John J.

Teodoro PTRP, RN

1. A home care nurse is preparing to visit a client with a diagnosis of Meniere’s

disease. The nurse review’s the physician’s orders and expects to note that which of the
following dietary measures will be prescribed?

A. low fiber diet with decreased fluids

B. low sodium diet and fluid restriction

C. low carbohydrate diet and elimination of red meats

D. low fat with restriction of citrus fruits

2. A nurse is assigned to care for a client who has just undergone eye surgery. The nurse
plans to instruct the client that which of the following activities is permitted in the
postoperative period?

A. reading

B. watching television

C. bending over

D. lifting objects

3. A nurse is instilling an otic solution into an adult client’s left ear. The nurse avoids
doing which of the following as part of this procedure?

A. warming the solution to room temperature

B. placing the client in a side lying position with the ear facing up

C. pulling the auricle backward and upward

D. placing the tip of the dropper on the edge of the ear canal

4. A client has undergone surgery for glaucoma. The nurse provides which discharge
instructions to the clients?

A. wound healing usually takes 12 weeks

B. expected the vision will be permanently impaired

C. a shield or eye patch should be worn to protect the eye

D. the sutures are removed after 1 week

5. Which assessment findings provide the best evidence that a client with acute angle-
closure glaucoma is responding to drug therapy?

A. swelling of the eyelids decreases

B. redness of the sclera is reduced

C. eye pain is reduced or eliminated

D. peripheral vision is diminished

6. At the time of retinal detachment, a client most likely describes which symptoms?

A. a seeing flashes of light

B. being unable to see light

C. feeling discomfort in light

D. seeing poorly in daylight

7. The most important health teaching the nurse can provide to the client with
conjunctivitis is to:

A. eat a well balanced, nutritious diet

B. wear sunglasses in bright light

C. cease sharing towels and washcloths

D. avoid products containing aspirin

8. When the nurse prepares the client or the myringotomy, the best explanation as to the
purpose for the procedures is that it will:

A. prevent permanent hearing loss

B. provide a pathway for drainage

C. aid in administering medications

D. maintain motion of the ear bones

9. A nurse is reviewing the record of the client with a disorder involving the inner
ear. Which of the following would the nurse expect to see documented as an assessment
finding in this client?

A. severe hearing loss

B. complaints of severe pain in the affected ear

C. complaints of burning in the ear

D. complaints of tinnitus

10. A client with a conduction hearing loss asks the nurse how a hearing aid improves
hearing. The nurse most accurately informs the client that a hearing aid:

A. amplifies sound heard

B. makes sounds sharper and clearer

C. produces more distinct, crisp, speech

D. eliminates garbled background sounds

11. Which nursing action is best for controlling the client’s nosebleed?

A. have the client lay down slowly and swallow frequently

B. have the client lay down and breathe through his mouth

C. have the client lean forward and apply direct pressure

D. have the client lean forward and clench his teeth

Situation: Benjie 59 years old male was admitted to the hospital complaining of nausea,
vomiting,

weight loss of 20 lbs, constipation and diarrhea. A diagnosis of carcinoma of the colon
was made.

12. A sigmoidoscopy was performed as a diagnostic measures. What position Benjie

should assume for hi examination?

A. knee-chest
B. Sim’s

C. Fowler’s

D. Trendelenburg

13. As part of the preparation of the client for sigmoidoscopy the nurse should:

A. explain to Benjie that he will swallow a chalk-like substance

B. administer a cathartic the night before

C. withhold fluids and foods on the day of examination

D. administer cleansing enema in the morning of the examination

14. The doctor performed a colostomy, post operative nursing care include:

A. keeping the skin around the opening clean and dry

B. limiting visitors

C. withholding

D. limiting fluid intake

15. During the irrigation of the colostomy, Benjie complains of abdominal cramps, the
nurse should:

A. discontinue the irrigation

B. clamp the catheter for a few minutes

C. advance the catheter about one inch

D. add color water

16. If colostomy irrigation is done, the height of the irrigator can must be how many
inches above the stoma?

A. 14-18 inches

B. 18-20 inches

C. 20-24 inches
D. 10-14 inches

17. Which of the following gastrointestinal condition is known to predispose to Cancer of

the colon?

A. hemorrhoids

B. intussusception

C. islated colonic polyps

D. pyloric stenosis

Situation: Mr. J was brought to the ER complaining of pain located in the upper abdomen

hematemesis and melena. Diagnosis is peptic ulcer.

18. A frequent discomfort experience by Mr. J due to his peptic ulcer is:

A. diarrhea

B. vomiting

C. eructation

D. nausea

19. Which of this diagnostic measure is not indicated for Mr. J?

A. x-ray of the abdomen

B. patient’s history

C. gastrointestinal series

D. gastric analysis

20. The purpose of dietary treatment of Mr. J is to:

A. neutralize the free HCL in the stomach

B. delay gastric emptying

C. prevent constipation

D. delay surgery
21. Antacids are administered to Mr. J to:

A. tranquilize the intestine

B. decrease gastric motility

C. lower the acidity of gastric secretion

D. aid in digestion

22. It is thought that emotional stress contribute to ulcer formation through:

A. excessive stimulation of the parasympathetic nervous system

B. increased activity of the sympathetic nervous system

C. disturbance o cerebral cortex appetite control

D. decrease of pituitary function

23. The tissue change most characteristics of peptic ulcer is:

A. a soft mass of the necrotic tissue with bleeding

B. an erosion of the mucosa covered with thick exudates

C. a sharp excavation of tissue membrane with a clean base

D. an elevated fibrous tissue membrane with soft margins

24. The stool Guiac test was ordered to detect the presence of:

A. hydrochloric acid

B. occult blood

C. inflammatory cells

D. undigested food

25. In addition to its antacids effects, aluminum hydroxide gel is locally:

A. analgesic

B. astringent
C. irritating

D. depressant

26. Intervention that would help control his bleeding:

A. gastric lavage using iced cold normal saline solution

B. gastric using warm normal saline solution

C. application of tourniquet

D. insertion of NGT

27. Since she has NGT the appropriate nursing action is:

A. render sponge bath

B. provide laxative at bedtime

C. administer enema once a day

D. provide oral hygiene 3x a day

28. He underwent total gastrectomy, dumping syndrome may occur and the least
symptoms he may experience would be:

A. feeling of soreness

B. weakness

C. feeling of fullness

D. diaphoresis

29. To prevent dumping syndrome the following includes your nursing care except:

A. serve dry meals

B. allow him to walk for a while after eating

C. instruct him to lie down after eating

D. giving of fluids after meals must be avoided

30. Your operative nursing assessment after surgery:

A. note and report excessive bleeding only

B. assess for excessive secretions from the operative site

C. ensure that the NG tube is detached from suction apparatus

D. check the drainage from the NG tube everyday

31. What is the involvement of her total gastrectomy?

A. removal of the stomach only

B. removal of the stomach with anastomosis of the esophagus to the jejunum

C. removal of the ovary and fallopian tube

D. removal of the stomach with anastomosis of the duodenal to jejunum

32. A nurse is giving instructions to the client with peptic ulcer disease about symptom
management. The nurse tells the client to:

A. eat slowly and chew food thoroughly

B. eat large meals to absorb gastric acid

C. limit the intake of water

D. use acetylsalicylic acid (aspirin) to relieve gastric pain

33. A client has been given a prescription for Propantheline (Probanthine) as adjunctive
treatment for peptic ulcer disease. The nurse tells the client to take this medication:

A. with antacids

B. 30 minutes before meals

C. with meals

D. just after meals

Situation: Kim was known to be alcoholic for 15 yrs. He was admitted in the hospital
after having

vomited a large quantity of bright red blood with some coffee ground appearance.

34. The most probable cause of Kim’s cirrhosis is:

A. malnutrition

B. bacterial inflammation of liver cells

C. alcoholism

D. obstruction of major bile ducts

35. Which of the following vitamins are stored by the normal liver?

A. vit. A, vit. B and vit. C

B. vit. A, vit. B, vit. C, and vit. D

C. vit A and vit B

D. vit. A and vit. C

36. The nurse should know how that pathophysiology predispose him to:

A. varicose veins

B. splenic rupture

C. inguinal hernia

D. umbilical hernia

37. Kim’s portal hypertension is the result of:

A. contraction of vascular muscles response to psychological stress

B. compression of the liver substance due to emotional stress

C. acceleration of portal blood flow secondary to severe anemia

D. twisting and constriction of intralobular and interlobular blood vessels

38. Kim is scheduled for a liver biopsy. What instructions regarding respiration is
essential for the nurse to give him prior to the biopsy:

A. exhale forcefully and to hold his breath for a few seconds

B. hold his breath when the needle has reached the liver site

C. take several deep breaths and to hold his breath while needle is being introduced
D. flat with one pillow under his head

39. Which position in bed would be best for Kim immediately after he has the needle
biopsy of the liver?

A. on his right side, with a small pillow under the costal margin

B. anyway that he is comfortable

C. semi-Fowler’s with his knees flexed

D. flat with one pillow under his head

40. A Blakemore-Sengstaken tube is inserted to prevent bleeding from esophageal

varices. The nurse responsibility in this instance would be to:

A. alternate inflate and deflate the esophageal balloon

B. make certain that the desired degree of pressure is constantly maintained

C. deflate both balloons periodically

D. encourage Kim to swallow frequently while tube is I place

41. A physician orders the deflation of the esophageal balloon of a Sengstaken-

Balkemore tube in a client. The nurse prepares for the procedure knowing that the
deflation of the esophageal balloon places. The client is at risk for:

A. increased ascites

B. esophageal necrosis

C. recurrent hemorrhage from the esophageal varices

D. gastritis

42. Foods usually omitted from diet of Kim with cirrhosis of liver are:

A. whole grain cereals

B. milk products

C. cereal products

D. rich gravies and sauces

43. Clay colored stool are caused by:

A. improper utilization of vitamin K by the body

B. the absence of bile salt in the feces

C. the absence of bile pigments in the urine

D. rich gravies and sauces

44. Kim develop ascites, this is caused by:

A. pulmonary failure

B. portal obstruction

C. capillary obstruction

D. arterial obstruction

45. Symptoms indicating progression into hepatic coma include:

1. flapping tremor

2. nystagmus

3. fruity odor breath

4. fetid breath

A. 2 and 4 C. 2 and 3

B. 1 and 4 D. 1 and 3

46. A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and
has difficulty breathing. A nurse performs which intervention as a priority measure to
assist the client with breathing?

A. auscultates the lung fields every 4 hours

B. repositions side to side every 2 hours

C. encourages deep breathing exercises every 2 hours

D. elevates the head of the bed 60 degrees

Situation: Karla is confine with a diagnosis of chronic cholecystitis.

47. After thorough examination your findings would be:

A. high red blood cell counts and fever

B. leukocyte count is low and high fever

C. leukocyte count high and pyrexia

D. leukocytosis and abdominal pain that radiates to the groin

48. The surgical intervention indicated for Karla is:

A. choledochostomy

B. cholecystostomy

C. cholecystotomy

D. cholecystectomy

49. Following exploration of the common duct is a T-tube inserted. The rationale for this
is to:

A. facilitate healing of the operative site

B. offer a route to post operative cholecystectomy

C. provide sufficient drainage to promote healing

D. ensure adequate bile drainage during duct healing

50. Upon admission her doctor ordered for cholecystoghram in AM. The preparations of
this procedure begins:

A. in early am

B. with evening meal

C. at bedtime

D. upon admission

51. The ingestion of fatty food usually precipitates rubies episodes of the upper
abdominal pain because;
A. fat in the stomach increases the rate of peristaltic movements

B. fat in the duodenal contents initiate the reaction that cause gallbladder
contraction

C. fatty foods are likely to generate gas

D. fatty foods contain higher amount of cholesterol than do proteins

52. Karla is having pruritus of the extremities. Which of the following nursing measures
might be most helpful in relieving her discomfort.

A. rubbing the skin with potassium permanganate 10:1000 solution

B. bathing in weak sodium bicarbonate solution

C. dusting with liberal amount of talcum powder

D. rubbing the skin with alcohol

53. Karla is experiencing severe biliary colic. The drug of choice during attack is:

A. ponstan

B. Demerol

C. atropine sulfate

D. morphine sulfate

54. A T-tube was inserted into the common bile duct. Her nursing care of the T-tube is:

A. empty and measure the bile drainage every 4 hours

B. report STAT for any bile seen in the drainage system

C. secure it very well

D. irrigate the T-tube with sterile normal saline every 4 hours

55. A client with diverticulitis has just been advanced from a liquid diet to solids. The
nurse encourages the client to eat foods that are:

A. low residue

B. high residue
C. moderate in fat

D. high roughage

56. A client has just undergone an upper gastrointestinal (GI) series. The nurse provides
which of the following upon the client’s return to the unit as an important part of routine
post procedure care?

A. increased fluids

B. bland diet

C. NPO status

D. laxative

57. A nurse is administering continuous tube feedings to the client. The nurse takes which
of the following actions as party of routine care for this client?

A. checks the residual every 4hours

B. changes the feeding bag and tubing every 12 hours

C. pours additional feeding into bag when 25 ml are left

D. holds the feeding if greater than 200 ml are aspirated

58. A nurse is monitoring drainage from a nasogastric (NG) tube in a client who had a
gastric resection. No drainage has been noted during the past 4 hours and the client
complains of severe nausea. The most appropriate nursing action would be to:

A. reposition the tube

B. irrigate the tube

C. notify the physician

D. medicate for nausea

59. A nurse is performing a health history on a client with chronic pancreatitis. The nurse
expects to most likely note which of the following when obtaining information regarding
the client’s health history?

A. abdominal pain relieved with food or antacids

B. exposure to occupational chemicals

C. weight gain

D. use of alcohol

60. A home care nurse visits a client with bowel cancer who recently received a course of
chemotherapy. The client has developed stomatitis. The nurse avoids telling the client to:

A. drink foods and liquids that are cold

B. eat foods without spices

C. maintain a diet of soft foods

D. drink juices that are not citrus

61. A nurse is caring for a client with is receiving total parenteral nutrition (TPN). The
nurse plans which nursing intervention to prevent infection?

