100

Pretest
1. A 19-year-old male is admitted to the emergency room following an automobile accident. The nurse
determines that
the client has severe flail chest. Which of these would be documented on the physical exam?
a. During inspiration, the flail segment will expand and will be pulled inward on expiration.
b. During inspiration, the flail segment will be pulled inward; and during expiration, the segment will bulge
outward.
c. During inspiration, the flail segment will not move when the unaffected area is expanded.
d. There is no movement of the flail segment on inspiration or expiration.
Flail chest causes a pulling inward during inspiration and bulging outward on expiration. Option #1 is
normal chest movement. Options #3 and #4 are not expected findings in flail chest.
2. Which observation by the nurse manager would evaluate the staff's understanding of the prevention of
exposure to
HIV?
a. Using a protective gown upon entering the room. b. Using sterile sheets for the client.
c. Wearing gloves when handling blood and body secretions.
d. Wearing a gown, gloves, and mask upon entering the room.
HIV is transmitted through blood and body secretions. Options #1, #2, and #4 are not necessary.
3. Which statement made by the 70-year-old client indicates he understands how to take his steroid and
bronchodilator inhalers?
a. "I will take my steroid first and follow it with my bronchodilator."
b. "I will take 2 puffs very quickly and then hold my breath."
c. "I will take my bronchodilator first and follow it with my steroid."
d. "I will separate the inhalers and rotate when I take them."
The bronchodilator inhaler will open up the bronchioles so the steroid can be effective. Option #1 is
incorrect. Option #2 is incorrect because the client needs time between the 2 puffs. Option #4 is incorrect.
4. Which nursing action has the highest priority following a cardiac catheterization procedure?
a. Place a warm pack to increase the temperature of the left foot.
b. Evaluate the vital signs every 2 hours.
c. Compare the quality of the pulses on the right and left legs.
d. Determine the presence of pulses above the catheterization site.
The two extremities should be compared in relation to the pain, pulse, pallor, temperature, and capillary
filling time. Option #1 makes no comparison to effectively evaluate the circulation. Option #2 is incorrect
because vital signs are usually evaluated every 15 minutes after the procedure to identify hypotension and
dysrhythmia. Option #4 should be evaluated distal to the site for equality between the two extremities.
5. Which nursing action has the highest priority in preparing the client the evening prior to an intrave nous
pyelogram
procedure?
a. Administer a cathartic enema to cleanse the bowel.
b. Identify through a history any client allergies to iodine or food.
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Field Experience in Medical-Surgical Nursing
c. Instruct the client to be NPO after midnight.
d. Teach the client that x-rays will be taken at multiple intervals.
Clients who are sensitive to iodine can develop anaphylaxis. The client should be asked specifically
regarding allergy to iodine. Iodine is present in the radiopaque material which is injected intravenously.
Options #1, #3, and #4 contain correct information but are not priorities. The test may be canceled if the
client is allergic to iodine.
6. Which equipment is more important for the nurse to have available at the bedside of a client with a
history of
seizures?
a. Pump for IV solution
b. Suction equipment
c. Defibrillator.
d. IV cutdown tray.
The suction equipment should be available to facilitate removing the nasal and pharyngeal secretions which
could lead to airway obstruction. Options # 1 and #4 are not specific to providing safety after a seizure.
Option #3 is unnecessary for the disorder.
7. A 2-year-old is admitted to the Pediatric Unit with numerous bruises, fractured left humerus
and several lacerations of
unexplained origin. Which nursing action is a priority?

a. Report the findings to the Child Protection Agency.
b. Share this information only with other health care professionals.
c. Document this information in the chart only.
d. Share the information with the Pediatric Social Worker.
Any suspicion of child abuse should be reported to the Child Protection Agency. Options #2, #3, and #4
do not provide nor plan for protection of the child.
8. Which documentation would be the most accurate when an error has been made on the flow sheet?
a. Make the record look neat by using correction fluid.
b. Draw several lines through the entry so it is not readable.
c. Write the word "error" above or beside the original words with your initials and draw a single line
through the
entry.
d. Cross through the error with correction fluid and write over the entry.
Out of the options, this is the best answer. Options #l and #4—A breach in the nursing standards of care
is alteration of records. The use of correction fluid cannot be used on medical records because it denotes
alteration of records. Words covered by correction fluid have been deciphered with x-ray equipment.
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Insurance companies will not cover nurses who use correction fluid on patient records. Option #2 is
incorrect. Errors should never be obliterated or covered up.
9. One hour to discharge, a postpartum client requests more peripads, diapers, tucks, and Americaine spray.
Which
response made by the nurse would be most appropriate and demonstrate an understanding of cost effectiveness?
a. "I will be glad to get these supplies for you."
b. "It would be much better if you would just stop and pick them up on your way home."
c. "I will be happy to get them for you and pull some extras for you to take home."
d. "What items do you need until you leave to go home?"
This option is the most diplomatic response and considers cost effectiveness. Many insurance companies
view extra supplies on the day of discharge as stockpiling, and the client may be stuck with the bill. While
some companies may still pay the entire bill as presented, many are becoming dollar-wise and view each
bill with a critical eye. Options #1 and #3 do not consider cost effectiveness. Option #2 is an inappropriate
response.
10. In a 7-month-oid infant, which is the best way to detect fluid retention?
a. Weigh the child daily.
b. Test the urine for hematuria
c. Measure abdominal girth weekly.
d. Count the number of wet diapers.
Fluid retention is best detected by weighing^ daily .and noting a gaining trend. Options #2 and #3 are
incorrect and will not provide information regarding fluid retention. Option #4 can provide an estimation
of the amount of urine output but not about fluid retention.
11. Which nursing approach would be most appropriate for obtaining a specimen from a retention catheter?
a. Disconnect the drain at the bottom of the draining bag and drain urine into a sterile container.
b. Disconnect the tubing between the catheter and the drainage bag and drain urine into a sterile container.
c. Clamp the drainage tube. When fresh urine collects, open the tubing and drain into a sterile container.
d. Use a sterile syringe and needle to obtain urine from the porthole.
This represents the appropriate process in collecting a "sterile" urine specimen. Options #1 and #2 open
a closed system which allows bacteria to be introduced. Option #3 is incorrect information.
12. Which evaluation would best determine if fluid is amniotic versus urine?
a. Digital evaluation
b. pH determination of fluid.
c. Urinalysis by lab.
d. Glucose determination.
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Amniotic fluid is alkaline; test with phena-phthazine (nitrazine) paper which turns blue if it is amniotic
fluid. Normal vaginal and urinary secretions are acidic. Option #1 will assist in evaluating a prolapsed cord
or dilation. Options #3 and #4 are incorrect.
13. The nurse would determine the client understands the collection of urine specimen for culture and
sensitivity when
he states:
a. "I will call the lab before I collect my urine."
b. "I will drink several glasses of water before the urine is collected."
c. "I will call the nurse to help me with aseptic technique."

d. "I will discard my first voiding in the morning."
Aseptic techniques decrease the possibility of contamination with organisms. Options #1, #2, and #4 are
incorrect.
14. Which nursing observation would most likely indicate an early side effect of the elderly client taking
digoxin
(Lanoxin)?
a. Confusion.
b. Bradycardia.
c. Constipation.
d. Hyperkalemia.
The elderly are particularly prone to digoxin-induced confused states which can occur in the presence
ofsubtoxic digoxin levels and without other signs oftoxicity. Option #2 occurs as a late side effect. Option
#3 and #4 are incorrect.
15. Which initial observation is most important following a tonsillectomy in an 8-year-old?

a. Heart rate of 88 beats per minute.
b. Bright red secretions.
c. 30 ml of dark brown secretions.
d. Infrequent swallowing.
Secretions which are bright red indicate a sign of hemorrhage. Option #1 is a normal rate for an 8-year- old.
Option #3 is to be expected due to the surgical procedure. Option #4 is expected after the surgery due to the
discomfort.
16. Which statement by a client would indicate an understanding of when to take the medication, cromolyn
sodium
(Intal)?
a. "I will take the medicine with my meals."
b. "It is important that I take the medication before going to bed."
c. "If I experience respiratory distress, I will take the medicine."
d. "I will take the medication before I begin any vigorous exercise."
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Cromolyn sodium (Intal) is used to prevent the release of histamine and other allergy- triggering
substances. Options #1 and #2 contain inappropriate information. Option #3 is incorrect because it is
ineffective.
17. In pre-eclampsia, the nurse would expect to assess which symptoms?

a. Blurred vision and proteinuria.
b. Epigastric pain and headache.
c. Facial swelling and proteinuria.
d. Polyuria and hypertonic reflexes.
Option #3 represents 2 of the 3 assessments in pre-eclampsia. The third is hypertension. Option #1 is only
partially correct. Blurred vision appears later with eclampsia. Option #2 contains signs of eclampsia
prior to seizure. Option #4 is incorrect because oliguria would be seen later with eclampsia versus
polyuria.
18. Which assessment indicates a neonate with an infection is not fully recovered?
a. Heart rate of 150.
b. Axillary temperature of 98.6°F.
c. Weight increase of 4 oz.
d. Resting respiratory rate of 65.
The normal respiratory rate of a neonate is 30-50. Tachypnea is a sign of sepsis or hy-poxia with a
neonate. Option #1 is incorrect because it is within the normal range. Option #2 is not significant. Option
#3 is incorrect. Neonates normally experience between a 5-10 percent loss of weight within the first few-
days of life.
19. Which order should be questioned on a client in vasoocclusive crisis due to sickle cell anemia.
a. Place client on bed rest with bathroom privileges.
b. Administer 2 liters oxygen via nasal cannula.
c. Maintain IV rate at keep open.
d. Administer analgesics as ordered.
The keep-open rate is too slow. Adequate hydration must be maintained to prevent sickling and clumping
of the affected cells. Options #1, #2, and #4 are appropriate orders for this client.
20. Which symptom is indicative of an increase in respiratory distress in a 4-year-old client with
drooling and an inflamed
epiglottis?
a. Bradycardia.
b. Tachypnea.
c. General pallor.
d. Irritability.
An increase in the respiratory rate is an early sign of hypoxia. Another early assessment of hypoxia
would be tachycardia. Option #1 is incorrect because tachycardia occurs early in hypoxia. Option #3 is a
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general symptom and not measurable for hypoxia. Option #4 is incorrect because the client may be
anxious and restless but is generally not described as irritable.
21. Which assessment findings indicate an early problem with shock in a 66-year-old client with severe
second and third
degree bums over 75 percent of his body?

