. HIV infection for an individual patient is
C. Baby oil based on three factors: the clinical condition
Baby oil will cause the condom to break. of the patient, CD4 T cell count level, and
D. Petroleum jelly HIV RNA (viral load).
The oil in petroleum jelly will cause the B. Treatment should be offered to all patients
condom to break. once they reach CDC category B – HIV
44. More than 500 CD4+ T symptomatic.
lymphocytes/mm3 indicates which stage Treatment should be offered to all patients
with the primary infection (acute HIV
of HIV infection?
syndrome).
A. CDC category A – HIV asymptomatic C. Treatment should be offered to only selected
More than 500 CD4+ T lymphocytes/mm3 patients once they reach CDC category B –
indicates CDC category A – HIV HIV symptomatic.
asymptomatic. Treatment should be offered to all patients
B. Primary infection (acute HIV infection or with the primary infection (acute HIV
acute HIV syndrome) syndrome).
The period from infection with HIV to the D. Treatment should be offered to individuals
development of antibodies to HIV is know as with plasma HIV RNA levels less than 55,000
primary infection. copies/mL (RT-PCR assay.)
C. CDC category B – HIV symptomatic In general, treatment should be offered to
200-499 CD4+ T lymphocytes/mm3 indicates individuals with fewer than 350 CD4+ T
CDC category B – HIV symptomatic. cells/mm3 or plasma HIV RNA levels
D. CDC category C – AIDS exceeding 55,000 copies/mL (RT-PCR assay).
Less than 200 CD4+ T lymphocytes/mm3 47. Which of the following body
indicates CDC category C – AIDS. substances causes increased gastric
45. The term used to define the balance secretion, dilation of capillaries, and
between the amount of HIV in the body constriction of the bronchial smooth
and the immune response is muscle?
A. viral set point A. Histamine
The viral set point is the balance between the When cells are damaged, histamine is
amount of HIV in the body and the immune released.
response. B. Bradykinin
B. window period Bradykinin is a polypeptide that stimulates
During the primary infection period, the nerve fibers and causes pain.
window period occurs since a person is C. Serotonin
infected with HIV but negative on the HIV Serotonin is a chemical mediator that acts as a
antibody blood test. potent vasoconstrictor and bronchoconstrictor.
C. primary infection stage D. Prostaglandin
The period from infection with HIV to the Prostaglandins are unsaturated fatty acids that
development of antibodies to HIV is known as have a wide assortment of biologic activity.
the primary infection stage. 48. Which type of hypersensitivity
D. viral clearance rate
reaction involves immune complexes
The amount of virus in circulation and the
number of infected cells equals the rate of formed when antigens bind to antibodies?
viral clearance.
A. Type III to the reappearance of an allergic reaction
Type III hypersensitivity is associated with when the medication is re-instituted.
systemic lupus erythematosus, rheumatoid D. Wearing of medical alert bracelet                    
arthritis, serum sickness, certain types of The medical alert bracelet will assist those
nephritis, and some types of bacterial rendering aid to the patient who has
endocarditis. experienced an anaphylactic reaction
B. Type I
Type I or anaphylactic hypersensitivity is an
immediate reaction, beginning within minutes
of exposure to an antigen.
C. Type II
Type II, or cytotoxic, hypersensitivity occurs
when the system mistakenly identifies a
normal constituent of the body as foreign.
D. Type IV
Type IV, or delayed-type, hypersensitivity
occurs 24-72 hours after exposure to an
allergen.
49. When the patient’s eosinophil count is
50-90% of blood leukocytes, the nurse
interprets the result as
A. indicative of idiopathic hypereosinophilic
syndrome.
When eosinophils make up 50-90% of white
cell count, the patient is demonstrating severe
eosinophilia.
B. indicating an allergic disorder.
Moderate eosinophilia, 15-40% of white cell
count consisting of eosinophils, are found in
patients with allergic disorders.
C. suggesting an allergic reaction.
A level between 5 and 15% eosinophils is
nonspecific but does suggest allergic reaction.
D. normal.
Eosinophils normally make up 1-3% of the
total number of white blood cells.
50. Which of the following interventions is
the single most important aspect for the
patient at risk for anaphylaxis?
A. Prevention
People who have experienced food,
medication, idiopathic, or exercise-induced
anaphylactic reactions should always carry an
emergency kit containing epinephrine for
injection to prevent the onset of the reaction
upon exposure.
B. Use of antihistamines
While helpful, the patient may require
epinephrine to treat a potential reaction.
C. Desensitization
While helpful, there must be no lapses in
desensitization therapy because this may lead
 Medical Surgical Nursing Exam 20 found in osteomyelitis, they do not cause the
majority of bone infections.
1. When the nurse notes that the patient’s D. Escherichia coli
left great toe deviates laterally, she While E. coli is frequently found in
recognizes that the patient has a osteomyelitis, it does not cause the majority of
bone infections
A. hallux valgus.
4. Which of the following statements
Hallux valgus is commonly referred to as a
bunion. reflects information to be included when
B. hammertoe. teaching the patient about plantar
Hammertoes are usually pulled upward. fasciitis?
C. pes cavus.
Pes cavus refers to a foot with an abnormally A. Management of plantar fasciitis includes
high arch and a fixed equinus deformity of the stretching exercises.
forefoot. Management also includes wearing shoes with
D. flatfoot. support and cushioning to relieve pain,
In flatfoot, the patient demonstrates a orthotic devices (e.g., heel cups, arch
diminished longitudinal arch of the foot. supports), and the use of non-steroidal anti-
inflammatory drugs (NSAIDs).
2. Localized rapid bone turnover, most
B. Plantar fasciitis presents as an acute onset of
commonly affecting the skull, femur, tibia, pain localized to the ball of the foot that
pelvic bones, and vertebrae, occurs when pressure is placed upon it and
characterizes which of the following bone diminishes when pressure is released.
disorders? Plantar fasciitis, an inflammation of the foot-
supporting fascia, presents as an acute onset
A. Osteitis deformans of heel pain experienced with the first steps in
Osteitis deformans (Paget’s disease) results in the morning. The pain is localized to the
bone that is highly vascularized and anterior medial aspect of the heel and
structurally weak, predisposing to pathologic diminishes with gentle stretching of the foot
fractures. and Achilles tendon.
B. Osteomalacia C. The pain of plantar fasciitis diminishes with
Osteomalacia is a metabolic bone disease warm water soaks.
characterized by inadequate mineralization of Plantar fasciitis, an inflammation of the foot-
bone. supporting fascia, presents as an acute onset
C. Osteoporosis of heel pain experienced with the first steps in
Osteoporosis is characterized by reduction of the morning. The pain is localized to the
total bone mass and a change in bone structure anterior medial aspect of the heel and
which increases susceptibility to fracture. diminishes with gentle stretching of the foot
D. Osteomyelitis and Achilles tendon.
Osteomyelitis is an infection of bone that D. Complications of plantar fasciitis include
comes from extension of soft tissue infection, neuromuscular damage and decreased ankle
direct bone contamination, or hematogenous range of motion.
spread. Unresolved plantar fasciitis may progress to
3. Most cases of osteomyelitis are caused fascial tears at the heel and eventual
by which of the following development of heel spurs.
microorganisms? 5. Lifestyle risk factors for osteoporosis
include
A. Staphylococcus
Staphylococcus aureus causes 70-80% of A. lack of exposure to sunshine.
bone infections. Lifestyle risk factors for osteoporosis include
B. Proteus species lack of exposure to sunshine, low calcium and
While Proteus species are frequently found in vitamin D diet, cigarette smoking, use of
osteomyelitis, they do not cause the majority alcohol and/or caffeine, and lack of weight-
of bone infections. bearing exercise.
C. Pseudomonas species B. lack of aerobic exercise.
While Pseudomonas species are frequently Lack of weight-bearing exercise, not aerobic
 exercise, is a lifestyle risk factor for 7. Instructions for the patient with low
osteoporosis. back pain include which of the following?
C. a low protein, high fat diet.
A low calcium and vitamin D diet, not a low A. When lifting, avoid overreaching.
protein, high fat diet, is a lifestyle risk factor Instructions for the patient with low back pain
for osteoporosis. should include that when lifting, the patient
D. an estrogen deficiency or menopause. should avoid overreaching. The patient should
An estrogen deficiency or menopause is an also keep the load close to the body, bend the
individual, not lifestyle risk factor for knees and tighten the abdominal muscles, use
osteoporosis. Other individual risk factors a wide base of support, and use a back brace
include female gender, white non-Hispanic or to protect the back.
Asian race, increased age, low weight and B. When lifting, place the load away from the
body mass index, family history of body.
osteoporosis, low initial bone mass, and When lifting, the patient with low back pain
contributing co-existing medical conditions should keep the load close to the body.
and medications. C. When lifting, use a narrow base of support.
6. The nurse teaches the patient with a When lifting, the patient with low back pain
high risk for osteoporosis about risk- should use a wide base of support.
D. When lifting, bend the knees and loosen the
lowering strategies including which of the
abdominal muscles.
following statements? When lifting, the patient with low back pain
A. Walk or perform weight-bearing exercises out should bend the knees and tighten the
of doors. abdominal muscles.
Risk-lowering strategies for osteoporosis 8. Dupuytren’s contracture causes flexion
include walking or exercising out of doors, of the
performing a regular weight-bearing exercise
regimen, increasing dietary calcium and A. fourth and fifth fingers.
vitamin D intake, smoking cessation, and Dupuytren’s contracture causes flexion of the
consuming alcohol and caffeine consumption fourth and fifth fingers, and frequently the
in moderation. middle finger.
B. Increase fiber in the diet. B. thumb.
Risk-lowering strategies for osteoporosis Dupuytren’s contracture causes flexion of the
include increasing dietary calcium and fourth and fifth fingers, and frequently the
vitamin D intake, middle finger.
walking or exercising out of doors, smoking C. index and middle fingers.
cessation, consuming alcohol and caffeine Dupuytren’s contracture causes flexion of the
consumption in moderation, and performing a fourth and fifth fingers, and frequently the
regular weight-bearing exercise regimen. middle finger.
C. Reduce stress. D. ring finger.
Risk-lowering strategies for osteoporosis Dupuytren’s contracture causes flexion of the
include walking or exercising out of doors, fourth and fifth fingers, and frequently the
increasing dietary calcium and vitamin D middle finger.
intake, smoking cessation, consuming alcohol 9. A metabolic bone disease
and caffeine consumption in moderation, and characterized by inadequate
performing a regular weight-bearing exercise mineralization of bone is
regimen.
D. Decrease the intake of vitamin A and D. A. osteomalacia
Risk-lowering strategies for osteoporosis Osteomalacia is a metabolic bone disease
include increasing dietary calcium and characterized by inadequate mineralization of
vitamin D intake, bone.
walking or exercising out of doors, smoking B. osteoporosis
cessation, consuming alcohol and caffeine Osteoporosis is characterized by reduction of
consumption in moderation, and performing a total bone mass and a change in bone structure
regular weight-bearing exercise regimen. which increases susceptibility to fracture.
C. osteomyelitis B. Rest, ice, circulation, and examination
Osteomyelitis is an infection of bone that While circulation problems must be
comes from extension of soft tissue infection, examined, the RICE treatment does not refer
direct bone contamination, or hematogenous to circulation and examination.
spread. C. Rotation, immersion, compression and
D. osteoarthritis elevation
Osteoarthritis (OA), also known as Rotation of a joint is contraindicated when
degenerative joint disease, is the most injury is suspected, and immersion of the area
common and frequently disabling of the joint may be anatomically difficult.
disorders. OA affects the articular cartilage, D. Rotation, ice, compression, and examination
subchondral bone, and synovium. Rotation of a joint is contraindicated when
10. Which of the following terms refers to injury is suspected, and examination, while
an injury to ligaments and other soft indicated, does not provide treatment.
tissues of a joint? 13. The nurse anticipates that the
physician will perform joint aspiration and
A. Sprain wrapping with compression elastic
A sprain is caused by a wrenching or twisting
dressing for which of the following
motion.
B. Dislocation musculoskeletal problems?
Dislocation refers to the separation of joint A. Joint effusion
surfaces. The described treatments are used with joint
C. Subluxation effusions and hemarthrosis.
Subluxation refers to partial separation or B. Strain
dislocation of joint surfaces. A strain is treated by RICE.
D. Strain                                                                 C. Sprain
Strain refers to a muscle pull or tear. A sprain is treated by RICE.
11. Which of the following terms refers to D. Avascular necrosis
failure of fragments of a fractured bone to Avascular necrosis describes death of tissue
heal together? due to insufficient blood supply and may be
associated with steroid use.
A. Nonunion 14. When x-ray demonstrates a fracture
When nonunion occurs, the patient complains
in which bone has splintered into several
of persistent discomfort and movement at the
fracture site. pieces, that fracture is described as
B. Dislocation A. comminuted.
Dislocation refers to the separation of joint A comminuted fracture may require open
surfaces. reduction and internal fixation.
C. Subluxation B. compound.
Subluxation refers to partial separation or A compound fracture is one in which damage
dislocation of joint surfaces. also involves the skin or mucous membranes.
D. Malunion C. depressed.
Malunion refers to growth of the fragments of A depressed fracture is one in which
a fractured bone in a faulty position, forming fragments are driven inward.
an imperfect union. D. impacted.
12. The Emergency Department nurse An impacted fracture is one in which a bone
teaches patients with sports injuries to fragment is driven into another bone
remember the acronym RICE, which fragment.
stands for which of the following 15. When x-ray demonstrates a fracture
combinations of treatment? in which the fragments of bone are driven
inward, the fracture is described as
A. Rest, ice, compression, elevation
RICE is used for the treatment of contusions, A. depressed.
sprains, and strains. Depressed skull fractures occur as a result of
blunt trauma.
B. compound. recognizes that the patient is likely
A compound fracture is one in which damage demonstrating signs of
also involves the skin or mucous membranes.
C. comminuted. A. reflex sympathetic dystrophy syndrome.
A comminuted fracture is one in which the RSD is frequently chronic and occurs most
bone has splintered into several pieces. often in women.
D. impacted. B. avascular necrosis of bone.
An impacted fracture is one in which a bone Avascular necrosis is manifested by pain and
fragment is driven into another bone limited movement.
fragment. C. a reaction to an internal fixation device.
16. A fracture is termed pathologic when Pain and decreased function are the prime
the fracture indicators of reaction to an internal fixation
device.
A. occurs through an area of diseased bone. D. heterotrophic ossification.
Pathologic fractures can occur without the Heterotrophic ossification causes muscular
trauma of a fall. pain and limited muscular contraction and
B. results in a pulling away of a fragment of movement.
bone by a ligament or tendon and its 19. Which of the following terms refers to
attachment. a fracture in which one side of a bone is
An avulsion fracture results in a pulling away
broken and the other side is bent?
of a fragment of bone by a ligament or tendon
and its attachment. A. Greenstick
C. presents as one side of the bone being broken A greenstick fracture is a fracture in which
and the other side being bent. one side of a bone is broken and the other side
A greenstick fracture presents as one side of is bent.
the bone being broken and the other side B. Spiral
being bent. A spiral fracture is a fracture twisting around
D. involves damage to the skin or mucous the shaft of the bone.
membranes. C. Avulsion
A compound fracture involves damage to the An avulsion is the pulling away of a fragment
skin or mucous membranes. of bone by a ligament or tendon and its
17. The most common complication after attachment.
knee arthroscopy is D. Oblique
An oblique is a fracture occurring at an angle
A. joint effusion. across the bone.
Joint effusion produces marked pain, and the 20. The nurse assesses subtle
physician may need to aspirate the joint to
personality changes, restlessness,
remove fluid and relieve the pressure.
B. infection. irritability, and confusion in a patient who
Infection is not a common complication of has sustained a fracture. The nurse
arthroscopy. suspects
C. knee giving way.
Complaints of the knee giving way are A. fat embolism syndrome.
associated with functioning of the injured Cerebral disturbances in the patient with fat
knee prior to arthroscopy. embolism syndrome include subtle personality
D. knee locking. changes, restlessness, irritability, and
Complaints of the knee locking are associated confusion.
with functioning of the injured knee prior to B. compartment syndrome.
arthroscopy. With compartment syndrome, the patient
complains of deep, throbbing, unrelenting
18. When the patient who has
pain.
experienced trauma to an extremity C. hypovolemic shock.
complains of severe burning pain, With hypovolemic shock, the patient would
vasomotor changes, and muscles spasms have a decreased blood pressure and increased
in the injured extremity, the nurse pulse rate.
D. reflex sympathetic dystrophy syndrome.           D. Emerging infectious diseases
Clinical manifestations of reflex sympathetic Emerging infectious diseases refer to diseases
dystrophy syndrome include severe, burning of infectious origin of which incidence in
pain, local edema, hyperesthesia, muscle humans has increased within the past two
spasms, and vasomotor skin changes. decades or threaten to increase in the near
21. A Colles’ fracture is a fracture of the future.
24. The usual incubation period (infection
A. distal radius.
to first symptom) for AIDS is
A Colles’ fracture is a fracture of the distal
radius (wrist). It is usually the result of a fall A. 10 years.
on an open, dorsiflexed hand. HIV is transmitted through sexual,
B. elbow. percutaneous, or perinatal contact.
A Colles’ fracture is a fracture of the distal B. 3–6 months.
radius. The incubation period for HIV infection is
C. humeral shaft. greater than 3-6 months.
A Colles’ fracture is a fracture of the distal C. 1 year.
radius. The incubation period for HIV infection is
D. clavicle. greater than 1 year.
A Colles’ fracture is a fracture of the distal D. 5 years.
radius. The incubation period for HIV infection is
22. With fractures of the femoral neck, the greater than 5 years.
leg is 25. The usual incubation period (infection
to first symptom) for hepatitis B is
A. shortened, adducted, and externally rotated.
With fractures of the femoral neck, the leg is A. 45-160 days.
shortened, adducted, and externally rotated. Hepatitis B is responsible for more than 200
B. shortened, abducted, and internally rotated. deaths of healthcare workers annually.
With fractures of the femoral neck, the leg is B. 15-50 days.
shortened, adducted, and externally rotated. The incubation period for hepatitis B is 45-
C. adducted and internally rotated. 160 days.
With fractures of the femoral neck, the leg is C. 6-9 months.
shortened, adducted, and externally rotated. The incubation period for hepatitis B is
D. abducted and externally rotated. shorter than 6-9 months.
With fractures of the femoral neck, the leg is D. unclear.
shortened, adducted, and externally rotated. The incubation periods for hepatitis D, E, and
23. Which of the following terms most G are unclear.
precisely refers to an infection acquired in 26. Which of the following terms refers to
the hospital that was not present or a state of microorganisms being present
incubating at the time of hospital within a host without causing host
admission? interference or interaction?
A. Nosocomial infection A. Colonization
A 1970 CDC study found that about one-third Understanding the principle of colonization
of nosocomial infections could be prevented facilitates interpretation of microbiologic
when effective infection control programs reports.
were in place. B. Susceptible
B. Primary bloodstream infection A susceptible host is a host who does not
A primary bloodstream infection is possess immunity to a particular pathogen.
bacteremia or fungemia, which occurs without C. Immune
infection, identified at another anatomic site. An immune host is a host who is not
C. Secondary bloodstream infection susceptible to a particular pathogen.
A secondary bloodstream infection is D. Infection
bacteremia of fungemia of another anatomic Infection refers to host interaction with an
site, which serves as a source for bloodstream organism.
contamination.
 27. The nurse teaches the parent of the prophylactic antibiotic. The aim of
child with chickenpox that the child is no prophylaxis is to assure that if spores were
inhaled, bacteria will be killed immediately
longer contagious to others when
upon release from spores. Those who have
A. the vesicles and pustules have crusted. symptoms of fever, cough, headache, chills,
When the lesions have crusted, the patient is and especially evidence of mediastinal lymph
no longer contagious to others. node involvement should be treated with
B. the first rash appears. intravenous antibiotics and respiratory
The child remains contagious when the rash is support, if needed.
present. B. 30 days.
C. the fever disappears. Those with symptoms who have been in the
The child remains contagious if the fever hot zone should be given 60 days of
occurs as the rash is progressing. prophylactic antibiotic
D. the rash is changing into vesicles, and pustules C. 14 days.
appear. Those with symptoms who have been in the
The child remains contagious when the rash is hot zone should be given 60 days of
changing into vesicles and pustules. prophylactic antibiotic
28. Which of the following statements D. 10 days.
Those with symptoms who have been in the
reflects the nursing management of the
hot zone should be given 60 days of
patient with West Nile Virus infection? prophylactic antibiotic
A. There is no treatment for West Nile Virus 30. If a case of smallpox is suspected, the
infection. nurse should
Patients are supported by fluid replacement,
airway management, and standard nursing A. call the CDC Emergency Preparedness Office.
care support during the time that the patient Anyone suspecting a case of smallpox should
hasmeningitis symptoms. call the CDC Emergency Preparedness Office
B. The incubation period is three to five days. at 770-488-7100. The CDC will respond by
The incubation period (from mosquito bite immmediate provision of diagnostic support
until onset of symptoms) is between 5–15 and eventual release of vaccine if a case is
days. confirmed. Until instructed otherwise by the
C. Patients with West Nile virus present with CDC, healthcare providers should carefully
gastrointestinal complaints, such as nausea, establish isolation with negative pressure, and
vomiting, diarrhea, and abdominal pain. maintain thorough lists of all those who have
Most human infections are asymptomatic. contact with the patient.
When symptoms are present, headache and B. immediately vaccinate the patient and anyone
fever are most frequently reported. Less than in contact with the patient.
one percent of those infected develop more The CDC will provide diagnostic support and
severe illness, including meningitis. will release the vaccine if the patient is
D. Transmission of West Nile virus occurs from confirmed to have smallpox.
human-to-human. C. establish isolation with positive pressure.
Birds are the natural reservoir for the virus. Isolation with negative pressure should be
Mosquitoes become infected when feeding on established.
birds and can transmit the virus to animals and D. Assess the patient for signs of a rash similar to
humans. There is no human-to-human chickenpox in appearance and progression.
transmission of virus. The lesions associated with smallpox may
appear similar in appearance, but the
29. Prophylaxis antibiotic for anthrax is
progression is very different from that of
given to people with symptoms who have chickenpox. Smallpox lesions will appear to
been in a defined “hot zone” for a period be at the same stage of development as the
of rash progresses from macules to papules to
pustules to scabs. This progression is very
A. 60 days. different from that of chickenpox. With
Those with symptoms who have been in the chickenpox, lesions appear at different
hot zone should be given 60 days of developmental stages.
 31. The six elements necessary for C. The viruses can be spread only by airborne
infection are a causative organism, a exposure.
The viruses can be spread by exposure to
reservoir of available organisms, a portal
blood or other body fluid, insect bite, and
or mode of exit from the reservoir, a mode mucous membrane exposure.
of transmission from reservoir to host, a D. Symptoms include severe lower abdominal
susceptible host, and a pain, nausea, vomiting, and dehydration.
Symptoms include fever, rash, and
A. mode of entry to host. encephalitis which progress rapidly to
The six elements necessary for infection are a profound hemorrhage, organ destruction, and
causative organism, a reservoir of available shock.
organisms, a portal or mode of exit from the
33. Bubonic plague occurs
reservoir, a mode of transmission from
reservoir to host, a susceptible host, and a A. after the organism enters through the skin.
mode of entry to host. Bubonic refers to enlarged lymph nodes that
B. mode of exit from the host. develop after the organism enters through the
A mode of entry to the host, not a mode of skin. Bubonic plague is the form seen most
exit from the host, is necessary for infection. frequently, as the organism is transferred from
C. virulent host. rodents or other animals to humans by insect
The six elements necessary for infection are a bite.
causative organism, a reservoir of available B. occurs after the organism is inhaled..
organisms, a portal or mode of exit from the Pneumonic plague occurs after the organism
reservoir, a mode of transmission from is inhaled. Only pneumonic plague can be
reservoir to host, a susceptible host, and a contagious from person to person by an
mode of entry to host. airborne route.
D. latent time period. C. occurs when the organism causes a
The six elements necessary for infection are a bloodstream infection.
causative organism, a reservoir of available Septicemic plague occurs when the organism
organisms, a portal or mode of exit from the causes a bloodstream infection usually
reservoir, a mode of transmission from secondary to either pneumonic or bubonic, but
reservoir to host, a susceptible host, and a sometimes without either entity.
mode of entry to host. D. after the organism is transferred by human to
32. Which of the following statements human contact.
reflect what is known about the Ebola and Bubonic plague is the form seen most
Marburg viruses? frequently, as the organism is transferred from
rodents or other animals to humans by insect
A. The diagnosis should be considered in a bite.
patient who has a febrile, hemorrhagic illness 34. The term given to the category of
after traveling to Asia or Africa. triage that refers to life-threatening or
The diagnosis should be considered in a
potentially life-threatening injury or illness
patient who has a febrile, hemorrhagic illness
after traveling to Asia or Africa, or who has requiring immediate treatment is
handled animals or animal carcasses from A. emergent.
those parts of the world. The patient triaged as emergent must be seen
B. Treatment during the acute phase includes immediately.
administration of acyclovir, and ventilator and B. urgent.
dialysis support. The triage category of urgent refers to minor
No antivirals have been approved or show illness or injury needing first-aid-level
promise against the viruses. Treatment must treatment.
be largely supportive maintenance of the C. immediate.
circulatory system and respiratory systems. It The triage category of immediate refers to
is likely that the infected patient would need non-acute, non-life-threatening injury or
ventilator and dialysis support through the illness.
acute phases of illness. D. non-acute.
The triage category of immediate refers to
 non-acute, non-life-threatening injury or C. Dextrose 5% in water
illness. Dextrose 5% in water should not be used to
35. When the patient has been field replace fluids in hypovolemic patients.
triaged and categorized as blue, the D. Hypertonic saline
Hypertonic saline is used only to treat severe
nurse recognizes that the patient requires
symptomatic hyponatremia and should be
A. fast-track or psychological support. used only in intensive care units.
When a patient is categorized as blue, field 38. Induction of vomiting is indicated for
triage has identified fast-track or the accidental poisoning patient who has
psychological support needs. ingested
B. emergent care.
Field triaged patients who require emergent A. aspirin.
care will be categorized as red. Overdose of aspirin should be treated with
C. immediate care. emesis or lavage, followed by ingestion of
Field triaged patients who require immediate activated charcoal to absorb the aspirin.
care will be categorized as yellow. B. rust remover.
D. urgent care. Rust remover is an alkaline product, which is
Field triaged patients who require urgent care corrosive, and induced vomiting is
will be categorized as green. contraindicated.
36. Which of the following guidelines is C. gasoline.
appropriate to helping family members Gasoline is a petroleum distillate, and induced
vomiting is contraindicated.
cope with sudden death?
D. toilet bowl cleaner.
A. Show acceptance of the body by touching it, Toilet bowl cleaners are corrosive, and
giving the family permission to touch. induced vomiting is contraindicated.
The nurse should encourage the family to 39. Which of the following phases of
view and touch the body if they wish, since psychological reaction to rape is
this action helps the family to integrate the characterized by fear and flashbacks?
loss.
B. Inform the family that the patient has passed A. Heightening anxiety phase
on. During the heightened anxiety phase, the
The nurse should avoid using euphemisms patient demonstrates anxiety, hyperalertness,
such as passed on. and psychosomatic reactions, in addition to
C. Obtain orders for sedation for family fear and flashbacks.
members. B. Acute disorganization phase
The nurse should avoid giving sedation to The acute disorganization phase is
family members, since this may mask or delay characterized by shock, disbelief, guilt,
the grieving process. humiliation, and anger.
D. Provide details of the factors attendant to the C. Denial phase
sudden death. The denial phase is characterized by an
The nurse should avoid volunteering unwillingness to talk.
unnecessary information (e.g., patient was D. Reorganization phase
drinking at the time of the accident). The reorganization phase occurs when the
37. Which of the following solutions incident is put into perspective. Some patients
should the nurse anticipate for fluid never fully recover from rape trauma.
replacement in the male patient? 40. When preparing for an emergency
bioterroism drill, the nurse instructs the
A. Lactated Ringer’s solution drill volunteers that each biological agents
Replacement fluids may include isotonic
requires specific patient management and
electrolyte solutions and blood component
therapy. medications to combat the virus, bacteria,
B. Type O negative blood or toxin. Which of the following
O negative blood is prepared for emergency statements reflect the patient
use in women of childbearing age. management of variola virus (small pox)?
A. Small pox spreads rapidly and requires moving vehicle, or compressed by
immediate isolation. machinery?
Small pox is spread by droplet or direct
contact. There are no antiviral agents effective A. Crush injuries
against small pox, however vaccination within Crush injuries are those that occur when a
two to three days of exposure is protective. person is caught between objects, run over by
B. Acyclovir is effective against smallpox. a moving vehicle, or compressed by
There are no antiviral agents effective against machinery.
small pox; however, vaccination within two to B. Blunt trauma
three days of exposure is protective. Blunt trauma is commonly associated with
C. Small pox is spread by inhalation of spores. extra-abdominal injuries to the chest, head, or
Small pox is spread by droplet or direct extremities.
contact. It spreads rapidly and requires C. Penetrating abdominal injuries
immediate isolation. Even in death, the Penetrating abdominal injuries include those
disease can be transmitted. such as gunshot wounds and stab wounds.
D. Vaccination is effective only if administered D. Intra-abdominal injuries
within 12 to 24 hours of exposure.       Intra-abdominal injuries are categorized as
Vaccination within two to three days of penetrating and blunt trauma.
exposure of the small pox virus is protective. 43. A person suffering from carbon
In four to five days, it may prevent death and monoxide poisoning
should be administered with vaccinia immune
globulin. A. appears intoxicated.
41. Which of the following statements A person suffering from carbon monoxide
reflect the nursing management of poisoning appears intoxicated (from cerebral
pulmonary anthrax (B. anthracis)? hypoxia). Other signs and symptoms include
headache, muscular weakness, palpitation,
A. Prophylaxis with fluoroquinone is suggested dizziness, and mental confusion.
after exposure. B. presents with severe hypertension.
Treatment is with ciprofloxacin or A person suffering from carbon monoxide
doxycycline. poisoning appears intoxicated (from cerebral
B. Airborne person-to-person transmission hypoxia). Other signs and symptoms include
occurs. headache, muscular weakness, palpitation,
Anthracis is a spore forming bacteria resulting dizziness, and mental confusion.
in gastrointestinal, pulmonary, and skin C. appears hyperactive.
symptoms. Symptoms are dependent upon A person suffering from carbon monoxide
contact, ingestion, or inhalation of the spores. poisoning appears intoxicated (from cerebral
Routine universal precautions are effective. hypoxia). Other signs and symptoms include
Anthrax survives in the spore form for long headache, muscular weakness, palpitation,
periods making the body a potential source of dizziness, and mental confusion.
infection for morticians. D. will always present with a cherry red skin
C. Diagnosis is by pulmonary function testing coloring.
and chest x-ray. The skin coloring in the patient with carbon
Blood cultures are required to confirm the monoxide poisoning can range from pink to
bacteria’s presence and diagnosis. cherry red to cynanotic and pale and is not a
D. Pulmonary effects include respiratory failure, reliable diagnostic sign.
shock, and death within five to seven days 44. Treatment of an acetaminophen
after exposure. overdose includes the administration of
The pulmonary effects include respiratory
failure, shock, and death within 24-36 hours A. N-acetylcysteine (Mucomyst).
after exposure. Treatment of acetaminophen overdose
42. Which of the following terms refers to includes administration of N-acetylcysteine
injuries that occur when a person is (Mucomyst).
B. flumazenil (Romazicon).
caught between objects, run over by a
Flumazenil is administered in the treatment of
nonbarbituate sedative overdoses.
C. naloxone (Narcan). A black triage tag (priority 4 or expectant)
Naloxone (Narcan) is administered in the indicates injuries that are extensive and
treatment of narcotic overdoses. chances of survival are unlikely even with
D. diazepam (Valium). definitive care.
Diazepam (Valium) may be administered to 47. If a person has been exposed to
treat uncontrolled hyperactivity in the patient radiation, presenting symptoms, such as
with a hallucinogen overdose.
nausea, vomiting, loss of appetite,
45. Which of the following statements
diarrhea, or fatigue can be expected to
reflect the nursing management of the
occur within _______ hours after
patient with a white phosphorus chemical
exposure?
burn?
A. 48 to 72
A. Do not apply water to the burn. The prodromal phase (presenting symptoms)
Water should not be applied to burns from lye of radiation exposure occurs within 48 to 72
or white phosphorus because of the potential hours after exposure. Signs and symptoms
for an explosion or deepening of the burn. include nausea, vomiting, loss of appetite,
B. Immediately drench the skin with running diarrhea, and fatigue. With high-dose
water from a shower, hose or faucet. radiation exposure, the signs and symptoms
Water should not be applied to burns from lye may include fever, respiratory distress, and
or white phosphorus because of the potential increased excitability.
for an explosion or deepening of the burn. B. 6 to 12
C. Alternate applications of water and ice to the The prodromal phase (presenting symptoms)
burn. of radiation exposure occurs within 48 to 72
Water should not be applied to burns from lye hours after exposure.
or white phosphorus because of the potential C. 12 to 24
for an explosion or deepening of the burn. The prodromal phase (presenting symptoms)
D. Wash off the chemical using warm water, then of radiation exposure occurs within 48 to 72
flush the skin with cool water. hours after exposure.
Water should not be applied to burns from lye D. 24 to 48
or white phosphorus because of the potential The prodromal phase (presenting symptoms)
for an explosion or deepening of the burn. of radiation exposure occurs within 48 to 72
46. During a disaster, the nurse sees a hours after exposure.
victim with a green triage tag. The nurse 48. Which of the following refers to a
knows that the person has management tool for organizing
A. injuries that are minor and treatment can be personnel, facilities, equipment, and
delayed hours to days. communication for any emergency
A green triage tag (priority 3 or minimal) situation?
indicates injuries that are minor and treatment
can be delayed hours to days. A. The Incident Command System
B. injuries that are life-threatening but survivable The Incident Command System (ICS) is a
with minimal intervention. management tool for organizing personnel,
A red triage tag (priority 1 or immediate) facilities, equipment and communication for
indicates injuries that are life-threatening but any emergency situation. The federal
survivable with minimal intervention. government mandates that the ICS be used
C. injuries that are significant and require during emergencies. Under this structure, one
medical care, but can wait hours without person is designated as incident commander.
threat to life or limb. This person must be continuously informed of
A yellow triage tag (priority 2 or delayed) all activities and informed about any deviation
indicates injuries that are significant and from the established plan. While the ICS is
require medical care, but can wait hours primarily a field structure and process, aspects
without threat to life or limb. of it are used at the level of an individual
D. indicates injuries that are extensive and hospital’s emergency response plan as well.
chances of survival are unlikely even with B. Office of Emergency Management
definitive care. Office of Emergency Management (OEM)
 coordinates the disaster relief efforts at the 50. The first step in decontamination is
state and local levels. The OEM is responsible
for providing interagency coordination during A. removal of the patient’s clothing and jewelry
an emergency. It maintains a corps of and then rinsing the patient with water.
emergency management personnel, including To be effective, decontamination must include
responders, planners, and administrative and a minimum of two steps. The first step is
support staff. removal of the patient’s clothing and jewelry
C. National Disaster Medical System and then rinsing the patient with water. The
National Disaster Medical System (NDMS). second step consists of a thorough soap and
The NDMS has many medical support teams water wash and rinse.
such as Disaster Medical Assistance Teams B. a thorough soap and water wash and rinse of
(DMATs) that provide medical personnel to the patient.
set up and staff a field hospital. A thorough soap and water wash and rinse of
D. The Hospital Emergency Preparedness Plan the patient is the second step in the
The Hospital Emergency Preparedness Plan is decontamination process. The first is to
a facility-specific plan for emergency remove the patient’s clothing and jewelry and
preparedness required by the Joint then rinsing the patient with water.
Commission on Accreditation of Healthcare C. to immediately apply personal protective
Organizations (JCAHO). equipment.
49. Which of the following terms refers to To be effective, decontamination must include
a minimum of two steps. The first step is
a process by which an individual receives
removal of the patient’s clothing and jewelry
education about recognition of stress and then rinsing the patient with water. The
reactions and management strategies for second step consists of a thorough soap and
handling stress? water wash and rinse.
D. to immediately apply a chemical
A. Defusing decontamination foam to the area of
Defusing is a process by which the individual contamination.        To be effective,
receives education about recognition of stress decontamination must include a minimum of
reactions and management strategies for two steps. The first step is removal of the
handling stress. It is a component of critical patient’s clothing and jewelry and then rinsing
incident stress management (CISM). the patient with water. The second step
B. Debriefing consists of a thorough soap and water wash
Debriefing is a more complicated intervention and rinse.
of critical incident stress management
(CISM); it involves 2- to 3- hour process
during which participants are asked about
their emotional reactions to the incident, what
symptoms they may be experiencing (e.g.,
flashbacks, difficulty sleeping, intrusive
thoughts) and other psychological
ramifications.
C. Follow-up
In follow-up, members of the critical incident
stress management (CISM) team contact the
participants of a debriefing and schedule a
follow-up meeting if necessary. People with
ongoing stress reactions are referred to mental
health specialists.
D. Critical incident stress management
Critical incident stress management (CISM) is
an approach to preventing and treating the
emotional trauma that can affect emergency
responders as a consequence of their jobs but
that can also occur to anyone involved in a
disaster or mass casualty incident.
 NCLEX Practice Exam for Medical Surgical Nursing 4 falling on an icy sidewalk. The nurse
1. The nurse is performing her admission knows that basilar skull factures:
assessment of a patient. When grading A. Are the least significant type of skull fracture.
arterial pulses, a 1+ pulse indicates: B. May have cause cerebrospinal fluid (CSF)
leaks from the nose or ears.
A. Above normal perfusion. C. Have no characteristic findings.
B. Absent perfusion. D. Are always surgically repaired.
C. Normal perfusion.
7. Which of the following types of drugs
D. Diminished perfusion.
might be given to control increased
2. Murmurs that indicate heart disease
intracranial pressure (ICP)?
are often accompanied by other
symptoms such as: A. Barbiturates
B. Carbonic anhydrase inhibitors
A. Dyspnea on exertion. C. Anticholinergics
B. Subcutaneous emphysema. D. Histamine receptor blockers
C. Thoracic petechiae.
8. The nurse is teaching family members
D. Periorbital edema.
of a patient with a concussion about the
3. Which pregnancy-related physiologic
early signs of increased intracranial
change would place the patient with a
pressure (ICP). Which of the following
history of cardiac disease at the greatest
would she cite as an early sign of
risk of developing severe cardiac
increased ICP?
problems?
A. Decreased systolic blood pressure
A. Decrease heart rate
B. Headache and vomiting
B. Decreased cardiac output
C. Inability to wake the patient with noxious
C. Increased plasma volume
stimuli
D. Increased blood pressure
D. Dilated pupils that don’t react to light
4. The priority nursing diagnosis for the
9. Jessie James is diagnosed with retinal
patient with cardiomyopathy is:
detachment. Which intervention is the
A. Anxiety related to risk of declining health most important for this patient?
status.
B. Ineffective individual coping related to fear of A. Admitting him to the hospital on strict bed
debilitating illness rest
C. Fluid volume excess related to altered B. Patching both of his eyes
compensatory mechanisms. C. Referring him to an ophthalmologist
D. Decreased cardiac output related to reduced D. Preparing him for surgery
myocardial contractility. 10. Dr. Bruce Owen, a chemist, sustained
5. A patient with thrombophlebitis reached a chemical burn to one eye. Which
her expected outcomes of care. Her intervention takes priority for a patient
affected leg appears pink and warm. Her with a chemical burn of the eye?
pedal pulse is palpable and there is no A. Patch the affected eye and call the
edema present. Which step in the nursing ophthalmologist.
process is described above? B. Administer a cycloplegic agent to reduce
ciliary spasm.
A. Planning C. Immediately instill a tropical anesthetic, then
B. Implementation irrigate the eye with saline solution.
C. Analysis D. Administer antibiotics to reduce the risk of
D. Evaluation infection
6. An elderly patient may have sustained 11. The nurse is assessing a patient and
a basilar skull fracture after slipping and notes a Brudzinski’s sign and Kernig’s
 sign. These are two classic signs of which 17. Which of the following is a cause of
of the following disorders? embolic brain injury?
A. Cerebrovascular accident (CVA) A. Persistent hypertension
B. Meningitis B. Subarachnoid hemorrhage
C. Seizure disorder C. Atrial fibrillation
D. Parkinson’s disease D. Skull fracture
12. A patient is admitted to the hospital 18. Although Ms. Priestly has a spinal
for a brain biopsy. The nurse knows that cord injury, she can still have sexual
the most common type of primary brain intercourse. Discharge teaching should
tumor is: make her aware that:
A. Meningioma. A. She must remove indwelling urinary catheter
B. Angioma. prior to intercourse.
C. Hemangioblastoma. B. She can no longer achieve orgasm.
D. Glioma. C. Positioning may be awkward.
13. The nurse should instruct the patient D. She can still get pregnant.
with Parkinson’s disease to avoid which 19.Ivy Hopkins, age 25, suffered a
of the following? cervical fracture requiring immobilization
with halo traction. When caring for the
A. Walking in an indoor shopping mall
patient in halo traction, the nurse must:
B. Sitting on the deck on a cool summer evening
C. Walking to the car on a cold winter day A. Keep a wrench taped to the halo vest for quick
D. Sitting on the beach in the sun on a summer removal if cardiopulmonary resuscitation is
day necessary.
14. Gary Jordan suffered a B. Remove the brace once a day to allow the
cerebrovascular accident that left her patient to rest.
unable to comprehend speech and C. Encourage the patient to use a pillow under
the ring.
unable to speak. This type of aphasia is
D. Remove the brace so that the patient can
known as: shower.
A. Receptive aphasia 20. The nurse asks a patient’s husband if
B. Expressive aphasia he understands why his wife is receiving
C. Global aphasia nimodipine (Nimotop), since she suffered
D. Conduction aphasia a cerebral aneurysm rupture. Which
15. Kelly Smith complains that her response by the husband indicates that
headaches are occurring more frequently he understands the drug’s use?
despite medications. Patients with a
history of headaches should be taught to A. “Nimodipine replaces calcium.”
B. “Nimodipine promotes growth of blood
avoid:
vessels in the brain.”
A. Freshly prepared meats. C. “Nimodipine reduces the brain’s demand for
B. Citrus fruits. oxygen.”
C. Skim milk D.  “Nimodipine reduces vasospasm in the
D. Chocolate brain.”
16. Immediately following cerebral 21. Many men who suffer spinal injuries
aneurysm rupture, the patient usually continue to be sexually active. The
complains of: teaching plan for a man with a spinal cord
injury should include sexually concerns.
A. Photophobia Which of the following injuries would most
B. Explosive headache
likely prevent erection and ejaculation?
C. Seizures
D. Hemiparesis A. C5
B. C7 A. Put on a mask and gown before entering the
C. T4 patient’s room.
D. S4 B. Wear gloves and a gown when removing the
22. Cathy Bates, age 36, is a homemaker patient’s bedpan.
who frequently forgets to take her C. Prevent the droplet spread of the organism.
D. Use caution when bringing food to the patient.
carbamazepine (Tegretol). As a result,
27. Discharge instructions for a patient
she has been experiencing seizures. How
who has been operated on for colorectal
can the nurse best help the patient
cancer include irrigating the colostomy.
remember to take her medication?
The nurse knows her teaching is effective
A. Tell her take her medication at bedtime. when the patient states he’ll contact the
B. Instruct her to take her medication after one of doctor if:
her favorite television shows.
C. Explain that she should take her medication A. He experiences abdominal cramping while the
with breakfast. irrigant is infusing
D. Tell her to buy an alarm watch to remind her. B. He has difficulty inserting the irrigation tube
23. Richard Barnes was diagnosed with into the stoma
pneumococcal meningitis. What response C. He expels flatus while the return is running
out
by the patient indicates that he
D. He’s unable to complete the procedure in 1
understands the precautions necessary hour
with this diagnosis? 28. The nurse explains to the patient who
A. “I’m so depressed because I can’t have any has an abdominal perineal resection that
visitors for a week.” an indwelling urinary catheter must be
B. “Thank goodness, I’ll only be in isolation for kept in place for several days afterward
24 hours.” because:
C. “The nurse told me that my urine and stool are
also sources of meningitis bacteria.” A. It prevents urinary tract infection following
D. “The doctor is a good friend of mine and surgery
won’t keep me in isolation.” B. It prevents urine retention and resulting
24. An early symptom associated with pressure on the perineal wound
amyotrophic lateral sclerosis (ALS) C. It minimizes the risk of wound contamination
by the urine
includes:
D. It determines whether the surgery caused
A. Fatigue while talking bladder trauma
B. Change in mental status 29. The first day after, surgery the nurse
C. Numbness of the hands and feet finds no measurable fecal drainage from
D. Spontaneous fractures a patient’s colostomy stoma. What is the
25. When caring for a patient with most appropriate nursing intervention?
esophageal varices, the nurse knows that
bleeding in this disorder usually stems A. Call the doctor immediately.
B. Obtain an order to irrigate the stoma.
from:
C. Place the patient on bed rest and call the
A. Esophageal perforation doctor.
B. Pulmonary hypertension D. Continue the current plan of care.
C. Portal hypertension 30. If a patient’s GI tract is functioning but
D. Peptic ulcers he’s unable to take foods by mouth, the
26. Tiffany Black is diagnosed with type A preferred method of feeding is:
hepatitis. What special precautions
A. Total parenteral nutrition
should the nurse take when caring for this
B. Peripheral parenteral nutrition
patient? C. Enteral nutrition
D. Oral liquid supplements
 31. Which type of solution causes water B. Has a urine output of less than 100 ml in 24
to shift from the cells into the plasma? hours
C. Has a urine output of at least 100 ml in 2
A. Hypertonic hours
B. Hypotonic D. Has pain and burning on urination
C. Isotonic 38. Which nursing action is appropriate to
D. Alkaline prevent infection when obtaining a sterile
32. Particles move from an area of urine specimen from an indwelling urinary
greater osmelarity to one of lesser catheter?
osmolarity through:
A. Aspirate urine from the tubing port using a
A. Active transport sterile syringe and needle
B. Osmosis B. Disconnect the catheter from the tubing and
C. Diffusion obtain urine
D. Filtration C. Open the drainage bag and pour out some
33. Which assessment finding indicates urine
dehydration? D. Wear sterile gloves when obtaining urine
39. After undergoing a transurethral
A. Tenting of chest skin when pinched resection of the prostate to treat benign
B. Rapid filling of hand veins
prostatic hypertrophy, a patient is retuned
C. A pulse that isn’t easily obliterated
D. Neck vein distention to the room with continuous bladder
34. Which nursing intervention would irrigation in place. One day later, the
most likely lead to a hypo-osmolar state? patient reports bladder pain. What should
the nurse do first?
A. Performing nasogastric tube irrigation with
normal saline solution A. Increase the I.V. flow rate
B. Weighing the patient daily B. Notify the doctor immediately
C. Administering tap water enema until the C. Assess the irrigation catheter for patency and
return is clear drainage
D. Encouraging the patient with excessive D. Administer meperidine (Demerol) as
perspiration to dink broth prescribed
35. Which assessment finding would 40. A patient comes to the hospital
indicate an extracellular fluid volume complaining of sudden onset of sharp,
deficit? severe pain originating in the lumbar
region and radiating around the side and
A. Bradycardia
toward the bladder. The patient also
B. A central venous pressure of 6 mm Hg
C. Pitting edema reports nausea and vomiting and appears
D. An orthostatic blood pressure change pale, diaphoretic, and anxious. The doctor
36. A patient with metabolic acidosis has tentatively diagnoses renal calculi and
a preexisting problem with the kidneys. orders flat-plate abdominal X-rays. Renal
Which other organ helps regulate blood calculi can form anywhere in the urinary
pH? tract. What is their most common
formation site?
A. Liver
B. Pancreas A. Kidney
C. Lungs B. Ureter
D. heart C. Bladder
37. The nurse considers the patient D. Urethra
anuric if the patient; 41. A patient comes to the hospital
complaining of severe pain in the right
A. Voids during the nighttime hours flank, nausea, and vomiting. The doctor
tentatively diagnoses right ureter-olithiasis
 (renal calculi). When planning this 46. Gregg Lohan, age 75, is admitted to
patient’s care, the nurse should assign the medical-surgical floor with weakness
highest priority to which nursing and left-sided chest pain. The symptoms
diagnosis? have been present for several weeks after
a viral illness. Which assessment finding
A. Pain
B. Risk of infection is most symptomatic of pericarditis?
C. Altered urinary elimination A. Pericardial friction rub
D. Altered nutrition: less than body requirements B. Bilateral crackles auscultated at the lung bases
42. The nurse is reviewing the report of a C. Pain unrelieved by a change in position
patient’s routine urinalysis. Which of the D. Third heart sound (S3)
following values should the nurse 47. James King is admitted to the hospital
consider abnormal? with right-side-heart failure. When
assessing him for jugular vein distention,
A. Specific gravity of 1.002
B. Urine pH of 3 the nurse should position him:
C. Absence of protein A. Lying on his side with the head of the bed flat.
D. Absence of glucose B. Sitting upright.
43. A patient with suspected renal C. Flat on his back.
insufficiency is scheduled for a D. Lying on his back with the head of the bed
comprehensive diagnostic work-up. After elevated 30 to 45 degrees.
the nurse explains the diagnostic tests, 48. The nurse is interviewing a slightly
the patient asks which part of the kidney overweight 43-year-old man with mild
“does the work.” Which answer is correct? emphysema and borderline hypertension.
He admits to smoking a pack of cigarettes
A. The glomerulus
per day. When developing a teaching
B. Bowman’s capsule
C. The nephron plan, which of the following should
D. The tubular system receive highest priority to help decrease
44. During a shock state, the renin- respiratory complications?
angiotensin-aldosterone system exerts A. Weight reduction
which of the following effects on renal B. Decreasing salt intake
function? C. Smoking cessation
D. Decreasing caffeine intake
A. Decreased urine output, increased
49. What is the ratio of chest
reabsorption of sodium and water
B. Decreased urine output, decreased compressions to ventilations when one
reabsorption of sodium and water rescuer performs cardiopulmonary
C. Increased urine output, increased reabsorption resuscitation (CPR) on an adult?
of sodium and water
D. Increased urine output, decreased reabsorption A. 15:1
of sodium and water B. 15:2
C. 12:1
45. While assessing a patient who
D. 12:2
complained of lower abdominal pressure,
50. When assessing a patient for fluid and
the nurse notes a firm mass extending
electrolyte balance, the nurse is aware
above the symphysis pubis. The nurse
that the organs most important in
suspects:
maintaining this balance are the:
A. A urinary tract infection
A. Pituitary gland and pancreas
B. Renal calculi
B. Liver and gallbladder.
C. An enlarged kidney
C. Brain stem and heart.
D. A distended bladder
D.  Lungs and kidneys.
 Answers and Rationales alkalosis. Anticholinergics have many uses
1. Answer: D. A 1+ pulse indicates weak pulses including reducing GI spasms. Histamine
and is associated with diminished perfusion. receptor blockers are used to decrease
A 4+ is bounding perfusion, a 3+ is increased stomach acidity.
perfusion, a 2+ is normal perfusion, and 0 is 8. Answer: B. Headache and projectile vomiting
absent perfusion. are early signs of increased ICP. Decreased
2. Answer: A.A murmur that indicates heart systolic blood pressure, unconsciousness, and
disease is often accompanied by dyspnea on dilated pupils that don’t reac to light are
exertion, which is a hallmark of heart failure. considered late signs.
Other indicators are tachycardia, syncope, and 9. Answer: A. Immediate bed rest is necessary
chest pain. Subcutaneous emphysema, to prevent further injury. Both eyes should be
thoracic petechiae, and perior-bital edema patched to avoid consensual eye movement
aren’t associated with murmurs and heart and the patient should receive early referral to
disease. an ophthalmologist should treat the condition
3. Answer: C.Pregnancy increase plasma immediately. Retinal reattachment can be
volume and expands the uterine vascular bed, accomplished by surgery only. If the macula
possibly increasing both the heart rate and is detached or threatened, surgery is urgent;
cardiac output. These changes may cause prolonged detachment of the macula results in
cardiac stress, especially during the second permanent loss of central vision.
trimester. Blood pressure during early 10.Answer: C. A chemical burn to the eye
pregnancy may decrease, but it gradually requires immediate instillation of a topical
returns to prepregnancy levels. anesthetic followed by irrigation with copious
4. Answer: D.Decreased cardiac output related amounts of saline solution. Irrigation should
to reduced myocardial contractility is the be done for 5 to 10 minutes, and then the pH
greatest threat to the survival of a patient with of the eye should be checked. Irrigation
cardiomyopathy. The other options can be should be continued until the pH of the eye is
addressed once cardiac output and myocardial restored to neutral (pH 7.0): Double eversion
contractility have been restored. of the eyelids should be performed to look for
5. Answer: D.Evaluation assesses the and remove ciliary spasm, and an antibiotic
effectiveness of the treatment plan by ointment can be administered to reduce the
determining if the patient has met the risk of infection. Then the eye should be
expected treatment outcome. Planning refers patched. Parenteral narcotic analgesia is often
to designing a plan of action that will help the required for pain relief. An ophthalmologist
nurse deliver quality patient care. should also be consulted.
Implementation refers to all of the nursing 11.Answer: B. A positive response to one or
interventions directed toward solving the both tests indicates meningeal irritation that is
patient’s nursing problems. Analysis is the present with meningitis. Brudzinski’s and
process of identifying the patient’s nursing Kernig’s signs don’t occur in CVA, seizure
problems. disorder, or Parkinson’s disease.
6. Answer: B.A basilar skull fracture carries the 12.Answer: D. Gliomas account for
risk of complications of dural tear, causing approximately 45% of all brain tumors.
CSF leakage and damage to cranial nerves I, Meningiomas are the second most common,
II, VII, and VIII. Classic findings in this type with 15%. Angiomas and hemangioblastomas
of fracture may include otorrhea, rhinorrhea, are types of cerebral vascular tumors that
Battle’s signs, and raccoon eyes. Surgical account for 3% of brain tumors.
treatment isn’t always required. 13.Answer: D. The patient with Parkinson’s
7. Answer: A. Barbiturates may be used to disease may be hypersensitive to heat, which
induce a coma in a patient with increased ICP. increases the risk of hyperthermia, and he
This decreases cortical activity and cerebral should be instructed to avoid sun exposure
metabolism, reduces cerebral blood volume, during hot weather.
decreases cerebral edema, and reduces the 14.Answer: C. Global aphasia occurs when all
brain’s need for glucose and oxygen. language functions are affected. Receptive
Carbonic anhydrase inhibitors are used to aphasia, also known as Wernicke’s aphasia,
decrease ocular pressure or to decrease the affects the ability to comprehend written or
serum pH in a patient with metabolic spoken words. Expressive aphasia, also
 known as Broca’s aphasia, affected the meals will also establish a regular routine,
patient’s ability to form language and express which should help compliance.
thoughts. Conduction aphasia refers to 23.Answer: B. Patient with pneumococcal
abnormalities in speech repetition. meningitis require respiratory isolation for the
15.Answer: D. Patients with a history of first 24 hours after treatment is initiated.
headaches, especially migraines, should be 24.Answer: A. Early symptoms of ALS include
taught to keep a food diary to identify fatigue while talking, dysphagia, and
potential food triggers. Typical headache weakness of the hands and arms. ALS doesn’t
triggers include alcohol, aged cheeses, cause a change in mental status, paresthesia,
processed meats, and chocolate and caffeine- or fractures.
containing products. 25.Answer: C. Increased pressure within the
16.Answer: B. An explosive headache or “the portal veins causes them to bulge, leading to
worst headache I’ve ever had” is typically the rupture and bleeding into the lower
first presenting symptom of a bleeding esophagus. Bleeding associated with
cerebral aneurysm. Photophobia, seizures, and esophageal varices doesn’t stem from
hemiparesis may occur later. esophageal perforation, pulmonary
17.Answer: C. An embolic injury, caused by a hypertension, or peptic ulcers.
traveling clot, may result from atrial 26.Answer: B. The nurse should wear gloves and
fibrillation. Blood may pool in the fibrillating a gown when removing the patient’s bedpan
atrium and be released to travel up the because the type A hepatitis virus occurs in
cerebral artery to the brain. Persistent stools. It may also occur in blood,
hypertension may place the patient at risk for nasotracheal secretions, and urine. Type A
a thrombotic injury to the brain. Subarachnoid hepatitis isn’t transmitted through the air by
hemorrhage and skull fractures aren’t way of droplets. Special precautions aren’t
associated with emboli. needed when feeding the patient, but
18.Answer: D. Women with spinal cord injuries disposable utensils should be used.
who were sexually active may continue 27.Answer: B. The patient should notify the
having sexual intercourse and must be doctor if he has difficulty inserting the
reminded that they can still become pregnant. irrigation tube into the stoma. Difficulty with
She may be fully capable of achieving insertion may indicate stenosis of the bowel.
orgasm. An indwelling urinary catheter may Abdominal cramping and expulsion of flatus
be left in place during sexual intercourse. may normally occur with irrigation. The
Positioning will need to be adjusted to fit the procedure will often take an hour to complete.
patient’s needs. 28.Answer: B. An indwelling urinary catheter is
19.Answer: A. The nurse must have a wrench kept in place several days after this surgery to
taped on the vest at all times for quick halo prevent urine retention that could place
removal in emergent situations. The brace pressure on the perineal wound. An
isn’t to be removed for any other reason until indwelling urinary catheter may be a source of
the cervical fracture is healed. Placing a postoperative urinary tract infection. Urine
pillow under the patient’s head may alter the won’t contaminate the wound. An indwelling
stability of the brace. urinary catheter won’t necessarily show
20.Answer: D. Nimodipine is a calcium channel bladder trauma.
blocker that acts on cerebral blood vessels to 29.Answer: D. The colostomy may not function
reduce vasospasm. The drug doesn’t increase for 2 days or more (48 to 72 hours) after
the amount of calcium, affect cerebral surgery. Therefore, the normal plan of care
vasculature growth, or reduce cerebral oxygen can be followed. Since no fecal drainage is
demand. expected for 48 to 72 hours after a colostomy
21.Answer: D. Men with spinal cord injury (only mucous and serosanguineous), the
should be taught that the higher the level of doctor doesn’t have to be notified and the
the lesion, the better their sexual function will stoma shouldn’t be irrigated at this time.
be. The sacral region is the lowest area on the 30.Answer: C. If the patient’s GI tract is
spinal column and injury to this area will functioning, enteral nutrition via a feeding
cause more erectile dysfunction. tube is the preferred method. Peripheral and
22.Answer: C. Tegretol should be taken with total parenteral nutrition places the patient at
food to minimize GI distress. Taking it at risk for infection. If the patient is unable to
 consume foods by mouth, oral liquid within the intravascular compartment would
supplements are contraindicated. cause tachycardia, not bradycardia or
31.Answer: A. A hypertonic solution causes orthostatic blood pressure change. A central
water to shift from the cells into the plasma venous pressure of 6 mm Hg is in the high
because the hypertonic solution has a greater normal range, indicating adequate hydration.
osmotic pressure than the cells. A hypotonic Pitting edema indicates fluid volume
solution has a lower osmotic pressure than overload.
that of the cells. It causes fluid to shift into the 36.Answer: C. The respiratory and renal systems
cells, possibly resulting in rupture. An act as compensatory mechanisms to
isotonic solution, which has the same osmotic counteract-base imbalances. The lungs alter
pressure as the cells, wouldn’t cause any shift. the carbon dioxide levels in the blood by
A solution’s alkalinity is related to the increasing or decreasing the rate and depth of
hydrogen ion concentration, not its osmotic respirations, thereby increasing or decreasing
effect. carbon dioxide elimination. The liver,
32.Answer: C. Particles move from an area of pancreas, and heart play no part in
greater osmolarity to one of lesser osmolarity compensating for acid-base imbalances.
through diffusion. Active transport is the 37.Answer: B. Anuria refers to a urine output of
movement of particles though energy less than 100 ml in 24 hours. The baseline for
expenditure from other sources such as urine output and renal function is 30 ml of
enzymes. Osmosis is the movement of a pure urine per hour. A urine output of at least 100
solvent through a semipermeable membrane ml in 2 hours is within normal limits. Voiding
from an area of greater osmolarity to one of at night is called nocturia. Pain and burning
lesser osmolarity until equalization occurs. on urination is called dysuria.
The membrane is impermeable to the solute 38.Answer: A. To obtain urine properly, the
but permeable to the solvent. Filtration is the nurse should aspirate it from a port, using a
process by which fluid is forced through a sterile syringe after cleaning the port. Opening
membrane by a difference in pressure; small a closed urine drainage system increases the
molecules pass through, but large ones don’t. risk of urinary tract infection. Standard
33.Answer: A. Tenting of chest skin when precautions specify the use of gloves during
pinched indicates decreased skin elasticity due contract with body fluids; however, sterile
to dehydration. Hand veins fill slowly with gloves aren’t necessary.
dehydration, not rapidly. A pulse that isn’t 39.Answer: C. Although postoperative pain is
easily obliterated and neck vein distention expected, the nurse should ensure that other
indicate fluid overload, not dehydration. factors, such as an obstructed irrigation
34.Answer: C. Administering a tap water enema catheter, aren’t the cause of the pain. After
until return is clear would most likely assessing catheter patency, the nurse should
contribute to a hypo-osmolar state. Because administer an analgesic such as meperidine as
tap water is hypotonic, it would be absorbed prescribed. Increasing the I.V. flow rate may
by the body, diluting the body fluid worse the pain. Notifying the doctor isn’t
concentration and lowering osmolarity. necessary unless the pain is severe or
Weighing the patient is the easiest, most unrelieved by the prescribed medication.
accurate method to determine fluid changes. 40.Answer: A. Renal calculi most commonly
Therefore, it helps identify rather than from in the kidney. They may remain there or
contribute to fluid imbalance. Nasogastric become lodged anywhere along the urinary
tube irrigation with normal saline solution tract. The ureter, bladder, and urethra are less
wouldn’t cause a shift in fluid balance. common sites of renal calculi formation.
Drinking broth wouldn’t contribute to a hypo- 41.Answer: A. Ureterolithiasis typically causes
osmolar state because it doesn’t replace such acute, severe pain that the patient can’t
sodium and water lost through excessive rest and becomes increasingly anxious.
perspiration. Therefore, the nursing diagnosis of pain takes
35.Answer: D. An orthostatic blood pressure highest priority. Risk for infection and altered
indicates an extracellular fluid volume deficit. urinary elimination are appropriate once the
(The extracellular compartment consists of patient’s pain is controlled. Altered nutrition:
both the intravascular compartment and less than body requirements isn’t appropriate
interstitial space.) A fluid volume deficit at this time.
42.Answer: B. Normal urine pH is 4.5 to 8; fluid and electrolytes. The other organs play
therefore, a urine pH of 3 is abnormal and secondary roles in maintaining homeostasis.
may indicate such conditions as renal
tuberculosis, pyrexia, phenylketonuria,
alkaptonuria, and acidosis. Urine specific
gravity normally ranges from 1.002 to 1.032,
making the patient’s value normal. Normally,
urine contains no protein, glucose, ketones,
bilirubin, bacteria, casts, or crystals.
43.Answer: C. The nephron is the kidney’s
functioning unit. The glomerulus, Bowman’s
capsule, and tubular system are components
of the nephron.
44.Answer: A. As a response to shock, the renin-
angiotensin-aldosterone system alters renal
function by decreasing urine output and
increasing reabsorption of sodium and water.
Reduced renal perfusion stimulates the renin-
angiotensin-aldosterone system in an effort to
conserve circulating volume.
45.Answer: D. The bladder isn’t usually
palpable unless it is distended. The feeling of
pressure is usually relieved with urination.
Reduced bladder tone due to general
anesthesia is a common postoperative
complication that causes difficulty in voiding.
A urinary tract infection and renal calculi
aren’t palpable. The kidneys aren’t palpable
above the symphysis pubis.
46.Answer: A. A pericardial friction rub may be
present with the pericardial effusion of
pericarditis. The lungs are typically clear
when auscultated. Sitting up and leaning
forward often relieves pericarditis pain. An S3
indicates left-sided heart failure and isn’t
usually present with pericarditis.
47.Answer: D. Assessing jugular vein distention
should be done when the patient is in semi-
Fowler’s position (head of the bed elevated 30
to 45 degrees). If the patient lies flat, the veins
will be more distended; if he sits upright, the
veins will be flat.
48.Answer: C. Smoking should receive highest
priority when trying to reduce risk factors for
with respiratory complications. Losing weight
and decreasing salt and caffeine intake can
help to decrease risk factors for hypertension.
49.Answer: B. The correct ratio of compressions
to ventilations when one rescuer performs
CPR is 15:2
50.Answer: D. The lungs and kidneys are the
body’s regulators of homeostasis. The lungs
are responsible for removing fluid and carbon
dioxide; the kidneys maintain a balance of
 NCLEX Practice Exam for Medical Surgical Nursing 1 B. “Mr, Pablo, you must be so worried, I’ll leave
you alone with your thoughts.
1. Following surgery, Mario complains of C. “Mr. Pablo, you’ll wear out the hospital floors
mild incisional pain while performing and yourself at this rate.”
deep- breathing and coughing exercises. D.  “Mr. Pablo, you appear anxious to me. How
The nurse’s best response would be: are you feeling about tomorrow’s surgery?”
6. After surgery, Gina returns from the
A. “Pain will become less each day.”
Post-anesthesia Care Unit (Recovery
B.  “This is a normal reaction after surgery.”
C. “With a pillow, apply pressure against the Room) with a nasogastric tube in place
incision.” following a gall bladder surgery. She
D.  “I will give you the pain medication the continues to complain of nausea. Which
physician ordered.” action would the nurse take?
2. The nurse needs to carefully assess
A. Call the physician immediately.
the complaint of pain of the elderly
B. Administer the prescribed antiemetic.
because older people C. Check the patency of the nasogastric tube for
A. are expected to experience chronic pain any obstruction.
B. have a decreased pain threshold D. Change the patient’s position.
C. experience reduced sensory perception 7. Mr. Perez is in continuous pain from
D. have altered mental function cancer that has metastasized to the bone.
3. Mary received AtropineSO4 as a pre- Pain medication provides little relief and
medication 30 minutes ago and is now he refuses to move. The nurse should
complaining of dry mouth and her PR is plan to:
higher, than before the medication was
A. Reassure him that the nurses will not hurt him
administered. The nurse’s best B. Let him perform his own activities of daily
A. The patient is having an allergic reaction to living
the drug. C. Handle him gently when assisting with
B. The patient needs a higher dose of this drug required care
C. This is normal side-effect of AtSO4 D. Complete A.M. care quickly as possible when
D. The patient is anxious about upcoming necessary
surgery 8. A client returns from the recovery room
4. Ana’s postoperative vital signs are a at 9AM alert and oriented, with an IV
blood pressure of 80/50 mm Hg, a pulse infusing. His pulse is 82, blood pressure
of 140, and respirations of 32. Suspecting is 120/80, respirations are 20, and all are
shock, which of the following orders within normal range. At 10 am and at 11
would the nurse question? am, his vital signs are stable. At noon,
however, his pulse rate is 94, blood
A. Put the client in modified Trendelenberg’s pressure is 116/74, and respirations are
position.
B. Administer oxygen at 100%. 24. What nursing action is most
C. Monitor urine output every hour. appropriate?
D. Administer Demerol 50mg IM q4h
A. Notify his physician.
5. Mr. Pablo, diagnosed with Bladder B. Take his vital signs again in 15 minutes.
Cancer, is scheduled for a cystectomy C.  Take his vital signs again in an hour.
with the creation of an ileal conduit in the D. Place the patient in shock position.
morning. He is wringing his hands and 9. A 56 year old construction worker is
pacing the floor when the nurse enters his brought to the hospital unconscious after
room. What is the best approach? falling from a 2-story building. When
assessing the client, the nurse would be
A. “Good evening, Mr. Pablo. Wasn’t it a
pleasant day, today?” most concerned if the assessment
revealed:
A.  Reactive pupils B. “Place one tablet under your tongue. If the
B. A depressed fontanel pain is not relieved in 15 minutes, go to the
C.  Bleeding from ears hospital.”
D.  An elevated temperature C. “Continue your activity, and if the pain does
10. Which of the ff. statements by the not go away in 10 minutes, begin taking the
client to the nurse indicates a risk factor nitro tablets one every 5 minutes for 15
minutes, then go lie down.”
for CAD?
D. “Place one Nitroglycerine tablet under the
A. “I exercise every other day.” tongue every five minutes for three doses. Go
B. “My father died of Myasthenia Gravis.” to the hospital if the pain is unrelieved.
C. “My cholesterol is 180.” 15. A client with chronic heart failure has
D. “I smoke 1 1/2 packs of cigarettes per day.” been placed on a diet restricted to
11. Mr. Braga was ordered Digoxin 0.25 2000mg. of sodium per day. The client
mg. OD. Which is poor knowledge demonstrates adequate knowledge if
regarding this drug? behaviors are evident such as not salting
food and avoidance of which food?
A. It has positive inotropic and negative
chronotropic effects A. Whole milk
B. The positive inotropic effect will decrease B. Canned sardines
urine output C. Plain nuts
C. Toxixity can occur more easily in the D. Eggs
presence of hypokalemia, liver and renal
16. A student nurse is assigned to a client
problems
D. Do not give the drug if the apical rate is less who has a diagnosis of thrombophlebitis.
than 60 beats per minute. Which action by this team member is
12. Valsalva maneuver can result in most appropriate?
bradycardia. Which of the following A. Apply a heating pad to the involved site.
activities will not stimulate Valsalva’s B. Elevate the client’s legs 90 degrees.
maneuver? C. Instruct the client about the need for bed rest.
D. Provide active range-of-motion exercises to
A. Use of stool softeners. both legs at least twice every shift.
B. Enema administration
17. A client receiving heparin sodium
C. Gagging while toothbrushing.
D. Lifting heavy objects asks the nurse how the drug works.
13. The nurse is teaching the patient Which of the following points would the
regarding his permanent artificial nurse include in the explanation to the
pacemaker. Which information given by client?
the nurse shows her knowledge deficit A. It dissolves existing thrombi.
about the artificial cardiac pacemaker? B. It prevents conversion of factors that are
needed in the formation of clots.
A. take the pulse rate once a day, in the morning C. It inactivates thrombin that forms and
upon awakening dissolves existing thrombi.
B. may be allowed to use electrical appliances D. It interferes with vitamin K absorption.
C. have regular follow up care
18. The nurse is conducting an education
D. may engage in contact sports
session for a group of smokers in a “stop
14. A patient with angina pectoris is being
smoking” class. Which finding would the
discharged home with nitroglycerine
nurse state as a common symptom of
tablets. Which of the following instructions
lung cancer? :
does the nurse include in the teaching?
A. Dyspnea on exertion
A. “When your chest pain begins, lie down, and
B. Foamy, blood-tinged sputum
place one tablet under your tongue. If the pain C. Wheezing sound on inspiration
continues, take another tablet in 5 minutes.”
D. Cough or change in a chronic cough
 19. Which is the most relevant knowledge 23. A client with COPD is being prepared
about oxygen administration to a client for discharge. The following are relevant
with COPD? instructions to the client regarding the use
of an oral inhaler EXCEPT
A. Oxygen at 1-2L/min is given to maintain the
hypoxic stimulus for breathing. A. Breath in and out as fully as possible before
B. Hypoxia stimulates the central placing the mouthpiece inside the mouth.
chemoreceptors in the medulla that makes the B. Inhale slowly through the mouth as the
client breath. canister is pressed down
C. Oxygen is administered best using a non- C. Hold his breath for about 10 seconds before
rebreathing mask exhaling
D. Blood gases are monitored using a pulse D. Slowly breath out through the mouth with
oximeter. pursed lips after inhaling the drug.
20. When suctioning mucus from a 24. A client is scheduled for a
client’s lungs, which nursing action would bronchoscopy. When teaching the client
be least appropriate? what to expect afterward, the nurse’s
A. Lubricate the catheter tip with sterile saline highest priority of information would be
before insertion. A. Food and fluids will be withheld for at least 2
B. Use sterile technique with a two-gloved hours.
approach B. Warm saline gargles will be done q 2h.
C. Suction until the client indicates to stop or no C. Coughing and deep-breathing exercises will
longer than 20 second be done q2h.
D. Hyperoxygenate the client before and after D.  Only ice chips and cold liquids will be
suctioning allowed initially.
21. Dr. Santos prescribes oral rifampin 25. The nurse enters the room of a client
(Rimactane) and isoniazid (INH) for a with chronic obstructive pulmonary
client with a positive Tuberculin skin test. disease. The client’s nasal cannula
When informing the client of this decision, oxygen is running at a rate of 6 L per
the nurse knows that the purpose of this minute, the skin color is pink, and the
choice of treatment is to respirations are 9 per minute and shallow.
A. Cause less irritation to the gastrointestinal What is the nurse’s best initial action?
tract
A. Take heart rate and blood pressure.
B. Destroy resistant organisms and promote
B. Call the physician.
proper blood levels of the drugs
C. Lower the oxygen rate.
C. Gain a more rapid systemic effect
D. Position the client in a Fowler’s position.
D. Delay resistance and increase the
tuberculostatic effect 26. The nurse is preparing her plan of
22. Mario undergoes a left thoracotomy care for her patient diagnosed with
and a partial pneumonectomy. Chest pneumonia. Which is the most
tubes are inserted, and one-bottle water- appropriate nursing diagnosis for this
seal drainage is instituted in the operating patient?
room. In the postanesthesia care unit A. Fluid volume deficit
Mario is placed in Fowler’s position on B. Decreased tissue perfusion.
either his right C. Impaired gas exchange.
side or on his back to D. Risk for infection
27. A nurse at the weight loss clinic
A. Reduce incisional pain. assesses a client who has a large
B. Facilitate ventilation of the left lung.
abdomen and a rounded face. Which
C. Equalize pressure in the pleural space.
D. Increase venous return additional assessment finding would lead
 the nurse to suspect that the client has D. “The medication will increase the synthesis of
Cushing’s syndrome rather than obesity? thyroid hormones.”
32. During the first 24 hours after thyroid
A. large thighs and upper arms surgery, the nurse should include in her
B. pendulous abdomen and large hips
care:
C. abdominal striae and ankle enlargement
D. posterior neck fat pad and thin extremities A. Checking the back and sides of the operative
28. Which statement by the client dressing
indicates understanding of the possible B. Supporting the head during mild range of
side effects of Prednisone therapy? motion exercise
C. Encouraging the client to ventilate her
A. “I should limit my potassium intake because feelings about the surgery
hyperkalemia is a side-effect of this drug.” D. Advising the client that she can resume her
B. “I must take this medicine exactly as my normal activities immediately
doctor ordered it. I shouldn’t skip doses.” 33. On discharge, the nurse teaches the
C. “This medicine will protect me from getting patient to observe for signs of surgically
any colds or infection.”
induced hypothyroidism. The nurse would
D. “My incision will heal much faster because of
this drug.” know that the patient understands the
29. A client, who is suspected of having teaching when she states she should
Pheochromocytoma, complains of notify the MD if she develops:
sweating, palpitation and headache. A. Intolerance to heat
Which assessment is essential for the B. Dry skin and fatigue
nurse to make first? C. Progressive weight gain
D. Insomnia and excitability
A. Pupil reaction 34. What is the best reason for the nurse
B. Hand grips
in instructing the client to rotate injection
C. Blood pressure
D. Blood glucose sites for insulin?
30. The nurse is attending a bridal shower A. Lipodystrophy can result and is extremely
for a friend when another guest, who painful
happens to be a diabetic, starts to tremble B. Poor rotation technique can cause superficial
and complains of dizziness. The next best hemorrhaging
C. Lipodystrophic areas can result, causing
action for the nurse to take is to:
erratic insulin absorption rates from these
A. Encourage the guest to eat some baked D. Injection sites can never be reused
macaroni 35. Which of the following would be
B. Call the guest’s personal physician inappropriate to include in a diabetic
C. Offer the guest a cup of coffee teaching plan?
D. Give the guest a glass of orange juice
31. An adult, who is newly diagnosed with A. Change position hourly to increase circulation
Graves disease, asks the nurse, “Why do B. Inspect feet and legs daily for any changes
C. Keep legs elevated on 2 pillows while
I need to take Propanolol (Inderal)?”
sleeping
Based on the nurse’s understanding of D. Keep the insulin not in use in the refrigerator
the medication and Grave’s disease, the 36. Included in the plan of care for the
best response would be: immediate post-gastroscopy period will
A. “The medication will limit thyroid hormone be:
secretion.”
A. Maintain NGT to intermittent suction
B. “The medication limit synthesis of the thyroid
B. Assess gag reflex prior to administration of
hormones.”
fluids
C. “The medication will block the cardiovascular
C. Assess for pain and medicate as ordered
symptoms of Grave’s disease.”
D. Measure abdominal girth every 4 hours
 37. Which description of pain would be 42. The husband of a client asks the
most characteristic of a duodenal ulcer? nurse about the protein-restricted diet
ordered because of advanced liver
A. Gnawing, dull, aching, hungerlike pain in the
epigastric area that is relieved by food intake disease. What statement by the nurse
B. RUQ pain that increases after meal would best explain the purpose of the
C. Sharp pain in the epigastric area that radiates diet?
to the right shoulder
D. A sensation of painful pressure in the A. “The liver cannot rid the body of ammonia
midsternal area that is made by the breakdown of protein in
the digestive system.”
38. The client underwent Billroth surgery
B. “The liver heals better with a high
for gastric ulcer. Post-operatively, the carbohydrates diet rather than protein.”
drainage from his NGT is thick and the C. “Most people have too much protein in their
volume of secretions has dramatically diets. The amount of this diet is better for liver
reduced in the last 2 hours and the client healing.”
feels like vomiting. The most appropriate D. “Because of portal hyperemesis, the blood
flows around the liver and ammonia made
nursing action is to:
from protein collects in the brain causing
A. Reposition the NGT by advancing it gently hallucinations.”
NSS 43. Which of the drug of choice for pain
B. Notify the MD of your findings controls the patient with acute
C. Irrigate the NGT with 50 cc of sterile pancreatitis?
D. Discontinue the low-intermittent suction
39. After Billroth II Surgery, the client A. Morphine
developed dumping syndrome. Which of B. NSAIDS
C. Meperidine
the following should the nurse exclude in
D. Codeine
the plan of care?
44. Immediately after cholecystectomy,
A. Sit upright for at least 30 minutes after meals the nursing action that should assume the
B. Take only sips of H2O between bites of solid highest priority is:
food
C. Eat small meals every 2-3 hours A. encouraging the client to take adequate deep
D. Reduce the amount of simple carbohydrate in breaths by mouth
the diet B. encouraging the client to cough and deep
40. The laboratory of a male patient with breathe
C. changing the dressing at least BID
Peptic ulcer revealed an elevated titer of
D. irrigate the T-tube frequently
Helicobacter pylori. Which of the following
45. A Sengstaken-Blakemore tube is
statements indicate an understanding of
inserted in the effort to stop the bleeding
this data?
esophageal varices in a patient with
A. Treatment will include Ranitidine and complicated liver cirrhosis. Upon insertion
Antibiotics of the tube, the client complains of
B. No treatment is necessary at this time difficulty of breathing. The first action of
C. This result indicates gastric cancer caused by
the nurse is to:
the organism
D. Surgical treatment is necessary A. Deflate the esophageal balloon
41. What instructions should the client be B. Monitor VS
given before undergoing a paracentesis? C. Encourage him to take deep breaths
D. Notify the MD
A. NPO 12 hours before procedure 46. The client presents with severe rectal
B. Empty bladder before procedure
bleeding, 16 diarrheal stools a day,
C. Strict bed rest following procedure
D. Empty bowel before procedure severe abdominal pain, tenesmus and
dehydration. Because of these symptoms
 the nurse should be alert for other against the incision with a pillow will help
problems associated with what disease? lessen the intra-abdominal pressure created by
coughing which causes tension on the incision
A. Chrons disease that leads to pain.
B. Ulcerative colitis 2. Answer: (C) experience reduced sensory
C. Diverticulitis perception . Degenerative changes occur in
D. Peritonitis the elderly. The response to pain in the elderly
47. A client is being evaluated for cancer maybe lessened because of reduced acuity of
of the colon. In preparing the client for touch, alterations in neural pathways and
diminished processing of sensory data.
barium enema, the nurse should:
3. Answer: (C) This is normal side-effect of
A. Give laxative the night before and a cleansing AtSO4. Atropine sulfate is a vagolytic drug
enema in the morning before the test that decreases oropharyngeal secretions and
B. Render an oil retention enema and give increases the heart rate.
laxative the night before 4. Answer: (D) Administer Demerol 50mg IM
C. Instruct the client to swallow 6 radiopaque q4h. Administering Demerol, which is a
tablets the evening before the study narcotic analgesic, can depress respiratory and
D. Place the client on CBR a day before the cardiac function and thus not given to a
study patient in shock. What is needed is promotion
48. The client has a good understanding for adequate oxygenation and perfusion. All
the other interventions can be expected to be
of the means to reduce the chances of
done by the nurse.
colon cancer when he states: 5. Answer: (D) “Mr. Pablo, you appear
A. “I will exercise daily.” anxious to me. How are you feeling about
B. “I will include more red meat in my diet.” tomorrow’s surgery?”. The client is showing
C. “I will have an annual chest x-ray.” signs of anxiety reaction to a stressful event.
D.  “I will include more fresh fruits and Recognizing the client’s anxiety conveys
vegetables in my diet.” acceptance of his behavior and will allow for
verbalization of feelings and concerns.
49. Days after abdominal surgery, the 6. Answer: (C) Check the patency of the
client’s wound dehisces. The safest nasogastric tube for any
nursing intervention when this occurs is to obstruction. Nausea is one of the common
complaints of a patient after receiving general
A. Cover the wound with sterile, moist saline anesthesia. But this complaint could be
dressing aggravated by gastric distention especially in
B. Approximate the wound edges with tapes a patient who has undergone abdominal
C. Irrigate the wound with sterile saline surgery. Insertion of the NGT helps relieve
D. Hold the abdominal contents in place with a the problem. Checking on the patency of the
sterile gloved hand NGT for any obstruction will help the nurse
50. An intravenous pyelogram reveals determine the cause of the problem and
that Paulo, age 35, has a renal calculus. institute the necessary intervention.
He is believed to have a small stone that 7. Answer: (C) Handle him gently when
will pass spontaneously. To increase the assisting with required care . Patients with
chance of the stone passing, the nurse cancer and bone metastasis experience severe
pain especially when moving. Bone tumors
would instruct the client to force fluids and weaken the bone to appoint at which normal
to activities and even position changes can lead
to fracture. During nursing care, the patient
A. Strain all urine.
needs to be supported and handled gently.
B. Ambulate.
8. Answer: (B) Take his vital signs again in 15
C. Remain on bed rest.
minutes. Monitoring the client’s vital signs
D. Ask for medications to relax him.
following surgery gives the nurse a sound
Answers and Rationales information about the client’s condition.
1. Answer: (C) “With a pillow, apply pressure Complications can occur during this period as
against the incision.” Applying pressure a result of the surgery or the anesthesia or
 both. Keeping close track of changes in the 17.Answer: (B) It prevents conversion of
VS and validating them will help the nurse factors that are needed in the formation of
initiate interventions to prevent complications clots. Heparin is an anticoagulant. It prevents
from occurring. the conversion of prothrombin to thrombin. It
9. Answer: (C) Bleeding from ears . The nurse does not dissolve a clot.
needs to perform a thorough assessment that 18.Answer: (D) Cough or change in a chronic
could indicate alterations in cerebral function, cough .Cigarette smoke is a carcinogen that
increased intracranial pressures, fractures and irritates and damages the respiratory
bleeding. Bleeding from the ears occurs only epithelium. The irritation causes the cough
with basal skull fractures that can easily which initially maybe dry, persistent and
contribute to increased intracranial pressure unproductive. As the tumor enlarges,
and brain herniation. obstruction of the airways occurs and the
10.Answer: (D) “I smoke 1 1/2 packs of cough may become productive due to
cigarettes per day.” Smoking has been infection.
considered as one of the major modifiable risk 19.Answer: (A) Oxygen at 1-2L/min is given to
factors for coronary artery disease. Exercise maintain the hypoxic stimulus for
and maintaining normal serum cholesterol breathing. COPD causes a chronic CO2
levels help in its prevention. retention that renders the medulla insensitive
11.Answer: (B) The positive inotropic effect to the CO2 stimulation for breathing. The
will decrease urine output . Inotropic effect hypoxic state of the client then becomes the
of drugs on the heart causes increase force of stimulus for breathing. Giving the
its contraction. This increases cardiac output clientoxygen in low concentrations will
that improves renal perfusion resulting in an maintain the client’s hypoxic drive.
improved urine output. 20.Answer: (C) Suction until the client
12.Answer: (A) Use of stool softeners. Straining indicates to stop or no longer than 20
or bearing down activities can cause vagal second .One hazard encountered when
stimulation that leads to bradycardia. Use of suctioning a client is the development of
stool softeners promote easy bowel hypoxia. Suctioning sucks not only the
evacuation that prevents straining or the secretions but also the gases found in the
valsalva maneuver. airways. This can be prevented by suctioning
13.Answer: (D) may engage in contact the client for an average time of 5-10 seconds
sports . The client should be advised by the and not more than 15 seconds and
nurse to avoid contact sports. This will hyperoxygenating the client before and after
prevent trauma to the area of the pacemaker suctioning.
generator. 21.Answer: (D) Delay resistance and increase
14.Answer: (D) “Place one Nitroglycerine the tuberculostatic effect . Pulmonary TB is
tablet under the tongue every five minutes treated primarily with chemotherapeutic
for three doses. Go to the hospital if the agents for 6-12 mons. A prolonged treatment
pain is unrelieved. Angina pectoris is caused duration is necessary to ensure eradication of
by myocardial ischemia related to decreased the organisms and to prevent relapse. The
coronary blood supply. Giving nitroglycerine increasing prevalence of drug resistance
will produce coronary vasodilation that points to the need to begin the treatment with
improves the coronary blood flow in 3 – 5 drugs in combination. Using drugs in
mins. If the chest pain is unrelieved, after combination can delay the drug resistance.
three tablets, there is a possibility of acute 22.Answer: (B) Facilitate ventilation of the left
coronary occlusion that requires immediate lung.  Since only a partial pneumonectomy is
medical attention. done, there is a need to promote expansion of
15.Answer: (B) Canned sardines . Canned this remaining Left lung by positioning the
foods are generally rich in sodium content as client on the opposite unoperated side.
salt is used as the main preservative. 23.Answer: (D) Slowly breath out through the
16.Answer: (C) Instruct the client about the mouth with pursed lips after inhaling the
need for bed rest. In a client with drug. If the client breathes out through the
thrombophlebitis, bedrest will prevent the mouth with pursed lips, this can easily force
dislodgment of the clot in the extremity which the just inhaled drug out of the respiratory
can lead to pulmonary embolism. tract that will lessen its effectiveness.
24.Answer: (A) Food and fluids will be 31.Answer: (C) “The medication will block the
withheld for at least 2 hours.  Prior to cardiovascular symptoms of Grave’s
bronchoscopy, the doctors sprays the back of disease.” Propranolol (Inderal) is a beta-
the throat with anesthetic to minimize the gag adrenergic blocker that controls the
reflex and thus facilitate the insertion of the cardiovascular manifestations brought about
bronchoscope. Giving the client food and by increased secretion of the thyroid hormone
drink after the procedure without checking on in Grave’s disease.
the return of the gag reflex can cause the 32.Answer: (A) Checking the back and sides
client to aspirate. The gag reflex usually of the operative dressing . Following surgery
returns after two hours. of the thyroid gland, bleeding is a potential
25.Answer: (C) Lower the oxygen rate.  The complication. This can best be assessed by
client with COPD is suffering from chronic checking the back and the sides of the
CO2 retention. The hypoxic drive is his chief operative dressing as the blood may flow
stimulus for breathing. Giving O2 inhalation towards the side and back leaving the front
at a rate that is more than 2-3L/min can make dry and clear of drainage.
the client lose his hypoxic drive which can be 33.Answer: (C) Progressive weight
assessed as decreasing RR. gain . Hypothyroidism, a decrease in thyroid
26.Answer: (C) Impaired gas exchange. hormone production, is characterized by
Pneumonia, which is an infection, causes hypometabolism that manifests itself with
lobar consolidation thus impairing gas weight gain.
exchange between the alveoli and the blood. 34.Answer: (C) Lipodystrophic areas can
Because the patient would require adequate result, causing erratic insulin absorption
hydration, this makes him prone to fluid rates from these . Lipodystrophy is the
volume excess. development of fibrofatty masses at the
27.Answer: (D) posterior neck fat pad and injection site caused by repeated use of an
thin extremities .“ Buffalo hump” is the injection site. Injecting insulin into these
accumulation of fat pads over the upper back scarred areas can cause the insulin to be
and neck. Fat may also accumulate on the poorly absorbed and lead to erratic reactions.
face. There is truncal obesity but the 35.Answer: (C) Keep legs elevated on 2 pillows
extremities are thin. All these are noted in a while sleeping . The client with DM has
client with Cushing’s syndrome. decreased peripheral circulation caused by
28.Answer: (B) “I must take this medicine microangiopathy. Keeping the legs elevated
exactly as my doctor ordered it. I shouldn’t during sleep will further cause circulatory
skip doses.”  The possible side effects of impairment.
steroid administration are hypokalemia, 36.Answer: (B) Assess gag reflex prior to
increase tendency to infection and poor administration of fluids . The client, after
wound healing. Clients on the drug must gastroscopy, has temporary impairment of the
follow strictly the doctor’s order since gag reflex due to the anesthetic that has been
skipping the drug can lower the drug level in sprayed into his throat prior to the procedure.
the blood that can trigger acute adrenal Giving fluids and food at this time can lead to
insufficiency or Addisonian Crisis aspiration.
29.Answer: (C) Blood 37.Answer: (A) Gnawing, dull, aching,
pressure . Pheochromocytoma is a tumor of hungerlike pain in the epigastric area that
the adrenal medulla that causes an increase is relieved by food intake . Duodenal ulcer is
secretion of catecholamines that can elevate related to an increase in the secretion of HCl.
the blood pressure. This can be buffered by food intake thus the
30.Answer: (D) Give the guest a glass of relief of the pain that is brought about by food
orange juice . In diabetic patients, the nurse intake.
should watch out for signs of hypoglycemia 38.Answer: (B) Notify the MD of your findings
manifested by dizziness, tremors, weakness, . The client’s feeling of vomiting and the
pallor diaphoresis and tachycardia. When this reduction in the volume of NGT drainage that
occurs in a conscious client, he should be is thick are signs of possible abdominal
given immediately carbohydrates in the form distention caused by obstruction of the NGT.
of fruit juice, hard candy, honey or, if This should be reported immediately to the
unconscious, glucagons or dextrose per IV.
 MD to prevent tension and rupture on the site is in the oropharynx causing airway
of anastomosis caused by gastric distention. obstruction
39.Answer: (A) Sit upright for at least 30 46.Answer: (B) Ulcerative colitis . Ulcerative
minutes after meals  . The dumping colitis is a chronic inflammatory condition
syndrome occurs within 30 mins after a meal producing edema and ulceration affecting the
due to rapid gastric emptying, causing entire colon. Ulcerations lead to sloughing
distention of the duodenum or jejunum that causes stools as many as 10-20 times a
produced by a bolus of food. To delay the day that is filled with blood, pus and mucus.
emptying, the client has to lie down after The other symptoms mentioned accompany
meals. Sitting up after meals will promote the the problem.
dumping syndrome. 47.Answer: (A) Give laxative the night before
40.Answer: (A) Treatment will include and a cleansing enema in the morning
Ranitidine and Antibiotics . One of the before the test .Barium enema is the
causes of peptic ulcer is H. Pylori infection. It radiologic visualization of the colon using a
releases toxin that destroys the gastric and die. To obtain accurate results in this
duodenal mucosa which decreases the gastric procedure, the bowels must be emptied of
epithelium’s resistance to acid digestion. fecal material thus the need for laxative and
Giving antibiotics will control the infection enema.
and Ranitidine, which is a histamine-2 48.Answer: (D) “I will include more fresh
blocker, will reduce acid secretion that can fruits and vegetables in my diet.”
lead to ulcer. Numerous aspects of diet and nutrition may
41.Answer: (B) Empty bladder before contribute to the development of cancer. A
procedure . Paracentesis involves the low-fiber diet, such as when fresh fruits and
removal of ascitic fluid from the peritoneal vegetables are minimal or lacking in the diet,
cavity through a puncture made below the slows transport of materials through the gut
umbilicus. The client needs to void before the which has been linked to colorectal cancer.
procedure to prevent accidental puncture of a 49.Answer: (A) Cover the wound with sterile,
distended bladder during the procedure. moist saline dressing . Dehiscence is the
42.Answer: (A) “The liver cannot rid the body partial or complete separation of the surgical
of ammonia that is made by the breakdown wound edges. When this occurs, the client is
of protein in the digestive system.”  The placed in low Fowler’s position and instructed
largest source of ammonia is the enzymatic to lie quietly. The wound should be covered to
and bacterial digestion of dietary and blood protect it from exposure and the dressing must
proteins in the GI tract. A protein-restricted be sterile to protect it from infection and moist
diet will therefore decrease ammonia to prevent the dressing from sticking to the
production. wound which can disturb the healing process.
43.Answer: (C) Meperidine . Pain in acute 50.Answer: (B) Ambulate. Free unattached
pancreatitis is caused by irritation and edema stones in the urinary tract can be passed out
of the inflamed pancreas as well as spasm due with the urine by ambulation which can
to obstruction of the pancreatic ducts. mobilize the stone and by increased fluid
Demerol is the drug of choice because it is intake which will flush out the stone during
less likely to cause spasm of the Sphincter of urination.
Oddi unlike Morphine which is spasmogenic.
44.Answer: (B) encouraging the client to
cough and deep breathe . Cholecystectomy
requires a subcostal incision. To minimize
pain, clients have a tendency to take shallow
breaths which can lead to respiratory
complications like pneumonia and atelectasis.
Deep breathing and coughing exercises can
help prevent such complications.
45.Answer: (A) Deflate the esophageal balloon
. When a client with a Sengstaken-Blakemore
tube develops difficulty of breathing, it means
the tube is displaced and the inflated balloon
 NCLEX Practice Exam for Medical Surgical Nursing 3 important activity to facilitate walking with
1. The nurse is assisting in planning care crutches before ambulation begun is:
for a client with a diagnosis of immune A. Exercising the triceps, finger flexors, and
deficiency. The nurse would incorporate elbow extensors
which of the ff. as a priority in the plan of B. Sitting up at the edge of the bed to help
care? strengthen back muscles
C. Doing isometric exercises on the unaffected
A.  providing emotional support to decrease fear leg
B.  protecting the client from infection D. Using the trapeze frequently for pull-ups to
C.  encouraging discussion about lifestyle strengthen the biceps muscles
changes 6. The nurse recognizes that a client
D. .identifying factors that decreased the immune understood the demonstration of crutch
function
walking when she places her weight on:
2. Joy, an obese 32 year old, is admitted
to the hospital after an automobile A. The palms and axillary regions
accident. She has a fractured hip and is B. Both feet placed wide apart
brought to the OR for surgery. C. The palms of her hands
D. Her axillary regions
After surgery Joy is to receive a piggy-
7. Joey is a 46 year-old radio technician
back of Clindamycin phosphate (Cleocin)
who is admitted because of mild chest
300 mg in 50 ml of D5W. The piggyback
pain. He is 5 feet, 8 inches tall and
is to infuse in 20 minutes. The drop factor
weighs 190 pounds. He is diagnosed with
of the IV set is 10 gtt/ml. The nurse
a myocardial infarct. Morphine sulfate,
should set the piggyback to flow at:
Diazepam (Valium) and Lidocaine are
A. 25 gtt/min prescribed.
B. 30 gtt/min The physician orders 8 mg of Morphine
C. 5 gtt/min Sulfate to be given IV. The vial on hand is
D. 45 gtt/min
labeled 1 ml/ 10 mg. The nurse should
3. The day after her surgery Joy asks the
administer:
nurse how she might lose weight. Before
answering her question, the nurse should A. 8 minims
bear in mind that long-term weight loss B. 10 minims
best occurs when: C. 12 minims
D. 15 minims
A. Fats are controlled in the diet 8. Joey asks the nurse why he is
B. Eating habits are altered receiving the injection of Morphine after
C. Carbohydrates are regulated he was hospitalized for severe anginal
D. Exercise is part of the program
pain. The nurse replies that it:
4. The nurse teaches Joy, an obese
client, the value of aerobic exercises in A. Will help prevent erratic heart beats
her weight reduction program. The nurse B. Relieves pain and decreases level of anxiety
would know that this teaching was C.  Decreases anxiety
D.  Dilates coronary blood vessels
effective when Joy says that exercise will:
9. Oxygen 3L/min by nasal cannula is
A. Increase her lean body mass prescribed for Joey who is admitted to the
B. Lower her metabolic rate hospital for chest pain. The nurse
C. Decrease her appetite institutes safety precautions in the room
D. Raise her heart rate
because oxygen:
5. The physician orders non-weight
bearing with crutches for Joy, who had A. Converts to an alternate form of matter
surgery for a fractured hip. The most B. Has unstable properties
C. Supports combustion
D. Is flammable B. Tell him that he certainly needs to be
10. Myra is ordered laboratory tests after especially careful about his diet and lifestyle.
she is admitted to the hospital for angina. C. Avoid giving him direct information and help
him explore his feelings
The isoenzyme test that is the most
D. Recognize that he is frightened and suggest he
reliable early indicator of myocardial insult talk with the psychiatrist or counselor.
is: 15. Ana, 55 years old, is admitted to the
A. SGPT hospital to rule out pernicious anemia. A
B. LDH Schilling test is ordered for Ana. The
C. CK-MB nurse recognizes that the primary
D. AST purpose of the Schilling test is to
11. An early finding in the EKG of a client determine the client’s ability to:
with an infarcted mycardium would be:
A. Store vitamin B12
A. Disappearance of Q waves B. Digest vitamin B12
B. Elevated ST segments C. Absorb vitamin B12
C. Absence of P wave D. Produce vitamin B12
D. Flattened T waves 16. Ana is diagnosed to have Pernicious
12. Jose, who had a myocardial infarction anemia. The physician orders 0.2 mg of
2 days earlier, has been complaining to Cyanocobalamin (Vitamin B12) IM.
the nurse about issues related to his Available is a vial of the drug labeled 1
hospital stay. The best initial nursing ml= 100 mcg. The nurse should
response would be to: administer:
A. Allow him to release his feelings and then A. 0.5 ml
leave him alone to allow him to regain his B. 1.0 ml
composure C.  1.5 ml
B. Refocus the conversation on his fears, D. 2.0 ml
frustrations and anger about his condition
17. Health teachings to be given to a
C. Explain how his being upset dangerously
disturbs his need for rest client with Pernicious Anemia regarding
D. Attempt to explain the purpose of different her therapeutic regimen concerning Vit.
hospital routines B12 will include:
13. Twenty four hours after admission for
A.  Oral tablets of Vitamin B12 will control her
an Acute MI, Jose’s temperature is noted symptoms
at 39.3 C. The nurse monitors him for B.  IM injections are required for daily control
other adaptations related to the pyrexia, C.  IM injections once a month will maintain
including: control
D.  Weekly Z-track injections provide needed
A. Shortness of breath control
B. Chest pain 18. The nurse knows that a client with
C. Elevated blood pressure
Pernicious Anemia understands the
D. Increased pulse rate
teaching regarding the vitamin B12
14. Jose, who is admitted to the hospital
injections when she states that she must
for chest pain, asks the nurse, “Is it still
take it:
possible for me to have another heart
attack if I watch my diet religiously and A.  When she feels fatigued
avoid stress?” The most appropriate initial B.  During exacerbations of anemia
response would be for the nurse to: C. Until her symptoms subside
D. For the rest of her life
A. Suggest he discuss his feelings of 19. Arthur Cruz, a 45 year old artist, has
vulnerability with his physician. recently had an abdominoperineal
 resection and colostomy. Mr. Cruz B. A difficult time accepting reality and is in a
accuses the nurse of being uncomfortable state of denial.
C. Impotency due to the surgery and needs
during a dressing change, because his
sexual counseling
“wound looks terrible.” The nurse D. Suicide thoughts and should be seen by
recognizes that the client is using the psychiatrist
defense mechanism known as: 24. The nurse would know that dietary
A. Reaction Formation teaching had been effective for a client
B. Sublimation with colostomy when he states that he will
C. Intellectualization eat:
D. Projection
A. Food low in fiber so that there is less stool
20. When preparing to teach a client with
B. Everything he ate before the operation but
colostomy how to irrigate his colostomy, will avoid those foods that cause gas
the nurse should plan to perform the C. Bland foods so that his intestines do not
procedure: become irritated
D. Soft foods that are more easily digested and
A. When the client would have normally had a absorbed by the large intestines
bowel movement
25. Eddie, 40 years old, is brought to the
B. After the client accepts he had a bowel
movement emergency room after the crash of his
C. Before breakfast and morning care private plane. He has suffered multiple
D. At least 2 hours before visitors arrive crushing wounds of the chest, abdomen
21. When observing an ostomate do a and legs. It is feared his leg may have to
return demonstration of the colostomy be amputated. When Eddie arrives in the
irrigation, the nurse notes that he needs emergency room, the assessment that
more teaching if he: assume the greatest priority are:

A. Stops the flow of fluid when he feels A. Level of consciousness and pupil size
uncomfortable B. Abdominal contusions and other wounds
B. Lubricates the tip of the catheter before C. Pain, Respiratory rate and blood pressure
inserting it into the stoma D. Quality of respirations and presence of
C. Hangs the bag on a clothes hook on the pulsesQuality of respirations and presence of
bathroom door during fluid insertion pulses
D. Discontinues the insertion of fluid after only 26. Eddie, a plane crash victim,
500 ml of fluid has been instilled undergoes endotracheal intubation and
22. When doing colostomy irrigation at positive pressure ventilation. The most
home, a client with colostomy should be immediate nursing intervention for him at
instructed to report to his physician : this time would be to:
A. Abdominal cramps during fluid inflow A. Facilitate his verbal communication
B. Difficulty in inserting the irrigating tube B. Maintain sterility of the ventilation system
C.  Passage of flatus during expulsion of feces C. Assess his response to the equipment
D.  Inability to complete the procedure in half an D. Prepare him for emergency surgery
hour
27. A chest tube with water seal drainage
23. A client with colostomy refuses to
is inserted to a client following a multiple
allow his wife to see the incision or stoma
chest injury. A few hours later, the client’s
and ignores most of his dietary
chest tube seems to be obstructed. The
instructions. The nurse on assessing this
most appropriate nursing action would be
data, can assume that the client is
to
experiencing:
A. Prepare for chest tube removal
A. A reaction formation to his recent altered B. Milk the tube toward the collection container
body image. as ordered
C. Arrange for a stat Chest x-ray film. rehabilitative activities. The best initial
D. Clam the tube immediately nursing approach would be to:
28. The observation that indicates a
desired response to thoracostomy A. Give him explanations of why there is a need
to quickly increase his activity
drainage of a client with chest injury is:
B. Emphasize repeatedly that with as prosthesis,
A. Increased breath sounds he will be able to return to his normal lifestyle
B. Constant bubbling in the drainage chamber C. Appear cheerful and non-critical regardless of
C. Crepitus detected on palpation of chest his response to attempts at intervention
D. Increased respiratory rate D. Accept and acknowledge that his withdrawal
29. In the evaluation of a client’s is an initially normal and necessary part of
grieving
response to fluid replacement therapy,
33. The key factor in accurately assessing
the observation that indicates adequate
how body image changes will be dealt
tissue perfusion to vital organs is:
with by the client is the:
A. Urinary output is 30 ml in an hour
B. Central venous pressure reading of 2 cm H2O A. Extent of body change present
C. Pulse rates of 120 and 110 in a 15 minute B. Suddenness of the change
period C. Obviousness of the change
D. Blood pressure readings of 50/30 and 70/40 D. Client’s perception of the change
within 30 minutes 34. Larry is diagnosed as having
30. A client with multiple injury following a myelocytic leukemia and is admitted to
vehicular accident is transferred to the the hospital for chemotherapy. Larry
critical care unit. He begins to complain of discusses his recent diagnosis of
increased abdominal pain in the left upper leukemia by referring to statistical facts
quadrant. A ruptured spleen is diagnosed and figures. The nurse recognizes that
and he is scheduled for emergency Larry is using the defense mechanism
splenectomy. In preparing the client for known as:
surgery, the nurse should emphasize in A. Reaction formation
his teaching plan the: B. Sublimation
C. Intellectualization
A. Complete safety of the procedure
D. Projection
B. Expectation of postoperative bleeding
C. Risk of the procedure with his other injuries 35. The laboratory results of the client
D. Presence of abdominal drains for several days with leukemia indicate bone marrow
after surgery depression. The nurse should encourage
31. To promote continued improvement in the client to:
the respiratory status of a client following
A. Increase his activity level and ambulate
chest tube removal after a chest surgery frequently
for multiple rib fracture, the nurse should: B. Sleep with the head of his bed slightly
elevated
A. Encourage bed rest with active and passive
C. Drink citrus juices frequently for nourishment
range of motion exercises
D. Use a soft toothbrush and electric razor
B. Encourage frequent coughing and deep
breathing 36. Dennis receives a blood transfusion
C. Turn him from side to side at least every 2 and develops flank pain, chills, fever and
hours hematuria. The nurse recognizes that
D. Continue observing for dyspnea and crepitus Dennis is probably experiencing:
32. A client undergoes below the knee
A. An anaphylactic transfusion reaction
amputation following a vehicular accident.
B. An allergic transfusion reaction
Three days postoperatively, the client is C. A hemolytic transfusion reaction
refusing to eat, talk or perform any D. A pyrogenic transfusion reaction
 37. A client jokes about his leukemia even A. 0.5 L
though he is becoming sicker and B. 1.0 L
C. 2.0 L
weaker. The nurse’s most therapeutic
D. 3.5 L
response would be:
43. Mr. Ong, a client with CHF, has been
A. “Your laugher is a cover for your fear.” receiving a cardiac glycoside, a diuretic,
B. “He who laughs on the outside, cries on the and a vasodilator drug. His apical pulse
inside.” rate is 44 and he is on bed rest. The
C.  “Why are you always laughing?”
nurse concludes that his pulse rate is
D.  “Does it help you to joke about your illness?”
most likely the result of the:
38. In dealing with a dying client who is in
the denial stage of grief, the best nursing A. Diuretic
approach is to: B. Vasodilator
C. Bed-rest regimen
A. Agree with and encourage the client’s denial D. Cardiac glycoside
B. Reassure the client that everything will be 44. The diet ordered for a client with CHF
okay
permits him to have a 190 g of
C. Allow the denial but be available to discuss
death carbohydrates, 90 g of fat and 100 g of
D. Leave the client alone to discuss the loss protein. The nurse understands that this
39. During and 8 hour shift, Mario drinks diet contains approximately:
two 6 oz. cups of tea and vomits 125 ml A. 2200 calories
of fluid. During this 8 hour period, his fluid B. 2000 calories
balance would be: C. 2800 calories
D. 1600 calories
A. +55 ml
45. After the acute phase of congestive
B.  +137 ml
C.  +235 ml heart failure, the nurse should expect the
D.  +485 ml dietary management of the client to
40. Mr. Ong is admitted to the hospital include the restriction of:
with a diagnosis of Left-sided CHF. In the A. Magnesium
assessment, the nurse should expect to B. Sodium
find: C. Potassium
D. Calcium
A. Crushing chest pain
46. Jude develops GI bleeding and is
B. Dyspnea on exertion
C. Extensive peripheral edema admitted to the hospital. An important
D. Jugular vein distention etiologic clue for the nurse to explore
41. The physician orders on a client with while taking his history would be:
CHF a cardiac glycoside, a vasodilator, A.  The medications he has been taking
and furosemide (Lasix). The nurse B. Any recent foreign travel
understands Lasix exerts is effects in the: C. His usual dietary pattern
D.  His working patterns
A. Distal tubule
47. The meal pattern that would probably
B. Collecting duct
C. Glomerulus of the nephron be most appropriate for a client
D. Ascending limb of the loop of Henle recovering from GI bleeding is:
42. Mr. Ong weighs 210 lbs on admission A. Three large meals large enough to supply
to the hospital. After 2 days of diuretic adequate energy.
therapy he weighs 205.5 lbs. The nurse B. Regular meals and snacks to limit gastric
could estimate that the amount of fluid he discomfort
has lost is: C. Limited food and fluid intake when he has
pain
D. A flexible plan according to his appetite C. Pronation, supination, rotation, and extension
48. A client with a history of recurrent GI D. Dorsiflexion, plantar flexion, eversion and
bleeding is admitted to the hospital for a inversion
gastrectomy. Following surgery, the client 53. A client has been in a coma for 2
has a nasogastric tube to low continuous months. The nurse understands that to
suction. He begins to hyperventilate. The prevent the effects of shearing force on
nurse should be aware that this pattern the skin, the head of the bed should be at
will alter his arterial blood gases by: an angle of:

A. Increasing HCO3 A. 30 degrees

B. Decreasing PCO2 B. 45 degrees
C. Decreasing pH C. 60 degrees
D. Decreasing PO2 D. 90 degrees
49. Routine postoperative IV fluids are 54. Rene, age 62, is scheduled for a
designed to supply hydration and TURP after being diagnosed with a
electrolyte and only limited energy. Benign Prostatic Hyperplasia (BPH). As
Because 1 L of a 5% dextrose solution part of the preoperative teaching, the
contains 50 g of sugar, 3 L per day would nurse should tell the client that after
apply approximately: surgery:

A. 400 Kilocalories A. Urinary control may be permanently lost to

B. 600 Kilocalories some degree
C. 800 Kilocalories B. Urinary drainage will be dependent on a
D. 1000 Kilocalories urethral catheter for 24 hours
C. Frequency and burning on urination will last
50. Thrombus formation is a danger for all
while the cystotomy tube is in place
postoperative clients. The nurse should D. His ability to perform sexually will be
act independently to prevent this permanently impaired
complication by: 55. The transurethral resection of the
A. Encouraging adequate fluids prostate is performed on a client with
B. Applying elastic stockings BPH. Following surgery, nursing care
C. Massaging gently the legs with lotion should include:
D. Performing active-assistive leg exercises
A. Changing the abdominal dressing
51. An unconscious client is admitted to
B. Maintaining patency of the cystotomy tube
the ICU, IV fluids are started and a Foley C. Maintaining patency of a three-way Foley
catheter is inserted. With an indwelling catheter for cystoclysis
catheter, urinary infection is a potential D. Observing for hemorrhage and wound
danger. The nurse can best plan to avoid infection
this problem by: 56. In the early postoperative period
following a transurethral surgery, the most
A. Emptying the drainage bag frequently
common complication the nurse should
B. Collecting a weekly urine specimen
C. Maintaining the ordered hydration observe for is:
D. Assessing urine specific gravity A. Sepsis
52. The nurse performs full range of B. Hemorrhage
motion on a bedridden client’s C. Leakage around the catheter
extremities. When putting his ankle D. Urinary retention with overflow
through range of motion, the nurse must 57. Following prostate surgery, the
perform: retention catheter is secured to the
client’s leg causing slight traction of the
A. Flexion, extension and left and right rotation
B. Abduction, flexion, adduction and extension
 inflatable balloon against the prostatic nurse plans to set up emergency
fossa. This is done to: equipment, which should include:
A. Limit discomfort A. A crash cart with bed board
B. Provide hemostasis B. A tracheostomy set and oxygen
C. Reduce bladder spasms C. An airway and rebreathing mask
D. Promote urinary drainage D. Two ampules of sodium bicarbonate
58. Twenty-four hours after TURP 63. When a post-thyroidectomy client
surgery, the client tells the nurse he has returns from surgery the nurse assesses
lower abdominal discomfort. The nurse her for unilateral injury of the laryngeal
notes that the catheter drainage has nerve every 30 to 60 minutes by:
stopped. The nurse’s initial action should
A. Observing for signs of tetany
be to: B. Checking her throat for swelling
A. Irrigate the catheter with saline C. Asking her to state her name out loud
B. Milk the catheter tubing D. Palpating the side of her neck for blood
C. Remove the catheter seepage
D. Notify the physician 64. On a post-thyroidectomy client’s
59. The nurse would know that a post- discharge, the nurse teaches her to
TURP client understood his discharge observe for signs of surgically induced
teaching when he says “I should:” hypothyroidism. The nurse would know
that the client understands the teaching
A. Get out of bed into a chair for several hours
when she states she should notify the
daily
B. Call the physician if my urinary stream physician if she develops:
decreases A. Intolerance to heat
C. Attempt to void every 3 hours when I’m B. Dry skin and fatigue
awake C. Progressive weight loss
D. Avoid vigorous exercise for 6 months after D. Insomnia and excitability
surgery
65. A client’s exopthalmos continues
60. Lucy is admitted to the surgical unit
inspite of thyroidectomy for Grave’s
for a subtotal thyroidectomy. She is
Disease. The nurse teaches her how to
diagnosed with Grave’s Disease. When
reduce discomfort and prevent corneal
assessing Lucy, the nurse would expect
ulceration. The nurse recognizes that the
to find:
client understands the teaching when she
A. Lethargy, weight gain, and forgetfulness says: “I should:
B. Weight loss, protruding eyeballs, and lethargy
C. Weight loss, exopthalmos and restlessness A. Elevate the head of my bed at night
D. Constipation, dry skin, and weight gain B. Avoid moving my extra-ocular muscles
C. Avoid using a sleeping mask at night
61. Lucy undergoes Subtotal
D.  Avoid excessive blinking
Thyroidectomy for Grave’s Disease. In
66. Clara is a 37-year old cook. She is
planning for the client’s return from the
admitted for treatment of partial and full-
OR, the nurse would consider that in a
thickness burns of her entire right lower
subtotal thyroidectomy:
extremity and the anterior portion of her
A. The entire thyroid gland is removed right upper extremity. Her respiratory
B. A small part of the gland is left intact status is compromised, and she is in pain
C. One parathyroid gland is also removed and anxious. Performing an immediate
D. A portion of the thyroid and four parathyroids appraisal, using the rule of nines, the
are removed
nurse estimates the percent of Clara’s
62. Before a post- thyroidectomy client
body surface that is burned is:
returns to her room from the OR, the
A. 4.5% response to the medication will confirm
B.  9% the diagnosis if Tensilon produces:
C. 18 %
D. 22.5% A. Brief exaggeration of symptoms
67. The nurse applies mafenide acetate B. Prolonged symptomatic improvement
(Sulfamylon cream) to Clara, who has C. Rapid but brief symptomatic improvement
D. Symptomatic improvement of just the ptosis
second and third degree burns on the
72. The initial nursing goal for a client with
right upper and lower extremities, as
myasthenia gravis during the diagnostic
ordered by the physician. This medication
phase of her hospitalization would be to:
will:
A.  Inhibit bacterial growth A. Develop a teaching plan
B. Facilitate psychologic adjustment
B.  Relieve pain from the burn
C.  Prevent scar tissue formation C.  Maintain the present muscle strength
D. Prepare for the appearance of myasthenic
D.  Provide chemical debridement
crisis
68. Forty-eight hours after a burn injury,
73. The most significant initial nursing
the physician orders for the client 2 liters
observations that need to be made about
of IV fluid to be administered q12 h. The
a client with myasthenia include:
drop factor of the tubing is 10 gtt/ml. The
nurse should set the flow to provide: A. Ability to chew and speak distinctly
B. Degree of anxiety about her diagnosis
A. 18 gtt/min C. Ability to smile an to close her eyelids
B. 28 gtt/min D. Respiratory exchange and ability to swallow
C. 32 gtt/min 74. Helen is diagnosed with myasthenia
D. 36 gtt/min
gravis and pyridostigmine bromide
69. Clara, a burn client, receives a
(Mestinon) therapy is started. The
temporary heterograft (pig skin) on some
Mestinon dosage is frequently changed
of her burns. These grafts will:
during the first week. While the dosage is
A. Debride necrotic epithelium being adjusted, the nurse’s priority
B. Be sutured in place for better adherence intervention is to:
C. Relieve pain and promote rapid
epithelialization A. Administer the medication exactly on time
D. Frequently be used concurrently with topical B. Administer the medication with food or mild
antimicrobials. C. Evaluate the client’s muscle strength hourly
70. A client with burns on the chest has after medication
D. Evaluate the client’s emotional side effects
periodic episodes of dyspnea. The
between doses
position that would provide for the
75. Helen, a client with myasthenia
greatest respiratory capacity would be
gravis, begins to experience increased
the:
difficulty in swallowing. To prevent
A. Semi-fowler’s position aspiration of food, the nursing action that
B. Sims’ position would be most effective would be to:
C. Orthopneic position
D. Supine position A. Change her diet order from soft foods to clear
71. Jane, a 20- year old college student is liquids
B. Place an emergency tracheostomy set in her
admiited to the hospital with a tentative
room
diagnosis of myasthenia gravis. She is C. Assess her respiratory status before and after
scheduled to have a series of diagnostic meals
studies for myasthenia gravis, including a D. Coordinate her meal schedule with the peak
Tensilon test. In preparing her for this effect of her medication, Mestinon
procedure, the nurse explains that her Answers and Rationales
1. Answer: (B) protecting the client from because of the altered contractility of the
infection. Immunodeficiency is an absent or heart. The other choices are not typical of MI.
depressed immune response that increases 12.Answer: (B) Refocus the conversation on
susceptibility to infection. So it is the nurse’s his fears, frustrations and anger about his
primary responsibility to protect the patient condition . This provides the opportunity for
from infection. the client to verbalize feelings underlying
2. Answer: (A) 25 gtt/min . To get the correct behavior and helpful in relieving anxiety.
flow rate: multiply the amount to be infused Anxiety can be a stressor which can activate
(50 ml) by the drop factor (10) and divide the the sympathoadrenal response causing the
result by the amount of time in minutes (20) release of catecholamines that can increase
3. Answer: (B) Eating habits are altered . For cardiac contractility and workload that can
weight reduction to occur and be maintained, further increase myocardial oxygen demand.
a new dietary program, with a balance of 13.Answer: (D) Increased pulse rate . Fever
foods from the basic four food groups, must causes an increase in the body’s metabolism,
be established and continued which results in an increase in oxygen
4. Answer: (A) Increase her lean body consumption and demand. This need for
mass . Increased exercise builds skeletal oxygen increases the heart rate, which is
muscle mass and reduces excess fatty tissue. reflected in the increased pulse rate. Increased
5. Answer: (A) Exercising the triceps, finger BP, chest pain and shortness of breath are not
flexors, and elbow extensors . These sets of typically noted in fever.
muscles are used when walking with crutches 14.Answer: (C) Avoid giving him direct
and therefore need strengthening prior to information and help him explore his
ambulation. feelings . To help the patient verbalize and
6. Answer: (C) The palms of her hands .The explore his feelings, the nurse must reflect and
palms should bear the client’s weight to avoid analyze the feelings that are implied in the
damage to the nerves in the axilla (brachial client’s question. The focus should be on
plexus) collecting data to minister to the client’s
7. Answer: (C) 12 minims . Using ratio and psychosocial needs.
proportion 8 mg/10 mg = X minims/15 15.Answer: (C) Absorb vitamin
minims 10 X= 120 X = 12 minims The nurse B12 . Pernicious anemia is caused by the
will administer 12 minims intravenously inability to absorb vitamin B12 in the stomach
equivalent to 8mg Morphine Sulfate due to a lack of intrinsic factor in the gastric
8. Answer: (B) Relieves pain and decreases juices. In the Schilling test, radioactive
level of anxiety. Morphine is a specific vitamin B12 is administered and its absorption
central nervous system depressant used to and excretion can be ascertained through the
relieve the pain associated with myocardial urine.
infarction. It also decreases anxiety and 16.Answer: (D) 2.0 ml . First convert milligrams
apprehension and prevents cardiogenic shock to micrograms and then use ratio and
by decreasing myocardial oxygen demand. proportion (0.2 mg= 200 mcg) 200 mcg : 100
9. Answer: (C) Supports combustion. The mcg= X ml : ml 100 X= 200 X = 2 ml. Inject
nurse should know that Oxygen is necessary 2 ml. to give 0.2 mg of Cyanocobalamin.
to produce fire, thus precautionary measures 17.Answer: (C) IM injections once a month
are important regarding its use. will maintain control . Deep IM injections
10.Answer: (C) CK-MB. The cardiac marker, bypass B12 absorption defect in the stomach
Creatinine phosphokinase (CPK) isoenzyme due to lack of intrinsic factor, the transport
levels, especially the MB sub-unit which is carrier component of gastric juices. A
cardio-specific, begin to rise in 3-6 hours, monthly dose is usually sufficient since it is
peak in 12-18 hours and are elevated 48 hours stored in active body tissues such as the liver,
after the occurrence of the infarct. They are kidney, heart, muscles, blood and bone
therefore most reliable in assisting with early marrow
diagnosis. The cardiac markers elevate as a 18.Answer: (D) For the rest of her life . Since
result of myocardial tissue damage. the intrinsic factor does not return to gastric
11.Answer: (B) Elevated STsegments . This is a secretions even with therapy, B12 injections
typical early finding after a myocardial infarct will be required for the remainder of the
client’s life.
19.Answer: (D) Projection. Projection is the obstructing drainage, toward the collection
attribution of unacceptable feelings and chamber
emotions to others which may indicate the 28.Answer: (A) Increased breath sounds . The
patients nonacceptance of his condition. chest tube normalizes intrathoracic pressure
20.Answer: (A) When the client would have and restores negative intra-pleural pressure,
normally had a bowel movement . Irrigation drains fluid and air from the pleural space,
should be performed at the time the client and improves pulmonary function
normally defecated before the colostomy to 29.Answer: (A) Urinary output is 30 ml in an
maintain continuity in lifestyle and usual hour . A rate of 30 ml/hr is considered
bowel function/habit. adequate for perfusion of kidney, heart and
21.Answer: (C) Hangs the bag on a clothes brain.
hook on the bathroom door during fluid 30.Answer: (D) Presence of abdominal drains
insertion . The irrigation bag should be hung for several days after surgery . Drains are
12-18 inches above the level of the stoma; a usually inserted into the splenic bed to
clothes hook is too high which can create facilitate removal of fluid in the area that
increase pressure and sudden intestinal could lead to abscess formation.
distention and cause abdominal discomfort to 31.Answer: (B) Encourage frequent coughing
the patient. and deep breathing . This nursing action
22.Answer: (B) Difficulty in inserting the prevents atelectasis and collection of
irrigating tube . Difficulty of inserting the respiratory secretions and promotes adequate
irrigating tube indicates stenosis of the stoma ventilation and gas exchange.
and should be reported to the physician. 32.Answer: (D) Accept and acknowledge that
Abdominal cramps and passage of flatus can his withdrawal is an initially normal and
be expected during colostomy irrigations. The necessary part of grieving . The withdrawal
procedure may take longer than half an hour. provides time for the client to assimilate what
23.Answer: (B) A difficult time accepting has occurred and integrate the change in the
reality and is in a state of denial. As long as body image. Acceptance of the client’s
no one else confirms the presence of the behavior is an important factor in the nurse’s
stoma and the client does not need to adhere intervention.
to a prescribed regimen, the client’s denial is 33.Answer: (D) Client’s perception of the
supported change . It is not reality, but the client’s
24.Answer: (B) Everything he ate before the feeling about the change that is the most
operation but will avoid those foods that important determinant of the ability to cope.
cause gas . There is no special diets for clients The client should be encouraged to his
with colostomy. These clients can eat a feelings.
regular diet. Only gas-forming foods that 34.Answer: (C) Intellectualization . People use
cause distention and discomfort should be defense mechanisms to cope with stressful
avoided. events. Intellectualization is the use of
25.Answer: (D) Quality of respirations and reasoning and thought processes to avoid the
presence of pulsesQuality of respirations emotional upsets.
and presence of pulses . Respiratory and 35.Answer: (D) Use a soft toothbrush and
cardiovascular functions are essential for electric razor . Suppression of red bone
oxygenation. These are top priorities to marrow increases bleeding susceptibility
trauma management. Basic life functions must associated with thrombocytopenia, decreased
be maintained or reestablished platelets. Anemia and leucopenia are the two
26.Answer: (C) Assess his response to the other problems noted with bone marrow
equipment . It is a primary nursing depression.
responsibility to evaluate effect of 36.Answer: (C) A hemolytic transfusion
interventions done to the client. Nothing is reaction . This results from a recipient’s
achieved if the equipment is working and the antibodies that are incompatible with
client is not responding transfused RBC’s; also called type II
27.Answer: (B) Milk the tube toward the hypersensitivity; these signs result from RBC
collection container as ordered . This assists hemolysis, agglutination, and capillary
in moving blood, fluid or air, which may be plugging that can damage renal function, thus
 the flank pain and hematuria and the other 49.Answer: (B) 600
manifestations. Kilocalories . Carbohydrates provide 4 kcal/
37.Answer: (D) “Does it help you to joke about gram; therefore 3L x 50 g/L x 4 kcal/g = 600
your illness?” . This non-judgmentally on the kcal; only about a third of the basal energy
part of the nurse points out the client’s need.
behavior. 50.Answer: (D) Performing active-assistive leg
38.Answer: (C) Allow the denial but be exercises . Inactivity causes venous stasis,
available to discuss death . This does not hypercoagulability, and external pressure
take away the client’s only way of coping, and against the veins, all of which lead to
it permits future movement through the thrombus formation. Early ambulation or
grieving process when the client is ready. exercise of the lower extremities reduces the
Dying clients move through the different occurrence of this phenomenon
stages of grieving and the nurse must be ready 51.Answer: (C) Maintaining the ordered
to intervene in all these stages. hydration . Promoting hydration, maintains
39.Answer: (C) +235 ml . The client’s intake urine production at a higher rate, which
was 360 ml (6oz x 30 ml) and loss was 125 ml flushes the bladder and prevents urinary stasis
of fluid; loss is subtracted from intake and possible infection
40.Answer: (B) Dyspnea on 52.Answer: (D) Dorsiflexion, plantar flexion,
exertion . Pulmonary congestion and edema eversion and inversion . These movements
occur because of fluid extravasation from the include all possible range of motion for the
pulmonary capillary bed, resulting in difficult ankle joint
breathing. Left-sided heart failure creates a 53.Answer: (A) 30 degrees . Shearing force
backward effect on the pulmonary system that occurs when 2 surfaces move against each
leads to pulmonary congestion. other; when the bed is at an angle greater than
41.Answer: (D) Ascending limb of the loop of 30 degrees, the torso tends to slide and causes
Henle . This is the site of action of Lasix this phenomenon. Shearing forces are good
being a potent loop diuretic. contributory factors of pressure sores.
42.Answer: (C) 2.0 L . One liter of fluid weighs 54.Answer: (B) Urinary drainage will be
approximately 2.2 lbs. Therefore a 4.5 lbs dependent on a urethral catheter for 24
weight loss equals approximately 2 Liters. hours . An indwelling urethral catheter is
43.Answer: (D) Cardiac glycoside . A cardiac used, because surgical trauma can cause
glycoside such as digitalis increases force of urinary retention leading to further
cardiac contraction, decreases the conduction complications such as bleeding.
speed of impulses within the myocardium and 55.Answer: (C) Maintaining patency of a
slows the heart rate. three-way Foley catheter for
44.Answer: (B) 2000 calories . There are 9 cystoclysis . Patency of the catheter promotes
calories in each gram of fat and 4 calories in bladder decompression, which prevents
each gram of carbohydrate and protein distention and bleeding. Continuous flow of
45.Answer: (B) Sodium . Restriction of sodium fluid through the bladder limits clot formation
reduces the amount of water retention that and promotes hemostasis
reduces the cardiac workload 56.Answer: (B) Hemorrhage . After
46.Answer: (A) The medications he has been transurethral surgery, hemorrhage is common
taking . Some medications, such as aspirin because of venous oozing and bleeding from
and prednisone, irritate the stomach lining and many small arteries in the prostatic bed.
may cause bleeding with prolonged use 57.Answer: (B) Provide hemostasis . The
47.Answer: (B) Regular meals and snacks to pressure of the balloon against the small blood
limit gastric discomfort . Presence of food in vessels of the prostate creates a tampon-like
the stomach at regular intervals interacts with effect that causes them to constrict thereby
HCl limiting acid mucosal irritation. Mucosal preventing bleeding.
irritation can lead to bleeding. 58.Answer: (B) Milk the catheter
48.Answer: (B) Decreasing tubing . Milking the tubing will usually
PCO2 . Hyperventilation results in the dislodge the plug and will not harm the client.
increased elimination of carbon dioxide from A physician’s order is not necessary for a
the blood that can lead to respiratory alkalosis. nurse to check catheter patency.
59.Answer: (B) Call the physician if my 70.Answer: (C) Orthopneic position . The
urinary stream decreases . Urethral mucosa orthopneic position lowers the diaphragm and
in the prostatic area is destroyed during provides for maximal thoracic expansion
surgery and strictures my form with healing 71.Answer: (C) Rapid but brief symptomatic
that causes partial or even complete ueinary improvement . Tensilon acts systemically to
obstruction. increase muscle strength; with a peak effect in
60.Answer: (C) Weight loss, exopthalmos and 30 seconds, It lasts several minutes.
restlessness . Classic signs associated with 72.Answer: (C) Maintain the present muscle
hyperthyroidism are weight loss and strength . Until diagnosis is confirmed,
restlessness because of increased basal primary goal should be to maintain adequate
metabolic rate. Exopthalmos is due to activity and prevent muscle atrophy
peribulbar edema. 73.Answer: (D) Respiratory exchange and
61.Answer: (B) A small part of the gland is left ability to swallow . Muscle weakness can
intact . Remaining thyroid tissue may provide lead to respiratory failure that will require
enough hormone for normal function. Total emergency intervention and inability to
thyroidectomy is generally done in clients swallow may lead to aspiration
with Thyroid Ca. 74.Answer: (C) Evaluate the client’s muscle
62.Answer: (B) A tracheostomy set and strength hourly after medication Peak
oxygen . Acute respiratory obstruction in the response occurs 1 hour after
post-operative period can result from edema, administration and lasts up to 8 hours; the
subcutaneous bleeding that presses on the response will influence dosage levels.
trachea, nerve damage, or tetany. 75.Answer: (D) Coordinate her meal schedule
63.Answer: (C) Asking her to state her name with the peak effect of her medication,
out loud . If the recurrent laryngeal nerve is Mestinon . Dysphagia should be minimized
damaged during surgery, the client will be during peak effect of Mestinon, thereby
hoarse and have difficult speaking. decreasing the probability of aspiration.
64.Answer: (B) Dry skin and fatigue . Dry skin Mestinon can increase her muscle strength
is most likely caused by decreased glandular including her ability to swallow.
function and fatigue caused by decreased
metabolic rate. Body functions and
metabolism are decreased in hypothyroidism.
65.Answer: (C) Avoid using a sleeping mask at
night . The mask may irritate or scratch the
eye if the client turns and lies on it during the
night.
66.Answer: (D) 22.5% . The entire right lower
extremity is 18% the anterior portion of the
right upper extremity is 4.5% giving a total of
22.5%
67.Answer: (A) Inhibit bacterial
growth . Sulfamylon is effective against a
wide variety of gram positive and gram
negative organisms including anaerobes
68.Answer: (B) 28 gtt/min . This is the correct
flow rate; multiply the amount to be infused
(2000 ml) by the drop factor (10) and divide
the result by the amount of time in minutes
(12 hours x 60 minutes)
69.Answer: (C) Relieve pain and promote
rapid epithelialization . The graft covers
nerve endings, which reduces pain and
provides a framework for granulation that
promotes effective healing.
 Medical Surgical Nursing Exam 9 vaso-occlusive crisis. Which of the
1. The nursing care plan for a toddler following actions would be most
diagnosed with Kawasaki Disease appropriate?
(mucocutaneous lymph node syndrome)
should be based on the high risk for A. Fluid restriction 1000cc per day
development of which problem? B. Ambulate in hallway 4 times a day
A. Chronic vessel plaque formation C. Administer analgesic therapy as ordered
B. Pulmonary embolism D. Encourage increased caloric intake
C. Occlusions at the vessel bifurcations 6. While working with an obese
D. Coronary artery aneurysms adolescent, it is important for the nurse to
2. A nurse has just received a medication recognize that obesity in adolescents is
order which is not legible. Which most often associated with what
statement best reflects assertive other behavior?
communication?
A. Sexual promiscuity
A. “I cannot give this medication as it is written. B. Poor body image
I have no idea of what you mean.” C. Dropping out of school
B. “Would you please clarify what you have D. Drug experimentation
written so I am sure I am reading it 7. A nurse and client are talking about the
correctly?” client’s progress toward understanding
C. “I am having difficulty reading your his behavior under stress. This is typical
handwriting. It would save me time if you
of which phase in the
would be more careful.”
D. “Please print in the future so I do not have to therapeutic relationship?
spend extra time attempting to read your A. Pre-interaction
writing.” B. Orientation
3. The nurse is discussing negativism C. Working
with the parents of a 30 month-old child. D. Termination
How should the nurse tell the parents to 8. A nurse is eating in the hospital
best respond to this behavior? cafeteria when a toddler at a nearby table
chokes on a piece of food and appears
A. Reprimand the child and give a 15 minute
“time out” slightly blue. The appropriate initial
B. Maintain a permissive attitude for this action should be to
behavior
C. Use patience and a sense of humor to deal A. Begin mouth to mouth resuscitation
with this behavior B. Give the child water to help in swallowing
D. Assert authority over the child through limit C. Perform 5 abdominal thrusts
setting D. Call for the emergency response team
4. An ambulatory client reports edema 9. The emergency room nurse admits a
during the day in his feet and an ankle child who experienced a seizure at
that disappears while sleeping at night. school. The father comments that this is
What is the most appropriate follow-up the first occurrence, and denies any
question for the nurse to ask? family history of epilepsy. What is the best
response by the nurse?
A. “Have you had a recent heart attack?”
B. “Do you become short of breath during your A. “Do not worry. Epilepsy can be treated with
normal daily activities?” medications.”
C. “How many pillows do you use at night to B. “The seizure may or may not mean your child
sleep comfortably?” has epilepsy.”
D. “Do you smoke?” C. “Since this was the first convulsion, it may
5. The nurse is planning care for a client not happen again.”
D. “Long term treatment will prevent future
during the acute phase of a sickle cell seizures.”
 10. A nurse admits a 3 week-old infant to A. Venturi mask
the special care nursery with a diagnosis B. Partial rebreather mask
C. Non-rebreather mask
of bronchopulmonary dysplasia. As the
D. Simple face mask
nurse reviews the birth
15. A nurse is caring for a client who had
history, which data would be most
a closed reduction of a fractured right
consistent with this diagnosis?
wrist followed by the application of a
A. Gestational age assessment suggested growth fiberglass cast 12 hours ago. Which
retardation finding requires the nurse’s immediate
B. Meconium was cleared from the airway at attention?
delivery
C. Phototherapy was used to treat Rh A. Capillary refill of fingers on right hand is 3
incompatibility seconds
D. The infant received mechanical ventilation for B. Skin warm to touch and normally colored
2 weeks C. Client reports prickling sensation in the right
11. Parents of a 6 month-old breast fed hand
baby ask the nurse about increasing the D. Slight swelling of fingers of right hand
baby’s diet. Which of the following should 16. Included in teaching the client with
be added first? tuberculosis taking INH about follow-up
home care, the nurse should emphasize
A. Cereal that a laboratory appointment for
B. Eggs
which of the following lab tests is critical?
C. Meat
D. Juice A. Liver function
12. A victim of domestic violence states, B. Kidney function
“If I were better, I would not have been C. Blood sugar
beat.” Which feeling best describes what D. Cardiac enzymes
the victim may be experiencing? 17. Which client is at highest risk for
developing a pressure ulcer?
A. Fear
B. Helplessness A. 23 year-old in traction for fractured femur
C. Self-blame B. 72 year-old with peripheral vascular disease,
D. Rejection who is unable to walk without assistance
13. The nurse is assessing the mental C. 75 year-old with left sided paresthesia and is
incontinent of urine and stool
status of a client admitted with possible
D. 30 year-old who is comatose following a
organic brain disorder. Which of these ruptured aneurysm
questions will best assess the 18. Which contraindication should the
function of the client’s recent memory? nurse assess for prior to giving a child
A. “Name the year.” “What season is this?” immunization?
(pause for answer after each question)
A. Mild cold symptoms
B. “Subtract 7 from 100 and then subtract 7 from
B. Chronic asthma
that.” (pause for answer) “Now continue to
C. Depressed immune system
subtract 7 from the new number.”
D. Allergy to eggs
C. “I am going to say the names of three things
and I want you to repeat them after me: blue, 19. The nurse is caring for a 2 year-old
ball, pen.” who is being treated with chelation
D. “What is this on my wrist?” (point to your therapy, calcium disodium edetate, for
watch) Then ask, “What is the purpose of it?” lead poisoning. The nurse should be
14. Which oxygen delivery system would alert for which of the following side
the nurse apply that would provide the effects?
highest concentrations of oxygen to the
A. Neurotoxicity
client?
B. Hepatomegaly C. “I have to sit at the side of the pool with the
C. Nephrotoxicity grandchildren since I can’t swim with this eye
D. Ototoxicity problem.”
20. A newborn is having difficulty D. “I take extra fiber and drink lots of water to
maintaining a temperature above 98 avoid getting constipated.”
degrees Fahrenheit and has been placed 24. The nurse is teaching a parent about
in a warming isolette. Which action side effects of routine immunizations.
is a nursing priority? Which of the following must be reported
immediately?
A. Protect the eyes of the neonate from the heat
lamp A. Irritability
B. Monitor the neonate’s temperature B. Slight edema at site
C. Warm all medications and liquids before C. Local tenderness
giving D. Temperature of 102.5 F
D. Avoid touching the neonate with cold hands 25. A client is admitted with the diagnosis
21. At a senior citizens meeting a nurse of pulmonary embolism. While taking a
talks with a client who has diabetes history, the client tells the nurse he was
mellitus Type 1. Which statement by the admitted for the same thing twice before,
client during the conversation is the last time just 3 months ago. The nurse
most predictive of a potential for impaired would anticipate the health care provider
skin integrity? ordering
A. “I give my insulin to myself in my thighs.” A. Pulmonary embolectomy
B. “Sometimes when I put my shoes on I don’t B. Vena caval interruption
know where my toes are.” C. Increasing the coumadin therapy to an INR of
C. “Here are my up and down glucose readings 3-4
that I wrote on my calendar.” D. Thrombolytic therapy
D. “If I bathe more than once a week my skin 26. A woman in her third trimester
feels too dry.” complains of severe heartburn. What is
22. A 4 year-old hospitalized child begins appropriate teaching by the nurse to help
to have a seizure while playing with hard the woman alleviate these symptoms?
plastic toys in the hallway. Of the
following nursing actions, which one A. Drink small amounts of liquids frequently
B. Eat the evening meal just before retiring
should the nurse do first?
C. Take sodium bicarbonate after each meal
A. Place the child in the nearest bed D. Sleep with head propped on several pillows
B. Administer IV medication to slow down the 27. The nurse is teaching the mother of a
seizure 5 month-old about nutrition for her baby.
C. Place a padded tongue blade in the child’s Which statement by the mother indicates
mouth
the need for further
D. Remove the child’s toys from the immediate
area teaching?
23. The nurse is at the community center A. “I’m going to try feeding my baby some rice
speaking with retired people. To which cereal.”
comment by one of the retirees during a B. “When he wakes at night for a bottle, I feed
discussion about glaucoma would the him.”
C. “I dip his pacifier in honey so he’ll take it.”
nurse give a supportive comment to
D. “I keep formula in the refrigerator for 24
reinforce correct information? hours.”
A. “I usually avoid driving at night since lights 28. For a 6 year-old child hospitalized
sometimes seem to make things blur.” with moderate edema and mild
B. “I take half of the usual dose for my sinuses to hypertension associated with acute
maintain my blood pressure.”
 glomerulonephritis (AGN), which one of 32. An adolescent client comes to the
the following nursing interventions would clinic 3 weeks after the birth of her first
be appropriate? baby. She tells the nurse she is
concerned because she has not returned
A. Institute seizure precautions
B. Weigh the child twice per shift to her pre-pregnant weight. Which action
C. Encourage the child to eat protein-rich foods should the nurse perform first?
D. Relieve boredom through physical activity
A. Review the client’s weight pattern over the
29. Which statement by the client with year
chronic obstructive lung disease indicates B. Ask the mother to record her diet for the last
an understanding of the major reason for 24 hours
the use of occasional pursed-lip C. Encourage her to talk about her view of
breathing? herself
D. Give her several pamphlets on postpartum
A. “This action of my lips helps to keep my nutrition
airway open.” 33. Which of the following measures
B. “I can expel more when I pucker up my lips to would be appropriate for the nurse to
breathe out.”
teach the parent of a nine month-old
C. “My mouth doesn’t get as dry when I breathe
with pursed lips.” infant about diaper dermatitis?
D. “By prolonging breathing out with pursed lips A. Use only cloth diapers that are rinsed in
the little areas in my lungs don’t collapse.” bleach
30. A 57 year-old male client has B. Do not use occlusive ointments on the rash
hemoglobin of 10 mg/dl and a hematocrit C. Use commercial baby wipes with each diaper
of 32%. What would be the most change
appropriate follow-up by the home care D. Discontinue a new food that was added to the
infant’s diet just prior to the rash
nurse?
34. A 16 year-old client is admitted to a
A. Ask the client if he has noticed any bleeding psychiatric unit with a diagnosis of
or dark stools attempted suicide. The nurse is aware
B. Tell the client to call 911 and go to the
that the most frequent cause for suicide in
emergency department immediately
C. Schedule a repeat Hemoglobin and adolescents is
Hematocrit in 1 month A. Progressive failure to adapt
D. Tell the client to schedule an appointment B. Feelings of anger or hostility
with a hematologist C. Reunion wish or fantasy
31. Which response by the nurse would D. Feelings of alienation or isolation
best assist the chemically impaired client 35. A mother brings her 26 month-old to
to deal with issues of guilt? the well-child clinic. She expresses
A. “Addiction usually causes people to feel frustration and anger due to her child’s
guilty. Don’t worry, it is a typical response constantly saying “no” and his refusal
due to your drinking behavior.” to follow her directions. The nurse
B. “What have you done that you feel most explains this is normal for his age, as
guilty about and what steps can you begin to negativism is attempting to meet which
take to help you lessen this guilt?” developmental need?
C. “Don’t focus on your guilty feelings. These
feelings will only lead you to drinking and A. Trust
taking drugs.” B. Initiative
D. “You’ve caused a great deal of pain to your C. Independence
family and close friends, so it will take time to D. Self-esteem
undo all the things you’ve done.” 36. Following mitral valve replacement
surgery a client develops PVC’s. The
 health care provider orders a bolus of 40. A client complained of nausea, a
Lidocaine followed by a metallic taste in her mouth, and fine hand
continuous Lidocaine infusion at a rate of tremors 2 hours after her first dose of
2 mgm/minute. The IV solution contains 2 lithium carbonate (Lithane).
grams of Lidocaine in 500 cc’s of D5W. What is the nurse’s best explanation of
The infusion pump delivers 60 these findings?
microdrops/cc. What rate would deliver 4
A. These side effects are common and should
mgm of Lidocaine/minute? subside in a few days
A. 60 microdrops/minute B. The client is probably having an allergic
B. 20 microdrops/minute reaction and should discontinue the drug
C. 30 microdrops/minute C. Taking the lithium on an empty stomach
D. 40 microdrops/minute should decrease these symptoms
D. Decreasing dietary intake of sodium and
37. A couple asks the nurse about risks of
fluids should minimize the side effects
several birth control methods. What is the
41. The nurse is caring for a post-surgical
most appropriate response by the nurse?
client at risk for developing deep vein
A. Norplant is safe and may be removed easily thrombosis. Which intervention is an
B. Oral contraceptives should not be used by effective preventive measure?
smokers
C. Depo-Provera is convenient with few side A. Place pillows under the knees
effects B. Use elastic stockings continuously
D. The IUD gives protection from pregnancy and C. Encourage range of motion and ambulation
infection D. Massage the legs twice daily
38. The nurse is caring for a client in the 42. The parents of a newborn male with
late stages of Amyotrophic Lateral hypospadias want their child circumcised.
Sclerosis (A.L.S.). Which finding would The best response by the nurse is to
the nurse expect? inform them that

A. Confusion A. Circumcision is delayed so the foreskin can be

B. Loss of half of visual field used for the surgical repair
C. Shallow respirations B. This procedure is contraindicated because of
D. Tonic-clonic seizures the permanent defect
39. A client experiences post partum C. There is no medical indication for performing
a circumcision on any child
hemorrhage eight hours after the birth of
D. The procedure should be performed as soon as
twins. Following administration of IV fluids the infant is stable
and 500 ml of whole blood, her 43. The nurse is teaching parents about
hemoglobin and hematocrit are within the treatment plan for a 2 weeks-old
normal limits. She asks the nurse whether infant with Tetralogy of Fallot. While
she should continue to breast feed the awaiting future surgery, the
infants. Which of the nurse instructs the parents to immediately
following is based on sound rationale? report
A. “Nursing will help contract the uterus and A. Loss of consciousness
reduce your risk of bleeding.” B. Feeding problems
B. “Breastfeeding twins will take too much C. Poor weight gain
energy after the hemorrhage.” D. Fatigue with crying
C. “The blood transfusion may increase the risks
44. An infant weighed 7 pounds 8 ounces
to you and the babies.”
D. “Lactation should be delayed until the “real at birth. If growth occurs at a normal rate,
milk” is secreted.” what would be the expected weight at 6
months of age?
A. Double the birth weight 49. A home health nurse is at the home of
B. Triple the birth weight a client with diabetes and arthritis. The
C. Gain 6 ounces each week
client has difficulty drawing up insulin. It
D. Add 2 pounds each month
would be most appropriate for the nurse
45. The nurse is caring for a 13 year-old
to refer the client to
following spinal fusion for scoliosis. Which
of the following interventions is A. A social worker from the local hospital
appropriate in the immediate post- B. An occupational therapist from the
operative period? community center
C. A physical therapist from the rehabilitation
A. Raise the head of the bed at least 30 degrees agency
B. Encourage ambulation within 24 hours D. Another client with diabetes mellitus and
C. Maintain in a flat position, logrolling as takes insulin
needed 50. A client was admitted to the
D. Encourage leg contraction and relaxation after psychiatric unit after complaining to her
48 hours
friends and family that neighbors have
46. A client asks the nurse about
bugged her home in order to hear all
including her 2 and 12 year-old sons in
of her business. She remains aloof from
the care of their newborn sister. Which of
other clients, paces the floor and believes
the following is an appropriate initial
that the hospital is a house of torture.
statement by the nurse?
Nursing interventions for the client should
A. “Focus on your sons’ needs during the first appropriately focus on efforts to
days at home.”
B. “Tell each child what he can do to help with A. Convince the client that the hospital staff is
the baby.” trying to help
C. “Suggest that your husband spend more time B. Help the client to enter into group recreational
with the boys.” activities
D. “Ask the children what they would like to do C. Provide interactions to help the client learn to
for the newborn.” trust staff
D. Arrange the environment to limit the client’s
47. A nurse is caring for a 2 year-old child
contact with other clients
after corrective surgery for Tetralogy of
51. A client is scheduled for a
Fallot. The mother reports that the child
percutaneous transluminal coronary
has suddenly begun seizing. The nurse
angioplasty (PTCA). The nurse knows
recognizes this problem is probably due
that a PTCA is the
to
A. Surgical repair of a diseased coronary artery
A. A cerebral vascular accident B. Placement of an automatic internal cardiac
B. Postoperative meningitis defibrillator
C. Medication reaction C. Procedure that compresses plaque against the
D. Metabolic alkalosis wall of the diseased coronary artery to
48. A client with schizophrenia is improve blood flow
receiving Haloperidol (Haldol) 5 mg t.i.d.. D. Non-invasive radiographic examination of the
The client’s family is alarmed and calls heart
the clinic when “his eyes rolled upward.” 52. A newborn has been diagnosed with
The nurse recognizes this as what type of hypothyroidism. In discussing the
side effect? condition and treatment with the family,
the nurse should emphasize
A. Oculogyric crisis
B. Tardive dyskinesia A. They can expect the child will be mentally
C. Nystagmus retarded
D. Dysphagia B. Administration of thyroid hormone will
prevent problems
C. This rare problem is always hereditary D. Inform the client that only 1 x-ray of his
D. Physical growth/development will be delayed abdomen is necessary
53. A priority goal of involuntary 58. Following a diagnosis of acute
hospitalization of the severely mentally ill glomerulonephritis (AGN) in their 6 year-
client is old child, the parent’s remark: “We just
don’t know how he caught the disease!”
A. Re-orientation to reality
B. Elimination of symptoms The nurse’s response is based on an
C. Protection from harm to self or others understanding that
D. Return to independent functioning
A. AGN is a streptococcal infection that involves
54. A 19 year-old client is paralyzed in a the kidney tubules
car accident. Which statement used by B. The disease is easily transmissible in schools
the client would indicate to the nurse that and camps
the client was using the C. The illness is usually associated with chronic
mechanism of “suppression”? respiratory infections
D. It is not “caught” but is a response to a
A. “I don’t remember anything about what previous B-hemolytic strep infection
happened to me.” 59. The nurse is caring for a 20 lbs (9 kg)
B. “I’d rather not talk about it right now.” 6 month-old with a 3 day history of
C. “It’s the other entire guy’s fault! He was
diarrhea, occasional vomiting and fever.
going too fast.”
D. “My mother is heartbroken about this.” Peripheral intravenous therapy
55. The nurse is caring for a woman 2 has been initiated, with 5% dextrose in
hours after a vaginal delivery. 0.33% normal saline with 20 mEq of
Documentation indicates that the potassium per liter infusing at 35 ml/hr.
membranes were ruptured for 36 hours Which finding should be reported to the
prior to delivery. What are the priority health care provider immediately?
nursing diagnoses at this time? A. 3 episodes of vomiting in 1 hour
B. Periodic crying and irritability
A. Altered tissue perfusion
C. Vigorous sucking on a pacifier
B. Risk for fluid volume deficit D. No measurable voiding in 4 hours
C. High risk for hemorrhage
D. Risk for infection 60. While caring for the client during the
56. A 3 year-old had a hip spica cast first hour after delivery, the nurse
applied 2 hours ago. In order to facilitate determines that the uterus is boggy and
drying, the nurse should there is vaginal bleeding. What should be
the nurse’s first action?
A. Expose the cast to air and turn the child
frequently A. Check vital signs
B. Use a heat lamp to reduce the drying time B. Massage the fundus
C. Handle the cast with the abductor bar C. Offer a bedpan
D. Turn the child as little as possible D. Check for perineal lacerations
57. A client is scheduled for an 61. The nurse is assessing an infant with
Intravenous Pyelogram (IVP). In order to developmental dysplasia of the hip.
prepare the client for this test, the nurse Which finding would the nurse anticipate?
would: A. Unequal leg length
A. Instruct the client to maintain a regular diet B. Limited adduction
the day prior to the examination C. Diminished femoral pulses
B. Restrict the client’s fluid intake 4 hours prior D. Symmetrical gluteal folds
to the examination 62. To prevent a valsalva maneuver in a
C. Administer a laxative to the client the evening client recovering from an acute
before the examination myocardial infarction, the nurse would
A. Assist the client to use the bedside commode B. Range of motion
B. Administer stool softeners every day as C. Aerobic
ordered D. Isotonic
C. Administer antidysrhythmics prn as ordered 68. A client is in her third month of her
D. Maintain the client on strict bed rest first pregnancy. During the interview, she
63. On admission to the psychiatric unit, tells the nurse that she has several sex
the client is trembling and appears fearful. partners and is unsure of the
The nurse’s initial response should be to identity of the baby’s father. Which of the
A. Give the client orientation materials and following nursing interventions is a
review the unit rules and regulations priority?
B. Introduce him/her and accompany the client to
the client’s room A. Counsel the woman to consent to HIV
C. Take the client to the day room and introduce screening
her to the other clients B. Perform tests for sexually transmitted diseases
D. Ask the nursing assistant to get the client’s C. Discuss her high risk for cervical cancer
vital signs and complete the admission search D. Refer the client to a family planning clinic
64. During the admission assessment on 69. A 16 month-old child has just been
a client with chronic bilateral glaucoma, admitted to the hospital. As the nurse
which statement by the client would the assigned to this child enters the hospital
nurse anticipate since it is room for the first time, the toddler
associated with this problem? runs to the mother, clings to her and
begins to cry. What would be the initial
A. “I have constant blurred vision.” action by the nurse?
B. “I can’t see on my left side.”
C. “I have to turn my head to see my room.” A. Arrange to change client care assignments
D. “I have specks floating in my eyes.” B. Explain that this behavior is expected
65. A client with asthma has low pitched C. Discuss the appropriate use of “time-out”
wheezes present on the final half of D. Explain that the child needs extra attention
exhalation. One hour later the client has 70. While planning care for a 2 year-old
high pitched wheezes extending hospitalized child, which situation would
throughout exhalation. This change in the nurse expect to most likely affect the
assessment indicates to the nurse that behavior?
the client A. Strange bed and surroundings
B. Separation from parents
A. Has increased airway obstruction
C. Presence of other toddlers
B. Has improved airway obstruction
D. Unfamiliar toys and games
C. Needs to be suctioned
D. Exhibits hyperventilation 71. While explaining an illness to a 10
66. Which behavioral characteristic year-old, what should the nurse keep in
describes the domestic abuser? mind about the cognitive development at
this age?
A. Alcoholic
B. Over confident A. They are able to make simple association of
C. High tolerance for frustrations ideas
D. Low self-esteem B. They are able to think logically in organizing
67. The nurse is caring for a client with a facts
C. Interpretation of events originate from their
long leg cast. During discharge teaching
own perspective
about appropriate exercises for the D. Conclusions are based on previous
affected extremity, the nurse experiences
should recommend 72. The nurse is has just admitted a client
A. Isometric with severe depression. From which focus
 should the nurse identify a prioriy nursing reflects the right of the professional to give
diagnosis? and receive information.
3. The correct answer is C: Use patience and
A. Nutrition a sense of humor to deal with this
B. Elimination behavior. The nurse should help the parents
C. Activity see the negativism as a normal growth of
D. Safety autonomy in the toddler. They can best handle
73. Which playroom activities should the the negative toddler by using patience and
nurse organize for a small group of 7 humor.
4. The correct answer is B: “Do you become
year-old hospitalized children?
short of breath during your normal daily
A. Sports and games with rules activities?”. These are the symptoms of right-
B. Finger paints and water play sided heart failure, which causes increased
C. “Dress-up” clothes and props pressure in the systemic venous system. To
D. Chess and television programs equalize this pressure, the fluid shifts into the
74. A client is discharged following interstitial spaces causing edema. Because of
gravity, the lower extremities are first affected
hospitalization for congestive heart
in an ambulatory patient. This question would
failure. The nurse teaching the family elicit information to confirm the nursing
suggests they encourage the client to rest diagnosis of activity intolerance and fluid
frequently in which of the following volume excess both associated with right-
positions? sided heart failure.
5. The correct answer is C: Administer
A. High Fowler’s analgesic therapy as ordered. The main
B. Supine general objectives in the treatment of a sickle
C. Left lateral cell crisis is bed rest, hydration, electrolyte
D. Low Fowler’s replacement, analgesics for pain, blood
75. The nurse is caring for a 10 year-old replacement and antibiotics to treat any
on admission to the burn unit. One existing infection.
assessment parameter that will indicate 6. The correct answer is B: Poor body
image. As the adolescent gains weight, there
that the child has adequate fluid
is a lessening sense of self esteem and poor
replacement is body image.
A. Urinary output of 30 ml per hour 7. The correct answer is C: Working. During
B. No complaints of thirst the working phase alternative behaviors and
C. Increased hematocrit techniques are explored. The nurse and the
D. Good skin turgor around burn client discuss the meaning behind the
behavior.
Answers and Rationales 8. The correct answer is C: Perform 5
1. The correct answer is D: Coronary artery abdominal thrusts. At this age, the most
aneurysms. Kawasaki Disease involves all effective way to clear the airway of food is to
the small and medium-sized blood vessels. perform abdominal thrusts.
There is progressive inflammation of the 9. The correct answer is B: “The seizure may
small vessels which progresses to the or may not mean your child has
medium-sized muscular arteries, potentially epilepsy.”. There are many possible causes
damaging the walls and leading to coronary for a childhood seizure. These include fever,
artery aneurysms. central nervous system conditions, trauma,
2. The correct answer is B: “Would you metabolic alterations and idiopathic
please clarify what you have written so I (unknown).
am sure I am reading it 10.The correct answer is D: The infant
correctly?”Assertive communication respects received mechanical ventilation for 2
the rights and responsibilities of both parties. weeks. Bronchopulmonary dysplasia is an
This statement is an honest expression of iatrogenic disease caused by therapies such as
concern for safe practice and a request for use of positive-pressure ventilation used to
clarification without self-depreciation. It treat lung disease.
11.The correct answer is A: Cereal. The is not indicated. While touching with cold
guidelines of the American Academy of hands can startle the infant it does not pose a
Pediatrics recommend that one new food be safety risk.
introduced at a time, beginning with strained 21.The correct answer is B:Peripheral
cereal. neuropathy can lead to lack of sensation in the
12.The correct answer is C: Self- lower extremities. Clients do not feel pressure
blame. Domestic violence victims may be and/or pain and are at high risk for skin
immobilized by a variety of affective impairment.
responses, one being self-blame. The victim 22.The correct answer is D:Nursing care for a
believes that a change in their behavior will child having a seizure includes, maintaining
cause the abuser to become nonviolent, which airway patency, ensuring safety, administering
is a myth. medications, and providing emotional support.
13.The correct answer is C: “I am going to say Since the seizure has already started, nothing
the names of three things and I want you to should be forced into the child”s mouth and
repeat them after me: blue, ball, pen.” they should not be moved. Of the choices
14.The correct answer is C: The non-rebreather given, first priority would be for safety.
mask has a one-way valve that prevents 23.The correct answer is D:Any activity that
exhales air from entering the reservoir bag involves straining should be avoided in clients
and one or more valves covering the air holes with glaucoma. Such activities would increase
on the face mask itself to prevent inhalation of intraocular pressure.
room air but to allow exhalation of air. When 24.The correct answer is D:An adverse reaction
a tight seal is achieved around the mask up to of a fever should be reported immediately.
100% of oxygen is available. Other reactions that should be reported
15.The correct answer is C: Prickling sensation include crying for > 3 hours, seizure activity,
is an indication of compartment syndrome and and tender, swollen, reddened areas.
requires immediate action by the nurse. The 25.The correct answer is B:Clients with
other findings are normal for a client in this contraindications to heparin, recurrent PE or
situation. those with complications related to the
16.The correct answer is A: INH can cause medical therapy may require vena caval
hepatocellular injury and hepatitis. This interruption by the placement of a filter device
side effect is age-related and can be detected in the inferior vena cava. A filter can be
with regular assessment of liver enzymes, placed transvenously to trap clots before they
which are released into the blood from travel to the pulmonary circulation.
damaged liver cells. 26.The correct answer is D:Heartburn is a
17.The correct answer is C: . Risk factors for burning sensation caused by regurgitation of
pressure ulcers include: immobility, absence gastric contents that is best relieved by
of sensation, decreased LOC, poor nutrition sleeping position, eating small meals, and not
and hydration, skin moisture, incontinence, eating before bedtime.
increased age, decreased immune response. 27.The correct answer is C:Honey has been
This client has the greatest number of risk associated with infant botulism and should be
factors. avoided. Older children and adults have
18.The correct answer is C: Children who have digestive enzymes that kill the botulism
a depressed immune system related to HIV or spores.
chemotherapy should not be given routine 28.The correct answer is A: Institute seizure
immunizations. precautions. The severity of the acute phase
19.The correct answer is C:Nephrotoxicity is a of AGN is variable and unpredictable;
common side effect of calcium disodium therefore, a child with edema, hypertension,
edetate, in addition to lead poisoning in and gross hematuria may be subject to
general. complications and anticipatory preparation
20.The correct answer is B: When using a such as seizure precautions are needed.
warming device the neonate’s temperature 29.The correct answer is D: “By prolonging
should be continuously monitored for breathing out with pursed lips my little
undesired elevations. The use of heat lamps is areas in my lungs don”t collapse.” Clients
not safe as there is no way to regulate their with chronic obstructive pulmonary disease
temperature. Warming medications and fluids have difficulty exhaling fully as a result of the
 weak alveolar walls from the disease process . pregnant woman who smokes increases her
Alveolar collapse can be avoided with the use risk of cardiovascular problems, such as
of pursed-lip breathing. This is the major thromboembolic disorders.
reason to use it. The other options are 38.The correct answer is C: Shallow
secondary effects of purse-lip breathing. respirations. A.L.S. is a chronic progressive
30.The correct answer is A: Ask the client if disease that involves degeneration of the
he has noticed any bleeding or dark anterior horn of the spinal cord as well as the
stools. Normal hemoglobin for males is 13.0 – corticospinal tracts. When the intercostal
18 g/100 ml. Normal hemotocrit for males is muscles and diaphragm become involved, the
42 – 52%. These values are below normal and respirations become shallow and coughing is
indicate mild anemia. The first thing the nurse ineffective.
should do is ask the client if he”s noticed any 39.The correct answer is A: “Nursing will help
bleeding or change in stools that could contract the uterus and reduce your risk of
indicate bleeding from the GI tract. bleeding.”  Stimulation of the breast during
31.The correct answer is B: “What have you nursing releases oxytocin, which contracts the
done that you feel most guilty about and uterus. This contraction is especially
what steps can you begin to take to help important following hemorrhage.
you lessen this guilt?” This response 40.The correct answer is A: These side effects
encourages the client to get in touch with their are common and should subside in a few
feelings and utilize problem solving steps to days. Nausea, metallic taste and fine hand
reduce guilt feelings. tremors are common side effects that usually
32.The correct answer is C: Encourage her to subside within days.
talk about her view of herself. To an 41.The correct answer is C: Encourage range
adolescent, body image is very important. The of motion and ambulation. Mobility reduces
nurse must acknowledge this before the risk of deep vein thrombosis in the post-
assessment and teaching. surgical client and the adult at risk.
33.The correct answer is D: Discontinue a new 42.The correct answer is A: Circumcision is
food that was added to the infant”s diet just delayed so the foreskin can be used for the
prior to the rash. The addition of new foods surgical repair. Even if mild hypospadias is
to the infant”s diet may be a cause of diaper suspected, circumcision is not done in order to
dermatitis. save the foreskin for surgical repair, if needed.
34.The correct answer is D: Feelings of 43.The correct answer is A: Loss of
alienation or isolation. The isolation may consciousness. While parents should report
occur gradually resulting in a loss of all any of the observations, they need to call the
meaningful social contacts. Isolation can be health care provider immediately if the level
self imposed or can occur as a result of the of alertness changes. This indicates anoxia,
inability to express feelings. At this stage of which may lead to death. The structural
development it is important to achieve a sense defects associated with Tetralogy of Fallot
of identity and peer acceptance. include pulmonic stenosis, ventricular septal
35.The correct answer is C: Independence. In defect, right ventricular hypertrophy and
Erikson’s theory of development, toddlers overriding of the aorta. Surgery is often
struggle to assert independence. They often delayed, or may be performed in stages.
use the word “no” even when they mean yes. 44.The correct answer is A: Double the birth
This stage is called autonomy versus shame weight. Although growth rates vary, infants
and doubt. normally double their birth weight by 6
36.The correct answer is A: 60 months.
microdrops/minute 45.The correct answer is C: Maintain in a flat
2 gm=2000 mgm position, logrolling as needed. The bed
2000 mgm/500 cc = 4 mgm/x cc should remain flat for at least the first 24
2000x = 2000 hours to prevent injury. Logrolling is the best
x= 2000/2000 = 1 cc of IV solution/minute way to turn for the client while on bed rest.
CC x 60 microdrops = 60 microdrops/minute 46.The correct answer is A: “Focus on your
37.The correct answer is B: Oral sons” needs during the first days at
contraceptives should not be used by home.” In an expanded family, it is important
smokers. The use of oral contraceptives in a
 for parents to reassure older children that they 56.The correct answer is A: Expose the cast to
are loved and as important as the newborn. air and turn the child frequently. The child
47.The correct answer is A: A cerebral should be turned every 2 hours, with surface
vascular accident. Polycythemia occurs as a exposed to the air.
physiological reaction to chronic hypoxemia 57.The correct answer is C: Administer a
which commonly occurs in clients with laxative to the client the evening before the
Tetralogy of Fallot. Polycythemia and the examination. Bowel prep is important
resultant increased viscosity of the blood because it will allow greater visualization of
increase the risk of thromboembolic events. the bladder and ureters.
Cerebrovascular accidents may occur. Signs 58.The correct answer is D: It is not “caught”
and symptoms include sudden paralysis, but is a response to a previous B-hemolytic
altered speech, extreme irritability or fatigue, strep infection. AGN is generally accepted as
and seizures. an immune-complex disease in relation to an
48.The correct answer is A: Oculogyric antecedent streptococcal infection of 4 to 6
crisis. This refers to involuntary muscles weeks prior, and is considered as a
spasm of the eye. noninfectious renal disease.
49.The correct answer is B: An occupational 59.The correct answer is D: No measurable
therapist from the community center. An voiding in 4 hours. The concern is possible
occupational therapist can assist a client to hyperkalemia, which could occur with
improve the fine motor skills needed to continued potassium administration and a
prepare an insulin injection. decrease in urinary output since potassium is
50.The correct answer is C: Provide excreted via the kidneys.
interactions to help the client learn to trust 60.The correct answer is B: Massage the
staff. This establishes trust, facilitates a fundus. The nurse’s first action should be to
therapeutic alliance between staff and client. massage the fundus until it is firm as uterine
51.The correct answer is C: Procedure that atony is the primary cause of bleeding in the
compresses plaque against the wall of the first hour after delivery.
diseased coronary artery to improve blood 61.The correct answer is A: Unequal leg
flow. PTCA is performed to improve coronary length. Shortening of a leg is a sign of
artery blood flow in a diseased artery. It is developmental dysplasia of the hip.
performed during a cardiac catheterization. 62.The correct answer is B: Administer stool
Aorta coronary bypass Graft is the surgical softeners every day as
procedure to repair a diseased coronary artery. ordered. Administering stool softeners every
52.The correct answer is B: Administration of day will prevent straining on defecation which
thyroid hormone will prevent causes the Valsalva maneuver. If constipation
problems. Early identification and continued occurs then laxatives would be necessary to
treatment with hormone replacement corrects prevent straining. If straining on defecation
this condition. produced the valsalva maneuver and rhythm
53.The correct answer is C: Protection from disturbances resulted then antidysrhythmics
self-harm and harm to others. Involuntary would be appropriate.
hospitalization may be required for persons 63.The correct answer is B: Introduce
considered dangerous to self or others or for him/herself and accompany the client to the
individuals who are considered gravely client’s room. Anxiety is triggered by change
disabled. that threatens the individual’s sense of
54.The correct answer is A: “I don”t security. In response to anxiety in clients, the
remember anything about what happened nurse should remain calm, minimize stimuli,
to me.” Suppression is willfully putting an and move the client to a calmer, more
unacceptable thought or feeling out of one’s secure/safe setting.
mind. A deliberate exclusion “voluntary 64.The correct answer is C: “I have to turn
forgetting” is generally used to protect one’s my head to see my room.”. Intraocular
own self esteem. pressure becomes elevated which slowly
55.The correct answer is D: Risk for produces a progressive loss of the peripheral
infection. Membranes ruptured over 24 hours visual field in the affected eye along with
prior to birth greatly increases the risk of rainbow halos around lights. Intraocular
infection to both mother and the newborn. pressure becomes elevated from the
 microscopic obstruction of the trabeculae Precautions to prevent suicide must be a part
meshwork. If left untreated or undetected of the plan.
blindness results in the affected eye. 73.The correct answer is A: Sports and games
65.The correct answer is A: Has increased with rules. The purpose of play for the 7
airway obstruction. The higher pitched a year-old is cooperation. Rules are very
sound is, the more narrow the airway. important. Logical reasoning and social skills
Therefore, the obstruction has increased or are developed through play.
worsened. With no evidence of secretions no 74.The correct answer is A: High
support exists to indicate the need for Fowler”s. Sitting in a chair or resting in a bed
suctioning. in high Fowler”s position decreases the
66.The correct answer is D: Low self- cardiac workload and facilitates breathing.
esteem. Batterers are usually physically or 75.The correct answer is A: Urinary output of
psychologically abused as children or have 30 ml per hour. For a child of this age, this is
had experiences of parental violence. adequate output, yet does not suggest
Batterers are also manipulative, have a low overload.
self-esteem, and have a great need to exercise
control or power-over partner.
67.The correct answer is A: Isometric. The
nurse should instruct the client on isometric
exercises for the muscles of the casted
extremity, i.e., instruct the client to alternately
contract and relax muscles without moving
the affected part. The client should also be
instructed to do active range of motion
exercises for every joint that is not
immobilized at regular and frequent intervals.
68.The correct answer is A: Counsel the
woman to consent to HIV screening. The
client”s behavior places her at high risk for
HIV. Testing is the first step. If the woman is
HIV positive, the earlier treatment begins, the
better the outcome.
69.The correct answer is B: Explain that this
behavior is expected. During normal
development, fear of strangers becomes
prominent beginning around age 6-8 months.
Such behaviors include clinging to parent,
crying, and turning away from the stranger.
These fears/behaviors extend into the toddler
period and may persist into preschool.
70.The correct answer is B: Separation from
parents. Separation anxiety if most evident
from 6 months to 30 months of age. It is the
greatest stress imposed on a toddler by
hospitalization. If separation is avoided,
young children have a tremendous capacity to
withstand other stress.
71.The correct answer is B: Think logically in
organizing facts. The child in the concrete
operations stage, according to Piaget, is
capable of mature thought when allowed to
manipulate and organize objects.
72.The correct answer is D: Safety. Safety is a
priority of care for the depressed client.
 Medical Surgical Nursing Exam 20 found in osteomyelitis, they do not cause the
majority of bone infections.
1. When the nurse notes that the patient’s D. Escherichia coli
left great toe deviates laterally, she While E. coli is frequently found in
recognizes that the patient has a osteomyelitis, it does not cause the majority of
bone infections
A. hallux valgus.
4. Which of the following statements
Hallux valgus is commonly referred to as a
bunion. reflects information to be included when
B. hammertoe. teaching the patient about plantar
Hammertoes are usually pulled upward. fasciitis?
C. pes cavus.
Pes cavus refers to a foot with an abnormally A. Management of plantar fasciitis includes
high arch and a fixed equinus deformity of the stretching exercises.
forefoot. Management also includes wearing shoes with
D. flatfoot. support and cushioning to relieve pain,
In flatfoot, the patient demonstrates a orthotic devices (e.g., heel cups, arch
diminished longitudinal arch of the foot. supports), and the use of non-steroidal anti-
inflammatory drugs (NSAIDs).
2. Localized rapid bone turnover, most
B. Plantar fasciitis presents as an acute onset of
commonly affecting the skull, femur, tibia, pain localized to the ball of the foot that
pelvic bones, and vertebrae, occurs when pressure is placed upon it and
characterizes which of the following bone diminishes when pressure is released.
disorders? Plantar fasciitis, an inflammation of the foot-
supporting fascia, presents as an acute onset
A. Osteitis deformans of heel pain experienced with the first steps in
Osteitis deformans (Paget’s disease) results in the morning. The pain is localized to the
bone that is highly vascularized and anterior medial aspect of the heel and
structurally weak, predisposing to pathologic diminishes with gentle stretching of the foot
fractures. and Achilles tendon.
B. Osteomalacia C. The pain of plantar fasciitis diminishes with
Osteomalacia is a metabolic bone disease warm water soaks.
characterized by inadequate mineralization of Plantar fasciitis, an inflammation of the foot-
bone. supporting fascia, presents as an acute onset
C. Osteoporosis of heel pain experienced with the first steps in
Osteoporosis is characterized by reduction of the morning. The pain is localized to the
total bone mass and a change in bone structure anterior medial aspect of the heel and
which increases susceptibility to fracture. diminishes with gentle stretching of the foot
D. Osteomyelitis and Achilles tendon.
Osteomyelitis is an infection of bone that D. Complications of plantar fasciitis include
comes from extension of soft tissue infection, neuromuscular damage and decreased ankle
direct bone contamination, or hematogenous range of motion.
spread. Unresolved plantar fasciitis may progress to
3. Most cases of osteomyelitis are caused fascial tears at the heel and eventual
by which of the following development of heel spurs.
microorganisms? 5. Lifestyle risk factors for osteoporosis
include
A. Staphylococcus
Staphylococcus aureus causes 70-80% of A. lack of exposure to sunshine.
bone infections. Lifestyle risk factors for osteoporosis include
B. Proteus species lack of exposure to sunshine, low calcium and
While Proteus species are frequently found in vitamin D diet, cigarette smoking, use of
osteomyelitis, they do not cause the majority alcohol and/or caffeine, and lack of weight-
of bone infections. bearing exercise.
C. Pseudomonas species B. lack of aerobic exercise.
While Pseudomonas species are frequently Lack of weight-bearing exercise, not aerobic
 exercise, is a lifestyle risk factor for 7. Instructions for the patient with low
osteoporosis. back pain include which of the following?
C. a low protein, high fat diet.
A low calcium and vitamin D diet, not a low A. When lifting, avoid overreaching.
protein, high fat diet, is a lifestyle risk factor Instructions for the patient with low back pain
for osteoporosis. should include that when lifting, the patient
D. an estrogen deficiency or menopause. should avoid overreaching. The patient should
An estrogen deficiency or menopause is an also keep the load close to the body, bend the
individual, not lifestyle risk factor for knees and tighten the abdominal muscles, use
osteoporosis. Other individual risk factors a wide base of support, and use a back brace
include female gender, white non-Hispanic or to protect the back.
Asian race, increased age, low weight and B. When lifting, place the load away from the
body mass index, family history of body.
osteoporosis, low initial bone mass, and When lifting, the patient with low back pain
contributing co-existing medical conditions should keep the load close to the body.
and medications. C. When lifting, use a narrow base of support.
6. The nurse teaches the patient with a When lifting, the patient with low back pain
high risk for osteoporosis about risk- should use a wide base of support.
D. When lifting, bend the knees and loosen the
lowering strategies including which of the
abdominal muscles.
following statements? When lifting, the patient with low back pain
A. Walk or perform weight-bearing exercises out should bend the knees and tighten the
of doors. abdominal muscles.
Risk-lowering strategies for osteoporosis 8. Dupuytren’s contracture causes flexion
include walking or exercising out of doors, of the
performing a regular weight-bearing exercise
regimen, increasing dietary calcium and A. fourth and fifth fingers.
vitamin D intake, smoking cessation, and Dupuytren’s contracture causes flexion of the
consuming alcohol and caffeine consumption fourth and fifth fingers, and frequently the
in moderation. middle finger.
B. Increase fiber in the diet. B. thumb.
Risk-lowering strategies for osteoporosis Dupuytren’s contracture causes flexion of the
include increasing dietary calcium and fourth and fifth fingers, and frequently the
vitamin D intake, middle finger.
walking or exercising out of doors, smoking C. index and middle fingers.
cessation, consuming alcohol and caffeine Dupuytren’s contracture causes flexion of the
consumption in moderation, and performing a fourth and fifth fingers, and frequently the
regular weight-bearing exercise regimen. middle finger.
C. Reduce stress. D. ring finger.
Risk-lowering strategies for osteoporosis Dupuytren’s contracture causes flexion of the
include walking or exercising out of doors, fourth and fifth fingers, and frequently the
increasing dietary calcium and vitamin D middle finger.
intake, smoking cessation, consuming alcohol 9. A metabolic bone disease
and caffeine consumption in moderation, and characterized by inadequate
performing a regular weight-bearing exercise mineralization of bone is
regimen.
D. Decrease the intake of vitamin A and D. A. osteomalacia
Risk-lowering strategies for osteoporosis Osteomalacia is a metabolic bone disease
include increasing dietary calcium and characterized by inadequate mineralization of
vitamin D intake, bone.
walking or exercising out of doors, smoking B. osteoporosis
cessation, consuming alcohol and caffeine Osteoporosis is characterized by reduction of
consumption in moderation, and performing a total bone mass and a change in bone structure
regular weight-bearing exercise regimen. which increases susceptibility to fracture.
C. osteomyelitis B. Rest, ice, circulation, and examination
Osteomyelitis is an infection of bone that While circulation problems must be
comes from extension of soft tissue infection, examined, the RICE treatment does not refer
direct bone contamination, or hematogenous to circulation and examination.
spread. C. Rotation, immersion, compression and
D. osteoarthritis elevation
Osteoarthritis (OA), also known as Rotation of a joint is contraindicated when
degenerative joint disease, is the most injury is suspected, and immersion of the area
common and frequently disabling of the joint may be anatomically difficult.
disorders. OA affects the articular cartilage, D. Rotation, ice, compression, and examination
subchondral bone, and synovium. Rotation of a joint is contraindicated when
10. Which of the following terms refers to injury is suspected, and examination, while
an injury to ligaments and other soft indicated, does not provide treatment.
tissues of a joint? 13. The nurse anticipates that the
physician will perform joint aspiration and
A. Sprain wrapping with compression elastic
A sprain is caused by a wrenching or twisting
dressing for which of the following
motion.
B. Dislocation musculoskeletal problems?
Dislocation refers to the separation of joint A. Joint effusion
surfaces. The described treatments are used with joint
C. Subluxation effusions and hemarthrosis.
Subluxation refers to partial separation or B. Strain
dislocation of joint surfaces. A strain is treated by RICE.
D. Strain                                                                 C. Sprain
Strain refers to a muscle pull or tear. A sprain is treated by RICE.
11. Which of the following terms refers to D. Avascular necrosis
failure of fragments of a fractured bone to Avascular necrosis describes death of tissue
heal together? due to insufficient blood supply and may be
associated with steroid use.
A. Nonunion 14. When x-ray demonstrates a fracture
When nonunion occurs, the patient complains
in which bone has splintered into several
of persistent discomfort and movement at the
fracture site. pieces, that fracture is described as
B. Dislocation A. comminuted.
Dislocation refers to the separation of joint A comminuted fracture may require open
surfaces. reduction and internal fixation.
C. Subluxation B. compound.
Subluxation refers to partial separation or A compound fracture is one in which damage
dislocation of joint surfaces. also involves the skin or mucous membranes.
D. Malunion C. depressed.
Malunion refers to growth of the fragments of A depressed fracture is one in which
a fractured bone in a faulty position, forming fragments are driven inward.
an imperfect union. D. impacted.
12. The Emergency Department nurse An impacted fracture is one in which a bone
teaches patients with sports injuries to fragment is driven into another bone
remember the acronym RICE, which fragment.
stands for which of the following 15. When x-ray demonstrates a fracture
combinations of treatment? in which the fragments of bone are driven
inward, the fracture is described as
A. Rest, ice, compression, elevation
RICE is used for the treatment of contusions, A. depressed.
sprains, and strains. Depressed skull fractures occur as a result of
blunt trauma.
B. compound. recognizes that the patient is likely
A compound fracture is one in which damage demonstrating signs of
also involves the skin or mucous membranes.
C. comminuted. A. reflex sympathetic dystrophy syndrome.
A comminuted fracture is one in which the RSD is frequently chronic and occurs most
bone has splintered into several pieces. often in women.
D. impacted. B. avascular necrosis of bone.
An impacted fracture is one in which a bone Avascular necrosis is manifested by pain and
fragment is driven into another bone limited movement.
fragment. C. a reaction to an internal fixation device.
16. A fracture is termed pathologic when Pain and decreased function are the prime
the fracture indicators of reaction to an internal fixation
device.
A. occurs through an area of diseased bone. D. heterotrophic ossification.
Pathologic fractures can occur without the Heterotrophic ossification causes muscular
trauma of a fall. pain and limited muscular contraction and
B. results in a pulling away of a fragment of movement.
bone by a ligament or tendon and its 19. Which of the following terms refers to
attachment. a fracture in which one side of a bone is
An avulsion fracture results in a pulling away
broken and the other side is bent?
of a fragment of bone by a ligament or tendon
and its attachment. A. Greenstick
C. presents as one side of the bone being broken A greenstick fracture is a fracture in which
and the other side being bent. one side of a bone is broken and the other side
A greenstick fracture presents as one side of is bent.
the bone being broken and the other side B. Spiral
being bent. A spiral fracture is a fracture twisting around
D. involves damage to the skin or mucous the shaft of the bone.
membranes. C. Avulsion
A compound fracture involves damage to the An avulsion is the pulling away of a fragment
skin or mucous membranes. of bone by a ligament or tendon and its
17. The most common complication after attachment.
knee arthroscopy is D. Oblique
An oblique is a fracture occurring at an angle
A. joint effusion. across the bone.
Joint effusion produces marked pain, and the 20. The nurse assesses subtle
physician may need to aspirate the joint to
personality changes, restlessness,
remove fluid and relieve the pressure.
B. infection. irritability, and confusion in a patient who
Infection is not a common complication of has sustained a fracture. The nurse
arthroscopy. suspects
C. knee giving way.
Complaints of the knee giving way are A. fat embolism syndrome.
associated with functioning of the injured Cerebral disturbances in the patient with fat
knee prior to arthroscopy. embolism syndrome include subtle personality
D. knee locking. changes, restlessness, irritability, and
Complaints of the knee locking are associated confusion.
with functioning of the injured knee prior to B. compartment syndrome.
arthroscopy. With compartment syndrome, the patient
complains of deep, throbbing, unrelenting
18. When the patient who has
pain.
experienced trauma to an extremity C. hypovolemic shock.
complains of severe burning pain, With hypovolemic shock, the patient would
vasomotor changes, and muscles spasms have a decreased blood pressure and increased
in the injured extremity, the nurse pulse rate.
D. reflex sympathetic dystrophy syndrome.           D. Emerging infectious diseases
Clinical manifestations of reflex sympathetic Emerging infectious diseases refer to diseases
dystrophy syndrome include severe, burning of infectious origin of which incidence in
pain, local edema, hyperesthesia, muscle humans has increased within the past two
spasms, and vasomotor skin changes. decades or threaten to increase in the near
21. A Colles’ fracture is a fracture of the future.
24. The usual incubation period (infection
A. distal radius.
to first symptom) for AIDS is
A Colles’ fracture is a fracture of the distal
radius (wrist). It is usually the result of a fall A. 10 years.
on an open, dorsiflexed hand. HIV is transmitted through sexual,
B. elbow. percutaneous, or perinatal contact.
A Colles’ fracture is a fracture of the distal B. 3–6 months.
radius. The incubation period for HIV infection is
C. humeral shaft. greater than 3-6 months.
A Colles’ fracture is a fracture of the distal C. 1 year.
radius. The incubation period for HIV infection is
D. clavicle. greater than 1 year.
A Colles’ fracture is a fracture of the distal D. 5 years.
radius. The incubation period for HIV infection is
22. With fractures of the femoral neck, the greater than 5 years.
leg is 25. The usual incubation period (infection
to first symptom) for hepatitis B is
A. shortened, adducted, and externally rotated.
With fractures of the femoral neck, the leg is A. 45-160 days.
shortened, adducted, and externally rotated. Hepatitis B is responsible for more than 200
B. shortened, abducted, and internally rotated. deaths of healthcare workers annually.
With fractures of the femoral neck, the leg is B. 15-50 days.
shortened, adducted, and externally rotated. The incubation period for hepatitis B is 45-
C. adducted and internally rotated. 160 days.
With fractures of the femoral neck, the leg is C. 6-9 months.
shortened, adducted, and externally rotated. The incubation period for hepatitis B is
D. abducted and externally rotated. shorter than 6-9 months.
With fractures of the femoral neck, the leg is D. unclear.
shortened, adducted, and externally rotated. The incubation periods for hepatitis D, E, and
23. Which of the following terms most G are unclear.
precisely refers to an infection acquired in 26. Which of the following terms refers to
the hospital that was not present or a state of microorganisms being present
incubating at the time of hospital within a host without causing host
admission? interference or interaction?
A. Nosocomial infection A. Colonization
A 1970 CDC study found that about one-third Understanding the principle of colonization
of nosocomial infections could be prevented facilitates interpretation of microbiologic
when effective infection control programs reports.
were in place. B. Susceptible
B. Primary bloodstream infection A susceptible host is a host who does not
A primary bloodstream infection is possess immunity to a particular pathogen.
bacteremia or fungemia, which occurs without C. Immune
infection, identified at another anatomic site. An immune host is a host who is not
C. Secondary bloodstream infection susceptible to a particular pathogen.
A secondary bloodstream infection is D. Infection
bacteremia of fungemia of another anatomic Infection refers to host interaction with an
site, which serves as a source for bloodstream organism.
contamination.
 27. The nurse teaches the parent of the prophylactic antibiotic. The aim of
child with chickenpox that the child is no prophylaxis is to assure that if spores were
inhaled, bacteria will be killed immediately
longer contagious to others when
upon release from spores. Those who have
A. the vesicles and pustules have crusted. symptoms of fever, cough, headache, chills,
When the lesions have crusted, the patient is and especially evidence of mediastinal lymph
no longer contagious to others. node involvement should be treated with
B. the first rash appears. intravenous antibiotics and respiratory
The child remains contagious when the rash is support, if needed.
present. B. 30 days.
C. the fever disappears. Those with symptoms who have been in the
The child remains contagious if the fever hot zone should be given 60 days of
occurs as the rash is progressing. prophylactic antibiotic
D. the rash is changing into vesicles, and pustules C. 14 days.
appear. Those with symptoms who have been in the
The child remains contagious when the rash is hot zone should be given 60 days of
changing into vesicles and pustules. prophylactic antibiotic
28. Which of the following statements D. 10 days.
Those with symptoms who have been in the
reflects the nursing management of the
hot zone should be given 60 days of
patient with West Nile Virus infection? prophylactic antibiotic
A. There is no treatment for West Nile Virus 30. If a case of smallpox is suspected, the
infection. nurse should
Patients are supported by fluid replacement,
airway management, and standard nursing A. call the CDC Emergency Preparedness Office.
care support during the time that the patient Anyone suspecting a case of smallpox should
hasmeningitis symptoms. call the CDC Emergency Preparedness Office
B. The incubation period is three to five days. at 770-488-7100. The CDC will respond by
The incubation period (from mosquito bite immmediate provision of diagnostic support
until onset of symptoms) is between 5–15 and eventual release of vaccine if a case is
days. confirmed. Until instructed otherwise by the
C. Patients with West Nile virus present with CDC, healthcare providers should carefully
gastrointestinal complaints, such as nausea, establish isolation with negative pressure, and
vomiting, diarrhea, and abdominal pain. maintain thorough lists of all those who have
Most human infections are asymptomatic. contact with the patient.
When symptoms are present, headache and B. immediately vaccinate the patient and anyone
fever are most frequently reported. Less than in contact with the patient.
one percent of those infected develop more The CDC will provide diagnostic support and
severe illness, including meningitis. will release the vaccine if the patient is
D. Transmission of West Nile virus occurs from confirmed to have smallpox.
human-to-human. C. establish isolation with positive pressure.
Birds are the natural reservoir for the virus. Isolation with negative pressure should be
Mosquitoes become infected when feeding on established.
birds and can transmit the virus to animals and D. Assess the patient for signs of a rash similar to
humans. There is no human-to-human chickenpox in appearance and progression.
transmission of virus. The lesions associated with smallpox may
appear similar in appearance, but the
29. Prophylaxis antibiotic for anthrax is
progression is very different from that of
given to people with symptoms who have chickenpox. Smallpox lesions will appear to
been in a defined “hot zone” for a period be at the same stage of development as the
of rash progresses from macules to papules to
pustules to scabs. This progression is very
A. 60 days. different from that of chickenpox. With
Those with symptoms who have been in the chickenpox, lesions appear at different
hot zone should be given 60 days of developmental stages.
 31. The six elements necessary for C. The viruses can be spread only by airborne
infection are a causative organism, a exposure.
The viruses can be spread by exposure to
reservoir of available organisms, a portal
blood or other body fluid, insect bite, and
or mode of exit from the reservoir, a mode mucous membrane exposure.
of transmission from reservoir to host, a D. Symptoms include severe lower abdominal
susceptible host, and a pain, nausea, vomiting, and dehydration.
Symptoms include fever, rash, and
A. mode of entry to host. encephalitis which progress rapidly to
The six elements necessary for infection are a profound hemorrhage, organ destruction, and
causative organism, a reservoir of available shock.
organisms, a portal or mode of exit from the
33. Bubonic plague occurs
reservoir, a mode of transmission from
reservoir to host, a susceptible host, and a A. after the organism enters through the skin.
mode of entry to host. Bubonic refers to enlarged lymph nodes that
B. mode of exit from the host. develop after the organism enters through the
A mode of entry to the host, not a mode of skin. Bubonic plague is the form seen most
exit from the host, is necessary for infection. frequently, as the organism is transferred from
C. virulent host. rodents or other animals to humans by insect
The six elements necessary for infection are a bite.
causative organism, a reservoir of available B. occurs after the organism is inhaled..
organisms, a portal or mode of exit from the Pneumonic plague occurs after the organism
reservoir, a mode of transmission from is inhaled. Only pneumonic plague can be
reservoir to host, a susceptible host, and a contagious from person to person by an
mode of entry to host. airborne route.
D. latent time period. C. occurs when the organism causes a
The six elements necessary for infection are a bloodstream infection.
causative organism, a reservoir of available Septicemic plague occurs when the organism
organisms, a portal or mode of exit from the causes a bloodstream infection usually
reservoir, a mode of transmission from secondary to either pneumonic or bubonic, but
reservoir to host, a susceptible host, and a sometimes without either entity.
mode of entry to host. D. after the organism is transferred by human to
32. Which of the following statements human contact.
reflect what is known about the Ebola and Bubonic plague is the form seen most
Marburg viruses? frequently, as the organism is transferred from
rodents or other animals to humans by insect
A. The diagnosis should be considered in a bite.
patient who has a febrile, hemorrhagic illness 34. The term given to the category of
after traveling to Asia or Africa. triage that refers to life-threatening or
The diagnosis should be considered in a
potentially life-threatening injury or illness
patient who has a febrile, hemorrhagic illness
after traveling to Asia or Africa, or who has requiring immediate treatment is
handled animals or animal carcasses from A. emergent.
those parts of the world. The patient triaged as emergent must be seen
B. Treatment during the acute phase includes immediately.
administration of acyclovir, and ventilator and B. urgent.
dialysis support. The triage category of urgent refers to minor
No antivirals have been approved or show illness or injury needing first-aid-level
promise against the viruses. Treatment must treatment.
be largely supportive maintenance of the C. immediate.
circulatory system and respiratory systems. It The triage category of immediate refers to
is likely that the infected patient would need non-acute, non-life-threatening injury or
ventilator and dialysis support through the illness.
acute phases of illness. D. non-acute.
The triage category of immediate refers to
 non-acute, non-life-threatening injury or C. Dextrose 5% in water
illness. Dextrose 5% in water should not be used to
35. When the patient has been field replace fluids in hypovolemic patients.
triaged and categorized as blue, the D. Hypertonic saline
Hypertonic saline is used only to treat severe
nurse recognizes that the patient requires
symptomatic hyponatremia and should be
A. fast-track or psychological support. used only in intensive care units.
When a patient is categorized as blue, field 38. Induction of vomiting is indicated for
triage has identified fast-track or the accidental poisoning patient who has
psychological support needs. ingested
B. emergent care.
Field triaged patients who require emergent A. aspirin.
care will be categorized as red. Overdose of aspirin should be treated with
C. immediate care. emesis or lavage, followed by ingestion of
Field triaged patients who require immediate activated charcoal to absorb the aspirin.
care will be categorized as yellow. B. rust remover.
D. urgent care. Rust remover is an alkaline product, which is
Field triaged patients who require urgent care corrosive, and induced vomiting is
will be categorized as green. contraindicated.
36. Which of the following guidelines is C. gasoline.
appropriate to helping family members Gasoline is a petroleum distillate, and induced
vomiting is contraindicated.
cope with sudden death?
D. toilet bowl cleaner.
A. Show acceptance of the body by touching it, Toilet bowl cleaners are corrosive, and
giving the family permission to touch. induced vomiting is contraindicated.
The nurse should encourage the family to 39. Which of the following phases of
view and touch the body if they wish, since psychological reaction to rape is
this action helps the family to integrate the characterized by fear and flashbacks?
loss.
B. Inform the family that the patient has passed A. Heightening anxiety phase
on. During the heightened anxiety phase, the
The nurse should avoid using euphemisms patient demonstrates anxiety, hyperalertness,
such as passed on. and psychosomatic reactions, in addition to
C. Obtain orders for sedation for family fear and flashbacks.
members. B. Acute disorganization phase
The nurse should avoid giving sedation to The acute disorganization phase is
family members, since this may mask or delay characterized by shock, disbelief, guilt,
the grieving process. humiliation, and anger.
D. Provide details of the factors attendant to the C. Denial phase
sudden death. The denial phase is characterized by an
The nurse should avoid volunteering unwillingness to talk.
unnecessary information (e.g., patient was D. Reorganization phase
drinking at the time of the accident). The reorganization phase occurs when the
37. Which of the following solutions incident is put into perspective. Some patients
should the nurse anticipate for fluid never fully recover from rape trauma.
replacement in the male patient? 40. When preparing for an emergency
bioterroism drill, the nurse instructs the
A. Lactated Ringer’s solution drill volunteers that each biological agents
Replacement fluids may include isotonic
requires specific patient management and
electrolyte solutions and blood component
therapy. medications to combat the virus, bacteria,
B. Type O negative blood or toxin. Which of the following
O negative blood is prepared for emergency statements reflect the patient
use in women of childbearing age. management of variola virus (small pox)?
A. Small pox spreads rapidly and requires moving vehicle, or compressed by
immediate isolation. machinery?
Small pox is spread by droplet or direct
contact. There are no antiviral agents effective A. Crush injuries
against small pox, however vaccination within Crush injuries are those that occur when a
two to three days of exposure is protective. person is caught between objects, run over by
B. Acyclovir is effective against smallpox. a moving vehicle, or compressed by
There are no antiviral agents effective against machinery.
small pox; however, vaccination within two to B. Blunt trauma
three days of exposure is protective. Blunt trauma is commonly associated with
C. Small pox is spread by inhalation of spores. extra-abdominal injuries to the chest, head, or
Small pox is spread by droplet or direct extremities.
contact. It spreads rapidly and requires C. Penetrating abdominal injuries
immediate isolation. Even in death, the Penetrating abdominal injuries include those
disease can be transmitted. such as gunshot wounds and stab wounds.
D. Vaccination is effective only if administered D. Intra-abdominal injuries
within 12 to 24 hours of exposure.       Intra-abdominal injuries are categorized as
Vaccination within two to three days of penetrating and blunt trauma.
exposure of the small pox virus is protective. 43. A person suffering from carbon
In four to five days, it may prevent death and monoxide poisoning
should be administered with vaccinia immune
globulin. A. appears intoxicated.
41. Which of the following statements A person suffering from carbon monoxide
reflect the nursing management of poisoning appears intoxicated (from cerebral
pulmonary anthrax (B. anthracis)? hypoxia). Other signs and symptoms include
headache, muscular weakness, palpitation,
A. Prophylaxis with fluoroquinone is suggested dizziness, and mental confusion.
after exposure. B. presents with severe hypertension.
Treatment is with ciprofloxacin or A person suffering from carbon monoxide
doxycycline. poisoning appears intoxicated (from cerebral
B. Airborne person-to-person transmission hypoxia). Other signs and symptoms include
occurs. headache, muscular weakness, palpitation,
Anthracis is a spore forming bacteria resulting dizziness, and mental confusion.
in gastrointestinal, pulmonary, and skin C. appears hyperactive.
symptoms. Symptoms are dependent upon A person suffering from carbon monoxide
contact, ingestion, or inhalation of the spores. poisoning appears intoxicated (from cerebral
Routine universal precautions are effective. hypoxia). Other signs and symptoms include
Anthrax survives in the spore form for long headache, muscular weakness, palpitation,
periods making the body a potential source of dizziness, and mental confusion.
infection for morticians. D. will always present with a cherry red skin
C. Diagnosis is by pulmonary function testing coloring.
and chest x-ray. The skin coloring in the patient with carbon
Blood cultures are required to confirm the monoxide poisoning can range from pink to
bacteria’s presence and diagnosis. cherry red to cynanotic and pale and is not a
D. Pulmonary effects include respiratory failure, reliable diagnostic sign.
shock, and death within five to seven days 44. Treatment of an acetaminophen
after exposure. overdose includes the administration of
The pulmonary effects include respiratory
failure, shock, and death within 24-36 hours A. N-acetylcysteine (Mucomyst).
after exposure. Treatment of acetaminophen overdose
42. Which of the following terms refers to includes administration of N-acetylcysteine
injuries that occur when a person is (Mucomyst).
B. flumazenil (Romazicon).
caught between objects, run over by a
Flumazenil is administered in the treatment of
nonbarbituate sedative overdoses.
C. naloxone (Narcan). A black triage tag (priority 4 or expectant)
Naloxone (Narcan) is administered in the indicates injuries that are extensive and
treatment of narcotic overdoses. chances of survival are unlikely even with
D. diazepam (Valium). definitive care.
Diazepam (Valium) may be administered to 47. If a person has been exposed to
treat uncontrolled hyperactivity in the patient radiation, presenting symptoms, such as
with a hallucinogen overdose.
nausea, vomiting, loss of appetite,
45. Which of the following statements
diarrhea, or fatigue can be expected to
reflect the nursing management of the
occur within _______ hours after
patient with a white phosphorus chemical
exposure?
burn?
A. 48 to 72
A. Do not apply water to the burn. The prodromal phase (presenting symptoms)
Water should not be applied to burns from lye of radiation exposure occurs within 48 to 72
or white phosphorus because of the potential hours after exposure. Signs and symptoms
for an explosion or deepening of the burn. include nausea, vomiting, loss of appetite,
B. Immediately drench the skin with running diarrhea, and fatigue. With high-dose
water from a shower, hose or faucet. radiation exposure, the signs and symptoms
Water should not be applied to burns from lye may include fever, respiratory distress, and
or white phosphorus because of the potential increased excitability.
for an explosion or deepening of the burn. B. 6 to 12
C. Alternate applications of water and ice to the The prodromal phase (presenting symptoms)
burn. of radiation exposure occurs within 48 to 72
Water should not be applied to burns from lye hours after exposure.
or white phosphorus because of the potential C. 12 to 24
for an explosion or deepening of the burn. The prodromal phase (presenting symptoms)
D. Wash off the chemical using warm water, then of radiation exposure occurs within 48 to 72
flush the skin with cool water. hours after exposure.
Water should not be applied to burns from lye D. 24 to 48
or white phosphorus because of the potential The prodromal phase (presenting symptoms)
for an explosion or deepening of the burn. of radiation exposure occurs within 48 to 72
46. During a disaster, the nurse sees a hours after exposure.
victim with a green triage tag. The nurse 48. Which of the following refers to a
knows that the person has management tool for organizing
A. injuries that are minor and treatment can be personnel, facilities, equipment, and
delayed hours to days. communication for any emergency
A green triage tag (priority 3 or minimal) situation?
indicates injuries that are minor and treatment
can be delayed hours to days. A. The Incident Command System
B. injuries that are life-threatening but survivable The Incident Command System (ICS) is a
with minimal intervention. management tool for organizing personnel,
A red triage tag (priority 1 or immediate) facilities, equipment and communication for
indicates injuries that are life-threatening but any emergency situation. The federal
survivable with minimal intervention. government mandates that the ICS be used
C. injuries that are significant and require during emergencies. Under this structure, one
medical care, but can wait hours without person is designated as incident commander.
threat to life or limb. This person must be continuously informed of
A yellow triage tag (priority 2 or delayed) all activities and informed about any deviation
indicates injuries that are significant and from the established plan. While the ICS is
require medical care, but can wait hours primarily a field structure and process, aspects
without threat to life or limb. of it are used at the level of an individual
D. indicates injuries that are extensive and hospital’s emergency response plan as well.
chances of survival are unlikely even with B. Office of Emergency Management
definitive care. Office of Emergency Management (OEM)
 coordinates the disaster relief efforts at the 50. The first step in decontamination is
state and local levels. The OEM is responsible
for providing interagency coordination during A. removal of the patient’s clothing and jewelry
an emergency. It maintains a corps of and then rinsing the patient with water.
emergency management personnel, including To be effective, decontamination must include
responders, planners, and administrative and a minimum of two steps. The first step is
support staff. removal of the patient’s clothing and jewelry
C. National Disaster Medical System and then rinsing the patient with water. The
National Disaster Medical System (NDMS). second step consists of a thorough soap and
The NDMS has many medical support teams water wash and rinse.
such as Disaster Medical Assistance Teams B. a thorough soap and water wash and rinse of
(DMATs) that provide medical personnel to the patient.
set up and staff a field hospital. A thorough soap and water wash and rinse of
D. The Hospital Emergency Preparedness Plan the patient is the second step in the
The Hospital Emergency Preparedness Plan is decontamination process. The first is to
a facility-specific plan for emergency remove the patient’s clothing and jewelry and
preparedness required by the Joint then rinsing the patient with water.
Commission on Accreditation of Healthcare C. to immediately apply personal protective
Organizations (JCAHO). equipment.
49. Which of the following terms refers to To be effective, decontamination must include
a minimum of two steps. The first step is
a process by which an individual receives
removal of the patient’s clothing and jewelry
education about recognition of stress and then rinsing the patient with water. The
reactions and management strategies for second step consists of a thorough soap and
handling stress? water wash and rinse.
D. to immediately apply a chemical
A. Defusing decontamination foam to the area of
Defusing is a process by which the individual contamination.        To be effective,
receives education about recognition of stress decontamination must include a minimum of
reactions and management strategies for two steps. The first step is removal of the
handling stress. It is a component of critical patient’s clothing and jewelry and then rinsing
incident stress management (CISM). the patient with water. The second step
B. Debriefing consists of a thorough soap and water wash
Debriefing is a more complicated intervention and rinse.
of critical incident stress management
(CISM); it involves 2- to 3- hour process
during which participants are asked about
their emotional reactions to the incident, what
symptoms they may be experiencing (e.g.,
flashbacks, difficulty sleeping, intrusive
thoughts) and other psychological
ramifications.
C. Follow-up
In follow-up, members of the critical incident
stress management (CISM) team contact the
participants of a debriefing and schedule a
follow-up meeting if necessary. People with
ongoing stress reactions are referred to mental
health specialists.
D. Critical incident stress management
Critical incident stress management (CISM) is
an approach to preventing and treating the
emotional trauma that can affect emergency
responders as a consequence of their jobs but
that can also occur to anyone involved in a
disaster or mass casualty incident.
 Medical Surgical Nursing Exam 12 C. Reflex (neurogenic) incontinence
Neurogenic incontinence is associated with a
1. During which stage of pressure ulcer spinal cord lesion.
development does the ulcer extend into D. Functional incontinence
the subcutaneous tissue? Functional incontinence refers to incontinence
in patients with intact urinary physiology who
A. Stage III experience mobility impairment,
Clinically, a deep crater with or without environmental barriers, or cognitive problems.
undermining of adjacent tissues is noted.
4. Ageism refers to
B. Stage IV
A stage IV pressure ulcer extends into the A. Bias against older people based solely on
underlying structure, including the muscle and chronological age
possibly the bone. Individuals demonstrating ageism base their
C. Stage II beliefs and attitudes about older people based
A stage II ulcer exhibits a break in the skin upon chronological age without consideration
through the epidermis or dermis. of functional capacity.
D. Stage I B. fear of old age.
A stage I pressure ulcer is an area of Fear of aging and the inability of many to
nonblanchable erythema, tissue swelling, and confront their own aging process may trigger
congestion, and the patient complains of ageist beliefs.
discomfort. C. loss of memory.
2. During which stage of pressure ulcer Age-related loss of memory occurs more with
development does the ulcer extend into short-term and recent memory.
the underlying structures, including the D. benign senescent forgetfulness.
muscle and possibly the bone? Benign senescent forgetfulness refers to the
age-related loss of memory in the absence of a
A. Stage IV pathologic process.
A stage IV pressure ulcer extends into the 5. When assessing the older adult, the
underlying structure, including the muscle and nurse anticipates increase in which of the
possibly the bone. follow components of respiratory status?
B. Stage III
A stage III ulcer extends into the A. Residual lung volume
subcutaneous tissue. As a result, patient experience fatigue and
C. Stage II breathlessness with sustained activity.
A stage II ulcer exhibits a break in the skin B. Vital capacity
through the epidermis or dermis. The nurse anticipates decreased vital capacity.
D. Stage I C. Gas exchange and diffusing capacity
A stage I pressure ulcer is an area of The nurse anticipates decreased gas exchange
nonblanchable erythema, tissue swelling, and and diffusing capacity resulting in impaired
congestion, and the patient complains of healing of tissues due to decreased
discomfort. oxygenation.
3. Which type of incontinence is D. Cough efficiency
associated with weakened perineal The nurse anticipates difficulty coughing up
muscles that permit leakage of urine secretions due to decreased cough efficiency.
when intra-abdominal pressure is 6. According to the classification of
increased? hypertension diagnosed in the older adult,
hypertension that can be attributed to an
A. Stress incontinence underlying cause is termed
Stress incontinence may occur with coughing
or sneezing. A. secondary.
B. Urge incontinence Secondary hypertension may be caused by a
Urge incontinence is involuntary elimination tumor of the adrenal gland (e.g.,
of urine associated with a strong perceived pheochromacytoma).
need to void.
B. primary. increasing dose requirements to maintain the
Primary hypertension has no known same level of pain relief.
underlying cause. B. addiction.
C. essential. Addiction refers to a behavioral pattern of
Essential hypertension has no known substance use characterized by a compulsion
underlying cause. to take the drug primarily to experience its
D. isolated systolic. psychic effects.
Isolated systolic hypertension is demonstrated C. dependence.
by readings in which the systolic pressure Dependence occurs when a patient who has
exceeds 140 mm Hg and the diastolic been taking opioids experiences a withdrawal
measurement is normal or near normal (less syndrome when the opioids are discontinued.
than 90 mm Hg). D. balanced analgesia.
7. Which of the following terms refers to Balanced analgesia occurs when the patient is
the decrease in lens flexibility that occurs using more than one form of analgesia
concurrently to obtain more pain relief with
with age, resulting in the near point of
fewer side effects.
focus getting farther away?
10. Prostaglandins are chemical
A. Presbyopia substances thought to
Presbyopia usually begins in the fifth decade
of life, when reading glasses are required to A. increase sensitivity of pain receptors.
magnify objects. Prostaglandins are believed to increase
B. Presbycusis sensitivity to pain receptors by enhancing the
Presbycusis refers to age-related hearing loss. pain-provoking effect of bradykinin.
C. Cataract B. reduce the perception of pain.
Cataract is the development of opacity of the Endorphins and enkephalins reduce or inhibit
lens of the eye. transmission or perception of pain.
D. Glaucoma C. inhibit the transmission of pain.
Glaucoma is a disease characterized by Endorphins and enkephalins reduce or inhibit
increased intraocular pressure. transmission or perception of pain.
D. inhibit the transmission of noxious stimuli.
8. Which of the following states is
Morphine and other opioid medications
characterized by a decline in intellectual inhibit the transmission of noxious stimuli by
functioning? mimicking enkephalin and endorphin.
A. Dementia 11. Which of the following principles or
Dementia is an acquired syndrome in which guidelines accurately informs the nurse
progressive deterioration in global intellectual regarding placebos?
abilities is of such severity that it interferes
with the person’s customary occupational and A. Placebos should never be used to test the
social performance. person’s truthfulness about pain.
B. Depression Perception of pain is highly individualized.
Depression is a mood disorder that disrupts B. A placebo effect is an indication that the
quality of life. person does not have pain.
C. Delirium A placebo effect is a true physiologic
Delirium is often called acute confusional response.
state. C. A placebo should be used as the first line of
D. Delusion treatment for the patient.
Delusion is a symptom of psychoses. A placebo should never be used as a first line
of treatment.
9. When a person who has been taking
D. A positive response to a placebo indicates that
opioids becomes less sensitive to their the person’s pain is not real.
analgesic properties, that person is said Reduction in pain as a response to placebo
to have developed a (an) should never be interpreted as an indication
that the person’s pain is not real.
A. tolerance.
12. Regarding tolerance and addiction,
Tolerance is characterized by the need for
the nurse understands that
A. although patients may need increasing levels B. Chloride
of opioids, they are not addicted. Chloride is an anion.
Physical tolerance usually occurs in the C. Bicarbonate
absence of addiction. Bicarbonate is an anion.
B. tolerance to opioids is uncommon. D. Phosphate
Tolerance to opioids is common. Phosphate is an anion.
C. addiction to opioids commonly develops. 16. Which of the following electrolytes is a
Addiction to opioids is rare. major anion in body fluid?
D. the nurse must be primarily concerned about
development of addiction by the patient in A. Chloride
pain. Chloride is a major anion found in
Addiction is rare and should never be the extracellular fluid.
primary concern for a patient in pain. B. Potassium
13. The preferred route of administration Potassium is a cation.
of medication in the most acute care C. Sodium
Sodium is a cation.
situations is which of the following routes?
D. Calcium
A. Intravenous Calcium is a cation.
The IV route is the preferred parenteral route 17. Oncotic pressure refers to
in most acute care situations because it is
much more comfortable for the patient, and A. the osmotic pressure exerted by proteins.
peak serum levels and pain relief occur more Oncotic pressure is a pulling pressure exerted
rapidly and reliably. by proteins, such as albumin.
B. Epidural B. the number of dissolved particles contained in
Epidural administration is used to control a unit of fluid.
postoperative and chronic pain. Osmolality refers to the number of dissolved
C. Subcutaneous particles contained in a unit of fluid.
Subcutaneous administration results in slow C. the excretion of substances such as glucose
absorption of medication. through increased urine output.
D. Intramuscular Osmotic diuresis occurs when the urine output
Intramuscular administration of medication is increases due to excretion of substances such
absorbed more slowly than intravenously as glucose.
administered medication. D. the amount of pressure needed to stop flow of
water by osmosis.
14. Mu opioids have which of the
Osmotic pressure is the amount of pressure
following effects on respiratory rate: needed to stop the flow of water by osmosis.
A. Stimulation, then depression 18. Which of the following solutions is
Mu opioids also cause bradycardia, hypotonic?
hypothermia, and constipation.
B. No change A. 0.45% NaCl.
Kappa opioids result in no change in Half-strength saline is hypotonic
respiratory rate. B. Lactated Ringer’s solution.
C. Stimulation, only Lactated Ringer’s is isotonic.
Delta opioids result in stimulation of C. 0.9% NaCl.
respiratory rate. Normal saline (0.9% NaCl) is isotonic.
D. Depression, only D. 5% NaCl.
Neither mu, nor kappa, nor delta opoids A solution that is 5% NaCl is hypertonic.
depress respiratory rate as its only effect upon 19. The normal serum value for
respiratory rate. potassium is
15. Which of the following electrolytes is a
A. 3.5-5.5 mEq/L.
major cation in body fluid?
Serum potassium must be within normal
A. Potassium limits to prevent cardiac dysrhythmias.
Potassium is a major cation that affects B. 135-145 mEq/L.
cardiac muscle functioning. Normal serum sodium is 135-145 mEq/L.
C. 96-106 mEq/L. the patient is demonstrating which stage
Normal serum chloride is 96-106 mEq/L. of shock?
D. 8.5-10.5 mg/dL.
Normal total serum calcium is 8.5-10.5mg/dL. A. Compensatory
20. In which type of shock does the In compensatory shock, the patient’s blood
patient experiences a mismatch of blood pressure is normal, respirations are above 20,
and heart rate is above 100 but below 150.
flow to the cells?
B. Progressive
A. Distributive In progressive shock, the patient’s skin
Distributive or vasogenic shock results from appears mottled and mentation demonstrates
displacement of blood volume, creating a lethargy.
relative hypovolemia. C. Refractory
B. Cardiogenic In refractory or irreversible shock, the patient
Cardiogenic shock results from the failure of a requires complete mechanical and
heart as a pump. pharmacologic support.
C. Hypovolemic D. Irreversible
In hypovolemic shock, there is a decrease in In refractory or irreversible shock, the patient
the intravascular volume. requires complete mechanical and
D. Septic pharmacologic support.
In septic shock, overwhelming infection 23. Which of the following vasoactive
results in a relative hypovolemia. drugs used in treating shock results in
21. Which stage of shock is best reduced preload and afterload, reducing
described as that stage when the oxygen demand of the heart?
mechanisms that regulate blood pressure
A. Nitroprusside (Nipride)
fail to sustain a systolic pressure above
A disadvantage of nitroprusside is that it
90 mm Hg? causes hypotension.
A. Progressive B. Dopamine (Intropin)
In the progressive stage of shock, the Dopamine improves contractility, increases
mechanisms that regulate blood pressure can stroke volume, and increases cardiac output.
no longer compensate, and the mean arterial C. Epinephrine (adrenaline)
pressure falls below normal limits. Epinephrine improves contractility, increases
B. Refractory stroke volume, and increases cardiac output.
The refractory or irreversible stage of shock D. Methoxamine (Vasoxyl)
represents the point at which organ damage is Methoxamine increases blood pressure by
so severe that the patient does not respond to vasoconstriction.
treatment and cannot survive. 24. The nurse anticipates that the
C. Compensatory immunosuppressed patient is at greatest
In the compensatory state, the patient’s blood risk for which type of shock?
pressure remains within normal limits due to
vasoconstriction, increased heart rate, and A. Septic
increased contractility of the heart. Septic shock is associated with
D. Irreversible immunosuppression, extremes of age,
The refractory or irreversible stage of shock malnourishment, chronic illness, and invasive
represents the point at which organ damage is procedures.
so severe that the patient does not respond to B. Neurogenic
treatment and cannot survive. Neurogenic shock is associated with spinal
22. When the nurse observes that the cord injury and anesthesia.
C. Cardiogenic
patient’s systolic blood pressure is less
Cardiogenic shock is associated with disease
than 80–90 mm Hg, respirations are rapid of the heart.
and shallow, heart rate is over 150 beats D. Anaphylactic
per minute, and urine output is less than Anaphylactic shock is associated with
30 cc per hour, the nurse recognizes that hypersensitivity reactions.
 25. Which of the following colloids is point of white blood cell depression after
expensive but rapidly expands plasma therapy that has toxic effects on the bone
marrow.
volume?
28. During which step of cellular
A. Albumin carcinogenesis do cellular changes
Albumin is a colloid that requires human exhibit increased malignant behavior?
donors, is limited in supply, and can cause
congestive heart failure. A. Progression
B. Dextran During this third step, cells show a propensity
Dextran is a colloid, synthetic plasma to invade adjacent tissues and metastasize.
expander that interferes with platelet B. Promotion
aggregation and is not recommended for During promotion, repeated exposure to
hemorrhagic shock. promoting agents causes the expression of
C. Lactated Ringers abnormal genetic information even after long
Lactated ringers is a crystalloid, not a colloid. latency periods.
D. Hypertonic Saline C. Initiation
Hypertonic saline is a crystalloid, not a During this first step, initiators such as
colloid. chemicals, physical factors, and biologic
26. Which of the following terms refers to agents escape normal enzymatic mechanisms
cells that lack normal cellular and alter the genetic structure of cellular
DNA.
characteristics and differ in shape and
D. Prolongation
organization with respect to their cells of No stage of cellular carcinogenesis is termed
origin? prolongation.
A. Anaplasia 29. The drug, Interleukin-2, is an example
Usually, anaplastic cells are malignant. of which type of biologic response
B. Neoplasia modifier?
Neoplasia refers to uncontrolled cell growth
that follows no physiologic demand. A. Cytokine
C. Dysplasia Other cytokines include interferon alfa and
Dysplasia refers to bizarre cell growth filgrastim.
resulting in cells that differ in size, shape, or B. Monoclonal antibodies
arrangement from other cells of the same type Monoclonal antibodies include rituximab,
of tissue. trastuzumab, and gemtuzumab.
D. Hyperplasia C. Retinoids
Hyperplasia refers to an increase in the Retinoic acid is an example of a retinoid.
number of cells of a tissue, most often D. Antimetabolites
associated with a period of rapid body growth. Antimetabolites are cell cycle-specific
antineoplastic agents.
27. Palliation refers to
30. Of the following terms, which is used
A. relief of symptoms associated with cancer. to refer to the period of time during which
Palliation is the goal for care in terminal mourning a loss takes place?
cancer patients.
B. hair loss. A. Bereavement
Alopecia is the term that refers to hair loss. Bereavement is the period of time during
C. the spread of cancer cells from the primary which mourning a loss takes place.
tumor to distant sites. B. Grief
Metastasis is the term that refers to the spread Grief is the personal feelings that accompany
of cancer cells from the primary tumor to an anticipated or actual loss
distant sites. C. Mourning
D. the lowest point of white blood cell Mourning is the individual, family, group and
depression after therapy that has toxic effects cultural expressions of grief and associated
on the bone marrow. behaviors
Nadir is the term that refers to the lowest
D. Hospice                                                             authorization of another individual to make
Hospice is a coordinated program of medical decisions on behalf of the person who
interdisciplinary care and services provided created anadvance directive when he/she is no
primarily in the home to terminally ill patients loner able to speak for him/herself.
and   their families. C. Health care power of attorney
31. Which of the following “awareness Health care power of attorney is a legal
contexts” is characterized by the patient, document that enables the signer to designate
another individual to make health care
the family, and the health care
decisions on his/her behalf when he/she is
professionals being aware that the patient unable to do so.
is dying but all pretend otherwise? D. Durable power of attorney for health
A durable power of attorney for health care is
A. Mutual pretense awareness
a legal document that enables the signer to
In mutual pretense awareness, the patient, the
designate another individual to make health
family and the health care professionals are
care decisions on his/her behalf when he/she
aware that the patient is dying but all pretend
is unable to do so.
otherwise.
B. Closed awareness 34. A malignant tumor
In closed awareness, the patient is unaware of A. gains access to the blood and lymphatic
his terminality in a context where others are channels.
aware. By this mechanism, the tumor metastasizes to
C. Suspected awareness other areas of the body.
In suspected awareness, the patient suspects B. demonstrates cells that are well-differentiated.
what others know and attempts to find it out. Cells of malignant tumors are
D. Open awareness undifferentiated.
In open awareness, all are aware that the C. is usually slow growing.
patient is dying and are able to openly Malignant tumors demonstrate variable rate of
acknowledge that reality. growth; however, the more anaplastic the
32. For individuals known to be dying by tumor, the faster its growth.
virtue of age and/or diagnoses, which of D. grows by expansion.
the following signs indicate approaching A malignant tumor grows at the periphery and
death: sends out processes that infiltrate and destroy
surrounding tissues.
A. Increased restlessness 35. Which of the following classes of
As the oxygen supply to the brain decreases, antineoplastic agents is cell–cycle-
the patient may become restless.
specific?
B. Increased wakefulness
As the body weakens, the patient will sleep A. Antimetabolites (5-FU)
more and begin to detach from the Antimetabolites are cell–cycle-specific (S
environment. phase).
C. Increased eating B. Antitumor antibiotics (bleomycin)
For many patients, refusal of food is an Antitumor antibiotics are cell-cycle
indication that they are ready to die. nonspecific.
D. Increased urinary output C. Alkylating agents (cisplatin)
Based upon decreased intake, urinary output Alkylating agents are cell-cycle nonspecific.
generally decreases in amount and frequency. D. Nitrosureas (carmustine)
33. Which of the following terms best Nitrosureas are cell-cycle nonspecific.
describes a living will? 36. Regarding the surgical patient, which
of the following terms refers to the period
A. Medical directive
The living will is a type of advance medical of time that constitutes the surgical
directive in which the individual of sound experience?
mind documents treatment preferences.
A. Perioperative phase
B. Proxy directive
Perioperative period includes the
A proxy directive is the appointment and
 preoperative, intraoperative, and postoperative Onset of symptoms depends upon time of last
phases. consumption of alcohol.
B. Preoperative phase D. Up to 24 hours after alcohol withdrawal
Preoperative phase is the period of time from Twenty-four hours is too short a time frame to
when the decision for surgical intervention is consider alcohol withdrawal delirium no
made to when the patient is transferred to the longer a threat to a chronic alcoholic.
operating room table. 39. Which of the following categories of
C. Intraoperative phase medications may result in seizure activity
Intraoperataive phase is the period of time
if withdrawn suddenly?
from when the patient is transferred to the
operating room table to when he or she is A. Tranquilizers
admitted to the postanesthesia care unit. Abrupt withdrawal of tranquilizers may result
D. Postoperative phase in anxiety, tension, and even seizures if
Postoperative phase is the period of time that withdrawn suddenly.
begins with the admission of the patient to the B. Adrenal corticosteroids
postanesthesia care unit and ends after a Abrupt withdrawal of steroids may precipitate
follow-up evaluation in the clinical setting or cardiovascular collapse.
home. C. Antidepressants
37. When the indication for surgery is Monoamine oxidase inhibitors increase the
without delay, the nurse recognizes that hypotensive effects of anesthetics.
the surgery will be classified as D. Diuretics
Thiazide diuretics may cause excessive
A. emergency. respiratory depression during anesthesia due
Emergency surgery means that the patient to an associated electrolyte imbalance.
requires immediate attention and the disorder 40. When the patient is encouraged to
may be life-threatening. concentrate on a pleasant experience or
B. urgent.
restful scene, the cognitive coping
Urgent surgery means that the patient requires
prompt attention within 24-30 hours. strategy being employed by the nurse is
C. required. A. imagery.
Required surgery means that the patient needs Imagery has proven effective for oncology
to have surgery, and it should be planned patients.
within a few weeks or months. B. optimistic self-recitation.
D. elective. Optimistic self-recitation is practiced when
Elective surgery means that there is an the patient is encouraged to recite optimistic
indication for surgery, but failure to have thoughts such as “I know all will go well.”
surgery will not be catastrophic. C. distraction.
38. When a person with a history of Distraction is employed when the patient is
chronic alcoholism is admitted to the encouraged to think of an enjoyable story or
hospital for surgery, the nurse anticipates recite a favorite poem.
that the patient may show signs of alcohol D. progressive muscular relaxation.                      
Progressive muscular relaxation requires
withdrawal delirium during which time
contracting and relaxing muscle groups and is
period? a physical coping strategy as opposed to
A. Up to 72 hours after alcohol withdrawal cognitive.
Alcohol withdrawal delirium is associated 41. According to the American Society of
with a significant mortality rate when it Anesthesiology Physical Status
occurs postoperatively. Classification System, a patient with
B. Immediately upon admission severe systemic disease that is not
Onset of symptoms depends upon time of last
incapacitating is noted to have physical
consumption of alcohol.
C. Upon awakening in the post-anesthesia care status classification
unit A. P3
Classification P3 patients are those who have
 compensated heart failure, cirrhosis, or poorly B. Hypotension
controlled diabetes, for example. Hypotension is a later sign of malignant
B. P4 hyperthermia.
Classification P4 patients have an C. Elevated temperature
incapacitating systemic disease that is a The rise in temperature is actually a late sign
constant threat to life. that develops rapidly.
C. P1 D. Oliguria
Classification P1 refers to a normal healthy Scant urinary output is a later sign of
patient malignant hyperthermia.
D. P2 45. Which of the following terms is used
Classification P2 reflects a patient with mild to refer to protrusion of abdominal organs
systemic disease
through the surgical incision?
42. Which stage of anesthesia is termed
surgical anesthesia? A. Evisceration
Evisceration is a surgical emergency.
A. III B. Hernia
With proper administration of the anesthetic, A hernia is a weakness in the abdominal wall.
this stage may be maintained for hours. C. Dehiscence
B. I Dehiscence refers to partial or complete
Stage I is beginning anesthesia, as the patient separation of wound edges.
breathes in the anesthetic mixture and D. Erythema
experiences warmth, dizziness, and a feeling Erythema refers to redness of tissue.
of detachment. 46. When the method of wound healing is
C. II
one in which wound edges are not
Stage II is the excitement stage, which may be
characterized by struggling, singing, laughing, surgically approximated and
or crying. integumentary continuity is restored by
D. IV granulations, the wound healing is termed
Stage IV is a stage of medullary depression
and is reached when too much anesthesia has A. second intention healing.
been administered. When wounds dehisce, they will be allowed to
heal by secondary intention.
43. Fentanyl (Sublimaze) is categorized
B. primary intention healing.
as which type of intravenous anesthetic Primary or first intention healing is the
agent? method of healing in which wound edges are
surgically approximated and integumentary
A. Neuroleptanalgesic
continuity is restored without granulating.
Fentanyl is 75-100 times more potent than
C. first intention healing.
morphine and has about 25% of the duration
Primary or first intention healing is the
of morphine (IV).
method of healing in which wound edges are
B. Tranquilizer
surgically approximated and integumentary
Examples of tranquilizers include midazolam
continuity is restored without granulating.
(Versed) and diazepam (Valium).
D. third intention healing.
C. Opioid
Third intention healing is a method of healing
Opioids include morphine and meperidine
in which surgical approximation of wound
hydrochloride (Demerol).
edges is delayed and integumentary continuity
D. Dissociative agent
is restored by bringing apposing granulations
Ketamine is a dissociative agent.
together.
44. Which of the following manifestations
47. The nurse recognizes which of the
is often the earliest sign of malignant
following signs as typical of the patient in
hyperthermia?
shock?
A. Tachycardia (heart rate above 150 beats per
A. Rapid, weak, thready pulse
minute)
Pulse increases as the body tries to
Tachycardia is often the earliest sign of
compensate.
malignant hyperthermia.
B. Flushed face A. Orthopnea
Pallor is an indicator of shock. Patients with orthopnea are placed in a high
C. Warm, dry skin Fowler’s position to facilitate breathing.
Skin is generally cool and moist in shock. B. Dyspnea
D. Increased urine output Dyspnea refers to labored breathing or
Usually, a low blood pressure and shortness of breath.
concentrated urine are observed in the patient C. Hemoptysis
in shock. Hemoptysis refers to expectoration of blood
48. When the nurse observes that the from the respiratory tract.
postoperative patient demonstrates a D. Hypoxemia                                                      
Hypoxemia refers to low oxygen levels in the
constant low level of oxygen saturation,
blood.
although the patient’s breathing appears
normal, the nurse identifies that the
patient may be suffering which type of
hypoxemia?
A. Subacute
Supplemental oxygen may be indicated.
B. Hypoxic
Hypoxic hypoxemia results from inadequate
breathing.
C. Episodic
Episodic hypoxemia develops suddenly, and
the patient may be at risk for myocardial
ischemia, cerebral dysfunction, and cardiac
arrest.
D. Anemic
Anemic hypoxemia results from blood loss
during surgery.
49. When the surgeon performs an
appendectomy, the nurse recognizes that
the surgical category will be identified as
A. clean contaminated.
Clean-contaminated cases are those with a
potential, limited source for infection, the
exposure to which, to a large extent, can be
controlled.
B. clean.
Clean cases are those with no apparent source
of potential infection.
C. contaminated.
Contaminated cases are those that contain an
open and obvious source of potential
infection.
D. dirty.
A traumatic wound with foreign bodies, fecal
contamination, or purulent drainage would be
considered a dirty case.
50. Which of the following terms is used
to describe inability to breathe easily
except in an upright position?
 PNLE: Medical Surgical Nursing Exam 3 assessments reveal painful flexion of the
1. Lisa is newly diagnosed with asthma neck to the chest. The nurse understands
and is being discharged from the hospital that nuchal rigidity is associated with:
after an episode of status asthmaticus. A. brain tumor
Discharge teaching should include which B. CVA
of the following: C. meningitis
D. subdural hematoma
A. Limitations in sports that will be imposed by 7. The nurse teaching the client about
the illness
behavioral changes, which can affect
B. Specific instructions on staying cal during an
attack development of atherosclerosis, should
C. The relationship of symptoms and a specific discuss which of the following as a non-
trigger such as physical exercise modifiable risk factor for atherosclerosis?
D. Incidence of status asthmaticus in children
and teens A. cigarette smoking
2. Which of the following symptoms is B. hyperlipidemia
C. female over 55 years of age
most characteristic of a client with a D. sedentary lifestyle
cancer of the lung?
8. A 76 year old man enters the ER with
A. air hunger complaints of back pain and feeling
B. exertional dyspnea fatigued. Upon examination, his blood
C. cough with night sweats pressure is 190/100, pulse is 118, and
D. persistent changing cough hematocrit and hemoglobin are both low.
3. The client has ST segment depression The nurse palpates the abdomen which is
on his 12-lead ECG. The nurse soft, non-tender and auscultates an
determines that this would indicate the abdominal pulse. The most likely
following: diagnosis is:
A. necrosis A. Buerger’s disease
B. injury B. CHF
C. ischemia C. Secondary hypertension
D. nothing significant D. Aneurysm
4. Red has just returned from the 9. Nurse Fiona is caring a patient with
postanesthesia care unit (PACU) from a Raynaud’s disease. Which of the
hemorrhidectomy. His postoperative following outcomes concerning
orders include sitz baths every morning. medication regimen is of highest priority?
The nurse understands that sitz bath is
use for: A. Controlling the pain once vasospasm occur
B. Relaxing smooth muscle to avoid vasospasms
A. promote healing C. Preventing major disabilities that may occur
B. relive tension D. Avoiding lesions on the feet
C. lower body temperature 10. Mr. Roberto Robles complains of a
D. cause swelling severe headache and is extremely
5. Trousseau’s sign is associated with anxious. The nurse checks his vital signs
which electrolyte imbalance? and finds him to have a heart rate of 57
A. hyponatremia bpm and a blood pressure of 230/110
B. hypocalcemia mmHg. The nurse should also assess
C. hypernatremia for?
D. hypercalcemia
6. A 36 year old female complains of A. presence of bowel sounds
B. presence of babinski reflex
headache and neck pain. The nurse’s
C. fecal incontinence
D. urinary catheter patency A. dehydration
11. A 40n year old male patient is B. protein deficiency
complaining of chronic progressive and C. bleeding disorders
D. vitamin deficiency
mental deterioration is admitted to the
17. A client with rheumatoid arthritis may
unit. The nurse recognizes that these
reveal which of the following assessment
characteristics indicate a disease that
data:
results in degeneration of the basal
ganglia and cerebral cortex. The disease A. Heberden’s nodes
is called: B. Morning stiffness no longer than 30 minutes
C. Asymmetric joint swelling
A. multiple sclerosis D. Swan neck deformities
B. myasthenia gravis 18. Elsa Santos is a 18 year old student
C. Huntington’s disease
admitted to the ward with a diagnosis of
D. Guillain-Barre syndrome
epilepsy. She tells the nurse that she is
12. Dianne Hizon is a 27 year old woman
experiencing a generalized tingling
who has been admitted to the ER due to
sensation and is “smelling roses”. The
severe vomiting. Her ABG values are pH=
nurse understands that Esla is probably
7.50, PaCO2= 85, HCO3= 31, and
experiencing:
SaO2= 93%. The nurse interpretation of
this ABG analysis is: A. an acute alcohol withdrawal
B. an acute CVA
A. respiratory acidosis C. an aura
B. respiratory alkalosis D. an olfactory hallucination
C. metabolic acidosis
19. Mr. Lucas, a 63 year old, went to the
D. metabolic alkalosis
clinic complaining of hoarseness of voice
13. Mr. Perkson has a parkinson’s
and a cough. His wife states that his voice
disease and he finds the resting tremor
has changed in the last few months. The
he is experiencing in his right hand very
nurse interprets that Mr. Lucas’s
frustrating. The nurse advises him to:
symptoms are consistent with which of
A. take a warm bath the following disorders:
B. hold an object
C. practice deep breathing A. chronic sinusitis
D. take diazepam as needed B. laryngeal cancer
14. A shuffling gait is typically associated C. gastroesophageal reflux disease
D. coronary artery disease
with the patient who has:
20. Sarah complains of a nursing
A. Parkinson’s disease sensation, cramping pain in the top part of
B. Multiple sclerosis her abdomen that becomes worse in the
C. Raynaud’s disease
afternoon and sometimes awakes her at
D. Myasthenia gravis
night. She reports that when she eats, it
15. The priority in preparing the room for
helps the pain go away but that pain is
a client with a C7 spinal cord injury is
now becoming more intense. Which of the
having:
following is the best condition for the
A. the halo brace device nurse to draw:
B. a catheterization tray
C. a ventilator on stand by A. these symptoms are consistent with an ulcer
D. the spinal kinetic bed B. The client probably has indigestion
16. A 47 year old man with liver failure C. A snack before going to bed should be
advised
who has developed ascites. The nurse D. The client probably developing cholelithiasis
understands that ascites is due to:
 21. Nurse Cynthia is providing a support a diagnosis of cardiac
discharge teaching to a client with chronic tamponade?
cirrhosis. His wife asks her to explain why
A. A deviated trachea
there is so much emphasis on bleeding B. Absent breath sounds to the lower lobes
precautions. Which of the following C. Pulse 40 with inspiration
provides the most appropriate response? D. Blood pressure 140/80
A. “The low protein diet will result in reduced Answers and Rationales
clotting.” 1. C. The relationship of symptoms and a
B. “The increased production of bile decreases specific trigger such as physical
clotting factors.” exercise. COPD clients have low oxygen and
C. “The liver affected by cirrhosis is unable to high carbon dioxide levels. Therefore,
produce clotting factors.” hypoxia is the main stimulus for ventilation is
D. “The required medications reduce clotting persons with chronic hypercapnea. Increasing
factors.” the level of oxygen would decrease the
stimulus to breathe.
22. Betty Lee is a 58 year old woman who 2. D. persistent changing cough. The most
is being admitted to the medical ward with common sign of lung cancer is a persistent
trigeminal neuralgia. The nurse cough that changes. Other signs are dyspnea,
anticipates that Mr. Lee will demonstrate bloody sputum and long term pulmonary
which of the following major complaints? infection. Option A is common with asthma,
option B is common with COPD and option C
A. excruciating, intermittent, paroxysmal facial is common with TB.
pain 3. C. ischemia. Depressed ST segment and
B. unilateral facial droop inverted T-waves represent myocardial
C. painless eye spasm ischemia. Injury has a ST segment elevation.
D. mildly painful unilateral eye twitching 4. A. promote healing. Sitz bath provides moist
23. A 38 year old woman returns from a heat to the perineal and anal area to clean,
subtotal thryroidectomy for the treatment promote healing and drainage and reduce
of hyperthyroidism. Upon assessment, soreness to the area. Sitz bath helps healing
with cleaning action and promotion of
the immediate priority that the nurse circulation, thereby reducing swelling. Sitz
would include is: bath usually has no therapeutic value in
lowering body temperature. Although relief of
A. Assess for pain
tension can occur, this effect is secondary to
B. Assess for neurological status
the promotion of healing.
C. Assess fluid volume status
5. B. hypocalcemia. Trousseau’s sign is a carpal
D. Assess for respiratory distress
pedal spasm elicited when a blood pressure
24. Nurse Shiela is teaching self-care to a cuff is inflated on the arm of a patient with
client with psoriasis. The nurse should hypocalcemia.
encourage which of the following for his 6. C. meningitis. A patient with meningitis will
scaled lesion? exhibit signs that include photophobia and
nuchal rigidity, which is pain on the flexion of
A. Importance of follow-up appointments the chin to chest.
B. Emollients and moisturizers to soften scales 7. C. female over 55 years of age. Lifestyle,
C. Keep occlusive dressings on the lesions 24 cigarette smoking and hyperlipidemia can be
hours a day changed by changing behaviors.
D. Use of a clean razor blade each time he shaves 8. D. Aneurysm. The symptoms exhibited by
25. A 48 year old woman presents to the the client are typical of an abdominal aortic
hospital complaining of chest pain, aneurysm. The most significant sign is the
tachycardia and dyspnea. On exam, heart audible pulse in the abdominal area. If
hemorrhage were present, the abdomen would
sounds are muffled. Which of the
be tender and firm.
following assessment findings would 9. B. Relaxing smooth muscle to avoid
vasospasms. The major task of the health care
 team is to medicate the client drugs that to the presence of fibrous connective tissue
produce smooth muscle relaxation, which will within the joint space. Clients with RA do
decrease the vasospasm and increase the experience morning stiffness, but it can last
arterial flow to the affected part. The drugs from 30 minutes up to several hours. RA is
used are calcium antagonists. characterized by symmetrical joint movement,
10.D. urinary catheter patency. The patient is and heberden’s nodes are characteristic of
complaining of symptoms of autonomic osteoarthritis.
dysreflexia, which consists of the triad of 18.C. an aura. An aura frequently precedes an
hypertension, bradycardia and a headache. epileptic seizure and may manifest as vague
Major causes of autonomic dysreflexia physic discomfort or specific aromas. Patients
include urinary bladder distention and fecal experiencing auras aren’t having a CVA,
impaction. Checking the patency of the substance withdrawal or hallucination.
urinary catheter will check for bladder 19.B. laryngeal cancer. These symptoms, along
distention. with dysphagia, foul-smelling breath, and pain
11.C. Huntington’s disease. Huntington’s when drinking hot or acidic, are common
disease is a hereditary disease in which signs of laryngeal cancer.
degeneration of the basal ganglia and cerebral 20.A. these symptoms are consistent with an
cortex causes chronic progressive chorea ulcer. The description of pain is consistent
(muscle twitching) and mental deterioration, with ulcer pain. The pain is epigastric and is
ending in dementia. Huntington’s disease worse when the stomach is empty and is
usually strikes people ages 25 to 55. relived by food.
12.D. metabolic alkalosis. Ms. Hizon’s pH is 21.C. “The liver affected by cirrhosis is unable
above 7.45, which makes it alkalatic, and her to produce clotting factors.” When bile
bicarbonate is high which is also makes it production is reduced, the body has reduced
basic. Thus, the diagnosis is metabolic ability to absorb fat-soluble vitamins. Without
alkalosis. adequate Vitamin K absorption, clotting
13.B. hold an object. The resting or non- factors II, VII, IX, and X are not produced in
intentional tremor may be controlled with sufficient amounts.
purposeful movement such as holding an 22.A. excruciating, intermittent, paroxysmal
object. A warm bath, deep breathing and facial pain. Trigeminal neuralgia is a
diazepam will promote relaxation but are not syndrome of excruciating, intermittent,
specific interventions for tremor. paroxysmal facial pain. It manifests as
14.A. Parkinson’s disease. A shuffling gait from intense, periodic pain in the lips, gums, teeth
the musculoskeletal rigidity of the patient with or chin. The other symptoms aren’t
Parkinson’s disease is common. Patients characteristic of trigeminal neuralgia.
experiencing a stroke usually exhibit loss of 23.D. Assess for respiratory distress. Though
voluntary control over motor movements fluid volume status, neurological status and
associated with generalized weakness; a pain are all important assessment, the
shuffling gait is usually not observed in stroke immediate priority for postoperative is the
patient. airway management. Respiratory distress may
15.C. a ventilator on stand by. Although a result from hemorrhage, edema, laryngeal
ventilator is not required for injury below C3, damage or tetany.
the innervation of intercostal muscles is 24.B. Emollients and moisturizers to soften
affected. Hemorrhage and cord swelling scales. Emollients will ease dry skin that
extends the level of injury making it likely increases pruritus and causes psoriasis to be
that this client will need a ventilator. worse. Washing and drying the skin with
16.B. protein deficiency. Protein deficiency rough linens or pressure may cause
allows fluid to leak out of the vascular system excoriation. Constant occlusion may increase
and third space into the tissues and spaces in the effects of the medication and increase the
the body such as the peritoneal space. risk of infection.
Bleeding tendencies, dehydration and vitamin 25.C. Pulse 40 with inspiration. Paradoxical
deficiency can occur but don’t cause ascites. pulse is a hallmark symptom of cardiac
17.D. Swan neck deformities. Swan neck tamponade. As pressure is exerted on the left
deformities of the hand are classic deformities ventricle from fluid, the natural increase in
associated with rheumatoid arthritis secondary pressure from the right ventricle during
inspiration creates even more pressure,
diminishing cardiac output.
 Medical Surgical Nursing Exam 13 D. kyphoscoliosis.
Kyphoscoliosis is characterized by elevation
1. In relation to the structure of the larynx, of the scapula and a corresponding S-shaped
the cricoid cartilage is spine.
A. the only complete cartilaginous ring in the 4. When the nurse auscultates chest
larynx. sounds that are harsh and cracking,
The cricoid cartilage is located below the sounding like two pieces of leather being
thyroid cartilage. rubbed together, she records her finding
B. used in vocal cord movement with the thyroid as
cartilage.
The arytenoid cartilages are used in vocal A. pleural friction rub.
cord movement with the thyroid cartilage. A pleural friction rub is heard secondary to
C. the largest of the cartilage structures. inflammation and loss of lubricating pleural
The thyroid cartilage is the largest of the fluid.
cartilage structures; part of it forms the B. crackles.
Adam’s apple. Crackles are soft, high-pitched, discontinuous
D. the valve flap of cartilage that covers the popping sounds that occur during inspiration.
opening to the larynx during swallowing. C. sonorous wheezes.
The epiglottis is the valve flap of cartilage that Sonorous wheezes are deep, low-pitched
covers the opening to the larynx during rumbling sounds heard primarily during
swallowing. expiration.
2. Which respiratory volume is the D. sibilant wheezes.
maximum volume of air that can be Sibilant wheezes are continuous, musical,
high-pitched, whistle-like sounds heard during
inhaled after maximal expiration?
inspiration and expiration.
A. Inspiratory reserve volume 5. Which of the following terms is used to
Inspiratory reserve volume is normally 3000 describe hemorrhage from the nose?
mL.
B. Tidal volume A. Epistaxis
Tidal volume is the volume of air inhaled and Epistaxis is due to rupture of tiny, distended
exhaled with each breath. vessels in the mucous membrane of any area
C. Expiratory reserve volume of the nose.
Expiratory reserve volume is the maximum B. Xerostomia
volume of air that can be exhaled forcibly Xerostomia refers to dryness of the mouth.
after a normal exhalation. C. Rhinorrhea
D. Residual volume Rhinorrhea refers to drainage of a large
Residual volume is the volume of air amount of fluid from the nose.
remaining in the lungs after a maximum D. Dysphagia
exhalation. Dysphagia refers to difficulties in swallowing.
3. The individual who demonstrates 6. The herpes simplex virus (HSV-1),
displacement of the sternum is described which produces a cold sore (fever blister),
as having a has an incubation period of

A. pigeon chest. A. 2-12 days.

Pigeon chest may occur with rickets, Marfan’s HSV-1 is transmitted primarily by direct
syndrome, or severe kyphoscoliosis. contact with infected secretions.
B. barrel chest. B. 0-3 months.
A barrel chest is seen in patients with The time period 0-3 months exceeds the
emphysema as a result of over-inflation of the incubation period.
lungs. C. 20-30 days.
C. funnel chest. The time period 20-30 days exceeds the
A funnel chest occurs when there is a incubation period.
depression in the lower portion of the
sternum.
D. 3-6 months. C. dehydration.
The time period 3-6 months exceeds the Dehydration may lead to poor wound healing
incubation period. and breakdown.
7. Another term for clergyman’s sore D. pneumonia.
throat is Pneumonia is a risk for any postoperative
patient.
A. chronic granular pharyngitis. 10. Which of the following terms refers to
In clergyman’s sore throat, the pharynx is lung tissue that has become more solid in
characterized by numerous swollen lymph
nature due to a collapse of alveoli or
follicles.
B. aphonia. infectious process?
Aphonia refers to the inability to use one’s A. Consolidation
voice. Consolidation occurs during an infectious
C. atrophic pharyngitis. process such as pneumonia.
Atrophic pharyngitis is characterized by a B. Atelectasis
membrane that is thin, white, glistening, and Atelectasis refers to collapse or airless
at times wrinkled. condition of the alveoli caused by
D. hypertrophic pharyngitis. hypoventilation, obstruction to the airways, or
Hypertrophic pharyngitis is characterized by compression.
general thickening and congestion of the C. Bronchiectasis
pharyngeal mucous membrane. Bronchiectasis refers to chronic dilation of a
8. Which type of sleep apnea is bronchi or bronchi in which the dilated airway
characterized by lack of airflow due to becomes saccular and a medium for chronic
pharyngeal occlusion? infection.
D. Empyema
A. Obstructive Empyema refers to accumulation of purulent
Obstructive sleep apnea occurs usually in material in the pleural space.
men, especially those who are older and 11. Which of the following community-
overweight.
acquired pneumonias demonstrates the
B. Simple
Types of sleep apnea do not include a simple highest occurrence during summer and
characterization. fall?
C. Mixed
A. Legionnaires’ disease
Mixed sleep apnea is a combination of central
Legionnaires’ disease accounts for 15% of
and obstructive apnea with one apneic
community-acquired pneumonias.
episode.
B. Streptococcal (pneumococcal) pneumonia
D. Central
Streptococcal pneumonia demonstrates the
In central sleep apnea, the patient
highest occurrence in winter months.
demonstrates simultaneous cessation of both
C. Mycoplasma pneumonia
airflow and respiratory movements.
Mycoplasma pneumonia demonstrates the
9. When the patient who has undergone highest occurrence in fall and early winter.
laryngectomy suffers wound breakdown, D. Viral pneumonia
the nurse monitors him very carefully Viral pneumonia demonstrates the greatest
because he is identified as being at high incidence during winter months.
risk for 12. When interpreting the results of a
Mantoux test, the nurse explains to the
A. carotid artery hemorrhage.
patient that a reaction occurs when the
The carotid artery lies close to the stoma and
may rupture from erosion if the wound does intradermal injection site shows
not heal properly. A. redness and induration.
B. pulmonary embolism. The site is inspected for redness and palpated
Pulmonary embolism is associated with for hardening.
immobility.
B. drainage. 15. Which of the following methods is the
Drainage at the site does not indicate a best method for determining nasogastric
reaction to the tubercle bacillus.
tube placement in the stomach?
C. tissue sloughing.
Sloughing of tissue at the site of injection A. X-ray
does not indicate a reaction to the tubercle Radiologic identification of tube placement in
bacillus. the stomach is most reliable.
D. bruising. B. Observation of gastric aspirate
Bruising of tissue at the site may occur from Gastric fluid may be grassy green, brown,
the injection, but does not indicate a reaction clear, or odorless while an aspirate from the
to the tubercle bacillus. lungs may be off-white or tan. Hence,
13. Which of the following actions is most checking aspirate is not the best method of
appropriate for the nurse to take when the determining nasogastric tube placement in the
patient demonstrates subcutaneous stomach.
C. Testing of pH of gastric aspirate
emphysema along the suture line or chest
Gastric pH values are typically lower or more
dressing 2 hours after chest surgery? acidic than that of the intestinal or
A. Record the observation. respiractory tract, but not always.
Subcutaneous emphysema occurs after chest D. Placement of external end of tube under water
surgery as the air that is located within the Placement of external end of tube under water
pleural cavity is expelled through the tissue and watching for air bubbles is not a reliable
opening created by the surgical procedure. method for determining nasogastric tube
B. Apply a compression dressing to the area. placement in the stomach.
Subcutaneous emphysema is a typical post- 16. Which of the following types of lung
operative finding in the patient after chest cancer is the most prevalent carcinoma of
surgery. the lung for both men and women?
C. Measure the patient’s pulse oximetry.
Subcutaneous emphysema is absorbed by the A. Adenocarcinoma
body spontaneously after the underlying leak Adenocarcinoma presents more peripherally
is treated or halted. as peripheral masses or nodules and often
D. Report the finding to the physician metastasizes.
immediately. B. Large cell carcinoma
Subcutaneous emphysema results from air Large cell carcinoma is a fast-growing tumor
entering the tissue planes. that tends to arise peripherally.
14. Which of the following types of lung C. Squamous cell carcinoma
Squamous cell carcinoma is more centrally
cancer is characterized as fast growing
located and arises more commonly in the
and tending to arise peripherally? segmental and subsegmental bronchi in
A. Large cell carcinoma response to repetitive carcinogenic exposures.
Large cell carcinoma is a fast-growing tumor D. Small cell carcinoma
that tends to arise peripherally. Small cell carcinomas arise primarily as
B. Bronchioalveolar carcinoma proximal lesions, but may arise in any part of
Bronchioalveolar cell cancer arises from the the tracheobronchial tree.
terminal bronchus and alveoli and is usually 17. Emphysema is described as:
slow-growing.
C. Adenocarcinoma A. A disease of the airways characterized by
destruction of the walls of overdistended
Adenocarcinoma presents as peripheral
masses or nodules and often metastasizes. alveoli. Emphysema is a category of COPD.
B. A disease that results in a common clinical
D. Squamous cell carcinoma
Squamous cell carcinoma arises from the outcome of reversible airflow obstruction.
Asthma is the disease described.
bronchial epithelium and is more centrally
located. C. The presence of cough and sputum production
for at least a combined total of two or three
months in each of two consecutive years.
Bronchitis is the disease described.
D. Chronic dilatation of a bronchus or bronchi A. Non-rebreather mask
Bronchiectasis is the condition described. The non-rebreather mask provides high
18. Which of the following is the most oxygen concentration but is usually poor
important risk factor for development of fitting.
B. Venturi mask
Chronic Obstructive Pulmonary Disease?
The Venturi mask provides low levels of
A. Cigarette smoking supplemental oxygen.
Pipe, cigar and other types of tobacco C. Catheter
smoking are also risk factors. The catheter is an inexpensive device that
B. Occupational exposure provides a variable fraction of inspired
While a risk factor, occupational exposure is oxygen and may cause gastric distention.
not the most important risk factor for D. Face tent
development of COPD. A face tent provides a fairly accurate fraction
C. Air pollution of inspired oxygen, but is bulky and
Air pollution is a risk factor for development uncomfortable. It would not be the device of
of COPD, but it is not the most important risk choice to provide high oxygen concentration.
factor. 22. Which of the following ranges
D. Genetic abnormalities identifies the amount of pressure within
A deficiency of alpha-antitrypsin is a risk the endotracheal tube cuff that is believed
factor for development of COPD, but it is not
to prevent both injury and aspiration?
the most important risk factor.
19. Which type of chest configuration is A. 20-25 mm Hg water pressure.
typical of the patient with COPD? Usually the pressure is maintained at less than
25 cm water pressure to prevent injury and at
A. Barrel chest more than 20 cm water pressure to prevent
“Barrel chest” results from fixation of the ribs aspiration.
in the inspiratory position. B. 10-15 mm Hg water pressure.
B. Pigeon chest A measure of 10–15 mm Hg water pressure
Pigeon chest results from a displaced sternum. would indicate that the cuff is underinflated.
C. Flail chest C. 30-35 mm Hg water pressure.
Flail chest results when the ribs are fractured. A measure of 30–35 mm Hg water pressure
D. Funnel chest would indicate that the cuff is overinflated.
Funnel chest occurs when there is a D. 0-5 mm Hg water pressure
depression in the lower portion of the sternum A measure of 0-5 mm Hg water pressure
and is associated with Mafan’s syndrome or would indicate that the cuff is underinflated.
rickets. 23. When performing endotracheal
20. In which stage of COPD is the forced suctioning, the nurse applies suctioning
expiratory volume (FEV1) < 30%? while withdrawing and gently rotating the
A. III catheter 360 degrees for which of the
Stage III patients demonstrate FEV1 < 30% following time periods?
with respiratory failure or clinical signs of
right heart failure A. 10-15 seconds
B. II In general, the nurse should apply suction no
Stage II patients demonstrate FEV1 between longer than 10-15 seconds because hypoxia
> 30% and 80% and dysrhythmias may develop, leading to
C. I cardiac arrest.
Stage I is mild COPD with FEV1 < 70%. B. 30-35 seconds
D. O Applying suction for 30-35 seconds is
Stage O is characterized by normal spirometry hazardous and may result in the patient’s
developing hypoxia, which can lead to
21. Of the following oxygen administration dysrhythmias and, ultimately, cardiac arrest.
devices, which has the advantage of C. 20-25 seconds
providing high oxygen concentration? Applying suction for 20-25 seconds is
hazardous and may result in the patient’s
 developing hypoxia, which can lead to beat or the point of maximum impulse, which
dysrhythmias and, ultimately, cardiac arrest. is normally palpable in the left midclavicular
D. 0-5 seconds line of the chest wall at the fifth intercostal
Applying suction for 0-5 seconds would space.
provide too little time for effective suctioning B. Mid-sternum
of secretions. The right ventricle lies anteriorly, just beneath
24. In general, chest drainage tubes are the sternum.
not used for the patient undergoing C. 2” to the left of the lower end of the sternum
Use of inches to identify the location of the
A. Pneumonectomy apex beat is inappropriate based upon
Usually, no drains are used for the variations in human anatomy.
pneumonectomy patient because the D. 1” to the left of the xiphoid process
accumulation of fluid in the empty hemithorax Auscultation below and to the left of the
prevents mediastinal shift. xiphoid process will detect gastrointestinal
B. Lobectomy sounds, but not the apex beat of the heart.
With lobectomy, two chest tubes are usually 27. Which of the following terms
inserted for drainage, the upper for air and the describes the amount of blood ejected per
lower for fluid
heartbeat?
C. Wedge resection
With wedge resection, the pleural cavity A. Stroke volume
usually is drained because of the possibility of Stroke volume is determined by preload,
an air or blood leak afterload, and contractility.
D. Segmentectomy B. Cardiac output
With segmentectomy, drains are usually used Cardiac output is the amount of blood pumped
because of the possibility of an air or blood by each ventricle during a given period and is
leak. computed by multiplying the stroke volume of
25. Which term is used to describe the the heart by the heart rate.
ability of the heart to initiate an electrical C. Ejection fraction
impulse? Ejection Fraction is the percentage of the end-
diastolic volume that is ejected with each
A. Automaticity stroke, measured at 42–50% in the normal
Automaticity is the ability of specialized heart.
electrical cells of the cardiac conduction D. Afterload
system to initiate an electrical impulse. Afterload is defined as the pressure that the
B. Contractility ventricular myocardium must overcome to
Contractility refers to the ability of the eject blood during systole and is one of the
specialized electrical cells of the cardiac determinants of stroke volume.
conduction system to contract in response to 28. When measuring the blood pressure
an electrical impulse. in each of the patient’s arms, the nurse
C. Conductivity
recognizes that in the normal adult, the
Conductivity refers to the ability of the
specialized electrical cells of the cardiac pressures
conduction system to transmit an electrical A. differ no more than 5 mm Hg between arm
impulse from one cell to another. pressures.
D. Excitability Normally, in the absence of disease of the
Excitability refers to the ability of the vasculature, there is a difference of no more
specialized electrical cells of the cardiac than 5 mm Hg between arm pressures.
conduction system to respond to an electrical B. must be equal in both arms.
impulse. The pressures in each arm do not have to be
26. The nurse auscultates the apex beat equal in order to be considered normal.
at which of the following anatomical C. may vary 10 mm Hg or more between arms.
locations? Pressures that vary more than 10 mm Hg
between arms indicate an abnormal finding.
A. Fifth intercostal space, midclavicular line D. may vary, with the higher pressure found in
The left ventricle is responsible for the apex the left arm.
 The left arm pressure is not anticipated to be C. PR interval
higher than the right as a normal anatomical The PR interval is a component of an ECG
variant. tracing reflecting conduction of an electrical
29. Central venous pressure is measured impulse through the AV node.
in which of the following heart chambers? D. QT interval
The QT interval is an ECG characteristic
A. Right atrium reflecting the time from ventricular
The pressure in the right atrium is used to depolarization to repolarization.
assess right ventricular function and venous 32. When the nurse observes that the
blood return to the heart. patient’s heart rate increases during
B. Left atrium
inspiration and decreases during
The left atrium receives oxygenated blood
from the pulmonary circulation. expiration, the nurse reports that the
C. Left ventricle patient is demonstrating
The left ventricle receives oxygenated blood
A. sinus dysrhythmia.
from the left atrium.
Sinus dysrhythmia occurs when the sinus
D. Right ventricle
node creates an impulse at an irregular
The right ventricle is not the central collecting
rhythm.
chamber of venous circulation.
B. normal sinus rhythm.
30. Which of the following ECG Normal sinus rhythm occurs when the
characteristics is usually seen when a electrical impulse starts at a regular rate and
patient’s serum potassium level is low? rhythm in the SA node and travels through the
normal conduction pathway.
A. U wave C. sinus bradycardia.
The U wave is an ECG waveform Sinus bradycardia occurs when the sinus node
characteristic that may reflect Purkinje fiber regularly creates an impulse at a slower-than-
repolarization. It is usually seen when a normal rate.
patient’s serum potassium level is low. D. sinus tachycardia.
B. T wave Sinus tachycardia occurs when the sinus node
The T wave is an ECG characteristic regularly creates an impulse at a faster-than-
reflecting repolarization of the ventricles. It normal rate.
may become tall or “peaked” if a patient’s
33. Which of the following terms is used
serum potassium level is high.
C. P wave to describe a tachycardia characterized
The P wave is an ECG characteristic by abrupt onset, abrupt cessation, and a
reflecting conduction of an electrical impulse QRS of normal duration?
through the atria.
D. QT interval A. Paroxysmal atrial tachycardia
The QT interval is an ECG characteristic PAT is often caused by a conduction problem
reflecting the time from ventricular in the AV node and is now called AV nodal
depolarization to repolarization. reentry tachycardia.
B. Sinus tachycardia
31. Which of the following ECG
Sinus tachycardia occurs when the sinus node
waveforms characterizes conduction of regularly creates an impulse at a faster-than-
an electrical impulse through the left normal rate.
ventricle? C. Atrial flutter
Atrial flutter occurs in the atrium and creates
A. QRS complex an atrial rate between 250-400 times per
The QRS complex represents ventricular minute.
depolarization D. Atrial fibrillation
B. P wave Atrial fibrillation causes a rapid, disorganized,
The P wave is an ECG characteristic and uncoordinated twitching of atrial
reflecting conduction of an electrical impulse musculature.
through the atria.
34. When the nurse observes an ECG
tracing on a cardiac monitor with a pattern
 in lead II and observes a bizarre, of the atrial impulses are conducted through
abnormal shape to the QRS complex, the the AV node into the ventricles.
D. Second degree, type II
nurse has likely observed which of the
In second degree AV block, type II, only
following ventricular dysrhythmias? some of the atrial impulses are conducted
A. Premature ventricular contraction                     through the AV node into the ventricles.
A PVC is an impulse that starts in a ventricle 37. Which of the following terms refers to
before the next normal sinus impulse. chest pain brought on by physical or
B. Ventricular bigeminy emotional stress and relieved by rest or
Ventricular bigeminy is a rhythm in which medication?
every other complex is a PVC.
C. Ventricular tachycardia A. angina pectoris
Ventricular tachycardia is defined as three or Angina pectoris is a symptom of myocardial
more PVCs in a row, occurring at a rate ischemia.
exceeding 100 beats per minute. B. atherosclerosis
D. Ventricular fibrillation Atherosclerosis is an abnormal accumulation
Ventricular fibrillation is a rapid but of lipid deposits and fibrous tissue within
disorganized ventricular rhythm that causes arterial walls and lumens.
ineffective quivering of the ventricles. C. atheroma
35. Premature ventricular contractions are Atheromas are fibrous caps composed of
considered precursors of ventricular smooth muscle cells that form over lipid
deposits within arterial vessels.
tachycardia when they
D. ischemia
A. occur at a rate of more than six per minute. Ischemia is insufficient tissue oxygenation
When PVCs occur at a rate of more than six and may occur in any part of the body.
per minute they indicate increasing ventricular 38. Of the following risk factors, which is
irritability and are considered forerunners of considered modifiable?
ventricular tachycardia (VT).
B. occur during the QRS complex. A. Diabetes mellitus
PVCs are dangerous when they occur on the T While diabetes mellitus cannot be cured,
wave. blood sugars and symptomatology can be
C. have the same shape. managed through healthy heart living.
PVCs are dangerous when they are multifocal B. Gender
(have different shapes). Gender is considered a non-modifiable risk
D. are paired with a normal beat. factor.
A PVC that is paired with a normal beat is C. Race
termed bigeminy. Race is considered a non-modifiable risk
36. When no atrial impulse is conducted factor.
D. Increasing age
through the AV node into the ventricles,
Increasing age is considered a non-modifiable
the patient is said to be experiencing risk factor.
which type of AV block? 39. When the patient with known angina
A. Third degree pectoris complains that he is experiencing
In third degree heart block, two impulses chest pain more frequently even at rest,
stimulate the heart—one stimulates the the period of pain is longer, and it takes
ventricles and one stimulates the atria. less stress for the pain to occur, the nurse
B. First degree
recognizes that the patient is describing
In first degree heart block, all the atrial
impulses are conducted through the AV node A. unstable angina.
into the ventricles at a rate slower than Unstable angina is also called crescendo or
normal. pre-infarction angina and indicates the need
C. Second degree, type I for a change in treatment.
In second degree AV block, type I, all but one B. intractable angina.
Intractable or refractory angina produces
 severe, incapacitating chest pain that does not 42. In order to be effective, Percutaneous
respond to conventional treatment. Transluminal Coronary Angioplasty
C. variant angina.
(PTCA) must be performed within what
Variant angina is described as pain at rest with
reversible ST-segment elevation and is time frame, beginning with arrival at the
thought to be caused by coronary artery emergency department after diagnosis of
vasospasm. myocardial infarction?
D. refractory angina.
Intractable or refractory angina produces A. 60 minutes
severe, incapacitating chest pain that does not The sixty minute interval is known as “door to
respond to conventional treatment. balloon time” for performance of PTCA on a
diagnosed MI patient.
40. Heparin therapy is usually considered
B. 30 minutes
therapeutic when the patient’s activated The thirty minute interval is known as “door
partial thromboplasin time (aPTT) is how to needle” time for administration of
many times normal? thrombolytics post MI.
C. 9 days
A. 1.5 to 2 The time frame of nine (9) days refers to the
The amount of heparin administered is based time for onset of vasculitis after
on aPTT results, which should be obtained in administration of Streptokinase for
follow-up to any alteration of dosage. thrombolysis in an acute MI patient.
B. .5 to 1 D. 6-12 months
The patient’s aPTT value would have to be The six to twelve month time frame refers to
greater than .5 to 1 times normal to be the time period during which streptokinase
considered therapeutic. will not be used again in the same patient for
C. 2.5 to 3 acute MI.
An aPTT value that is 2.5 to 3 times normal
43. Which of the following statements
would be too high to be considered
therapeutic. reflect a goal of rehabilitation for the
D. .25 to .75                                                           patient with an MI:
The patient’s aPTT value would have to be
A. To improve the quality of life
greater than .25 to .75 times normal to be
Overall, cardiac rehabilitation is a complete
considered therapeutic.
program dedicated to extending and
41. When the post-cardiac surgery patient improving quality of life.
demonstrates restlessness, nausea, B. To limit the effects and progression of
weakness, and peaked T waves, the atherosclerosis
nurse reviews the patient’s serum An immediate objective of rehabilitation of
electrolytes anticipating which the MI patient is to limit the effects and
progression of atherosclerosis.
abnormality?
C. To return the patient to work and a pre illness
A. Hyperkalemia lifestyle
Hyperkalemia is indicated by mental An immediate objective of rehabilitation of
confusion, restlessness, nausea, weakness, and the MI patient is to return the patient to work
dysrhythmias (tall, peaked T waves). and a pre illness lifestyle.
B. Hypercalcemia D. To prevent another cardiac event
Hypercalcemia would likely be demonstrated An immediate objective of rehabilitation of
by asystole. the MI patient is to prevent another cardiac
C. Hypomagnesemia event.
Hypomagenesemia would likely be 44. Which of the following methods to
demonstrated by hypotension, lethargy, and induce hemostasis after sheath removal
vasodilation. post Percutaneous Transluminal
D. Hyponatremia
Coronary Angioplasty is the least
Hyponatremia would likely be indicated by
weakness, fatigue, and confusion without effective?
change in T wave formation.
A. Application of a sandbag to the area [Plavix]) therapy for 2 weeks and lifetime use
Several nursing interventions frequently used of aspirin).
as part of the standard of care, such as 46. Which of the following medications
applying a sandbag to the sheath insertion site, are used to reverse the effects of
have not been shown to be effective in
heparin?
reducing the incidence of bleeding.
B. Application of a vascular closure device, such A. Protamine sulfate
as AngiosealTM, VasosealTM, DuettTM, Protamine sulfate is known as the antagonist
Syvek patchTM to heparin.
Application of a vascular closure device has B. Streptokinase
been demonstrated to be very effective. Streptokinase is a thrombolytic agent.
C. Direct manual pressure C. Clopidigrel (Plavix)
Direct manual pressure to the sheath Clopidigrel (Plavix) is an antiplatelet
introduction site has been demonstrated to be medication that is given to reduce the risk of
effective and was the first method used to thrombus formation post coronary stent
induce hemostasis post PTCA. placement.
D. Application of a pneumatic compression D. Aspirin
device (e.g., Fem-StopTM) The antiplatelet effect of aspirin does not
Application of a pneumatic compression reverse the effects of heparin.
device post PTCA has been demonstrated to 47. Which of the following terms refers to
be effective.
leg pain that is brought on walking and
45. A long-term effect of which of the
caused by arterial insufficiency?
following procedures post acute MI
induces angioneogenesis? A. Intermittent claudication
Intermittent claudication is leg pain that is
A. Transmyocardial laser revascularization brought on by exercise and relieved by rest.
TNR procedures usually involves making 20 B. Dyspnea
to 40 channels in ventricular muscle. It is Dyspnea is the patient’s subjective statement
thought that some blood flows into the of difficulty breathing.
channels, decreasing the ischemia directly. C. Orthopnea
Within the next few days to months, the Orthopnea is the inability of the patient to
channels close as a result of the body’s breathe except in the upright (sitting) position.
inflammatory process of healing a wound and D. Thromboangitis obliterans
new blood vessels form as a result of the Thomroangitis obliterans is a peripheral
inflammatory process. vascular disease also known as Burger’s
B. Bracytherapy disease.
Brachytherapy involves the delivery of 48. When the post-cardiac surgical
gamma or beta radiation by placing a
patient demonstrates vasodilation,
radioisotope close to the lesion and has been
shown to be effective in reducing the hypotension, hyporeflexia, slow
recurrence of obstruction, preventing vessell gastrointestinal motility (hypoactive bowel
restenosis by inhibiting smooth muscle cell sounds), lethargy, and respiratory
proliferation. depression, the nurse suspects which of
C. Atherectomy the following electrolyte imbalances?
Atherectomy is an invasive interventional
procedure that involves the removal of the A. Hypermagnesemia
atheroma, or plaque, from a coronary artery. Untreated hypomagnesemia may result in
D. Stent placement coma, apnea, cardiac arrest.
A stent is a woven stainless steel mesh that B. Hypokalemia
provides structural support to a vessel at risk Signs and symptoms of hypokalemia include
of acute closure. Eventually, endothelium signs of digitalis toxicity and dysrhythmias (U
covers the stent and it is incorporated into the wave, AV block, flat or inverted T waves).
vessel wall. Because of the risk of thrombus C. Hyperkalemia
formation in the stent, the patient receives Signs of hyperkalemia include: mental
antiplatelet medications (e.g., clopidigrel confusion, restlessness, nausea, weakness,
 paresthesias of extremities, dysrhythmias (tall,
peaked T waves; increased amplitude,
widening QRS complex; prolonged QT
interval).
D. Hypomagnesemia
Signs and symptoms of hypomagnesemia
include: paresthesias, carpopedal spasm,
muscle cramps, tetany, irritability, tremors,
hyperexcitability, hyperreflexia, cardiac
dysrhythmias (prolonged PR and QT
intervals, broad flat T waves), disorientation,
depression, and hypotension.
49. When the nurse notes that the post
cardiac surgery patient demonstrates low
urine output (< 25 ml/hr) with high specific
gravity (> 1.025), the nurse suspects:
A. Inadequate fluid volume
Urine output of less than 25 ml/hr may
indicate a decrease in cardiac output. A high
specific gravity indicates increased
concentration of solutes in the urine which
occurs with inadequate fluid volume.
B. Normal glomerular filtration
Indices of normal glomerular filtration are
output of 25 ml or greater per hour and
specific gravity between 1.010 and 1.025.
C. Overhydration
Overhydration is manifested by high urine
output with low specific gravity.
D. Anuria
The anuric patient does not produce urine.
50. When the valve used in valve
replacement surgery is made from the
patient’s own heart valve, which of the
following terms is used?
A. Autograft
An example of autograft is found when the
surgeon excises the pulmonic valve and uses
it for an aortic valve replacement.
B. Allograft
Allograft refers to replacement using human
tissue and is a synonym for homograft.
C. Homograft
Homograft refers to replacement using human
tissue and is a synonym for allograft.
D. Xenograft                                                          
Xenograft refers to replacement of tissue from
animal tissue.
 Medical Surgical Nursing Exam 10 6. Morphine 8 mg IM has been ordered
1. The nurse would evaluate that the for a client. The ampule label reads 15
client understands his home care mg/mL. How many milliliters will the nurse
instructions after scleral buckling for a give?
detached retina if he says his activity A. 0.45 mL
should include: B. 0.53 mL
C. 0.66 mL
A. Avoiding abrupt movements of the head D. 0.75 mL
B. Exercising the eye muscles each day
7. The correct procedure for auscultating
C. Turning the entire head rather than just the
eyes for sight the client’s abdomen for bowel sounds
D. Avoiding activities requiring good depth would include:
perception
A. Palpating the abdomen first to determine
2. Lomotil has been prescribed to treat a correct stethoscope placement
client’s diarrhea. The nurse should teach B. Encouraging the client to cough to stimulate
the client to report which of the following movement of fluid and air through the
common side effects? abdomen
C. Placing the client on the left side to aid
A. Urinary retention auscultation
B. Diaphoresis D. Listening for 5minutes in all four quadrants to
C. Hypotension confirm absence of bowel sound
D. Lethargy 8. A client is admitted to the hospital with
3. Nitroglycerin is also available in a diagnosis of a right hip fracture. She
ointment or paste form. Before applying complains of right hip pain and cannot
nitroglycerin ointment, the nurse should: move her right leg. Which of
A. Cleanse the skin with alcohol where the the following assessments made by the
ointment will be placed. nurse indicates that the client has a
B. Obtain the client’s pulse rate and rhythm typical sign of hip fracture? The client’s
C. Remove the ointment previously applied right leg is:
D. Instruct the client to expect pain relief in the
next 15 minutes A. Rotated internally
4. While a client with hypertension is B. Held in a flexed position
being assessed, he says to the nurse, “I C. Adducted
D. Shorter than the leg on the unaffected side
really don’t know why I am here. I feel fine
9. The nurse assesses the client’s
and haven’t had any  symptoms.” The
understanding of the relationship between
nurse would explain to the client that
body position and gastroesophageal
symptoms of hypertension:
reflux. Which response would indicate
A. Are often not present that the client understands measures to
B. Signify a high risk of stroke avoid problems with reflux while
C. Occur only with malignant hypertension
sleeping?
D. Appear after irreversible kidney damage has
occurred A. I can elevate the foot of the bed 4 to 6 inches
5. For a neurologically injured client, the B. I can sleep on my stomach with my head
nurse would best assess motor strength turned to the left
by: C. I can sleep on my back without a pillow under
my head
A. Comparing equality of hand grasps D. I can elevate the head of the bed 4 to 6 inches
B. Observing spontaneous movements 10.  Which of the following would be an
C. Observing the client feed himself appropriate nursing diagnosis for a
D. Asking him to signal if he feels pressure
applied to his feet
 hospitalized client with bacterial B. The mucus is caused by elevated levels of
pneumonia and shortness of breath? glucose in the urine
C. These findings are normal for a client with an
A. Ineffective cardiopulmonary tissue perfusion ileal conduit
related to myocardial damage D. There is irritation of the stoma
B. Risk for self-care deficit related to fatigue 16.  Which of the following assessments
C. Deficient fluid volume related to nausea and would be important for the nurse to make
vomiting
to determine whether or not a client is
D. Disturbed thought processes related to
inadequate relief of chest pain recovering as expected from
11.  Theophylline ethylenediamide is spinal anesthesia?
administered to a client with COPD to: A. Level of consciousness
B. Rate and depth of respirations
A. Reduce bronchial secretions
C. Rate of capillary refill in the toes
B. Relax bronchial smooth muscle D. Degree of response to pinpricks in the legs
C. Strengthen myocardial contractions
and toes
D. Decrease alveolar elasticity
17.  A client with iron-deficiency anemia is
12.  Which of the following lab results
prescribed liquid iron supplements. The
would be unexpected in a client with
nurse evaluates the client’s
chronic renal failure?
understanding of how to take this drug.
A. Serum potassium 6.0 mEq/L Which of the following statements
B. Serum creatinine 9 mg/dL indicates the client has adequate
C. BUN 15 mg/dL knowledge?
D. Serum phosphate 5.2 mg/dL.
13. Which of the following criteria are A. I can use antidiarrheal drugs if I develop
acceptable for a rescuer to discontinue diarrhea
CPR? B. I will report any black stools to the physician
C. I will check my gums for any bleeding
A. When it is obvious that the victim will not D. I will dilute the medication and drink it with a
survive straw
B. When the rescuer is exhausted 18.  The nurse has instructed the client
C. After 30 minutes of CPR without a pulse rate about the correct positioning of his leg
D. When the family requests discontinuation and hip following hip replacement
14. A client is scheduled to undergo an surgery. Which of the following
abdominal perineal resection with a statements indicate that the client has
permanent colostomy. Which of the understood these instructions?
following measures would be an
anticipated part of the client’s A. I may cross my legs as long as I keep my
preoperative care? knees extended
B. I should avoid bending over to tie my shoes
A. Keep the client NPO for 24 hrs before surgery C. I can sit in any chair that I find comfortable
B. Administer neomycin sulfate the evening D. I should avoid any unnecessary walking for
before surgery about 3 months after my surgery
C. Inform the client that total parenteral nutrition 19.  Clients with diabetes mellitus require
will likely be implemented after surgery frequent vision assessment. The nurse
D. Advise the client to limit physical activity should instruct the client about which of
15.  The nurse notes that the client’s the following eye problems most likely to
urinary appliance contains yellow urine be associated with diabetes mellitus?
with large amounts of mucus. How would
the nurse best interpret these data? A. Cataracts
B. Retinopathy
A. The client is developing an infection of the C. Astigmatism
urinary tract D. Glaucoma
 20.  An autograft is taken from the client’s 25.  Which of the following observations
left leg. The nurse should care for the should the postanesthesia care unit
donor site by: (PACU) nurse plan to make first when the
client who has had a modified radical
A. Covering it with an occlusive dry dressing
B. Keeping the site clean and dry mastectomy returns from the operating
C. Applying a pressure dressing room?
D. Wrapping the extremity with an elastic
A. Obtaining and recording vital signs
bandage
B. Observing that drainage tubes are patent and
21.  Which of the following categories of functioning
medications would the nurse anticipate C. Ensuring that the client’s airway is free of
being included in the conservative obstruction
management of a client with a herniated D. Checking the client’s dressings for drainage
lumbar disk? 26.  The classic signs and symptoms of
rheumatoid arthritis include which of the
A. Muscle relaxant
following?
B. Sedatives
C. Tranquilizers A. Pain on weight-bearing, rash and low-grade
D. Parenteral analgesics fever
22.  The client has a nursing diagnosis of B. Joint swelling, joint stiffness in the morning
Constipation related to decreased mobility and bilateral joint movement
secondary to traction. A care plan that C. Crepitus, development of Heberden’s nodes
and anemia
incorporates which of the following
D. Fatigue, leucopenia and joint pain
breakfasts would be most helpful in
27.  Nursing measures for the client who
reestablishing a normal bowel routine?
has had an MI include helping the client
A. Eggs and bacon, buttered white toast, orange to avoid activity that results in Valsalva’s
juice and coffee maneuver. Valsalva’s maneuver may
B. Corn flakes with sliced banana, milk and cause cardiac dysrhythmias, increased
English muffin with jelly
venous pressure, increased intrathoracic
C. Orange juice, breakfast pastries (doughnut and
Danish) and coffee pressure and thrombi dislodgement.
D. An orange, raisin bran and milk, and wheat Which of the following actions would help
toast with butter prevent Valsalva’s maneuver? Have the
23.  A client has been placed on levodopa client:
to treat Parkinson’s disease.  Which of
A. Assume a side-lying position
the following is a common side effects of B. Clench her teeth while moving in bed
levodopa that the nurse should include in C. Drink fluids through a straw
the client’s teaching plan? D. Avoid holding her breath during activity
28.  A client is scheduled for radical neck
A. Pancytopenia
B. Peptic ulcer surgery and a total laryngectomy. During
C. Postural hypotension the preoperative teaching, the nurse
D. Weight loss should prepare the client for  which of the
24.  The client would be experiencing a following postoperative possibilities?
typical symptom of Meniere’s disease if,
A. Endotracheal intubation
before an attack, he experienced: B. Insertion of laryngectomy tube
A. A severe headache C. Immediate speech therapy
B. Blurred vision D. Gastrostomy tube
C. Nausea 29.  The client is being taught to self-
D. A feeling of inner ear fullness administer insulin. Learning goals most
 likely will be attained when they are 33.  Oxtriphylline (Choledyl SA) 0.2 g has
established by the: been ordered. Available tablets are
100mg. How many tablets should be
A. Nurse and client because both need to be
responsible for teaching given?
B. Physician and client because the physician is A. 0.5 tablets
the manager of care and the client is the main B. 2.0 tablets
participant C. 2.5 tablets
C. Client because the client is best able to D. 5.0 tablets
identify his or her own needs and how to meet
34.  The most common causes of
those needs
D. Client, nurse and physician so the client can megaloblastic, macrocytic anemias are:
participate in planning care with the nurse and A. Folate or vitamin B deficiency
physician B. Chronic disease
30.   Which statement by the client with C. Iron deficiency
rheumatoid arthritis would indicate that D. Infection
she needs additional teaching to safely 35.  Which of the following nutrients
receive the maximum benefit provides a little over half of the energy
of her aspirin therapy? needed during sleep?
A. I always take aspirin with food to protect my A. Protein
stomach B. Carbohydrate
B. Once I learned to take aspirin with meals, I C. Fat
was able to start using the inexpensive generic D. Water
brand 36.  An anticipated outcome for the client
C. I always watch for bleeding gums or blood in after cataract removal surgery would
my stool
include which of the following?
D. I try to take aspirin only on days when the
pain seems particularly bad A. The client states her vision is clear
31.  A client has stress incontinence has B. The client states her infection is under control
been given a pamphlet that describes C. The client describes methods to prevent an
Kegel exercises. Which of the following increase in intraocular pressure
statements indicates to the nurse that the D. The client states she is able to administer
parenteral pain medication
client has understood the instructions
37.  The nurse understands that
contained in the pamphlet?
Hodgkin’s disease is suspected when a
A. I should perform these exercises every client presents with a painless, swollen
evening lymph node. Hodgkin’s disease typically
B. It will probably take a year before the affects people in which age group?
exercises are effective
C. I can do these exercises sitting up, lying down A. Children (ages 6-12 years)
or standing B. Teenagers (ages 13-20 years)
D. I need to tighten my abdominal muscles to do C. Young adults (ages 21-40 years)
these exercises correctly D. Older adults (ages 41-50 years)
32.  The development of laryngeal cancer 38.  The nurse notes the following
is most clearly linked to which of the assessment findings regarding the client’s
following factors? peripheral vascular status: cramping leg
pain relieved by rest; cool, pale  feet; and
A. High-fat, low-fiber diet
B. Alcohol and tobacco use delayed capillary refilling. Based on these
C. Low socioeconomic status data, the nurse would make a nursing
D. Overuse of artificial sweeteners diagnosis of:
A. Impaired skin integrity
B. Impaired gas exchange A. I’ll empty my pouch when it’s about one-third
C. Ineffective peripheral tissue perfusion full
D. Impaired physical mobility B. I can take my pouch off at night
39.  The client with urinary tract infection C. I should change my pouch immediately after
is given a prescription for trimethoprim lunch
D. I must apply a new pouch system every day
(Bactrim-DS) for her infection. Which of
44.  A client’s laboratory tests indicate
the following statements would indicate
that the client has hypocalcemia. Which
that she understands the principles of
of the following symptoms should the
antibiotic therapy?
nurse look for in the client?
A. I’ll take the pills until I feel better and keep
the rest for recurrences A. Flushed skin
B. I’ll take all the pills then return to my doctor B. Depressed reflexes
C. I’ll take the pills until the symptoms go away C. Tingling in extremities
then reduce the dose to one pill a day D. Diarrhea
D. I’ll take all the pills then have the prescription 45.  Which of the following symptoms
renewed once would the nurse most likely observe in a
40.  Which of the following clients would client with cholecystitis from
the nurse expect to be at highest risk for cholelithiasis?
developing a urinary tract infection?
A. Black stools
A. Woman who has delivered two children B. Nausea after ingestion of high fat foods
vaginally C. Elevated temperature of 103 F (39.4 C)
B. Man with an indwelling urinary catheter for D. Decreased WBC count
incontinence 46.  Pain control is an important nursing
C. Man with a past medical history of renal goal for the client with pancreatitis. Which
calculi of the following medications would the
D. Woman with well-controlled diabetes mellitus
nurse plan to administer in this situation?
41.  When bandaging the burned client’s
hand, the nurse should make certain that: A. Meperidine hydrochloride (Demerol)
B. Cimetidine (Tagamet)
A. The bandage is free of elastic C. Morphine sulfate
B. The hand and finger surfaces do not touch D. Codeine sulfate
C. The hand and fingers are not elevated above 47.  A client is recovering from a gastric
heart level
resection for peptic ulcer disease. Which
D. The bandage material is moistened with sterile
normal saline solution of the following outcomes indicates that
42.  The nurse is caring for a client who the goal of adequate nutritional intake is
has a history of aplastic anemia. Which of being achieved 3 weeks following
the following data from the nursing history surgery?
indicates that the anemia is not being A. Increases food intake and tolerance gradually
managed effectively? B. Experiences occasional episodes of nausea
and vomiting
A. Pallor of skin and mucous membranes C. Drinks 2000 mL/day of water
B. Heart rate of 68 bpm, bounding pulse D. Experiences a rapid weight gain within 1
C. Blood pressure of 146/90 mm Hg week
D. Poor skin turgor
48.  What would be the most important
43.  A client is learning about caring for
nursing intervention in caring for the
her ileostomy. Which of the following
client’s residual limb during the first 24 hrs
statements would indicate that she
after amputation of the left leg?
understands how to care for her ileostomy
pouch? A. Keeping the residual limb flat on the bed
B. Abducting the residual limb on a scheduled 22.D. An orange, raisin bran and milk, and
basis wheat toast with butter
C. Applying traction to the residual limb 23.C. Postural hypotension
D. Elevating the residual limb on a pillow 24.D. A feeling of inner ear fullness
49.  After the client returns from surgery 25.C. Ensuring that the client’s airway is free
for a deviated nasal septum, the nurse of obstruction
26.B. Joint swelling, joint stiffness in the
would anticipate placing her in what
morning and bilateral joint movement
position? 27.D. Avoid holding her breath during activity
A. Supine 28.B. Insertion of laryngectomy tube
B. Left side-lying 29.D. Client, nurse and physician so the client
C. Semi-Fowler’s can participate in planning care with the
D. Reverse Trendelenburg’s nurse and physician
30.D. I try to take aspirin only on days when
50.  While suctioning a client’s
the pain seems particularly bad
laryngectomy tube, the nurse insert the 31.C. I can do these exercises sitting up, lying
catheter: down or standing
32.B. Alcohol and tobacco use
A. About 1-2 inches
33.B. 2.0 tablets
B. As the client exhales
34.A. Folate or vitamin B deficiency
C. Until resistance is met, then withdraw it 1-2
35.C. Fat
cm
36.C. The client describes methods to prevent
D. Until the client begins coughing
an increase in intraocular pressure
Answers 37.C. Young adults (ages 21-40 years)
1. A. Avoiding abrupt movements of the head 38.C. Ineffective peripheral tissue perfusion
2. A. Urinary retention 39.B. I’ll take all the pills then return to my
3. C. Remove the ointment previously applied doctor
4. A. Are often not present 40.B. Man with an indwelling urinary catheter
5. A. Comparing equality of hand grasps for incontinence
6. B. 0.53 mL 41.B. The hand and finger surfaces do not
7. D. Listening for 5minutes in all four touch
quadrants to confirm absence of bowel 42.A. Pallor of skin and mucous membranes
sound 43.A. I’ll empty my pouch when it’s about
8. D. Shorter than the leg on the unaffected one-third full
side 44.B. Depressed reflexes
9. D. I can elevate the head of the bed 4 to 6 45.B. Nausea after ingestion of high fat foods
inches 46.A. Meperidine hydrochloride (Demerol)
10.B. Risk for self-care deficit related to 47.A. Increases food intake and tolerance
fatigue gradually
11.B. Relax bronchial smooth muscle 48.D. Elevating the residual limb on a pillow
12.C. BUN 15 mg/dL 49.C. Semi-Fowler’s
13.B. When the rescuer is exhausted 50.C. Until resistance is met, then withdraw it
14.B. Administer neomycin sulfate the evening 1-2 cm
before surgery
15.C. These findings are normal for a client
with an ileal conduit
16.D. Degree of response to pinpricks in the
legs and toes
17.D. I will dilute the medication and drink it
with a straw
18.B. I should avoid bending over to tie my
shoes
19.B. Retinopathy
20.B. Keeping the site clean and dry
21.A. Muscle relaxant
 NCLEX RN Practice Exam 1 only immunoglobulin that will provide
1. A nurse is reviewing a patient’s protection to the fetus in the womb?
medication during shift change. Which of A. IgA
the following medication would be B. IgD
contraindicated if the patient were C. IgE
pregnant? Note: More than one answer D. IgG
may be correct. 6. A second year nursing student has just
suffered a needlestick while working with
A. Coumadin a patient that is positive for AIDS. Which
B. Finasteride
of the following is the most important
C. Celebrex
D. Catapress action that nursing student should take?
E. Habitrol
A. Immediately see a social worker
F. Clofazimine B. Start prophylactic AZT treatment
2. A nurse is reviewing a patient’s PMH. C. Start prophylactic Pentamide treatment
The history indicates photosensitive D. Seek counseling
reactions to medications. Which of the 7. A thirty five year old male has been an
following drugs has not been associated insulin-dependent diabetic for five years
with photosensitive reactions? Note: More and now is unable to urinate. Which of the
than one answer may be correct. following would you most likely suspect?
A. Cipro A. Atherosclerosis
B. Sulfonamide B. Diabetic nephropathy
C. Noroxin C. Autonomic neuropathy
D. Bactrim D. Somatic neuropathy
E. Accutane 8. You are taking the history of a 14 year
F. Nitrodur
old girl who has a (BMI) of 18. The girl
3. A patient tells you that her urine is reports inability to eat, induced vomiting
starting to look discolored. If you believe and severe constipation. Which of the
this change is due to medication, which of following would you most likely suspect?
the following patient’s medication does
not cause urine discoloration? A. Multiple sclerosis
B. Anorexia nervosa
A. Sulfasalazine C. Bulimia
B. Levodopa D. Systemic sclerosis
C. Phenolphthalein 9. A 24 year old female is admitted to the
D. Aspirin
ER for confusion. This patient has a
4. You are responsible for reviewing the
history of a myeloma diagnosis,
nursing unit’s refrigerator. If you found the
constipation, intense abdominal pain, and
following drug in the refrigerator it should
polyuria. Which of the following would you
be removed from the refrigerator’s
most likely suspect?
contents?
A. Diverticulosis
A. Corgard B. Hypercalcaemia
B. Humulin (injection) C. Hypocalcaemia
C. Urokinase D. Irritable bowel syndrome
D. Epogen (injection)
10. Rho gam is most often used to
5. A 34 year old female has recently been treat____ mothers that have a ____
diagnosed with an autoimmune disease. infant.
She has also recently discovered that she
is pregnant. Which of the following is the A. RH positive, RH positive
B. RH positive, RH negative
C. RH negative, RH positive clinical signs would most likely be
D. RH negative, RH negative present?
11. A new mother has some questions
about (PKU). Which of the following A. Slow pulse rate
B. Weight gain
statements made by a nurse is not correct
C. Decreased systolic pressure
regarding PKU? D. Irregular WBC lab values
A. A Guthrie test can check the necessary lab 16. A mother has recently been informed
values. that her child has Down’s syndrome. You
B. The urine has a high concentration of will be assigned to care for the child at
phenylpyruvic acid shift change. Which of the following
C. Mental deficits are often present with PKU.
characteristics is not associated with
D. The effects of PKU are reversible.
Down’s syndrome?
12. A patient has taken an overdose of
aspirin. Which of the following should a A. Simian crease
nurse most closely monitor for during B. Brachycephaly
acute management of this patient? C. Oily skin
D. Hypotonicity
A. Onset of pulmonary edema 17. A patient has recently experienced a
B. Metabolic alkalosis (MI) within the last 4 hours. Which of the
C. Respiratory alkalosis
following medications would most like be
D. Parkinson’s disease type symptoms
administered?
13. A fifty-year-old blind and deaf patient
has been admitted to your floor. As the A. Streptokinase
charge nurse your primary responsibility B. Atropine
for this patient is? C. Acetaminophen
D. Coumadin
A. Let others know about the patient’s deficits. 18. A patient asks a nurse, “My doctor
B. Communicate with your supervisor your recommended I increase my intake of
patient safety concerns.
folic acid. What type of foods contain the
C. Continuously update the patient on the social
environment. highest concentration of folic acids?”
D. Provide a secure environment for the patient. A. Green vegetables and liver
14. A patient is getting discharged from a B. Yellow vegetables and red meat
SNF facility. The patient has a history of C. Carrots
severe COPD and PVD. The patient is D. Milk
primarily concerned about their ability to 19. A nurse is putting together a
breath easily. Which of the following presentation on meningitis. Which of the
would be the best instruction for this following microorganisms has NOT been
patient? linked to meningitis in humans?

A. Deep breathing techniques to increase O2 A. S. pneumonia

levels. B. H. influenza
B. Cough regularly and deeply to clear airway C. N. meningitis
passages. D. Cl. difficile
C. Cough following bronchodilator utilization 20. A nurse is administering blood to a
D. Decrease CO2 levels by increase oxygen take patient who has a low hemoglobin count.
output during meals. The patient asks how long to RBC’s last
15. A nurse is caring for an infant that has in my body? The correct response is.
recently been diagnosed with a congenital
heart defect. Which of the following A. The life span of RBC is 45 days.
B. The life span of RBC is 60 days.
C. The life span of RBC is 90 days.
D.  The life span of RBC is 120 days. medications would the patient most likely
21. A 65 year old man has been admitted be taking?
to the hospital for spinal stenosis surgery.
A. Elavil
When does the discharge training and
B. Calcitonin
planning begin for this patient? C. Pergolide
A. Following surgery D. Verapamil
B. Upon admit 27. Which of the following conditions
C. Within 48 hours of discharge would a nurse not administer
D. Preoperative discussion erythromycin?
22. A child is 5 years old and has been
A. Campylobacterial infection
recently admitted into the hospital.
B. Legionnaire’s disease
According to Erickson which of the C. Pneumonia
following stages is the child in? D. Multiple Sclerosis
A. Trust vs. mistrust 28. A patient’s chart indicates a history of
B. Initiative vs. guilt hyperkalemia. Which of the following
C. Autonomy vs. shame would you not expect to see with this
D. Intimacy vs. isolation patient if this condition were acute?
23. A toddler is 16 months old and has
A. Decreased HR
been recently admitted into the hospital.
B. Paresthesias
According to Erickson which of the C. Muscle weakness of the extremities
following stages is the toddler in? D. Migranes
A. Trust vs. mistrust 29. A patient’s chart indicates a history of
B. Initiative vs. guilt ketoacidosis. Which of the following
C. Autonomy vs. shame would you not expect to see with this
D. Intimacy vs. isolation patient if this condition were acute?
24. A young adult is 20 years old and has
A. Vomiting
been recently admitted into the hospital.
B. Extreme Thirst
According to Erickson which of the C. Weight gain
following stages is the adult in? D. Acetone breath smell
A. Trust vs. mistrust 30. A patient’s chart indicates a history of
B. Initiative vs. guilt meningitis. Which of the following would
C. Autonomy vs. shame you NOT expect to see with this patient if
D. Intimacy vs. isolation this condition were acute?
25. A nurse is making rounds taking vital
A. Increased appetite
signs. Which of the following vital signs is
B. Vomiting
abnormal? C. Fever
A. 11 year old male – 90 b.p.m, 22 resp/min. , D. Poor tolerance of light
100/70 mm Hg 31. A nurse if reviewing a patient’s chart
B. 13 year old female – 105 b.p.m., 22 resp/min., and notices that the patient suffers from
105/60 mm Hg conjunctivitis. Which of the following
C. 5 year old male- 102 b.p.m, 24 resp/min., microorganisms is related to this
90/65 mm Hg
condition?
D. 6 year old female- 100 b.p.m., 26 resp/min.,
90/70mm Hg A. Yersinia pestis
26. When you are taking a patient’s B. Helicobacter pyroli
history, she tells you she has been C. Vibrio cholera
depressed and is dealing with an anxiety D. Hemophilus aegyptius
disorder. Which of the following
 32. A nurse if reviewing a patient’s chart C. Blood cultures
and notices that the patient suffers from D. Arterial blood gases
Lyme disease. Which of the following 37. A mother is inquiring about her child’s
microorganisms is related to this ability to potty train. Which of the following
condition? factors is the most important aspect of
toilet training?
A. Borrelia burgdorferi
B. Streptococcus pyrogens A. The age of the child
C. Bacilus anthracis B. The child ability to understand instruction.
D. Enterococcus faecalis C. The overall mental and physical abilities of
33. A fragile 87 year-old female has the child.
D. Frequent attempts with positive
recently been admitted to the hospital
reinforcement.
with increased confusion and falls over
38. A parent calls the pediatric clinic and
last 2 weeks. She is also noted to have a
is frantic about the bottle of cleaning fluid
mild left hemiparesis. Which of the
her child drank 20 minutes. Which of the
following tests is most likely to be
following is the most important instruction
performed?
the nurse can give the parent?
A. FBC (full blood count)
A. This too shall pass.
B. ECG (electrocardiogram)
B. Take the child immediately to the ER
C. Thyroid function tests
C. Contact the Poison Control Center quickly
D. CT scan
D. Give the child syrup of ipecac
34. A 84 year-old male has been loosing
39. A nurse is administering a shot of
mobility and gaining weight over the last 2
Vitamin K to a 30 day-old infant. Which of
months. The patient also has the heater
the following target areas is the most
running in his house 24 hours a day, even
appropriate?
on warm days. Which of the following
tests is most likely to be performed? A. Gluteus maximus
B. Gluteus minimus
A. FBC (full blood count) C. Vastus lateralis
B. ECG (electrocardiogram) D. Vastus medialis
C. Thyroid function tests 40. A nurse has just started her rounds
D. CT scan
delivering medication. A new patient on
35. A 20 year-old female attending
her rounds is a 4 year-old boy who is non-
college is found unconscious in her dorm
verbal. This child does not have on any
room. She has a fever and a noticeable
identification. What should the nurse do?
rash. She has just been admitted to the
hospital. Which of the following tests is A. Contact the provider
most likely to be performed first? B. Ask the child to write their name on paper.
C. Ask a co-worker about the identification of
A. Blood sugar check the child.
B. CT scan D. Ask the father who is in the room the child’s
C. Blood cultures name.
D. Arterial blood gases 41. A nurse is monitoring a pregnant
36. A 28 year old male has been found client with pregnancy induced
wandering around in a confused pattern. hypertension who is at risk for
The male is sweaty and pale. Which of Preeclampsia. The nurse checks the
the following tests is most likely to be client for which specific signs of
performed first? Preeclampsia (select all that apply)?
A. Elevated blood pressure
A. Blood sugar check
B. Negative urinary protein
B. CT scan
C. Facial edema C. Consuming a small glass of warm milk at
D. Increased respirations bedtime
42. A nurse is caring for a pregnant client D. Performing mild exercises 30 minutes before
with severe preeclampsia who is going to bed
receiving IV magnesium 46. The nurse recognizes that a client is
sulfate. Select all nursing interventions that experiencing insomnia when the client
apply in the care for the client. reports(select all that apply):
A. Monitor maternal vital signs every 2 hours A. Extended time to fall asleep
B. Notify the physician if respirations are less B. Falling asleep at inappropriate times
than 18 per minute. C. Difficulty staying asleep
C. Monitor renal function and cardiac function D. Feeling tired after a night’s sleep
closely 47. The nurse teaches the mother of a
D. Keep calcium gluconate on hand in case of a newborn that in order to prevent sudden
magnesium sulfate overdose infant death syndrome (SIDS) the best
E. Monitor deep tendon reflexes hourly position to place the baby after nursing
F. Monitor I and O’s hourly
is (select all that apply):
G. Notify the physician if urinary output is less
A. Prone
than 30 ml per hour.
B. Side-lying
43. When interpreting an ECG, the nurse C. Supine
would keep in mind which of the following D. Fowler’s
about the P wave? Select all that apply. 48. A client has a diagnosis of primary
A. Reflects electrical impulse beginning at the insomnia. Before assessing this client, the
SA node
nurse recalls the numerous causes of this
B. Indicated electrical impulse beginning at the
AV node disorder. Select all that apply:
C. Reflects atrial muscle depolarization A. Chronic stress
D. Identifies ventricular muscle depolarization B. Severe anxiety
E. Has duration of normally 0.11 seconds or less. C. Generalized pain
D. Excessive caffeine
44.  When caring for a client with a central
E. Chronic depression
venous line, which of the following F. Environmental noise
nursing actions should be implemented in 49. Select all that apply to the use of
the plan of care for chemotherapy barbiturates in treating insomnia:
administration?Select all that apply. A. Barbiturates deprive people of NREM sleep
A. Verify patency of the line by the presence of a B. Barbiturates deprive people of REM sleep
blood return at regular intervals. C. When the barbiturates are discontinued, the
B. Inspect the insertion site for swelling, NREM sleep increases.
erythema, or drainage. D. When the barbiturates are discontinued, the
C. Administer a cytotoxic agent to keep the REM sleep increases.
regimen on schedule even if blood return is E. Nightmares are often an adverse effect when
not present. discontinuing barbiturates.
D. If unable to aspirate blood, reposition the 50. Select all that apply that is appropriate
client and encourage the client to cough.
when there is a benzodiazepine
E. Contact the health care provider about
verifying placement if the status is overdose:
questionable. A. Administration of syrup of ipecac
B. Gastric lavage
45. To assist an adult client to sleep
C. Activated charcoal and a saline cathartic
better the nurse recommends which of D. Hemodialysis
the following? E. Administration of Flumazenil
A. Drinking a glass of wine just before retiring to Answers and Rationale
bed 1. A. Coumadin and B. Finasteride. They are
B. Eating a large meal 1 hour before bedtime both contraindicated with pregnancy.
2. F. Nitrodur. All of the others have can cause 24.D. Intimacy vs. isolation. Intimacy vs.
photosensitivity reactions. isolation- 18-35 years old
3. D. Aspirin . All of the others can cause urine 25.B. 13 year old female – 105 b.p.m., 22
discoloration. resp/min., 105/60 mm Hg. HR and
4. A. Corgard . Corgard could be removed from Respirations are slightly increased. BP is
the refigerator. down.
5. D. IgG. IgG is the only immunoglobulin that 26.A. Elavil. Elavil is a tricyclic antidepressant.
can cross the placental barrier. 27.D. Multiple Sclerosis. Erythromycin is used
6. B. Start prophylactic AZT treatment. AZT to treat conditions A-C.
treatment is the most critical innervention. 28.D. Migraines. Answer choices A-C were
7. C. Autonomic neuropathy. Autonomic symptoms of acute hyperkalemia.
neuropathy can cause inability to urinate. 29.C. Weight gain. Weight loss would be
8. B. Anorexia nervosa. All of the clinical signs expected.
and systems point to a condition of anorexia 30.A. Increased appetite . Loss of appetite
nervosa. would be expected.
9. B. Hypercalcaemia. Hypercalcaemia can 31.D. Hemophilus aegyptius. Choice A is
cause polyuria, severe abdominal pain, and linked to Plague, Choice B is linked to peptic
confusion. ulcers, Choice C is linked to Cholera.
10.C. RH negative, RH positive. Rho gam 32.A. Borrelia burgdorferi. Choice B is linked
prevents the production of anti-RH antibodies to Rheumatic fever, Choice C is linked to
in the mother that has a Rh positive fetus. Anthrax, Choice D is linked to Endocarditis.
11.D. The effects of PKU are reversible. The 33.D. CT scan. A CT scan would be performed
effects of PKU stay with the infant throughout for further investigation of the hemiparesis.
their life. 34.C. Thyroid function tests. Weight gain and
12.D. Parkinson’s disease type poor temperature tolerance indicate something
symptoms. Aspirin overdose can lead to may be wrong with the thyroid function.
metabolic acidosis and cause pulmonary 35.C. Blood cultures. Blood cultures would be
edema development. performed to investigate the fever and rash
13.D. Provide a secure environment for the symptoms.
patient. This patient’s safety is your primary 36.A. Blood sugar check. With a history of
concern. diabetes, the first response should be to check
14.C. Cough following bronchodilator blood sugar levels.
utilization. The bronchodilator will allow a 37.C. The overall mental and physical abilities
more productive cough. of the child. Age is not the greatest factor in
15.B. Weight gain. Weight gain is associated potty training. The overall mental and
with CHF and congenital heart deficits. physical abilities of the child is the most
16.C. Oily skin. The skin would be dry and not important factor.
oily. 38.C. Contact the Poison Control Center
17.A. Streptokinase . Streptokinase is a clot quickly. The poison control center will have
busting drug and the best choice in this an exact plan of action for this child.
situation. 39.C. Vastus lateralis. Vastus lateralis is the
18.A. Green vegetables and liver. Green most appropriate location.
vegetables and liver are a great source of folic 40.D. Ask the father who is in the room the
acid. child’s name..In this case you are able to
19.D. Cl. difficile . Cl. difficile has not been determine the name of the child by the
linked to meningitis. father’s statement. You should not withhold
20.D. The life span of RBC is 120 days. RBC’s the medication from the child following
last for 120 days in the body. identification.
21.B. Upon admit. Discharge education begins 41.A and C.  The three classic signs of
upon admit. preeclampsia are hypertension, generalized
22.B. Initiative vs. guilt. Initiative vs. guilt- 3-6 edema, and proteinuria. Increased respirations
years old are not a sign of preeclampsia.
23.A. Trust vs. mistrust. Trust vs. Mistrust- 12- 42.C, D, E, F, and G. When caring for a client
18 months old receiving magnesium sulfate therapy, the
nurse would monitor maternal vital signs,
 especially respirations, every 30-60 minutes caffeine intake is an example of disruptive
and notify the physician if respirations are less sleep hygiene; caffeine is a stimulant that
than 12, because this would indicate inhibits sleep. Environmental noise causes
respiratory depression. Calcium gluconate is physical and/or emotional and therefore is
kept on hand in case of magnesium sulfate related to primary insomnia.
overdose, because calcium gluconate is the 49.B, D, and E. Barbiturates deprive people of
antidote for magnesium sulfate toxicity. Deep REM sleep. When the barbiturate is stopped
tendon reflexes are assessed hourly. Cardiac and REM sleep once again occurs, a rebound
and renal function is monitored closely. The phenomenon occurs. During this
urine output should be maintained at 30 ml phenomenon, the persons dream time
per hour because the medication is eliminated constitutes a larger percentage of the total
through the kidneys. sleep pattern, and the dreams are often
43.A, C, E. In a client who has had an ECG, the nightmares.
P wave represents the activation of the 50.B, C, and E. If ingestion is recent,
electrical impulse in the SA node, which is decontamination of the GI system is indicated.
then transmitted to the AV node. In addition, The administration of syrup of ipecac is
the P wave represents atrial muscle contraindicated because of aspiration risks
depolarization, not ventricular depolarization. related to sedation. Gastric lavage is generally
The normal duration of the P wave is 0.11 the best and most effective means of gastric
seconds or less in duration and 2.5 mm or decontamination. Activated charcoal and a
more in height. saline cathartic may be administered to
44.A, B, D, E. A major concern with intravenous remove any remaining drug. Hemodialysis is
administration of cytotoxic agents is vessel not useful in the treatment of benzodiazepine
irritation or extravasation. The Oncology overdose. Flumazenil can be used to acutely
Nursing Society and hospital guidelines reverse the sedative effects of
require frequent evaluation of blood return benzodiazepines, though this is normally done
when administering vesicant or non vesicant only in cases of extreme overdose or sedation.
chemotherapy due to the risk of extravasation.
These guidelines apply to peripheral and
central venous lines. In addition, central
venous lines may be long-term venous access
devices. Thus, difficulty drawing or aspirating
blood may indicate the line is against the
vessel wall or may indicate the line has
occlusion. Having the client cough or move
position may change the status of the line if it
is temporarily against a vessel wall. Occlusion
warrants more thorough evaluation via x-ray
study to verify placement if the status is
questionable and may require a declotting
regimen.
45.C. A small glass of milk relaxes the body and
promotes sleep.
46.A, C, and D. These symptoms are often
reported by clients with insomnia. Clients
report nonrestorative sleep. Arising once at
night to urinate (nocturia) is not in and of
itself insomnia.
47.B and C. Research demonstrate that the
occurrence of SIDS is reduced with these two
positions.
48.A, D, and F. Acute or primary insomnia is
caused by emotional or physical discomfort
not caused by the direct physiologic effects of
a substance or a medical condition. Excessive
 NCLEX RN Practice Exam 2 6. You are taking the history of a 14 year
1. A patient tells you that her urine is old girl who has a (BMI) of 18. The girl
starting to look discolored. If you believe reports inability to eat, induced vomiting
this change is due to medication, which of and severe constipation. Which of the
the following patient’s medication does following would you most likely suspect?
not cause urine discoloration? A. Multiple sclerosis
B. Anorexia nervosa
A. Sulfasalazine
C. Bulimia
B. Levodopa
D. Systemic sclerosis
C. Phenolphthalein
D. Aspirin 7. A 24 year old female is admitted to the
2. You are responsible for reviewing the ER for confusion. This patient has a
nursing unit’s refrigerator. If you found the history of a myeloma diagnosis,
following drug in the refrigerator it should constipation, intense abdominal pain, and
be removed from the refrigerator’s polyuria. Which of the following would you
contents? most likely suspect?

A. Corgard A. Diverticulosis
B. Humulin (injection) B. Hypercalcaemia
C. Urokinase C. Hypocalcaemia
D. Epogen (injection) D. Irritable bowel syndrome
3. A 34 year old female has recently been 8. Rho gam is most often used to
diagnosed with an autoimmune disease. treat____ mothers that have a ____
She has also recently discovered that she infant.
is pregnant. Which of the following is the A. RH positive, RH positive
only immunoglobulin that will provide B. RH positive, RH negative
protection to the fetus in the womb? C. RH negative, RH positive
D. RH negative, RH negative
A. IgA 9. A new mother has some questions
B. IgD
about (PKU). Which of the following
C. IgE
D. IgG statements made by a nurse is not correct
4. A second year nursing student has just regarding PKU?
suffered a needlestick while working with A. A Guthrie test can check the necessary lab
a patient that is positive for AIDS. Which values.
of the following is the most important B. The urine has a high concentration of
action that nursing student should take? phenylpyruvic acid
C. Mental deficits are often present with PKU.
A. Immediately see a social worker D. The effects of PKU are reversible.
B. Start prophylactic AZT treatment 10. A patient has taken an overdose of
C. Start prophylactic Pentamide treatment aspirin. Which of the following should a
D. Seek counseling
nurse most closely monitor for during
5. A thirty five year old male has been an
acute management of this patient?
insulin-dependent diabetic for five years
and now is unable to urinate. Which of the A. Onset of pulmonary edema
following would you most likely suspect? B. Metabolic alkalosis
C. Respiratory alkalosis
A. Atherosclerosis D. Parkinson’s disease type symptoms
B. Diabetic nephropathy 11. A fifty-year-old blind and deaf patient
C. Autonomic neuropathy has been admitted to your floor. As the
D. Somatic neuropathy
 charge nurse your primary responsibility D. Coumadin
for this patient is? 16. A patient asks a nurse, “My doctor
recommended I increase my intake of
A. Let others know about the patient’s deficits
folic acid. What type of foods contain folic
B. Communicate with your supervisor your
concerns about the patient’s deficits. acids?”
C. Continuously update the patient on the social A. Green vegetables and liver
environment. B. Yellow vegetables and red meat
D. Provide a secure environment for the patient. C. Carrots
12. A patient is getting discharged from a D. Milk
SNF facility. The patient has a history of 17. A nurse is putting together a
severe COPD and PVD. The patient is presentation on meningitis. Which of the
primarily concerned about their ability to following microorganisms has not been
breath easily. Which of the following linked to meningitis in humans?
would be the best instruction for this
A. S. pneumonia
patient?
B. H. influenza
A. Deep breathing techniques to increase O2 C. N. meningitis
levels. D. Cl. difficile
B. Cough regularly and deeply to clear airway 18. A nurse is administering blood to a
passages. patient who has a low hemoglobin count.
C. Cough following bronchodilator utilization The patient asks how long to RBC’s last
D. Decrease CO2 levels by increase oxygen take
in my body? The correct response is.
output during meals.
13. A nurse is caring for an infant that has A. The life span of RBC is 45 days.
recently been diagnosed with a congenital B. The life span of RBC is 60 days.
heart defect. Which of the following C. The life span of RBC is 90 days.
D. The life span of RBC is 120 days.
clinical signs would most likely be
present? 19. A 65 year old man has been admitted
to the hospital for spinal stenosis surgery.
A. Slow pulse rate When does the discharge training and
B. Weight gain planning begin for this patient?
C. Decreased systolic pressure
D. Irregular WBC lab values A. Following surgery
14. A mother has recently been informed B. Upon admit
that her child has Down’s syndrome. You C. Within 48 hours of discharge
D. Preoperative discussion
will be assigned to care for the child at
20. A child is 5 years old and has been
shift change. Which of the following
recently admitted into the hospital.
characteristics is not associated with
According to Erickson which of the
Down’s syndrome?
following stages is the child in?
A. Simian crease
B. Brachycephaly A. Trust vs. mistrust
C. Oily skin B. Initiative vs. guilt
D. Hypotonicity C. Autonomy vs. shame
D. Intimacy vs. isolation
15. A patient has recently experienced a
(MI) within the last 4 hours. Which of the 21. A toddler is 16 months old and has
following medications would most like be been recently admitted into the hospital.
administered? According to Erickson which of the
following stages is the toddler in?
A. Streptokinase
B. Atropine A. Trust vs. mistrust
C. Acetaminophen B. Initiative vs. guilt
C. Autonomy vs. shame 11.D. Provide a secure environment for the
D. Intimacy vs. isolation patient.
22. A young adult is 20 years old and has 12.C. Cough following bronchodilator
been recently admitted into the hospital. utilization
13.B. Weight gain
According to Erickson which of the
14.C. Oily skin
following stages is the adult in? 15.A. Streptokinase
A. Trust vs. mistrust 16.A. Green vegetables and liver
B. Initiative vs. guilt 17.D. Cl. difficile
C. Autonomy vs. shame 18.D. The life span of RBC is 120 days.
D. Intimacy vs. isolation 19.B. Upon admit
20.B. Initiative vs. guilt
23. A nurse is making rounds taking vital
21.A. Trust vs. mistrust
signs. Which of the following vital signs is 22.D. Intimacy vs. isolation
abnormal? 23.B. 13 year old female – 105 b.p.m., 22
resp/min., 105/60 mm Hg
A. 11 year old male – 90 b.p.m, 22 resp/min.,
24.A. Elavil
100/70 mm Hg
25.D. Multiple Sclerosis
B. 13 year old female – 105 b.p.m., 22 resp/min.,
105/60 mm Hg
C. 5 year old male- 102 b.p.m, 24 resp/min.,
90/65 mm Hg
D. 6 year old female- 100 b.p.m., 26 resp/min.,
90/70mm Hg
24. When you are taking a patient’s
history, she tells you she has been
depressed and is dealing with an anxiety
disorder. Which of the following
medications would the patient most likely
be taking?
A. Elavil
B. Calcitonin
C. Pergolide
D. Verapamil
25. Which of the following conditions
would a nurse not administer
erythromycin?
A. Campylobacterial infection
B. Legionnaire’s disease
C. Pneumonia
D. Multiple Sclerosis
Answers and Rationales
1. D. Aspirin
2. A. Corgard
3. D. IgG 
4. B. Start prophylactic AZT treatment  
5. C. Autonomic neuropathy
6. B. Anorexia nervosa
7. B. Hypercalcaemia
8. C. RH negative, RH positive
9. D. The effects of PKU are reversible.
10.D. Parkinson’s disease type symptoms
 NCLEX RN Practice Exam 3 A. Partial thromboplastin time.
B. Prothrombin time.
1. A patient is admitted to the hospital C. Platelet count.
with a diagnosis of primary D. Hemoglobin
hyperparathyroidism. A nurse checking 6. A nurse is assessing a clinic patient
the patient’s lab results would expect with a diagnosis of hepatitis A. Which of
which of the following changes in the following is the most likely route of
laboratory findings? transmission?
A. Elevated serum calcium. A. Sexual contact with an infected partner.
B. Low serum parathyroid hormone (PTH). B. Contaminated food.
C. Elevated serum vitamin D. C. Blood transfusion.
D. Low urine calcium. D. Illegal drug use.
2. A patient with Addison’s disease asks a 7. A leukemia patient has a relative who
nurse for nutrition and diet advice. Which wants to donate blood for transfusion.
of the following diet modifications is NOT Which of the following donor medical
recommended? conditions would prevent this?
A. A diet high in grains. A. A history of hepatitis C five years previously.
B. A diet with adequate caloric intake. B. Cholecystitis requiring cholecystectomy one
C. A high protein diet. year previously.
D. A restricted sodium diet. C. Asymptomatic diverticulosis.
3. A patient with a history of diabetes D.  Crohn’s disease in remission.
mellitus is in the second post-operative 8. A physician has diagnosed acute
day following cholecystectomy. She has gastritis in a clinic patient. Which of the
complained of nausea and isn’t able to following medications would be
eat solid foods. The nurse enters the contraindicated for this patient?
room to find the patient confused and
A. Naproxen sodium (Naprosyn).
shaky. Which of the following is the most
B. Calcium carbonate.
likely explanation for the patient’s C. Clarithromycin (Biaxin).
symptoms? D. Furosemide (Lasix).
A. Anesthesia reaction. 9. The nurse is conducting nutrition
B. Hyperglycemia. counseling for a patient with cholecystitis.
C. Hypoglycemia. Which of the following information is
D. Diabetic ketoacidosis. important to communicate?
4. A nurse assigned to the emergency
A. The patient must maintain a low calorie diet.
department evaluates a patient who
B. The patient must maintain a high protein/low
underwent fiberoptic colonoscopy 18 carbohydrate diet.
hours previously. The patient reports C. The patient should limit sweets and sugary
increasing abdominal pain, fever, and drinks.
chills. Which of the following conditions D. The patient should limit fatty foods.
poses the most immediate concern? 10. A patient admitted to the hospital with
myocardial infarction develops severe
A. Bowel perforation.
pulmonary edema. Which of the following
B. Viral gastroenteritis.
C. Colon cancer. symptoms should the nurse expect the
D. Diverticulitis. patient to exhibit?
5. A patient is admitted to the same day A. Slow, deep respirations.
surgery unit for liver biopsy. Which of the B. Stridor.
following laboratory tests assesses C. Bradycardia.
coagulation? D. Air hunger.
 11. A nurse caring for several patients on C. The patient will be admitted to the surgical
the cardiac unit is told that one is unit and resection will be scheduled.
D. The patient will be discharged home to
scheduled for implantation of an
follow-up with his cardiologist in 24 hours.
automatic internal cardioverter-
15. A patient with leukemia is receiving
defibrillator. Which of the following
chemotherapy that is known to depress
patients is most likely to have this
bone marrow. A CBC (complete blood
procedure?
count) reveals a platelet count of
A. A patient admitted for myocardial infarction 25,000/microliter. Which of the following
without cardiac muscle damage. actions related specifically to the platelet
B. A post-operative coronary bypass patient, count should be included on the nursing
recovering on schedule.
care plan?
C. A patient with a history of ventricular
tachycardia and syncopal episodes. A. Monitor for fever every 4 hours.
D. A patient with a history of atrial tachycardia B. Require visitors to wear respiratory masks and
and fatigue. protective clothing.
12. A patient is scheduled for a magnetic C. Consider transfusion of packed red blood
resonance imaging (MRI) scan for cells.
suspected lung cancer. Which of the D. Check for signs of bleeding, including
examination of urine and stool for blood.
following is a contraindication to the study
16. A nurse in the emergency department
for this patient?
is observing a 4-year-old child for signs of
A. The patient is allergic to shellfish. increased intracranial pressure after a fall
B. The patient has a pacemaker. from a bicycle, resulting in head trauma.
C. The patient suffers from claustrophobia.
Which of the following signs or symptoms
D. The patient takes anti-psychotic medication.
would be cause for concern?
13. A nurse calls a physician with the
concern that a patient has developed a A. Bulging anterior fontanel.
pulmonary embolism. Which of the B. Repeated vomiting.
following symptoms has the nurse most C. Signs of sleepiness at 10 PM.
D. Inability to read short words from a distance
likely observed?
of 18 inches.
A. The patient is somnolent with decreased 17. A nonimmunized child appears at the
response to the family. clinic with a visible rash. Which of the
B. The patient suddenly complains of chest pain following observations indicates the child
and shortness of breath.
may have rubeola (measles)?
C. The patient has developed a wet cough and
the nurse hears crackles on auscultation of the A. Small blue-white spots are visible on the oral
lungs. mucosa.
D. The patient has a fever, chills, and loss of B. The rash begins on the trunk and spreads
appetite. outward.
14. A patient comes to the emergency C. There is low-grade fever.
department with abdominal pain. Work-up D. The lesions have a “tear drop on a rose petal”
reveals the presence of a rapidly appearance.
enlarging abdominal aortic aneurysm. 18. A child is seen in the emergency
Which of the following actions should the department for scarlet fever. Which of the
nurse expect? following descriptions of scarlet fever is
NOT correct?
A. The patient will be admitted to the medicine
unit for observation and medication. A. Scarlet fever is caused by infection with group
B. The patient will be admitted to the day A Streptococcus bacteria.
surgery unit for sclerotherapy. B. “Strawberry tongue” is a characteristic sign.
C. Petechiae occur on the soft palate.
D. The pharynx is red and swollen. he is using the MDI correctly? Select all
19. A child weighing 30 kg arrives at the that apply.
clinic with diffuse itching as the result of A. The inhaler is held upright.
an allergic reaction to an insect bite. B. Head is tilted down while inhaling the
Diphenhydramine (Benadryl) 25 mg 3 medication
C. Client waits 5 minutes between puffs.
times a day is prescribed. The correct
D. Mouth is rinsed with water following
pediatric dose is 5 mg/kg/day. Which of administration
the following best describes the E. Client lies supine for 15 minutes following
prescribed drug dose? administration.
24. The nurse is teaching a client with
A. It is the correct dose.
B. The dose is too low. polycythemia vera about potential
C. The dose is too high. complications from this disease. Which
D.  The dose should be increased or decreased, manifestations would the nurse include in
depending on the symptoms. the client’s teaching plan? Select all that
20. The mother of a 2-month-old infant apply.
brings the child to the clinic for a well A. Hearing loss
baby check. She is concerned because B. Visual disturbance
she feels only one testis in the scrotal C. Headache
D. Orthopnea
sac. Which of the following statements
E. Gout
about the undescended testis is the most F. Weight loss
accurate? 25. Which of the following would be
A. Normally, the testes are descended by birth. priority assessment data to gather from a
B. The infant will likely require surgical client who has been diagnosed with
intervention. pneumonia? Select all that apply.
C. The infant probably has with only one testis. A. Auscultation of breath sounds
D. Normally, the testes descend by one year of B. Auscultation of bowel sounds
age. C. Presence of chest pain.
21. A patient is admitted to the same day D. Presence of peripheral edema
surgery unit for liver biopsy. Which of the E. Color of nail beds
following laboratory tests assesses 26. The nurse is teaching a client who
coagulation? Select all that apply.  has been diagnosed with TB how to avoid
A. Partial thromboplastin time. spreading the disease to family members.
B. Prothrombin time. Which statement(s) by the client
C. Platelet count. indicate(s) that he has understood the
D. Hemoglobin nurses instructions? Select all that apply.
E. Complete Blood Count A. “I will need to dispose of my old clothing
F. White Blood Cell Count when I return home.”
22. A patient is admitted to the hospital B.  “I should always cover my mouth and nose
with suspected polycythemia vera. Which when sneezing.”
of the following symptoms is consistent C.  “It is important that I isolate myself from
with the diagnosis? Select all that apply.  family when possible.”
A. Weight loss. D.  “I should use paper tissues to cough in and
B. Increased clotting time. dispose of them properly.”
C. Hypertension. E.  “I can use regular plate and utensils whenever
D. Headaches. I eat.”
23. The nurse is teaching the client how 27. The nurse is admitting a client with
to use a metered dose inhaler (MDI) to hypoglycemia. Identify the signs and
administer a Corticosteroid drug. Which of symptoms the nurse should expect. Select
the following client actions indicates that all that apply.
A.  Thirst
B. Palpitations high in protein and complex carbohydrates,
C. Diaphoresis including grains.
D. Slurred speech 3. C. Hypoglycemia. A post-operative diabetic
E. Hyperventilation patient who is unable to eat is likely to be
28. Which adaptations should the nurse suffering from hypoglycemia. Confusion and
caring for a client with diabetic shakiness are common symptoms. An
anesthesia reaction would not occur on the
ketoacidosis expect the client to
second post-operative day. Hyperglycemia
exhibit? Select all that apply: and ketoacidosis do not cause confusion and
A. Sweating shakiness.
B. Low PCO2 4. A. Bowel perforation. Bowel perforation is
C. Retinopathy the most serious complication of fiberoptic
D. Acetone breath colonoscopy. Important signs include
E. Elevated serum bicarbonate progressive abdominal pain, fever, chills, and
29. When planning care for a client with tachycardia, which indicate advancing
ulcerative colitis who is experiencing peritonitis. Viral gastroenteritis and colon
symptoms, which client care activities can cancer do not cause these symptoms.
the nurse appropriately delegate to a Diverticulitis may cause pain, fever, and
unlicensed assistant? Select all that apply. chills, but is far less serious than perforation
A. Assessing the client’s bowel sounds and peritonitis.
B. Providing skin care following bowel 5. A.Partial thromboplastin time, B.
movements Prothrombin time, and C. Platelet
C. Evaluating the client’s response to count. Prothrombin time, partial
antidiarrheal medications thromboplastin time, and platelet count are all
D. Maintaining intake and output records included in coagulation studies. The
E. Obtaining the client’s weight. hemoglobin level, though important
information prior to an invasive procedure
30. Which of the following nursing like liver biopsy, does not assess coagulation.
diagnoses would be appropriate for a 6. B. Contaminated food. Hepatitis A is the
client with heart failure? Select all that only type that is transmitted by the fecal-oral
apply. route through contaminated food. Hepatitis B,
A. Ineffective tissue perfusion related C, and D are transmitted through infected
to decreased peripheral blood flow secondary bodily fluids.
to decreased cardiac output. 7. A. A history of hepatitis C five years
B. Activity intolerance related to increased previously. Hepatitis C is a viral infection
cardiac output. transmitted through bodily fluids, such as
C. Decreased cardiac output related to structural blood, causing inflammation of the liver.
and functional changes. Patients with hepatitis C may not donate
D. Impaired gas exchange related to decreased blood for transfusion due to the high risk of
sympathetic nervous system activity. infection in the recipient. Cholecystitis (gall
Answers and Rationales bladder disease), diverticulosis, and history of
1. A. Elevated serum calcium. The parathyroid Crohn’s disease do not preclude blood
glands regulate the calcium level in the blood. donation.
In hyperparathyroidism, the serum calcium 8. A. Naproxen sodium (Naprosyn). Naproxen
level will be elevated. Parathyroid hormone sodium is a nonsteroidal anti-inflammatory
levels may be high or normal but not low. The drug that can cause inflammation of the upper
body will lower the level of vitamin D in an GI tract. For this reason, it is contraindicated
attempt to lower calcium. Urine calcium may in a patient with gastritis. Calcium carbonate
be elevated, with calcium spilling over from is used as an antacid for the relief of
elevated serum levels. This may cause renal indigestion and is not contraindicated.
stones. Clarithromycin is an antibacterial often used
2. D. A restricted sodium diet. A patient with for the treatment of Helicobacter pylori in
Addison’s disease requires normal dietary gastritis. Furosemide is a loop diuretic and is
sodium to prevent excess fluid loss. Adequate contraindicated in a patient with gastritis.
caloric intake is recommended with a diet
9. D. The patient should limit fatty possible. No other appropriate treatment
foods. Cholecystitis, inflammation of the options currently exist.
gallbladder, is most commonly caused by the 15.D. Check for signs of bleeding, including
presence of gallstones, which may block bile examination of urine and stool for blood. A
(necessary for fat absorption) from entering platelet count of 25,000/microliter is severely
the intestines. Patients should decrease dietary thrombocytopenic and should prompt the
fat by limiting foods like fatty meats, fried initiation of bleeding precautions, including
foods, and creamy desserts to avoid irritation monitoring urine and stool for evidence of
of the gallbladder. bleeding. Monitoring for fever and requiring
10.D. Air hunger. Patients with pulmonary protective clothing are indicated to prevent
edema experience air hunger, anxiety, and infection if white blood cells are decreased.
agitation. Respiration is fast and shallow and Transfusion of red cells is indicated for severe
heart rate increases. Stridor is noisy breathing anemia.
caused by laryngeal swelling or spasm and is 16.B. Repeated vomiting. Increased pressure
not associated with pulmonary edema. caused by bleeding or swelling within the
11.C. A patient with a history of ventricular skull can damage delicate brain tissue and
tachycardia and syncopal episodes. An may become life threatening. Repeated
automatic internal cardioverter-defibrillator vomiting can be an early sign of pressure as
delivers an electric shock to the heart to the vomit center within the medulla is
terminate episodes of ventricular tachycardia stimulated. The anterior fontanel is closed in a
and ventricular fibrillation. This is necessary 4-year-old child. Evidence of sleepiness at 10
in a patient with significant ventricular PM is normal for a four year old. The average
symptoms, such as tachycardia resulting in 4-year-old child cannot read yet, so this too is
syncope. A patient with myocardial infarction normal.
that resolved with no permanent cardiac 17.A. Small blue-white spots are visible on the
damage would not be a candidate. A patient oral mucosa. Koplik’s spots are small blue-
recovering well from coronary bypass would white spots visible on the oral mucosa and are
not need the device. Atrial tachycardia is less characteristic of measles infection. The body
serious and is treated conservatively with rash typically begins on the face and travels
medication and cardioversion as a last resort. downward. High fever is often present. “Tear
12.B. The patient has a pacemaker. The drop on a rose petal” refers to the lesions
implanted pacemaker will interfere with the found in varicella (chicken pox).
magnetic fields of the MRI scanner and may 18.C. Petechiae occur on the soft
be deactivated by them. Shellfish/iodine palate. Petechiae on the soft palate are
allergy is not a contraindication because the characteristic of rubella infection. Choices A,
contrast used in MRI scanning is not iodine- B, and D are characteristic of scarlet fever, a
based. Open MRI scanners and anti-anxiety result of group A Streptococcus infection.
medications are available for patients with 19.B. The dose is too low. This child weighs 30
claustrophobia. Psychiatric medication is not a kg, and the pediatric dose of diphenhydramine
contraindication to MRI scanning. is 5 mg/kg/day (5 X 30 = 150/day). Therefore,
13.B. The patient suddenly complains of chest the correct dose is 150 mg/day. Divided into 3
pain and shortness of breath. Typical doses per day, the child should receive 50 mg
symptoms of pulmonary embolism include 3 times a day rather than 25 mg 3 times a day.
chest pain, shortness of breath, and severe Dosage should not be titrated based on
anxiety. The physician should be notified symptoms without consulting a physician.
immediately. A patient with pulmonary 20.D. Normally, the testes descend by one year
embolism will not be sleepy or have a cough of age. Normally, the testes descend by one
with crackles on exam. A patient with fever, year of age. In young infants, it is common for
chills and loss of appetite may be developing the testes to retract into the inguinal canal
pneumonia. when the environment is cold or the
14.C. The patient will be admitted to the cremasteric reflex is stimulated. Exam should
surgical unit and resection will be be done in a warm room with warm hands. It
scheduled. A rapidly enlarging abdominal is most likely that both testes are present and
aortic aneurysm is at significant risk of will descend by a year. If not, a full
rupture and should be resected as soon as
 assessment will determine the appropriate symptom; as the brain receives insufficient
treatment. glucose, the activity of the CNS becomes
21.A, B, and C. Prothrombin time, partial depressed.
thromboplastin time, and platelet count are all 28.B, D. Metabolic acidosis initiates respiratory
included in coagulation studies. The compensation in the form of Kussmaul
hemoglobin level, though important respirations to counteract the effects of ketone
information prior to an invasive procedure buildup, resulting in a lowered PCO2. A fruity
like liver biopsy, does not assess coagulation. odor to the breath (acetone breath) occurs
22.B, C, and D. Polycythemia vera is a condition when the ketone level is elevated in
in which the bone marrow produces too many ketoacidosis.
red blood cells. This causes an increase in 29.B, D, and E. The nurse can delegate the
hematocrit and viscosity of the blood. Patients following basic care activities to the
can experience headaches, dizziness, and unlicensed assistant: providing skin care
visual disturbances. Cardiovascular effects following bowel movements, maintaining
include increased blood pressure and delayed intake and output records, and obtaining the
clotting time. Weight loss is not a client’s weight. Assessing the client’s bowel
manifestation of polycythemia vera. sounds and evaluating the client’s response to
23.A and D. medication are registered nurse activities that
24.B, C, D and E. Polycythemia vera, a cannot be delegated.
condition in which too many RBCs are 30.A and C. HF is a result of structural and
produced in the blood serum, can lead to an functional abnormalities of the heart tissue
increase in the hematocrit and hypervolemia, muscle. The heart muscle becomes weak and
hyperviscosity, and hypertension. does not adequately pump the blood out of the
Subsequently, the client can experience chambers. As a result, blood pools in the left
dizziness, tinnitus, visual disturbances, ventricle and backs up into the left atrium, and
headaches, or a feeling of fullness in the head. eventually into the lungs. Therefore, greater
The client may also experience cardiovascular amounts of blood remain in the ventricle after
symptoms such as heart failure (shortness of contraction thereby decreasing cardiac output.
breath and orthopnea) and increased clotting In addition, this pooling leads to thrombus
time or symptoms of an increased uric acid formation and ineffective tissue perfusion
level such as painful swollen joints (usually because of the decrease in blood flow to the
the big toe). Hearing loss and weight loss are other organs and tissues of the body.
not manifestations associated with Typically, these clients have an ejection
polycythemia vera. fraction of less than 50% and poorly tolerate
25.A, C, E. A respiratory assessment, which activity. Activity intolerance is related to a
includes auscultation of breath sounds and decrease, not increase, in cardiac output. Gas
assessing the color of the nail beds, is a exchange is impaired. However, the decrease
priority for clients with pneumonia. Assessing in cardiac output triggers compensatory
for the presence of chest pain is also an mechanisms, such as an increase in
important respiratory assessment as chest pain sympathetic nervous system activity.
can interfere with the client’s ability to
breathe deeply. Auscultating bowel sounds
and assessing for peripheral edema may be
appropriate assessments, but these are not
priority assessments for the patient with
pneumonia.
26.B, D, E.
27.B, C, D. Palpitations, an adrenergic symptom,
occur as the glucose levels fall; the
sympathetic nervous system is activated and
epinephrine and norepinephrine are secreted
causing this response. Diaphoresis is a
sympathetic nervous system response that
occurs as epinephrine and norepinephrine are
released. Slurred speech is a neuroglycopenic
 NCLEX RN Practice Exam 4 patient complains of burning and tingling
1. A child is admitted to the hospital with a of the hands and feet and cannot tolerate
diagnosis of Wilm’s tumor, stage II. Which touch of any kind. Which of the following
of the following statements most is the most likely explanation for these
accurately describes this stage? symptoms?

A. The tumor is less than 3 cm. in size and A. Inadequate tissue perfusion leading to nerve
requires no chemotherapy. damage.
B. The tumor did not extend beyond the kidney B. Fluid overload leading to compression of
and was completely resected. nerve tissue.
C. The tumor extended beyond the kidney but C. Sensation distortion due to psychiatric
was completely resected. disturbance.
D. The tumor has spread into the abdominal D. Inflammation of the skin on the hands and
cavity and cannot be resected. feet.
2. A teen patient is admitted to the 6. A patient in the cardiac unit is
hospital by his physician who suspects a concerned about the risk factors
diagnosis of acute glomerulonephritis. associated with atherosclerosis. Which of
Which of the following findings is the following are hereditary risk factors for
consistent with this diagnosis? Note: developing atherosclerosis?
More than one answer may be correct. A. Family history of heart disease.
B. Overweight.
A. Urine specific gravity of 1.040.
C. Smoking.
B. Urine output of 350 ml in 24 hours.
D. Age.
C. Brown (“tea-colored”) urine.
D. Generalized edema. 7. Claudication is a well-known effect of
3. Which of the following conditions most peripheral vascular disease. Which of the
commonly causes acute following facts about claudication is
glomerulonephritis? correct?

A. A congenital condition leading to renal A. It results when oxygen demand is greater than
dysfunction. oxygen supply.
B. Prior infection with group A Streptococcus B. It is characterized by pain that often occurs
within the past 10-14 days. duing rest.
C. Viral infection of the glomeruli. C. It is a result of tissue hypoxia.
D. Nephrotic syndrome. D. It is characterized by cramping and weakness.
4. An infant with hydrocele is seen in the 8. A nurse is providing discharge
clinic for a follow-up visit at 1 month of information to a patient with peripheral
age. The scrotum is smaller than it was at vascular disease. Which of the following
birth, but fluid is still visible on information should be included in
illumination. Which of the following instructions?
actions is the physician likely to A. Walk barefoot whenever possible.
recommend? B. Use a heating pad to keep feet warm.
C. Avoid crossing the legs.
A. Massaging the groin area twice a day until the D. Use antibacterial ointment to treat skin lesions
fluid is gone. at risk of infection.
B. Referral to a surgeon for repair.
9. A patient who has been diagnosed with
C. No treatment is necessary; the fluid is
reabsorbing normally. vasospastic disorder (Raynaud’s disease)
D. Keeping the infant in a flat, supine position complains of cold and stiffness in the
until the fluid is gone. fingers. Which of the following
5. A nurse is caring for a patient with descriptions is most likely to fit the
peripheral vascular disease (PVD). The patient?
A. An adolescent male. C. The student experiences pain in the inferior
B. An elderly woman. aspect of the knee.
C. A young woman. D. The student is trying to avoid participation in
D. An elderly man. physical education.
10. A 23 year old patient in the 27th week 14. The clinic nurse asks a 13-year-old
of pregnancy has been hospitalized on female to bend forward at the waist with
complete bed rest for 6 days. She arms hanging freely. Which of the
experiences sudden shortness of breath, following assessments is the nurse most
accompanied by chest pain. Which of the likely conducting?
following conditions is the most likely
A. Spinal flexibility.
cause of her symptoms? B. Leg length disparity.
A. Myocardial infarction due to a history of C. Hypostatic blood pressure.
atherosclerosis. D. Scoliosis.
B. Pulmonary embolism due to deep vein 15. A clinic nurse interviews a parent who
thrombosis (DVT). is suspected of abusing her child. Which
C. Anxiety attack due to worries about her of the following characteristics is the
baby’s health. nurse LEAST likely to find in an abusing
D. Congestive heart failure due to fluid overload.
parent?
11. Thrombolytic therapy is frequently
used in the treatment of suspected stroke. A. Low self-esteem.
Which of the following is a significant B. Unemployment.
C. Self-blame for the injury to the child.
complication associated with thrombolytic
D. Single status.
therapy?
16. A nurse is assigned to the pediatric
A. Air embolus. rheumatology clinic and is assessing a
B. Cerebral hemorrhage. child who has just been diagnosed with
C. Expansion of the clot. juvenile idiopathic arthritis. Which of the
D. Resolution of the clot.
following statements about the disease is
12. An infant is brought to the clinic by his
most accurate?
mother, who has noticed that he holds his
head in an unusual position and always A. The child has a poor chance of recovery
faces to one side. Which of the following without joint deformity.
B. Most children progress to adult rheumatoid
is the most likely explanation?
arthritis.
A. Torticollis, with shortening of the C. Nonsteroidal anti-inflammatory drugs are the
sternocleidomastoid muscle. first choice in treatment.
B. Craniosynostosis, with premature closure of D. Physical activity should be minimized.
the cranial sutures. 17. A child is admitted to the hospital
C. Plagiocephaly, with flattening of one side of several days after stepping on a sharp
the head. object that punctured her athletic shoe
D. Hydrocephalus, with increased head size.
and entered the flesh of her foot. The
13. An adolescent brings a physician’s
physician is concerned about
note to school stating that he is not to
osteomyelitis and has ordered parenteral
participate in sports due to a diagnosis of
antibiotics. Which of the following actions
Osgood-Schlatter disease. Which of the
is done immediately before the antibiotic
following statements about the disease is
is started?
correct?
A. The admission orders are written.
A. The condition was caused by the student’s B. A blood culture is drawn.
competitive swimming schedule. C. A complete blood count with differential is
B. The student will most likely require surgical drawn.
intervention.
D. The parents arrive. the plan of care for chemotherapy
18. A two-year-old child has sustained an administration?Select all that apply.
injury to the leg and refuses to walk. The A. Verify patency of the line by the presence of a
nurse in the emergency department blood return at regular intervals.
documents swelling of the lower affected B. Inspect the insertion site for swelling,
erythema, or drainage.
leg. Which of the following does the nurse
C. Administer a cytotoxic agent to keep the
suspect is the cause of the child’s regimen on schedule even if blood return is
symptoms? not present.
D. If unable to aspirate blood, reposition the
A. Possible fracture of the tibia.
client and encourage the client to cough.
B. Bruising of the gastrocnemius muscle.
E. Contact the health care provider about
C. Possible fracture of the radius.
verifying placement if the status is
D. No anatomic injury, the child wants his
questionable.
mother to carry him.
22. A 20-year old college student has
19. A toddler has recently been
been brought to the psychiatric hospital
diagnosed with cerebral palsy. Which of
by her parents. Her admitting diagnosis is
the following information should the nurse
borderline personality disorder. When
provide to the parents? Note: More than
talking with the parents, which information
one answer may be correct.
would the nurse expect to be included in
A. Regular developmental screening is important the client’s history? Select all that apply.
to avoid secondary developmental delays. A. Impulsiveness
B. Cerebral palsy is caused by injury to the upper B. Lability of mood
motor neurons and results in motor C. Ritualistic behavior
dysfunction, as well as possible ocular and D. psychomotor retardation
speech difficulties. E. Self-destructive behavior
C. Developmental milestones may be slightly 23. When assessing a client diagnosed
delayed but usually will require no additional with impulse control disorder, the nurse
intervention.
observes violent, aggressive, and
D. Parent support groups are helpful for sharing
strategies and managing health care issues. assaultive behavior. Which of the
20. A child has recently been diagnosed following assessment data is the nurse
with Duchenne’s muscular dystrophy. The also likely to find? Select all that apply.
A. The client functions well in other areas of his
parents are receiving genetic counseling
life.
prior to planning another pregnancy. B. The degree of aggressiveness is out of
Which of the following statements proportion to the stressor.
includes the most accurate information? C. The violent behavior is most often justified by
the stressor.
A. Duchenne’s is an X-linked recessive disorder, D. The client has a history of parental alcoholism
so daughters have a 50% chance of being and chaotic, abusive family life.
carriers and sons a 50% chance of developing E. The client has no remorse about the inability
the disease. to control his anger.
B. Duchenne’s is an X-linked recessive disorder,
24. Which of the following nursing
so both daughters and sons have a 50%
chance of developing the disease. interventions are written correctly? (Select
C. Each child has a 1 in 4 (25%) chance of all that apply.)
developing the disorder. A. Apply continuous passive motion machine
D. Sons only have a 1 in 4 (25%) chance of during day.
developing the disorder. B. Perform neurovascular checks.
21. When caring for a client with a central C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
venous line, which of the following
25. The nurse is monitoring a client
nursing actions should be implemented in
receiving peritoneal dialysis and nurse
 notes that a client’s outflow is less than correctly understood the teaching? Select
the inflow. Select actions that the nurse all that apply.
should take. (Select all that apply.) A. “If I limit my fluid intake I will not have to
A. Place the client in good body alignment empty my ostomy pouch as often.”
B. Check the level of the drainage bag B.  “I can place an aspirin tablet in my pouch to
C. Contact the physician decrease odor.”
D. Check the peritoneal dialysis system for kinks C.  “I can usually keep my ostomy pouch on for
E. Reposition the client to his or her side. 3 to 7 days before changing it.”
26. The nurse is caring for a hospitalized D.  “I must use a skin barrier to protect my skin
from urine.”
client who has chronic renal failure.
E.  “I should empty my ostomy pouch of urine
Which of the following nursing diagnoses when it is full.”
are most appropriate for this client? Select 30. A nurse is assisting in performing an
all that apply. assessment on a client who suspects that
A. Excess Fluid Volume
she is pregnant and is checking the client
B. Imbalanced Nutrition; Less than Body
Requirements for probable signs of
C. Activity Intolerance pregnancy. Select all probable signs of
D. Impaired Gas Exchange pregnancy.
E. Pain. A. Uterine enlargement
27. The nurse is assessing a child B. Fetal heart rate detected by nonelectric device
diagnosed with a brain tumor. Which of C. Outline of the fetus via radiography or
ultrasound
the following signs and symptoms would
D. Chadwick’s sign
the nurse expect the child to E. Braxton Hicks contractions
demonstrate?Select all that apply. F. Ballottement
A. Head tilt Answers and Rationales
B. Vomiting 1. C. The tumor extended beyond the kidney
C. Polydipsia but was completely resected. The staging of
D. Lethargy Wilm’s tumor is confirmed at surgery as
E. Increased appetite follows: Stage I, the tumor is limited to the
F. Increased pulse kidney and completely resected; stage II, the
28. The nurse is caring for a client with a tumor extends beyond the kidney but is
T5 complete spinal cord injury. Upon completely resected; stage III, residual
assessment, the nurse notes flushed skin, nonhematogenous tumor is confined to the
diaphoresis above the T5, and a blood abdomen; stage IV, hematogenous metastasis
pressure of 162/96. The client reports a has occurred with spread beyond the
abdomen; and stage V, bilateral renal
severe, pounding headache. Which of the
involvement is present at diagnosis.
following nursing interventions would be 2. A. Urine specific gravity of 1.040, B. Urine
appropriate for this client? Select all that output of 350 ml in 24 hours. , and C.
apply. Brown (“tea-colored”) urine. Acute
A. Elevate the HOB to 90 degrees glomerulonephritis is characterized by high
B. Loosen constrictive clothing urine specific gravity related to oliguria as
C. Use a fan to reduce diaphoresis well as dark “tea colored” urine caused by
D. Assess for bladder distention and bowel large amounts of red blood cells. There is
impaction periorbital edema, but generalized edema is
E. Administer antihypertensive medication seen in nephrotic syndrome, not acute
F. Place the client in a supine position with legs glomerulonephritis.
elevated 3. B. Prior infection with group A
29. The nurse is evaluating the discharge Streptococcus within the past 10-14
teaching for a client who has an ileal days. Acute glomerulonephritis is most
commonly caused by the immune response to
conduit. Which of the following
a prior upper respiratory infection with group
statements indicates that the client has A Streptococcus. Glomerular inflammation
 occurs about 10-14 days after the infection, 9. C. A young woman. Raynaud’s disease is
resulting in scant, dark urine and retention of most common in young women and is
body fluid. Periorbital edema and frequently associated with rheumatologic
hypertension are common signs at diagnosis. disorders, such as lupus and rheumatoid
4. C. No treatment is necessary; the fluid is arthritis.
reabsorbing normally. A hydrocele is a 10.B. Pulmonary embolism due to deep vein
collection of fluid in the scrotum that results thrombosis (DVT). In a hospitalized patient
from a patent tunica vaginalis. Illumination of on prolonged bed rest, he most likely cause of
the scrotum with a pocket light demonstrates sudden onset shortness of breath and chest
the clear fluid. In most cases the fluid pain is pulmonary embolism. Pregnancy and
reabsorbs within the first few months of life prolonged inactivity both increase the risk of
and no treatment is necessary. Massaging the clot formation in the deep veins of the legs.
area or placing the infant in a supine position These clots can then break loose and travel to
would have no effect. Surgery is not the lungs. Myocardial infarction and
indicated. atherosclerosis are unlikely in a 27-year-old
5. A. Inadequate tissue perfusion leading to woman, as is congestive heart failure due to
nerve damage. Patients with peripheral fluid overload. There is no reason to suspect
vascular disease often sustain nerve damage an anxiety disorder in this patient. Though
as a result of inadequate tissue perfusion. anxiety is a possible cause of her symptoms,
Fluid overload is not characteristic of PVD. the seriousness of pulmonary embolism
There is nothing to indicate psychiatric demands that it be considered first.
disturbance in the patient. Skin changes in 11.B. Cerebral hemorrhage. Cerebral
PVD are secondary to decreased tissue hemorrhage is a significant risk when treating
perfusion rather than primary inflammation. a stroke victim with thrombolytic therapy
6. A. Family history of heart disease. Family intended to dissolve a suspected clot. Success
history of heart disease is an inherited risk of the treatment demands that it be instituted
factor that is not subject to life style change. as soon as possible, often before the cause of
Having a first degree relative with heart stroke has been determined. Air embolus is
disease has been shown to significantly not a concern. Thrombolytic therapy does not
increase risk. Overweight and smoking are lead to expansion of the clot, but to resolution,
risk factors that are subject to life style change which is the intended effect.
and can reduce risk significantly. Advancing 12.A. Torticollis, with shortening of the
age increases risk of atherosclerosis but is not sternocleidomastoid muscle. In torticollis,
a hereditary factor. the sternocleidomastoid muscle is contracted,
7. A. It results when oxygen demand is limiting range of motion of the neck and
greater than oxygen supply, C. It is a result causing the chin to point to the opposing side.
of tissue hypoxia, and D. It is characterized In craniosynostosis one of the cranial sutures,
by cramping and weakness. Claudication often the sagittal, closes prematurely, causing
describes the pain experienced by a patient the head to grow in an abnormal shape.
with peripheral vascular disease when oxygen Plagiocephaly refers to the flattening of one
demand in the leg muscles exceeds the side of the head, caused by the infant being
oxygen supply. This most often occurs during placed supine in the same position over time.
activity when demand increases in muscle Hydrocephalus is caused by a build-up of
tissue. The tissue becomes hypoxic, causing cerebrospinal fluid in the brain resulting in
cramping, weakness, and discomfort. large head size.
8. C. Avoid crossing the legs. Patients with 13.C. The student experiences pain in the
peripheral vascular disease should avoid inferior aspect of the knee. Osgood-Schlatter
crossing the legs because this can impede disease occurs in adolescents in rapid growth
blood flow. Walking barefoot is not advised, phase when the infrapatellar ligament of the
as foot protection is important to avoid trauma quadriceps muscle pulls on the tibial tubercle,
that may lead to serious infection. Heating causing pain and swelling in the inferior
pads can cause injury, which can also increase aspect of the knee. Osgood-Schlatter disease
the risk of infection. Skin lesions at risk for is commonly caused by activities that require
infection should be examined and treated by a repeated use of the quadriceps, including track
physician. and soccer. Swimming is not a likely cause.
 The condition is usually self-limited, as well as possible ocular and speech
responding to ice, rest, and analgesics. difficulties, D. Parent support groups are
Continued participation will worsen the helpful for sharing strategies and managing
condition and the symptoms. health care issues. Delayed developmental
14.D. Scoliosis. A check for scoliosis, a lateral milestones are characteristic of cerebral palsy,
deviation of the spine, is an important part of so regular screening and intervention is
the routine adolescent exam. It is assessed by essential. Because of injury to upper motor
having the teen bend at the waist with arms neurons, children may have ocular and speech
dangling, while observing for lateral curvature difficulties. Parent support groups help
and uneven rib level. Scoliosis is more families to share and cope. Physical therapy
common in female adolescents. Choices A, B, and other interventions can minimize the
and C are not part of the routine adolescent extent of the delay in developmental
exam. milestones.
15.C. Self-blame for the injury to the 20.A. Duchenne’s is an X-linked recessive
child. The profile of a parent at risk of disorder, so daughters have a 50% chance
abusive behavior includes a tendency to blame of being carriers and sons a 50% chance of
the child or others for the injury sustained. developing the disease. The recessive
These parents also have a high incidence of Duchenne’s gene is located on one of the two
low self-esteem, unemployment, unstable X chromosomes of a female carrier. If her son
financial situation, and single status. receives the X bearing the gene he will be
16.C. Nonsteroidal anti-inflammatory drugs affected. Thus, there is a 50% chance of a son
are the first choice in being affected. Daughters are not affected, but
treatment. Nonsteroidal anti-inflammatory 50% are carriers because they inherit one
drugs are important first line treatment for copy of the defective gene from the mother.
juvenile idiopathic arthritis (formerly known The other X chromosome comes from the
as juvenile rheumatoid arthritis). NSAIDs father, who cannot be a carrier.
require 3-4 weeks for the therapeutic anti- 21.A, B, D, E. A major concern with intravenous
inflammatory effects to be realized. Half of administration of cytotoxic agents is vessel
children with the disorder recover without irritation or extravasation. The Oncology
joint deformity, and about a third will Nursing Society and hospital guidelines
continue with symptoms into adulthood. require frequent evaluation of blood return
Physical activity is an integral part of therapy. when administering vesicant or non vesicant
17.B. A blood culture is drawn. Antibiotics chemotherapy due to the risk of extravasation.
must be started after the blood culture is These guidelines apply to peripheral and
drawn, as they may interfere with the central venous lines. In addition, central
identification of the causative organism. The venous lines may be long-term venous access
blood count will reveal the presence of devices. Thus, difficulty drawing or aspirating
infection but does not help identify an blood may indicate the line is against the
organism or guide antibiotic treatment. vessel wall or may indicate the line has
Parental presence is important for the occlusion. Having the client cough or move
adjustment of the child but not for the position may change the status of the line if it
administration of medication. is temporarily against a vessel wall. Occlusion
18.A. Possible fracture of the tibia. The child’s warrants more thorough evaluation via x-ray
refusal to walk, combined with swelling of the study to verify placement if the status is
limb is suspicious for fracture. Toddlers will questionable and may require a declotting
often continue to walk on a muscle that is regimen.
bruised or strained. The radius is found in the 22.A, B, E.
lower arm and is not relevant to this question. 23.A, B, D. A client with an impulse control
Toddlers rarely feign injury to be carried, and disorder who displays violent, aggressive, and
swelling indicates a physical injury. assaultive behavior generally functions well in
19.A.Regular developmental screening is other areas of his life. The degree of
important to avoid secondary aggressiveness is typically out of proportion
developmental delays , B. Cerebral palsy is with the stressor. Such a client commonly has
caused by injury to the upper motor a history of parental alcoholism and a chaotic
neurons and results in motor dysfunction,
 family life, and often verbalizes sincere stoma and ostomy appliances. The client
remorse and guilt for the aggressive behavior. should be taught to increase fluid intake to
24.C. It is specific in what to do and when. about 3,000 ml per day and should not limit
25.A, B, D, E. If outflow drainage is inadequate, intake. Adequate fluid intake helps to flush
the nurse attempts to stimulate outflow by mucus from the ileal conduit. The ostomy
changing the client’s position. Turning the appliance should be changed approximately
client to the other side or making sure that the every 3 to 7 days and whenever a leak
client is in good body alignment may assist develops. A skin barrier is essential to
with outflow drainage. The drainage bag protecting the skin from the irritation of the
needs to be lower than the client’s abdomen to urine. An aspirin should not be used as a
enhance gravity drainage. The connecting method of odor control because it can be an
tubing and the peritoneal dialysis system is irritant to the stoma and lead to ulceration.
also checked for kinks or twisting and the The ostomy pouch should be emptied when it
clamps on the system are checked to ensure is one-third to one-half full to prevent the
that they are open. There is no reason to weight from pulling the appliance away from
contact the physician. the skin.
26.A, B, C. Appropriate nursing diagnoses for 30.A, D, E, and F. The probable signs of
clients with chronic renal failure include pregnancy include:
excess fluid volume related to fluid and  Uterine Enlargement
sodium retention; imbalanced nutrition, less  Hegar’s sign or softening and thinning of the
than body requirements related to anorexia, uterine segment that occurs at week 6.
nausea, and vomiting; and activity intolerance  Goodell’s sign or softening of the cervix that
related to fatigue. The nursing diagnoses of occurs at the beginning of the 2nd month
impaired gas exchange and pain are not  Chadwick’s sign or bluish coloration of the
commonly related to chronic renal failure. mucous membranes of the cervix, vagina and
27.A, B, D. Head tilt, vomiting, and lethargy are vulva. Occurs at week 6.
classic signs assessed in a child with a brain  Ballottement or rebounding of the fetus
tumor. Clinical manifestations are the result of against the examiner’s fingers of palpation
location and size of the tumor.  Braxton-Hicks contractions
28.A, B, D, E. The client has signs and  Positive pregnancy test measuring for hCG.
symptoms of autonomic dysreflexia. The Positive signs of pregnancy include:
potentially life-threatening condition is caused
by an uninhibited response from the  Fetal Heart Rate detected by electronic device
sympathetic nervous system resulting from a (doppler) at 10-12 weeks
lack of control over the autonomic nervous  Fetal Heart rate detected by nonelectronic
system. The nurse should immediately elevate device (fetoscope) at 20 weeks AOG
the HOB to 90 degrees and place extremities  Active fetal movement palpable by the
dependently to decrease venous return to the examiners
heart and increase venous return from the  Outline of the fetus via radiography or
brain. Because tactile stimuli can trigger ultrasound
autonomic dysreflexia, any constrictive
clothing should be loosened. The nurse should
also assess for distended bladder and bowel
impaction, which may trigger autonomic
dysreflexia, and correct any problems.
Elevated blood pressure is the most life-
threatening complication of autonomic
dysreflexia because it can cause stroke, MI, or
seizures. If removing the triggering event
doesn’t reduce the client’s blood pressure, IV
antihypertensives should be administered. A
fan shouldn’t be used because cold drafts may
trigger autonomic dysreflexia.
29.C, D. The client with an ileal conduit must
learn self-care activities related to care of the
 NCLEX RN Practice Exam 5 B. Bradycardia.
C. Bounding pulse.
1. A nurse is administering IV furosemide
D. Confusion.
to a patient admitted with congestive
heart failure. After the infusion, which of 6. A patient with a history of congestive
the following symptoms is NOT heart failure arrives at the clinic
expected? complaining of dyspnea. Which of the
A. Increased urinary output. following actions is the first the nurse
B. Decreased edema. should perform?
C. Decreased pain.
D. Decreased blood pressure. A. Ask the patient to lie down on the exam table.
2. There are a number of risk factors B. Draw blood for chemistry panel and arterial
associated with coronary artery disease. blood gas (ABG).
Which of the following is a modifiable risk C. Send the patient for a chest x-ray.
factor? D. Check blood pressure.
A. Obesity. 7. A clinic patient has recently been
B. Heredity. prescribed nitroglycerin for treatment of
C. Gender.
angina. He calls the nurse complaining of
D. Age.
frequent headaches. Which of the
3. Tissue plasminogen activator (t-PA) is
following responses to the patient is
considered for treatment of a patient who
correct?
arrives in the emergency department
following onset of symptoms of A. “Stop taking the nitroglycerin and see if the
myocardial infarction. Which of the headaches improve.”
following is a contraindication for B. “Go to the emergency department to be
treatment with t-PA? checked because nitroglycerin can cause
bleeding in the brain.”
A. Worsening chest pain that began earlier in the C. “Headaches are a frequent side effect of
evening. nitroglycerine because it causes vasodilation.”
B. History of cerebral hemorrhage. D. “The headaches are unlikely to be related to
C. History of prior myocardial infarction. the nitroglycerin, so you should see your
D.  Hypertension. doctor for further investigation.”
4. Following myocardial infarction, a 8. A patient received surgery and
hospitalized patient is encouraged to chemotherapy for colon cancer,
practice frequent leg exercises and completing therapy 3 months previously,
ambulate in the hallway as directed by his and she is now in remission. At a follow-
physician. Which of the following choices up appointment, she complains of fatigue
reflects the purpose of exercise for this following activity and difficulty with
patient? concentration at her weekly bridge
games. Which of the following
A. Increases fitness and prevents future heart
explanations could account for her
attacks.
B. Prevents bedsores. symptoms?
C. Prevents DVT (deep vein thrombosis). A. The symptoms may be the result of anemia
D. Prevent constipations. caused by chemotherapy.
5. A patient arrives in the emergency B. The patient may be immunosuppressed.
department with symptoms of myocardial C. The patient may be depressed.
infarction, progressing to cardiogenic D. The patient may be dehydrated.
shock. Which of the following symptoms 9. A clinic patient has a hemoglobin
should the nurse expect the patient to concentration of 10.8 g/dL and reports
exhibit with cardiogenic shock? sticking to a strict vegetarian diet. Which
of the follow nutritional advice is
A. Hypertension.
appropriate?
A. The diet is providing adequate sources of iron 14. A nurse in the emergency department
and requires no changes. assesses a patient who has been taking
B. The patient should add meat to her diet; a
long-term corticosteroids to treat renal
vegetarian diet is not advised.
C. The patient should use iron cookware to disease. Which of the following is a
prepare foods, such as dark green, leafy typical side effect of corticosteroid
vegetables and legumes, which are high in treatment? Note: More than one answer
iron. may be correct.
D. A cup of coffee or tea should be added to
every meal. A. Hypertension.
10. A hospitalized patient is receiving B. Cushingoid features.
C. Hyponatremia.
packed red blood cells (PRBCs) for
D. Low serum albumin.
treatment of severe anemia. Which of the
15. A nurse is caring for patients in the
following is the most accurate statement?
oncology unit. Which of the following is
A. Transfusion reaction is most likely the most important nursing action when
immediately after the infusion is completed. caring for a neutropenic patient?
B. PRBCs are best infused slowly through a 20g.
IV catheter. A. Change the disposable mask immediately
C. PRBCs should be flushed with a 5% dextrose after use.
solution. B. Change gloves immediately after use.
D. A nurse should remain in the room during the C. Minimize patient contact.
first 15 minutes of infusion. D. Minimize conversation with the patient.
11. A patient who has received 16. A patient is undergoing the induction
chemotherapy for cancer treatment is stage of treatment for leukemia. The
given an injection of Epoetin. Which of the nurse teaches family members about
following should reflect the findings in a infectious precautions. Which of the
complete blood count (CBC) drawn following statements by family members
several days later? indicates that the family needs more
education?
A. An increase in neutrophil count.
B. An increase in hematocrit. A. We will bring in books and magazines for
C. An increase in platelet count. entertainment.
D. An increase in serum iron. B. We will bring in personal care items for
12. A patient is admitted to the hospital comfort.
with suspected polycythemia vera. Which C. We will bring in fresh flowers to brighten the
room.
of the following symptoms is consistent
D. We will bring in family pictures and get well
with the diagnosis? cards.
A. Weight loss. 17. A nurse is caring for a patient with
B. Increased clotting time. acute lymphoblastic leukemia (ALL).
C. Hypertension. Which of the following is the most likely
D. Headaches. age range of the patient?
13. A nurse is caring for a patient with a
platelet count of 20,000/microliter. Which A. 3-10 years.
B. 25-35 years.
of the following is an important
C. 45-55 years.
intervention? D. over 60 years.
A. Observe for evidence of spontaneous 18. A patient is admitted to the oncology
bleeding. unit for diagnosis of suspected Hodgkin’s
B. Limit visitors to family only. disease. Which of the following symptoms
C. Give aspirin in case of headaches. is typical of Hodgkin’s disease?
D. Impose immune precautions.
A. Painful cervical lymph nodes. seizures were occurring. The mother
B. Night sweats and fatigue. states that her son is taking medication
C. Nausea and vomiting.
for the seizure disorder. The nurse plans
D. Weight gain.
care, knowing that which of the following
19. The Hodgkin’s disease patient
medications are used for long-term
described in the question above
control of tonic-clonic seizures? Select all
undergoes a lymph node biopsy for
that apply.
definitive diagnosis. If the diagnosis of
A. Diazepam (Valium)
Hodgkin’s disease were correct, which of B. Alprazolam (Xanax)
the following cells would the pathologist C. Gabapentin (Neurontin)
expect to find? D. Ethosuximide (Zarontin)
E. Carbamazepine (Tegretol)
A. Reed-Sternberg cells. F. Methylphenidate (Ritalin)
B. Lymphoblastic cells.
23. A child has been diagnosed with
C. Gaucher’s cells.
D. Rieder’s cells meningococcal meningitis. Which of the
20. A patient is about to undergo bone following isolation techniques is
marrow aspiration and biopsy and appropriate?
expresses fear and anxiety about the A. Enteric precautions
procedure. Which of the following is the B. Neutropenic precautions
most effective nursing response? C. No precautions are required as long as
antibiotics have been started.
A. Warn the patient to stay very still because the D. Isolation precautions for at least 24 hours after
smallest movement will increase her pain. the initiation of antibiotics
B. Encourage the family to stay in the room for 24. A client enters the emergency
the procedure.
department confused, twitching, and
C. Stay with the patient and focus on slow, deep
breathing for relaxation. having seizures. His family states he
D. Delay the procedure to allow the patient to recently was placed on corticosteroids for
deal with her feelings. arthritis and was feeling better and
21. A 6-year-old child with leukemia is exercising daily. On data collection, he
hospitalized and is receiving combination has flushed skin, dry mucous
chemotherapy. Laboratory results indicate membranes, an elevated temperature,
that the child is neutropenic, and the and poor skin turgor. His serum sodium
nurse prepares to implement protective level is 172 mEq/L. Choose the
isolation procedures. Which interventions interventions that the health care provider
would the nurse initiate? Select all that would likely prescribe. Select all that apply.
apply. A. Monitor intake and output.
A. Restrict all visitors. B. Monitor vital signs.
B. Place the child on a low-bacteria diet. C. Maintain sodium-reduced diet.
C. Change dressings using sterile technique. D. Monitor electrolyte levels.
D. Encourage the consumption of fresh fruits and E. Increase water intake orally.
vegetables. F. Administer sodium replacements.
E. Perform meticulous hand washing before 25. A client has died, and a nurse asks a
caring for the child. family member about the funeral
F. Allow fresh-cut flowers in the room as long as arrangements. The family member
they are kept in a vase with fresh water. refuses to discuss the issue. The nurse’s
22. A 16-year-old child is brought to the appropriate action is to:
emergency department by his mother with
a complaint that the child just experienced A. Show acceptance of feelings.
a tonic-clonic seizure. On arrival in the B. Provide information needed for decision
making.
emergency department no apparent
C. Suggest a referral to a mental health effects such as headache, dizziness, and
professional. hypotension. Patients should be counseled,
D. Remain with the family member without and the dose titrated, to minimize these
discussing funeral arrangements. effects. In spite of the side effects,
Answers and Rationales nitroglycerine is effective at reducing
1. Answer: C. Furosemide, a loop diuretic, does myocardial oxygen consumption and
not alter pain. Furosemide acts on the kidneys increasing blood flow. The patient should not
to increase urinary output. Fluid may move stop the medication. Nitroglycerine does not
from the periphery, decreasing edema. Fluid cause bleeding in the brain.
load is reduced, lowering blood pressure. 8. Answer: A. Three months after surgery and
2. Answer: A. Obesity is an important risk chemotherapy the patient is likely to be
factor for coronary artery disease that can be feeling the after-effects, which often includes
modified by improved diet and weight loss. anemia because of bone-marrow suppression.
Family history of coronary artery disease, There is no evidence that the patient is
male gender, and advancing age increase risk immunosuppressed, and fatigue is not a
but cannot be modified. typical symptom of immunosuppression. The
3. Answer: B. A history of cerebral hemorrhage information given does not indicate that
is a contraindication to tPA because it may depression or dehydration is a cause of her
increase the risk of bleeding. TPA acts by symptoms.
dissolving the clot blocking the coronary 9. Answer: C. Normal hemoglobin values range
artery and works best when administered from 11.5-15.0. This vegetarian patient is
within 6 hours of onset of symptoms. Prior MI mildly anemic. When food is prepared in iron
is not a contraindication to tPA. Patients cookware its iron content is increased. In
receiving tPA should be observed for changes addition, dark green leafy vegetables, such as
in blood pressure, as tPA may cause spinach and kale, and legumes are high in
hypotension. iron. Mild anemia does not require that animal
4. Answer: C. Exercise is important for all sources of iron be added to the diet. Many
hospitalized patients to prevent deep vein non-animal sources are available. Coffee and
thrombosis. Muscular contraction promotes tea increase gastrointestinal activity and
venous return and prevents hemostasis in the inhibit absorption of iron.
lower extremities. This exercise is not 10.Answer: D. Transfusion reaction is most
sufficiently vigorous to increase physical likely during the first 15 minutes of infusion,
fitness, nor is it intended to prevent bedsores and a nurse should be present during this
or constipation. period. PRBCs should be infused through a
5. Answer: D. Cardiogenic shock severely 19g or larger IV catheter to avoid slow flow,
impairs the pumping function of the heart which can cause clotting. PRBCs must be
muscle, causing diminished blood flow to the flushed with 0.45% normal saline solution.
organs of the body. This results in diminished Other intravenous solutions will hemolyze the
brain function and confusion, as well as cells.
hypotension, tachycardia, and weak pulse. 11.Answer: B. Epoetin is a form of
Cardiogenic shock is a serious complication erythropoietin, which stimulates the
of myocardial infarction with a high mortality production of red blood cells, causing an
rate. increase in hematocrit. Epoetin is given to
6. Answer: D. A patient with congestive heart patients who are anemic, often as a result of
failure and dyspnea may have pulmonary chemotherapy treatment. Epoetin has no effect
edema, which can cause severe hypertension. on neutrophils, platelets, or serum iron.
Therefore, taking the patient’s blood pressure 12.Answer: B, C, and D. Polycythemia vera is a
should be the first action. Lying flat on the condition in which the bone marrow produces
exam table would likely worsen the dyspnea, too many red blood cells. This causes an
and the patient may not tolerate it. Blood increase in hematocrit and viscosity of the
draws for chemistry and ABG will be blood. Patients can experience headaches,
required, but not prior to the blood pressure dizziness, and visual disturbances.
assessment. Cardiovascular effects include increased
7. Answer: C. Nitroglycerin is a potent blood pressure and delayed clotting time.
vasodilator and often produces unwanted
 Weight loss is not a manifestation of tachycardia. The disease is characterized by
polycythemia vera. painless, enlarged cervical lymph nodes.
13.Answer: A. Platelet counts under Weight loss occurs early in the disease.
30,000/microliter may cause spontaneous Nausea and vomiting are not typically
petechiae and bruising, particularly in the symptoms of Hodgkin’s disease.
extremities. When the count falls below 19.Answer: A. A definitive diagnosis of
15,000, spontaneous bleeding into the brain Hodgkin’s disease is made if Reed-Sternberg
and internal organs may occur. Headaches cells are found on pathologic examination of
may be a sign and should be watched for. the excised lymph node. Lymphoblasts are
Aspirin disables platelets and should never be immature cells found in the bone marrow of
used in the presence of thrombocytopenia. patients with acute lymphoblastic leukemia.
Thrombocytopenia does not compromise Gaucher’s cells are large storage cells found
immunity, and there is no reason to limit in patients with Gaucher’s disease. Rieder’s
visitors as long as any physical trauma is cells are myeloblasts found in patients with
prevented. acute myelogenous leukemia.
14.Answer: A, B, and D. Side effects of 20.Answer: C. Slow, deep breathing is the most
corticosteroids include weight gain, fluid effective method of reducing anxiety and
retention with hypertension, Cushingoid stress. It reduces the level of carbon dioxide in
features, a low serum albumin, and suppressed the brain to increase calm and relaxation.
inflammatory response. Patients are Warning the patient to remain still will likely
encouraged to eat a diet high in protein, increase her anxiety. Encouraging family
vitamins, and minerals and low in sodium. members to stay with the patient may make
Corticosteroids cause hypernatremia, not her worry about their anxiety as well as her
hyponatremia. own. Delaying the procedure is unlikely to
15.Answer: B. The neutropenic patient is at risk allay her fears.
of infection. Changing gloves immediately 21.Answer: B, C, and E. For the hospitalized
after use protects patients from contamination neutropenic child, flowers or plants should not
with organisms picked up on hospital be kept in the room because standing water
surfaces. This contamination can have serious and damp soil harbor Aspergillus and
consequences for an immunocompromised Pseudomonas, to which these children are
patient. Changing the respiratory mask is very susceptible. Fruits and vegetables not
desirable, but not nearly as urgent as changing peeled before being eaten harbor molds and
gloves. Minimizing contact and conversation should be avoided until the white blood cell
are not necessary and may cause nursing staff count rises. The child is placed on a low-
to miss changes in the patient’s symptoms or bacteria diet. Dressings are always changed
condition. with sterile technique. Not all visitors need to
16.Answer: C. During induction chemotherapy, be restricted, but anyone who is ill should not
the leukemia patient is severely be allowed in the child’s room. Meticulous
immunocompromised and at risk of serious hand washing is required before caring for the
infection. Fresh flowers, fruit, and plants can child. In addition, gloves, a mask, and a gown
carry microbes and should be avoided. Books, are worn (per agency policy).
pictures, and other personal items can be 22.Answers: C, D, and E. Medications that are
cleaned with antimicrobials before being prescribed for long-term control of tonic-
brought into the room to minimize the risk of clonic seizures are gabapentin, ethosuximide,
contamination. and carbamazepine. Diazepam is a medication
17.Answer: A. The peak incidence of ALL is at that is prescribed to halt tonic-clonic episodes,
4 years (range 3-10). It is uncommon after the and methylphenidate is a medication used to
mid-teen years. The peak incidence of chronic treat attention deficit hyperactivity disorder.
myelogenous leukemia (CML) is 45-55 years. Both of these medications are not suitable for
The peak incidence of acute myelogenous long-term control of a seizure condition.
leukemia (AML) occurs at 60 years. Two- Alprazolam is a medication used to treat
thirds of cases of chronic lymphocytic anxiety.
leukemia (CLL) occur after 60 years. 23.Answer: D. Meningococcal meningitis is
18.Answer: B. Symptoms of Hodgkin’s disease transmitted primarily by droplet infection.
include night sweats, fatigue, weakness, and Isolation is begun and maintained for at least
 24 hours after antibiotics are given. Other
options are incorrect.
24.Answers: A, B, C, D, and E. Hypernatremia
is described as having a serum sodium level
that exceeds 145 mEq/L. Signs and symptoms
would include dry mucous membranes, loss of
skin turgor, thirst, flushed skin, elevated
temperature, oliguria, muscle twitching,
fatigue, confusion, and seizures. Interventions
include monitoring fluid balance, monitoring
vital signs, reducing dietary intake of sodium,
monitoring electrolyte levels, and increasing
oral intake of water. Sodium replacement
therapy would not be prescribed for a client
with hypernatremia.
25.Answer: D. The family member is exhibiting
the first stage of grief (denial), and the nurse
should remain with the family
member.Showing acceptance of feelings is an
appropriate intervention for the acceptance or
reorganization and restitution stage.Providing
information needed for decision making may
be an appropriate intervention for the
bargaining stage.Suggesting a referral to a
mental health professional may be an
appropriate intervention for depression.
 NCLEX RN Practice Exam 6 A. A 72-year-old patient with diabetes who
requires a dressing change for a stasis ulcer.
Safe and Effective Care Environment B. A 42-year-old patient with cancer of the bone
1. A 68-year-old woman is diagnosed with complaining of pain.
thrombocytopenia due to acute C. A 55-year-old patient with terminal cancer
lymphocytic leukemia. She is admitted to being transferred to hospice home care.
the hospital for treatment. The nurse D. A 23-year-old patient with a fracture of the
right leg who asks to use the urinal.
should assign the patient
Health Promotion And Maintenace
A. to a private room so she will not infect other 6. An 18-year-old woman comes to the
patients and health care workers. physician’s office for a routine prenatal
B. to a private room so she will not be infected
checkup at 34 weeks gestation.
by other patients and health care workers.
C. to a semiprivate room so she will have Abdominal palpation reveals the fetal
stimulation during her hospitalization. position as right occipital anterior (ROA).
D. to a semiprivate room so she will have the At which of the following sites would the
opportunity to express her feelings about her nurse expect to find the fetal heart tone?
illness.
2. The nurse teaches a group of mothers A. Below the umbilicus, on the mother’s left
side.
of toddlers how to prevent accidental
B. Below the umbilicus, on the mother’s right
poisoning. Which of the following side.
suggestions should the nurse give C. Above the umbilicus, on the mother’s left
regarding medications? side.
D. Above the umbilicus, on the mother’s right
A. Lock all medications in a cabinet. side.
B. Child proof all the caps to medication bottles.
7. The nurse in an outpatient clinic is
C. Store medications on the highest shelf in a
cupboard. supervising student nurses administering
D. Place medications in different containers. influenza vaccinations. The nurse should
3. While inserting a nasogastric tube, the question the administration of the vaccine
nurse should use which of the following to which of the following clients?
protective measures? A. A 45-year-old male who is allergic to
A. Gloves, gown, goggles, and surgical cap. shellfish.
B. Sterile gloves, mask, plastic bags, and gown. B. A 60-year-old female who says she has a sore
C. Gloves, gown, mask, and goggles. throat.
D. Double gloves, goggles, mask, and surgical C. A 66-year-old female who lives in a group
cap. home.
D. A 70-year-old female with congestive heart
4. A 6-year-old boy is returned to his
failure.
room following a tonsillectomy. He
8. The nurse performs a home visit on a
remains sleepy from the anesthesia but is
client who delivered two days ago. The
easily awakened. The nurse should place
client states that she is bottle-feeding her
the child in which of the following
infant. The nurse notes white, curd-like
positions?
patches on the newborn’s oral mucous
A. Sims’. membranes. The nurse should take which
B. Side-lying. of the following actions?
C. Supine.
D. Prone. A. Determine the baby’s blood glucose level.
5. A nursing team consists of an RN, an B. Suggest that the newborn’s formula be
changed.
LPN/LVN, and a nursing assistant. The
C. Remind the caretaker not to let the infant
nurse should assign which of the sleep with the bottle.
following patients to the LPN/LVN?
D. Explain that the newborn will need to receive B. The nurse should verify that the consent form
some medication. has been signed by the patient and that it is
9. A two-month-old infant is brought to the attached to her chart.
pediatrician’s office for a well-baby visit. C. The nurse should tell the physician that the
patient agrees to have the examination.
During the examination, congenital
D. The nurse should verify that the patient or a
subluxation of the left hip is suspected. family member has signed the consent form.
The nurse knows that symptoms of 13. The nurse cares for an elderly patient
congenital hip dislocation include with moderate hearing loss. The nurse
A. lengthening of the limb on the affected side. should teach the patient’s family to use
B. deformities of the foot and ankle. which of the following approaches when
C. asymmetry of the gluteal and thigh folds. speaking to the patient?
D. plantar flexion of the foot.
10. The nurse teaches a 20-year-old A. Raise your voice until the patient is able to
hear you.
primigravida how to measure the
B. Face the patient and speak quickly using a
frequency of uterine contractions. The high voice.
nurse should explain to the patient that C. Face the patient and speak slowly using a
the frequency of uterine contractions is slightly lowered voice.
determined D. Use facial expressions and speak as you
would normally.
A. from the beginning of one contraction to the 14. A 52-year-old man is admitted to a
end of the next contraction.
hospital after sustaining a severe head
B. from the beginning of one contraction to the
end of the same contraction. injury in an automobile accident. When
C. by the strength of the contraction at its peak. the patient dies, the nurse observes the
D. by the number of contractions that occur patient’s wife comforting other family
within a given period of time. members. Which of the following
Psychosocial Integrity interpretations of this behavior is MOST
11. An adolescent male being treated for justifiable?
depression arrives with his family at the
A. She has already moved through the stages of
Adolescent Day Treatment Center for an
the grieving process.
initial therapy meeting with the staff. The B. She is repressing anger related to her
nurse explains that one of the goals of the husband’s death.
family meeting is to encourage the C. She is experiencing shock and disbelief
adolescent to: related to her husband’s death.
D. She is demonstrating resolution of her
A. trust the nurse who will solve his problem. husband’s death.
B. learn to live with anxiety and tension. 15. After two weeks of receiving lithium
C. accept responsibility for his actions and
therapy, a patient in the psychiatric unit
choices.
D. use the members of the therapeutic milieu to becomes depressed. Which of the
solve his problems. following evaluations of the patient’s
12. A 23-year-old-woman comes to the behavior by the nurse would be MOST
emergency room stating that she had accurate?
been raped. Which of the following A. The treatment plan is not effective; the patient
statements BEST describes the nurse’s requires a larger dose of lithium.
responsibility concerning written consent? B. This is a normal response to lithium therapy;
the patient should continue with the current
A. The nurse should explain the procedure to the treatment plan.
patient and ask her to sign the consent form. C.  This is a normal response to lithium therapy;
the patient should be monitored for suicidal
behavior.
D. The treatment plan is not effective; the patient intravenous set delivers 15 drops per
requires an antidepressant. milliliter. The nurse should regulate the
Physiological Integrity flow rate so that the patient receives how
16. A 65-year-old patient with pneumonia many drops of fluid per minute?
is receiving garamycin (Gentamicin). It
would be MOST important for a nurse to A. 21
B. 28
monitor which of the following laboratory
C. 31
values in this patient? D. 42
A. Hemoglobin and hematocrit. 21. A client is scheduled for a myelogram,
B. BUN and creatinine. and the nurse provides a list of
C. Platelet count and clotting time. instructions to the client regarding
D. Sodium and potassium. preparation for the procedure. Which
17. A 22-year-old man is admitted to the instructions should the nurse place on the
hospital with complaints of fatigue and list? Select all that apply.
weight loss. Physical examination reveals A. Jewelry will need to be removed.
pallor and multiple bruises on his arms B.  An informed consent will need to be signed.
and legs. The results of the patients tests C. A trained x-ray technician performs the
reveal acute lymphocytic leukemia and procedure.
D. The procedure will take approximately 45
thrombocytopenia. Which of the following
minutes.
nursing diagnoses MOST accurately E. A liquid diet can be consumed on the day of
reflects his condition? the procedure.
F. Solid food intake needs to be restricted only
A. Potential for injury.
on the day of the procedure.
B. Self-care deficit.
C. Potential for self-harm. 22. A client with a closed head injury is
D. Alteration in comfort. receiving phenytoin (Dilantin), an
18. To enhance the percutaneous anticonvulsant medication. Which of the
absorption of nitroglycerine ointment, it following would indicate that the client is
would be MOST important for the nurse to experiencing side effects related to this
select a site that is medication? Select all that apply.
A. Ataxia
A. muscular. B. Sedation
B. near the heart. C. Constipation
C. non-hairy. D. Bleeding gums
D. over a bony prominence. E. Hyperglycemia
19. A man is admitted to the Telemetry F. Decreased platelet count
Unit for evaluation of complaints of chest 23. A client with carcinoma of the lung
pain. Eight hours after admission, the develops the syndrome of inappropriate
patient goes into ventricular fibrillation. antidiuretic hormone (SIADH) as a
The physician defibrillates the patient. complication of the cancer. The nurse
The nurse understands that the purpose anticipates that which of the following
of defibrillation is to: may be prescribed? Select all that apply.
A. Radiation
A. increase cardiac contractility and cardiac B. Chemotherapy
output. C. Increased fluid intake
B. cause asystole so the normal pacemaker can D. Serum sodium blood levels
recapture. E. Decreased oral sodium intake
C. reduce cardiac ischemia and acidosis. F. Medication that is antagonistic to antidiuretic
D. provide energy for depleted myocardial cells. hormone (ADH)
20. A patient is to receive 3,000 ml of 24. A client with carcinoma of the lung
0.9% NaCl IV in 24 hours. The develops the syndrome of inappropriate
 antidiuretic hormone (SIADH) as a C. to a semiprivate room so she will have
complication of the cancer. The nurse stimulation during her hospitalization —
should be placed in a room alone
anticipates that which of the following
D.  to a semiprivate room so she will have the
may be prescribed? Select all that apply. opportunity to express her feelings about her
A. Radiation illness — ensure that patient is provided with
B. Chemotherapy opportunities to express feelings about illness
C. Increased fluid intake 2. The correct answer is A. 
D. Serum sodium blood levels Question: What is the BEST way to
E. Decreased oral sodium intake prevent accidental poisoning in children?
F. Medication that is antagonistic to antidiuretic Strategy: Picture toddlers at play.
hormone (ADH) A. Lock all medications in a cabinet —
25. The clinic nurse is assisting to CORRECT: improper storage most common
perform a focused data collection process cause of poisoning; highest incidence in two-
on a client who is complaining of year-olds
symptoms of a cold, a cough, and lung B. Child proof all the caps to medication bottles
congestion. Which of the following would — children can open
C. Store medications on the highest shelf in a
the nurse include for this type of data cupboard — toddlers climb
collection? Select all that apply. D. Place medications in different containers —
A. Auscultating lung sounds keep in original container
B. Obtaining the client’s temperature 3. The correct answer is C. 
C. Checking the strength of peripheral pulses
D. Obtaining information about the client’s Question: What is the correct universal
respirations precaution?
E. Performing a musculoskeletal and Strategy: Think about each answer
neurological examination choice. How is each measure protecting
F. Asking the client about a family history of any the nurse?
illness or disease Needed Info: Mask, eye protection, face
Answers and Rationales shield protect mucous membrane
1. The correct answer is B. 
exposure; used if activities are likely to
Question: What are the needs of the
patient with acute lymphocytic leukemia generate splash or sprays. Gowns used if
and thrombocytopenia? activities are likely to generate splashes
Needed Info: Lymphocytic leukemia, or sprays.
disease characterized by proliferation of
immature WBCs. Immature cells unable A. Gloves, gown, goggles, and surgical cap —
to fight infection as competently as surgical caps offer protection to hair but aren’t
mature white cells. Treatment: required.
chemotherapy, antibiotics, blood B. Sterile gloves, mask, plastic bags, and gown
transfusions, bone marrow — plastic bags provide no direct protection
transplantation. Nursing responsibilities: and aren’t part of universal precautions
private room, no raw fruits or vegs, small C. Gloves, gown, mask, and goggles —
frequent meals, O2, good skin care. CORRECT: must use universal precautions
A. to a private room so she will not infect other on ALL patients; prevent skin and mucous
patients and health care workers — poses membrane exposure when contact with blood
little or no threat or other body fluids is anticipated
B.  to a private room so she will not be infected D. Double gloves, goggles, mask, and surgical
by other patients and health care workers — cap — surgical cap not required; unnecessary
CORRECT: protects patient from exogenous to double glove
bacteria, risk for developing infection from 4. The correct answer is B. 
others due to depressed WBC count, alters Question: What is the best position after
ability to fight infection tonsillectomy to help with drainage of oral
secretions?
Strategy: Picture the patient as described.
A. Sims’ — on side with top knee flexed and practice of defining position of baby
thigh drawn up to chest and lower knee less relative to mother’s pelvis. The point of
sharply flexed: used for vaginal or rectal
maximum intensity (PMI) of the fetus:
examination
B. Side-lying — CORRECT: most effective to point on the mother’s abdomen where the
facilitate drainage of secretions from the FHT is the loudest, usually over the fetal
mouth and pharynx; reduces possibility of back. Divide the mother’s pelvis into 4
airway obstruction. parts or quadrants: right and left anterior,
C. Supine — increased risk for aspiration, would which is the front, and right and left
not facilitate drainage of oral secretions posterior, which is the back. Abbreviated:
D. Prone — risk for airway obstruction and
aspiration, unable to observe the child for R and L for right and left, and A and P for
signs of bleeding such as increased anterior and posterior. The head,
swallowing particularly the occiput, is the most
5. The correct answer is A.  common presenting part, and is
Question: Which patient is an appropriate abbreviated O. LOA is most common fetal
assignment for the LPN/LVN? position and FHT heard on left side. In a
Strategy: Think about the skill level vertex presentation, FHT is heard below
involved in each patient’s care. the umbilicus. In a breech presentation,
Needed Info: LPN/LVN: assists with FHT is heard above the umbilicus.
implementation of care; performs
A. Below the umbilicus, on the mother’s left side
procedures; differentiates normal from — found on right not left side
abnormal; cares for stable patients with B. Below the umbilicus, on the mother’s right
predictable conditions; has knowledge of side — CORRECT: occiput and back are
asepsis and dressing changes; pressing against right side of mother’s
administers medications (varies with abdomen; FHT would be heard below
umbilicus on right side
educational background and state nurse
C. Above the umbilicus, on the mother’s left side
practice act). — found in breech presentation
A. A 72-year-old patient with diabetes who D. Above the umbilicus, on the mother’s right
requires a dressing change for a stasis ulcer — side — found in breech presentation
CORRECT: stable patient with an expected 7. The correct answer is B. 
outcome Question: What is a contraindication to
B. A 42-year-old patient with cancer of the bone receiving flu vaccine?
complaining of pain — requires assessment; Strategy: Think about what each answer
RN is the appropriate caregiver choice means.
C. A 55-year-old patient with terminal cancer
being transferred to hospice home care — Needed Info: Influenza vaccine: given
requires nursing judgement; RN is the yearly, preferably Oct.-Nov.;
appropriate caregiver recommended for people age 65 or older;
D. A 23-year-old patient with a fracture of the people under 65 with heart disease, lung
right leg who asks to use the urinal — disease, diabetes, immuno-suppression,
standard unchanging procedure; assign to the chronic care facility residents.
nursing assistant
6. The answer is B.  A. A 45-year-old male who is allergic to shellfish
Question: The fetus is ROA. Where — allergy to eggs is a contraindication
should the nurse listen for the FHT? B. A 60-year-old female who says she has a sore
throat — CORRECT: vaccine deferred in
Strategy: Picture the situation described.
presence of acute respiratory disease
It may be helpful for you to draw this out C. A 66-year-old female who lives in a group
so that you can imagine where the home — vaccine deferred only if patient has
heartbeat would be found. an active immunization
Needed Info: Describing fetal position:
D. A 70-year-old female with congestive heart Needed Info: There must be at least 3
failure — no contraindication contractions to establish frequency.
8. The correct answer is D. 
Question: What is the treatment for A. from the beginning of one contraction to the
end of the next contraction — not accurate
thrush?
B. from the beginning of one contraction to the
Strategy: Determine the outcome of each end of the same contraction — defines
answer choice. duration
Needed Info: Thrush (oral candidiasis): C. by the strength of the contraction at its peak
white plaque on oral mucous membranes, — describes intensity
gums, or tongue; treatment includes good D. by the number of contractions that occur
handwashing, nystatin (Mycostatin). within a given period of time — CORRECT
11. The correct answer is C. 
A. Determine the baby’s blood glucose level — Question: What is the goal of family
thrush in newborns caused by poor therapy?
handwashing or exposure to an infected
Needed Info: Symptoms of depression: a
vagina during birth
B. Suggest that the newborn’s formula be low self-esteem, obsessive thoughts,
changed — not related to thrush regressive behavior, unkempt
C. Remind the caretaker not to let the infant appearance, a lack of energy, weight
sleep with the bottle — not related to thrush loss, decreased concentration, withdrawn
D. Explain that the newborn will need to receive behavior.
some medication — CORRECT: thrush most
often treated with nystatin (Mycostatin) A. trust the nurse who will solve his problem —
9. The correct answer is C.  not realistic
Question: What will you see with B. learn to live with anxiety and tension —
minimizes concerns
congenital hip dislocation?
C. accept responsibility for his actions and
Strategy: Form a mental image of the choices — CORRECT
deformity. D. use the members of the therapeutic milieu to
Needed Info: Subluxation: most common solve his problems — must do it himself
type of congenital hip dislocation. Head of 12. The correct answer is B. 
femur remains in contact with acetabulum Question: What is your responsibility
but is partially displaced. Diagnosed in concerning informed consent?
infant less than 4 weeks old S/S: unlevel Needed Info: Physician’s responsibility to
gluteal folds, limited abduction of hip, obtain informed consent.
shortened femur affected side, Ortolani’s
A. The nurse should explain the procedure to the
sign (click). Treatment: abduction splint,
patient and ask her to sign the consent form
hip spica cast, Bryant’s traction, open — Physician should get patient to sign
reduction. consent
B. The nurse should verify that the consent form
A. lengthening of the limb on the affected side —
has been signed by the patient and that it is
inaccurate
attached to her chart — CORRECT
B. deformities of the foot and ankle —
C. The nurse should tell the physician that the
inaccurate
patient agrees to have the examination —
C. asymmetry of the gluteal and thigh folds —
Physician should explain procedure and get
CORRECT: restricted movement on affected
consent form signed
side
D.  The nurse should verify that the patient or a
D. plantar flexion of the foot — seen with
family member has signed the consent form
clubfoot
— must be signed by patient unless unable to
10. The correct answer is D.  do
Question: How do you determine the 13. The correct answer is C. 
frequency of uterine contractions? Question: What should you do to
 communicate with a person with a D. The treatment plan is not effective; the patient
moderate hearing loss? requires an antidepressant — normal response
Needed Info: Presbycusis: age-related 16. The correct answer is B. 
hearing loss due to inner ear changes. Question: Which lab values should you
Decreased ability to hear high sounds. monitor for a patient receiving
Gentamicin?
A. Raise your voice until the patient is able to Needed Info: Gentamicin: broad spectrum
hear you — would result in high tones patient
antibiotic. Side effects: neuromuscular
unable to hear
B. Face the patient and speak quickly using a blockage, ototoxic to eighth cranial nerve
high voice — usually unable to hear high (tinnitus, vertigo, ataxia, nystagmus,
tones hearing loss), nephrotoxic. Nursing
C. Face the patient and speak slowly using a responsibilities: monitor renal function,
slightly lowered voice — CORRECT: also force fluids, monitor hearing acuity. Draw
decrease background noise; speak at a slow blood for peak levels 1 hr. after IM and 30
pace, use nonverbal cues
min – 1 hr. after IV infusion, draw blood
D. Use facial expressions and speak as you
would normally — nonverbal cues help, but for trough just before next dose.
need low tones A. Hemoglobin and hematocrit — can cause
14. The correct answer is C.  anemia; less common
Question: What is the reason for the B. BUN and creatinine — CORRECT:
wife’s behavior? nephrotoxic; will see proteinuria, oliguria,
Needed Info: Stages of grief: 1) shock hematuria, thirst, increased BUN, decreased
and disbelief, 2) awareness of pain and creatine clearance
C. Platelet count and clotting time — do not
loss, 3) restitution. Acute period: 4-8
usually change
weeks, usual resolution: 1 year. D. Sodium and potassium — hypokalemia
A. She has already moved through the stages of infrequent problem
the grieving process — takes one year 17. The correct answer is A. 
B. She is repressing anger related to her Question: What nursing diagnosis is seen
husband’s death — not accurate; second with acute lymphocytic leukemia and
stage: crying, regression thromocytopenia?
C. She is experiencing shock and disbelief Needed Info: Thromocytopenia:
related to her husband’s death — CORRECT:
decreased platelet count increases the
denial first stage; inability to comprehend
reality of situation patient’s risk for injury, normal count:
D. She is demonstrating resolution of her 200,000-400,000 per mm3. Leukemia:
husband’s death — too soon group of malignant disorders involving
15. The correct answer is C.  overproduction of immature leukocytes in
Question: Is the depression normal, or bone marrow. This shuts down normal
something to be concerned about? bone marrow production of erythrocytes,
platelets, normal leukocytes. Causes
A. The treatment plan is not effective; the patient
requires a larger dose of lithium — not anemia, leukopenia, and
accurate thrombocytopenia leading to infection and
B. This is a normal response to lithium therapy; hemorrhage. Symptoms: pallor of nail
the patient should continue with the current beds and conjunctiva, petechiae (small
treatment plan — does not address safety hemorrhagic spot on skin), tachycardia,
needs dyspnea, weight loss, fatigue. Treatment:
C. This is a normal response to lithium therapy;
chemotherapy, antibiotics, blood
the patient should be monitored for suicidal
behavior — CORRECT: delay of 1-3 weeks transfusions, bone marrow
before med benefits seen transplantation. Nursing responsibilities:
 private room, no raw fruits or vegs, small for natural pacemaker (SA node) to
frequent meals, O2, good skin care. resume as pacer of heart activity.
A. Potential for injury — CORRECT: low A. increase cardiac contractility and cardiac
platelet increases risk of bleeding from even output — inaccurate
minor injuries. Safety measures: shave with B. cause asystole so the normal pacemaker can
an electric razor, use soft tooth brush, avoid recapture — CORRECT: allows SA node to
SQ or IM meds and invasive procedures resume as pacer of heart activity
(urinary drainage catheter or a nasogastric C. reduce cardiac ischemia and acidosis —
tube), side-rails up, remove sharp objects, inaccurate
frequently assess for signs of bleeding, D. provide energy for depleted myocardial cells
bruising, hemorrhage. — inaccurate
B. Self-care deficit — may feel weak, doesn’t 20. The correct answer is C. 
address condition Question: How should you regulate the IV
C. Potential for self-harm — implies risk for
flow rate?
purposeful self-injury, not given any info,
assumption Strategy: Use formula and avoid making
D. Alteration in comfort — patient is not math errors.
comfortable, and comfort measures would Needed Info: total volume x the drop
address problem factor divided by the total time in minutes.
18. The correct answer is C. 
A. 21 — inaccurate
Question: What is the best site for
B.  28 — inaccurate
nitroglycerine ointment? C. 31 — CORRECT: 3,000 x 15 divided by 24 x
Strategy: Think about each site. 60
Needed Info: Nitroglycerine: used in D. 42 — inaccurate
treatment of angina pectoris to reduce 21. The correct answer are A, B, and D.
ischemia and relieve pain by decreasing Client preparation for a myelogram
myocardial oxygen consumption; dilates includes instructing the client to restrict
veins and arteries. Side effects: throbbing food and fluids for 4 to 8 hours before the
headache, flushing, hypotension, procedure. The client is told that the
tachycardia. Nursing responsibilities: procedure takes about 45 minutes. An
teach appropriate administration, storage, informed consent is required because the
expected pain relief, side effects. procedure is invasive and is therefore
Ointment applied to skin; sites rotated to performed by the health care provider.
avoid skin irritaion. Prolonged effect up to The client will need to remove jewelry and
24 hours. metal objects from the chest area. The
client is also told that pretest medications
A. muscular — not most important
B. near the heart — not most important may be prescribed for relaxation.
C. non-hairy — CORRECT: skin site free of hair 22.The correct answer are C, D, E, and F.
will increase absorption; avoid distal part of Dilantin causes blood dyscrasias, such as
extremities due to less than maximal decreased platelet counts and decreased
absorption white blood cell counts; it contributes to
D. over a bony prominence — most important is constipation as well. Gingival hyperplasia
that the site be non-hairy
can occur, causing gums to bleed easily,
19. The correct answer is B. 
and blood glucose levels can elevate
Question: Why is a patient defibrillated?
when taking phenytoin. Sedation is a side
Strategy: Think about each answer
effect of barbiturates, not phenytoin.
choice.
Ataxia is a side effect of benzodiazepines.
Needed Info: Defibrillation: produces
23.The correct answer are A, B, D, and F.
asystole of heart to provide opportunity
Cancer is a common cause of SIADH. In
clients with SIADH, excessive amounts of system and the presence of an infection.
water are reabsorbed by the kidney and A complete data collection includes a
put into the systemic circulation. The complete health history and physical
increased water causes hyponatremia examination and forms a baseline
(decreased serum sodium levels) and database. Checking the strength of
some degree of fluid retention. SIADH is peripheral pulses relates to a vascular
managed by treating the condition and its assessment, which is not related to this
cause, and treatment usually includes client’s complaints. A musculoskeletal
fluid restriction, increased sodium intake, and neurological examination also is not
and a medication with a mechanism of related to this client’s complaints.
action that is antagonistic to ADH. However, strength of peripheral pulses
Sodium levels are monitored closely, and a musculoskeletal and neurological
because hypernatremia can suddenly examination would be included in a
develop as a result of treatment. The complete data collection. Likewise, asking
immediate institution of appropriate the client about a family history of any
cancer therapy (usually either radiation or illness or disease would be included in a
chemotherapy) can cause tumor complete assessment.
regression so that ADH
synthesis and release processes return to
normal.
24. The correct answer are A, B, D and F.
Cancer is a common cause of SIADH. In
clients with SIADH, excessive amounts of
water are reabsorbed by the kidney and
put into the systemic circulation. The
increased water causes hyponatremia
(decreased serum sodium levels) and
some degree of fluid retention. SIADH is
managed by treating the condition and its
cause, and treatment usually includes
fluid restriction, increased sodium intake,
and a medication with a mechanism of
action that is antagonistic to ADH.
Sodium levels are monitored closely,
because hypernatremia can suddenly
develop as a result of treatment. The
immediate institution of appropriate
cancer therapy (usually either radiation or
chemotherapy) can cause tumor
regression so that ADH synthesis and
release processes return to normal.
25.The correct answer are A, B, and D.
A focused data collection process focuses
on a limited or short-term problem, such
as the client’s complaint. Because the
client is complaining of symptoms of a
cold, a cough, and lung congestion the
nurse would focus on the respiratory
 NCLEX RN Practice Exam 7 B. Give a bolus of IV fluids
C. Start O2
1. A 43-year-old African American male is D. Administer meperidine (Demerol) 75mg IV
admitted with sickle cell anemia. The push
nurse plans to assess circulation in the 6. The nurse is instructing a client with
lower extremities every 2 hours. Which of iron-deficiency anemia. Which of the
the following outcome criteria would the following meal plans would the nurse
nurse use? expect the client to select?
A. Body temperature of 99°F or less A. Roast beef, gelatin salad, green beans, and
B. Toes moved in active range of motion peach pie
C. Sensation reported when soles of feet are B. Chicken salad sandwich, coleslaw, French
touched fries, ice cream
D. Capillary refill of < 3 seconds C. Egg salad on wheat bread, carrot sticks,
2. A 30-year-old male from Haiti is lettuce salad, raisin pie
brought to the emergency department in D. Pork chop, creamed potatoes, corn, and
sickle cell crisis. What is the best position coconut cake
for this client? 7. Clients with sickle cell anemia are
taught to avoid activities that cause
A. Side-lying with knees flexed hypoxia and hypoxemia. Which of the
B. Knee-chest
following activities would the nurse
C. High Fowler’s with knees flexed
D. Semi-Fowler’s with legs extended on the bed recommend?
3. A 25-year-old male is admitted in sickle A. A family vacation in the Rocky Mountains
cell crisis. Which of the following B. Chaperoning the local boys club on a snow-
interventions would be of highest priority skiing trip
for this client? C. Traveling by airplane for business trips
D. A bus trip to the Museum of Natural History
A. Taking hourly blood pressures with 8. The nurse is conducting an admission
mechanical cuff assessment of a client with vitamin B12
B. Encouraging fluid intake of at least 200mL
deficiency. Which of the following would
per hour
C. Position in high Fowler’s with knee gatch the nurse include in the physical
raised assessment?
D. Administering Tylenol as ordered
A. Palpate the spleen
4. Which of the following foods would the B. Take the blood pressure
nurse encourage the client in sickle cell C. Examine the feet for petechiae
crisis to eat? D. Examine the tongue
9. An African American female comes to
A. Peaches
B. Cottage cheese the outpatient clinic. The physician
C. Popsicle suspects vitamin B12 deficiency anemia.
D. Lima beans Because jaundice is often a clinical
5. A newly admitted client has sickle cell manifestation of this type of anemia, what
crisis. The nurse is planning care based body part would be the best indicator?
on assessment of the client. The client is
A. Conjunctiva of the eye
complaining of severe pain in his feet and B. Soles of the feet
hands. The pulse oximetry is 92. Which of C. Roof of the mouth
the following interventions would be D. Shins
implemented first? Assume that there are 10. The nurse is conducting a physical
orders for each intervention. assessment on a client with anemia.
Which of the following clinical
A. Adjust the room temperature
 manifestations would be most indicative A. Oral mucous membrane, altered related to
of the anemia? chemotherapy
B. Risk for injury related to thrombocytopenia
A. BP 146/88 C. Fatigue related to the disease process
B. Respirations 28 shallow D. Interrupted family processes related to life-
C. Weight gain of 10 pounds in 6 months threatening illness of a family member
D. Pink complexion 16. A 21-year-old male with Hodgkin’s
11. The nurse is teaching the client with lymphoma is a senior at the local
polycythemia vera about prevention of university. He is engaged to be married
complications of the disease. Which of and is to begin a new job upon
the following statements by the client graduation. Which of the following
indicates a need for further teaching? diagnoses would be a priority for this
client?
A. “I will drink 500mL of fluid or less each day.”
B. “I will wear support hose when I am up.” A. Sexual dysfunction related to radiation
C.  “I will use an electric razor for shaving.” therapy
D. “I will eat foods low in iron.” B. Anticipatory grieving related to terminal
12. A 33-year-old male is being evaluated illness
for possible acute leukemia. Which of the C. Tissue integrity related to prolonged bed rest
following would the nurse inquire about as D. Fatigue related to chemotherapy
a part of the assessment? 17. A client has autoimmune
thrombocytopenic purpura. To determine
A.  The client collects stamps as a hobby. the client’s response to treatment, the
B. The client recently lost his job as a postal
nurse would monitor:
worker.
C. The client had radiation for treatment of A. Platelet count
Hodgkin’s disease as a teenager. B. White blood cell count
D.  The client’s brother had leukemia as a child. C. Potassium levels
13. An African American client is admitted D. Partial prothrombin time (PTT)
with acute leukemia. The nurse is 18. The home health nurse is visiting a
assessing for signs and symptoms of client with autoimmune thrombocytopenic
bleeding. Where is the best site for purpura (ATP). The client’s platelet count
examining for the presence of petechiae? currently is 80, It will be most important to
teach the client and family about:
A. The abdomen
B. The thorax A. Bleeding precautions
C. The earlobes B. Prevention of falls
D. The soles of the feet C. Oxygen therapy
14. A client with acute leukemia is D. Conservation of energy
admitted to the oncology unit. Which of 19. A client with a pituitary tumor has had
the following would be most important for a transphenoidal hyposphectomy. Which
the nurse to inquire? of the following interventions would be
appropriate for this client?
A. “Have you noticed a change in sleeping habits
recently?” A. Place the client in Trendelenburg position for
B. “Have you had a respiratory infection in the postural drainage
last 6 months?” B. Encourage coughing and deep breathing every
C. “Have you lost weight recently?” 2 hours
D. “Have you noticed changes in your C. Elevate the head of the bed 30°
alertness?” D. Encourage the Valsalva maneuver for bowel
15. Which of the following would be the movements
priority nursing diagnosis for the adult 20. The client with a history of diabetes
client with acute leukemia? insipidus is admitted with polyuria,
 polydipsia, and mental confusion. The months, and the client is wearing two
priority intervention for this client is: sweaters. The client is diagnosed with
hypothyroidism. Which of the following
A. Measure the urinary output
B. Check the vital signs nursing diagnoses is of highest priority?
C. Encourage increased fluid intake A. Impaired physical mobility related to
D. Weigh the client decreased endurance
21. A client with hemophilia has a B. Hypothermia r/t decreased metabolic rate
nosebleed. Which nursing action is most C. Disturbed thought processes r/t interstitial
appropriate to control the bleeding? edema
D. Decreased cardiac output r/t bradycardia
A. Place the client in a sitting position with the 26. A community health nurse is
head hyperextended
conducting a teaching session about
B. Pack the nares tightly with gauze to apply
pressure to the source of bleeding terrorism with members of the community
C. Pinch the soft lower part of the nose for a and discussing information regarding
minimum of 5 minutes anthrax. The nurse tells those attending
D. Apply ice packs to the forehead and back of that anthrax can be transmitted via which
the neck route(s)? Select all that apply.
22. A client has had a unilateral A. Skin
adrenalectomy to remove a tumor. To B. Kissing
prevent complications, the most important C. Inhalation
measurement in the immediate post- D. Gastrointestinal
E. Direct contact with an infected individual
operative period for the nurse to take is: F. Sexual contact with an infected individual
A. Blood pressure 27. The emergency room nurse is
B.  Temperature providing discharge teaching to the
C. Output parents of a 2-year-old child who
D. Specific gravity sustained burns from a hot cup of coffee
23. A client with Addison’s disease has that had been left on the kitchen counter.
been admitted with a history of nausea The nurse evaluates that the parents
and vomiting for the past 3 days. The have correctly understood the teaching
client is receiving IV glucocorticoids when they state which of the following?
(Solu-Medrol). Which of the following
interventions would the nurse implement? A. “We will be sure to not leave hot liquids
unattended.”
A. Glucometer readings as ordered B. “I guess my child needs to understand what
B. Intake/output measurements the word ‘hot’ means.”
C. Sodium and potassium levels monitored C. “We will be sure that our child stays in his
D. Daily weights room when we work in the kitchen.”
24. A client had a total thyroidectomy D. “We will install a safety gate as soon as we
yesterday. The client is complaining of get home so that our child can’t get into the
kitchen.”
tingling around the mouth and in the
28. A licensed practical nurse is attending
fingers and toes. What would the nurses’
an agency orientation meeting about the
next action be?
nursing model of practice implemented in
A. Obtain a crash cart the facility. The nurse is told that the
B. Check the calcium level nursing model is a team nursing
C. Assess the dressing for drainage
approach. The nurse understands that
D. Assess the blood pressure for hypertension
which of the following is a characteristic of
25. A 32-year-old mother of three is
this type of nursing model of practice?
brought to the clinic. Her pulse is 52,
there is a weight gain of 30 pounds in 4
A. A task approach method is used to provide 3. Answer B . It is important to keep the client
care to clients. in sickle cell crisis hydrated to prevent further
B. Managed care concepts and tools are used sickling of the blood. Answer A is incorrect
when providing client care. because a mechanical cuff places too much
C. Nursing staff are led by a nurse when pressure on the arm. Answer C is incorrect
providing care to a group of clients. because raising the knee gatch impedes
D. A single registered nurse is responsible for circulation. Answer D is incorrect because
providing nursing care to a group of clients. Tylenol is too mild an analgesic for the client
29. A licensed practical nurse is planning in crisis.
the client assignments for the day. Which 4. Answer C . Hydration is important in the
client with sickle cell disease to prevent
of the following is the most appropriate
thrombus formation. Popsicles, gelatin, juice,
assignment for the nursing assistant? and pudding have high fluid content. The
A. A client who requires wound irrigation foods in answers A, B, and D do not aid in
B. A client who requires frequent ambulation hydration and are, therefore, incorrect.
C. A client who is receiving continuous tube 5. Answer C . The most prominent clinical
feedings manifestation of sickle cell crisis is pain.
D. A client who requires frequent vital signs after However, the pulse oximetry indicates that
a cardiac catheterization oxygen levels are low; thus, oxygenation
takes precedence over pain relief. Answer A is
30. A male client who has heart failure
incorrect because although a warm
receives an additional dose of environment reduces pain and minimizes
bumetanide as prescribed 4 hours after sickling, it would not be a priority. Answer B
the daily dose. The nurse assesses him is incorrect because although hydration is
15 minutes after administering the important, it would not require a bolus.
medication and reminds him to save all Answer D is incorrect because Demerol is
acidifying to the blood and increases sickling.
urine in the bathroom. Thirty minutes later
6. Answer C. Egg yolks, wheat bread, carrots,
the nurse finds the client on the floor, raisins, and green, leafy vegetables are all
unresponsive, and bleeding from a high in iron, which is an important mineral for
laceration. Determine the issues that this client. Roast beef, cabbage, and pork
support the client’s malpractice chops are also high in iron, but the side dishes
claim. Select all that apply. accompanying these choices are not;
A. Failure to replace body fluids therefore, answers A, B, and D are incorrect.
B. Increased risk of hypotension 7. Answer D . Taking a trip to the museum is
C. Failure to teach the client adequately the only answer that does not pose a threat. A
D. Increased need to protect the client family vacation in the Rocky Mountains at
E. Excessive bumetanide administration high altitudes, cold temperatures, and airplane
F. Lack of follow-up nursing actions travel can cause sickling episodes and should
be avoided; therefore, answers A, B, and C
Answers and Rationales
are incorrect.
1. Answer D . It is important to assess the
8. Answer D. The tongue is smooth and beefy
extremities for blood vessel occlusion in the
red in the client with vitamin B12 deficiency,
client with sickle cell anemia because a
so examining the tongue should be included in
change in capillary refill would indicate a
the physical assessment. Bleeding,
change in circulation. Body temperature,
splenomegaly, and blood pressure changes do
motion, and sensation would not give
not occur, making answers A, B, and C
information regarding peripheral circulation;
incorrect.
therefore, answers A, B, and C are incorrect.
9. Answer C. The oral mucosa and hard palate
2. Answer D. Placing the client in semi-
(roof of the mouth) are the best indicators of
Fowler’s position provides the best
jaundice in dark-skinned persons. The
oxygenation for this client. Flexion of the hips
conjunctiva can have normal deposits of fat,
and knees, which includes the knee-chest
which give a yellowish hue; thus, answer A is
position, impedes circulation and is not
incorrect. The soles of the feet can be yellow
correct positioning for this client. Therefore,
if they are calloused, making answer B
answers A, B, and C are incorrect.
 incorrect; the shins would be an area of darker to address in light of the age and life choices.
pigment, so answer D is incorrect. Hodgkin’s disease, however, has a good
10.Answer B . When there are fewer red blood prognosis when diagnosed early. Answers B,
cells, there is less hemoglobin and less C, and D are incorrect because they are of
oxygen. Therefore, the client is often short of lesser priority.
breath, as indicated in answer B. The client 17.Answer A . Clients with autoimmune
with anemia is often pale in color, has weight thrombocytopenic purpura (ATP) have low
loss, and may be hypotensive. Answers A, C, platelet counts, making answer A the correct
and D are within normal and, therefore, are answer. White cell counts, potassium levels,
incorrect. and PTT are not affected in ATP; thus,
11.Answer A. The client with polycythemia vera answers B, C, and D are incorrect.
is at risk for thrombus formation. Hydrating 18.Answer A. The normal platelet count is
the client with at least 3L of fluid per day is 120,000–400, Bleeding occurs in clients with
important in preventing clot formation, so the low platelets. The priority is to prevent and
statement to drink less than 500mL is minimize bleeding. Oxygenation in answer C
incorrect. Answers B, C, and D are incorrect is important, but platelets do not carry
because they all contribute to the prevention oxygen. Answers B and D are of lesser
of complications. Support hose promotes priority and are incorrect in this instance.
venous return, the electric razor prevents 19.Answer C. Elevating the head of the bed 30°
bleeding due to injury, and a diet low in iron avoids pressure on the sella turcica and
is essential to preventing further red cell alleviates headaches. Answers A, B, and D are
formation. incorrect because Trendelenburg, Valsalva
12.Answer C. Radiation treatment for other maneuver, and coughing all increase the
types of cancer can result in leukemia. Some intracranial pressure.
hobbies and occupations involving chemicals 20.Answer B . The large amount of fluid loss can
are linked to leukemia, but not the ones in cause fluid and electrolyte imbalance that
these answers; therefore, answers A and B are should be corrected. The loss of electrolytes
incorrect. Answer D is incorrect because the would be reflected in the vital signs.
incidence of leukemia is higher in twins than Measuring the urinary output is important, but
in siblings. the stem already says that the client has
13.Answer D . Petechiae are not usually polyuria, so answer A is incorrect.
visualized on dark skin. The soles of the feet Encouraging fluid intake will not correct the
and palms of the hand provide a lighter problem, making answer C incorrect. Answer
surface for assessing the client for petichiae. D is incorrect because weighing the client is
Answers A, B, and C are incorrect because the not necessary at this time.
skin might be too dark to make an assessment. 21.Answer C . The client should be positioned
14.Answer B . The client with leukemia is at risk upright and leaning forward, to prevent
for infection and has often had recurrent aspiration of blood. Answers A, B, and D are
respiratory infections during the previous 6 incorrect because direct pressure to the nose
months. Insomnolence, weight loss, and a stops the bleeding, and ice packs should be
decrease in alertness also occur in leukemia, applied directly to the nose as well. If a pack
but bleeding tendencies and infections are the is necessary, the nares are loosely packed.
primary clinical manifestations; therefore, 22.Answer A . Blood pressure is the best
answers A, C, and D are incorrect. indicator of cardiovascular collapse in the
15.Answer B. The client with acute leukemia has client who has had an adrenal gland removed.
bleeding tendencies due to decreased platelet The remaining gland might have been
counts, and any injury would exacerbate the suppressed due to the tumor activity.
problem. The client would require close Temperature would be an indicator of
monitoring for hemorrhage, which is of higher infection, decreased output would be a clinical
priority than the diagnoses in answers A, C, manifestation but would take longer to occur
and D, which are incorrect. than blood pressure changes, and specific
16.Answer A. Radiation therapy often causes gravity changes occur with other disorders;
sterility in male clients and would be of therefore, answers B, C, and D are incorrect.
primary importance to this client. The 23.Answer A. IV glucocorticoids raise the
psychosocial needs of the client are important glucose levels and often require coverage with
 insulin. Answer B is not necessary at this this task. The client who had a cardiac
time, sodium and potassium levels would be catheterization will require specific
monitored when the client is receiving mineral monitoring in addition to that of the vital
corticoids, and daily weights is unnecessary; signs. Wound irrigations and tube feedings are
therefore, answers B, C, and D are incorrect. not performed by unlicensed personnel.
24.Answer B . The parathyroid glands are 30.Answers B, C, D, and F. To prove
responsible for calcium production and can be malpractice against a nurse, the plaintiff must
damaged during a thyroidectomy. The tingling prove that the nurse owed a duty to the client,
is due to low calcium levels. The crash cart that the nurse breached the duty, and that as a
would be needed in respiratory distress but result harm was caused to person or property.
would not be the next action to take; thus, The client has an increased risk of
answer A is incorrect. Hypertension occurs in hypotension because hypotension is a
thyroid storm and the drainage would occur in common adverse effect of bumetanide, this is
hemorrhage, so answers C and D are the second dose within 4 hours, and the client
incorrect. has heart failure. The client can prove that the
25.Answer D . The decrease in pulse can affect nurse did not protect him by failing to provide
the cardiac output and lead to shock, which adequate teaching and perform correct and
would take precedence over the other choices; timely nursing interventions after
therefore, answers A, B, and C are incorrect. administering the bumetanide. After the first
26.Answers A, C, and D. Anthrax is caused by 15-minute check, the nurse should continue
Bacillus anthracis, and it can be contracted increased client monitoring to ensure client
through the digestive system, abrasions in the compliance with safety measures. Replacing
skin, or inhalation. It cannot be spread from fluid volume is not the issue; furthermore, the
person to person. goal of therapy is to reduce total body fluid.
27.Answer A. Toddlers, with their increased No data indicate that the dose of bumetanide,
mobility and developing motor skills, can a loop diuretic, was excessive. However,
reach hot water, open fires, or hot objects because this medication can cause
placed on counters and stoves above their eye hypotension, especially after a repeat dose, the
level. Parents should be encouraged to remain nurse should instruct the client to remain in
in the kitchen when preparing a meal and bed and provide him with a urinal. It may be
reminded to use the back burners on the stove. difficult for the client to prove that the second
Pot handles should be turned inward and dose of bumetanide caused the injury.
toward the middle of the stove. Hot liquids
should never be left unattended, and the
toddler should always be supervised. All other
answer choices do not reflect an adequate
understanding of the principles of safety.
28.Answer C. In team nursing, nursing
personnel are led by a nurse when providing
care to a group of clients. A task approach
method is used to provide care to clients-
identifies functional nursing. Managed care
concepts and tools used when providing client
care – identifies a component of case
management.  The statement a single
registered nurse is responsible for providing
nursing care to a group of clients- identifies
primary nursing.
29.Answer B. The nurse must determine the
most appropriate assignment on the basis of
the skills of the staff member and the needs of
the client. In this case, the most appropriate
assignment for a nursing assistant would be to
care for the client who requires frequent
ambulation. The nursing assistant is skilled in
 NCLEX RN Practice Exam 8 D. Sacrum
7. The nurse is checking the client’s
1. The client presents to the clinic with a
central venous pressure. The nurse
serum cholesterol of 275mg/dL and is
should place the zero of the manometer
placed on rosuvastatin (Crestor). Which
at the:
instruction should be given to the client?
A. Phlebostatic axis
A. Report muscle weakness to the physician.
B. PMI
B. Allow six months for the drug to take effect.
C. Erb’s point
C. Take the medication with fruit juice.
D.  Tail of Spence
D. Ask the doctor to perform a complete blood
count before starting the medication. 8. The physician orders lisinopril (Zestril)
2. The client is admitted to the hospital and furosemide (Lasix) to be
with hypertensive crises. Diazoxide administered concomitantly to the client
(Hyperstat) is ordered. During with hypertension. The nurse should:
administration, the nurse should: A. Question the order
B. Administer the medications
A. Utilize an infusion pump
C. Administer separately
B. Check the blood glucose level
D. Contact the pharmacy
C. Place the client in Trendelenburg position
D. Cover the solution with foil 9. The best method of evaluating the
3. The 6-month-old client with a ventral amount of peripheral edema is:
septal defect is receiving Digitalis for A. Weighing the client daily
regulation of his heart rate. Which finding B. Measuring the extremity
should be reported to the doctor? C. Measuring the intake and output
D. Checking for pitting
A. Blood pressure of 126/80 10. A client with vaginal cancer is being
B. Blood glucose of 110mg/dL
treated with a radioactive vaginal implant.
C. Heart rate of 60bpm
D. Respiratory rate of 30 per minute The client’s husband asks the nurse if he
4. The client admitted with angina is given can spend the night with his wife. The
a prescription for nitroglycerine. The client nurse should explain that:
should be instructed to: A. Overnight stays by family members is against
hospital policy.
A. Replenish his supply every 3 months
B. There is no need for him to stay because
B. Take one every 15 minutes if pain occurs
staffing is adequate.
C. Leave the medication in the brown bottle
C. His wife will rest much better knowing that he
D. Crush the medication and take with water
is at home.
5. The client is instructed regarding foods D. Visitation is limited to 30 minutes when the
that are low in fat and cholesterol. Which implant is in place.
diet selection is lowest in saturated fats? 11. The nurse is caring for a client
A. Macaroni and cheese hospitalized with a facial stroke. Which
B. Shrimp with rice diet selection would be suited to the
C. Turkey breast client?
D. Spaghetti
A. Roast beef sandwich, potato chips, pickle
6. The client is admitted with left-sided
spear, iced tea
congestive heart failure. In assessing the B. Split pea soup, mashed potatoes, pudding,
client for edema, the nurse should check milk
the: C. Tomato soup, cheese toast, Jello, coffee
D. Hamburger, baked beans, fruit cup, iced tea
A. Feet
12. The physician has prescribed Novalog
B. Neck
C. Hands insulin for a client with diabetes mellitus.
 Which statement indicates that the client A. 30 minutes before meals
knows when the peak action of the insulin B. With each meal
C. In a single dose at bedtime
occurs?
D. 30 minutes after meals
A. “I will make sure I eat breakfast within 10 17. A client on the psychiatric unit is in an
minutes of taking my insulin.” uncontrolled rage and is threatening other
B.  “I will need to carry candy or some form of clients and staff. What is the most
sugar with me all the time.”
appropriate action for the nurse to take?
C. “I will eat a snack around three o’clock each
afternoon.” A. Call security for assistance and prepare to
D. “I can save my dessert from supper for a sedate the client.
bedtime snack.” B. Tell the client to calm down and ask him if he
13. The nurse is teaching basic infant would like to play cards.
care to a group of first-time parents. The C. Tell the client that if he continues his behavior
nurse should explain that a sponge bath he will be punished.
D.  Leave the client alone until he calms down.
is recommended for the first 2 weeks of
18. When the nurse checks the fundus of
life because:
a client on the first postpartum day, she
A. New parents need time to learn how to hold notes that the fundus is firm, is at the
the baby. level of the umbilicus, and is displaced to
B. The umbilical cord needs time to separate.
the right. The next action the nurse
C. Newborn skin is easily traumatized by
washing. should take is to:
D. The chance of chilling the baby outweighs the A. Check the client for bladder distention
benefits of bathing. B. Assess the blood pressure for hypotension
14. A client with leukemia is receiving C. Determine whether an oxytocic drug was
Trimetrexate. After reviewing the client’s given
chart, the physician orders Wellcovorin D. Check for the expulsion of small clots
(leucovorin calcium). The rationale for 19. A client is admitted to the hospital with
administering leucovorin calcium to a a temperature of 99.8°F, complaints of
client receiving Trimetrexate is to: blood-tinged hemoptysis, fatigue, and
night sweats. The client’s symptoms are
A. Treat iron-deficiency anemia caused by
consistent with a diagnosis of:
chemotherapeutic agents
B. Create a synergistic effect that shortens A. Pneumonia
treatment time B. Reaction to antiviral medication
C. Increase the number of circulating neutrophils C. Tuberculosis
D. Reverse drug toxicity and prevent tissue D. Superinfection due to low CD4 count
damage 20. The client is seen in the clinic for
15. A 4-month-old is brought to the well- treatment of migraine headaches. The
baby clinic for immunization. In addition to drug Imitrex (sumatriptan succinate) is
the DPT and polio vaccines, the baby prescribed for the client. Which of the
should receive: following in the client’s history should be
A. Hib titer reported to the doctor?
B. Mumps vaccine
A. Diabetes
C. Hepatitis B vaccine
B. Prinzmetal’s angina
D. MMR
C. Cancer
16. The physician has prescribed Nexium D. Cluster headaches
(esomeprazole) for a client with erosive 21. The client with suspected meningitis
gastritis. The nurse should administer the is admitted to the unit. The doctor is
medication: performing an assessment to determine
 meningeal irritation and spinal nerve root D. Nausea
inflammation. A positive Kernig’s sign is 26. A nurse develops a plan of care for a
charted if the nurse notes: client following a lumbar puncture. Which
interventions should be included in the
A. Pain on flexion of the hip and knee
plan? Select all that apply.
B. Nuchal rigidity on flexion of the neck A. Monitor the client’s ability to void.
C. Pain when the head is turned to the left side
B. Maintain the client in a flat position.
D. Dizziness when changing positions C. Restrict fluid intake for a period of 2 hours.
22. The client with Alzheimer’s disease is D. Monitor the client’s ability to move the
being assisted with activities of daily living extremities.
when the nurse notes that the client uses E. Inspect the puncture site for swelling, redness,
her toothbrush to brush her hair. The and drainage.
nurse is aware that the client is exhibiting: F. Maintain the client on a nothing-by-mouth
(NPO) status for 24 hours.
A. Agnosia 27. A nurse employed in an emergency
B. Apraxia department is assigned to assist with the
C. Anomia triage of clients arriving to the emergency
D. Aphasia
department for treatment on the evening
23. The client with dementia is
shift. The nurse would assign the highest
experiencing confusion late in the
priority to which of the following clients?
afternoon and before bedtime. The nurse
is aware that the client is experiencing A. A client complaining of muscle aches, a
what is known as: headache, and malaise
B. A client who twisted her ankle when she fell
A. Chronic fatigue syndrome while rollerblading
B. Normal aging C. A client with a minor laceration on the index
C. Sundowning finger sustained while cutting an eggplant
D. Delusions D. A client with chest pain who states that he just
24. The client with confusion says to the ate pizza that was made with a very spicy
nurse, “I haven’t had anything to eat all sauce
day long. When are they going to bring 28. A nurse enters a client’s room and
breakfast?” The nurse saw the client in notes that the client’s lawyer is present
the day room eating breakfast with other and that the client is preparing a living
clients 30 minutes before this will. The living will requires that the
conversation. Which response would be client’s signature be witnessed, and the
best for the nurse to make? client asks the nurse to witness the
signature. Which of the following is the
A. “You know you had breakfast 30 minutes appropriate nursing action?
ago.”
B. “I am so sorry that they didn’t get you A. Decline to sign the will.
breakfast. I’ll report it to the charge nurse.” B. Sign the will as a witness to the signature
C. “I’ll get you some juice and toast. Would you only.
like something else?” C. Call the hospital lawyer before signing the
D. “You will have to wait a while; lunch will be will.
here in a little while.” D. Sign the will, clearly identifying credentials
25. The doctor has prescribed Exelon and employment agency.
(rivastigmine) for the client with 29. A nurse has reinforced instructions to
Alzheimer’s disease. Which side effect is the client with hyperparathyroidism
most often associated with this drug? regarding home care measures related to
exercise. Which statement by the client
A. Urinary incontinence
indicates a need for further
B. Headaches
C. Confusion instruction? Select all that apply.
A. “I enjoy exercising but I need to be careful.” 4. Answer C. Nitroglycerine should be kept in a
B. “I need to pace my activities throughout the brown bottle (or even a special air- and water-
day.” tight, solid or plated silver or gold container)
C. “I need to limit playing football to only the because of its instability and tendency to
weekends.” become less potent when exposed to air, light,
D. “I should gauge my activity level by my or water. The supply should be replenished
energy level.” every 6 months, not 3 months, and one tablet
E. “I should exercise in the evening to encourage should be taken every 5 minutes until pain
a good sleep pattern.” subsides, so answers A and B are incorrect. If
30. A nurse in a medical unit is caring for the pain does not subside, the client should
a client with heart failure. The client report to the emergency room. The medication
should be taken sublingually and should not
suddenly develops extreme dyspnea,
be crushed, as stated in answer D.
tachycardia, and lung crackles, and the 5. Answer C . Turkey contains the least amount
nurse suspects pulmonary edema. The of fats and cholesterol. Liver, eggs, beef,
nurse immediately notifies the registered cream sauces, shrimp, cheese, and chocolate
nurse and expects which interventions to should be avoided by the client; thus, answers
be prescribed? Select all that apply. A, B, and D are incorrect. The client should
A. Administering oxygen bake meat rather than frying to avoid adding
B. Inserting a Foley catheter fat to the meat during cooking.
C. Administering furosemide (Lasix) 6. Answer B . The jugular veins in the neck
D. Administering morphine sulfate intravenously should be assessed for distension. The other
E. Transporting the client to the coronary care parts of the body will be edematous in right-
unit sided congestive heart failure, not left-sided;
F. Placing the client in a low Fowler’s side-lying thus, answers A, C, and D are incorrect.
position 7. Answer A . The phlebostatic axis is located at
the fifth intercostals space midaxillary line
Answers and Rationales
and is the correct placement of the
1. Answer A . The client taking antilipidemics
manometer. The PMI or point of maximal
should be encouraged to report muscle
impulse is located at the fifth intercostals
weakness because this is a sign of
space midclavicular line, so answer B is
rhabdomyositis. The medication takes effect
incorrect. Erb’s point is the point at which you
within 1 month of beginning therapy, so
can hear the valves close simultaneously,
answer B is incorrect. The medication should
making answer C incorrect. The Tail of
be taken with water because fruit juice,
Spence (the upper outer quadrant) is the area
particularly grapefruit, can decrease the
where most breast cancers are located and has
effectiveness, making answer C incorrect.
nothing to do with placement of a manometer;
Liver function studies should be checked
thus, answer D is incorrect.
before beginning the medication, not after the
8. Answer B . Zestril is an ACE inhibitor and is
fact, making answer D incorrect.
frequently given with a diuretic such as Lasix
2. Answer B. Hyperstat is given IV push for
for hypertension. Answers A, C, and D are
hypertensive crises, but it often causes
incorrect because the order is accurate. There
hyperglycemia. The glucose level will drop
is no need to question the order, administer
rapidly when stopped. Answer A is incorrect
the medication separately, or contact the
because the hyperstat is given by IV push.
pharmacy.
The client should be placed in dorsal
9. Answer B . The best indicator of peripheral
recumbent position, not a Trendelenburg
edema is measuring the extremity. A paper
position, as stated in answer C. Answer D is
tape measure should be used rather than one
incorrect because the medication does not
of plastic or cloth, and the area should be
have to be covered with foil.
marked with a pen, providing the most
3. Answer C . A heart rate of 60 in the baby
objective assessment. Answer A is incorrect
should be reported immediately. The dose
because weighing the client will not indicate
should be held if the heart rate is below
peripheral edema. Answer C is incorrect
100bpm. The blood glucose, blood pressure,
because checking the intake and output will
and respirations are within normal limits; thus
not indicate peripheral edema. Answer D is
answers A, B, and D are incorrect.
 incorrect because checking for pitting edema 17.Answer A. If the client is a threat to the staff
is less reliable than measuring with a paper and to other clients the nurse should call for
tape measure. help and prepare to administer a medication
10.Answer D. Clients with radium implants such as Haldol to sedate him. Answer B is
should have close contact limited to 30 incorrect because simply telling the client to
minutes per visit. The general rule is limiting calm down will not work. Answer C is
time spent exposed to radium, putting distance incorrect because telling the client that if he
between people and the radium source, and continues he will be punished is a threat and
using lead to shield against the radium. may further anger him. Answer D is incorrect
Teaching the family member these principles because if the client is left alone he might
is extremely important. Answers A, B, and C harm himself.
are not empathetic and do not address the 18.Answer A . If the fundus of the client is
question; therefore, they are incorrect. displaced to the side, this might indicate a full
11.Answer B. The client with a facial stroke will bladder. The next action by the nurse should
have difficulty swallowing and chewing, and be to check for bladder distention and
the foods in answer B provide the least catheterize, if necessary. The answers in B, C,
amount of chewing. The foods in answers A, and D are actions that relate to postpartal
C, and D would require more chewing and, hemorrhage.
thus, are incorrect. 19.Answer C . A low-grade temperature, blood-
12.Answer A . Novalog insulin onsets very tinged sputum, fatigue, and night sweats are
quickly, so food should be available within symptoms consistent with tuberculosis. If the
10–15 minutes of taking the insulin. Answer answer in A had said pneumocystis
B does not address a particular type of insulin, pneumonia, answer A would have been
so it is incorrect. NPH insulin peaks in 8–12 consistent with the symptoms given in the
hours, so a snack should be eaten at the stem, but just saying pneumonia isn’t specific
expected peak time. It may not be 3 p.m. as enough to diagnose the problem. Answers B
stated in answer C. Answer D is incorrect and D are not directly related to the stem.
because there is no need to save the dessert 20.Answer B . If the client has a history of
until bedtime. Prinzmetal’s angina, he should not be
13.Answer B . The umbilical cord needs time to prescribed triptan preparations because they
dry and fall off before putting the infant in the cause vasoconstriction and coronary spasms.
tub. Although answers A, C, and D might be There is no contraindication for taking triptan
important, they are not the primary answer to drugs in clients with diabetes, cancer, or
the question. cluster headaches making answers A, C, and
14.Answer D. Leucovorin is the antidote for D incorrect.
Methotrexate and Trimetrexate which are 21.Answer A . Kernig’s sign is positive if pain
folic acid antagonists. Leucovorin is a folic occurs on flexion of the hip and knee. The
acid derivative. Answers A, B, and C are Brudzinski reflex is positive if pain occurs on
incorrect because Leucovorin does not treat flexion of the head and neck onto the chest so
iron deficiency, increase neutrophils, or have answer B is incorrect. Answers C and D might
a synergistic effect. be present but are not related to Kernig’s sign.
15.Answer A. The Hemophilus influenza 22.Answer B. Apraxia is the inability to use
vaccine is given at 4 months with the polio objects appropriately. Agnosia is loss of
vaccine. Answers B, C, and D are incorrect sensory comprehension, anomia is the
because these vaccines are given later in life. inability to find words, and aphasia is the
16.Answer B. Proton pump inhibitors such as inability to speak or understand so answers A,
Nexium and Protonix should be taken with C, and D are incorrect.
meals, for optimal effect. Histamine-blocking 23.Answer C . Increased confusion at night is
agents such as Zantac should be taken 30 known as “sundowning” syndrome. This
minutes before meals, so answer A is increased confusion occurs when the sun
incorrect. Tagamet can be taken in a single begins to set and continues during the night.
dose at bedtime, making answer C incorrect. Answer A is incorrect because fatigue is not
Answer D does not treat the problem necessarily present. Increased confusion at
adequately and, therefore, is incorrect. night is not part of normal aging; therefore,
 answer B is incorrect. A delusion is a firm, including a nurse in a facility in which the
fixed belief; therefore, answer D is incorrect. client is receiving care.
24.Answer C . The client who is confused might 29.Answers C and E. The client should be
forget that he ate earlier. Don’t argue with the instructed to avoid high-impact activity or
client. Simply get him something to eat that contact sports such as football. Exercising late
will satisfy him until lunch. Answers A and D in the evening may interfere with restful sleep.
are incorrect because the nurse is dismissing The client with hyperparathyroidism should
the client. Answer B is validating the pace activities throughout the day and plan for
delusion. periods of uninterrupted rest. The client
25.Answer D . Nausea and gastrointestinal upset should plan for at least 30 minutes of walking
are very common in clients taking each day to support calcium movement into
acetlcholinesterase inhibitors such as Exelon. the bones. The client should be instructed to
Other side effects include liver toxicity, use energy level as a guide to activity.
dizziness, unsteadiness, and clumsiness. The 30.Answers A, B, C, and D. Pulmonary edema
client might already be experiencing urinary is a life-threatening event that can result from
incontinence or headaches, but they are not severe heart failure. In pulmonary edema the
necessarily associated; and the client with left ventricle fails to eject sufficient blood,
Alzheimer’s disease is already confused. and pressure increases in the lungs because of
Therefore, answers A, B, and C are incorrect. the accumulated blood. Oxygen is always
26.Answers A, B, D, and E. Following a lumbar prescribed, and the client is placed in a high
puncture, the client remains flat in bed for 6 to Fowler’s position to ease the work of
24 hours, depending on the health care breathing. Furosemide, a rapid-acting diuretic,
provider’s prescriptions. A liberal fluid intake will eliminate accumulated fluid. A Foley
(not NPO status) is encouraged to replace catheter is inserted to accurately measure
cerebrospinal fluid removed during the output. Intravenously administered morphine
procedure, unless contraindicated by the sulfate reduces venous return (preload),
client’s condition. The nurse checks the decreases anxiety, and reduces the work of
puncture site for redness and drainage, and breathing. Transporting the client to the
monitors the client’s ability to void and move coronary care unit is not a priority
the extremities. intervention. In fact, this may not be
27.Answers D. In an emergency department, necessary at all if the client’s response to
triage involves classifying clients according to treatment is successful.
their need for care, and it includes establishing
priorities of care. The type of illness, the
severity of the problem, and the resources
available govern the process. Clients with
trauma, chest pain, severe respiratory distress,
cardiac arrest, limb amputation, or acute
neurological deficits and those who sustained
a chemical splash to the eyes are classified as
emergent, and these clients are the number 1
priority. Clients with conditions such as
simple fractures, asthma without respiratory
distress, fever, hypertension, abdominal pain,
or renal stones have urgent needs, and these
clients are classified as the number 2 priority.
Clients with conditions such as minor
lacerations, sprains, or cold symptoms are
classified as non urgent, and they are the
number 3 priority.
28.Answers A. Living wills are required to be in
writing and signed by the client. The client’s
signature either must be witnessed by
specified individuals or notarized. Many states
prohibit any employee from being a witness,
 NCLEX RN Practice Exam 9 A. The nurse places her thumb on the muscle
inset in the antecubital space and taps the
1. A client is admitted to the labor and thumb briskly with the reflex hammer.
delivery unit in active labor. During B. The nurse loosely suspends the client’s arm in
examination, the nurse notes a papular an open hand while tapping the back of the
lesion on the perineum. Which initial client’s elbow.
action is most appropriate? C. The nurse instructs the client to dangle her
legs as the nurse strikes the area below the
A. Document the finding patella with the blunt side of the reflex
B. Report the finding to the doctor hammer.
C. Prepare the client for a C-section D. The nurse instructs the client to place her arms
D. Continue primary care as prescribed loosely at her side as the nurse strikes the
2. A client with a diagnosis of HPV is at muscle insert just above the wrist.
risk for which of the following? 7. A primigravida with diabetes is
admitted to the labor and delivery unit at
A. Hodgkin’s lymphoma
34 weeks gestation. Which doctor’s order
B. Cervical cancer
C. Multiple myeloma should the nurse question?
D. Ovarian cancer A. Magnesium sulfate 4gm (25%) IV
3. During the initial interview, the client B. Brethine 10mcg IV
reports that she has a lesion on the C. Stadol 1mg IV push every 4 hours as needed
perineum. Further investigation reveals a prn for pain
small blister on the vulva that is painful to D. Ancef 2gm IVPB every 6 hours
touch. The nurse is aware that the most 8. A diabetic multigravida is scheduled for
likely source of the lesion is: an amniocentesis at 32 weeks gestation
to determine the L/S ratio and
A. Syphilis phosphatidyl glycerol level. The L/S ratio
B. Herpes
is 1:1 and the presence of
C. Gonorrhea
D. Condylomata phosphatidylglycerol is noted. The nurse’s
4. A client visiting a family planning clinic assessment of this data is:
is suspected of having an STI. The best A. The infant is at low risk for congenital
diagnostic test for treponema pallidum is: anomalies.
B. The infant is at high risk for intrauterine
A. Venereal Disease Research Lab (VDRL) growth retardation.
B. Rapid plasma reagin (RPR) C. The infant is at high risk for respiratory
C. Florescent treponemal antibody (FTA) distress syndrome.
D. Thayer-Martin culture (TMC) D. The infant is at high risk for birth trauma.
5. A 15-year-old primigravida is admitted 9. Which observation in the newborn of a
with a tentative diagnosis of HELLP diabetic mother would require immediate
syndrome. Which laboratory finding is nursing intervention?
associated with HELLP syndrome?
A. Crying
A. Elevated blood glucose B. Wakefulness
B. Elevated platelet count C. Jitteriness
C. Elevated creatinine clearance D. Yawning
D. Elevated hepatic enzymes 10. The nurse caring for a client receiving
6. The nurse is assessing the deep intravenous magnesium sulfate must
tendon reflexes of a client with closely observe for side effects
preeclampsia. Which method is used to associated with drug therapy. An
elicit the biceps reflex? expected side effect of magnesium
sulfate is:
A. Decreased urinary output visitation, a visitor brings a basket of fruit.
B. Hypersomnolence What action should the nurse take?
C. Absence of knee jerk reflex
D. Decreased respiratory rate A. Allow the client to keep the fruit
11. The client has elected to have B. Place the fruit next to the bed for easy access
epidural anesthesia to relieve labor pain. by the client
C. Offer to wash the fruit for the client
If the client experiences hypotension, the
D.  Tell the family members to take the fruit
nurse would: home
A. Place her in Trendelenburg position 17. The nurse is caring for the client
B. Decrease the rate of IV infusion following a laryngectomy when suddenly
C. Administer oxygen per nasal cannula the client becomes nonresponsive and
D. Increase the rate of the IV infusion pale, with a BP of 90/40 systolic. The
12. A client has cancer of the pancreas. initial nurse’s action should be to:
The nurse should be most concerned
about which nursing diagnosis? A. Place the client in Trendelenburg position
B. Increase the infusion of Dextrose in normal
A. Alteration in nutrition saline
B. Alteration in bowel elimination C. Administer atropine intravenously
C. Alteration in skin integrity D. Move the emergency cart to the bedside
D. Ineffective individual coping 18. The client admitted 2 days earlier with
13. The nurse is caring for a client with a lung resection accidentally pulls out the
ascites. Which is the best method to use chest tube. Which action by the nurse
for determining early ascites? indicates understanding of the
A. Inspection of the abdomen for enlargement management of chest tubes?
B. Bimanual palpation for hepatomegaly A. Order a chest x-ray
C. Daily measurement of abdominal girth B. Reinsert the tube
D. Assessment for a fluid wave C. Cover the insertion site with a Vaseline gauze
14. The client arrives in the emergency D. Call the doctor
department after a motor vehicle 19. A client being treated with sodium
accident. Nursing assessment findings warfarin has a Protime of 120 seconds.
include BP 80/34, pulse rate 120, and Which intervention would be most
respirations 20. Which is the client’s most important to include in the nursing care
appropriate priority nursing diagnosis? plan?
A. Alteration in cerebral tissue perfusion A. ssess for signs of abnormal bleeding
B. Fluid volume deficit B. Anticipate an increase in the Coumadin
C. Ineffective airway clearance dosage
D. Alteration in sensory perception C. Instruct the client regarding the drug therapy
15. The home health nurse is visiting an D. Increase the frequency of neurological
18-year-old with osteogenesis imperfecta. assessments
Which information obtained on the visit 20. Which selection would provide the
would cause the most concern? The most calcium for the client who is 4
client: months pregnant?

A. Likes to play football A. A granola bar

B. Drinks several carbonated drinks per day B. A bran muffin
C. Has two sisters with sickle cell tract C. A cup of yogurt
D. Is taking acetaminophen to control pain D. A glass of fruit juice
16. The nurse working the organ 21. The client with preeclampsia is
transplant unit is caring for a client with a admitted to the unit with an order for
white blood cell count of During evening magnesium sulfate. Which action by the
 nurse indicates understanding of the A. Pain beneath the cast
possible side effects of magnesium B. Warm toes
C. Pedal pulses weak and rapid
sulfate?
D. Paresthesia of the toes
A. The nurse places a sign over the bed not to 26. A nurse is admitting a client with a
check blood pressure in the right arm. possible diagnosis of chronic bronchitis.
B. The nurse places a padded tongue blade at the The nurse collects data from the client
bedside.
and notes that which of the following
C. The nurse inserts a Foley catheter.
D.  The nurse darkens the room. signs supports this diagnosis? Select all
22. A 6-year-old client is admitted to the that apply.
A. Scant mucus
unit with a hemoglobin of 6g/dL. The B. Early onset cough
physician has written an order to C. Marked weight loss
transfuse 2 units of whole blood. When D. Purulent mucus production
discussing the treatment, the child’s E. Mild episodes of dyspnea
mother tells the nurse that she does not 27. A nurse is assigned to care for a client
believe in having blood transfusions and admitted to the hospital after sustaining
that she will not allow her child to have an injury from a house fire. The client
the treatment. What nursing action is attempted to save a neighbor involved in
most appropriate? the fire but, in spite of the client’s efforts,
the neighbor died. Which action would the
A. Ask the mother to leave while the blood
nurse take to enable the client to work
transfusion is in progress
B. Encourage the mother to reconsider through the meaning of the crisis?
C. Explain the consequences without treatment
A. Identifying the client’s ability to function
D. Notify the physician of the mother’s refusal B. Identifying the client’s potential for self-harm
23. A client is admitted to the unit 2 hours C. Inquiring about the client’s feelings that may
after an explosion causes burns to the affect coping
face. The nurse would be most concerned D. Inquiring about the client’s perception of the
with the client developing which of the cause of the neighbor’s death
following? 28. A nurse is assigned to care for a client
with a peripheral IV infusion. The nurse is
A. Hypovolemia providing hygiene care to the client and
B. Laryngeal edema
would avoid which of the following while
C. Hypernatremia
D. Hyperkalemia changing the client’s hospital gown?
24. The nurse is evaluating nutritional A. Using a hospital gown with snaps at the
outcomes for an elderly client with sleeves
bulimia. Which data best indicates that B. Disconnecting the IV tubing from the catheter
the plan of care is effective? in the vein
C. Checking the IV flow rate immediately after
A. The client selects a balanced diet from the changing the hospital gown
menu. D. Putting the bag and tubing through the sleeve,
B. The client’s hemoglobin and hematocrit followed by the client’s arm
improve. 29. A nurse is assigned to care for four
C. The client’s tissue turgor improves. clients. When planning client rounds,
D.  The client gains weight.
which client would the nurse check first?
25. The client is admitted following repair
of a fractured tibia and cast application. A. A client on a ventilator
Which nursing assessment should be B. A client in skeletal traction
reported to the doctor? C. A postoperative client preparing for discharge
D. A client admitted on the previous shift who 34. A nurse is caring for a client with a
has a diagnosis of gastroenteritis healthcare-associated infection caused by
30. A nurse is assisting with collecting methicillin-resistant Staphylococcus
data from an African-American client aureus who is on contact precautions.
admitted to the ambulatory care unit who The nurse prepares to provide colostomy
is scheduled for a hernia repair. Which of care to the client. Which of the following
the following information about the client protective items will be required to
is of least priority during the data perform this procedure?
collection?
A. Gloves and a gown
A. Respiratory B. Gloves and goggles
B. Psychosocial C. Gloves, a gown, and goggles
C. Neurological D. Gloves, a gown, and shoe protectors
D. Cardiovascular 35. A nurse is caring for a client with a
31. A nurse is assisting with planning care nasogastric tube that is attached to low
for a client with an internal radiation suction. The nurse monitors the client
implant. Which of the following should be closely for which acid-base disorder that
included in the plan of care? Select all that is most likely to occur in this situation?
apply.
A. Wearing gloves when emptying the client’s A. Metabolic acidosis
bedpan B. Metabolic alkalosis
B. Keeping all linens in the room until the C. Respiratory acidosis
implant is removed D. Respiratory alkalosis
C. Wearing a film (dosimeter) badge when in the 36. A nurse is caring for a client with
client’s room diabetic ketoacidosis and documents that
D. Wearing a lead apron when providing direct the client is experiencing Kussmaul’s
care to the client
respirations. Based on this
E. Placing the client in a semiprivate room at the
end of the hallway documentation, which of the following did
32. The nurse is caring for a client after a the nurse most likely observe?
supratentorial craniotomy in which a large A. Respirations that cease for several seconds
tumor was removed from the left side. B. Respirations that are regular but abnormally
Choose the positions in which the nurse slow
can safely place the client. Select all that C. Respirations that are labored and increased in
apply. depth and rate
A. On the left side D. Respirations that are abnormally deep,
B. With the neck flexed regular, and increased in rate
C. Supine on the left side 37. Which nursing interventions are
D. With extreme hip flexion appropriate for a client recovering from
E. In a semi-Fowler’s position surgery for retinal detachment? Select all
F. With the head in a midline position that apply.
33. A nurse is caring for a client after A. Monitor for hemorrhage.
thyroidectomy and notes that calcium B. Administer eye medications.
gluconate is prescribed for the client. The C. Maintain the eye patch or shield.
nurse determines that this medication has D. Assist with activities of daily living.
E. Encourage coughing and deep breathing.
been prescribed to:
F. Educate regarding symptoms of retinal
A. Treat thyroid storm. detachment.
B. Prevent cardiac irritability. 38. A nurse is caring for a client with
C. Treat hypocalcemic tetany. leukemia and notes that the client has
D. Stimulate the release of parathyroid hormone. poor skin turgor and flat neck and hand
veins. The nurse suspects hyponatremia.
 What additional signs would the nurse 3. Answer B . A lesion that is painful is most
expect to note in this client if likely a herpetic lesion. A chancre lesion
associated with syphilis is not painful, so
hyponatremia is present?
answer A is incorrect. Condylomata lesions
A. Intense thirst are painless warts, so answer D is incorrect. In
B. Slow bounding pulse answer C, gonorrhea does not present as a
C. Dry mucous membranes lesion, but is exhibited by a yellow discharge.
D. Postural blood pressure changes 4. Answer C . Florescent treponemal antibody
39. A nurse is caring for a group of clients (FTA) is the test for treponema pallidum.
VDRL and RPR are screening tests done for
who are taking herbal medications at
syphilis, so answers A and B are incorrect.
home. Which of the following clients The Thayer-Martin culture is done for
should be instructed not to take herbal gonorrhea, so answer D is incorrect.
medications? 5. Answer D . The criteria for HELLP is
hemolysis, elevated liver enzymes, and low
A. A 60-year-old male client with rhinitis platelet count. In answer A, an elevated blood
B. A 24-year-old male client with a lower back glucose level is not associated with HELLP.
injury Platelets are decreased, not elevated, in
C. A 10-year-old female client with a urinary HELLP syndrome as stated in answer B. The
tract infection creatinine levels are elevated in renal disease
D. A 45-year-old female client with a history of and are not associated with HELLP syndrome
migraine headaches so answer C is incorrect.
40. A nurse is caring for an infant with a 6. Answer A . Answer B elicits the triceps
diagnosis of tetralogy of Fallot. The infant reflex, so it is incorrect. Answer C elicits the
suddenly becomes cyanotic and the patella reflex, making it incorrect. Answer D
oxygen saturation reading drops to 60%. elicits the radial nerve, so it is incorrect.
7. Answer B . Brethine is used cautiously
Choose the interventions that the nurse
because it raises the blood glucose levels.
should perform. Select all that apply. Answers A, C, and D are all medications that
A. Call a code blue. are commonly used in the diabetic client, so
B. Notify the registered nurse. they are incorrect.
C. Place the infant in a prone position. 8. Answer C. When the L/S ratio reaches 2:1,
D. Prepare to administer morphine sulfate. the lungs are considered to be mature. The
E. Prepare to administer intravenous fluids. infant will most likely be small for gestational
F. Prepare to administer 100% oxygen by face age and will not be at risk for birth trauma, so
mask. answer D is incorrect. The L/S ratio does not
Answers and Rationales indicate congenital anomalies, as stated in
1. Answer B. Any lesion should be reported to answer A, and the infant is not at risk for
the doctor. This can indicate a herpes lesion. intrauterine growth retardation, making
Clients with open lesions related to herpes are answer B incorrect.
delivered by Cesarean section because there is 9. Answer C . Jitteriness is a sign of seizure in
a possibility of transmission of the infection to the neonate. Crying, wakefulness, and
the fetus with direct contact to lesions. It is yawning are expected in the newborn, so
not enough to document the finding, so answers A, B, and D are incorrect.
answer A is incorrect. The physician must 10.Answer B. The client is expected to become
make the decision to perform a C-section, sleepy, have hot flashes, and be lethargic. A
making answer C incorrect. It is not enough to decreasing urinary output, absence of the
continue primary care, so answer D is knee-jerk reflex, and decreased respirations
incorrect. indicate toxicity, so answers A, C, and D are
2. Answer B . The client with HPV is at higher incorrect.
risk for cervical and vaginal cancer related to 11.Answer D. If the client experiences
this STI. She is not at higher risk for the other hypotension after an injection of epidural
cancers mentioned in answers A, C, and D, so anesthetic, the nurse should turn her to the left
those are incorrect. side, apply oxygen by mask, and speed the IV
infusion. If the blood pressure does not return
 to normal, the physician should be contacted. further hypotension. Answer D is not
Epinephrine should be kept for emergency necessary at this time.
administration. Answer A is incorrect because 18.Answer C. If the client pulls the chest tube
placing the client in Trendelenburg position out of the chest, the nurse’s first action should
(head down) will allow the anesthesia to move be to cover the insertion site with an occlusive
up above the respiratory center, thereby dressing. Afterward, the nurse should call the
decreasing the diaphragm’s ability to move up doctor, who will order a chest x-ray and
and down and ventilate the client. In answer possibly reinsert the tube. Answers A, B, and
B, the IV rate should be increased, not D are not the first action to be taken.
decreased. In answer C, the oxygen should be 19.Answer A. The normal Protime is 12–20
applied by mask, not cannula. seconds. A Protime of 120 seconds indicates
12.Answer A . Cancer of the pancreas frequently an extremely prolonged Protime and can
leads to severe nausea and vomiting and result in a spontaneous bleeding episode.
altered nutrition. The other problems are of Answers B, C, and D may be needed at a later
lesser concern; thus, answers B, C, and D are time but are not the most important actions to
incorrect. take first.
13.Answer C. Measuring with a paper tape 20.Answer C. The food with the most calcium is
measure and marking the area that is the yogurt. Answers A, B, and D are good
measured is the most objective method of choices, but not as good as the yogurt, which
estimating ascites. Inspecting and checking has approximately 400mg of calcium.
for fluid waves are more subjective, so 21.Answer C.  The client receiving magnesium
answers A and B are incorrect. Palpation of sulfate should have a Foley catheter in place,
the liver will not tell the amount of ascites; and hourly intake and output should be
thus, answer D is incorrect. checked. There is no need to refrain from
14.Answer B. The vital signs indicate checking the blood pressure in the right arm.
hypovolemic shock. They do not indicate A padded tongue blade should be kept in the
cerebral tissue perfusion, airway clearance, or room at the bedside, just in case of a seizure,
sensory perception alterations, so answers A, but this is not related to the magnesium sulfate
C, and D are incorrect. infusion. Darkening the room is unnecessary,
15.Answer A. The client with osteogenesis so answers A, B, and D are incorrect.
imperfecta is at risk for pathological fractures 22.Answer D. If the client’s mother refuses the
and is likely to experience these fractures if he blood transfusion, the doctor should be
participates in contact sports. The client might notified. Because the client is a minor, the
experience symptoms of hypoxia if he court might order treatment. Answer A is
becomes dehydrated or deoxygenated; incorrect. Because it is not the primary
extreme exercise, especially in warm weather, responsibility for the nurse to encourage the
can exacerbate the condition. Answers B, C, mother to consent or explain the
and D are not factors for concern. consequences, so answers B and C are
16.Answer D. The client with neutropenia incorrect.
should not have fresh fruit because it should 23.Answer B. The nurse should be most
be peeled and/or cooked before eating. He concerned with laryngeal edema because of
should also not eat foods grown on or in the the area of burn. The next priority should be
ground or eat from the salad bar. The nurse answer A, as well as hyponatremia and
should remove potted or cut flowers from the hypokalemia in C and D, but these answers
room as well. Any source of bacteria should are not of primary concern so are incorrect.
be eliminated, if possible. Answers A, B, and 24.Answer D. The client with anorexia shows
C will not help prevent bacterial invasions. the most improvement by weight gain.
17.Answer B. In clients who have not had Selecting a balanced diet does little good if
surgery to the face or neck, the answer would the client will not eat, so answer A is
be answer A; however, in this situation, this incorrect. The hematocrit might improve by
could further interfere with the airway. several means, such as blood transfusion, but
Increasing the infusion and placing the client that does not indicate improvement in the
in supine position would be better. Answers C anorexic condition; therefore, answer B is
is incorrect because it is not necessary at this incorrect. The tissue turgor indicates fluid
time and could cause hyponatremia and
 stasis, not improvement of anorexia, so options identify interventions that are
answer C is incorrect. necessary for a client with a radiation device.
25.Answer D. At this time, pain beneath the cast 32.Answers: E and F. Clients who have
is normal. The client’s toes should be warm to undergone supratentorial surgery should have
the touch, and pulses should be present. the head of the bed elevated 30 degrees to
Paresthesia is not normal and might indicate promote venous drainage from the head. The
compartment syndrome. Therefore, Answers client is positioned to avoid extreme hip or
A, B, and C are incorrect. neck flexion, and the head is maintained in a
26.Answers: B, D, and E. Key features of midline, neutral position. If a large tumor has
pulmonary emphysema include dyspnea that been removed, the client should be placed on
is often marked, late cough (after onset of the nonoperative side to prevent the
dyspnea), scant mucus production, and displacement of the cranial contents.
marked weight loss. By contrast, chronic 33.Answer: C.
bronchitis is characterized by an early onset of 34.Answer: C. Goggles are worn to protect the
cough (before dyspnea), copious purulent mucous membranes of the eye during
mucus production, minimal weight loss, and interventions that may produce splashes of
milder severity of dyspnea. blood, body fluids, secretions, and excretions.
27.Answer: C. The client must first deal with In addition, contact precautions require the
feelings and negative responses before the use of gloves, and a gown should be worn if
client is able to work through the meaning of direct client contact is anticipated. Shoe
the crisis.Inquiring about the client’s feelings protectors are not necessary.
that may affect coping pertains directly to the 35.Answer: B. The loss of gastric fluid via
client’s feelings. Other answer choices do not nasogastric suction or vomiting causes
directly address the client’s feelings. metabolic alkalosis as a result of the loss of
28.Answer: B. The tubing should not be hydrochloric acid; this results in an alkalotic
removed from the IV catheter. With each condition.Respiratory acidosis and respiratory
break in the system, there is an increased alkalosis deal with respiratory problems.
chance of introducing bacteria into the Metabolic acidosis relates to acidosis.
system, which can lead to infection.Using a 36.Answer: D. Kussmaul’s respirations are
hospital gown with snaps at the sleeves and abnormally deep, regular, and increased in
putting the bag and tubing through the sleeve, rate. In apnea, respirations cease for several
followed by the client’s arm are appropriate. seconds. In bradypnea, respirations are regular
The flow rate should be checked immediately but abnormally slow. In hyperpnea,
after changing the hospital gown, because the respirations are labored and increased in depth
position of the roller clamp may have been and rate.
affected during the change. 37. Answers: A, B, C, D, and F. An eye patch
29.Answer: A. The airway is always a high or shield is applied to protect the eye and
priority, and the nurse first checks the client prevent any further detachment. Educating the
on a ventilator. The clients described in client regarding symptoms is necessary
remaining options have needs that would be because the client is at risk for subsequent
identified as intermediate priorities. retinal detachment. Positioning, activity
30.Answer: B. The psychosocial data is the least restrictions, and eye patches hinder the client
priority during the initial admission data in the performance of activities of daily living,
collection. In the African-American culture, it and the client needs the nurse’s assistance
is considered intrusive to ask personal with these activities. Eye medications are
questions during the initial contact or meeting. prescribed postoperatively, and hemorrhage is
Additionally, respiratory, neurological, and also a risk post surgery. Coughing is not
cardiovascular data include physiological encouraged because this can increase
assessments that would be the priority. intraocular pressure and harm the client.
31.Answer: A, B, C, and D. A private room 38.Answer: D. Postural blood pressure changes
with a private bath is essential if a client has occur in the client with hyponatremia. Dry
an internal radiation implant. This is mucous membranes and intense thirst are seen
necessary to prevent the accidental exposure in clients with hypernatremia. A slow,
of other clients to radiation. The remaining bounding pulse is not indicative of
 hyponatremia. In a client with hyponatremia,
a rapid thready pulse is noted.
39.Answer: C. Children should not be given
herbal therapies, especially in the home and
without professional supervision. There are no
general contraindications for the clients
described in the remaining options.
40.Answers: B, D, E, and F. The child who is
cyanotic with oxygen saturations dropping to
60% is having a hypercyanotic episode.
Hypercyanotic episodes often occur among
infants with tetralogy of Fallot, and they may
occur among infants whose heart defect
includes the obstruction of pulmonary blood
flow and communication between the
ventricles. If a hypercyanotic episode occurs,
the infant is placed in a knee-chest position
immediately. The registered nurse is notified,
who will then contact the health care provider.
The knee-chest position improves systemic
arterial oxygen saturation by decreasing
venous return so that smaller amounts of
highly saturated blood reach the heart.
Toddlers and children squat to get into this
position and relieve chronic hypoxia. There is
no reason to call a code blue unless
respirations cease. Additional interventions
include administering 100% oxygen by face
mask, morphine sulfate, and intravenous
fluids, as prescribed.
 NCLEX RN Practice Exam 10 Which instruction should be given
1. The client is having an arteriogram. regarding the medication?
During the procedure, the client tells the A. Treatment is not recommended for children
nurse, “I’m feeing really hot.” Which less than 10 years of age.
response would be best? B. The entire family should be treated.
C. Medication therapy will continue for 1 year.
A. “You are having an allergic reaction. I will get D. Intravenous antibiotic therapy will be ordered.
an order for Benadryl.” 6. The registered nurse is making
B. “That feeling of warmth is normal when the
assignments for the day. Which client
dye is injected.”
C. “That feeling of warmth indicates that the should be assigned to the pregnant
clots in the coronary vessels are dissolving.” nurse?
D.  “I will tell your doctor and let him explain to
you the reason for the hot feeling that you are A. The client receiving linear accelerator
experiencing.” radiation therapy for lung cancer
B. The client with a radium implant for cervical
2. The nurse is observing several cancer
healthcare workers providing care. Which C.  The client who has just been administered
action by the healthcare worker indicates soluble brachytherapy for thyroid cancer
a need for further teaching? D. The client who returned from placement of
iridium seeds for prostate cancer
A. The nursing assistant wears gloves while 7. The nurse is planning room
giving the client a bath.
assignments for the day. Which client
B.  The nurse wears goggles while drawing
blood from the client. should be assigned to a private room if
C.  The doctor washes his hands before only one is available?
examining the client.
D. The nurse wears gloves to take the client’s A. The client with Cushing’s disease
vital signs. B. The client with diabetes
C. The client with acromegaly
3. The client is having electroconvulsive D. The client with myxedema
therapy for treatment of severe
8. The nurse caring for a client in the
depression. Which of the following
neonatal intensive care unit administers
indicates that the client’s ECT has been
adult-strength Digitalis to the 3-pound
effective?
infant. As a result of her actions, the baby
A. The client loses consciousness. suffers permanent heart and brain
B. The client vomits. damage. The nurse can be charged with:
C. The client’s ECG indicates tachycardia.
D. The client has a grand mal seizure. A. Negligence
4. The 5-year-old is being tested for B. Tort
C. Assault
enterobiasis (pinworms). To collect a D. Malpractice
specimen for assessment of pinworms, 9. Which assignment should not be
the nurse should teach the mother to: performed by the licensed practical
A. Examine the perianal area with a flashlight 2 nurse?
or 3 hours after the child is asleep
B. Scrape the skin with a piece of cardboard and A. Inserting a Foley catheter
bring it to the clinic B. Discontinuing a nasogastric tube
C. Obtain a stool specimen in the afternoon C. Obtaining a sputum specimen
D.  Bring a hair sample to the clinic for D. Starting a blood transfusion
evaluation 10. The client returns to the unit from
5. The nurse is teaching the mother surgery with a blood pressure of 90/50,
regarding treatment for enterobiasis. pulse 132, and respirations 30. Which
 action by the nurse should receive D. The 30-year-old with an exacerbation of
priority? multiple sclerosis being treated with cortisone
via a centrally placed venous catheter
A. Continuing to monitor the vital signs 15. The emergency room is flooded with
B. Contacting the physician clients injured in a tornado. Which clients
C. Asking the client how he feels
can be assigned to share a room in the
D. Asking the LPN to continue the post-op care
emergency department during the
11. Which nurse should be assigned to
disaster?
care for the postpartal client with
preeclampsia? A. A schizophrenic client having visual and
auditory hallucinations and the client with
A. The RN with 2 weeks of experience in ulcerative colitis
postpartum B. The client who is 6 months pregnant with
B.  The RN with 3 years of experience in labor abdominal pain and the client with facial
and delivery lacerations and a broken arm
C. The RN with 10 years of experience in C. A child whose pupils are fixed and dilated and
surgery his parents, and a client with a frontal head
D.  The RN with 1 year of experience in the injury
neonatal intensive care unit D. The client who arrives with a large puncture
12. Which information should be reported wound to the abdomen and the client with
to the state Board of Nursing? chest pain
16. The nurse is caring for a 6-year-old
A. The facility fails to provide literature in both
client admitted with a diagnosis of
Spanish and English.
B. The narcotic count has been incorrect on the conjunctivitis. Before administering
unit for the past 3 days. eyedrops, the nurse should recognize that
C. The client fails to receive an itemized account it is essential to consider which of the
of his bills and services received during his following?
hospital stay.
D. The nursing assistant assigned to the client A. The eye should be cleansed with warm water,
with hepatitis fails to feed the client and give removing any exudate, before instilling the
the bath. eyedrops.
13. The nurse is suspected of charting B.  The child should be allowed to instill his own
medication administration that he did not eyedrops.
C. The mother should be allowed to instill the
give. After talking to the nurse, the charge eyedrops.
nurse should: D. If the eye is clear from any redness or edema,
the eyedrops should be held.
A. Call the Board of Nursing
B. File a formal reprimand 17. The nurse is discussing meal planning
C. Terminate the nurse with the mother of a 2-year-old toddler.
D. Charge the nurse with a tort Which of the following statements, if
14. The home health nurse is planning for made by the mother, would require a
the day’s visits. Which client should be need for further instruction?
seen first?
A. “It is okay to give my child white grape juice
A. The 78-year-old who had a gastrectomy 3 for breakfast.”
weeks ago and has a PEG tube B. “My child can have a grilled cheese sandwich
B. The 5-month-old discharged 1 week ago with for lunch.”
pneumonia who is being treated with C. “We are going on a camping trip this
amoxicillin liquid suspension weekend, and I have bought hot dogs to grill
C. The 50-year-old with MRSA being treated for his lunch.”
with Vancomycin via a PICC line D. “For a snack, my child can have ice cream.”
 18. A 2-year-old toddler is admitted to the would the nurse expect the admitting
hospital. Which of the following nursing assessment to reveal?
interventions would you expect?
A. Bradycardia
A. Ask the parent/guardian to leave the room B. Decreased appetite
when assessments are being performed. C. Exophthalmos
B. Ask the parent/guardian to take the child’s D. Weight gain
favorite blanket home because anything from 24. The nurse is providing dietary
the outside should not be brought into the instructions to the mother of an 8-year-old
hospital. child diagnosed with celiac disease.
C. Ask the parent/guardian to room-in with the
Which of the following foods, if selected
child.
D. If the child is screaming, tell him this is by the mother, would indicate her
inappropriate behavior. understanding of the dietary instructions?
19. Which instruction should be given to A. Ham sandwich on whole-wheat toast
the client who is fitted for a behind-the-ear B. Spaghetti and meatballs
hearing aid? C. Hamburger with ketchup
D. Cheese omelet
A. Remove the mold and clean every week.
25. The nurse is caring for an 80-year-old
B. Store the hearing aid in a warm place.
C. Clean the lint from the hearing aid with a with chronic bronchitis. Upon the morning
toothpick. rounds, the nurse finds an O2 sat of 76%.
D. Change the batteries weekly. Which of the following actions should the
20. A priority nursing diagnosis for a child nurse take first?
being admitted from surgery following a
A. Notify the physician
tonsillectomy is: B. Recheck the O2 saturation level in 15 minutes
A. Body image disturbance C. Apply oxygen by mask
B. Impaired verbal communication D. Assess the child’s pulse
C. Risk for aspiration 26. A nurse is collecting data on a client
D. Pain with severe preeclampsia. Choose the
21. A client with bacterial pneumonia is findings that would be noted in severe
admitted to the pediatric unit. What would preeclampsia. Select all that apply.
the nurse expect the admitting A. Oliguria
assessment to reveal? B. Seizures
C. Contractions
A. High fever D. Proteinuria 3+
B. Nonproductive cough E. Muscle cramps
C. Rhinitis F. Blood pressure 168/116 mm Hg
D. Vomiting and diarrhea 27. A nurse is monitoring a client with
22. The nurse is caring for a client Graves’ disease for signs of
admitted with epiglottis. Because of the thyrotoxicosis (thyroid storm). Which of
possibility of complete obstruction of the the following signs and symptoms, if
airway, which of the following should the noted in the client, will alert the nurse to
nurse have available? the presence of this crisis? Select all that
apply.
A. Intravenous access supplies
A. Bradycardia
B. A tracheostomy set
B. Fever
C. Intravenous fluid administration pump
C. Sweating
D. Supplemental oxygen
D. Agitation
23. A 25-year-old client with Grave’s E. Pallor
disease is admitted to the unit. What 28. A nurse is monitoring a group of
clients for acid-base imbalances. Which
 clients are at highest risk for metabolic B, and C indicate knowledge of infection
acidosis? Select all that apply. control by their actions.
A. Severely anxious client 3. Answer D. During ECT, the client will have a
B. Pneumonia client grand mal seize. This indicates completion of
C. Diabetic mellitus client the electroconvulsive therapy. Answers A, B,
D. Malnourished client and C do not indicate that the ECT has been
E. Asthma client effective, so are incorrect.
F. Renal failure client 4. Answer A . Infection with pinworms begins
when the eggs are ingested or inhaled. The
29. The nurse is preparing a teaching
eggs hatch in the upper intestine and mature in
plan for a client who is undergoing 2–8 weeks. The females then mate and
cataract extraction with intraocular migrate out the anus, where they lay up to
implant. Which home care measures will 17,000 eggs. This causes intense itching. The
the nurse include in the plan? Select all mother should be told to use a flashlight to
that apply. examine the rectal area about 2–3 hours after
A. To avoid activities that require bending over the child is asleep. Placing clear tape on a
B. To contact the surgeon if eye scratchiness tongue blade will allow the eggs to adhere to
occurs the tape. The specimen should then be brought
C. To place an eye shield on the surgical eye at in to be evaluated. There is no need to scrap
bedtime the skin, collect a stool specimen, or bring a
D. That episodes of sudden severe pain in the eye sample of hair, so answers B, C, and D are
is expected incorrect.
E. To contact the surgeon if a decrease in visual 5. Answer B . Erterobiasis, or pinworms, is
acuity occurs treated with Vermox (mebendazole) or
F. To take acetaminophen (Tylenol) for minor Antiminth (pyrantel pamoate). The entire
eye discomfort family should be treated to ensure that no eggs
30. A nurse is providing a list of remain. Because a single treatment is usually
sufficient, there is usually good compliance.
instructions to a client who is scheduled The family should then be tested again in 2
to have an electroencephalogram (EEG). weeks to ensure that no eggs remain. Answers
Choose the instructions that the nurse A, C, and D are incorrect statements.
places on the list.Select all that apply. 6. Answer A . The pregnant nurse should not be
A. Cola is acceptable to drink on the day of the assigned to any client with radioactivity
test. present. The client receiving linear accelerator
B. Tea and coffee are restricted on the day of the therapy travels to the radium department for
test. therapy. The radiation stays in the department,
C. The test will take between 45 minutes and 2 so the client is not radioactive. The clients in
hours. answers B, C, and D pose a risk to the
D. The hair should be washed the evening before pregnant nurse. These clients are radioactive
the test. in very small doses, especially upon returning
E. All medications need to be withheld on the from the procedures. For approximately 72
day of the test. hours, the clients should dispose of urine and
F. A nothing-by-mouth (NPO) status is required feces in special containers and use plastic
on the day of the test. spoons and forks.
Answers and Rationales 7. Answer A . The client with Cushing’s disease
1. Answer B . It is normal for the client to have has adrenocortical hypersecretion. This
a warm sensation when dye is injected. increase in the level of cortisone causes the
Answers A, C, and D indicate that the nurse client to be immune suppressed. In answer B,
believes that the hot feeling is abnormal, so the client with diabetes poses no risk to other
they are incorrect. clients. The client in answer C has an increase
2.  Answer D . It is not necessary to wear gloves in growth hormone and poses no risk to
to take the vital signs of the client. If the client himself or others. The client in answer D has
has active infection with methicillin-resistant hyperthyroidism or myxedema and poses no
staphylococcus aureus, gloves should be risk to others or himself.
worn. The healthcare workers in answers A,
8. Answer D . The nurse could be charged with staphylococcus aureus. Vancomycin is the
malpractice, which is failing to perform, or drug of choice and is given at scheduled times
performing an act that causes harm to the to maintain blood levels of the drug. The
client. Giving the infant an overdose falls into clients in answers A, B, and C are more stable
this category. Answers A, B, and C are and can be seen later.
incorrect because they apply to other wrongful 15.Answer B . The pregnant client and the client
acts. Negligence is failing to perform care for with a broken arm and facial lacerations are
the client; a tort is a wrongful act committed the best choices for placing in the same room.
on the client or their belongings; and assault is The clients in answers A, C, and D need to be
a violent physical or verbal attack. placed in separate rooms due to the serious
9. Answer D . The licensed practical nurse natures of their injuries.
should not be assigned to begin a blood 16.Answer A . Before instilling eyedrops, the
transfusion. The licensed practical nurse can nurse should cleanse the area with water. A 6-
insert a Foley catheter, discontinue a year-old child is not developmentally ready to
nasogastric tube, and collect sputum instill his own eyedrops, so answer B is
specimen; therefore, answers A, B, and C are incorrect. Although the mother of the child
incorrect. can instill the eyedrops, the area must be
10.Answer B . The vital signs are abnormal and cleansed before administration, making
should be reported immediately. Continuing answer C incorrect. Although the eye might
to monitor the vital signs can result in appear to be clear, the nurse should instill the
deterioration of the client’s condition, making eyedrops, as ordered, so answer D is incorrect.
answer A incorrect. Asking the client how he 17.Answer C . Remember the ABCs (airway,
feels in answer C will only provide subjective breathing, circulation) when answering this
data, and the nurse in answer D is not the best question. Answer C is correct because a
nurse to assign because this client is unstable. hotdog is the size and shape of the child’s
11.Answer B . The nurse with 3 years of trachea and poses a risk of aspiration.
experience in labor and delivery knows the Answers A, B, and C are incorrect because
most about possible complications involving white grape juice, a grilled cheese sandwich,
preeclampsia. The nurse in answer A is a new and ice cream do not pose a risk of aspiration
nurse to the unit, and the nurses in answers C for a child.
and D have no experience with the postpartum 18.Answer C . The nurse should encourage
client. rooming-in to promote parent-child
12.Answer B. The Joint Commission on attachment. It is okay for the parents to be in
Accreditation of Hospitals will probably be the room for assessment of the child.
interested in the problems in answers A and Allowing the child to have items that are
C. The failure of the nursing assistant to care familiar to him is allowed and encouraged;
for the client with hepatitis might result in therefore, answers A and B are incorrect.
termination, but is not of interest to the Joint Answer D is not part of the nurse’s
Commission. responsibilities.
13.Answer B . The next action after discussing 19.Answer B . The hearing aid should be stored
the problem with the nurse is to document the in a warm, dry place. It should be cleaned
incident by filing a formal reprimand. If the daily but should not be moldy, so answer A is
behavior continues or if harm has resulted to incorrect. A toothpick is inappropriate to use
the client, the nurse may be terminated and to clean the aid; the toothpick might break off
reported to the Board of Nursing, but these are in the hearing aide, making answer C
not the first actions requested in the stem. A incorrect. Changing the batteries weekly, as in
tort is a wrongful act to the client or his answer D, is not necessary.
belongings and is not indicated in this 20.Answer C. Always remember your ABCs
instance. Therefore, Answers A, C, and D are (airway, breathing, circulation) when selecting
incorrect. an answer. Although answers B and D might
14.Answer D . The client at highest risk for be appropriate for this child, answer C should
complications is the client with multiple have the highest priority. Answer A does not
sclerosis who is being treated with cortisone apply for a child who has undergone a
via the central line. The others are more tonsillectomy.
stable. MRSA is methicillin-resistant
21.Answer A . If the child has bacterial metabolic acidosis because of the increasing
pneumonia, a high fever is usually present. acids in the body. Severe anxiousness ,
Bacterial pneumonia usually presents with a pneumonia  and asthma are respiratory
productive cough, not a nonproductive cough, problems, not metabolic, and result in either
making answer B incorrect. Rhinitis is often respiratory acidosis or respiratory alkalosis.
seen with viral pneumonia, and vomiting and 29.Answers: A, C, E, and F. After eye surgery,
diarrhea are usually not seen with pneumonia, some scratchiness and mild eye discomfort
so answers C and D are incorrect. may occur in the operative eye and is usually
22.Answer B . For a child with epiglottis and the relieved by mild analgesics. If the eye pain
possibility of complete obstruction of the becomes severe, the client should notify the
airway, emergency tracheostomy equipment surgeon because this may indicate
should always be kept at the bedside. hemorrhage, infection, or increased
Intravenous supplies, fluid, and oxygen will intraocular pressure. The nurse would also
not treat an obstruction; therefore, answers A, instruct the client to notify the surgeon of
C, and D are incorrect. purulent drainage, increased redness, or any
23.Answer C. Exophthalmos (protrusion of decrease in visual acuity. The client is
eyeballs) often occurs with hyperthyroidism. instructed to place an eye shield over the
The client with hyperthyroidism will often operative eye at bedtime to protect the eye
exhibit tachycardia, increased appetite, and from injury during sleep and to avoid
weight loss; therefore, answers A, B, and D activities that increase intraocular pressure
are incorrect. such as bending over.
24.Answer D . The child with celiac disease 30.Answers: B, C, and D. Pre-procedure
should be on a gluten-free diet. Answers A, B, instructions include informing the client that
and C all contain gluten, while answer D the procedure is painless. The procedure
gives the only choice of foods that does not requires no dietary restrictions other than
contain gluten. avoidance of cola, tea, and coffee on the
25.Answer C . Remember the ABCs (airway, morning of the test. These products have a
breathing, circulation) when answering this stimulating effect and should be avoided. The
question. Before notifying the physician or hair should be washed the evening before the
assessing the pulse, oxygen should be applied test, and gels, hairsprays, and lotion should be
to increase the oxygen saturation, so answers avoided. The client is informed that the test
A and D are incorrect. The normal oxygen will take 45 minutes to 2 hours and that
saturation for a child is 92%–100%, making medications are usually not withheld before
answer B incorrect. the test.
26.Answers: A, D, and F. Severe preeclampsia
is characterized by blood pressure higher than
160/110 mm Hg, proteinuria 3+ or higher, and
oliguria. Seizures (convulsions) are present in
eclampsia and are not a characteristic of
severe preeclampsia. Muscle cramps and
contractions are not findings noted in severe
preeclampsia, although the client is monitored
for these occurrences.
27.Answers: B, C, and D. Thyrotoxic crisis
(thyroid storm) is an acute, potentially life-
threatening state of extreme thyroid activity
that represents a breakdown in the body’s
tolerance to a chronic excess of thyroid
hormones. The clinical manifestations include
fever greater than 100° F, severe tachycardia,
flushing and sweating, and marked agitation
and restlessness. Delirium and coma can
occur.
28.Answers: C, D, and F. Diabetes mellitus,
malnutrition, and renal failure lead to
 NCLEX RN Practice Exam 11 A. The cervix is closed.
B. The membranes are still intact.
1. A gravida III para 0 is admitted to the C. The fetal heart tones are within normal limits.
labor and delivery unit. The doctor D.  The contractions are intense enough for
performs an amniotomy. Which insertion of an internal monitor.
observation would the nurse be expected 7. The following are all nursing diagnoses
to make after the amniotomy? appropriate for a gravida 1 para 0 in
labor. Which one would be most
A. Fetal heart tones 160bpm
B. A moderate amount of straw-colored fluid appropriate for the primagravida as she
C. A small amount of greenish fluid completes the early phase of labor?
D. A small segment of the umbilical cord
A. Impaired gas exchange related to
2. The client is admitted to the unit. A hyperventilation
vaginal exam reveals that she is 2cm B. Alteration in placental perfusion related to
dilated. Which of the following statements maternal position
would the nurse expect her to make? C. Impaired physical mobility related to fetal-
monitoring equipment
A. “We have a name picked out for the baby.” D. Potential fluid volume deficit related to
B. “I need to push when I have a contraction.” decreased fluid intake
C. “I can’t concentrate if anyone is touching 8. As the client reaches 8cm dilation, the
me.”
nurse notes late decelerations on the fetal
D. “When can I get my epidural?”
monitor. The FHR baseline is 165–
3. The client is having fetal heart rates of
175bpm with variability of 0–2bpm. What
90–110bpm during the contractions. The
is the most likely explanation of this
first action the nurse should take is:
pattern?
A. Reposition the monitor
B. Turn the client to her left side A. The baby is asleep.
C. Ask the client to ambulate B. The umbilical cord is compressed.
D. Prepare the client for delivery C. There is a vagal response.
D. There is uteroplacental insufficiency.
4. In evaluating the effectiveness of IV
9. The nurse notes variable decelerations
Pitocin for a client with secondary
on the fetal monitor strip. The most
dystocia, the nurse should expect:
appropriate initial action would be to:
A. A painless delivery
B. Cervical effacement A. Notify her doctor
C. Infrequent contractions B. Start an IV
D. Progressive cervical dilation C. Reposition the client
D. Readjust the monitor
5. A vaginal exam reveals a footling
10. Which of the following is a
breech presentation. The nurse should
characteristic of a reassuring fetal heart
take which of the following actions at this
rate pattern?
time?
A. A fetal heart rate of 170–180bpm
A. Anticipate the need for a Caesarean section
B. A baseline variability of 25–35bpm
B. Apply the fetal heart monitor
C. Ominous periodic changes
C. Place the client in Genu Pectoral position
D. Acceleration of FHR with fetal movements
D. Perform an ultrasound exam
11. The rationale for inserting a French
6. A vaginal exam reveals that the cervix
catheter every hour for the client with
is 4cm dilated, with intact membranes and
epidural anesthesia is:
a fetal heart tone rate of 160–170bpm.
The nurse decides to apply an external A. The bladder fills more rapidly because of the
fetal monitor. The rationale for this medication used for the epidural.
implementation is:
B. Her level of consciousness is such that she is C. Baked chicken, fruit cup, potato salad,
in a trancelike state. coleslaw, yogurt, and iced tea
C.  The sensation of the bladder filling is D. Fish sandwich, gelatin with fruit, and coffee
diminished or lost. 17. The client with hyperemesis
D. She is embarrassed to ask for the bedpan that gravidarum is at risk for developing:
frequently.
12. A client in the family planning clinic A. Respiratory alkalosis without dehydration
asks the nurse about the most likely time B. Metabolic acidosis with dehydration
C. Respiratory acidosis without dehydration
for her to conceive. The nurse explains
D. Metabolic alkalosis with dehydration
that conception is most likely to occur
18. A client tells the doctor that she is
when:
about 20 weeks pregnant. The most
A. Estrogen levels are low. definitive sign of pregnancy is:
B. Lutenizing hormone is high.
C. The endometrial lining is thin. A. Elevated human chorionic gonadatropin
D. The progesterone level is low. B. The presence of fetal heart tones
C. Uterine enlargement
13. A client tells the nurse that she plans
D. Breast enlargement and tenderness
to use the rhythm method of birth control.
19. The nurse is caring for a neonate
The nurse is aware that the success of
whose mother is diabetic. The nurse will
the rhythm method depends on the:
expect the neonate to be:
A. Age of the client
B. Frequency of intercourse A. Hypoglycemic, small for gestational age
B. Hyperglycemic, large for gestational age
C. Regularity of the menses
D. Range of the client’s temperature C. Hypoglycemic, large for gestational age
D. Hyperglycemic, small for gestational age
14. A client with diabetes asks the nurse
20. Which of the following instructions
for advice regarding methods of birth
should be included in the nurse’s teaching
control. Which method of birth control is
regarding oral contraceptives?
most suitable for the client with diabetes?
A. Weight gain should be reported to the
A. Intrauterine device physician.
B. Oral contraceptives B. An alternate method of birth control is needed
C. Diaphragm when taking antibiotics.
D. Contraceptive sponge C. If the client misses one or more pills, two pills
15. The doctor suspects that the client should be taken per day for 1 week.
has an ectopic pregnancy. Which D. Changes in the menstrual flow should be
symptom is consistent with a diagnosis of reported to the physician.
ectopic pregnancy? 21. The nurse is discussing breastfeeding
with a postpartum client. Breastfeeding is
A. Painless vaginal bleeding
contraindicated in the postpartum client
B. Abdominal cramping
C. Throbbing pain in the upper quadrant with:
D. Sudden, stabbing pain in the lower quadrant A. Diabetes
16. The nurse is teaching a pregnant B. Positive HIV
client about nutritional needs during C. Hypertension
pregnancy. Which menu selection will D.  Thyroid disease
best meet the nutritional needs of the 22. A client is admitted to the labor and
pregnant client? delivery unit complaining of vaginal
bleeding with very little discomfort. The
A. Hamburger pattie, green beans, French fries,
nurse’s first action should be to:
and iced tea
B. Roast beef sandwich, potato chips, baked A. Assess the fetal heart tones
beans, and cola B. Check for cervical dilation
C.  Check for firmness of the uterus 27. The nurse is providing discharge
D. Obtain a detailed history teaching to the client who was given a
23. A client telephones the emergency prescription for nifedipine (Adalat) for
room stating that she thinks that she is in blood pressure management. Which
labor. The nurse should tell the client that instructions should the nurse
labor has probably begun when: include? Select all that apply.
A. Her contractions are 2 minutes apart. A. “Increase water intake.”
B. She has back pain and a bloody discharge. B. “Increase calcium intake.”
C. She experiences abdominal pain and frequent C. “Take pulse rate each day.”
urination. D. “Weigh at the same time each day.”
D. Her contractions are 5 minutes apart. E. “Palpitations may occur early in therapy.”
F. “Be careful when rising from sitting to
24. The nurse is teaching a group of standing.”
prenatal clients about the effects of 28. A nurse is providing teaching
cigarette smoke on fetal development. regarding the prevention of Lyme disease
Which characteristic is associated with to a group of teenagers going on a hike in
babies born to mothers who smoked a wooded area. Which of the following
during pregnancy? points should the nurse include in the
A. Low birth weight session? Select all that apply.
B. Large for gestational age A. Tuck pant legs into socks.
C. Preterm birth, but appropriate size for B. Wear closed shoes when hiking.
gestation C. Apply insect repellent containing DEET.
D. Growth retardation in weight and length D. Cover the ground with a blanket when sitting.
25. The physician has ordered an E. Remove attached ticks by grasping with
thumb and forefinger.
injection of RhoGam for the postpartum
F. Wear long sleeves and long pants in dark
client whose blood type is A negative but colors when in high-risk areas.
whose baby is O positive. To provide 29. A nurse is reinforcing instructions to a
postpartum prophylaxis, RhoGam should client following a total laryngectomy about
be administered: caring for the stoma. Choose the
A. Within 72 hours of delivery instructions that the nurse provides to the
B. Within 1 week of delivery client.Select all that apply.
C. Within 2 weeks of delivery A. Protect the stoma from water.
D. Within 1 month of delivery B. Soaps should be avoided near the stoma.
26. A nurse is providing a list of C. Wash the stoma daily using a washcloth.
instructions to a client who is scheduled D. Use diluted alcohol on the stoma to clean it.
E. Apply a thin layer of petroleum jelly to the
to have an electroencephalogram (EEG).
skin surrounding the stoma.
Choose the instructions that the nurse F. Use soft tissues to clean any secretions that
places on the list.Select all that apply. accumulate around the stoma.
A. Cola is acceptable to drink on the day of the 30. A nurse is reviewing the health
test.
records of assigned clients. The nurse
B. Tea and coffee are restricted on the day of the
test. plans care knowing that which client is at
C. The test will take between 45 minutes and 2 risk for fluid volume deficit?
hours.
A. The client with cirrhosis
D. The hair should be washed the evening before
B. The client with a colostomy
the test.
C. The client with decreased kidney function
E. All medications need to be withheld on the
D. The client with congestive heart failure (CHF)
day of the test.
F. A nothing-by-mouth (NPO) status is required Answers and Rationales
on the day of the test. 1. Answer B is correct. An amniotomy is an
artificial rupture of membranes and normal
 amniotic fluid is straw-colored and odorless. 8. Answer D is correct. This information
Fetal heart tones of 160 indicate tachycardia, indicates a late deceleration. This type of
and greenish fluid is indicative of meconium, deceleration is caused by uteroplacental lack
so answers A and C are incorrect. If the nurse of oxygen. Answer A has no relation to the
notes the umbilical cord, the client is readings, so it’s incorrect; answer B results in
experiencing a prolapsed cord, so answer D is a variable deceleration; and answer C is
incorrect and would need to be reported indicative of an early deceleration.
immediately. 9. Answer C is correct. The initial action by the
2. Answer D is correct. Dilation of 2cm marks nurse observing a late deceleration should turn
the end of the latent phase of labor. Answer A the client to the side—preferably, the left side.
is a vague answer, answer B indicates the end Administering oxygen is also indicated.
of the first stage of labor, and answer C Answer A might be necessary but not before
indicates the transition phase. turning the client to her side. Answer B is not
3. Answer B is correct. The normal fetal heart necessary at this time. Answer D is incorrect
rate is 120–160bpm; 100–110bpm is because there is no data to indicate that the
bradycardia. The first action would be to turn monitor has been applied incorrectly.
the client to the left side and apply oxygen. 10.Answer D is correct. Accelerations with
Answer A is not indicated at this time. movement are normal. Answers A, B, and C
Answer C is not the best action for clients indicate ominous findings on the fetal heart
experiencing bradycardia. There is no data to monitor.
indicate the need to move the client to the 11.Answer C is correct. Epidural anesthesia
delivery room at this time. decreases the urge to void and sensation of a
4. Answer D is correct. The expected effect of full bladder. A full bladder will decrease the
Pitocin is cervical dilation. Pitocin causes progression of labor. Answers A, B, and D are
more intense contractions, which can increase incorrect for the stem.
the pain, making answer A incorrect. Cervical 12.Answer B is correct. Lutenizing hormone
effacement is caused by pressure on the released by the pituitary is responsible for
presenting part, so answer B is incorrect. ovulation. At about day 14, the continued
Answer C is opposite the action of Pitocin. increase in estrogen stimulates the release of
5. Answer B is correct. Applying a fetal heart lutenizing hormone from the anterior
monitor is the correct action at this time. pituitary. The LH surge is responsible for
There is no need to prepare for a Caesarean ovulation, or the release of the dominant
section or to place the client in Genu Pectoral follicle in preparation for conception, which
position (knee-chest), so answers A and C are occurs within the next 10–12 hours after the
incorrect. Answer D is incorrect because there LH levels peak. Answers A, C, and D are
is no need for an ultrasound based on the incorrect because estrogen levels are high at
finding. the beginning of ovulation, the endometrial
6. Answer B is correct. The nurse decides to lining is thick, not thin, and the progesterone
apply an external monitor because the levels are high, not low.
membranes are intact. Answers A, C, and D 13.Answer C is correct. The success of the
are incorrect. The cervix is dilated enough to rhythm method of birth control is dependent
use an internal monitor, if necessary. An on the client’s menses being regular. It is not
internal monitor can be applied if the client is dependent on the age of the client, frequency
at 0-station. Contraction intensity has no of intercourse, or range of the client’s
bearing on the application of the fetal monitor. temperature; therefore, answers A, B, and D
7. Answer D is correct. Clients admitted in are incorrect.
labor are told not to eat during labor, to avoid 14.Answer C is correct. The best method of
nausea and vomiting. Ice chips may be birth control for the client with diabetes is the
allowed, but this amount of fluid might not be diaphragm. A permanent intrauterine device
sufficient to prevent fluid volume deficit. In can cause a continuing inflammatory response
answer A, impaired gas exchange related to in diabetics that should be avoided, oral
hyperventilation would be indicated during contraceptives tend to elevate blood glucose
the transition phase. Answers B and C are not levels, and contraceptive sponges are not good
correct in relation to the stem. at preventing pregnancy. Therefore, answers
A, B, and D are incorrect.
15.Answer D is correct. The signs of an ectopic instructed to take the pill as soon as she
pregnancy are vague until the fallopian tube remembers the pill. Answer C is incorrect. If
ruptures. The client will complain of sudden, she misses two, she should take two; if she
stabbing pain in the lower quadrant that misses more than two, she should take the
radiates down the leg or up into the chest. missed pills but use another method of birth
Painless vaginal bleeding is a sign of placenta control for the remainder of the cycle. Answer
previa, abdominal cramping is a sign of labor, D is incorrect because changes in menstrual
and throbbing pain in the upper quadrant is flow are expected in clients using oral
not a sign of an ectopic pregnancy, making contraceptives. Often these clients have
answers A, B, and C incorrect. lighter menses.
16.Answer C is correct. All of the choices are 21.Answer B is correct. Clients with HIV
tasty, but the pregnant client needs a diet that should not breastfeed because the infection
is balanced and has increased amounts of can be transmitted to the baby through breast
calcium. Answer A is lacking in fruits and milk. The clients in answers A, C, and D—
milk. Answer B contains the potato chips, those with diabetes, hypertension, and thyroid
which contain a large amount of sodium. disease—can be allowed to breastfeed.
Answer C contains meat, fruit, potato salad, 22.Answer A is correct. The symptoms of
and yogurt, which has about 360mg of painless vaginal bleeding are consistent with
calcium. Answer D is not the best diet placenta previa. Answers B, C, and D are
because it lacks vegetables and milk products. incorrect. Cervical check for dilation is
17.Answer B is correct. The client with contraindicated because this can increase the
hyperemesis has persistent nausea and bleeding. Checking for firmness of the uterus
vomiting. With vomiting comes dehydration. can be done, but the first action should be to
When the client is dehydrated, she will have check the fetal heart tones. A detailed history
metabolic acidosis. Answers A and C are can be done later.
incorrect because they are respiratory 23.Answer D is correct. The client should be
dehydration. Answer D is incorrect because advised to come to the labor and delivery unit
the client will not be in alkalosis with when the contractions are every 5 minutes and
persistent vomiting. consistent. She should also be told to report to
18.Answer B is correct. The most definitive the hospital if she experiences rupture of
diagnosis of pregnancy is the presence of fetal membranes or extreme bleeding. She should
heart tones. The signs in answers A, C, and D not wait until the contractions are every 2
are subjective and might be related to other minutes or until she has bloody discharge, so
medical conditions. Answers A and C may be answers A and B are incorrect. Answer C is a
related to a hydatidiform mole, and answer D vague answer and can be related to a urinary
is often present before menses or with the use tract infection.
of oral contraceptives. 24.Answer A is correct. Infants of mothers who
19.Answer C is correct. The infant of a diabetic smoke are often low in birth weight. Infants
mother is usually large for gestational age. who are large for gestational age are
After birth, glucose levels fall rapidly due to associated with diabetic mothers, so answer B
the absence of glucose from the mother. is incorrect. Preterm births are associated with
Answer A is incorrect because the infant will smoking, but not with appropriate size for
not be small for gestational age. Answer B is gestation, making answer C incorrect. Growth
incorrect because the infant will not be retardation is associated with smoking, but
hyperglycemic. Answer D is incorrect because this does not affect the infant length;
the infant will be large, not small, and will be therefore, answer D is incorrect.
hypoglycemic, not hyperglycemic. 25. Answer A is correct. To provide protection
20.Answer B is correct. When the client is against antibody production, RhoGam should
taking oral contraceptives and begins be given within 72 hours. The answers in B,
antibiotics, another method of birth control C, and D are too late to provide antibody
should be used. Antibiotics decrease the protection. RhoGam can also be given during
effectiveness of oral contraceptives. pregnancy.
Approximately 5–10 pounds of weight gain is 26.Answers: B, C, and D are correct. Pre-
not unusual, so answer A is incorrect. If the procedure instructions include informing the
client misses a birth control pill, she should be client that the procedure is painless. The
 procedure requires no dietary restrictions fistulas, ileostomy, and colostomy. A client
other than avoidance of cola, tea, and coffee with cirrhosis, CHF, or decreased kidney
on the morning of the test. These products function is at risk for fluid volume excess.
have a stimulating effect and should be
avoided. The hair should be washed the
evening before the test, and gels, hairsprays,
and lotion should be avoided. The client is
informed that the test will take 45 minutes to
2 hours and that medications are usually not
withheld before the test.
27.Answers: C, D, E, and F are
correct. Nifedipine is a calcium-channel
blocker. Its therapeutic outcome is to decrease
blood pressure. Its method of action is
blockade of the calcium channels in vascular
smooth muscle, promoting vasodilation. Side
effects that can occur early in therapy include
reflex tachycardia (palpitations) and first-dose
hypotension, leading to orthostatic
hypotension. Weight should be checked
regularly to monitor for early signs of heart
failure. Also the client is taught to take his or
her own pulse. Nifedipine does not affect
serum calcium levels. Increased water intake
is not indicated in the client with
cardiovascular disease.
28.Answers: A, B, C, and D are
correct. Measures to prevent tick bites focus
on covering the body as completely as
possible and spraying insect repellent
containing DEET on the skin and clothing.
Long sleeves and pants tucked into the socks
along with closed shoes will offer some
protection. Light-colored clothing should be
worn so that ticks would be easily visible.
Hikers should not sit directly on the ground
and should cover the ground with an item
such as a blanket. Ticks should be removed
with tweezers.
29.Answers: A, B, C, and E are correct. The
client with a stoma should be instructed to
wash the stoma daily with a washcloth. Soaps,
cotton swabs, or tissues should be avoided
because their particles may enter and obstruct
the airway. The client should be instructed to
avoid applying alcohol to a stoma because it is
both drying and irritating. A thin layer of
petroleum jelly applied to the skin around the
stoma helps prevent cracking. The client is
instructed to protect the stoma from water.
30. Answer B is correct. Causes of a fluid
volume deficit include vomiting, diarrhea,
conditions that cause increased respirations or
increased urinary output, insufficient
intravenous fluid replacement, draining