A. using strict aseptic technique for intravenous site dressing changes

B. monitoring serum blood urea nitrogen (BUN) daily

C. weighing the client daily

D. encouraging increased fluid intake

62. A nurse is caring for a client with possible cholelithiasis who is being prepared for a
cholangiogram. The nurse teaches the client about the procedure. Which client statement
indicates that the client understands the purpose of this procedure?

A. “they are going to look at my gallbladder and ducts.”

B. “this procedure will drain my gallbladder”

C. “my gallbladder will be irritated”

D. “they will put medication in my gallbladder”

63. A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The
nurse interprets that which of the following factors is most likely responsible for the
anemia?

A. decrease intake of dietary iron

B. intestinal malabsorption
C. blood loss

D. intestinal hookworm

64. A client’s nasogastric (NG) feeding tube has become clogged. The nurse’s first action
is to:

A. flush the tube with warm water

B. aspirate the tube

C. flush the carbonated liquids, such as cola

D. Replace the tube

65. When the client ask the nurse why he must take the neomycin sulfate (Mycifradin),
the most accurate explanation in this case is that the drug is given to:

A. treat any current infection he may have

B. suppress the growth of intestinal bacteria

C. prevent the onset of postoperative diarrhea

D. reduce the number of bacteria near the incision

66. If the client is typical of others with appendicitis the nurse can expect that when the
client’s abdomen is palpated midway between the umbilicus and right iliac crest, the
client will:

A. experienced more pain when pressure is released

B. lack any sensation of pain or pressure on palpation

C. have extreme discomfort with the slightest pressure

D. will feel referred pain in the opposite quadrant

67. Which factor most probably contributed to the development of the client’s
hemorrhoids?

A. the client takes a daily stool softener

B. the client has a history of ulcerative colitis

C. the client is frequently constipated

D. the client works as a computer programmer

68. When the client describes her discomfort to the nurse she is most likely to indicate
that the pain she experiences becomes worse:

A. shortly after eating

B. especially on an empty stomach

C. following periods of activities

D. before rising in the morning

69. When the nurse empties the drainage in the Jackson Pratt bulb reservoir. Which
nursing action is essential for reestablishing the negative pressure within this drainage
device?

A. the nurse compresses the bulb reservoir and closes the drainage valve

B. the nurse opens the drainage valve, allowing the bulb to fill with air

C. the nurse fill the bulb reservoir with sterile normal saline

D. the nurse secures the bulb reservoir to the skin near the wound

70. When the client asks the nurse how she acquired hepatitis A, the best answer is that a
common route of hepatitis. A transmission is from:

A. fecal contamination

B. insect carries

C. infected blood

D. wound drainage

71. It is essential that the nurse inform the client with hepatitis B that for the remainder of
his lifetime he must avoid:

A. sexual activity

B. donating blood

C. excessive caffeine

D. foreign travel
72. Which nursing action is appropriate prior to assisting with the paracentesis?

A. the nurse asks the client to void

B. the nurse withholds food and water

C. the nurse cleanses the client’s abdomen with Betadine

D. the nurse obtains a suction machine from storage room

73. Which statements provides the best evidence that a client with colostomy is adjusting
to the change in body image?

A. the client wears loose-fitting garments

B. the client takes a shower each day

C. the client empties the appliance

D. the client avoids foods that form gas

74. A previously health client comes to the emergency department complaining of severe
nausea and vomiting hours after eating in a restaurant. Which assessment question best
determines if a food borne pathogen is the cause of the client’s syndrome?

A. “what food did you eat?”

B. “did you take something for you nausea?”

C. “did your food look spoiled?”

D. “have you ever had food poisoning?”

75. A nurse is caring for a client with peptic ulcer. In assessing the client for
gastrointestinal perforation (GI), the nurse monitors for:

A. increase bowel sounds

B. sudden, severe abdominal pain

C. positive Guaiac test

D. slow, strong pulse

76. Which assessment is most important for the nurse to make before advancing a client
from liquid to solid food?
A. increase bowel sounds

B. appetite

C. presence of bowel sounds

D. chewing ability

77. What method would a nurse use to most accurately assess the effectiveness of a
weight loss diet for an obese client?

A. daily weights

B. serum protein levels

C. daily caloric counts

D. daily intake and output

78. A pregnant client has been diagnosed with a vaginal infection from the organism
Candida albicans. Which findings would the nurse expect to note on assessment of the
client?

A. absence of any and symptoms

B. pain, itching and vaginal discharge

C. proteinuria, hematuria, edema and hypertension

D. costovertebral angle pain

79. A nurse is caring for a client who is hospitalized with acute systemic lupus
erythematosus (SLE). The nurse monitors the client knowing that which of the following
clinical manifestation is not associated with this disease?

A. fever

B. muscular aches and pains

C. butterfly rash on the face

D. bradycardia

80. A male being seen in the ambulatory care clinic has a history of being treated for
syphilis infection. The nurse interprets that the client has been reinfected if which of the
following characteristics is noted in a penile lesion?
A. multiple vesicles, with some that have ruptured

B. popular areas and erythema

C. cauliflower-like appearance

D. induration and absence of pain

81. A nurse is preparing a poster for a booth at a health care to promote primary
prevention of cervical cancer. The nurse includes which of the following
recommendations on the poster?

A. perform monthly breast self-examination (BSE)

B. use oral contraceptives as a preferred method of birth control

C. use a commercial douches on a daily basis

D. seek treatment promptly for infections of the cervix

82. A nurse is caring for a client who has just had a mastectomy. The nurse assists the
client in doing which of the following exercises during the first 24 hours following
surgery?

A. elbow flexion and extension

B. shoulder abduction and external rotation

C. pendulum arm swing

D. hand wall climbing

83. Tretinoin (Retin-A) is prescribed for a client with acne. The client calls the clinic
nurse and says that the skin has become very red and is beginning to pee. Which of the
following nursing statements to the client would be most appropriate?

A. “come to the clinic immediately”

B. “discontinue the medication”

C. “notify the physician”

D. this is a normal occurrence with the use of medication”

Situation: Luz 19 years old single is scheduled for mastectomy of the right breast
84. Based on the health history and other assessment data, Luz’s nursing diagnosis
includes the following except:

A. potential sexual dysfunction

B. body image disturbance

C. pain related to anesthesia

D. self-care deficit related to immobility of arm on the operative side

85. The following are her possible post operative complication except:

A. hematoma

B. lymphedema

C. neurovascular deficits

D. infection

86. Luz complains of pain 2 hours after receiving her medication of Meperidine HCL 50
mg IM ordered every 4 hours for the first 24 hours only. You should:

A. tell Luz to wait for 2 hours more

B. give the medicine STAT

C. give fractional dose of Meperidine HCL

D. use nursing measure to relieve pain

87. You informed her that the most common breast tumor occurring in young women is:

A. fibrocystic

B. papilloma

C. gynecomastia

D. fibroadenoma

88. Which of these work-up is not related to her surgery?

A. CBC
B. Urinalysis

C. B.T.

D. C.T.

89. Rationale for moderately elevating post operative affected arm is to:

A. prevent lymphedema

B. reduce pain

C. B.T.

D. C.T.

90. Which of these maybe used to her post operatively?

A. pleural drainage

B. hemovac

C. prevent infection

D. improve coping ability

91. Which of the following is not a post operative complication

A. bronchopneumonia

B. pneumonia

C. atelectasis

D. decubitus ulcer

92. Allowing her to do deep breathing exercise every 2 hours would prevent:

A. bronchopneumonia

B. atelectasis

C. bronchitis

D. pneumonia
93. A client has a left mastectomy with axillary lymph node dissection. The nurse
determines that client understands post operative restrictions and arm care if the client
states to:

A. use a straight razor to shave under the arms

B. allow blood pressures to be taken only on the left arm

C. carry a handbag and heavy objects on the left arm

D. use gloves when working in the garden

94. A nurse has provided instructions to a client who is receiving external radiation
therapy. Which of the following if started by the client would indicate a need for further
instructions regarding self-care related to the radiation therapy?

A. “I need to avoid exposure to sunlight?”

B. “I need to wash my skin with a mild soap and pat dry”

C. “I need to apply pressure to the irritated area to prevent bleeding”

D. “I need to eat a high-protein diet”

95. A nurse is teaching a client about the modifiable risk factors that can reduce the risk
for colorectal cancer. The nurse places highest priority on discussing which of the
following risk factors with this client?

A. personal history of ulcerative colitis or gastrointestinal (GI) polyps

B. distant relative with colorectal cancer

C. age over 30 years

D. high-fat, low fiber diet

Situation: Fe, a 21-year-old fourth year physical therapy student has been diagnosed with
peptic

ulcer. The personal and family history shows that she has difficulty coping with the
demands of the

course and her mother is being treated for peptic ulcer to:

96. A relevant diagnosis the nurse identifies is one of the following:

A. defensive coping

B. self-esteem disturbance

C. sensory-perceptual alteration

D. ineffective individual coping

97. Typical personality traits of a person with peptic ulcer:

A. submissive and dependent

B. competitive and aggressive

C. self-sacrificing and dependent

D. perfectionist and assertive

98. One of the nursing intervention is to teach Fe:

A. relaxation technique

B. behavior modification

C. stress management technique

D. desensitization technique

99. The following are psycho-physiological reactions except:

A. migraine

B. constipation

C. bronchial asthma

D. peptic ulcer

100. The defense mechanism usually used by patient with peptic ulcer is:

A. denial

B. reaction formation

C. projection
D. sublimation

1. The home health nurse is visiting the client who has had a prosthetic valve replacement
for severe mitral valve stenosis. Which statement by the client reflects an understanding
of specific postoperative care for this surgery?

A. “I threw away my straight razor and brought an electric razor.”

B. “I have to go to the bathroom several times at night”

C. “I count my pulse everyday”

D. “I still do my deep breathing exercise”

2. A client has been diagnosed with thromboangitis obliterans. The nurse is considering
measures to help the client cope up with lifestyle changes needed to control the disease
process. The nurse plans to refer the client to a:

A. medical social worker

B. dietician

C. smoking cessation program

D. pain management clinic

3. The nurse is implementing a plan of care for a client with deep pain thrombosis of the
right leg. Which of the following interventions does the nurse avoid when delivering care
to this client?

A. elevation of the right leg

B. ambulation in the hall twice per shift

C. application of moist heat to the right leg

D. administration of acetaminophen (Tylenol)

4. The client was hospitalized 5 days ago have developed left calf tenderness and have a
positive Homan’s sign. The nurse assigned to this client next assess to this client next
assesses the client for:

A. coolness and pallor of the affected limb

B. diminished distal peripheral pulses

C. increased calf circumference

D. bilateral edema

5. The nurse is monitoring a client with leukemia who is receiving Doxorubicin

(Adriamycin) by IV infusion. Which of the following assessment findings indicate
toxicity of the medication?

A. Elevated BUN C. ECG changes

B. elevated creatinine D. a red coloration of the urine

6. A 45-year-old male returned to his room an hour ago following a bronchoscopy. He

is requesting for some water. The nurse must:

A. keep the client NPO until n order is written

B. check the vital signs first

C. check the gag and swallowing reflex

D. encourage coughing and deep breathing

7. A 45-year-old client is receiving heparin sodium for a pulmonary embolus. The nurse
evaluates which of the following laboratory reports of partial thromboplastin time as
indicative of effective heparin therapy.

A. within normal range

B. one to 1.5 times the control value

C. two to 2.5 times the control value

D. three times the control value

8. A client is taking Wafarin (coumadin) following the placement of an artificial mitral

valve. The nurse instructs this client to avoid taking the following commonly used drug:

A. Maalox plus C. Tylenol cold and flu medication

B. sudafed D. aspirin

9. A client with insulin dependent diabetes mellitus (IDDM) is being discharged. The
nurse knows that the client has understood essential teaching when the following
statement is heard:
A. “I need to cut my nails straight across”

B. “I can’t make any substitutions in my diet”

C. “my insulin should be given into my arms”

D. “I should eat less before exercising”

10. A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the
following laboratory test daily:

A. complete blood count C. prothrombin time

B. electrolyte studies D. BUN and creatinine

11. A client has developed depression of the bone marrow from antineoplastic drugs. The
nurse states the nursing diagnosis of highest priority as:

A. fluid volume deficit C. ineffective thermoregulation

B. High risk for aspiration D. high risk for infection

12. Radioactive iodine is being used to treat a client with cancer of the thyroid gland. The
nurse knows that the client has understood teaching about the treatment when the
following statement is heard:

A. “only my thyroid gland will be radioactive”

B. “I need not be concerned about radioactivity”

C. “my whole body will be radioactive”

D. “my body fluids will be radioactive for a short time”

13. A client’s TPN is 6 hours behind schedule. The nurse would:

A. run the fluid at rate to make up the lost time.

B. report the situation to the physician

C. run the IV at the prescribed site

D. check the blood glucose level

14. A 45-year-old client is in acute congestive heart failure. The nurse and client establish
a goal of highest priority as:
A. rest mentally as well as physically

B. learn stress management

C. train for a less demanding job

D. prevent complications of immobility

15. A client diagnosed with IDDM becomes irritable and confused; the skin is cool and
clammy and the pulse rate is 110. The first action of the nurse would be to:

A. give a half-cup of orange juice

B. check the serum glucose

C. administer regular insulin

D. call the physician

16. A client with IDDM is recovering from DKA. Information of the serum level of the
following substance will be very important to the nurse:

A. sodium C. potassium

B. calcium D. magnesium

17. A 17-year-old client’s mother has been recently diagnosed with pulmonary
tuberculosis. The nurse would expect the doctor to order which of the following tests
initially?