a. Epigastric pain and seizures.
b. Widening pulse pressure and bradycardia.
c. Cool, clammy skin and tachypnea.
d. Kussmaul respirations and lethargy.
The body responds to early hypovolemic shock by adrenergic stimulation. Vasocon-striction compensates
for the loss of fluid, resulting in cool, clammy skin, tachycardia, tachypnea, and pale color. Option #1
occurs with the pre-eclamptic client prior to seizure. Option #2 occurs in cardiac problems. Option #4
occurs in ketoacidosis.
22. A client has a history of oliguria, hypertension. and peripheral edema. Current lab values include BUN-
25, K-5.0.
Which nutrients should be restricted in this client’s diet?
a. Protein.
b. Fats.
c. Carbohydrates.
d. Magnesium.
A decreased production of urea nitrogen can be achieved by restricting protein. These metabolic wastes
cannot be excreted by the kidneys. Options #2 and #3 decrease the non-protein nitrogen production;
therefore, these foods are encouraged. Option #4 is incorrect.
23. An older client with diabetes is being managed with insulin in the AM and PM. Which observation is
the best for
indicating the overall therapeutic response to. the management?
a. Glycosylated hemoglobin (HbAlc)%.
b. Fasting blood sugar 128 mg/dl.

c. Blood pressure is maintained at 130/82
d. Serum amylase is normal.
The glycosylated hemoglobin will indicate the overall glucose control for approximately the past 120
days. This allows evaluation of " control of the blood sugar regardless of increases or decreases in blood
sugar immediately prior to drawing the sample. Option #2 is not a priority to #1. Option #3 would be
evaluating the response to an antihypertensive medication. Option #4 is evaluating for pancreatitis.
24. Which assessment finding would indicate an increase in the intracranial pressure in a 4-month-old
infant?
a. A positive Babinski
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b. High pitched cry.
c. Bulging posterior fontanelle.
d. Pinpoint pupils.
A high-pitched cry is one of the first signs of an increase in intracranial pressure in infants. Option #1 is
normal for the first year of life. Option #3 is incorrect because the fontanelle should be closed by the third
month. Option #4 is incorrect because with increased pressure, the pupils may respond to light slowly
rather than with the usual brisk response.
25. The client shares some very confidential information with her nurse. The nurse demonstrates
appropriate
management with this information when he:

a. openly discusses this information with all of his colleagues
b. documents the information only on the client's flow sheet.
c. reviews the information with those staff involved in the plan of care.
d. shares the information with nobody.
This information must be respected and remain confidential. Under the invasion of privacy it states that
the client has the constitutional right to be free from publicity and exposure to public view. Option #4
does not benefit the client in any constructive way.
26. The nurse demonstrates an appropriate understanding of safely prioritizing the workload when she
assesses which
client initially?
a. A client who had a lobectomy 24 hours ago with a chest tube inserted.
b. A postoperative laryngectomy client.
c. A client with headaches of unknown origin.
d. A client who is in Buck's traction.
The maintenance of a patent airway for a postoperative larnygectomy client would be a priority. Options
#1, #3, and #4 would not be a priority to a potential airway issue.
27. Which food should the client be taught to avoid if they are taking a MAO inhibitor?
a. Roast beef, slice of white bread
b. Fried chicken, green beans
c. Boiled fish, milk

d. Grilled cheddar cheese sandwich
MAO inhibitors and aged cheese may cause hypertensive crisis. Options #1, #2, and #3 should be safe
foods.
28. Which statement indicates the nurse has an appropriate understanding of immunizations?
a. "The influenza vaccine should be contraindicated for any allergies to pork."
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b. "The pneumococcal and influenza vaccine can be administered at the same time."
c. "The pneumococcal vaccine will prevent any complications from a chronic illness."
d. "Vaccinations have not shown to decrease the hospitalizations for older adults."
This is a true statement. They can be admin istered at the same time in different sites. Option #1 should
read eggs instead of pork to be a true statement. Option #3 is incorrect. It may decrease the
complications, but there is no guarantee there will be no complications. Option #4 is not true. Research
has proven that when older clients take their immunizations, hospitalizations are decreased.
29. A hospitalized client has been vomiting for three days with a low grade temperature, and feels lethargic.
Which
nursing action is most appropriate in evaluating for fluid volume deficit?

a. Obtain a urinalysis for casts and specific gravity.
b. Determine client's weight and assess gain or loss.
c. Ask client to provide a 24-hour intake and output record.
d. Determine the quality of the skin turgor.
The daily weight is the best way to evaluate for fluid volume deficit. Options #1, #3, and #4 provide
information regarding the fluid volume level, but are not the best actions for evaluation.
30. A client is placed on bedrest with an order to immobilize the right leg due to tenderness, increased
warmth, and
diffuse swelling. Which nursing action is most appropriate to maintain skin integrity?
a. Apply a trapeze to client's bed.
b. Assess bony prominence every 12 hours.
c. Apply granular spray to the bony prominence.
d. Turn client every 2 hours.
Turning client at frequent intervals is one of the most effective methods of preventing the development of
skin breakdown caused by pressure, friction, or shearing forces. Option #1 encourages independent
moving but does not relieve pressure. Option #2 is an incorrect standard of practice. Skin inspection
should be carried out at least once every 8 hours. Option #3 does not offer any prevention.
31. During the first 24 hours after a below-the-knee amputation, which nursing action would be most important
a. Notify the physician for a small amount of serosan guineous drainage.
b. Elevate the stump on a pillow to decrease edema.
c. Maintain the stump flat on the bed by placing the client in the prone position.
d. Do passive range of motion TID to the unaffected leg.
Elevation after surgery will minimize edema and optimize venous return. This would not be done for more
than 24 hours due to the potential development of contracture. Option #1 is not corrrect because some
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bloody drainage is expected. The nurse should outline the drainage and assess again in 5 minutes. Options
#3 and #4 contain incorrect information.
32. Which measure should the nurse take in reducing the discomfort of gas pains in a client?
a. Encourage a diet high in fiber
b. Assist with early ambulation.
c. Teach how to splint the abdomen with activity.
d. Position on right side.
MEDICAL SURGICAL NURSING
NOTE: THIS QUESTIONAIRES WAS JUST GRAB FROM THE WEB,

NurseReview.Org IS NOT RESPONSIBLE FOR ANY TYPOS, WRONG
ANSWERS, WRONG RATIONALE, INCONSISTENCIES, ETC.. USE
THIS AT YOUR DESGRESSION
adc 10/7/2008
1. Following surgery, Mario complains of mild incisional pain while
performing deep- breathing and coughing exercises. The nurse¶s best
response would be:
A. ³Pain will become less each day.´
B. ³This is a normal reaction after surgery.´
C. ³With a pillow, apply pressure against the incision.´
D. ³I will give you the pain medication the physician ordered.´
Answer: (C) ³With a pillow, apply pressure against the incision.´

Applying pressure against the incision with a pillow will help lessen the
intra-abdominal pressure created by coughing which causes tension on
the incision that leads to pain.
2. The nurse needs to carefully assess the complaint of pain of the

elderly because older people
A. are expected to experience chronic pain
B. have a decreased pain threshold
C. experience reduced sensory perception
D. have altered mental function
Answer: (C) experience reduced sensory perception

Degenerative changes occur in the elderly. The response to pain in the
elderly maybe lessened because of reduced acuity of touch, alterations
in neural pathways and diminished processing of sensory data.
3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and

is now complaining of dry mouth and her PR is higher, than before the
medication was administered. The nurse¶s best
A. The patient is having an allergic reaction to the drug.
B. The patient needs a higher dose of this drug
C. This is normal side-effect of AtSO4
D. The patient is anxious about upcoming surgery
Answer: (C) This is normal side-effect of AtSO4

Atropine sulfate is a vagolytic drug that decreases oropharyngeal
secretions and increases the heart rate.
4. Ana¶s postoperative vital signs are a blood pressure of 80/50 mm Hg,

a pulse of 140, and respirations of 32. Suspecting shock, which of the
following orders would the nurse question?
A. Put the client in modified Trendelenberg's position.
B. Administer oxygen at 100%.
C. Monitor urine output every hour.
D. Administer Demerol 50mg IM q4h
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Answer: (D) Administer Demerol 50mg IM q4h
Administering Demerol, which is a narcotic analgesic, can depress
respiratory and cardiac function and thus not given to a patient in shock.
What is needed is promotion for adequate oxygenation and perfusion.
All the other interventions can be expected to be done by the nurse.
5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a

cystectomy with the creation of an ileal conduit in the morning. He is
wringing his hands and pacing the floor when the nurse enters his room.
What is the best approach?
A. "Good evening, Mr. Pablo. Wasn't it a pleasant day, today?"
B. "Mr, Pablo, you must be so worried, I'll leave you alone with your
thoughts.
C. ³Mr. Pablo, you'll wear out the hospital floors and yourself at this
rate."
D. "Mr. Pablo, you appear anxious to me. How are you feeling about
tomorrow's surgery?"
Answer: (D) "Mr. Pablo, you appear anxious to me. How are you feeling
about tomorrow's surgery?"
The client is showing signs of anxiety reaction to a stressful event.
Recognizing the client¶s anxiety conveys acceptance of his behavior and
will allow for verbalization of feelings and concerns.
6. After surgery, Gina returns from the Post-anesthesia Care Unit

(Recovery Room) with a nasogastric tube in place following a gall
bladder surgery. She continues to complain of nausea. Which action
would the nurse take?
A. Call the physician immediately.
B. Administer the prescribed antiemetic.
C. Check the patency of the nasogastric tube for any obstruction.
D. Change the patient¶s position.
Answer: (C) Check the patency of the nasogastric tube for any
obstruction.
Nausea is one of the common complaints of a patient after receiving
general anesthesia. But this complaint could be aggravated by gastric
distention especially in a patient who has undergone abdominal surgery.
Insertion of the NGT helps relieve the problem. Checking on the patency
of the NGT for any obstruction will help the nurse determine the cause
of the problem and institute the necessary intervention.
7. Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication
provides little relief and he refuses to move. The nurse should plan to:
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A. Reassure him that the nurses will not hurt him
B. Let him perform his own activities of daily living
C. Handle him gently when assisting with required care
D. Complete A.M. care quickly as possible when necessary
Answer: (C) Handle him gently when assisting with required care
Patients with cancer and bone metastasis experience severe pain
especially when moving. Bone tumors weaken the bone to appoint at
which normal activities and even position changes can lead to fracture.
During nursing care, the patient needs to be supported and handled
gently.
8. A client returns from the recovery room at 9AM alert and oriented,
with an IV infusing. His pulse is 82, blood pressure is 120/80,
respirations are 20, and all are within normal range. At 10 am and at 11
am, his vital signs are stable. At noon, however, his pulse rate is 94,
blood pressure is 116/74, and respirations are 24. W hat nursing action
is most appropriate?
A. Notify his physician.

