CTN: (Doc BJ)
CTN: (Doc BJ)
CTN: (Doc BJ)
29. The nurse is assessing the respiratory status of a 34. The perioperative nurse has admitted a patient
client who has suffered a fractured rib. The who has just underwent a tonsillectomy. The
nurses should expect to note which finding? nurses postoperative assessment should
A. Slow, deep respirations prioritize which of the following potential
B. Rapid, deep respirations complications of this surgery?
C. Paradoxical respirations A. difficulty ambulating
D. Pain, especially with inspiration B. hemorrhage
C. infrequent swallowing
30. The nurse is assessing a client with multiple D. bradycardia
trauma who is at risk for developing acute
respiratory distress syndrome. The nurse should 35. a client who is human immunodeficiency virus
assess for which earliest sign of acute (HIV)- positive has had a tuberculin skin test
respiratory distress syndrome? (TST). The nurse notes a 7-mm area of
A. Bilateral wheezing induration at the site of the skin test and
B. Inspiratory crackles interprets the results as which finding?
C. Intercostal retractions A. Positive
D. Increased respiratory rate B. Negative
C. Inconclusive secretions. What should the nurse encourage
D. Need for repeat testing the patient to do?
A. Increase oral fluids unless contraindicated
36. The nurse is instructing a hospitalized client B. Call the nurse for oral suctioning, as needed
with a diagnosis of emphysema about measures C. Lie in a low fowlers or supine position
that will enhance the effectiveness of breathing D. Increase activity
during dyspneic periods. Which position should
the nurse instruct the client to assume? 41. The nurse is caring for a patient who is
A. Sitting up in bed scheduled for a lobectomy for a diagnosis of
B. Side-lying in bed lung cancer. While assisting with a subclavian
C. Sitting ina recliner chair vein central line insertion, the nurse notes the
D. Sitting up and leaning on an overbed table clients oxygen saturation rapidly dropping. The
patient complains of shortness of breath and
37. The nurse performs an admission assessment becomes tachypneic. The nurse suspects a
on a client with diagnosis of tuberculosis. The pneumothorax has developed. Further
nurse should check the results of which assessment findings supporting the presence of
diagnostic test that will confirm this diagnosis? a pneumothorax include what?
A. Chest x-ray A. Diminished or absent breath sounds on the
B. Bronchoscopy affected side
C. Sputum culture B. Paradoxical chest wall movement with
D. Tuberculin skin test respirations
C. Sudden loss of consciousness
38. The nurse is planning the care of a patient who D. Muffled heart sounds
is scheduled for a laryngectomy. The nurse
should assign the highest priority to which 42. The nurse is caring for a patient at risk for
postoperative nursing diagnosis? atelectasis. The nurse implements a first-line
A. Anxiety related to diagnosis of cancer measure to prevent atelectasis development in
B. Altered nutrition related to swallowing the patient. What is an example of a first-line
difficulties measure to minimize atelectasis?
C. Ineffective airway clearance related to airway A. Incentive spirometry
alterations B. Intermittent positive-pressure breathing (IPPB)
D. Impaired verbal communication related to C. Positive end-expiratory pressure (PEEP)
removal of the larynx D. Bronchoscopy
39. A 45-year-old obese man arrives in a clinic with 43. The perioperative nurse is writing a care plan for
complaints of daytime sleepiness, difficultu a patient who has returned from surgery 2
going to sleep at night, and snoring. The nurse hours prior. Which measure should the nurse
should recognize the manifestations of what implement to most decrease the patients risk of
health problem? developing pulmonary emboli?
A. Adenoiditis A. Early ambulation
B. Chronic tonsillitis B. Increased dietary intake of protein
C. Obstructive sleep apnea C. Maintaining the patient in a supine position
D. Laryngeal cancer D. Administering aspirin with warfarin
40. A critical care nurse is caring for a patient 44. The school nurse is presenting a class on
diagnosed with pneumonia as a surgical smoking cessation at the local high school. A
complication. The nurses assessment reveals participant in the class asks the nurse about the
that the patient has an increased work of risk of lung cancer in those who smoke. What
breathing due to copious tracheobronchial
response related to risk for lung cancer in assessment finding would the nurse expect to
smokers is most accurate? note specifically in the client?
