SCHOOL OF HEALTH AND ALLIED HEALTH SCIENCES

NUR 155 P1 EXAMINATION

SET A

GENERAL INSTRUCTIONS:
1. This test questionnaire contains 200 test questions
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded
will invalidate your answer.
3. AVOID ERASURES.
4. Any student caught cheating (asking seatmate a question; rolling of eyeballs; glancing; turning
of head; “codigo”, markings on the chair; ,marking/writing on any part of the body; dictating;
texting) or students who will allow their seatmates to copy or glance at their paper will be given a
grade of 5.0 for this examination.
5. Read the questions carefully, you have 3 hours to complete the examination.
6. Raise your hand if you have questions or clarifications, a proctor will approach you.
7. Make sure you switch off or set all your mobile phones in silent mode.
8. Good Luck and God Bless!

MULTIPLE CHOICE. SELECT THE LETTER OF THE CORRECT ANSWER.

1. A nurse is evaluating the blood pressure (BP) results for multiple clients with
cardiac problems on a telemetry unit. Which BP reading suggests to the nurse that
the client’s mean arterial pressure (MAP) is abnormal and warrants notifying the
physician?
a. 94/60 mm Hg
b. 98/36 mm Hg
c. 110/50 mm Hg
d. 140/78 mm Hg

2. A nurse assesses a client who has just returned to a telemetry unit after having
a coronary angiogram using the left femoral artery approach. The client’s baseline
blood pressure (BP) during the procedure was 130/72 mm Hg and the cardiac
rhythm was a normal sinus throughout. Which assessment finding should indicate
to the nurse that the client may be experiencing a complication?
a. BP 144/78 mm Hg
b. Pedal pulses palpable at +1
c. Left groin soft with 1 cm ecchymotic area
d. Apical pulse 132 beats per minute (bpm) with an irregular-irregular
rhythm

3. A nurse is caring for a client immediately following insertion of a permanent

pacemaker via the right subclavian vein approach. The nurse best prevents
pacemaker lead dislodgement by:
a. inspecting the incision site dressing for bleeding and the incision for
approximation.
b. limiting the client’s right arm activity and preventing the client reaching
above shoulder level.
c. assisting the client with getting out of bed and ambulating with a walker.
d. ordering a stat chest x-ray following return from the implant procedure.

4. A nurse is assessing a client diagnosed with an anterior-lateral myocardial

infarction (MI). The nurse adds a nursing diagnosis to the client’s plan of care of
decreased cardiac output when which finding is noted on assessment?
a. One-sided weakness
b. Presence of an S4 heart sound
c. Crackles auscultated in bilateral lung bases

NUR 155 P1 EXAMINATION SET A 1

d. Vesicular breath sounds over lung lobe

5. After an inferior-septal wall myocardial infarction, which complication should a

nurse suspect when noting jugular venous distention (JVD) and ascites?
a. Left-sided heart failure
b. Pulmonic valve malfunction
c. Right-sided heart failure
d. Ruptured septum

6. A nurse notes that a client, who experienced a myocardial infarction (MI) 3 days
ago, seems unusually fatigued. Upon assessment, the nurse finds that the client is
dyspneic with activity, has a heart rate (HR) of 110 beats per minute (bpm), and
has generalized edema. Which action by the nurse is most appropriate?
a. Administer high-flow oxygen
b. Encourage the client to rest more
c. Continue to monitor the client’s heart rhythm
d. Compare the client’s admission weight with the client’s current weight

7. A client is hospitalized for heart failure secondary to alcohol-induced

cardiomyopathy. The client is started on milrinone (Primacor®) and placed on a
transplant waiting list. The client has been curt and verbally aggressive in
expressing dissatisfaction with the medication orders, overall care, and the need for
energy conservation. A nurse should interpret that the client’s behavior is likely
related to the client’s:
a. denial of the illness.
b. reaction to milrinone (Primacor®).
c. fear of the diagnosis.
d. response to cerebral anoxia

8. A client diagnosed with class II heart failure according to the New York Heart
Association Functional Classification has been taught about the initial treatment
plan for this disease. A nurse determines that the client needs additional teaching if
the client states that the treatment plan includes:
a. diuretics.
b. a low-sodium diet.
c. home oxygen therapy.
d. angiotensin-converting enzyme (ACE) inhibitor

9. A client admitted with unstable angina is started on intravenous heparin and

nitroglycerin. The client’s chest pain resolves, and the client is weaned from the
nitroglycerin. Noting that the client had a synthetic valve replacement for aortic
stenosis 2 years ago, a physician writes an order to restart the oral warfarin
(Coumadin®) 5 mg at 1900 hours. Which is the nurse’s best action?
a. Administer the warfarin as prescribed.
b. Call the physician to question the warfarin order.
c. Discontinue the heparin drip and then administer the warfarin.
d. Hold the dose of warfarin until the heparin has been discontinued.

10. A nurse is caring for a client following a coro nary artery bypass graft. Which
assessment finding in the immediate postoperative period should be most
concerning to the nurse?
a. No chest tube output for 1 hour when previously it was copious
b. Client temperature of 99.1°F (37.2°C)
c. Arterial blood gas (ABG) results show pH 7.32; Pco2 48; HCO3 28; Po2 80
d. Urine output of 160 mL in the last 4 hours

NUR 155 P1 EXAMINATION SET A 2

11. A nurse, assessing a client hospitalized following a myocardial infarction (MI),
obtains the following vital signs: blood pressure (BP) 78/38 mm Hg, heart rate (HR)
128, respiratory rate (RR) 32. For which life-threatening complication should the
nurse carefully monitor the client?
a. Pulmonary embolism
b. Cardiac tamponade
c. Cardiomyopathy
d. Cardiogenic shock

12. A client admitted to a telemetry unit with a diagnosis of Prinzmetal’s angina,

has the following medications ordered. Upon interpretation of the client’s electro
cardiogram (ECG) rhythm, the nurse notes a prolonged PR interval of 0.32 second.
Based on this information, which medication order should the nurse question
administering to the client
a. Isosorbide mononitrate (Imdur®) 20 mg oral daily upon awakening
b. Amlodipine (Norvasc®) 10 mg oral daily
c. Nitroglycerin (Nitrostat®) 0.4 mg sublingual prn for chest pain
d. Atenolol (Tenormin®) 50 mg oral daily.

13. Elevated homocysteine levels are associated with the development of

arteriosclerosis and venous thrombosis. A clinic nurse should teach a client that the
dietary therapy to decrease homocysteine levels includes eating foods rich in:
a. monosaturated fats.
b. B-complex vitamins.
c. Vitamin C.
d. Calcium

14. A client taking medication for treatment of essential hypertension has a serum
potassium level of 3.2 mEq/L. A nurse is reviewing the list of medications being
taken by the client. Which medication on the list should the nurse conclude to be
the causative factor for this serum potassium level?
a. Spironolactone (Aldactone®)
b. Potassium chloride (K-Dur®)
c. Enalapril (Vasotec®)
d. Hydrochlorothiazide (Esidrix®, HydroDIURIL®)

15. A client has an appointment at a vascular clinic after being treated with
pentoxifylline (Trental®) for 6 weeks. A nurse determines the pentoxifylline has
been effective by noting that the client:
a. has a decrease in lower extremity edema.
b. is experiencing less symptoms of withdrawal after quitting smoking.
c. has a venous ulcer on the ankle that has decreased in size and depth.
d. is able to walk a greater distance without claudication

16. A 31-year-old male client seeks care at a vascular clinic because of painful
fingers and toes. He is diagnosed with Buerger’s disease (thromboangiitis
obliterans). A nurse is teaching the client ways to prevent progression of the
disease. Which prevention measure should be the nurse’s initial focus when
teaching the client?
a. Avoiding exposure to cold
b. Maintaining meticulous hygiene practices
c. Abstaining from all tobacco products in all forms
d. Following a low-fat diet

NUR 155 P1 EXAMINATION SET A 3

17. A client with Raynaud’s disease is seen in a vascular clinic 6 weeks after
nifedipine (Procardia®) has been prescribed. A nurse evaluates that the medication
has been effective when which findings are noted?
a. The client’s blood pressure is 110/68 mm Hg.
b. The client states experiencing less pain and numbness.
c. The client states that tolerance to heat is improved.
d. The client walks without claudication.

18. After seeing a primary care provider for a routine appointment, a 48-year-old
client tells a nurse that she experienced pain in the calf of her left leg earlier in the
week, but she is pain-free now. The nurse assesses the client and finds the dorsalis
pedis pulses palpable and no pain upon dorsiflexion bilaterally. A few varicose veins
are visible in each leg. There is very slight swelling in the left foot and none in the
right foot. Which is the best action by the nurse?
a. Ask the client if she has been walking more lately.
b. Notify the primary care provider.
c. Ask the client if she has thought about taking a baby aspirin once a day.
d. Explain to the client that there are no significant findings but to call the office if
the pain returns.