B. Take his vital signs again in 15 minutes.
C. Take his vital signs again in an hour.
D. Place the patient in shock position.
Answer: (B) Take his vital signs again in 15 minutes.

Monitoring the client¶s vital signs following surgery gives the nurse a
sound information about the client¶s condition. Complications can occur
during this period as a result of the surgery or the anesthesia or both.
Keeping close track of changes in the VS and validating them will help
the nurse initiate interventions to prevent complications from occurring.
9. A 56 year old construction worker is brought to the hospital

unconscious after falling from a 2-story building. When assessing the
client, the nurse would be most concerned if the assessment revealed:
A. Reactive pupils
B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature
Answer: (C) Bleeding from ears

The nurse needs to perform a thorough assessment that could indicate
alterations in cerebral function, increased intracranial pressures,
fractures and bleeding. Bleeding from the ears occurs only with basal
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skull fractures that can easily contribute to increased intracranial
pressure and brain herniation
10. Which of the ff. statements by the client to the nurse indicates a risk
factor for CAD?
A. ³I exercise every other day.´
B. ³My father died of Myasthenia Gravis.´
C. ³My cholesterol is 180.´
D. ³I smoke 1 1/2 packs of cigarettes per day.´
Answer: (D) ³I smoke 1 1/2 packs of cigarettes per day.´

Smoking has been considered as one of the major modifiable risk
factors for coronary artery disease. Exercise and maintaining normal
serum cholesterol levels help in its prevention.
11. Mr. Braga was ordered Digoxin 0.25 mg. OD. W hich is poor
knowledge regarding this drug?
A. It has positive inotropic and negative chronotropic effects
B. The positive inotropic effect will decrease urine output
C. Toxixity can occur more easily in the presence of hypokalemia, liver
and renal problems
D. Do not give the drug if the apical rate is less than 60 beats per
minute.
Answer: (B) The positive inotropic effect will decrease urine output
Inotropic effect of drugs on the heart causes increase force of its
contraction. This increases cardiac output that improves renal perfusion
resulting in an improved urine output.
12. Valsalva maneuver can result in bradycardia. Which of the following

activities will not stimulate Valsalva's maneuver?
A. Use of stool softeners.
B. Enema administration
C. Gagging while toothbrushing.
D. Lifting heavy objects
Answer: (A) Use of stool softeners.

Straining or bearing down activities can cause vagal stimulation that
leads to bradycardia. Use of stool softeners promote easy bowel
evacuation that prevents straining or the valsalva maneuver.
13. The nurse is teaching the patient regarding his permanent artificial
pacemaker. Which information
given by the nurse shows her knowledge deficit about the artificial
cardiac pacemaker?
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A. take the pulse rate once a day, in the morning upon awakening
B. may be allowed to use electrical appliances
C. have regular follow up care
D. may engage in contact sports
Answer: (D) may engage in contact sports

The client should be advised by the nurse to avoid contact sports. This
will prevent trauma to the area of the pacemaker generator.
14. A patient with angina pectoris is being discharged home with

nitroglycerine tablets. Which of the
following instructions does the nurse include in the teaching?
A. ³When your chest pain begins, lie down, and place one tablet under
your tongue. If the pain continues, take another tablet in 5 minutes.´
B. ³Place one tablet under your tongue. If the pain is not relieved in 15
minutes, go to the hospital.´
C. ³Continue your activity, and if the pain does not go away in 10
minutes, begin taking the nitro tablets one every 5 minutes for 15
minutes, then go lie down.´
D. ³Place one Nitroglycerine tablet under the tongue every five minutes
for three doses. Go to the hospital if the pain is unrelieved.
Answer: (D) ³Place one Nitroglycerine tablet under the tongue every five
minutes for three doses. Go to the hospital if the pain is unrelieved.
Angina pectoris is caused by myocardial ischemia related to decreased
coronary blood supply. Giving nitroglycerine will produce coronary
vasodilation that improves the coronary blood flow in 3 ± 5 mins. If the
chest pain is unrelieved, after three tablets, there is a possibility of acute
coronary occlusion that requires immediate medical attention.
15. A client with chronic heart failure has been placed on a diet
restricted to 2000mg. of sodium per day. The client demonstrates
adequate knowledge if behaviors are evident such as not salting food
and avoidance of which food?
A. Whole milk
B. Canned sardines
C. Plain nuts
D. Eggs
Answer: (B) Canned sardines

Canned foods are generally rich in sodium content as salt is used as the
main preservative.
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16. A student nurse is assigned to a client who has a diagnosis of
thrombophlebitis. W hich action by this team member is most
appropriate?
A. Apply a heating pad to the involved site.
B. Elevate the client's legs 90 degrees.
C. Instruct the client about the need for bed rest.
D. Provide active range-of-motion exercises to both legs at least twice
every shift.
Answer: (C) Instruct the client about the need for bed rest.
In a client with thrombophlebitis, bedrest will prevent the dislodgment of
the clot in the extremity which can lead to pulmonary embolism.
17. A client receiving heparin sodium asks the nurse how the drug
works. Which of the following points would the nurse include in the
explanation to the client?
A. It dissolves existing thrombi.
B. It prevents conversion of factors that are needed in the formation of
clots.
C. It inactivates thrombin that forms and dissolves existing thrombi.
D. It interferes with vitamin K absorption.
Answer: (B) It prevents conversion of factors that are needed in the

formation of clots.
Heparin is an anticoagulant. It prevents the conversion of prothrombin to
thrombin. It does not dissolve a clot.
18. The nurse is conducting an education session for a group of

smokers in a ³stop smoking´ class.
Which finding would the nurse state as a common symptom of lung
cancer? :
A. Dyspnea on exertion
B. Foamy, blood-tinged sputum
C. W heezing sound on inspiration
D. Cough or change in a chronic cough
Answer: (D) Cough or change in a chronic cough

Cigarette smoke is a carcinogen that irritates and damages the
respiratory epithelium. The irritation causes the cough which initially
maybe dry, persistent and unproductive. As the tumor enlarges,
obstruction of the airways occurs and the cough may become
productive due to infection.
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19. Which is the most relevant knowledge about oxygen administration
to a client with COPD?
A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for
breathing.
B. Hypoxia stimulates the central chemoreceptors in the medulla that
makes the client breath.
C. Oxygen is administered best using a non-rebreathing mask
D. Blood gases are monitored using a pulse oximeter.
Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic

stimulus for breathing.
COPD causes a chronic CO2 retention that renders the medulla
insensitive to the CO2 stimulation for breathing. The hypoxic state of the
client then becomes the stimulus for breathing. Giving the clientoxygen
in low concentrations will maintain the client¶s hypoxic drive.
20. W hen suctioning mucus from a client's lungs, which nursing action
would be least appropriate?
A. Lubricate the catheter tip with sterile saline before insertion.
B. Use sterile technique with a two-gloved approach
C. Suction until the client indicates to stop or no longer than 20 second
D. Hyperoxygenate the client before and after suctioning
Answer: (C) Suction until the client indicates to stop or no longer than 20
second
One hazard encountered when suctioning a client is the development of

hypoxia. Suctioning sucks not only the secretions but also the gases
found in the airways. This can be prevented by suctioning the client for
an average time of 5-10 seconds and not more than 15 seconds and
hyperoxygenating the client before and after suctioning.
21. Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive
Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this
choice of
treatment is to
A. Cause less irritation to the gastrointestinal tract

B. Destroy resistant organisms and promote proper blood levels of the
drugs
C. Gain a more rapid systemic effect
D. Delay resistance and increase the tuberculostatic effect
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Answer: (D) Delay resistance and increase the tuberculostatic effect
Pulmonary TB is treated primarily with chemotherapeutic agents for 6-
12 mons. A prolonged treatment duration is necessary to ensure
eradication of the organisms and to prevent relapse. The increasing
prevalence of drug resistance points to the need to begin the treatment
with drugs in combination. Using drugs in combination can delay the
drug resistance.
22. Mario undergoes a left thoracotomy and a partial pneumonectomy.

Chest tubes are inserted, and one-bottle water-seal drainage is
instituted in the operating room. In the
postanesthesia care unit Mario is placed in Fowler's position on either
his right
side or on his back to
A. Reduce incisional pain.

B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous return
Answer: (B) Facilitate ventilation of the left lung.