A. The younger you are when you start smoking, A. Fatigue
the higher your risk for lung cancer B. Weakness
B. The risk for lung cancer never decreases once C. Weight gain
you have smoked, which is why smokers need D. Enlarged lymph nodes
annual chest x-rays
C. The risk for lung cancer is determined mostly by 49. A gastrectomy is performed on a client with
what type of cigarettes you smoke gastric cancer. In the immediate postoperative
D. The risk for lung cancer depends primarily on period, the nurse notes bloody drainage from
the other risk factors for cancer that you have the nasogastric tube. The nurse should take
which most appropriate action?
45. The nurse is caring for a patient in the ICU A. Measure abdominal girth
admitted with ARDS after exposure to toxic B. Irrigate the nasogastric tube
fumes from a hazardous spill at work. The C. Continue to monitor the drainage
patient has become hypotensive. What is the D. Notify the primary health care provider (PHCP)
cause of this complication to the ARDS
treatment? 50. The nurse is teaching a client about the risk
A. Pulmonary hypotension due to decreased factors associated with colorectal cancer. The
cardiac output nurse determines that further teaching is
B. Severe and progressive pulmonary hypertension necessary related to colorectal cancer if the
C. Hypovolemia secondary to leakage of fluid into client identifies which item as an associated risk
the interstitial spaces factor?
D. Increased cardiac output from high levels of A. Age younger than 50 years
PEEP therapy B. History of colorectal polyps
C. Family history of colorectal cancer
46. The nurse is reviewing the laboratory results of D. Chronic inflammatory bowel disease.
a client diagnosed with multiple myeloma.
Which would the nurse expect to note
specifically in this disorder?
A. Increased calcium level
B. Increased white blood cell
C. Decreased blood urea nitrogen level
D. Decreased number of plasma cells in the bone
marrow
QUESTION 76
A 22-vear-old male comes to the clinic reporting severe penile itching and new skin lesions. His last
sexual encounter was unprotected sex 3 weeks prior with a new female partner in her bed. He has
not seen her since. Over the last 3 davs he noticed new lesions on his penis and scrotum. The
lesions are extremely pruritic. particularly at night and after a shower. His physical examination is
shown in the figure. Which of the rollowing is the best therapy.
A. Ceftriaxone plus azithromycin
B. Penicillin G
C. Permethrin
D. vancomycin
QUESTION 77
Which non-medical intervention is no longer recommended in the prevention of COVID-19
transmission and infection as per DOH
Workplace Guideline Version 2 (October 2021)?
A. Face mask + protective eyewear (face shield) in areas with sustained community transmission
B. Properly fitted surgical masks for workers with high risk of exposure to COVID-19
C. Snugly fitting cloth masks (at least 2 layers of cotton and non-woven nylon with aluminum nose
bridge)
D. Disinfection tents, misting chambers, sanitation booths
QUESTION 78
Patient RW, a 44YO male, working as a seafarer submitted for COVID-19 RTPCR testing as a
requirement prior to boarding the ship which turned out unfortunately positive. He claimed to have
no close contact or any potential/suspicious exposure. No comorbidities, intake of maintenance,
and medications claimed. No signs and symptoms claimed by patient. He claimed to have received
his second dose of COVID vaccine 3 days ago. What is an expected management of Patient RW's
case? (PSMID Unified COVID-19
Algorithm Version 4)
A. Complete 7 days of isolation from day 0
B. Anticipate to give Azithromycin and antihistamine as ordered
C. Complete 10 days of isolation from day 0
D. Discharge from isolation
QUESTION 79
Patient GO a 55VO female known case of diahetes and ischemic heart disease with non-compliance
to maintenance medications was admitted due to dusonea
At the ER, BP noted at 70/80 mmHg, HR 133 bpm, RR 36 cm, afebrile at 37.5 C.