19. A nurse is caring for multiple clients on a medical unit. Which client, who has
been diagnosed with a lower extremity deep venous thrombosis (DVT), should the
nurse plan for possible placement of a filter in the inferior vena cava to protect
against pulmonary embolism?
a. A 22-year-old female who has been taking oral contraceptives
b. A 65-year-old client admitted with a bleeding gastric ulcer
c. A 55-year-old client who had a total knee joint replacement
d. A 52-year-old female who had a vaginal hysterectomy 6 weeks earlier

20. Which intervention should a nurse plan to incorporate in the care of a surgical
client to decrease the risk of deep venous thrombosis (DVT) and pulmonary
embolism (PE)?
a. Use of intermittent compression devices on the lower extremities
b. Administration of heparin intravenously
c. Coughing and deep breathing exercises
d. Isometric leg exercises

21. A nurse is assessing a client who is taking atorvastatin (Lipitor®). For which
manifestations should the nurse specifically assess?
a. Constipation and hemorrhoids
b. Muscle pain and weakness
c. Fatigue and dysrhythmias
d. Flushing and postural hypotension

22. A client, following a total hip replacement, asks a nurse why she is receiving
enoxaparin (Lovenox®) for prevention of deep vein thrombosis (DVT) when, with
her last hip surgery, she received heparin subcutaneously. What is the nurse’s best
response?
a. “Enoxaparin is less expensive and easier to administer than the heparin.”
b. “There is less risk of bleeding with enoxaparin, and it doesn’t affect your
laboratory results.”
c. “Enoxaparin is a low-molecular-weight heparin that lasts twice as long
as regular heparin.”
d. “Enoxaparin can be administered orally whereas heparin is only administered by
injection.

NUR 155 P1 EXAMINATION SET A 4

23. An emergency department nurse is assessing a pediatric client suspected of
having acute pericarditis. Which assessment finding should the nurse conclude
supports the diagnosis of acute pericarditis?
a. Bilateral lower extremity pain
b. Pain on expiration
c. Pleural friction rub
d. Pericardial friction rub

24. A nurse is interpreting an ECG rhythm strip for a 2-year-old child with heart
failure secondary to a congenital heart defect. In analyzing the rhythm, the nurse
notes the measurements of PR interval is 0.26 seconds, the QRS is 0.08 seconds,
and the QT is 0.28. The ventricular rate is 126 bpm. A nurse interprets the rhythm
as:
a. sinus bradycardia.
b. sinus rhythm with a bundle branch block.
c. sinus rhythm with a first-degree AV block.
d. sinus tachycardia with a first-degree AV block.

25. A pediatric nurse evaluates that a nursing assistant knows emergency

procedures when the nursing assistant activated the emergency response system
for a 6-year-old child admitted with a diagnosis of heart failure. The sign observed
by the nurse indicating that lifesaving measures were necessary likely was:
a. gagging. c. inability to speak.
b. coughing. d. heart rate of 125 bpm

26. The parent of a child diagnosed with rheumatic heart disease questions the
nurse following the doctor’s statement that the child has a heart murmur. The
nurse explains that a heart murmur is an abnormal or extra heart sound produced
by which malfunctioning structure of the heart?
a. Heart valve c. Heart chamber
b. Heart vessel d. Heart conduction

27. A nurse is caring for a child who has liver enlargement secondary to infectious
endocarditis. For which associated cardiac condition should the nurse assess the
client?
a. Dysrhythmia c. Myocardial infarction (MI)
b. Right-sided heart failure d. Tetralogy of Fallot

28. Before administering oral digoxin (Lanoxin®) to a pediatric client, a nurse notes
that the child has bradycardia and mild vomiting. Which is the nurse’s most
appropriate action?
a. Explain to the parent that bradycardia is an expected effect of the digoxin.
b. Administer the medication, document the observations, and reevaluate after the
next dose.
c. Withhold the medication and immediately notify the prescriber because
these are signs of toxicity.
d. Administer an oral beta-blocker medication

29. A homeless client, visiting a health clinic, is noted to have a smooth and
reddened tongue and ulcers at the corners of the mouth. The client was tentatively
diagnosed with a hematological disorder, and laboratory tests were prescribed.
Based on this information, a nurse should expect the client’s laboratory results to
reveal
a. low hemoglobin.
b. elevated red blood cells (RBCs).
c. prolonged prothrombin time (PT).
d. low white blood cells (WBCs).

NUR 155 P1 EXAMINATION SET A 5

30. A nurse should assess a client with hemolytic anemia for weakness, fatigue,
malaise, skin and mucous membrane pallor, and:
a. jaundice. c. a craving for ice.
b. a smooth red tongue. d. a poor intake of fresh vegetables

31. The family of a client who is scheduled for emergency surgery following an
accident asks if they can donate blood for the client. The client’s blood type is B
negative. A nurse informs the family that packed red blood cells (PRBCs) could
likely be used from family members whose blood type is:
a. type A positive. d. type O positive.
b. type B positive. e. type O negative.
c. type B negative.

32. A nurse is reviewing a plan of care for a postoperative client with a history of
sickle cell disease. Which nursing diagnosis, documented on the client’s care plan,
should the nurse address first?
a. Anxiety c. Deficient fluid volume
b. Impaired skin integrity d. Ineffective airway clearance

33. Which nursing diagnosis should be the priority for a child hospitalized in sickle
cell crisis?
a. Risk for deficient fluid volume related to inadequate fluid intake
b. Chronic pain related to chronic physical disability and clustering of sickled cells
c. Risk for infection related to ineffectively functioning spleen
d. Ineffective tissue perfusion related to pulmonary infiltrates of abnormal
blood cells

34. The parents of an 8-year-old African American child diagnosed with sickle cell
anemia are being taught pain control measures for their child. Which measure is
most important to teach the parents to prevent the onset of vaso-occlusive pain?
a. Apply ice packs to all joints as soon as the child awakens.
b. Encourage drinking large amounts of fluids daily.
c. Administer acetaminophen (Tylenol®) 650 mg orally daily.
d. Increase outdoor exercise and exposure to the fresh air and sunshine

35. After 7 days of iron therapy, a child diagnosed with iron-deficiency anemia has
serum laboratory tests completed. Which finding indicates that the medication is
beginning to correct the anemia?
a. Increased reticulocyte count
b. Increased granulocytes
c. Increased indirect bilirubin
d. Increased erythropoietin level

36. A nurse plans care for a client and notes that all of the following must be
completed for a client being prepared for surgery. Which intervention should the
nurse complete first?
a. Complete the preoperative checklist.
b. Assess the client’s preoperative vital signs.
c. Remove the client’s rings, gold chain, and wristwatch.
d. Administer 10 mEq KCL IV for a serum potassium level of 3.0 mEq/L.

NUR 155 P1 EXAMINATION SET A 6

37. Which client statement made during a presurgical admission assessment needs
the most immediate follow-up?
a. “I haven’t eaten foods or had any fluids for the past 12 hours.”
b. “I donated my own blood in case I need a transfusion; the last donation was 4
days ago.”
c. “I took my usual dose of warfarin (Coumadin®) and other cardiac meds
this morning with a sip of water.”
d. “I brought a copy of my Health Care Directives so others will know my wishes
should my heart stop during surgery.”

38. A nurse is to witness the signature of a surgical con sent for multiple clients
scheduled for surgery the following day. In evaluating the health history of each
client, the nurse should plan to obtain a signature from the next of kin for:
a. a 75-year-old client who is blind.
b. a 60-year-old client who does not understand English.
c. a 50-year-old client who is forgetful, but fully oriented.
d. a 16-year-old educated client who fully understands the surgery

39. A nurse receives the written laboratory results of a positive pregnancy test for a
client scheduled for an emergency appendectomy. The nurse should first:
a. call the lab to verify the results of the test.
b. inform the client of the positive results.
c. report the results immediately to the surgeon.
d. notify the client’s primary physician of the results

40. During a presurgical admission assessment, a client states, “I’ve told my

surgeon that I am a Jehovah’s Witness and I won’t accept a blood transfusion.”
Which statement by the nurse would be most appropriate?
a. “Tell me about your fear of receiving a blood transfusion.”
b. “Your request to not receive a transfusion would be honored. Your
consent is needed to administer blood or blood products.”
c. “You don’t need to worry about getting a blood transfusion. We have newer
equipment that causes less blood loss during surgery.”
d. “Are you sure you wouldn’t want a blood transfusion if one is needed during
surgery? You can always change your mind after surgery.”

41. A nurse is analyzing serum laboratory results for a 73-year-old female client
scheduled for surgery in 2 hours. The nurse concludes that which result would
warrant the most immediate notification of the physician?
a. Hemoglobin 10 g/dL c. Potassium 4.5 mEq/dL
b. Creatinine 1.0 mg/dL d. Prothrombin time 22 seconds

42. Which client statement indicates that a client who is scheduled for a 3-hour
surgery under general anesthesia needs further teaching?
a. “A breathing tube will be placed when I am in the operating room.”
b. “I should shave the skin in the surgical area the evening prior to surgery.”
c. “I should splint my incision with a pillow when coughing and deep breathing after
surgery.”
d. “I might need a urinary catheter inserted before surgery so my urine
output can be monitored.”