Since only a partial pneumonectomy is done, there is a need to promote
expansion of this remaining Left lung by positioning the client on the
opposite unoperated side.
23. A client with COPD is being prepared for discharge. The following
are relevant instructions to the client regarding the use of an oral inhaler
EXCEPT
A. Breath in and out as fully as possible before placing the mouthpiece
inside the mouth.
B. Inhale slowly through the mouth as the canister is pressed down
C. Hold his breath for about 10 seconds before exhaling
D. Slowly breath out through the mouth with pursed lips after inhaling
the drug.
Answer: (D) Slowly breath out through the mouth with pursed lips after
inhaling the drug.
If the client breathes out through the mouth with pursed lips, this can
easily force the just inhaled drug out of the respiratory tract that will
lessen its effectiveness.
24. A client is scheduled for a bronchoscopy. When teaching the client

what to expect afterward, the nurse's highest priority of information
would be
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A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.
Answer: (A) Food and fluids will be withheld for at least 2 hours.
Prior to bronchoscopy, the doctors sprays the back of the throat with
anesthetic to minimize the gag reflex and thus facilitate the insertion of
the bronchoscope. Giving the client food and drink after the procedure
without checking on the return of the gag reflex can cause the client to
aspirate. The gag reflex usually returns after two hours.
25. The nurse enters the room of a client with chronic obstructive
pulmonary disease. The client's nasal cannula oxygen is running at a
rate of 6 L per minute, the skin color is pink, and the respirations are 9
per minute and shallow. W hat is the nurse¶s best initial action?
A. Take heart rate and blood pressure

B. Call the physician.
C. Lower the oxygen rate.

D. Position the client in a Fowler's position.
Answer: (C) Lower the oxygen rate.

The client with COPD is suffering from chronic CO2 retention. The
hypoxic drive is his chief stimulus for breathing. Giving O2 inhalation at
a rate that is more than 2-3L/min can make the client lose his hypoxic
drive which can be assessed as decreasing RR.
26. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most
appropriate nursing diagnosis for this patient?
A. Fluid volume deficit

B. Decreased tissue perfusion.
C. Impaired gas exchange.
D. Risk for infection
Answer: (C) Impaired gas exchange.

Pneumonia, which is an infection, causes lobar consolidation thus
impairing gas exchange between the alveoli and the blood. Because the
patient would require adequate hydration, this makes him prone to fluid
volume excess.
27. A nurse at the weight loss clinic assesses a client who has a large
abdomen and a rounded face. Which additional assessment finding
would lead the nurse to suspect that the client has Cushing¶s syndrome
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rather than obesity?
A. large thighs and upper arms
B. pendulous abdomen and large hips
C. abdominal striae and ankle enlargement
D. posterior neck fat pad and thin extremities
Answer: (D) posterior neck fat pad and thin extremities

³Buffalo hump´ is the accumulation of fat pads over the upper back and
neck. Fat may also accumulate on the face. There is truncal obesity but
the extremities are thin. All these are noted in a client with Cushing¶s
syndrome.
28. Which statement by the client indicates understanding of the

possible side effects of Prednisone therapy?
A. ³I should limit my potassium intake because hyperkalemia is a side-
effect of this drug.´
B. ³I must take this medicine exactly as my doctor ordered it. I shouldn¶t
skip doses.´
C. ³This medicine will protect me from getting any colds or infection.´
D. ³My incision will heal much faster because of this drug.´
Answer: (B) ³I must take this medicine exactly as my doctor ordered it. I
shouldn¶t skip doses.´
The possible side effects of steroid administration are hypokalemia,
increase tendency to infection and poor wound healing. Clients on the
drug must follow strictly the doctor¶s order since skipping the drug can
lower the drug level in the blood that can trigger acute adrenal
insufficiency or Addisonian Crisis
29. A client, who is suspected of having Pheochromocytoma, complains

of sweating, palpitation and headache. Which assessment is essential
for the nurse to make first?
A. Pupil reaction
B. Hand grips
C. Blood pressure
D. Blood glucose
Answer: (C) Blood pressure

Pheochromocytoma is a tumor of the adrenal medulla that causes an
increase secretion of catecholamines that can elevate the blood
pressure.
30. The nurse is attending a bridal shower for a friend when another
guest, who happens to be a diabetic, starts to tremble and complains of
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dizziness. The next best action for the nurse to take is to:
A. Encourage the guest to eat some baked macaroni
B. Call the guest¶s personal physician
C. Offer the guest a cup of coffee
D. Give the guest a glass of orange juice
Answer: (D) Give the guest a glass of orange juice

In diabetic patients, the nurse should watch out for signs of
hypoglycemia manifested by dizziness, tremors, weakness, pallor
diaphoresis and tachycardia. When this occurs in a conscious client, he
should be given immediately carbohydrates in the form of fruit juice,
hard candy, honey or, if unconscious, glucagons or dextrose per IV.
31. An adult, who is newly diagnosed with Graves disease, asks the
nurse, ³Why do I need to take
Propanolol (Inderal)?´ Based on the nurse¶s understanding of the
medication and Grave¶s
disease, the best response would be:
A. ³The medication will limit thyroid hormone secretion.´

B. ³The medication limit synthesis of the thyroid hormones.´
C. ³The medication will block the cardiovascular symptoms of Grave¶s
disease.´
D. ³The medication will increase the synthesis of thyroid hormones.´
Answer: (C) ³The medication will block the cardiovascular symptoms of
Grave¶s disease.´
Propranolol (Inderal) is a beta-adrenergic blocker that controls the
cardiovascular manifestations brought about by increased secretion of
the thyroid hormone in Grave¶s disease.
32. During the first 24 hours after thyroid surgery, the nurse should
include in her care:
A. Checking the back and sides of the operative dressing
B. Supporting the head during mild range of motion exercise
C. Encouraging the client to ventilate her feelings about the surgery
D. Advising the client that she can resume her normal activities
immediately
Answer: (A) Checking the back and sides of the operative dressing
Following surgery of the thyroid gland, bleeding is a potential
complication. This can best be assessed by checking the back and the
sides of the operative dressing as the blood may flow towards the side
and back leaving the front dry and clear of drainage.
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33. On discharge, the nurse teaches the patient to observe for signs of
surgically induced hypothyroidism. The nurse would know that the
patient understands the teaching when she states she should notify the
MD if she develops:
A. Intolerance to heat
B. Dry skin and fatigue
C. Progressive weight gain
D. Insomnia and excitability
Answer: (C) Progressive weight gain

Hypothyroidism, a decrease in thyroid hormone production, is
characterized by hypometabolism that manifests itself with weight gain.
34. What is the best reason for the nurse in instructing the client to
rotate injection sites for insulin?
A. Lipodystrophy can result and is extremely painful
B. Poor rotation technique can cause superficial hemorrhaging
C. Lipodystrophic areas can result, causing erratic insulin absorption
rates from these
D. Injection sites can never be reused
Answer: (C) Lipodystrophic areas can result, causing erratic insulin
absorption rates from these

Lipodystrophy is the development of fibrofatty masses at the injection
site caused by repeated use of an injection site. Injecting insulin into
these scarred areas can cause the insulin to be poorly absorbed and
lead to erratic reactions.
35. Which of the following would be inappropriate to include in a diabetic

teaching plan?
A. Change position hourly to increase circulation
B. Inspect feet and legs daily for any changes

C. Keep legs elevated on 2 pillows while sleeping
D. Keep the insulin not in use in the refrigerator
Answer: (C) Keep legs elevated on 2 pillows while sleeping

The client with DM has decreased peripheral circulation caused by
microangiopathy. Keeping the legs elevated during sleep will further
cause circulatory impairment.

36. Included in the plan of care for the immediate post-gastroscopy
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period will be:
A. Maintain NGT to intermittent suction
B. Assess gag reflex prior to administration of fluids
C. Assess for pain and medicate as ordered
D. Measure abdominal girth every 4 hours
Answer: (B) Assess gag reflex prior to administration of fluids

The client, after gastroscopy, has temporary impairment of the gag
reflex due to the anesthetic that has been sprayed into his throat prior to
the procedure. Giving fluids and food at this time can lead to aspiration.
36. Included in the plan of care for the immediate post-gastroscopy
period will be:

A. Maintain NGT to intermittent suction
B. Assess gag reflex prior to administration of fluids
C. Assess for pain and medicate as ordered
D. Measure abdominal girth every 4 hours
Answer: (B) Assess gag reflex prior to administration of fluids

The client, after gastroscopy, has temporary impairment of the gag
reflex due to the anesthetic that has been sprayed into his throat prior to
the procedure. Giving fluids and food at this time can lead to aspiration.
37. W hich description of pain would be most characteristic of a

duodenal ulcer?
A. Gnawing, dull, aching, hungerlike pain in the epigastric area that is
relieved by food intake
B. RUQ pain that increases after meal
C. Sharp pain in the epigastric area that radiates to the right shoulder
D. A sensation of painful pressure in the midsternal area
Answer: (A) Gnawing, dull, aching, hungerlike pain in the epigastric area
that is relieved by food intake
Duodenal ulcer is related to an increase in the secretion of HCl. Thisan be buffered by food intake thus the
relief of the pain that is brought
about by food intake.
38. The client underwent Billroth surgery for gastric ulcer. Post-
operatively, the drainage from his NGT is thick and the volume of
secretions has dramatically reduced in the last 2 hours and the client
feels like vomiting. The most appropriate nursing action is to:
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A. Reposition the NGT by advancing it gently NSS
B. Notify the MD of your findings
C. Irrigate the NGT with 50 cc of sterile
D. Discontinue the low-intermittent suction
Answer: (B) Notify the MD of your findings

The client¶s feeling of vomiting and the reduction in the volume of NGT
drainage that is thick are signs of possible abdominal distention caused
by obstruction of the NGT. This should be reported immediately to the
MD to prevent tension and rupture on the site of anastomosis caused by
gastric distention.
39. After Billroth II Surgery, the client developed dumping syndrome.