Chest CT scan revealed peripheral ground-glass opacities with consolidation. sPO2 noted at 87%
with FIO2 0.6. Pa02/FiO2 ratio of 85. RTPCR revealed positive result for COVID-19. Which of the
following interventions will best management Patient GQ? SELECT ALL THAT APPLY. (Interim
Guidelines in Clinical Management of Adult Patients with Suspected or Confirmed COVID-19
Infection, Version 3.1, July 2020,
A. Perform in bag-mask ventilation in preparation for for rapid sequence intubation usine
videolarvngoscope
B. Use IV fluids instead of crystalloids in addressing hypotension.
C. Initiate prone position for 16-20 hours.
D. Anticipate the need to start y steroids and anticoagulation therapy.
E. Avoid sedation until radiographic findings have improved
QUESTION 80
The following are TRUE about the use of corticosteroids in the management of COVID-19 infection:
(SELECT ALL THAT APPLY)
Interim Guidelines in Clinica Management of Adult Patients with Susoected or Confirmed COVID-19
Infection. Version 3.1. Julv 20201
A. They inhibit multiple inflammatory cytokines resulting in decreased edema, capillary leakage,
migration of inflammatory cells
B. Recommended regimen is Dexamethasone 6mg IV for 10 days
C. Inhaled steroids are recommended as adjunctive treatment
D. Oral, inhaled, or IV steroids are recommended for prophylaxis
E. It inhibits viral replication through premature termination of RNA transcription.
F. Blocks viral entry into cells by inhibiting glycosylation of host receptors, proteolytic processing,
endosomal acidification.
QUESTION 81
A client arrives at the emergency department with complaints of low abdominal pain and hematuria.
The client is afebrile. The nurse next assesses the client to determine a history of which condition?
A. Pyelonephritis
B. Glomerulonephritis
C. Trauma to the bladder or abdomen
D. Renal cancer in the client's family
QUESTION 82
The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating
hemodialysis. Which finding indicates that the fistula is patent? ignatavicius, Workman, Rebar
(2018), p. 1415.
A. Palpation of a thrill over the fistula.
B. Presence of a radial pulse in the left wrist.
C. Visualization of enlarged blood vessels at the fistula site.
D. Capillary refill less than 3 seconds in the nailbeds of the fingers on the left hand.
QUESTION 83
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse
would plan which actions as a priority? SELECT ALL THAT APPLY.
A. Place the client on a cardiac monitor.
B. Notify the primary health care provider (PHCP).
C. Put the client on NPO (nothing by mouth) status except for ice chips.
D. Review the client's medications to determine whether any contain or retain potassium.
E. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.
QUESTION 84
A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and
complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air
embolism. What are the priority nursing actions? SELECT ALL THAT APPLY. Lewis, S., Harding, M.,
Kwong, J., Roberts, D., Hagler,
D., & Reinisch, C. (2020).
QUESTION 85
The nurse is performing an assessment on a client who has returned from the dialysis unit following
hemodialysis. The client is complaining of head- ache and nausea and is extremely restless.
Which is the priority nursing action?
A. Monitor the client.
B. Elevate the head of the bed.
C. Assess the fistula site and dressing.
D. Notify the primary health care provider (PHCP). -
DISEQUILIBRIUM SYNDROME
QUESTION 86
A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis.
The nurse anticipates that which treatment will be done to relieve the obstruction? SELECT ALL
THAT APPLY.
A. Peritoneal dialysis
B. Analysis of the urinary stone
C. Intravenous opioid analgesics
D. Insertion of a nephrostomy tube
E. Placement of a ureteral stent with ureteroscopy
QUESTION 87
A client is brought to the emergency department in an unresponsive state, and a diagnosis of
hyperosmolar hyperglycemic syndrome (HHS) is made. The nurse would immediately prepare to
initiate which anticipated primary health
care provider's prescription
Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagier, D., & Reinisch, C (2020). pp 1133
A. Endotracheal intubation
B. 100 units of NPH insulin
C. Intravenous infusion of normal saline
D. Intravenous infusion of sodium bicarbonate
QUESTION 88
The nurse is performing an assessment on a client
with pheochromocytoma. Which assessment data would indicate a potential complication
associated with this disorder?
Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). pp. 1168-1169.
A. A urinary output of 50 mL/hr
B. A coagulation time of 5 minutes
C. A heart rate that is 90 beats per minute and irregular
D. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L)
QUESTION 89
The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic
hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mol/L). Which primary health
care provider prescriptions would the nurse anticipate receiving? SELECT ALL THAT APPLY.