43. Which nursing action would be best when a pre operative client verbalizes fear
of postoperative?
a. Providing diversional activities when client reports fear of pain
b. Encouraging the client to verbalize concerns regarding the fear of pain
c. Informing the client of experiences and the likelihood of pain pre- and
postoperatively
d. Explaining the medications ordered for pain control, availability, and
treatment goals

NUR 155 P1 EXAMINATION SET A 7

44. Which statement by a nurse is most effective when collecting data about a
preoperative client’s recreational drug use?
a. “Describe the drugs you use and the frequency that you use these drugs.”
b. “Do you use any over-the-counter medications or illegal substances?”
c. “Tell me about all medications and substances you take because complications
can occur if you are taking something we do not know about.”
d. “Because herbs, medications, and recreational drugs such as marijuana
and cocaine affect the type and amount of anesthesia you need, list any of
these you take and how often you use them.”

45. A client in an operating room holding area, who is to receive general

anesthesia, reports having a dry mouth because food and fluids have been withheld
for 8 hours. Which action by a nurse is most appropriate?
a. Teach the client that the primary reason food and fluids have been
withheld is to prevent vomiting and potential complications
b. Clarify that food and fluids should have been withheld only for 4 hours and offer
a small sip of water
c. Explain to the client that a full stomach puts pressure on the diaphragm and
prevents full lung expansion during surgery
d. Tell the client that the general anesthetic will soon make the client sleepy and
unaware of the mouth dryness

46. A nurse is caring for a client who received conscious sedation during a surgical
procedure. Which assessment of this client is most important for a nurse to make
postoperatively?
a. Lung sounds c. Ability to swallow liquids
b. Amount of urine output d. Rate and depth of breathing

47. Upon arrival to an operating room holding area, a client who is scheduled for
abdominal surgery is noted to have replaced a tongue ring that was re moved when
the operative checklist was completed. Which is the most appropriate initial action
by a nurse?
a. Document the findings on the client’s medical record
b. Request that the client once again remove the tongue ring
c. Complete a variance report, noting that the client has replaced the tongue ring
d. Notify the surgeon and the anesthesiologist of the replacement of the tongue
ring

48. A nurse is orienting a new nurse to a postanesthesia care unit (PACU). Which
statement by the new nurse indicates further orientation is needed?
a. “Lactated Ringer’s (LR) and 5% dextrose with LR are typical IV solutions
administered in the PACU.”
b. “If a client has an opioid overdose, I should expect to administer naloxone
hydrochloride (Narcan®).”
c. “I should monitor vital signs and perform a pain assessment every 15 minutes or
more often if necessary.”
d. “Once a client responds verbally after a spinal anesthetic, the client can
be transferred to the nursing unit.”

49. Which information is most important for a postanesthesia care unit nurse to
include in a report on a post operative client to a surgical unit nurse?
a. Location of the relatives
b. Review of the surgical consent
c. Placement of client belongings
d. Last dose and type of pain medication

NUR 155 P1 EXAMINATION SET A 8

50. A nurse evaluates that a client has achieved an expected outcome for the
second postoperative day following abdominal surgery under general anesthesia.
Which finding supports the nurse’s conclusion?
a. Passing flatus
b. Urine output 680 mL in 24 hours
c. Crackles in bilateral lung bases
d. Rates incisional pain at 4 out of 10 on a 0 to 10 rating scale 60 minutes after
analgesic given

51. A postoperative client who received a spinal anesthetic is experiencing a

headache, photophobia, and double vision. A nurse’s initial intervention should be
to:
a. immediately notify the surgeon.
b. position the client flat in bed.
c. limit the client’s fluid intake.
d. administer steroid medications

52. In reviewing a physician’s orders for a postoperative client who underwent

gynecological surgery, which order should a nurse determine is specifically written
with the intent to prevent postoperative thrombophlebitis and pulmonary
embolism?
a. Have the client dangle the legs the evening of surgery
b. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily
c. Administer hydromorphone (Dilaudid®) 1 to 4 mg IV every 3 to 4 hours as
needed (prn)
d. Encourage coughing and deep breathing (C&DB) every hour while awake

53. A client is to receive a second dose of oxycodone/ acetaminophen (Percocet®)

for postoperative incisional pain. When a nurse brings the medication to the client,
the client says, “Why bring this medication again? It makes me feel sick.” Which
statement is the most appropriate initial nurse response?
a. “I can call the doctor to see what else can be ordered for your pain.”
b. “Describe what you feel when you say that the medication makes you
feel sick.”
c. “The doctor has ordered an antacid. I can give you this along with the
medication.”
d. “Many people say the same thing. The aspirin in the medication is hard on your
stomach

54. A nurse notifies a physician after assessing a client 5 days after an exploratory
laparotomy and noting a distended abdomen, abdominal pain, absence of flatus,
and absent bowel sounds. Which typical complication of abdominal surgery should
the nurse conclude may be occurring?
a. Paralytic ileus
b. Silent peritonitis
c. Fluid volume excess
d. Malabsorption syndrome

55. Which statement should a nurse include when teach ing a client prior to
discharge following abdominal surgery?
a. “Return to work in about 4 weeks because working increases your physical
activity gradually.”
b. “The ordered iron and vitamins tablets will promote wound healing and
red blood cell growth.”
c. “Daily walking carrying 10-pound weights will help to strengthen your incision.”
d. “Home-care nursing service is usually paid by insurance if you need help around
the house.”

NUR 155 P1 EXAMINATION SET A 9

56. A client with asthma has pronounced wheezing upon auscultation. Suspecting
an impending asthma attack, a nurse should:
a. have the client cough and deep breathe.
b. prepare to intubate the client.
c. prepare to administer a nebulized beta-2 adrenergic agonist.
d. have the client lay on his or her right side

57. A client, newly diagnosed with asthma is preparing for discharge. Which point
should a nurse emphasize during the client’s teaching?
a. Contact care provider only if nighttime wheezing becomes a concern
b. Limit exposure to sources that trigger an attack
c. Use peak flow meter only if symptoms are worsening
d. Use inhaled steroid medication as a rescue inhale

58. A nurse is working with a client to update the client’s asthma action plan. The
nurse knows that this action plan should include information on
a. medication adjustments that should be made if peak flow is less than
50% normal.
b. timeline for allergy skin testing.
c. the most direct route when the client drives to the hospital.
d. the best methods for chest physiotherapy (CPT).

59. Which finding should a nurse expect when completing an assessment on a client
with chronic bronchitis?
a. Minimal sputum with cough
b. Pink, frothy sputum
c. Barrel chest
d. Stridor on expiration

60. A client learning about chronic obstructive pulmonary disease self-care at a

community health class, asks a nurse why the participants are being taught about
the “lip-breathing.” The nurse should respond by explaining that pursed-lip
breathing can help to:
a. reduce upper airway inflammation.
b. reduce anxiety through humor.
c. strengthen respiratory muscles.
d. increase effectiveness of inhaled medications.

61. A home health nurse is visiting a client whose chronic bronchitis has recently
worsened. Which instruction should the nurse reinforce with this client
a. Increase amount of bedrest
b. Increase fluid intake
c. Decrease caloric intake
d. Reduce home oxygen use

62. A nurse is assessing lung sounds on a client with pneumonia who is having pain
during inspiration and expiration. The nurse hears loud grating sounds over the
lung fields. The nurse should document the client’s pain level and should document
that:
a. lung sounds were clear upon auscultation.
b. fine crackles were heard upon auscultation.
c. wheezing was heard upon auscultation.
d. pleural friction rub was heard upon auscultation.

NUR 155 P1 EXAMINATION SET A 10

63. A client, hospitalized for a severe case of pneumonia, is asking a nurse why a
sputum sample is needed. The nurse should reply that the primary reason is to
a. complete the first of three samples to be collected.
b. differentiate between pneumonia and atelectasis.
c. encourage expectoration of secretions.
d. help select the appropriate antibiotic.

64. A nurse is preparing to admit a client with a confirmed case of tuberculosis.

Which action is essential to infection control for this client?
a. Providing a positive-pressure airflow room
b. Wearing gown and gloves when handling the client’s stool or urine
c. Using a National Institute for Occupational Safety and Health (NIOSH)–
approved N95 respirator mask for staff and visitors
d. Keeping the client quarantined in the room until antibiotic therapy has been
initiated

65. A nurse observes for early manifestations of acute respiratory distress

syndrome (ARDS) in a client being treated for smoke inhalation. Which signs
indicates the possible onset of ARDS in this client?
a. Cough with blood-tinged sputum and respiratory alkalosis
b. Decrease in both white and red blood cell counts
c. Diaphoresis and low SaO2 unresponsive to increased oxygen
administration
d. Hypertension and elevated PaO2

66. Oral terbutaline (Brethaire®) is prescribed for a client with bronchitis. Which
comorbidity should prompt a nurse to monitor the client closely following
administration of this medication?
a. Strabismus c. Diabetes insipidus
b. Hypertension d. Hypothyroidism

67. A client is admitted to an emergency department with tachypnea, tachycardia,

and hypotension. The client has been taking theophylline (Theo-Dur®) for
treatment of asthma and erythromycin (Erythrocin®) for an upper respiratory tract
infection. Which con clusion by the nurse and action taken is correct
a. The client is experiencing an asthma attack and the nurse requests an order for
albuterol.
b. The client is experiencing septicemia and the nurse requests an order for blood
cultures.
c. The client is experiencing theophylline toxicity and the nurse requests
an order for a serum theophylline level.
d. The client is experiencing an allergic reaction to erythromycin and the nurse
requests an order for diphenhydramine (Benadryl®)

68. A hospitalized client is being treated for tuberculosis (TB). When administering
medications, which medication on the client’s medication administration record
(MAR) should a nurse conclude is used for the treatment of TB?
A. Isoniazid (Nydrazid®)
B. Fluconazole (Diflucan®)
C. Azithromycin (Zithromax®)
D. Acyclovir (Zovirax®)

69. Which method should a nurse use to assess the arterial oxygen saturation of a
pediatric client?
a. Finger pulse oximetry c. Hemoglobin levels
b. Arterial blood gases d. Peak flow

NUR 155 P1 EXAMINATION SET A 11

70. A nurse documented a nursing outcome of oxygen saturation (SaO2) greater
than 95% for a pediatric client diagnosed with heart failure. When the nurse obtains
a SaO2 value of 90%, the nurse determines that the outcome was not achieved and
intervenes by administering oxygen. The nurse’s intervention is based on the
nurse’s knowledge that the 90% SaO2 value indicates a PaO2 value of
a. 40 mm Hg. c. 80 mm Hg.
b. 60 mm Hg. d. 90 mm Hg

71. A 2-year-old child, admitted to an acute care pediatric unit with a sore throat, is
tentatively diagnosed with epiglottitis. Which diagnostic test should a nurse plan to
review to confirm the diagnosis?
a. Blood culture
b. Complete blood count (CBC)
c. Throat culture
d. Lateral neck x-ray

72. A physician orders arterial blood gases (ABGs) on a 5-year-old client admitted
with severe asthma. Which signs and symptoms noted during a nurse’s assessment
of the child are consistent with the blood gas findings of pH = 7.30, PaCO2 = 49
mm Hg, and HCO3 = 24 mEq/L?
a. Diaphoresis, headache, tachycardia, confusion, restlessness,
apprehension, and flushed face
b. Rapid and deep respirations, paresthesia, light headedness, twitching, anxiety,
and fear
c. Rapid and deep breathing, fruity breath, fatigue, headache, lethargy, drowsiness,
nausea, vomiting, and abdominal pain
d. Slow and shallow breathing, hypertonic muscles, restlessness, twitching,
confusion, irritability, apathy, tetany, and seizures

73. A triage nurse determines that a child brought to an emergency department is

experiencing severe respiratory distress when observing
a. diaphoresis, restlessness, tachypnea, and anorexia.
b. pallor, coughing, wheezing, and confusion.
c. retractions, grunting, cyanosis, and bradycardia.
d. agitation, decreased level of consciousness, diarrhea, and tachypnea

74. An 11-month-old infant is brought to the hospital after experiencing a

respiratory infection and severe diarrhea for 5 days. The child has poor skin turgor,
respirations 30, temperature 101.3°F (39°C), low serum potassium levels, and
watery green stools. A physician orders an antipyretic and to begin intra venous
(IV) fluid replacement of D5NS with a potassium additive. It is most important for a
nurse to:
a. ensure the infant had urine output before beginning the ordered IV
fluids.
b. apply oxygen because the child is experiencing rapid respirations.
c. change the infant’s diaper to prevent skin breakdown.
d. administer the antipyretic first.

NUR 155 P1 EXAMINATION SET A 12

75. A 5-month-old infant hospitalized with a diagnosis of Pneumocystis carinii
pneumonia is being treated with trimethoprim-sulfamethoxazole (TMP-SMZ) with no
adverse effects. A nurse assesses that the infant has thick tenacious secretions and
poor cough effort, diarrhea, anorexia, and is diaphoretic. Which nursing diagnosis
should the nurse establish as the priority?
a. Ineffective airway clearance related to increased secretions and inability
to clear the respiratory tract
b. Altered nutrition: less than body requirements related to recurrent illness,
diarrheal losses, loss of appetite, and oral candidiasis
c. Risk for infection related to impaired body defenses and presence of infective
organisms
d. Risk for fluid volume deficit related to difficulty taking fluids, insensible fluid
losses from hyperventilation, and diaphoresis

76. A child with asthma is being discharged to home and has an order for a
bronchodilator (albuterol) to be administered via a metered dose inhaler (MDI).
Which point should a nurse address for appropriate administration of this
medication?
a. When administering medication via a MDI, avoid shaking the canister before
discharging the medication.
b. Medication is ordered in two “puffs”; press on the canister twice in succession to
discharge the medication.
c. There should be a tight seal around the mouthpiece of the inhaler before
discharging the medication.
d. There should be a 2- to 3-inch space (or spacer device) between the
inhaler and the open mouth of the child.

77. A nurse is caring for a 5-year-old child diagnosed with bronchial asthma. Which
statement is most important for the nurse to make when teaching the parents?
a. “Bronchial asthma is also called hyperactive airway disease.”
b. “Frequent occurrences of bronchiolitis before 5 years of age could be a sign of
asthma.”
c. “Severe respiratory alkalosis can result from respiratory failure in asthma.”
d. “Severe bronchoconstriction can occur when exposed to cold air and
irritating odors.”

78. An initial treatment regimen of isoniazid (Laniazid®), rifampin (Rifadin®), and

ethambutol (Myambutol®) are prescribed for a 16-year-old client who has a
positive tuberculin skin test. The client confides that she thinks she may have
become pregnant since she was diagnosed and asks if she should be taking the
medication while pregnant. On which rationale should a nurse base a response to
the client’s question?
a. These drugs cross the placental barrier and treatment should be withheld until
the postpartum period.
b. The medications should be taken but the diagnosis is an indication for
termination of the pregnancy.
c. The medications should be postponed because the risk for hepatitis is greatly
increased in the intrapartum period.
d. The medications should be taken because untreated tuberculosis
represents a far greater hazard to a pregnant woman and her fetus than
does the treatment of the disease.

79. While putting an elderly client with an indwelling catheter in bed, a nurse
notices the tubing hanging below the bed. She places the tubing in a loop on the
bed with the client and makes sure the client won’t lie on the tubing. Which of the
following rationales explains the nurse’s action?
a. to inhibit drainage
b. to allow drainage to occur
c. to allow the urine to collect in the tubing

NUR 155 P1 EXAMINATION SET A 13

d. to have the client check the tubing for urine

80. Which of the following actions is correct when collecting a urine specimen from
a client’s indwelling urinary catheter?
a. Collect urine from the drainage collection bag.
b. Disconnect the catheter from the drainage tubing to collect urine.
c. Remove the indwelling catheter and insert a sterile straight catheter to collect
urine.
d. Insert a sterile needle with syringe though a tubing drainage port
cleaned with alcohol to collect the specimen.

81. A nurse is performing a bladder catheterization and is inserting an indwelling

Foley catheter. The nurse understands that which of the following represents an
unsafe action when performing this procedure?
a. Inflating the balloon to test patency before catheter insertion.
b. Inflating the balloon with 4 to5 mL more than the balloon capacity.
c. Placing the drainage bag lower than bladder level, with no kinks in the tubing.
d. Advancing the catheter an additional 2.5 to 5 cm (1 to 2 inches) once urine
appears in the catheter.

82. Nurse Bing has an order to obtain a urinalysis from a client with an indwelling
urinary catheter. Nurse Bing avoids which of the following, which could contaminate
the specimen?
a. Clamping the tubing of the drainage bag.
b. Obtaining the specimen from the urinary drainage bag.
c. Aspirating a sample from the port on the drainage bag.
d. Wiping the port with an alcohol swab before inserting the syringe.

83. A female client is being discharged from the hospital to home with an indwelling
urinary catheter following surgical repair of the bladder. The nurse determines that
the client understands the principles of catheter management if the client states to:
a. limit fluid intake so the bag won’t become full so quickly.
b. cleanse the perineal area with soap and water once a day.
c. keep the drainage bag lower than the level of the bladder.
d. coil the tubing and place it under the thigh when sitting to avoid tugging on the
bladder.

SITUATION: Mr. Duffy is admitted to the CCU with a diagnosis of R/O MI. He
presented in the ER with a typical description of pain associated with an MI, and is
now cold and clammy, pale and dyspneic. He has an IV of D5W running, and is
complaining of chest pain. Oxygen therapy has not been started, and he is not on
the monitor. He is frightened.

84. The nurse is aware of several important tasks that should all be done
immediately in order to give Mr. Duffy the care he needs. Which of the following
nursing interventions will relieve his current myocardial ischemia?
a. Stool softeners, rest
b. O2 therapy, analgesia
c. Reassurance, cardiac monitoring
d. Adequate fluid intake, low-fat diet

85. During the first three days that Mr. Duffy is in the CCU, a number of diagnostic
blood tests are obtained. Which of the following patterns of cardiac enzyme
elevation are most common following an MI?
a. SGOT, CK, and LDH are all elevated immediately.
b. SGOT rises 4-6 hours after infarction with CK and LDH rising slowly 24 hours
later.
c. CK peaks first (12-24 hours), followed by the SGOT (peaks in 24-36
hours) and then the LDH (peaks 3-4 days).

NUR 155 P1 EXAMINATION SET A 14

d. CK peaks first and remains elevated for 1 to 2 weeks.

86. On his second day in CCU, Mr. Duffy suffers a life-threatening cardiac
arrhythmia. Considering his diagnosis, which is the most probable arrhythmia?
a. atrial tachycardia
b. ventricular fibrillation
c. atrial fibrillation
d. heart block

87. Mr. Duffy is placed on digitalis on discharge from the hospital. The nurse
planning with him for his discharge should educate him as to the purpose and
actions of his new medication. What should she or he teach Mr. Duffy to do at home
to monitor his reaction to this medication?
a. take his blood pressure
b. take his radial pulse for one minute
c. check his serum potassium (K) level
d. weigh himself every day

88. You know that all but one of the following may eventually result in uremia.
Which option is not implicated?
a. glomerular disease
b. uncontrolled hypertension
c. renal disease secondary to drugs, toxins, infections, or radiations
d. all of the above

89. The point of maximal impulse (PMI) is an important landmark in the cardiac
exam. Which statement best describes the location of the PMI in the healthy adult?
a. Base of the heart, 5th intercostal space, 7-9 cm to the left of the midsternal line.
b. Base of the heart, 7th intercostal space, 7-9 cm to the left of the midsternal line.
c. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal
line.
d. Apex of the heart, intercostal space, 7-9 cm to the left of the midsternal line.

90. During the physical examination of the well adult client, the health care
provider auscultates the heart. When the stethoscope is placed on the 5th
intercostal space along the left sternal border, which valve closure is best
evaluated?
a. Tricuspid
b. Pulmonic
c. Aortic
d. Mitral

91. The pulmonic component of which heart sound is best heard at the 2nd LICS at
the LSB?
a. S1 c. S3
b. S2 d. S4

92. The coronary arteries furnish blood supply to the myocardium. Which of the
following is a true statement relative to the coronary circulation?
a. the right and left coronary arteries are the first of many branches off the
ascending aorta
b. blood enters the right and left coronary arteries during systole only
c. the right coronary artery forms almost a complete circle around the heart, yet
supplies only the right ventricle

NUR 155 P1 EXAMINATION SET A 15

d. the left coronary artery has two main branches, the left anterior
descending and left circumflex: both supply the left ventricle

Sally Baker, a 40-year-old woman, is admitted to the hospital with an established

diagnosis of mitral stenosis. She is scheduled for surgery to repair her mitral valve.

93. Ms. Baker has decided to have surgical correction of her stenosed valve at this
time because her subjective complaints of dyspnea, hemoptysis, orthopnea, and
paroxysmal nocturnal dyspnea have become unmanageable. These complaints are
probably due to:
a. thickening of the pericardium c. pulmonary hypertension
b. right heart failure d. left ventricular hypertrophy

94. An esophageal obturator airway (EOA):

a. Can be inserted by any person trained in ACLS.
b. Requires visualization of the trachea before insertion.
c. Never causes regurgitation.
d. Should not be used with a conscious person, pediatric patients, or
patients who have swallowed caustic substances.

95. During an acute myocardial infarct (MI):

a. A patient may have a normal appearing ECG.
b. Chest pain will always be present.
c. A targeted history is rarely useful in making the diagnosis of MI.
d. The chest pain is rarely described as crushing, pressing, or heavy.

96. The most common lethal arrhythmia in the first hour of an MI is:
a. Pulseless Ventricular Tachycardia
b. Asystole
c. Ventricular fibrillation
d. First-degree heart block.

97. Which of the following is true about verapamil?

a. It is used for wide-complex tachycardia.
b. It may cause a drop in blood pressure.
c. It is a first line drug for Pulseless Electrical Activity.
d. It is useful for treatment of severe hypotension.

98. Atropine:
a. Is always given for a heart rate less than 60 bpm.
b. Cannot be given via ET tube.
c. Has a maximum total dosage of 0.03-0.04 mg/kg IV in the setting of
cardiac arrest.
d. When given IV, should always be given slowly.

99. Asystole should not be “defibrillated.”

a. True c. Partially False
b. False d. Partially True

100. When giving bag-valve mask ventilations:

a. Rapid and forceful ventilations are desirable so that adequate ventilation will be
assured
b. Effective ventilations can always be given by one person.
c. Cricoid pressure may prevent gastric inflation during ventilations.
d. Tidal volumes will always be larger than when giving mouth to pocket mask
ventilations.

NUR 155 P1 EXAMINATION SET A 16

101. When does the entire PERI-OPERATIVE PERIOD begin and end?
a. Begins with admission and ends with discharge.
b. Begins upon the diagnosis of diseases and ends the moment the patient
recovers.
c. Begins when decision for surgery is made and ends with follow up
checkups until the patient fully recovers and resumes ADLs.
d. Begins as soon as the patient decides to undergo surgery and ends when patient
is transferred to O.R. table.

102. Which of the following activities suggests that the perioperative nurse is in the
intraoperative period?
a. Witnessing the signing of consent form.
b. Counting of surgical sponges and instruments.
c. Monitoring the patient after operation for anesthesia complications.
d. Providing discharge instructions for the patient after repair of heart valves.

103. Which of the following surgical procedures involves removal of a body organ?
a. Colostomy c. Mammoplasty
b. Laparotomy d. Cholecystectomy

104. Which of the following patients scheduled for surgery has the greatest risk
factor for the surgical complication?
a. Mark, a 29-year-old, male athletic client scheduled for intramedullary nailing due
to fracture of the right tibia.
b. Zyra Belle, a 72-year-old female client diagnosed with diabetes for 20
years now, will be scheduled for total abdominal hysterectomy and
bilateral salphingo-oophorectomy.
c. Tin, a 10-year-old, with gangrenous type of appendicitis scheduled for
emergency appendectomy.
d. Mac Calvin, a 45-year-old patient with BMI of 26, is scheduled for heart
transplantation.

105. A patient is scheduled for INCISIONAL BIOPSY in the left breast to determine
if the nodule is malignant or benign. When the patient asks the nurse, what is the
procedure all about, the nurse would be correct when she states
a. “The breast with nodule will be numbed first and a large needle attached to a
syringe will be inserted to suck out the nodule.”
b. “The surgeon will make a big incision in your breast to open it up to reveal the
nodule. The surgeon will then remove this once visible.”
c. “The surgeon will make a small incision in your breast and nodule will be
cut away.”
d. “An endoscope will be inserted into your breast and forceps will pass through it
to grasp the nodule.”

106. All of the following conditions require surgery, BUT:

a. Systemic metastasis of lung cancer C. Ureteral obstruction
caused by a polyp
b. Penetrating foreign object injury D. Ruptured Appendicitis

107. The perioperative nurse’s primary responsibility for the care of the patient
undergoing surgery is
a. developing an individualized plan of nursing care for the patient.
b. carrying out specific tasks related to surgical policies and procedures.
c. ensuring that the patient has been assessed for safe administration of
anesthesia.
d. performing a preoperative history and physical assessment to identify patient
needs.

NUR 155 P1 EXAMINATION SET A 17

108. One of the most important goals of the preoperative assessment by the nurse
is to
a. determine if the patient’s stress is too high to undergo surgery.
b. identify what information the patient needs to give voluntary, informed
consent for surgery.
c. establish baseline data for comparison of the patient’s status in the
intraoperative and postoperative period.
d. determine whether the patient’s surgery should be done as an inpatient, an
outpatient, or a same-day admission.

109. A patient who is scheduled for a hysterectomy report using gingko biloba to
improve her memory. Which of the following questions is the most important for
the perioperative nurse to ask the patient?
a. “How long have you used gingko biloba?”
b. “How have you been able to tell if this herb is effective?”
c. “Have you been taking this herb during the last seal weeks?”
d. “Have you experienced any side effects of taking this herbal product?”

110. A nursing intervention to assist a preoperative patient in coping with fear of

pain would be to
a. describe the degree of pain expected.
b. explain the availability of pain medication.
c. divert the patient’s attention when talking about pain.
d. inform the patient of the frequency of pain medication.

111. The nurse’s role in informed consent for surgery may include
a. obtaining the patient’s signature on the consent form.
b. explaining the risks and consequences of the proposed surgery.
c. informing the patient of the prognosis if the surgical procedure is refused.
d. identifying whether the patient has sufficient understanding about the
procedure he is about to undergo.

112. The nursing measure that should be performed last in the morning of surgery
is to
a. ask patient to void in the bathroom.
b. administer pre-anesthetic medications.
c. check the chart for signed consent form.
d. lock up the patient’s jewelry and money.

113. The nurse administering preoperative medications recognizes that

a. preoperative medications may help reduce anesthetic requirements.
b. intravenous medications can be administered only by an anesthesiologist on the
day of surgery.
c. a preoperative diazepam (Valium) tablet should be administered within 15
minutes of scheduled surgery.
d. an intramuscular injection of secobarbital (Seconal) should be administered 2
hours before the scheduled surgery.

SITUATION: Irina, a 25 y/o patient was admitted at The Medical City – Iloilo with
chief complaints of right iliac pain accompanied by nausea, vomiting, chills and
fever. She was diagnosed of having acute appendicitis. She was scheduled for a
stat appendectomy under spinal anesthesia.

114. Pre-operative instructions to the client would NOT include which of the
following:
a. Deep breathing and coughing exercises.
b. Instructing the benefits of early ambulation after surgery.

NUR 155 P1 EXAMINATION SET A 18

c. Demonstrating proper leg exercises.
d. Reassuring pain-free experience after surgery because of narcotics.

115. The client gave her consent for the surgery. To ensure the legality of consent,
the following conditions must be met EXCEPT:
a. She gave her consent without any form of coercion.
b. She fully understood the nature of the surgery.
c. A witness was present during consent-signing.
d. Consent was signed after pre-op meds were administered

116. Hair clipping prior to surgery is done in order to:

a. prevent wound infection C. indicate the site to be draped
b. facilitate skin incision D. reduce possibility of post-op wound
scarring

117. A newly wed female client is scheduled for stat repair of ruptured fallopian
tube due to ectopic pregnancy. The nurse asks the patient to remove the ring, but
the patient says, “Would it be okay to stay my wedding ring in my finger? You see,
it was just only 24 hours after I got married to the love of my life.” The nurse would
respond
a. “I’m sorry ma’am, but the ring can’t stay in your finger. It may interfere with the
proper blood circulation during the operation.”
b. “Okay but let me secure it in your finger. Would you like it to be taped to
prevent it from slipping?”
c. “Okay fine. I understand that you still have ‘hang-over’ in your wedding.”
d. “No, it’s part of the safety checklist that I need to accomplish.”

118. While the patient is being transferred to O.R., you made an assessment and
you found out that the patient appears anxious. Which among the following is the
MOST appropriate nursing intervention?
a. Ignore the patient’s anxiety since the operation is more important than what the
patient feels.
b. Administer sedatives as prescribed.
c. Explain the nature of the surgery to the patient.
d. Allow the client to ask questions and ventilate feelings.

119. A patient who receives preoperative medication wants to walk going to the OR
30 minutes before his scheduled operation. The nurse should
a. let the patient walk going to the OR, provided significant others will accompany
the patient.
b. not let the patient walk going to the OR. Call an assistant to get gurney.
c. allow the patient as long as she will assist the patient in walking through.
d. not allow the patient because the doctor will scold her.

120. Who among the following members of the O.R. team is always involved in
laparoscopic surgeries?
a. Biomedical Technician C. Ancillary
b. Radiographic Technician D. Institutional Electrician

121. Which of the following is experienced by a patient who is under spinal

anesthesia during an operation?
a. The patient is unconscious C. The patient experiences
amnesia
b. The patient experiences total loss of sensation D. The patient is
awake

122. Once a general anesthetic agent and its adjuncts are administered, the patient
experiences transitions from loss of consciousness to loss of most reflexes. Which

NUR 155 P1 EXAMINATION SET A 19

stage of general anesthesia is being aimed by anesthesiologists for the patient to
maintain?
a. Stage I B. Stage II C. Stage III D. Stage IV

123. Auditory hallucinations are common during which stage of general anesthesia?
a. Stage I B. Stage II C. Stage III D. Stage IV

124. Although very effective in facilitating performance of a surgery, complications

may come with administration of general anesthetic agents. Which of the following
is considered as the MOST serious and potentially fatal?
a. Severe renal and GI function impairment C. Convulsions
b. Metabolic activity disturbances D. Malignant hyperthermia

125. All of the following signs can make the anesthesiologist suspect that this
condition (your answer in the previous question) is developing, EXCEPT:
a. Constant and significant increase in blood pressure
b. Muscular rigidity
c. Difficulty of breathing accompanied by cyanosis and skin mottling
d. Sudden increase in body temperature

126. The nurse went to the sterilization room wearing a scrub suit, shoe cover and
head cap. She is within the ____________ premises of the O.R. Department
a. unrestricted Area B. semi-restricted Area C. restricted Area D.
sterile Area

127. He/she has the authority to signal patient’s transfer from the O.R. Department
into the Post-Anesthesia Care Unit.
a. Nurse Anesthetist C. Circulating Nurse
b. Scrub Nurse D. Registered Nurse First Assistant

128. The proper attire for the semi-restricted area of the surgery department is
a. street clothing. C. surgical attire and head cover.
b. surgical attire, head cover, and mask. D. street clothing with the
addition of shoe covers.

129. The characteristic of the operating room environment that facilitates the
prevention of infection in the surgical patient is
a. adjustable lighting. C. conductive furniture.
b. filters in the ventilating system. D. explosion-proof electrical plugs.

130. Assessment of a patient with musculoskeletal impairment on arriving to the

operating room enables the nurse to meet the patient’s needs during
a. preparation of the skin. C. induction of anesthesia.
b. positioning in the operating room bed. D. explanations about the
surgical activities.

131. When scrubbing at the scrub sink, the surgical team members should
a. scrub from elbows to hands. C. scrub without mechanical friction.
b. scrub for a minimum of 10 minutes. D. hold the hands higher than the
elbow.

132. When positioning a patient in preparation for surgery, the perioperative nurse
understands that injury to the patient is MOST likely to occur as a result of
a. incorrect skeletal alignment.
b. pooling of blood in the peripheral vessels.
c. loss of perception of pain or pressure.
d. disregarding the patient’s needs for modesty.

NUR 155 P1 EXAMINATION SET A 20

133. A patient being prepared for surgery tells the nurse that the anesthesia care
provider told her the she would receive “laughing gas” in addition to some other
inhaled drugs for her anesthesia. The nurse recognizes that an advantage of this
anesthetic agent is that it
a. is safer than other inhaled anesthetic agents.
b. has a strong analgesic effect during surgery.
c. is easier to administer than other anesthetic agents.
d. has strong anesthetic properties, allowing a decreased dose of other
anesthetics.

134. Intravenous induction for general anesthesia is the method of choice for most
patients because
a. the patient is not intubated. C. the agents are nonexplosive.
b. induction is rapid and pleasant. D. the odor of the agent is not
offensive.

135. The injection of local anesthetic into the tissues through which the surgical
incision will pass is the technique of
a. nerve block. B. local infiltration. C. topical application. D. regional
application.

136. This is a nurse who works in collaboration with the surgeon that handles
tissue, uses instruments to assist with hemostasis, expose the surgical site and
does suturing, provided a formal education.
a. Registered nurse first assistant C. Nurse anesthetist
b. Nurse technician D. Nurse surgical technologist

137. The nurse received a patient 2 hours ago from the OR who had undergone
general surgery, is now difficult to arouse. Which of the following actions of the
nurse is the MOST appropriate?
a. Continue monitoring the patient. C. Call the attention of the doctor
immediately.
b. Call a code blue team. D. Start cardiopulmonary resuscitation
instantaneously.

138. A postop client who had abdominal surgery is holding a pillow against his
abdomen during deep breathing and coughing. What term does the nurse use to
describe this technique?
a. Kangarooing B. Splitting C. Splinting D. Anchoring

139. A semi-conscious client in the post-anesthesia care unit (PACU) is

experiencing dyspnea. Which of the following immediate actions should the nurse
perform first?
a. Place a pillow under the client’s head. C. Remove the oropharyngeal airway.
b. Apply oxygen by mask. D. Reposition the client to keep
the tongue forward.

140. To prevent the effects of postoperative immobility on the gastrointestinal

system, the nurse suggests that the patient:
a. avoid taking antibiotics. C. increase her fluid intake.
b. avoid high-fiber foods. D. limit her activity for the first 3 to 4 days.

141. The post anesthesia care nurse is evaluating the patient for possible transfer
to the surgical unit. The following assessment would prevent the patient’s transfer:
a. Blood pressure is 126/78 mm Hg. C. Pulse rate is 82 beats per minute.
b. Pulse oximeter reading is 85%. D. Respirations are 22 per minute.

NUR 155 P1 EXAMINATION SET A 21

142. A nurse is assisting in the transfer of a postoperative patient from the post
anesthesia care unit to the surgical nursing unit. To ensure the safety of the
patient, the nurse would:
a. put the side rails up after moving the patient from the stretcher to the
bed.
b. ask the patient to move from the stretcher to the bed.
c. move the patient rapidly from the stretcher to the bed.
d. uncover the patient before transferring from the stretcher to the bed.

143. The nurse is doing an assessment of a patient who has returned from a
cardiac catheterization and had conscious sedation. The nurse should report which
of the following findings?
a. Patient is difficult to arouse C. Blood pressure of 124/72
b. Oxygen saturation of 96% D. Patient complains of needing to
void

144. A postoperative patient is complaining of incisional pain. An order has been

given for morphine every 4 to 6 hours PRN. The first assessment by the nurse
should be to:
a. assess for the presence of bowel sounds. C. assess pupillary reaction.
b. ask the patient’s family if she is having pain. D. see when the patient last
received pain medication.

145. A patient who had a hysterectomy yesterday has been NPO. The physician has
now ordered the patient’s diet to be clear liquids. Before administering the diet, the
nurse should check for:
a. feelings of hunger. C. bowel sounds.
b. positive Homans’ sign. D. gag reflex.

146. The technique the nurse should use to change a postoperative dressing is:
a. enteric isolation. C. aseptic technique.
b. clean technique. D. respiratory isolation.

147. The nurse is caring for the postoperative patient who has had spinal
anesthesia. The nurse would place highest priority on reporting which of these
assessments?
a. Complaints of a headache C. Pulse rate of 78 beats per minute
b. Voided 300 mL D. Blood pressure of 126/78

148. The nurse is caring for a postoperative patient. To best prevent deep vein
thrombosis (DVT) in this patient, the nurse plans to diligently ensure that the
patient:
a. splints the incision. C. coughs and deep-breathes every 2
hours.
b. regularly removes antiembolism stockings. D. ambulates frequently.

149. The nurse is performing a postoperative assessment on a patient who has just
returned from a hernia repair. The patient’s blood pressure is 90/60 mm Hg and
apical pulse is 102. The nurse’s first action would be to:
a. check the dressing for bleeding. C. notify the RN.
b. document the vital signs. D. increase the rate of infusion of IV
fluids.

150. A nurse who is about to administer due Morphine Sulfate to a client 4-hour
post-op should temporarily withhold the next dose when she finds which of the
following condition?
a. Urine output is 100 mL for 2 hours. C. Blood pressure is 90/50 mmHg.
b. Positive patellar reflex. D. Respiratory rate of 13 bpm.

NUR 155 P1 EXAMINATION SET A 22

151. A 7-year-old client is brought to the E.R. He’s tachypneic and afebrile and has
a respiratory rate of 36 breaths/minute and a nonproductive cough. He recently had
a cold. From his history, the client may have which of the following?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema

152. Which of the following assessment findings would help confirm a diagnosis of
asthma in a client suspected of having the disorder?
a. Circumoral cyanosis
b. Increased forced expiratory volume
c. Inspiratory and expiratory wheezing
d. Normal breath sounds

153. A 58-year-old client with a 40-year history of smoking one to two packs of
cigarettes a day has a chronic cough producing thick sputum, peripheral edema,
and cyanotic nail beds. Based on this information, he most likely has which of the
following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

154. The term “blue bloater” refers to which of the following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema

155. The term “pink puffer” refers to the client with which of the following
conditions?
a. ARDS c. Chronic obstructive bronchitis
b. Asthma d. Emphysema

156. Exercise has which of the following effects on clients with asthma, chronic
bronchitis, and emphysema?
a. It enhances cardiovascular fitness.
b. It improves respiratory muscle strength.
c. It reduces the number of acute attacks.
d. It worsens respiratory function and is discouraged.

157. Clients with chronic obstructive bronchitis are given diuretic therapy. Which of
the following reasons best explains why?
a. Reducing fluid volume reduces oxygen demand.
b. Reducing fluid volume improves clients’ mobility.
c. Restricting fluid volume reduces sputum production.
d. Reducing fluid volume improves respiratory function.

158. A 69-year-old client appears thin and cachectic. He’s short of breath at rest
and his dyspnea increases with the slightest exertion. His breath sounds are
diminished even with deep inspiration. These signs and symptoms fit which of the
following conditions?
a. ARDS c. Chronic obstructive bronchitis
b. Asthma d. Emphysema

NUR 155 P1 EXAMINATION SET A 23

159. A nurse explains to a client with pleurisy that pain resulting from breathing is
due to:
a. Weak diaphragm
b. Damaged nerve endings
c. Inflamed pleura
d. Damaged lungs

160. Pleural friction rub will cause which of the following problems?
a. Intercostal tenderness
b. Pleural inflammation
c. Pleural infection
d. Pleuritic pain

161. Thoracentesis is effective if:

a. Decreased severity of cough
b. Decreased tactile fremitus
c. Notes dull percussions
d. Absence of dyspnea

162. Which is incorrect in pleural effusion?

a. Dull, flat sound when chest is percussed
b. Diminished breath sounds in the area
c. Is secondary to pulmonary infections
d. Pleural fluid is at least 15cc

163. The following are the functions of water- seal bottle system. (SATA)
1. It futhers pnemothorax
2. It drains the pleural space
3. It facilitates re-expansion of the lung
4. It corrects positive pressure in the lung

a. 1 and 4 only
b. None of the above except 1 and 4
c. 2, 3 and 4
d. All of the above except 4 and 2
e. 1, 2 and 4 only

164. The RN observes continuous, mild bubbling in the suction control bottle, what
would be her initial nursing intervention?
a. Report to the physician
b. Do nothing, it is expected
c. Suspect for leakage
d. Re-attach the chest tube

165. Cystic fibrosis is diagnosed by:

a. Echocardiogram
b. Complete blood panel
c. Chest X-ray
d. Sweat test

166. A patient is admitted with a chest wound and experiencing extreme dyspnea,
tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area
of the chest. On assessment, you note there is unequal rise and fall of the chest
with absent breath sounds on the left side. You also note a “sucking” sound when
the patient inhales and exhales. The patient’s chest x-ray shows a pneumothorax.
What type of pneumothorax is this known as?
a. Closed pneumothorax

NUR 155 P1 EXAMINATION SET A 24

b. Open pneumothorax
c. Tension pneumothorax
d. Spontaneous pneumothorax

167. In regard to the patient in the question above, which of the following options
below is a nursing intervention you would provide to this patient?
a. Place the patient in supine position
b. Place a non-occlusive dressing over the chest wound
c. Place an occlusive dressing over the chest wound and tape it on three
sides
d. Prepare the patient for a thoracentesis

168. Which statement is CORRECT about a tension pneumothorax?

a. This condition happens when an opening to the intrapleural space creates a two-
way valve which causes pressure to build up in the space leading to shifting of the
mediastinum.
b. A tension pneumothorax is a medical emergency and is treated with
needle decompression.
c. Tracheal deviation is an early sign of a tension pneumothorax
d. An open pneumothorax is the only cause of a tension pneumothorax.

169. A patient receiving treatment for a pneumothorax calls on the call light to tell
you something is wrong with their chest tube. When you arrive to the room you
note that the drainage system has fallen on its side and there is a large crack in the
system. What is your next PRIORITY?
a. Place the patient in supine position and clamp the tubing.
b. Notify the physician immediately.
c. Disconnect the drainage system and get a new one.
d. Disconnect the tubing from the drainage system and insert the tubing 1
inch into a bottle of sterile water and obtain a new system.

170. You’re providing care to a patient with a pneumothorax who has a chest tube.
On assessment of the chest tube system, you note there is no fluctuation of water
in the water seal chamber as the patient inhales and exhales. You check the system
for kinks and find none. What is your next nursing action?
a. Keep monitoring the patient because this is a normal finding.
b. Increase wall suction to the system until the water fluctuates in the water seal
chamber.
c. Assess patient’s lung sounds to assess if the affected lung has re-
expanded.
d. Notify the physician.

171. Medical treatment of coronary artery disease includes which of the following
procedures?
a. Cardiac catheterization
b. Coronary artery bypass surgery
c. Oral medication administration
d. Percutaneous transluminal coronary angioplasty

172. Atherosclerosis impedes coronary blood flow by which of the following

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

173. Preventable factors that increase the risk of CAD include: Select all that apply.
a. High blood cholesterol levels
b. Use of personal protective equipment

NUR 155 P1 EXAMINATION SET A 25

c. Cigarette smoking
d. Obesity
e. Exposure to polyacrylamide

a. A, B and C
b. A, C and E
c. B, C, D and E
d. A, C and D

174. There are a number of risk factors associated with coronary artery disease.
Which of the following is a modifiable risk factor?
a. Obesity.
b. Heredity.
c. Gender.
d. Age.

175. During the previous few months, a 56-year-old woman felt brief twinges of
chest pain while working in her garden and has had frequent episodes of
indigestion. She comes to the hospital after experiencing severe anterior chest pain
while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris.
After stabilization and treatment, the client is discharged from the hospital. At her
follow-up appointment, she is discouraged because she is experiencing pain with
increasing frequency. She states that she is visiting an invalid friend twice a week
and now cannot walk up the second flight of steps to the friend’s apartment without
pain. Which of the following measures that the nurse could suggest would most
likely help the client deal with this problem?
a. Visit her friend earlier in the day.
b. Rest for at least an hour before climbing the stairs.
c. Take a nitroglycerin tablet before climbing the stairs.
d. Lie down once she reaches the friend’s apartment.

176. Which of the following symptoms should the nurse teach the client with
unstable angina to report immediately to her physician?
a. A change in the pattern of her pain
b. Pain during sex
c. Pain during an argument with her husband
d. Pain during or after an activity such as lawnmowing

177. The physician refers the client with unstable angina for a cardiac
catheterization. The nurse explains to the client that this procedure is being used in
this specific case to:
a. Open and dilate the blocked coronary arteries
b. Assess the extent of arterial blockage
c. Bypass obstructed vessels
d. Assess the functional adequacy of the valves and heart muscle.

178. As an initial step in treating a client with angina, the physician prescribes
nitroglycerin tablets, 0.3mg given sublingually. This drug’s principal effects are
produced by:
a. Antispasmotic effect on the pericardium
b. Causing an increased mycocardial oxygen demand
c. Vasodilation of peripheral vasculature
d. Improved conductivity in the myocardium

179. The nurse teaches the client with angina about the common expected side
effects of nitroglycerin, including:
a. Headache

NUR 155 P1 EXAMINATION SET A 26

b. High blood pressure
c. Shortness of breath
d. Stomach cramps

180. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How

should the nurse instruct the client to use the drug when chest pain occurs?
a. Take one tablet every 2 to 5 minutes until the pain stops.
b. Take one tablet and rest for 10 minutes. Call the physician if pain persists after
10 minutes.
c. Take one tablet, then an additional tablet every 5 minutes for a total of 3
tablets. Call the physician if pain persists after three tablets.
d. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still
persists 5 minutes later, call the physician.

181. Which of the following arteries primarily feeds the anterior wall of the heart?
a. Circumflex artery
b. Internal mammary artery
c. Left anterior descending artery
d. Right coronary artery

182. Which of the following blood tests is most indicative of cardiac damage?
a. Lactate dehydrogenase
b. Complete blood count (CBC)
c. Troponin I
d. Creatine kinase (CK)

183. A patient with stable angina is more likely to experience chest pain when the
heart needs extra oxygen. During which of the following situations does the heart
need extra oxygen?
a. Smoking a cigarette
b. Eating and digesting a heavy meal
c. Running up the stairs or other physical activity
d. All of the above

184. A patient admitted to the hospital with myocardial infarction develops severe
pulmonary edema. Which of the following symptoms should the nurse expect the
patient to exhibit?
a. Slow, deep respirations. c. Bradycardia.
b. Stridor. d. Air hunger.

185. A 55-year-old client is admitted with chest pain that radiates to the neck, jaw
and shoulders that occurs at rest, with high body temperature, weak with
generalized sweating and with decreased blood pressure. A myocardial infarction is
diagnosed. The nurse knows that the most accurate explanation for one of these
presenting adaptations is:
a. Catecholamines released at the site of the infarction causes intermittent localized
pain.
b. Parasympathetic reflexes from the infarcted myocardium causes diaphoresis.
c. Constriction of central and peripheral blood vessels causes a decrease in blood
pressure.
d. Inflammation in the myocardium causes a rise in the systemic body
temperature.

186. Which of the following is the most common symptom of myocardial infarction?
a. Chest pain c. Edema
b. Dyspnea d. Palpitations

NUR 155 P1 EXAMINATION SET A 27

187. A nurse is preparing for the admission of a client with heart failure who is
being sent directly to the hospital from the physician’s office. The nurse would plan
on having which of the following medications readily available for use?
a. Diltiazem (Cardizem) c. Propranolol (Inderal)
b. Digoxin (Lanoxin) d. Metoprolol (Lopressor)

188. Which of the following nursing diagnoses would be appropriate for a client with
heart failure? Select all that apply.
a. Ineffective tissue perfusion related to decreased peripheral blood flow
secondary to decreased cardiac output.
b. Activity intolerance related to increased cardiac output.
c. Decreased cardiac output related to structural and functional changes.
d. Impaired gas exchange related to decreased sympathetic nervous system
activity.

189. Which of the following would be a priority nursing diagnosis for the client with
heart failure and pulmonary edema?
a. Risk for infection related to stasis of alveolar secretions
b. Impaired skin integrity related to pressure
c. Activity intolerance related to pump failure
d. Constipation related to immobility

190. Captopril may be administered to a client with HF because it acts as a:

a. Vasopressor c. Vasodilator
b. Volume expander d. Potassium-sparing diuretic

191. The following patients are MOST at risk for developing heart failure? Which of
the following statements are TRUE?
a. A 69 year old male with a history of alcohol abuse and is recovering from a
myocardial infarction.
b. A 55 year old female with a health history of asthma and hypoparathyroidism.
c. A 30 year old male with a history of endocarditis and has severe mitral stenosis.
d. A 45 year old female with lung cancer stage 2.
e. A 58 year old female with uncontrolled hypertension and is being treated for
influenza.

a. Statement A is True and Statement B is False

b. Statement A, C and E are true, Statement B is False
c. Statement B, C, D are True, Statement A and E is False
d. Statement D and E are False, Statement A, B, C are True

192. A patient is being discharged home after hospitalization of left ventricular

systolic dysfunction. As the nurse providing discharge teaching to the patient, which
statement is NOT a correct statement about this condition?*
a. "Signs and symptoms of this type of heart failure can include: dyspnea,
persistent cough, difficulty breathing while lying down, and weight gain."
b. "It is important to monitor your daily weights, fluid and salt intake."
c. "Left-sided heart failure can lead to right-sided heart failure, if left untreated."
d. "This type of heart failure can build up pressure in the hepatic veins and
cause them to become congested with fluid which leads to peripheral
edema."

193. Which of the following are NOT typical signs and symptoms of right-sided
heart failure? Select-all-that-apply:*
a. Jugular venous distention c. Weight gain
b. Persistent cough d. Crackles

a. All of the above except C and D

b. A, B, C and D

NUR 155 P1 EXAMINATION SET A 28

c. B, D and F
d. None of the above except C and E
e. B, C, D and E only

194. A patient is diagnosed with left-sided systolic dysfunction heart failure. Which
of the following are expected findings with this condition?*
a. Echocardiogram shows an ejection fraction of 38%.
b. Heart catheterization shows an ejection fraction of 65%.
c. Patient has frequent episodes of nocturnal paroxysmal dyspnea.
d. Options A and C are both expected findings with left-sided systolic
dysfunction heart failure

195. What is the most common complication of an MI?

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

196. A client is recovering from coronary artery bypass graft (CABG) surgery.
Which nursing diagnosis takes highest priority at this time?
a. Decreased cardiac output related to depressed myocardial function, fluid
volume deficit, or impaired electrical conduction
b. Anxiety related to an actual threat to health status, invasive procedures, and
pain
c. Ineffective family coping related to knowledge deficit and a temporary change in
family dynamics
d. Hypothermia related to exposure to cold temperatures and a long
cardiopulmonary bypass time

197. A client reports recent onset of chest pain that occurs sporadically with
exertion. The client also has fatigue and mild ankle swelling, which is most
pronounced at the end of the day. The nurse suspects a cardiovascular disorder.
When exploring the chief complaint, the nurse should find out if the client has any
other common cardiovascular symptoms, such as:
a. Insomnia c. Confusion
b. Irritability d. Shortness of breath

198. The nurse is caring for a client with left-sided heart failure. To reduce fluid
volume excess, the nurse can anticipate using:
a. Antiembolism stockings c. Diuretics
b. Oxygen d. Anticoagulants

199. The nurse is caring for a client experiencing dyspnea, dependent edema,
hepatomegaly, crackles, and jugular vein distention. What condition should the
nurse suspect?
a. Pulmonary embolism c. Cardiac tamponade
b. Heart failure d. Tension pneumothorax

200. A client with an acute myocardial infarction is receiving nitroglycerin by

continuous I.V. infusion. Which statement by the client indicates that this drug is
producing its therapeutic effect?
a. "I have a bad headache."
b. "My chest pain is decreasing."
c. "I feel a tingling sensation around my mouth."
d. "My blood pressure must be up because my vision is blurred

NUR 155 P1 EXAMINATION SET A 29