Which of the following should
the nurse exclude in the plan of care?
A. Sit upright for at least 30 minutes after meals

B. Take only sips of H2O between bites of solid food
C. Eat small meals every 2-3 hours
D. Reduce the amount of simple carbohydrate in the diet
Answer: (A) Sit upright for at least 30 minutes after meals

The dumping syndrome occurs within 30 mins after a meal due to rapid
gastric emptying, causing distention of the duodenum or jejunum
produced by a bolus of food. To delay the emptying, the client has to lie
down after meals. Sitting up after meals will promote the dumping
syndrome.
40. The laboratory of a male patient with Peptic ulcer revealed an

elevated titer of Helicobacter pylori.
Which of the following statements indicate an understanding of this
data?
A. Treatment will include Ranitidine and Antibiotics

B. No treatment is necessary at this time
C. This result indicates gastric cancer caused by the organism
D. Surgical treatment is necessary
Answer: (A) Treatment will include Ranitidine and Antibiotics

One of the causes of peptic ulcer is H. Pylori infection. It releases toxin
that destroys the gastric and duodenal mucosa which decreases the
gastric epithelium¶s resistance to acid digestion. Giving antibiotics will
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control the infection and Ranitidine, which is a histamine-2 blocker, will
reduce acid secretion that can lead to ulcer.
41. What instructions should the client be given before undergoing a

paracentesis?
A. NPO 12 hours before procedure
B. Empty bladder before procedure
C. Strict bed rest following procedure
D. Empty bowel before procedure
Answer: (B) Empty bladder before procedure

Paracentesis involves the removal of ascitic fluid from the peritoneal
cavity through a puncture made below the umbilicus. The client needs to
void before the procedure to prevent accidental puncture of a distended
bladder during the procedure.
42. The husband of a client asks the nurse about the protein-restricted
diet ordered because of advanced liver disease. What statement by the
nurse would best explain the purpose of the diet?
A. ³The liver cannot rid the body of ammonia that is made by the
breakdown of protein in the digestive system.´
B. ³The liver heals better with a high carbohydrates diet rather than
protein.´
C. ³Most people have too much protein in their diets. The amount of this
diet is better for liver healing.´
D. ³Because of portal hyperemesis, the blood flows around the liver and
ammonia made from protein collects in the brain causing hallucinations.´
Answer: (A) ³The liver cannot rid the body of ammonia that is made by
the breakdown of protein in the digestive system.´
The largest source of ammonia is the enzymatic and bacterial digestion
of dietary and blood proteins in the GI tract. A protein-restricted diet will
therefore decrease ammonia production.
43. Which of the drug of choice for pain controls the patient with acute
pancreatitis?
A. Morphine
B. NSAIDS
C. Meperidine
D. Codeine
Answer: (C) Meperidine

Pain in acute pancreatitis is caused by irritation and edema of the
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inflamed pancreas as well as spasm due to obstruction of the pancreatic
ducts. Demerol is the drug of choice because it is less likely to cause
spasm of the Sphincter of Oddi unlike Morphine which is spasmogenic.
44. Immediately after cholecystectomy, the nursing action that should
assume the highest priority is:

A. encouraging the client to take adequate deep breaths by mouth
B. encouraging the client to cough and deep breathe
C. changing the dressing at least BID
D. irrigate the T-tube frequently
Answer: (B) encouraging the client to cough and deep breathe

Cholecystectomy requires a subcostal incision. To minimize pain, clients
have a tendency to take shallow breaths which can lead to respiratory
complications like pneumonia and atelectasis. Deep breathing and
coughing exercises can help prevent such complications.
45. A Sengstaken-Blakemore tube is inserted in the effort to stop the

bleeding esophageal varices in a patient with complicated liver cirrhosis.
Upon insertion of the tube, the client complains of difficulty of breathing.
The first action of the nurse is to:
A. Deflate the esophageal balloon

B. Monitor VS
C. Encourage him to take deep breaths
D. Notify the MD
Answer: (A) Deflate the esophageal balloon

When a client with a Sengstaken-Blakemore tube develops difficulty of
breathing, it means the tube is displaced and the inflated balloon is in
the oropharynx causing airway obstruction
46. The client presents with severe rectal bleeding, 16 diarrheal stools a
day, severe abdominal pain, tenesmus and dehydration. Because of
these symptoms the nurse should be alert for other problems associated
with what disease?

A. Chrons disease
B. Ulcerative colitis
C. Diverticulitis
D. Peritonitis
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Answer: (B) Ulcerative colitis
Ulcerative colitis is a chronic inflammatory condition producing edema
and ulceration affecting the entire colon. Ulcerations lead to sloughing
that causes stools as many as 10-20 times a day that is filled with blood,
pus and mucus. The other symptoms mentioned accompany the
problem.
47. A client is being evaluated for cancer of the colon. In preparing the
client for barium enema, the nurse should:
A. Give laxative the night before and a cleansing enema in the morning
before the test
B. Render an oil retention enema and give laxative the night before
C. Instruct the client to swallow 6 radiopaque tablets the evening before
the study
D. Place the client on CBR a day before the study
Answer: (A) Give laxative the night before and a cleansing enema in the
morning before the test
Barium enema is the radiologic visualization of the colon using a die. To
obtain accurate results in this procedure, the bowels must be emptied of
fecal material thus the need for laxative and enema.
48. The client has a good understanding of the means to reduce the
chances of colon cancer when
he states:
A. ³I will exercise daily.´

B. ³I will include more red meat in my diet.´
C. ³I will have an annual chest x-ray.´
D. ³I will include more fresh fruits and vegetables in my diet.´
Answer: (D) ³I will include more fresh fruits and vegetables in my diet.´
Numerous aspects of diet and nutrition may contribute to the
development of cancer. A low-fiber diet, such as when fresh fruits and
vegetables are minimal or lacking in the diet, slows transport of
materials through the gut which has been linked to colorectal cancer.
49. Days after abdominal surgery, the client¶s wound dehisces. The
safest nursing intervention when
this occurs is to
A. Cover the wound with sterile, moist saline dressing

B. Approximate the wound edges with tapes
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C. Irrigate the wound with sterile saline
D. Hold the abdominal contents in place with a sterile gloved hand
Answer: (A) Cover the wound with sterile, moist saline dressing
Dehiscence is the partial or complete separation of the surgical wound
edges. When this occurs, the client is placed in low Fowler¶s position
and instructed to lie quietly. The wound should be covered to protect it
from exposure and the dressing must be sterile to protect it from
infection and moist to prevent the dressing from sticking to the wound
which can disturb the healing process.
50. An intravenous pyelogram reveals that Paulo, age 35, has a renal
calculus. He is believed to have a small stone that will pass
spontaneously. To increase the chance of the stone passing, the nurse
would instruct the client to force fluids and to
A. Strain all urine.

B. Ambulate.
C. Remain on bed rest.
D. Ask for medications to relax him.
Answer: (B) Ambulate.

Free unattached stones in the urinary tract can be passed out with the
urine by ambulation which can mobilize the stone and by increased fluid
intake which will flush out the stone during urination.
51. A female client is admitted with a diagnosis of acute renal failure.

She is awake, alert, oriented, and complaining of severe back pain,
nausea and vomiting and abdominal cramps. Her vital signs are blood
pressure 100/70 mm Hg, pulse 110, respirations 30, and oral
temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L,
potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml.
The client is displaying signs of which electrolyte imbalance?
A. Hyponatremia
B. Hyperkalemia
C. Hyperphosphatemia
D. Hypercalcemia
Answer: (A) Hyponatremia

The normal serum sodium level is 135 ± 145 mEq/L. The client¶s serum
sodium is below normal. Hyponatremia also manifests itself with
abdominal cramps and nausea and vomiting
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52. Assessing the laboratory findings, which result would the nurse most
likely expect to find in a
client with chronic renal failure?
A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl

B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl
D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased
serum calcium
Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5
mEq/L
52. Assessing the laboratory findings, which result would the nurse most
likely expect to find in a
client with chronic renal failure?
A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl

B. Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl
D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased
serum calcium
Answer: (B) Decreased serum calcium, blood pH 7.2, potassium 6.5

mEq/L
Chronic renal failure is usually the end result of gradual tissue
destruction and loss of renal function. With the loss of renal function, the
kidneys ability to regulate fluid and electrolyte and acid base balance
results. The serum Ca decreases as the kidneys fail to excrete
phosphate, potassium and hydrogen ions are retained.
53. Treatment with hemodialysis is ordered for a client and an external shunt is created. Which nursing
action would be of highest priority with regard to the external shunt?
A. Heparinize it daily.
B. Avoid taking blood pressure measurements or blood samples from
the affected arm.
C. Change the Silastic tube daily.
D. Instruct the client not to use the affected arm.
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Answer: (B) Avoid taking blood pressure measurements or blood
samples from the affected arm.
In the client with an external shunt, don¶t use the arm with the vascular
access site to take blood pressure readings, draw blood, insert IV lines,
or give injections because these procedures may rupture the shunt or
occlude blood flow causing damage and obstructions in the shunt.
54. Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of
benign prostatic hyperplasia (BPH). He is scheduled for a transurethral
resection of the prostate (TURP). It would be inappropriate to include
which of the following points in the preoperative teaching?
A. TURP is the most common operation for BPH.

B. Explain the purpose and function of a two-way irrigation system.
C. Expect bloody urine, which will clear as healing takes place.
D. He will be pain free.
Answer: (D) He will be pain free.

Surgical interventions involve an experience of pain for the client which
can come in varying degrees. Telling the pain that he will be pain free is
giving him false reassurance.
55. Roxy is admitted to the hospital with a possible diagnosis of

appendicitis. On physical examination, the nurse should be looking for
tenderness on palpation at McBurney¶s point, which is located in the
A. left lower quadrant
B. left upper quadrant
C. right lower quadrant
D. right upper quadrant
Answer: (C) right lower quadrant

To be exact, the appendix is anatomically located at the Mc Burney¶s
point at the right iliac area of the right lower quadrant.
56. Mr. Valdez has undergone surgical repair of his inguinal hernia.
Discharge teaching should include

A. telling him to avoid heavy lifting for 4 to 6 weeks
B. instructing him to have a soft bland diet for two weeks
C. telling him to resume his previous daily activities without limitations
D. recommending him to drink eight glasses of water daily
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Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks
The client should avoid lifting heavy objects and any strenuous activity
for 4-6 weeks after surgery to prevent stress on the inguinal area. There
is no special diet required. The fluid intake of eight glasses a day is
good advice but is not a priority in this case.
57. A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the
face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of
total body-surface area burned?
A. 18% B. 22% C. 31% D. 40%
Answer: (C) 31%
Using the Rule of Nine in the estimation of total body surface burned,
we allot the following: 9% - head; 9% - each upper extremity; 18%- front
chest and abdomen; 18% - entire back; 18% - each lower extremity and
1% - perineum.
58. Nursing care planning is based on the knowledge that the first 24-48
hours post-burn are characterized by:
A. An increase in the total volume of intracranial plasma

B. Excessive renal perfusion with diuresis
C. Fluid shift from interstitial space
D. Fluid shift from intravascular space to the interstitial space
Answer: (D) Fluid shift from intravascular space to the interstitial space
This period is the burn shock stage or the hypovolemic phase. Tissue
injury causes vasodilation that results in increase capillary permeability
making fluids shift from the intravascular to the interstitial space. This
can lead to a decrease in circulating blood volume or hypovolemia
which decreases renal perfusion and urine output.
59. If a client has severe bums on the upper torso, which item would be
a primary concern?
A. Debriding and covering the wounds

B. Administering antibiotics
C. Frequently observing for hoarseness, stridor, and dyspnea
D. Establishing a patent IV line for fluid replacement
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Answer: (C) Frequently observing for hoarseness, stridor, and dyspnea Burns located in the upper torso,
especially resulting from thermal injury related to fires can lead to inhalation burns. This causes swelling of
the respiratory mucosa and blistering which can lead to airway obstruction manifested by hoarseness, noisy
and difficult breathing. Maintaining a patent airway is a primary concern.
60. Contractures are among the most serious long-term complications of

severe burns. If a burn is located on the upper torso, which nursing
measure would be least effective to help prevent contractures?
A. Changing the location of the bed or the TV set, or both, daily

B. Encouraging the client to chew gum and blow up balloons
C. Avoiding the use of a pillow for sleep, or placing the head in a
position of hyperextension
D. Helping the client to rest in the position of maximal comfort
Answer: (D) Helping the client to rest in the position of maximal comfort
Mobility and placing the burned areas in their functional position can
help prevent contracture deformities related to burns. Pain can
immobilize a client as he seeks the position where he finds less pain
and provides maximal comfort. But this approach can lead to
contracture deformities and other complications.
61. An adult is receiving Total Parenteral Nutrition (TPN). W hich of the

following assessment is essential?
A. evaluation of the peripheral IV site
B. confirmation that the tube is in the stomach
C. assess the bowel sound
D. fluid and electrolyte monitoring
Answer: (D) fluid and electrolyte monitoring

Total parenteral nutrition is a method of providing nutrients to the body
by an IV route. The admixture is made up of proteins, carbohydrates,
fats, electrolytes, vitamins, trace minerals and sterile water based on
individual client needs. It is intended to improve the clients nutritional
status. Because of its composition, it is important to monitor the clients
fluid intake and output including electrolytes, blood glucose and weight.
62. Which drug would be least effective in lowering a client's serum
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potassium level?
A. Glucose and insulin
B. Polystyrene sulfonate (Kayexalate)
C. Calcium glucomite
D. Aluminum hydroxide
Answer: (D) Aluminum hydroxide

Aluminum hydroxide binds dietary phosphorus in the GI tract and helps
treat hyperphosphatemia. All the other medications mentioned help treat
hyperkalemia and its effects.
63. A nurse is directed to administer a hypotonic intravenous solution.
Looking at the following labeled solutions, she should choose

A. 0.45% NaCl
B. 0.9% NaCl
C. D5W
D. D5NSS
Answer: (A) 0.45% NaCl

Hypotonic solutions like 0.45% NaCl has a lower tonicity that the blood;
0.9% NaCl and D5W are isotonic solutions with same tonicity as the
blood; and D5NSS is hypertonic with a higher tonicity thab the blood.
64. A patient is hemorrhaging from multiple trauma sites. The nurse

expects that compensatory mechanisms associated with hypovolemia
would cause all of the following symptoms EXCEPT
A. hypertension
B. oliguria
C. tachycardia
D. tachypnea
Answer: (A) hypertension

In hypovolemia, one of the compenasatory mechanisms is activation of
the sympathetic nervous system that increases the RR & PR and helps
restore the BP to maintain tissue perfusion but not cause a
hypertension. The SNS stimulation constricts renal arterioles that
increases release of aldosterone, decreases glomerular filtration and
increases sodium & water reabsorption that leads to oliguria.
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65. Maria Sison, 40 years old, single, was admitted to the hospital with a diagnosis of Breast Cancer. She
was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of
A. assuring Maria that she will be cured of cancer
B. assessing Maria's expectations and doubts

C. maintaining a cheerful and optimistic environment
D. keeping Maria's visitors to a minimum so she can have time for
herself
Answer: (B) assessing Maria's expectations and doubts
Assessing the client¶s expectations and doubts will help lessen her fears and anxieties. The nurse needs to
encourage the client to verbalize and to listen and correctly provide explanations when needed.
66. Maria refuses to acknowledge that her breast was removed. She
believes that her breast is intact under the dressing. The nurse should
A. call the MD to change the dressing so Kathy can see the incision B. recognize that Kathy is experiencing
denial, a normal stage of the grieving process
C. reinforce Kathy¶s belief for several days until her body can adjust to
stress of surgery.
D. remind Kathy that she needs to accept her diagnosis so that she can
begin rehabilitation exercises.
Answer: (B) recognize that Kathy is experiencing denial, a normal stage

of the grieving process
A person grieves to a loss of a significant object. The initial stage in the
grieving process is denial, then anger, followed by bargaining,
depression and last acceptance. The nurse should show acceptance of
the patient¶s feelings and encourage verbalization.
67. A chemotherapeutic agent 5FU is ordered as an adjunct measure to
surgery. Which of the ff. statements about chemotherapy is true?

A. it is a local treatment affecting only tumor cells
B. it affects both normal and tumor cells
C. it has been proven as a complete cure for cancer
D. it is often used as a palliative measure.
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Answer: (B) it affects both normal and tumor cells
Chemotherapeutic agents are given to destroy the actively proliferating
cancer cells. But these agents cannot differentiate the abnormal actively
proliferating cancer cells from those that are actively proliferating normal
cells like the cells of the bone marrow, thus the effect of bone marrow
depression.
68. Which is an incorrect statement pertaining to the following

procedures for cancer diagnostics?
A. Biopsy is the removal of suspicious tissue and the only definitive
method to diagnose cancer
B. Ultrasonography detects tissue density changes difficult to observe
by X-ray via sound waves.
C. CT scanning uses magnetic fields and radio frequencies to provide
cross-sectional view of tumor

D. Endoscopy provides direct view of a body cavity to detect
abnormality.
Answer: (C) CT scanning uses magnetic fields and radio frequencies to

provide cross-sectional view of tumor
CT scan uses narrow beam x-ray to provide cross-sectional view. MRI
uses magnetic fields and radio frequencies to detect tumors.
69. A post-operative complication of mastectomy is lymphedema. This
can be prevented by
A. ensuring patency of wound drainage tube

B. placing the arm on the affected side in a dependent position
C. restricting movement of the affected arm
D. frequently elevating the arm of the affected side above the level of
the heart.
Answer: (D) frequently elevating the arm of the affected side above the
level of the heart.
Elevating the arm above the level of the heart promotes good venous
return to the heart and good lymphatic drainage thus preventing
swelling.
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70. Which statement by the client indicates to the nurse that the patient understands precautions necessary
during internal radiation therapy for cancer of the cervix?
A. ³I should get out of bed and walk around in my room.´

B. ³My 7 year old twins should not come to visit me while I¶m receiving
treatment.´
C. ³I will try not to cough, because the force might make me expel the
application.´
D. ³I know that my primary nurse has to wear one of those badges like
the people in the x-ray department, but they are not necessary for
anyone else who comes in here.´
Answer: (B) ³My 7 year old twins should not come to visit me while I¶m
receiving treatment.´
Children have cells that are normally actively dividing in the process of
growth. Radiation acts not only against the abnormally actively dividing
cells of cancer but also on the normally dividing cells thus affecting the
growth and development of the child and even causing cancer itself.
71. High uric acid levels may develop in clients who are receiving
chemotherapy. This is caused by:
A. The inability of the kidneys to excrete the drug metabolites
B. Rapid cell catabolism
C. Toxic effect of the antibiotic that are given concurrently
D. The altered blood ph from the acid medium of the drugs
Answer: (B) Rapid cell catabolism
One of the oncologic emergencies, the tumor lysis syndrome, is caused

by the rapid destruction of large number of tumor cells. . Intracellular
contents are released, including potassium and purines, into the
bloodstream faster than the body can eliminate them. The purines are
converted in the liver to uric acid and released into the blood causing
hyperuricemia. They can precipitate in the kidneys and block the tubules
causing acute renal failure.
72. W hich of the following interventions would be included in the care of

plan in a client with cervical
implant?
A. Frequent ambulation
B. Unlimited visitors
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C. Low residue diet
D. Vaginal irrigation every shift
Answer: (C) Low residue diet

It is important for the nurse to remember that the implant be kept intact
in the cervix during therapy. Mobility and vaginal irrigations are not
done. A low residue diet will prevent bowel movement that could lead to
dislodgement of the implant. Patient is also strictly isolated to protect
other people from the radiation emissions
73. Which nursing measure would avoid constriction on the affected arm
immediately after mastectomy?
A. Avoid BP measurement and constricting clothing on the affected arm

B. Active range of motion exercises of the arms once a day.
C. Discourage feeding, washing or combing with the affected arm
D. Place the affected arm in a dependent position, below the level of the
heart
Answer: (A) Avoid BP measurement and constricting clothing on the

affected arm
A BP cuff constricts the blood vessels where it is applied. BP
measurements should be done on the unaffected arm to ensure
adequate circulation and venous and lymph drainage in the affected arm
74. A client suffering from acute renal failure has an unexpected

increase in urinary output to 150ml/hr. The nurse assesses that the
client has entered the second phase of acute renal failure. Nursing
actions throughout this phase include observation for signs and
symptoms of
A. Hypervolemia, hypokalemia, and hypernatremia.

B. Hypervolemia, hyperkalemia, and hypernatremia.
C. Hypovolemia, wide fluctuations in serum sodium and potassium
levels.
D. Hypovolemia, no fluctuation in serum sodium and potassium levels.
Answer: (C) Hypovolemia, wide fluctuations in serum sodium and
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potassium levels.
The second phase of ARF is the diuretic phase or high output phase.
The diuresis can result in an output of up to 10L/day of dilute urine. Loss
of fluids and electrolytes occur.
75. An adult has just been brought in by ambulance after a motor
vehicle accident. When assessing the client, the nurse would expect
which of the following manifestations could have resulted from
sympathetic nervous system stimulation?
A. A rapid pulse and increased RR

B. Decreased physiologic functioning
C. Rigid posture and altered perceptual focus
D. Increased awareness and attention
Answer: (A) A rapid pulse and increased RR

The fight or flight reaction of the sympathetic nervous system occurs
during stress like in a motor vehicular accident. This is manifested by
increased in cardiovascular function and RR to provide the immediate
needs of the body for survival.
76. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft.
When she arrives in the RR she is still in shock. The nurse's priority should be
A. placing her in a trendeleburg position

B. putting several warm blankets on her
C. monitoring her hourly urine output
D. assessing her VS especially her RR
Answer: (D) assessing her VS especially her RR

Shock is characterized by reduced tissue and organ perfusion and
eventual organ dysfunction and failure. Checking on the VS especially
the RR, which detects need for oxygenation, is a priority to help detect
its progress and provide for prompt management before the occurrence
of complications.
77. A major goal for the client during the first 48 hours after a severe bum is to prevent hypovolemic shock.
The best indicator of adequate fluid balance during this period is
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A. Elevated hematocrit levels.
B. Urine output of 30 to 50 ml/hr.
C. Change in level of consciousness.
D. Estimate of fluid loss through the burn eschar.
Answer: (B) Urine output of 30 to 50 ml/hr.

Hypovolemia is a decreased in circulatory volume. This causes a
decrease in tissue perfusion to the different organs of the body.
Measuring the hourly urine output is the most quantifiable way of
measuring tissue perfusion to the organs. Normal renal perfusion should
produce 1ml/kg of BW /min. An output of 30-50 ml/hr is considered
adequate and indicates good fluid balance.
78. A thoracentesis is performed on a chest-injured client, and no fluid or air is found. Blood and fluids is
administered intravenously (IV), but the client's vital signs do not improve. A central venous pressure line is
inserted, and the initial reading is 20 cm H^O. The most likely cause of these findings is which of the
following?
A. Spontaneous pneumothorax
B. Ruptured diaphragm
C. Hemothorax
D. Pericardial tamponade
Answer: (D) Pericardial tamponade

Pericardial tamponade occurs when there is presence of fluid
accumulation in the pericardial space that compresses on the ventricles
causing a decrease in ventricular filling and stretching during diastole
with a decrease in cardiac output. . This leads to right atrial and venous
congestion manifested by a CVP reading above normal.
79. Intervention for a pt. who has swallowed a Muriatic Acid includes all
of the following except
A. administering an irritant that will stimulate vomiting
B. aspirating secretions from the pharynx if respirations are affected
C. neutralizing the chemical
D. washing the esophagus with large volumes of water via gastric
lavage
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Answer: (A) administering an irritant that will stimulate vomiting
Swallowing of corrosive substances causes severe irritation and tissue
destruction of the mucous membrane of the GI tract. Measures are
taken to immediately remove the toxin or reduce its absorption. For
corrosive poison ingestion, such as in muriatic acid where burn or
perforation of the mucosa may occur, gastric emptying procedure is
immediately instituted, This includes gastric lavage and the
administration of activated charcoal to absorb the poison. Administering
an irritant with the concomitant vomiting to remove the swallowed
poison will further cause irritation and damage to the mucosal lining of
the digestive tract. Vomiting is only indicated when non-corrosive poison
is swallowed.
80. Which initial nursing assessment finding would best indicate that a
client has been successfully resuscitated after a cardio-respiratory
arrest?
A. Skin warm and dry
B. Pupils equal and react to light
C. Palpable carotid pulse

D. Positive Babinski's reflex
Answer: (C) Palpable carotid pulse

Presence of a palpable carotid pulse indicates the return of cardiac
function which, together with the return of breathing, is the primary goal
of CPR. Pulsations in arteries indicates blood flowing in the blood
vessels with each cardiac contraction. Signs of effective tissue perfusion
will be noted after.
81. Chemical burn of the eye are treated with

A. local anesthetics and antibacterial drops for 24 ± 36 hrs.
B. hot compresses applied at 15-minute intervals
C. Flushing of the lids, conjunctiva and cornea with tap or preferably
sterile water
D. cleansing the conjunctiva with a small cotton-tipped applicator
Answer: (C) Flushing of the lids, conjunctiva and cornea with tap or
preferably sterile water
Prompt treatment of ocular chemical burns is important to prevent
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further damage. Immediate tap-water eye irrigation should be started on
site even before transporting the patient to the nearest hospital facility.
In the hospital, copious irrigation with normal saline, instillation of local
anesthetic and antibiotic is done.
82. The Heimlich maneuver (abdominal thrust), for acute airway

obstruction, attempts to:
A. Force air out of the lungs

B. Increase systemic circulation
C. Induce emptying of the stomach
D. Put pressure on the apex of the heart
Answer: (A) Force air out of the lungs

The Heimlich maneuver is used to assist a person choking on a foreign
object. The pressure from the thrusts lifts the diaphragm, forces air out
of the lungs and creates an artificial cough that expels the aspirated
material.
83. John, 16 years old, is brought to the ER after a vehicular accident.

He is pronounced dead on arrival. W hen his parents arrive at the
hospital, the nurse should:
A. ask them to stay in the waiting area until she can spend time alone
with them
B. speak to both parents together and encourage them to support each

other and express their emotions freely
C. Speak to one parent at a time so that each can ventilate feelings of
loss without upsetting the other
D. ask the MD to medicate the parents so they can stay calm to deal
with their son¶s death.
Answer: (B) speak to both parents together and encourage them to

support each other and express their emotions freely
Sudden death of a family member creates a state of shock on the
family. They go into a stage of denial and anger in their grieving.
Assisting them with information they need to know, answering their
questions and listening to them will provide the needed support for them
to move on and be of support to one another.
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84. An emergency treatment for an acute asthmatic attack is Adrenaline
1:1000 given hypodermically. This is given to:
A. increase BP
B. decrease mucosal swelling
C. relax the bronchial smooth muscle
D. decrease bronchial secretions
Answer: (C) relax the bronchial smooth muscle

Acute asthmatic attack is characterized by severe bronchospasm which
can be relieved by the immediate administration of bronchodilators.
Adrenaline or Epinephrine is an adrenergic agent that causes bronchial

dilation by relaxing the bronchial smooth muscles.
85. A nurse is performing CPR on an adult patient. W hen performing
chest compressions, the nurse understands the correct hand placement

is located over the
A. upper half of the sternum
B. upper third of the sternum
C. lower half of the sternum
D. lower third of the sternum
Answer: (C) lower half of the sternum
The exact and safe location to do cardiac compression is the lower half
of the sternum. Doing it at the lower third of the sternum may cause
gastric compression which can lead to a possible aspiration.
86. The nurse is performing an eye examination on an elderly client. The client states µMy vision is blurred,
and I don¶t easily see clearly when I get into a dark room.´ The nurse best response is:
A. ³You should be grateful you are not blind.´

B. ³As one ages, visual changes are noted as part of degenerative
changes. This is normal.´
C. ³You should rest your eyes frequently.´
D. ³You maybe able to improve you vision if you move slowly.´
Answer: (B) ³As one ages, visual changes are noted as part of
degenerative changes. This is normal.´
Aging causes less elasticity of the lens affecting accommodation leading
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to blurred vision. The muscles of the iris increase in stiffness and the
pupils dilate slowly and less completely so that it takes the older person
to adjust when going to and from light and dark environment and needs
brighter light for close vision.
87. W hich of the following activities is not encouraged in a patient after

an eye surgery?
A. sneezing, coughing and blowing the nose
B. straining to have a bowel movement
C. wearing tight shirt collars
D. sexual intercourse
Answer: (D) sexual intercourse

To reduce increases in IOP, teach the client and family about activity
restrictions. Sexual intercourse can cause a sudden rise in IOP.
88. Which of the following indicates poor practice in communicating with

a hearing-impaired client?
A. Use appropriate hand motions
B. Keep hands and other objects away from your mouth when talking to
the client
C. Speak clearly in a loud voice or shout to be heard
D. Converse in a quiet room with minimal distractions
Answer: (C) Speak clearly in a loud voice or shout to be heard

Shouting raises the frequency of the sound and often makes
understanding the spoken words difficult. It is enough for the nurse to
speak clearly and slowly.
89. A client is to undergo lumbar puncture. W hich is least important

information about LP?
A. Specimens obtained should be labeled in their proper sequence.

B. It may be used to inject air, dye or drugs into the spinal canal.
C. Assess movements and sensation in the lower extremities after the
D. Force fluids before and after the procedure.
Answer: (D) Force fluids before and after the procedure.

LP involves the removal of some amount of spinal fluid. To facilitate
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CSF production, the client is instructed to increase fluid intake to 3L,
unless contraindicated, for 24 to 48 hrs after the procedure.
90. A client diagnosed with cerebral thrombosis is scheduled for

cerebral angiography. Nursing care of the client includes the following
EXCEPT
A. Inform the client that a warm, flushed feeling and a salty taste may be
B. Maintain pressure dressing over the site of puncture and check for
C. Check pulse, color and temperature of the extremity distal to the site
of
D. Kept the extremity used as puncture site flexed to prevent bleeding.
Answer: (D) Kept the extremity used as puncture site flexed to prevent
bleeding.
Angiography involves the threading of a catheter through an artery
which can cause trauma to the endothelial lining of the blood vessel.
The platelets are attracted to the area causing thrombi formation. This is
further enhanced by the slowing of blood flow caused by flexion of the
affected extremity. The affected extremity must be kept straight and
immobilized during the duration of the bedrest after the procedure. Ice
bag can be applied intermittently to the puncture site.

91. W hich is considered as the earliest sign of increased ICP that the
nurse should closely observed for?
A. abnormal respiratory pattern

B. rising systolic and widening pulse pressure
C. contralateral hemiparesis and ipsilateral dilation of the pupils
D. progression from restlessness to confusion and disorientation to
lethargy
Answer: (D) progression from restlessness to confusion and

disorientation to lethargy
The first major effect of increasing ICP is a decrease in cerebral
perfusion causing hypoxia that produces a progressive alteration in the
LOC. This is initially manifested by restlessness.
92. W hich is irrelevant in the pharmacologic management of a client

with CVA?
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A. Osmotic diuretics and corticosteroids are given to decrease cerebral
edema
B. Anticonvulsants are given to prevent seizures
C. Thrombolytics are most useful within three hours of an occlusive CVA
D. Aspirin is used in the acute management of a completed stroke.
Answer: (D) Aspirin is used in the acute management of a completed

stroke.
The primary goal in the management of CVA is to improve cerebral
issue perfusion. Aspirin is a platelet deaggregator used in the

prevention of recurrent or embolic stroke but is not used in the acute
management of a completed stroke as it may lead to bleeding.
93. W hat would be the MOST therapeutic nursing action when a client¶s
expressive aphasia is severe?
A. Anticipate the client wishes so she will not need to talk
B. Communicate by means of questions that can be answered by the
client shaking the head

C. Keep us a steady flow rank to minimize silence
D. Encourage the client to speak at every possible opportunity.
Answer: (D) Encourage the client to speak at every possible opportunity.

Expressive or motor aphasia is a result of damage in the Broca¶s area of
the frontal lobe. It is amotor speech problem in which the client generally
understands what is said but is unable to communicate verbally. The
patient can best he helped therefore by encouraging him to
communicate and reinforce this behavior positively.
94. A client with head injury is confused, drowsy and has unequal
pupils. W hich of the following nursing diagnosis is most important at this
time?
A. altered level of cognitive function

B. high risk for injury
C. altered cerebral tissue perfusion
D. sensory perceptual alteration
Answer: (C) altered cerebral tissue perfusion

The observations made by the nurse clearly indicate a problem of
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decrease cerebral perfusion. Restoring cerebral perfusion is most
important to maintain cerebral functioning and prevent further brain
damage.
95. Which nursing diagnosis is of the highest priority when caring for a
client with myasthenia gravis?
A. Pain
B. High risk for injury related to muscle weakness
C. Ineffective coping related to illness
D. Ineffective airway clearance related to muscle weakness
Answer: (D) Ineffective airway clearance related to muscle weakness

Myasthenia gravis causes a failure in the transmission of nerve
impulses at the neuromuscular junction which may be due to a
weakening or decrease in acetylcholine receptor sites. This leads to
sporadic, progressive weakness or abnormal fatigability of striated
muscles that eventually causes loss of function. The respiratory muscles
can become weak with decreased tidal volume and vital capacity
making breathing and clearing the airway through coughing difficult. The
respiratory muscle weakness may be severe enough to require and
emergency airway and mechanical ventilation.
96. The client has clear drainage from the nose and ears after a head
injury. How can the nurse determine if the drainage is CSF?
A. Measure the ph of the fluid

B. Measure the specific gravity of the fluid
C. Test for glucose
D. Test for chlorides
Answer: (C) Test for glucose

The CSF contains a large amount of glucose which can be detected by
using glucostix. A positive result with the drainage indicate CSF
leakage.
97. The nurse includes the important measures for stump care in the
teaching plan for a client with an amputation. Which measure would be
excluded from the teaching plan?
A. Wash, dry, and inspect the stump daily.
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B. Treat superficial abrasions and blisters promptly.
C. Apply a "shrinker" bandage with tighter arms around the proximal end
of the affected limb.
D. Toughen the stump by pushing it against a progressively harder
substance (e.g., pillow on a foot-stool).
Answer: (C) Apply a "shrinker" bandage with tighter arms around the
proximal end of the affected limb.
The ³shrinker´ bandage is applied to prevent swelling of the stump. It
should be applied with the distal end with the tighter arms. Applying the
tighter arms at the proximal end will impair circulation and cause
swelling by reducing venous flow.
98. A 70-year-old female comes to the clinic for a routine checkup. She
is 5 feet 4 inches tall and weighs 180 pounds. Her major complaint is
pain in her joints. She is retired and has had to give up her volunteer
work because of her discomfort. She was told her diagnosis was
osteoarthritis about 5 years ago. W hich would be excluded from the
clinical pathway for this client?
A. Decrease the calorie count of her daily diet.
B. Take warm baths when arising.

C. Slide items across the floor rather than lift them.
D. Place items so that it is necessary to bend or stretch to reach them.
Answer: (D) Place items so that it is necessary to bend or stretch to

reach them.
Patients with osteoarthritis have decreased mobility caused by joint
pain. Over-reaching and stretching to get an object are to be avoided as
this can cause more pain and can even lead to falls. The nurse should
see to it therefore that objects are within easy reach of the patient.
99. A client is admitted from the emergency department with severe-

pain and edema in the right foot. His diagnosis is gouty arthritis. W hen
developing a plan of care, which action would have the highest priority?
A. Apply hot compresses to the affected joints.

B. Stress the importance of maintaining good posture to prevent
deformities.
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C. Administer salicylates to minimize the inflammatory reaction.
D. Ensure an intake of at least 3000 ml of fluid per day.
Answer: (D) Ensure an intake of at least 3000 ml of fluid per day.

Gouty arthritis is a metabolic disease marked by urate deposits that
cause painful arthritic joints. The patient should be urged to increase his
fluid intake to prevent the development of urinary uric acid stones.
100. A client had a laminectomy and spinal fusion yesterday. Which

statement is to be excluded from your plan of care?
A. Before log rolling, place a pillow under the client's head and a pillow
between the client's legs.
B. Before log rolling, remove the pillow from under the client's head and
use no pillows between the client's legs.
C. Keep the knees slightly flexed while the client is lying in a semi-
Fowler's position in bed.

D. Keep a pillow under the client's head as needed for comfort.
Answer: (B) Before log rolling, remove the pillow from under the client's
head and use no pillows between the client's legs.
Following a laminectomy and spinal fusion, it is important that the back
of the patient be maintained in straight alignment and to support the
entire vertebral column to promote complete healing.
101. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse
would incorporate which of the ff. as a priority in the plan of care?
A. providing emotional support to decrease fear

B. protecting the client from infection
C. encouraging discussion about lifestyle changes
D. identifying factors that decreased the immune function
Answer: (B) protecting the client from infection

Immunodeficiency is an absent or depressed immune response that
increases susceptibility to infection. So it is the nurse¶s primary
responsibility to protect the patient from infection.
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102. Joy, an obese 32 year old, is admitted to the hospital after an
automobile accident. She has a fractured hip and is brought to the OR
for surgery.
After surgery Joy is to receive a piggy-back of Clindamycin phosphate

(Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20
minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set
the piggyback to flow at:
A. 25 gtt/min
B. 30 gtt/min C. 35 gtt/min D. 45 gtt/min
Answer: (A) 25 gtt/min

To get the correct flow rate: multiply the amount to be infused (50 ml) by
the drop factor (10) and divide the result by the amount of time in
minutes (20
adc 10/7/2008

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unexplained origin. Which nursing action is a priority?

c. "I will call the nurse to help me with aseptic technique."

15. Which initial observation is most important following a tonsillectomy in an 8-year-old?

17. In pre-eclampsia, the nurse would expect to assess which symptoms?

degree bums over 75 percent of his body?

b. Fasting blood sugar 128 mg/dl.

management with this information when he:

c. Boiled fish, milk

nursing action is most appropriate in evaluating for fluid volume deficit?

MEDICAL SURGICAL NURSING

NOTE: THIS QUESTIONAIRES WAS JUST GRAB FROM THE WEB,

THIS AT YOUR DESGRESSION

Answer: (C) ³With a pillow, apply pressure against the incision.´

2. The nurse needs to carefully assess the complaint of pain of the

Answer: (C) experience reduced sensory perception

3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and

Answer: (C) This is normal side-effect of AtSO4

4. Ana¶s postoperative vital signs are a blood pressure of 80/50 mm Hg,

5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a

6. After surgery, Gina returns from the Post-anesthesia Care Unit

D. Complete A.M. care quickly as possible when necessary

A. Notify his physician.

Answer: (B) Take his vital signs again in 15 minutes.

9. A 56 year old construction worker is brought to the hospital

Answer: (C) Bleeding from ears

Answer: (D) ³I smoke 1 1/2 packs of cigarettes per day.´

12. Valsalva maneuver can result in bradycardia. Which of the following

Answer: (A) Use of stool softeners.

Answer: (D) may engage in contact sports

14. A patient with angina pectoris is being discharged home with

Answer: (B) Canned sardines

Answer: (B) It prevents conversion of factors that are needed in the

18. The nurse is conducting an education session for a group of

Answer: (D) Cough or change in a chronic cough

Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic

One hazard encountered when suctioning a client is the development of

A. Cause less irritation to the gastrointestinal tract

22. Mario undergoes a left thoracotomy and a partial pneumonectomy.

A. Reduce incisional pain.

D. Increase venous return

Answer: (B) Facilitate ventilation of the left lung.

24. A client is scheduled for a bronchoscopy. When teaching the client

A. Take heart rate and blood pressure

C. Lower the oxygen rate.

Answer: (C) Lower the oxygen rate.

A. Fluid volume deficit

Answer: (C) Impaired gas exchange.

Answer: (D) posterior neck fat pad and thin extremities

28. Which statement by the client indicates understanding of the

29. A client, who is suspected of having Pheochromocytoma, complains

Answer: (C) Blood pressure

Answer: (D) Give the guest a glass of orange juice

A. ³The medication will limit thyroid hormone secretion.´

Answer: (C) Progressive weight gain

Answer: (C) Lipodystrophic areas can result, causing erratic insulin

absorption rates from these

35. Which of the following would be inappropriate to include in a diabetic

B. Inspect feet and legs daily for any changes

Answer: (C) Keep legs elevated on 2 pillows while sleeping

cause circulatory impairment.

Answer: (B) Assess gag reflex prior to administration of fluids

36. Included in the plan of care for the immediate post-gastroscopy