A. the mantoux C. a sputum culture

B. an X-ray D. gram stain of the sputum

18. The nurse injects 0.1 ml. of purified protein derivative (PPD) intradermally into the
inner aspect of the forearm of a client. This nurse will interpret the reaction to this test as
positive when the following is seen:

A. redness greater than 5mm.

B. swelling greater than 7mm.

C. induration greater than 10mm.

D. exudates covering more than 12mm

19. A 29-year-old has been taking Prednisone 60 mg. daily for an inflammatory condition
for the past 6 months. The physician just wrote an order to discontinue the
medication. The nurse should:

A. stop the medication as ordered

B. continue the medication until physician is available

C. call the physician and question the order

D. hold the medication until the physician is available

20. A 55 year old has a chest tube connected to a Pleur Evac system to remove blood
from the pleural cavity. While turning the client the nurse remembers to:

A. keep the Pleur Evac below the level of the wound

B. Remove the suction from the Pleur vac

C. Clamp the tubing connected to the Pleur Evac

D. drain the sterile water from the Pleur Evac

21. A client on anti-neoplastic therapy has a platelet count of 20,000/cu.mm. An

appropriate intervention for the nurse to use would be:

A. administering Vit. K IM

B. massaging injection sites to avoid absorption

C. encouraging the use of firm toothbrushes and vigorous flossing

D. avoiding rectal temperatures and other rectal procedures

22. A nurse assumes responsibility for the care of the client at 7 A.M. NPH insulin is
ordered for 7:30 A.M. Before giving the insulin, the nurse checks to see if the client will
eat that day and for the:

A. signs and symptoms of hypoglycemia

B. previous sites of injection

C. serum glucagons level

D. serum glucose level

23. A nurse is teaching a client to observe for signs of hypoxia. The nurse explains that
cyanosis is not reliable indicator of the amount that tissues are receiving because the blue
color is caused by:

A. reduced hemoglobin

B. a low partial pressure of oxygen in the blood

C. inability of oxygen to enter the cell

D. increased pH of the blood

24. A client has ARDS. The lowest fraction of inspired oxygen possible for optimizing
gas exchange is used. The nurse explains to the family that the reason for this precaution
is to:

A. avoid respiratory depression

B. prevent oxygen toxicity

C. increase lung compliance

D. promote production of surfactant

25. A client who is recovering from a myocardial infarction demonstrates that touching
has been effective with the statements:

A. “if my chest pain lasts for more than 5 minutes, I should get myself to the emergency
room”

B. “I just need to avoid salty foods and not add salt to my food”

C. “I need to avoid constipation and all activities that have caused me chest pain in
the past”

D. “I need to get to the drugstore to get some medicine for my cold”

26. A client is admitted to the hospital complaining of nervousness, heat intolerance and
muscle weakness. Her pulse rate is 118 and she has exopthalmos. An essential part of her
assessment will be:

A. palpation of the thyroid gland

B. evaluation of fluid and electrolyte balance

C. evaluation of deep tendon reflexes

D. use of the Glasgow Coma Scale

27. A client is scheduled for thyroidectomy. The nurse explains that PTU or an iodine
preparation is given prior to surgery in order to:

A. increase the size of the thyroid gland

B. render the parathyroid glands visible

C. induce a euthyroid state in the body

D. Separate the thyroid from the laryngeal nerve

28. A client is being evaluated for the possibility of Grave’s disease. The nurse teaches
that the best laboratory test for evaluating whether a client has hypothyroidism or
hyperthyroidism is the serum level of:

A. thyroxine (T4) C. TSH

B. triiodothyroinine (T3) D. epinephrine

29. A client is taking Levothyroxine (synthroid) for hypothyroidism. The nurse teaches
the client to:

A. monitor the pulse regularly

B. restrict sodium in the diet

C. take the drug with meals

D. measure urinary output

30. A client with NIDDM is admitted to the hospital. The client is confused and has dry
mucus membranes and poor skin turgor. The serum sodium is 149; the blood pressure
90/60 mmHg; the pulse is 118; and the serum glucose 465 mg/dl. The nurse anticipates
that insulin and the following will be needed:

A. a potassium drip C. intravenous fluids

B. sodium bicarbonate D. calcium gluconate

31. A nurse is teaching a diabetic client how to attain the optimal level of health. When
assessing for other risk factors stroke and heart attack, this nurse looks for:

A. hypervolemia C. proteinuria
B. hypokalemia D. hypertension

32. A nurse stops at the sight of a motor vehicle accident to find a young woman slumped
over the wheel. She is breathing with a regular rhythm at a rate of 22; ventilation efforts
normal. Her pulse rate is 110. The nurse’s next action would be:

A. check the level of consciousness

B. immobilize the spine

C. call the rescue squad

D. check for bleeding

33. A 57-year-old client is being prepared for discharge following a myocardial

infarction. The nurse knows that her teaching has been understood when she hears:

A. “I guess my sex life is over”

B. “depression is bad for me. I must stay happy and optimistic”

C. “ the best way to know the amount of exercise I should take is to watch my
pulse”

D. “the injured area will be replaced with a new heart tissue”

34. A client with IDDM has just been admitted to the ER after hitting a telephone pole
with her car. Bystanders said she acted as if she has been drinking. Her temperature is
37.4 degrees Celsius, pulse 80, resp. 44 and deep. She complained of headache and acted
confused. A fruity odor was noted on her breath. Her ABG report read= pH= 7.32,
pCO2= 36, and bicarbonate= 18. The nurse prepared for the treatment of:

A. metabolic acidosis C. respiratory acidosis

B. metabolic alkalosis D. respiratory alkalosis

35. A client with peptic ulcer is taking Maalox, Amoxicillin and Famotidine. The nurse
teaches the client to take the Maalox:

A. 1-2 hours before meals C. ½ hour before meals

B. with meals D. 1-2 hours after meals

36. A client with varicose veins tells the nurse, “I am afraid they will burst while I am
walking.” Which response by the nurse would be the BEST?
A. “the only way to prevent rupture is to have surgery”

B. “you must find another job, one that requires less walking”

C. “if that happens, you could bleed to death”

D. “rupture of varicose veins rarely occur”

37. A client asks why is it important to check the pupils. The nurse replies that changes in
the pupils are a reflection of how well the following area of the nervous system is
functioning:

A. spinal cord C. midbrain

B. brain stem D. cerebellum

38. A 32-year-old client is being evaluated in the clinic today for possible Addison’s
disease. The nurse knows that the most common cause of the disease is attributed to:

A. autoimmune response C. disseminated tuberculosis

B. blastomycosis D. diabetes mellitus

39. The nurse knows that the recommended diet for a client with Addison’s disease
includes:

A. 1 mg. Na C. low fat, low cholesterol

B. 3 gms. Na D. high potassium, high cholesterol

40. A 36-year-old client with a history of Cushing’s disease is being seen in the ER for
complaints of anorexia, vomiting, weakness and muscle cramps for the past 24
hours. The nurse recognizes that these clinical findings are a result of:

A. hypernatremia C. hyperglycemia

B. hypoglycemia D. hypokalemia

41. When teaching a patient about home care related to outpatient corticosteroid therapy,
the nurse emphasizes that side effects of corticosteroid therapy include:

A. hyperglycemia and weight loss

B. hyponatremia and hypotension

C. hypoglycemia and gastric ulcers

D. hyperglycemia and weight gain

42. Additional teaming to a newly diagnosed diabetic client related to the effects of
regular insulin is necessary when the client asks, “if I take my regular insulin at 8 A.M.,
when might I experience signs of low blood sugar reaction?

A. 8:30 am

B. 11 am

C. 1:30 pm

D. 4 pm

43. The nurse recognizes which of the following as signs of early hypoxia?

A. bradycardia, hypotension, facial flushing

B. confusion, bradycardia, headache

C. hypotension, tachypnea, lethargy

D. restlessness, yawning, tachycardia

44. A 68-year-old client has a new colostomy and is being treated today at the clinic for
diarrhea. When discussing diet with the client, the nurse explains to him that the one food
that caused this problem was:

A. cabbage C. tapioca

B. eggs D. fried chicken

45. The nurse is caring for a client with folic acid deficiency. The nurse recalls that one of
the most frequent causes of folic acid deficiency is:

A. poor nutritional intake due to alcoholism

B. lack of absorption of the intrinsic factor

C. a diet that consists of vegetables only and no meat

D. a complicated pregnancy during the second trimester

46. When planning care for a patient who is pancytopenic, the major goal should be:

A. prevent hemorrhage and infection

B. administering an oral iron preparation

C. preventing fatigue and fluid overload

D. encouraging consumption of a neutropenic diet

47. when explaining different effects of chemotherapy to students, the nurse correctly
identifies which group of chemotherapy drugs that does not affect DNA synthesis to kill
tumor cells?

A. hormones C. antimetabolites

B. vinca alkalosis D. alkylating agents

48. The nurse evaluates the client’s ability to self-monitor blood glucose level at
home. What information BEST indicates the average degree of diabetes control during
the past 2 to 4 months?

A. serum glycosylated hemoglobin

B. postprandial blood glucose level

C. a written record of daily blood glucose levels

D. a written record of daily double voided urine glucose levels

49. Which of the findings would the nurse most likely note during an Addisonian crisis?

A. serum potassium of 3 mEq/L, BP=158/72 mmHg

B. serum potassium of 5.8 mEq/L, BP=62/48 mmHg

C. serum sodium of 150 mEq/L, BP= 158/72

D. serum sodium of 135 mEq/L, BP=62/48

50. Propanolol (Inderal) is commonly prescribed for clients with hyperthyroidism to:

A. block formation of the thyroid hormone

B. decrease the vascularity of the thyroid gland

C. inhibit peripheral conversion of T4 and T3

D. decrease CNS stimulation

51. The client with cancer is receiving chemotherapy and develops
thrombocytopenia. Which goal should be given the highest priority in the NCP?

A. ambulation tree times a day

B. monitoring temperature

C. monitoring hemoglobin and hematocrit

D. monitoring for pathologic fractures

52. The nurse assesses the oral cavity of a client with cancer and notes white patches on
the mucous membranes. The nurse determines that this occurrence:

A. is common

B. is characteristic of thrush infection

C. indicates that oral hygiene need to be improved

D. suggests that the client is anemic

53. The nurse is monitoring the laboratory results of a client preparing to receive
chemotherapy. The nurse determines that the WBC count is normal if which of the
following results is present?

A. 3,000 to 8,000/cu.mm.

B. 4,000 to 9,000/cu.mm.

C. 7,000 to 15,000/cu.mm.

D. 2,000 to 5,000/cu. Mm.

54. The client suspected of having an abdominal tumor is scheduled for a CT scan with
dye injection. Which of the following is an accurate description of the scan?

A. the test maybe painful

B. the dye injected may cause a warm, flushing, sensation

C. fluids will be restricted following the test

D. the test takes approximately 2 hours

55. The client is diagnosed as having a bowel tumor. Several diagnostic test are
prescribed. Which of the following test will confirm the diagnosis of the malignancy?

A. MRI C. abdominal ultrasound

B. CT scan D. biopsy of the tumor

56. The oncology nurse is preparing to administer chemotherapy to the client with
Hodgkin’s disease. A multiagent medication regimen known as MOPP is prescribed. The
medications included in the therapy are:

A. belomycin, oncovin, vincristine, prednisone

B. adrimycin, vincristine, oncovin, prednisone

C. adriamycin, cytoxan, prednisone, oncovin

D. procarbazine, mechlorethemine, oncovin, prednisone

57. The nurse is analyzing the laboratory results of a client with leukemia who received a
regimen of chemotherapy. Which of the following laboratory values does the nurse note
specifically as a result of massive cell destruction that occurred from chemotherapy?

A. anemia C. decrease platelets

B. decreased WBC D. increased uric acid level

58. The client is receiving external radiation to the neck for cancer of the larynx. The
MOST likely side effect to be expected is:

A. constipation C. sore throat

B. dyspnea D. diarrhea

59. The nurse is providing instructions to the client receiving external radiation
therapy. Which of the following is NOT a component of the instructions?

A. avoid exposure to sunlight

B. wash the skin with a mild soap and pat dry

C. apply pressure on the irritated area to prevent bleeding

D. eat a high protein diet

60. The nurse teaches skin care to the client receiving external radiation therapy. Which
of the following statements, if made by the client indicates the need for further
instruction?

A. “I will handle the area gently”

B. “I will avoid the use of deodorants”

C. “I will limit sun exposure to 1 hour daily”

D. “I will wear loose fitting clothing”

61. The nurse is reviewing the laboratory results of a client receiving chemotherapy. The
platelet count is 10,000/cu.mm. Based on this laboratory value, the priority nursing
assessment is which of the following?

A. assess level of consciousness

B. assess temperature

C. assess bowel sounds

D. assess skin turgor

62. The client is admitted to the hospital with a diagnosis of suspected Hodgkin’s
disease. Which of the following assessment signs would the nurse MOST likely to note in
the client?

A. weakness C. weight gain

B. fatigue D. enlarged lymph nodes

63. The client with leukemia is receiving Busulfan (myleran). Allopurinol (Zyloprim) is
prescribed for the client. The purpose of Allopurinol (Zyloprim) is to:

A. preventgouty arthritis C. prevent hyperuricemia

B. prevent stomatitis D. prevent diarrhea

64. A gastrectomy is performed on a client with gastyric cancer. In the immediate

postoperative period, the nurse notes bloody drainage from the NGT. Which of the ff. is
the MOST appropriate nursing intervention?

A. notify the physician C. continue to monitor the drainage

B. measure abdominal girth D. irrigate the NGT

65. The nurse is reviewing the history of a client with bladder cancer. The MOST
common symptom of this type of cancer is which of the following?

A. frequency of urination C. hematuria

B. urgency of urination D. dysuria

66. The nurse is assessing the stoma of a client following a ureterostomy. Which of the
following does the nurse expect to note?

A. a pale stoma C. a red and moist stoma

B. a dry stoma D. a dark-colored stoma

67. The nurse is caring for a client following a radical mastectomy. Which of the
following nursing interventions would assist in preventing lymphedema of the affected
arm?

A. placing cool compress on the affected arm

B. elevating the affected arm on pillow below the heart level

C. maintaining an IV site below the antecubital area of the affected side

D. avoiding arm exercises in the immediate post-operative period

68. The nurse is teaching BSE to a client who had a hysterectomy. The MOST
appropriate instruction regarding BSE should be performed is:

A. 7 to 10 days after menstruation

B. just before menses begin

C. at ovulation time

D. at a specific day of the month and on the same day every month thereafter

69. The nurse is instructing the client, Ben how to perform testicular self-
examination. Which instruction is correct?

A. examine testicles when lying down

B. the best time for the examination is after a shower

C. gently feel the testicle with one finger to feel for a growth
D. testicular examination should be done at least every 6 months

70. The nurse is instructing a group of female about BSE. The nurse instructs the clients
to perform the examination:

A. at the onset of menstruation

B. one week after menstruation begins

C. every month during ovulation

D. weekly at the same time of the day

71. The client has undergone esophagogastroduodenoscopy (EGD). The nurse places
highest priority on which of the following items as apart of the client’s care plan?

A. assessing for the return of the gag reflex

B. giving warm gargle for sore throat

C. monitoring temperature

D. monitoring complaints of heartburn

72. The client being seen in a physician’s office has just been schedule for a barium
swallow the next day. The nurse writes down which of the following instructions for the
client to follow before the test?

A. removal all metal and jewelry before the test

B. eat regular supper and breakfast

C. continue to take all oral medication as scheduled

D. monitor own bowel movement pattern for constipation

73. The client is diagnosed with bleed and the bleeding has been controlled antacid are
prescribed to be administered every hour. The nurse should plan on maintaining an
approximately gastric pH of:

A. 3 B. 9 C. 6 D. 15

74. The nurse is caring for a client following a Billroth II Procedure. On review of the
post-operative orders, which of the following, if prescribed, does the nurse question and
verify?
A. irrigating the NG tube

B. coughing and deep breathing exercises

C. leg exercises

D. early ambulation

75. A client who has a peptic ulcer is schedule for a vagotomy. The client asks about the
purpose of this procedure. The BEST nursing response is which of the following?

A. “decreases food absorption in the stomach”

B. “heal the gastric mucosa”

C. “halts stress reaction”

D. “reduces the stimulus to acid secretion”

76. The nurse ins monitoring a client for the early signs and symptoms of dumping
syndrome. Which of the following syndrome indicate this occurrence?

A. abdominal cramping and pain

B. bradycardia and indigestion

C. sweating and pallor

D. double vision and chest pain

77. The nurse is caring for a hospitalized patient with a diagnosis of ulcerative
colitis. When assessing the client, which finding, if noted, would the nurse report to the
physician?

A. bloody diarrhea C. hemoglobin level of 12 mg/dl

B. hypotension D. rebound tenderness

78. The nurse is providing discharge instruction to a client following gastrectomy which
of the following measures will the nurse instruct the client to the following assist in
preventing dumping syndrome?

A. eat high carbonated food

B. limit the fluid taking with food

C. ambulate following a meal

D. sit in a high-fowler’s position during meals

79. The nurse is caring for a client post-operatively following the creation of a
colostomy. Which of the ff. nursing diagnosis does the nurse include in the plan of care?

A. altered nutrition; more than body requirements

B. body image disturbance

C. fear related to poor diagnosis

D. sexual dysnfunction

80. The nurse is reviewing the record of the client with Crohn’s disease. Which of the
following stool characteristic does the nurse expect to note in this client?

A. bloody stool

B. diarrhea

C. constipation alternating with diarrhea

D. stool constantly oozing from the rectum

81. The client with cirrhosis has ascites and a fluid volume excess. Which measure will
the nurse include in the plan of care for this client?

A. increase the amount of sodium in diet

B. restrict the amount of fluids consumed

C. encourage ambulation frequently

D. administer magnesium antacids

82. The client with ascites is schedule for a paracentesis. The nurse is assisting the
physician in performing the procedure. Which of the following positions will the nurse
assist the client to assume for this procedure?

A. supine C. right side lying

B. left side lying D. upright

83. An ultrasound of the gallbladder is schedule for the client with a suspect diagnosis of
cholecystitis. The nurse explain to the client that this test:

A. requires the client to lie still for short intervals

B. requires that the client be NPO

C. requires the administration of oral tables

D. is uncomfortable

84. The nurse is providing preoperative teaching to a client scheduled for a

cholecystectomy. Which of the following interventions is of highest priority in the
preoperative teaching plan?

A. teaching coughing and deep breathing exercises

B. teaching leg exercises

C. instructions regarding fluid restrictions

D. frequent need to work overtime on short notice

85. A client with peptic ulcer states that stress frequently causes exacerbation of the
disease. The nurse interprets that which of the following items mentioned by the client is
most likely responsible for the exacerbations?

A. sleeping 8 hours a night

B. eating 5 to 6 small meals per day

C. ability to work at home periodically

D. frequent need to work overtime on short notice

86. The client with peptic ulcer disease needs dietary modification to reduce episode of
epigastric pain. The nurse plans to teach the client that which of the following items,
which the client enjoys, does not need to be limited or eliminated with this disease?

A. wine C. coffee

B. baked chicken D. fresh fruit

87. The medication history of a client with peptic ulcer disease reveals intermittent use of
the following medications. The nurse teaches the client to avoid which of these
medications altogether because of the irritating effects on the lining of the GI tract?
A. (Prilosec)

B. ibuprofen (Motrin)

C. sucralfate (Carafate)

D. Nizatidine (Axid)

88. The nurse instructs the ileostomy client to do which of the following as part of
essential care of the stoma?

A. cleanse the peristomal skin meticulously

B. take in high-fiber foods such as nuts

C. massage the area below the stoma

D. limit fluid intake to prevent diarrhea

89. The client who has undergone creation of a colostomy has a nursing diagnosis of
Body Image disturbance. The nurse evaluates that he client is making the most significant
progress toward identified goals if the client:

A. watches the nurse empty the ostomy bag

B. looks at the ostomy site

C. reads the ostomy product literature

D. practices cutting the ostomy appliance

90. The client with a new colostomy is concerned about odor from stool in the ostomy
drainage bag. The nurse should teach the client to include which of the following foods in
the diet to reduce odor?

A. yogurt C. cucumbers

B. broccoli D. eggs

91. The nurse is giving dietary instruction for the client who has a new colostomy. The
nurse encourages the client to eat foods representing which of the following diets for the
first 4 to 6 weeks postoperatively?

A. high protein C. low calorie

B. high carbohydrates D. low residue

92. The nurse has given instructions to the client with an ileostomy about foods to eat to
thicken the stool. The nurse evaluates that the client did not fully understand the
instructions if the client stated that eating which of the following foods makes the stool
less watery?

A. pasta C. bran

B. boiled rice D. low-fat cheese

93. The client has just had surgery to create an ileostomy. The nurse assesses the client in
the immediate postoperatively period for which of the following most frequent
complications of this type of surgery?

A. intestinal obstruction

B. fluid and electrolyte imbalance

C. malabsorption of fat

D. folate deficiency

94. The client with acute pancreatitis is experiencing severe pain from the disorder. The
nurse teaches the client to avoid which of the following positions that could aggravate the
pain?

A. sitting up C. leaning forward

B. lying flat D. flexing the left leg

95. The nurse is evaluating the effect of dietary counseling on the client with
cholecystitis. The nurse evaluates that the client understands the instructions given if the
client stated that which of the following food items is acceptable in the diet?

A. baked scrod C. fried chicken

B. sauces and gravies D. fresh whipped cream

96. The nurse assesses the client experiencing an acute episode of cholecystitis for pain
that is located in the right:

A. upper quadrant and radiates to the left scapula and shoulder

B. upper quadrant and radiates to the right scapula and shoulder

C. lower quadrant and radiates to the umbilicus

D. lower quadrant and radiates to the back

97. The client is beginning to show signs of hepatic encephalopathy. The nurse plans a
dietary consult to limit the amount of which of the following ingredients in the client’s
diet?

A. fat C. protein

B. carbohydrates D. minerals

98. The client with Crohn’s disease has an order to begin taking antispasmodic
medication. The nurse should time the medication so that each dose is taken:

A. 30 minutes before meals

B. during meals

C. 60 minutes after meals

D. upon arising and at bedtime

99. The client with ulcerative colitis is diagnosed with mild case of the disease. The
nurse doing dietary teaching gives the client examples of foods to eat that represent
which of the following therapeutic diets?

A. high-fat with milk

B. high-protein without milk

C. low-roughage without milk

D. low-roughage with milk

100. It has been determined that the client with hepatitis has contracted the infection from
contaminated food. What type of hepatitis is this client most likely experiencing?

A. hepatitis A

B. hepatitis B

C. hepatitis C

D. hepatitis D

Situation: The head nurse of an eye and ear clinic is ordering nursing students.
1. Normal visual acuity as measured with a Snellen eye chart is 20/20. What does a visual
acuity of 20/30 indicate?

A at 20 feet, an individual can only read letters large enough to be read at 30 feet

B. at 30 feet, an individual can read letters large enough to be read at 20 feet

C. an individual can read 20 out of 30 total letters on the chart

D. an individual can read 30 out of 50 total letters on the chart at 20 feet

2. Damage to the visual area of the occipital love of cerebrum, on the left side, would
produce what type of visual loss?

A. left eye only

B. right eye only

C. medial half of the right eye and lateral half of the left eye

D. medial half of the left eye and lateral half of the right eye

3. An anterior chamber of the eye refers to all the space in what area?

A. anterior to the retina

B. between the iris and the cornea

C. between the lens and the cornea

D. between the lens and the iris

4. What condition results when rays of light are focused in front of the retina?

A. myopia

B. hyperopia

C. presbyopia

D. emmetropia

5. As the person grows older, the lens losses its elasticity, causing which kind of
farsightedness?

A. emmetropia
 B. presbyopia

C. diplopia

D. myopia

6. If a person has a foreign object of unknown material that is not readily seen in one eye,
what would the first action be?

A. irrigate the eye with a boric acid solution

B. examine the lower eyelid and then the upper eyelid

C. irrigate the eye with opious amounts of water

D. shield the eye from pressure, and seek medical help

7. A sudden loss of an area of vision, as if a curtain were being drawn, is a principal

symptom of?

A. retinal detachment

B. glaucoma

C. cataracts

D. keratitis

8. Postoperative care following stapedectomy would not include which of the following

A. out of bed as desired

B. no moisture in the affected ear

C. avoid sneezing

D. no bending over or lifting

9. Dimenhydrinate (Dramamine) is given after a stapedectomy

A. to accelerate the auditory process

B. to dull the pain experienced with the semicircular canal is disturbed

C. to minimize the sensations of equilibrium disturbances and imbalance

D. to prevent an increase tendency toward nausea

10. A client with Meniere’s syndrome is extremely uncomfortable because of which of

these?

A. severe earache

B. many perceptual difficulties

C. vertigo and resultant nausea

D. facial paralysis

11. What is the cataract of the eyes?

A. opacity of the cornea

B. clouding of the aqueous humor

C. opacity of the lens

D. papilledema

12. Treating a cataract primarily involves which of the following?

A. instillation of miotics

B. installation of mydriatics

C. removal of the lens

D. enucleation

13. Preoperative instruction will not need to include

A. type of surgery

B. how to use the call bell

C. how to prevent paralytic illeus

D. how to prevent respiratory infetins

14. In preparing to teach patient about adjustment to cataract lenses, the nurse needs to
know that the lenses will.
A. magnify objects by one-third- with central vision

B. magnify objects by one-third with peripheral vision

C. reduce objects by one-third with central vision

D. reduce objects by one-third with peripheral vision

15. In the immediate postoperative period the one action that is contraindicated for
patient compared with clients after most other operations is which of the following?

A. coughing

B. turning on the unoperative side

C. measures to control nausea and vomiting

D. eating after nausea passes

16. Immediate nursing care following cataract extraction is directed primarily toward
preventing

A. Atelectasis

B. infection of the cornea

C. hemorrhage

D. prolapse of the iris

17. The patient is confused during her first night after eye surgery. What would the nurse
do?

A. tell her to stay in bed

B. apply restraints to keep her in bed

C. explain why she cannot get out of bed, keep side rails up, and check her
frequently

D. sedate her

18. Discharge teaching would probably not need to include

A. staying in a darkened room as much as possible

B. avoiding alcoholic drinks,; limiting the use of tea and coffee

C. using no eye washes or drops unless they were prescribed by the physician

D. avoiding being excessively sedentary

19. Patient also needs to be instructed to limit.

A. sewing

B. watching TV

C. walking

D. weeding her garden

Situation: Lea visit her ophthalmologist and receives a mydriatic drug in order to
facilitate the

examination. After returning home, she experiences severe pain, nausea and vomiting,
and blurred

vision. During a visit to the emergency room, a diagnosis of acute glaucoma is made.

20. Lea’s glaucoma has been caused by the dilation of the pupil.

A. blockage of he outflow of aqueous humor by the dilation of the pupil

B. blockage of the outflow of aqueous humor by the constriction of the pupil

C. increase intraocular pressure resulting from the increased production of aqueous

humor

D. decrease intraocular pressure resulting from decrease production of aqueous humor

21. Intraocular pressure is measured clinically by tonometer. What tonometer reading

would be indicative of glaucoma?

A. pressure of 10 mmHg

B. pressure of 15 mmHg

C. pressure of 20 mmHg

D. pressure of 25 mmHg
22. Which cranial nerve transmits visual impulses?

A. I (olfactory)

B. II (optic)

C. III (oculomotor)

D. IV (abducens)

23. Untreated or uncontrolled glaucoma damages the optic nerve. Three of the following
signs and symptoms result from optic nerve atrophy; which one does not?

A. colored halos around lights

B. severe pain in the eye

C. dilated and fixed pupils

D. opacity of the lens

24. Glaucoma is conservatively managed with miotic eye drops. Mydriatic eye drops are
contraindicated for glaucoma. Which of the following drugs is a mydriatic?

A. neostigmine

B. pilocarpine

C. physostigmatine

D. atropine

25. Glaucoma may require surgical treatment. Preoperatively, the client would be taught
to expect which of the following postoperatively?

A. cough and deep-breathing qh.

B. turn only to the unaffected side

C. medication for severe eye pain

D. restriction of fluids for the first 24 hours

Situation: Roy, a 55-year-old man, is admitted to the hospital with wide-angle glaucoma

26. What was the symptom that probably brought Roy to the ophthalmologist initially?
A. decreasing vision

B. extreme pain in eye

C. redness and tearing of the eye

D. seeing colored flashes of light

27. The teaching plan for Roy would include which of the following?

A. reduce fluid intake

B. add extra lighting in the home

C. wear dark glasses/during the day

D. avoid exercise

28. Miotics are used in the treatment of glaucoma. What is an example of a commonly
used miotic?

A. atropine

B. pilocarpine

C. acetazolamide (Diamox)

D. scopolamine

29. What is the rationale for using miotics in the treatment of glaucoma?

A. they decrease the rate of aqueous humor production

B. pupil constriction increases outflow of aqueous humor

C. increased pupil size relaxes the ciliary muscles

D. the blood flow to the conjunctiva is increased

30. When instilling eye drops for a client with glaucoma, what procedure would the nurse
follow?

A. place the medication in the middle of the lower lid, and put pressure on the
lacrimal duct after instillation.

B. Instill the drug to the outer angle of the eye, have client tilt head back
C. instill the drug at the innermost angle; wipe with cotton away from inner aspect

D. instill medication in middle eye, have client blink for better absorption

31. Carbonic anhydrase inhibitors are sometimes used in the treatment of glaucoma
because they:

A. depress secretion of a aqueous humor

B. dilate the pupil

C. paralyze the power of accommodation

D. increase the power of accommodation

32. Teaching a client with glaucoma will not include which of the following?

A. vision can be restored only if the client remains under a physician’s care

B. avoid stimulant (eg., caffeine)

C. take all medications conscientiously

D. prevent constipation and avid heavy lifting and emotional excitement

33. Glaucoma is a progressive disease that can lead to blindness. It can be managed if
diagnosed early. Preventive health teaching would best include which of the points?

A. early surgical action may be necessary

B. all clients over 40 years of age should have an annual tonometry exam

C. the use of contract lances in older clients is not advisable

D. clients should seek early treatment for eye infections

34. A client with progressive glaucoma may be experiencing sensory deprivation. Which
of the following actions would best minimize this problem?

A. speak in a louder voice

B. ensure that a sedative is ordered

C. orient the client to time, place, and person

D. use touch frequently when providing care

Situation: 5-Gary is seen in the emergency room with the diagnosis of epitaxis.

35. It is unlikely that Gary’s history will include

A. minor trauma to the nose

B. a deviated septum

C. acute sinusitis

D. hypotension

36. Which of the following medications would be used with in order to promote
vasoconstriction and control bleeding?

A. epinephrine

B. lidocaine

C. pilovarpine

D. cylospentolate

37. Which of the following positions would be most desirable for Gary?

A. trendelenburg’s to control shock

B. a sitting position, unless he is hypotensive

C. side-lying, to prevent aspiration

D. prone, to prevent aspiration

38. The physician decides to insert nasal packing. Of the following nursing actions,
which would have the highest priority?

A. encourage Gary to breath through his mouth, because he may feel panicky after the
insertion.

B. advice Gary to expectorate the blood in the nasopharynx gently and not to swallow it

C. periodically check the position of the nasal packing, because airway obstruction
can occur if the packing accidentally slip out of place

D. take rectal temperature, because he must rely on mouth breathing and would be
unable to keep his mouth closed on the thermometer.
39. After bleeding has been controlled, Gary taken to surgery to correct a deviated nasal
septum. Which of the following is likely complication of this surgery?

A. loss of the ability to smell

B. inability to breath through the nose

C. infection

D. hemorrhage

40. Upon his discharge, the nurse instructs Gary on the use of vasoconstrictive nose drops
and cautions him to avoid too frequent, and excessive use to these drugs, which of the
following provides the best rationale for this caution

A. A rebound effect occurs in which stuffness worsens after each successive dose

B. cocaine, a frequent ingredient in nose drops, may lead to psychological addiction

C. these medications may be absorbed systematically, causing severe hypotension

D. persistent vasoconstriction of the nasal mucosa can lead to alterations in the olfactory
nerve

Situation: Brix had redial and neck surgery for cancer of the larynx.

41. Brix has tracheostomy. When suctioning and suctioning through laryngectomy
tube. When doing these two procedures at the same time, the nurse would not do which
of the ff:

A. Use sterile technique

B. turn head to right to suction left bronchus

C. suction for no longer then 10 to 15 seconds

D. observe for tachycardia

42. Brix requires both nasopharyngeal suctioning and suctioning through laryngectomy
tube. When doing these two procedures at the same time, the nurse would not do which
of the ff:

A. use a sterile suction setup

B. suction the nose first, then the laryngectomy tube

C. suction the laryngectomy tube first, then the nose

D. lubricate the catheter with saline

43. A nasogastric tube is used to provide Brix with fluids and nutrient for approximately
10 days, for which of the following reasons?

A. to prevent pain while swallowing

B. to prevent contamination of the suture line

C. to decrease need for swallowing

D. to prevent need for holding head up to ear

44. Brix’s children are concerned about their own risk of developing cancer. All but one
of the following are facts that describe malignant neoplasia and must be considered by
the nurse in her responses. Which one is correct?

A. family factors may influence an individual’s susceptibility to neoplasia

B. long-term use of corticosteroids enhances the body’s defense

C. Sexual differences influence an individuals susceptibility to specific neoplasm

D. living in industrialized areas increase an individual’s susceptibility to a malignant

neoplasm

45. When would Brix best begin speech rehabilitation?

A. when he leaves the hospital

B. when the esophageal suture line is healed

C. three months after surgery

D. when he regains all his strength

46. The nurse is complaining the initial morning assessment on the client. Which physical
examination technique would be used first when assessing the abdomen?

A. inspection

B. light palpation

C. auscultation
D. percussion

47. The client has orders for a nasogastric (NG) tube insertion. During the procedure,
instruction that will assist in insertion would be:

A. instruct the client to tilt his head back for insertion into the nostril, then flex his
neck for final insertion

B. after insertion into the nostril, instruct the client to extend his neck

C. introduce the tube with the client’s head tilted back, then instruct him to keep his head
upright for final insertion

D. instruct the client to hold his chin down, then back for insertion of the tube

48. The most important pathophysiologic factor contributing to the formation of

esophageal varices is:

A. decreased prothrombin formation

B. decreased albumin formation by the liver

C. portal hypertension

D. increased central venous pressure

49. The nurse analyzes the results of the blood chemistry tests done on a client with acute
pancreatitis. Which of the following results would the nurse expect to find?

A. low glucose

B. low alkaline phosphatase

C. elevated amylase

D. elevated creatinine

50. A client being treated for esophageal varices has a Sengstaken-Blakemore tube
inserted to control the bleeding. The most important assessment is for the nurse to:

A. check that a hemostat is at the bedside

B. monitor IV fluids for the shift

C. regularly assess respiratory status

D. check that the balloon is deflated on a regular basis

51. A female client complains of gnawing midepigastric pain for a few hours after
meals. At times, when the pain is severe, vomiting occurs. Specific tests are indicated to
rule out:

A. cancer of the stomach

B. peptic ulcer disease

C. chronic gastritis

D. pylorospasm

52. When a client has peptic ulcer disease, the nurse would expect a priority intervention
to be:

A. assisting in inserting a Miller-Abbott tube

B. assisting in inserting an atrial pressure line

C. inserting a nasogastric tube

D. inserting an IV

53. A 40-year-old male client has been hospitalized with peptic ulcer disease. He is being
treated with a histamine receptor antagonists (cimetidine), antacids, and diet. The nurse
doing discharge planning will teach him that the action of cimetidine is to:

A. reduce gastric acid output

B. protect the ulcer surface

C. inhibit the production of hydrochloric acid (HCl)

D. inhibit vagal nerve stimulation

54. The nurse is admitting a client with Crohn’s disease who is scheduled for intestinal
surgery. Which surgical procedure would the nurse anticipate for the treatment of this
condition:

A. ileostomy with total colectomy

B. sigmoid colostomy with mucous fistula

C. intestinal resection with end-to-end anastomosis

D. colonoscopy with biopsy and polypectomy

55. A client who has just returned home following ileostomy surgery will need a diet that
is supplemented:

A. potassium

B. vitamin B12

C. sodium

D. fiber

56. A client scheduled for colostomy surgery. An appropriate preoperative diet will
include:

preoperative diet will include:

A. broiled chicken, baked potato, and wheat bread

B. ground hamburger, rice, and salad

C. broiled fish, rice, squash, and tea

D. steak, mashed potatoes, raw carrots, and celery

57. As the nurse is completing evening care for a client, he observes that the client is
upset, quiet, and withdrawn. The nurse knows that the client is scheduled for diagnostic
tests the following day. An important assessment question to ask the client is:

A. “would you like to go to the dayroom to watch TV?”

B. “are you prepared for the test tomorrow?”

C. “have you talked with anyone about the test tomorrow?”

D. “have you asked your physician to give you a sleeping pill tonight?”

58. Following abdominal surgery, a client complaining of “gas pains” will have a rectal
tube inserted. The client should be positioned on his:

A. left side, recumbent

B. left side, sims

C. right side, semi-fowler’s

D. left side, semi-Fowler’s

59. Which of the following statements is most correct regarding colostomy irrigations?

A. the solution temperature should be 100 deg. F

B. 1000 ml is the usual amount of solution for the irrigation

C. the solution container should be placed 10 inches above the stoma

D. the irrigation cone is inserted in an upward direction in relation to the stoma

60. The nurse is teaching a client with a new colostomy how to apply an appliance to a
colostomy. How much skin should remain exposed between the stoma and the ring of the
appliance?

A. 1/8 inch

B. ½ inch

C. ¾ inch

D. 1 inch

61. Following a liver biopsy, the highest priority assessment of the client’s condition is to
check for:

A. pulmonary edema

B. uneven respiratory pattern

C. hemorrhage

D. pain

62. A client has a bile duct obstruction and is jaundiced. Which intervention will be most
effective in controlling the itching associated with his jaundice?

A. keep the client’s nails clean and short

B. maintain the client’s room temperature at 72 to 75 deg. F

C. provide tepid water for bathing

D. use alcohol for back rubs

63. When a client is in liver failure, which of the following behavioral changes is the
most important assessment to report?

A. shortness of breath

B. lethargy

C. fatigue

D. nausea

64. A client with a history of cholecystitis is now being admitted to the hospital for
possible surgical intervention. The orders include NPO, IV therapy, and bed rest. In
addition to assessing for nausea, vomiting and anorexia, the nurse should observe for
pain:

A. in the right lower quadrant

B. after ingesting food

C. radiating to the left shoulder

D. in the upper quadrant

65. The nurse taking a nursing history from a newly admitted client learns that he has a
Denver shunt. This suggest that he has a history of:

A. hydrocephalus

B. renal failure

C. peripheral occlusive disease

D. cirrhosis

66. A female client had a laparoscopic cholecystectomy this morning. She is now
complaining of right shoulder pain. The nurse would explain to the client this symptom
is:

A. common following this operation

B. expected after general anesthesia

C. unusual and will be reported to the surgeon

D. indicative of a need to use the incentive spirometer

67. For a client with the diagnosis of acute pancreatitis, the nurse would plan for which
critical component of his care?

A. testing for Homan’s sign

B. measuring the abdominal girth

C. performing a glucometer test

D. straining the urine

68. After removing a fecal impaction, the client complains of feeling lightheaded and the
pulse rate is 44. The priority intervention is:

A. monitoring vital signs

B. place in shock position

C. call the physician

D. begin CPR

69. Peritoneal reaction to acute pancreatitis results in a shift of fluid from the vascular
space into the peritoneal cavity. If this occurs, the nurse would evaluate for:

A. decreased serum albumin

B. abdominal pain

C. oliguria

D. peritonitis

70. The assessment finding should be reported immediately should it develop in the client
with acute pancreatitis is:

A. nausea and vomiting

B. abdominal pain

C. decreased bowel sounds

D. shortness of breath
71. Following brain surgery, the client suddenly exhibits polyuria and begins voiding 15
to 20 L/day. Specific gravity of the urine is 1.006. The nurse will recognize these
symptoms as the possible development of:

A. diabetes insipidus

B. diabetes, type 1

C. diabetes, type 2

D. Addison’s disease

72. A person with a diagnosis of adult Diabetes, type 2, should understand the symptoms
of a hyperglycemic reaction. The nurse will know this client understands if she says these
symptoms are:

A. thirst, polyuria and decreased appetite

B. flushed cheeks, acetone breath, and increased thirst

C. nausea, vomiting and diarrhea

D. weight gain, normal breath and thirst

73. The non-insulin dependent diabetic who is obese is best controlled by weight loss
because obesity:

A. reduces the number of insulin receptors

B. causes pancreatic islet cell exhaustion

C. reduces insulin binding t receptor sites

D. reduces pancreatic insulin production

74. A nursing assessment for initial signs of hypoglycemia will include:

A. Pallor, blurred vision, weakness, behavioral changes

B. frequent urination, flushed face, pleural friction rub

C. abdominal pain, diminished deep tendon reflexes, double vision

D. weakness, lassitude, irregular pulse, dilated pupils

75. Which of the following nursing diagnosis would be most appropriate for the client
with decreased thyroid function:

A. alteration in growth and development related to increased growth hormone production

B. alteration in thought processes related to decreased neurologic function

C. fluid volume deficit related to polyuria

D. hypothermia related to decreased metabolic rate

76. The RN should assess for which of the following clinical manifestations in the client
with Cushing’s syndrome?

A. hypertension, diaphoresis, nausea and vomiting

B. tetany, irritability, dry skin and seizures

C. unexplained weight gain, energy loss, and cold intolerance

D. water retention, moon face, hirsutism and purple striae

77. The client hyperparathyroidism should have extremities handled gently because:

A. decreased calcium bone deposits can lead to pathologic fractures

B. edema causes stretched tissue to tear easily

C. hypertension can lead to stroke with residual paralysis

D. polyuria leads to dry skin and mucous membrane that can breakdown

78. Which of the following priority nursing implementation for a client with a tumor of
the posterior lobe of the pituitary gland who has had a urine output of 3 L in the last hour
with a specific gravity of 1.002?

A. measure and record vital signs each shift

B. turn client every 2 hours to prevent skin breakdown

C. administer Pitressin Tannate as ordered

D. maintain a dark and quiet room

79. A client has a diagnosis of diabetes. His physician has ordered short and long acting
insulin. When administering two type of insulin, the nurse would:
A. withdraw the long acting insulin into the syringe before the short acting insulin

B. withdraw the short acting insulin into the syringe before the long acting insulin

C. draw up in two separate syringes, then combine in one syringe

D. withdraw long acting insulin, inject air into regular insulin, and withdraw insulin

80. Certain physiological changes will result from the treatment for myxedem. The
symptoms that may indicate adverse changes in the body that the nurse should observe
for are:

A. increased respiratory excursion

B. increased the frequency of rest periods

C. initiate postural drainage

D. continue with routine nursing care

81. A client with myxedema has been in the hospital for 3 days. The nursing assessment
reveals the following clinical manifestations: respiratory rate 8/min, diminished breath
sounds in the right lower lobe, crackles in the left lower lobe. The most appropriate
nursing intervention is to:

A. increased the use of ROM, turning, deep breathing exercises

B. increased the frequency of rest periods

C. initiate postural drainage

D. continue with routine nursing care

82. In an individual with the diagnosis of hyperparathyroidism, the nurse will assess for
which primary symptom:

A. fatigue, muscular weakness

B. cardiac arrhytmias

C. tetany

D. constipation
83. The nurse explains to a client who has just received the diagnosis of type 2 non-
insulin dependent diabetes mellitus (NIDDM) that sulfonylureas, one group of oral
hypoglycemic agents, as act by:

A. stimulating the pancreas to produce or release insulin

B. making the insulin that is produce more available for use

C. lowering the blood sugar by facilitating the uptake and utilization of glucose

D. altering both fat and protein metabolism

84. A client has been admitted to the hospital with a tentative diagnosis of adrenocortical
hyperfucntion. In assessing the client, an observable sign the nurse would chart is:

A. butterfly rash on the face

B. moon face

C. positive Chvostek’s sign

D. bloated extremities

85. The nurse is teaching a diabetic client to monitor glucose using a glucometer. The
nurse will know the client is competent in performing her finger-stick to obtain blood
when she:

A. uses a ball of a finger as the puncture site

B. uses the side of fingertip as the puncture site

C. avoid using the fingers of her dominant hand as puncture sites

D. avoid using the thumbs as puncture sites

86. A client is scheduled for a voiding cystogram. Which nursing intervention would be
essential to carry put several hours before the test?

A. maintain NPO status

B. medicating with urinary antiseptics

C. administering bowel preparations

D. forcing fluids
87. A retention catheter for a male client is correctly taped if it is:

A. on the lower abdomen

B. on the umbilicus

C. under the thigh

D. on the inner thigh

88. A client with a diagnosis of gout will betaking colchicines and allopurinol BID to
prevent recurrence. The most common early sign of colchicines toxicity that the nurse
assess for is:

A. blurred vision

B. anorexia

C. diarrhea

D. fever

89. A client’s laboratory results have been returned and the creatinine level is 7
mg/dl. This finding would lead the nurse to place the highest priority on assessing:

A. temperature

B. intake andoutput

C. capillary refill

D. pupillary reflex

90. After the lungs, the kidneys work to maintain body pH. The best explanation of how
the kidneys accomplish regulation of pH is that they:

A. secrete hydrogen ions and sodium

B. secrete ammonia

C. exchange hydrogen and sodium in the kidney tubules

D. decrease sodium ions, hold on to the hydrogen ions, and then secrete sodium
bicarbonate

91. Conditions known to predispose to renal calculi formation include:

A. Polyuria

B. dehydration, immobility

C. glycosuria

D. presence of an indwelling Foley catheter

92. the most appropriate nursing intervention, based on physician’s orders, for treating
metabolic acidosis is to:

A. replace potassium ions immediately to prevent hypokalemia

B. administer oral sodium bicarbonate to act as a buffer

C. administer IV cathecholamines (Levophed) to prevent hypertension

D. administer fluids to prevent dehydration

93. IV is attached to a controller to maintain the flow rate. If the alarm sounds on the
controller:

A. ensure that drip chamber is full

B. assess that height of IV container is at least 30 inches above venipuncture site

C. ensure that the drop sensor is properly placed on the drip chamber

D. evaluate the needle and IV tubing to determine if they are patent and positioned
appropriately

94. A 76-year-old woman who has been in good health develops urinary incontinence
over a period of several days and is admitted to the hospital for a diagnostic workup. The
nurse would assess the client for other indicators of:

A. renal failure

B. urinary tract infection

C. fluid volume excess

D. dementia

95. A 60-year-old male client’s physician schedules a prostatectomy and orders a straight
urinary drainage system to be inserted preoperatively. For the system to be effective, the
nurse would:
A. coil the tubing above the level of the bladder

B. position the collection bag above the level of the bladder

C. check that the collection bag is vented and distensible

D. determine that the tubing is less that 3 feet in length

96. During a retention catheter insertion or bladder irrigation, the nurse must use:

A. sterile equipment and wear sterile gloves

B. clean equipment and maintain surgical asepsis

C. sterile equipment and maintain medical asepsis

D. clean equipment and technique

97. The physician has ordered a 24 hours urine specimen. After explaining the procedure
to the client, the nurse collects the first specimen. This specimen. This specimen is the:

A. discarded, then collection begins

B. saved as part of the 24 hours collection

C. tested, then discarded

D. placed in a separate container and later added to collection

98. The most common cause of bladder infection in the client with a retention catheter is
contamination:

A. due to insertion technique

B. at the time of the catheter removal

C. of the urethral/ catheter interface

D. of the internal lumen of the catheter

99. A client in acute renal failure receive an IV infusion of 10 percent dextrose in water
with 20 units of regular insulin. The nurse understands that the rational for this therapy is
to:

A. correct the hyperglycemia that occurs with acute renal failure

B. facilitate the intracellular movement of potassium

C. provide calories to prevent tissue catabolism and azotemia

D. force potassium into cells to prevent arrhythmias

100. A client with chronic renal failure is on continuous ambulatory peritoneal dialysis
(CAPD). Which nursing diagnosis should have the highest priority?

A. powerlessness

B. high risk for infection

C. altered nutrition: less than body requirements

D. high risk for fluid volume deficit

AM-CARE Review Academy for Nurses

Room 301 3rd Floor P & J Lim Bldg.

Tiano Brothers Kalambaguhan Sts., Cagayan de Oro City

Tel. No. (08822) 721-805

NLE DECEMBER 2005

MEDICAL SURGICAL NURSING IV

Situation: John Lee is an 18-year old high school student who suffered an injury to his
cervical spine in a football game.

1. In directing emergency care until the ambulance arrives, it is most important that the
school nurse

A. place a small makeshift pillow under his head

B. check to see if he can move all of his extremities

C. keep him flat and immobilized in a natural position

D. cover him with a blanket

2. A primary goal of nursing care when John is brought into the emergency room will be

A. prevention of spinal shock

 B. maintenance of respiration

C. maintenance of orientation

D provision for pain relief

Situation: Crutchfield tongs are used to apply traction to realign the spinal cord.

3. A nursing measure for john while he is in cervical traction should be to

A. massage the back of his head

B. position him from side to side

C. remove the weights at least once a shift

D. encourage involvement in his own care

Situation: John is found to have a temperature of 36ºC (96.8ºF).

4. The most appropriate initial nursing measure for John in response to his hypothermia
would be to

A. cover him with additional blankets

B. place a hot-water bottle at his feet

C. check for signs of shock

D. notify his physician

Situation: John has a tracheostomy performed and is on assisted ventilation.

5. The alarm on the ventilator sounds. The initial response by the nurse should be to
quickly

A. notify the respiratory therapist

B. check all connections from the respirator

C. notify the respiratory therapist to come immediately

D. use a self-inflating bag to ventilate John

6. When suctioning John, the nurse should

 A. ensure that he is able to take a breath between insertions of the catheter

B. suction him for at least 30 seconds with each catheter insertion

C. apply suction and gently rotate the catheter while inserting it into the bronchial
bifurcation

D. use clean technique during the suction procedure

7. John suddenly becomes diaphoretic, his blood pressure rises to 190/110, and he
complains of a headache. The nurse should assess the patient for signs of

A. increased intracranial pressure

B. spinal meningitis

C. pulmonary congestion

D. fecal impaction

8. Upon admission John had a complete loss of motor ability. Within 48 hours he is noted
to be having muscle spasms. His family becomes very excited when they notice these
movements. Which of the following choices would be the most appropriate response by
the nurse?

A. at this stage, muscle spasms are expected, but it is too soon to evaluate the extent
of the injury or its permanent effects

B. I can understand your excitement. These movements are a good sign that he is
making progress

C. these movements are an indication that he is trying to move and that his will is
very strong

D. these movements are reflex activities that indicate that his spinal cord is intact

Situation: Mark Richards has a compound fracture of the temporal bone.

9. The nurse notices bleeding from the orifice of the ear. Which of the following actions
by the nurse can be safely used to determine if the drainage contains cerebrospinal fluid
(CSF)? The nurse should

A. swab the orifice of the ear with sterile applicator and send the specimen to the
laboratory
 B. blot the drainage with a sterile gauze pad and look for a clear halo or ring
around the spot of blood

C. gently suction the ear an send the specimen to the laboratory

D. test the CSF with a Tes-Tape and get a negative reading for sugar

10. The nursing care plans states “Observe for early signs of increased intracranial
pressure (IIP).” Early symptoms of IIP include

A. widening pulse pressure and dilated pupils

B. rising blood pressure and bradycardia

C. elevated temperature and decerebrate posturing

D. nausea, vomiting, and restlessness

11. During the initial period after a head injury, nursing intervention for Mr. Richards
should include

A. packing the ear with cotton balls to stop bleeding

B. awakening the patient every 2 hours to determine his level of consciousness

C. placing the patient in Trendelenburg’s position

D. forcing fluids to restore hydration

12. Before discharge, a computerized axial tomogram will be performed to rule out any
intracranial or extracranial bleeding. Mr. Richards should be told that

A. the procedure is noninvasive and he will not feel any pain

B. he will experience a burning sensation as the dye is being injected

C. the procedure is done in the operating room under anesthesia

D. local anesthetic is used before injecting air into the ventricles of the brain via the
spinal canal

Situation: Tonnie Miccio is a 43-year old divorced man who has been rushed to the
emergency room with an acute gouty arthritis.

13. While admitting Mr. Miccio to the hospital, the nurse should recognize those factors
that can precipitate an acute attack. They include
A. excessive smoking

B. large alcohol intake

C. emotional stress

D. improper rest

14. A serum uric acid level is performed by the hospital laboratory. In acute gout, the uric
acid level is approximately

A. 1.0 mg/100 ml

B. 2.1 mg/100 ml

C. 6.5 mg/100 ml

D. 10 mg/100 ml

15. Colchicine is the standard drug used to treat acute gout: The physician orders
colchicines, 1.0 mg every 2 hours. After receiving the third dose, the patient complains
of nausea, vomiting, and diarrhea. The nurse should recognize that this is

A. a transient side effect and give the next dose

B. a sign of toxicity and withhold the medication

C. an allergic response to the drug and notify the physician

D. a psychogenic response to the severe pain

16. The expected outcome for colchicine is to

A. reduce uric acid levels

B. relieve joint pain and inflammation

C. increase blood flow to the kidney

D. detoxify purines in the liver

17. During the night, Mr. Miccio complains of severe pain in his toe and asks the nurse
for 2 aspirin tablets. The nurse should

A. give the patient the 2 aspirin tablets

 B. elevate the foot on a pillow

C. notify the physician

D. offer the patient a cup of tea

18. Some physicians prescribe an alkali-ash diet to enhance the effect of the
medications. Which of the following foods are allowed?

A. liver, shellfish, and fats

B. cranberries, cheese, and whole grain cereals

C. milk, vegetables, and most fruits

D. eggs, milk, prunes, and plums

19. After the acute attack subsides, the physician orders allopurinol (Zyloprim), 300
mg/day. The expected outcome for this drug is to

A. lower the plasma and urinary uric acid level

B. reduce inflammation of the affected joints

C. produce diuresis

D. relieve pain

20. A teaching program for Mr. Miccio should include

A. emphasizing that aspirin is contraindicated in patient’s taking allopurinol

B. restricting fluid intake to 1,000 ml/day

C. explaining that acute gouty attacks often occur during initiation of allopurinol
therapy

D. stating that a low-purine diet should be followed while taking allopurinol

21. About 2 months after taking the allopurinol, Mr. Miccio develops a skin rash. The
nurse should

A. recognize this as a minor side effect that will subside

B. ask the patient if he has been taking any aspirin while taking the allopurinol
 C. recognize this is an indication to discontinue the drug

D. be aware that concomitant use of colchicines with allopurinol causes this reaction

22. One day, Jennifer asks her roommate, Erin, how her scoliosis was first
recognized. Erin replies, “The school health nurse told me that there may be a problem
after all the girls in my class were asked to stand erect while she examined our backs.”
The nurse suspected scoliosis when she observed that Erin’s shoulder on one side was
elevated and her

A. head appeared aligned to the opposite side

B. leg on the same side appeared shorter

C. hip on the opposite side appeared prominent

D. arm on the same side appeared longer

23. When Erin’s scoliosis was diagnosed after x-ray examination of her spine, she was
fitted with a Milwaukee brace. Erin asks the nurse when it could be removed each
day. Which of the following would be the best response?

A. only when you are lying flat, either resting or sleeping

B. for 1 hour a day when you bathe, shower, or go swimming

C. only for special occasions, such as a party

D. for 3 hours a day: one in the morning, one in the afternoon, and one in the evening

Situation: Erin’s admission to the hospital for spinal fusion was necessary because hr
scoliosis did not respond to the Milwaukee brace.

24. Preoperative preparation for Erin includes explaining that for 2 weeks after surgery
she will be positioned

A. on either side or prone

B. sitting upright

C. flat and will be logrolled

D. on her back
25. When Erin is told that after surgery she will wear a body cast for about 1 year, she
begins to sob. She tells the nurse she will look like a football player, not a girl. Which of
the following is the best response the nurse can make?

A. the people who really care about you won’t even notice your cast

B. it only will be for a year. You’re mature enough to wait

C. just ignore any comments that people make

D. a pretty hairstyle and some loose peasant blouses will keep you looking
feminine

26. After surgery, the nurse applies slight pressure to Erin’s toes and asks Erin is he can
feel her foot being touched. Erin replies, “No, I don’t feel anything.” The nurse should
then

A. wait 1 hour and supply pressure again

B. record Erin’s expected response

C. ask Erin if her toes feel cold

D. report Erin’s response to the surgeon

Situation: Virginia K is a 25- year old woman who works as a lifeguard at the local
beach. On her way to work she is in an automobile accident and is rushed to the hospital
by ambulance. A diagnosis of complete transaction of the spinal cord at the third lumbar
(L3) level is made.

27. While assess Ms. K for neurologic function, the nurse can expect she will be unable
to

A. shrug her shoulders

B. tighten her abdominal muscles

C. bend her elbow

D. straighten her legs

28. Long-term goals for Ms. K include developing skills in

A. performing wheelchair ambulation

B. activating an electric wheelchair

 C. walking with leg braces and crutches

D. walking without aids

29. observing for symptoms of which of the following is the priority of care for Ms. K in
the acute stages of complete transaction of the lumbar cord?

A. spinal shock

B. respiratory insufficiency

C. autonomic hyperreflexia

D. hypertensive crisis

30. To prevent the complication of urinary tract infections, which of the following
measures should be included in the nursing care plan?

A. encouraging extra fluid intake

B. offering at least two servings of citrus fruit juice per day

C. telling the patient to avoid fruit juices such as plum, prune, and cranberry

D. notifying the dietician to include a container of milk at all meals

Situation: Jim, a 17-year old senior in high school, has sustained a simple fracture of the
mandible after falling from his motorbike.

31. Upon admission to the emergency room, which of the following choices should the
nurse expect to observe?

A. bleeding in the external auditory canal

B. dropped prominence of the cheek on the affected side

C. edema of the eyes and cheeks

D. teeth unevenly lined up

Situation: An open reduction with wiring of the lower jaw to the upper jaw has been done
by the surgeon.

32. In anticipating the postoperative needs o the patient, which of the following actions
has the priority for Jim?
A. placing paper and pencil at the bedside

B. providing a tracheostomy set for tracheostomy care

C. taping a wire cutter to the head of the bed

D. inserting a gauze wick in the inside of the cheek

33. While teaching Jim mouth care the nurse should

A. show him how to use moistened gauze sponges to clean his mouth and tongue

B. demonstrate how an oral irrigation can be performed by inserting the

catheter along the inside of the mouth between the teeth and the cheek

C. explain to him that mouth care should not be done until the wires are removed

D. tell him to use an astringent mouthwash to remove all the debris

Mrs. Marian H is a 50-year old woman who has a spinal cord lesion at the fourth thoracic
(T4) vertebra.

34. When there are lesions above T4 and T6, the patient may experience autonomic
hyperreflexia. This condition can be prevented by

A. avoiding bladder distention

B. changing the patient’s position hourly

C. wearing supportive elastic hose

D. doing a neurologic check

35. Mrs. H complains of severe headache and is extremely anxious. The nurse checks her
blood pressure and finds it is 210/110. The nurse should then

A. check the patency of the urinary catheter

B. apply ice packs to her head

C. place the patient in a flat position

D. sit with the patient until the symptoms subside

Situation: Dorothy C, RN, age 35, is at work. After moving a particularly heavy patient,
she suddenly develops severe pain in the lumbosacral area that radiates down her right
leg. The preliminary diagnosis is rupture of an intervertebral disk.

36. Proper body mechanics may have prevented this injury to Ms. C. If she had adhered
to the correct method of turning a patient from the supine position to the left side, she
would have crossed the patient’s right arm over chest, and crossed the right leg over the
left leg. Then, while standing with her feet

A. together at the patient’s right side, she would gently turn the patient by pushing at the
shoulder and sacral areas

B. apart at the right side of the bed, she would turn the patient by gently pushing at
the shoulder and center of the back

C. apart at the left side of the bed, she would gently roll the patient toward her while
keeping her legs straight

D. apart at the left side of the bed, she would gently roll the patient toward her
while flexing her knees

37. Instructions for Ms. C’s recuperation at home should include the use of a bed board,
firm mattress, and rest in which of the following positions?

A. completely flat in bed

B. head elevated on a pillow, and knees and feet elevated with pillows

C. head elevated with several pillows, and her legs flat

D. Head elevated with several pillows, and several pillows under her knees

38. Ms. C should be reminded that if she is turning on her side, it is best if she

A. grasps a chair leg by the side of the bed, and slowly pulls herself over, flexing the
uppermost knee

B. keeps her legs extended while crossing them to the side to which she is turning,
and then uses her

arms to help turn the upper portion of her body

C. crosses her arms, flexes the uppermost knee toward the side to which she is
turning, and then rolls over
 D. crosses her arms, crosses her legs while they are extended to the side toward which
she is turning,

and then rolls over

39. The physician gives Ms. C a prescription for methocarbamol (Robaxin). Because of
her nursing background, Ms. C will know that the mediation is having the desired effects
if which of the following occurs?

A. She feels drowsy, and is sleeping more

B. she has a feeling of euphoria

C. there is a decrease in muscle spasms

D. there is an increase in the knee-jerk reflex

Situation: After a week of bed rest at home, Ms. C’s condition remains about the
same. She is admitted to the hospital for further treatment and diagnostic tests.

40. Phenylbutazone (Butazolidin) is ordered for Ms. C. Planning for the administration of
this medication should include directions to

A. administer it immediately before or after eating

B. avoid administering it with dairy products

C. administer it at least 2 hours after eating

D. administer it at specific time intervals, without regard to meals

41. In addition to the order for phenylbutazone, Ms. C is placed on bed rest and in pelvic
traction. To diminish adverse responses to this treatment, the nurse should request an
order for

A. acetylsalicylic acid (aspirin)

B. diphenoxylate hydrochloride (Lomotil)

C. prochlorpeazine (Compazine)

D. dioctyl sodium sulosuccinate (Colace)

42. A myelogram is performed on Mrs. C with a water-soluble contrast medium. Care

after this procedure should include
 A. limiting fluid intake and elevating the head of the bed to 15 to 30 degrees

B. not allowing anything by mouth and keeping the bed flat

C. encouraging fluid intake and keeping the bed flat

D. encouraging fluid intake and raising the head of the bed to 15 to 30 degrees

43. Ms. C has a laminectomy. Postoperatively, she complains that the pain is no different
now than it was before surgery. The nurse should

A. administer analgesics as ordered, and explain that the pain is to be expected

because of the edema that results from the surgery

B. administer the analgesics as ordered, but request that the physician check the
patient immediately

C. withhold the analgesic and notify the physician

D. administer the analgesics as ordered, and tell Ms. C it will give her relief shortly

44. Rehabilitation will be facilitated if Ms. C is encouraged to do which of the following?

A. sleep in prone position

B. sit up for at least part of he day

C. perform abdominal-strengthening exercise

D. perform full trunk range-of-motion exercises

Situation: Martha S is a 27-year old patient who has experienced increasing generalized
stiffness, especially in the morning, fatigue, general malaise, and swelling and pain in the
finger joints. She has a tentative diagnosis of rheumatoid arthritis.

45. Upon admission, Mrs. S is noted to have a rectal temperature of 37.7ºC (100ºF). A
white blood count is ordered, and the report comes back at 8,500/mm³. The nurse should
recognize this as being consistent with rheumatoid arthritis because it is

A. within normal limits

B. evidence of leukopenia

C. only slightly elevated

D. indicative of a generalized infectious process

46. Which of the following blood-analysis tests would be consistent with diagnosis of
rheumatoid arthritis?

A. an elevated erythrocyte sedimentation rate and negative C-reactive protein

B. an elevated erythrocyte sedimentation rate and positive C-reactive protein

C. a low erythrocyte sedimentation rate and negative C-reactive protein

D. a low erythrocyte sedimentation rate and positive C-reactive protein

47. The primary goal of nursing care for Mrs. S during this initial acute phase of
rheumatoid arthritis should be to

A. prevent deformity and reduce inflammation

B. prevent the spread of the inflammation to other joints

C. provide for comfort and relief of pain

D. assist her to accept the fact that rheumatoid arthritis is a log-term illness

48. During hospitalization, the nurse should explain to Mrs. Samuel that analgesics of
choice would be

A. codeine

B. acetylsalicylic acid (aspirin)

C. acetaminophen (Tylenol)

D. proppoxyphene hydrochloride (Darvon)

49. During the acute phase of Mrs. S’s illness, which of the following measures would be
the most appropriate?

A. frequent periods of active exercises

B. frequent periods of bed rest

C. rest for he affected joints only

D. encouragement to perform activities of daily living independently

50. The nurse understands that the main nursing goal in helping Mrs. S adapt to her
chronic illness and plan is to
 A. provide the care she is unable to give herself

B. provide guidance so that she will not repress her illness

C. plan for social contacts so that she will not feel alone

D. arrange for her after-care with the home health aide

51. Mrs. S is given instructions for using paraffin for her hands. The nurse should include
the fact that the dips will be most effective if they are performed

A. before exercising her hands

B. after exercising her hands

C. instead of exercising her fingers

D. while exercising her fingers

52. Whenever Mrs. S feels pain from her arthritis, she tells the nurse she feels not
only the pain but that her “whole body feels threatened.” Which response by the nurse is
the most therapeutic?

A. I will have someone stay with you so you won’t harm yourself

B. I will teach you some relaxing exercises so you won’t be so tense

C. you must have some medication to help you gain control

D. arthritic pain will lessen if you try to grin and bear it

53. When Mrs. S is discharged, she is instructed to take aspirin at home. It is important
that she be told to take the drug

A. on a regular basis throughout the day

B. only when other measures are not effective

C. upon arising and again at bedtime

D. between meals to promote its absorption

54. When Mrs. S is discharged, the nursing staff refers her to a nurse therapist who will
assist her in dealing with the anxiety over her arthritis and the changes it has made in her
life. The nursing team recognizes that the role of the nurse therapist is to
 A. work in conjunction with a psychiatrist

B. provide individual nursing psychotherapy

C. lead groups in therapy for those with similar problems

D. give family nursing psychotherapy

Situation: Twenty years after Mrs. S was first diagnosed with rheumatoid arthritis, she is
admitted for a right total hip replacement. She has experienced severe right hip pain that
has not responded to treatment for several years, and has had increasing difficulty moving
about because of damage to the right hip joint.

55. Preoperative teaching for Mrs. S should include

A. isometric exercises of the quadriceps and gluteal muscles

B. instructions on the necessity for keeping the right leg perfectly straight after
surgery

C. the need to flex the involved hip postoperatively to maintain mobility

D. the avoidance of aspirin for 4 days prior to surgery

56. Which of the following should the nurse consider to be most significant if noted when
checking Mrs. S 3 days postoperatively?

A. pain in the operative site

B. swelling of the operative sites

C. pain and tenderness in the calf

D. orthostatic hypotension

57. The physical therapist orders exercises of Mrs. S’s right hip, knee, and foot to
gradually increase range of motion to the right hip. The nurse can best assist Mrs. S by

A. administering an analgesic before the exercises

B. stopping the exercises if Mrs. S experiences pain

C. performing the exercises for Mrs. S

D. observing Mrs. S’s ability to perform the exercises

58. Mrs. S should be instructed to avoid

A. adduction of her right leg

B. abduction of hr right leg

C. bearing any weight on her right leg

D. the prone position in bed

59. The nurse and Mrs. S plan for her rehabilitation. Mrs. S asks the nurse, “What do I
have to do in therapy?” Which reply by the nurse most accurately describes the task of
the patient in rehabilitation? To

A. follow the instructions of the rehabilitation team

B. regain some function that was lost

C. prevent further loss of your ability to function

D. learn to deal realistically with your disability

60. When the rehabilitation therapist tells Mrs. S that the outcome of her therapy depends
on “the ability of the nursing staff” as well as on her motivation, Mrs. S questions the
nurse on the meaning of this phrase. The nurse should reply that “the nurse’s role in
rehabilitation is to

A. make the patient as comfortable as possible

B. follow the directions of the rehabilitation therapist

C. supervise the patient’s therapy appointments and exercise program

D. assist the patient in establishing therapy priorities and goals

61. Mrs. S asks the nurse if her new joint will function normally. The nurse can best
answer this by saying that

A. the new joint will be stronger than the old one

B. the new joint won’t function as well as a normal joint, but it will be better than the
arthritic joint

C. the new joint will function almost as well as a normal joint, particularly if you
perform your exercise faithfully
 D. the doctor will be able to assess your limitations in 6 weeks and then explain them to
you

Situation: Mr. Lee is a 20-year-old patient who sustains a compound fracture of the right
shaft of the femur and a simple fracture of the ulna in a motorcycle accident.

62. While serving as a member of a first aid squad, Mary V, RN, reaches the scene of the
motorcycle accident and administers emergency treatment, which includes the
application of a splint. It is important that the splint

A. be applied while the limb is in good alignment

B. be applied to the limb in the position in which it is found

C. extend from the fracture site downward

D. extend from the fracture site upward

63. While Mr. Lee is being transported in the ambulance to the hospital, he should be
positioned with the affected limbs

A. elevated

B. in a flat position

C. lower than his heart

D. slightly abducted

64. While taking a history from the patient, the nurse determines that his last booster
injection for tetanus immunization was 5 years ago. The nurse should recognize that
this information is important because it

means that he should receive

A. a full tetanus immunization program

B. nothing, because he is sufficiently immunized against tetanus

C. an additional booster injection

D. human tetanus immune globulin

Situation: Mr. Lee is taken to the operating room and the wound caused by the fracture of
the femur is cleansed and debrided. The fracture is then reduced, and a Steinmann pin for
skeletal traction is inserted. A closed reduction of the ulna is performed, and a cast is
applied.

65. The most important nursing measure in the immediate postoperative period will be

A. encouragement of isometric exercises

B. cleansing of the area around the Steinmann pin

C. careful observation of vital signs

D. massage of pressure areas

66. After Mr. Lee returns to his room, he complains of pain in his right arm. The initial
action of the nurse should be to

A. administer analgesics as ordered

B. check his fingers

C. notify his physician immediately

D. pad the edges of the cast

67. To maintain proper alignment and immobilization of the femur, the physician has
ordered skeletal traction with a Thomas splint. While caring for Mr. Lee, the nurse
should explain to him that he

A. cannot turn or sit up

B. cannot turn but can sit up

C. can turn but cannot sit up

D. can turn and can sit up

68. In dealing with the weights that are applying the traction, the nurse should

A. allow them to hang freely in place

B. hold them up if the patient is shifting position in bed

C. remove them if the patient is being moved up in bed

D. lighten them for short periods if the patient complains of pain

69. Mr. Lee has a Thomas knee splint in place. In addition to the usual measures for a
patient in traction, it will be important that the nurse observe

A. the groin area for pressure

B. for constipation

C. his skin for sings of decubiti

D. for signs of hypostatic pneumonia

70. If Mr. Lee should show an increase in blood pressure and signs of confusion and
increased restlessness, the nurse should suspect

A. a concussion

B. impending shock

C. fat emboli

D. anxiety

71. Because of the nature of Mr. Lee’s wound and the insertion of a Steinmann pin, it is
especially important that the nurse observe for

A. a foul odor

B. foot drop

C. pulmonary congestion

D. fecal impaction

72. Mr. Lee develops an acute localized osteomyelitis. He is placed on intravenous

antibiotic therapy. The wound is incised and drained, and neomycin irrigations are
ordered four times a day. It is important that these irrigations be performed

A. with strict aseptic techniques

B. with a warm solution

C. for at least 5 minutes

D. at equal time intervals

Situation: Maria Alfredo is a 30-year old married woman who has systemic lupus
erythematosus (SLE).

73. While doing as nursing history on Mrs. Alfredo, the nurse should recognize that the
most common initial symptoms of SLE are

A. petechiae in the skin, nosebleeds, and pallor

B. hematuria, increased blood pressure, and edema

C. tachycardia, tremors, and loss of weight

D. painful muscles and joints, stiffness, and inflammation of joints

74. Mrs. Afredo is instituted on long-term prednisone therapy. Her daily maintenance
dose is 5 mg/day. In the instructions to Mrs. Alfredo, the nurse should emphasize that

A. once the symptoms of SLE subside, the medication will be discontinued gradually

B. a weight gain 2 pounds per week should be reported to the physician

C. the maintenance dose will be the lowest dose that controls symptoms

D. if adrenal atrophy occurs, adrenocorticotropic hormone (ACTH) will have to be

prescribed

75. Mrs. Alfredo questions the nurse about family planning and birth control. Which of
the following choices should the nurse include in her answer?

A. oral contraceptives can precipitate an acute exacerbation of your condition

B. Intrauterine devices are the recommended brithcontrol measures

C. there are no contraindications for pregnancy, as long as the disease is being treated

D. studies indicate that the corticosteroids produce fetal damage

76. The nursing care plan states, “Observe for signs of Raynaud’s phenomenon.” The
nurse should recognize that this phenomenon

A. occurs as a side effect of prednisone

B. is aggravated by smoking

C. is relieved by application of cold compresses to the hands

 D. is the priority care

77. Although many abnormal laboratory findings are found in SLE, there is no one
specific diagnostic test. The test that is positive in over 95 percent of all patients with
SLE is the blood test for

A. the lupus erythematosus (LE) factor

B. the rheumatoid factor

C. antinuclear antibodies (ANA)

D. C-reactive protein (CRP)

78. The teaching program for Mrs. Alfredo planned by the nurse should include emphasis
on which of the following?

A. once the symptoms are controlled, the corticosteroids will be discontinued

B. if hair loss occurs, it is irreversible

C. overexposure to the sun can produce an exacerbation of symptoms

D. a low-potassium, low-protein diet is recommended

79. Mrs. Alfredo tells the nurse that she has had black, tarry stools. The nurse should

A. reassure the patient that this is a minor side effect of prednisone

B. tell the patient that if she takes the prednisone with milk, black, tarry stools will be
avoided

C. tell the patient that she will ask the physician to prescribe aluminum hydroxide

D. notify the physician because black, tarry stools can be an indication of

bleeding peptic ulcer

80. Mrs. Alfredo calls the physician’s office and complains that she has chills, a fever,
and a cough. The nurse should

A. advise that she remain in bed, drink extra fluids, and take aspirin every 4 hours

B. recommended that she increase her dose of prednisone until her temperature is
normal

C. recommended that she come to the office to be examined by the physician

 D. tell Mrs. Alfredo to call for an appointment when she is feeling better

Situation: Irene P is being treated in the emergency room for an acute attack of Meniere’s
syndrome

81. The nurse should recognize that the triad of symptoms associated with Meniere’s
syndrome is

A. nystagmus, arthralgia, and vertigo

B. nausea, vomiting, and arthralgia

C. syncope, headache, and hearing loss

D. hearing loss, vertigo, and tinnitus

82. Patient teaching for Mrs. P includes helping her to recognize that

A. Meniere’s syndrome is psychogenic and is brought on by stress

B. most patients can be successfully treated with a low-salt diet and diuretics

C. acute infection can precipitate an attack

D. a labyrinthectomy is the preferred treatment for relieving symptoms and restoring

hearing

83. Nursing intervention during an acute attack includes

A. encouraging the patient to walk

B. placing the patient in a semi-Fowler’s position

C. Having the patient lie flat

D. placing the patient in Trendelenburg’s position

Situation: Mrs. C, 30 years old, has symptoms of diplopia, fatigue, slight vertigo, and a
lack of coordination. After a neurological work-up she is diagnosed as having multiple
sclerosis.

84. The main goal of nursing care for Mrs. C during the acute phase of the disease should
be to

A. promotes rest
 B. prevent constipation

C. maintain normal functioning

D. encourage activities of daily living

85. Mrs. C is note d to be having mood swings. In deciding what approach to use with
her, the nursing staff should recognize that this

A. is probably the result of an underlying mental disorder

B. indicates that Mrs. C is having difficulty accepting her diagnosis

C. may be a result of pathology and involvement of the limbic system in the

disease

D. indicates that Mrs. C’s intellectual capacity has been compromised

86. Mrs. C questions the nurse concerning the usual course of multiple sclerosis. Which
would be the best reply by the nurse?

A. each individual is very different; we cannot tell what will happen

B. I know you are worried, but it is too soon to predict what will happen

C. usually, acute episodes like this are followed by remissions, which may last a
long time

D. the future will take care of itself; let’s concentrate on the present

87. As Mrs. C’s condition improves, it is most important that she be given guidance in

A. developing a program of exercise

B. learning to handle stressful situations

C. seeking vocational rehabilitation

D. limiting her activities to those that are absolutely necessary

Situation: Barbara is a 23-year-old woman who lives with her mother, sister, and brother
in a private residence. She is attending the neurological out-patient clinic for the first
time. Her health history includes two grand mal seizures./ A diagnosis of idiopathic
epilepsy has been made. The physician has ordered an electroencephalogram (EEG) and
phenytoin sodium (Dilantin), 300 mg/day
88. While doing a nursing history on Barbara, the nurse should recognize that

A. persons with idiopathic epilepsy have a lower intelligence level

B. grand mal seizures do not cause mental deterioration

C. a common characteristic of idiopathic epilepsy is committing acts of violence

D. idiopathic epilepsy is a form of mental illness

89. To prepare Barbara for EEG, the nurse should explain that

A. during the test she will experience small electric shocks that feels like pin pricks

B. the test measures mental status as well as electrical brain waves

C. during the hyperventilation portion of the test, she may experience dizziness

D. she will be unconscious during the test

90. Health teaching for Barbara includes ensuring that she understands that

A. proper prophylactic medication can control the incidence of seizures

B. moderate use of alcohol is permitted

C. forcing fluids helps to reduce the incidence of seizures

D. the incidence of seizures is related to hyperglycemia

91. During a follow-up clinic visit, Barbara tells the nurse that her urine has had a
reddish-brown color. The nurse should

A. reassure Barabara that this is a harmless side effect of phenytoin sodium

(Dilantin)

B. tell Barbara that this is a sign of hepatic toxicity

C. recommend that Barbara go to the laboratory for a serum Dilantin concentration

test

D. notify the physician that Barbara has hematuria

92. A long-term goal for Barbara is to minimize the gingival hyperplasia associated with
Dilantin therapy. The nurse should recognize that
 A. another anticonvulsant will be prescribed if it occurs

B. the physician will reduce the dosage at the first sign of hyperplasia

C. a regular plan of good oral hygiene is essential

D. vitamin C should be taken daily with the Dilantin

93. Barbara’s serum concentration level Dilantin is 15 µg/ml. The nurse should recognize
this as

A. a desired therapeutic serum level

B. below the desired therapeutic level

C. above the recommended serum level

D. a toxic serum level

94. Family members should be instructed about caring Barbara during a grand mal
seizure. Immediate care during a seizure should include

A. restraining Barbara’s arms and legs

B. forcing the mouth open to insert an airway

C. giving orange juice before the clonic stage begins

D. turning Barbara’s head to the side

95. The nurse explains to Barbara that safety precautions can be taken by those who have
warning symptoms before the seizure. (These symptoms are not part of the seizure, as
the aura is.) What warning symptoms should the nurse tell Barbara to be aware of?

A. Hot and cold sensations, gastrointestinal problems, anxiety, and mood

changes

B. Muscle twitching, lapse of consciousness, anxiety, and gastrointestinal problems

C. tingling in a local region, anxiety, and lapse of consciousness

D. increased tonicity of muscles and autonomic behavior

96. The nurse should tell Barbara’s family that after a seizure she will be in a confused
state and will need some supervision. It is most important for the caring one to be calm
because the confused state of the epileptic is considered to be
 A. One mood swings and a feeling of general inadequacy and fatigue that result in a
decrease of interest

B. an adaptive period, when one slowly learns to cope with the devastating
insults to one’s psychological and physical integrity

C. a gross impairment in social and intellectual functioning with crude, tactless, and
impulsive

behavior

D. a helpless state, with intellectual deterioration, difficulty in communication, and

regression to the

infantile state

97. Barbara asks the nurse if it is true that there is an “epileptic personality.” Which of the
following choices would be the nurse’s best response/

A. the person must be aware that anxiety over anticipation of a seizure may cause
personality problems

B. No, deviation in personality is caused by restrictions imposed by society

C. Yes, one may learn to induce seizures as a way of getting attention from others

D. the person may take on a sick role if mismanaged at home or in the

community

Situation: Ms. R, a 35-year old woman, has myasthenia gravis. She has been referred to
the neurology clinic by her physician.

98. While doing a nursing history on Ms. R, the nurse should expect her to complain of
which of the following symptoms?

A. passive tremors, cogwheel rigidity, and drooling

B. spastic weakness of the limbs, intention tremors, and incontinence

C. diplopia, ptosis, and fatigue

D. nystagmus, ataxia, and tinnitus

99. In preparing a teaching plan for Ms. R, the nurse should emphasize that
 A. the anticholinesterase medications cause fewer side effects when taken on an
empty stomach

B. physical activity should be planned for the late afternoon early evening

C. a member of the family should be taught how to use suction for emergency
use

D. edrophonium chloride (Tensilon) is the drug of choice in the treatment of

myasthenia gravis

100. Respiratory distress is common in people with myasthenic crisis? Marked

improvement of respirations occurs after the administration of intravenous

A. diazepam (Valium)

B. hydrocortisone

C. atropine sulfate

D. edrophonium chloride (Tensilon)

101. The medication used to treat cholinergic crisis

A. atropine sulfate

B. neostigmine (Prostigmin)

C. aminophylline

D. hydrocortisone

102. The physician has prescribed pyridostigmine (Mestinon), 180 mg/day. Ms. R tells
the nurse that each time she takes the medication she feels nauseated. The nurse should
tell Ms. R to

A. crush the tablet before taking it

B. take the tablet with food or milk

C. take the tablet on an empty stomach

D. not to take the medication until she notifies the physician

Mr. Go, who has had Parkinsosn’s disease for 4 years, visits his wife daily during her
hospital stay. His illness is being treated with levodopa (L-dopa).
103. When Mr. Go visits his wife, he is observed to be walking rather slowly. The nurse
should recognize that Mr. Go is

A. exhibiting a long-range side effect of L-dopa

B. exhibiting a symptom that is characteristic of stage II Parkinson’s disease

C. beginning to experience atrophy of the cerebral cortex and cellular changes

D. probably doing this on purpose as a way of

104. The nurse can help him to be more comfortable by

A. discussing this problem and how he handles it, and discussing hygiene
measures with him

B. opening the windows and providing as much ventilation as possible while he is

visiting

C. suggesting that he is probably dressing too warmly for the hospital environment

D. explaining that this is a side effect of his medication, and encouraging increased
intake of fluids

Situation: Mr. go has a sudden exacerbation of symptoms. He develops tachycardia, a

respiratory rate of 40, and appears extremely anxious. He is hospitalized with a diagnosis
of parkinsonian crisis.

105. Planning for Mr. Go’s care should include measures to

A. provide a quiet, restful environment

B. maintain joint range of motion

C. decrease social isolation

D. improve his nutritional status

106. Mr. Go responds to treatment, and his condition gradually improves. However, he
complains that he feels dizzy whenever he tries to stand up from a lying position. The
nurse should

A. explain that this is just part of his illness

B. tell him that his doctor will be notified of this symptom

 C. encourage him to change his position slowly

D. discuss his feelings about his wife’s hospitalization

107. Mr. Go has problems in dressing himself as a result of tremors, but he refuses all
assistance. Which of the following is the best initial action by the nurse in response to
this complaint?

A. tell him he needs assistance, and gradually help him

B. give him more time and encouragement to dress himself

C. suggest that for the present he wear only the hospital gown

D. listen to his refusal, but give him assistance as needed

108. Mr. Go discusses his work as an accountant with the nurse. He states that he his glad
that he will be able to continue working. An appropriate initial response would be based
on the nurse’s recognition that he

A. should be encouraged to be active

B. should be cautioned against overfatigue

C. is being unrealistic about his future

D. needs to recognize that his situation is unique

109. Mr. Go tells the nurse that someone told him that people with Parkinson’s disease
develop early senility. In response, the nurse should explain that

A. Parkinson’s disease progresses very slowly over a period of years, and it is

only in the late stages that any mental changes might take place

B. his information is false, because Parkinson’s disease does not cause any changes in
the individual’s

intellectual capacities

C. he does not have to worry about senility because he is responding so well to

treatment

D. although Parkinson’s disease does cause mental confusion, this condition is

clinically different from senility