A. Initiate an infusion of 3% NaCI.
B. Administer intravenous furosemide.
C. Restrict fluids to 800 mL over 24 hours.
D. Elevate the head of the bed to high-Fowler's.
E. Administer a vasopressin antagonist as prescribed.
QUESTION 90
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute
pancreatitis. Which interventions would the nurse expect to be prescribed for the client? SELECT
ALL THAT APPLY. Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020).
pp. 994-996.
A. Maintain NPO (nothing by mouth) status.
B. Encourage coughing and deep breathing.
C. Give small, frequent high-calorie feedings.
D. Maintain the client in a supine and flat position.
E. Give hydromorphone intravenously as prescribed for pain.
F. Maintain intravenous fluids at 10 mL/hr to keep the vein open.
QUESTION 91
The primary health care provider has determined that a client has contracted hepatitis A based on
flulike symptoms and jaundice. Which statement made by the client supports this medical
diagnosis?
A. "I have had unprotected sex with multiple partners."
B. "I ate shellfish about 2 weeks ago at a local restaurant."
C. "I was an intravenous drug abuser in the past and shared needles."
D. "I had a blood transfusion 30 years ago after major abdominal surgery."
QUESTION 92
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is
scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and
begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds
are di-minished. Which is the most appropriate nursing intervention? Lewis, s., Harding,
M. Kwong. . Roberts, D. Hagler, D. & Reinisch, c. 20201 pp. 937-938.
QUESTION 93
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of
these clinical manifestations support this diagnosis? SELECT ALL THAT APPLY. Ignatavicius, D.,
Workman,
M., Rebar, C., & Heimgartner, N. (2021). pp. 1178-1179
A.Fever
B. Positive Cullen's sign
C. Complaints of indigestion
D. Palpable mass in the left upper quadrant
E. Pain in the upper right quadrant after a fatty meal
F. Vague lower right quadrant abdominal discomfort
QUESTION 94
A client with severe Crohn's disease has just had surgery to create an ileostomy. The nurse
assesses the client in the immediate postoperative period for which most frequent complication of
this type of surgery? Lewis, s. Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020).
pp. 956
A. Folate deficiency
B. Malabsorption of fat
C. Intestinal obstruction
D. Fluid and electrolyte imbalance
QUESTION 95
The nurse is providing discharge instructions to a client following gastrectomy and would instruct
the client to take which measure to assist in preventing dumping syndrome? ignatavicius, D.,
Workman, M., Rebar, C., & Heimgartner, N. (2021). pp. 1106-1108.
A. Ambulate following a meal.
B. Limit the fluids taken with meals.
C. Eat cakes and pastries only if they are homemade.
D. Eat three meals a day rather than small frequent meals.
QUESTION 96
The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The
nurse reminds the children that chemical sunscreens are most effective when applied at which
times? Lewis, s., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). PP. 410
A. Immediately before swimming
B. 5 minutes before exposure to the sun
C. Immediately before exposure to the sun
D. At least 30 minutes before exposure to the sun
QUESTION 97
QUESTION 98
Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication,
the nurse anticipates that which laboratory test will be prescribed?
A. Potassium level
B. Triglyceride level
C. Hemoglobin Alc
D. Total cholesterol level
QUESTION 99
Which cast care instructions would the nurse provide to a client who just had a plaster cast applied
to the right forearm? SELECT ALL THAT APPLY. Lewis, s., Harding, M., Kwong, J., Roberts, D.,
Hagler, D., & Reinisch, C. (2020). pp. 1453
A. Keep the cast clean and dry.
B. Allow the cast 24 to 72 hours to dry.
C. Keep the cast and extremity elevated.
D. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to
dry the cast.
E. Use a soft, padded object that will t under the cast to scratch the skin under the cast.
QUESTION 100
The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury
who has just returned from the recovery room following a thoracotomy with wedge resection. Which
are the expected assessment findings? SELECT ALL THAT APPLY.
A. Excessive bubbling in the water seal chamber
B. Vigorous bubbling in the suction control chamber
C. Drainage system maintained below the client's chest
D. 50 ml of drainage in the drainage collection chamber
E. Occlusive dressing in place over the chest tube insertion site
F. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation