Professional Documents
Culture Documents
1.. . Gregorio, a 54 year old client diagnosed with benign prostatic hyperplasia is
being scheduled for TURP at 7am the following day.
The circulating nurse anticipates that in order to perform TURP Gregorio must be
placed in what position?
/· . DorsaI Recumbent
· · . Lithotomy
/· :. Jack knife
/ [. Trendelenburg
:::: . .E::T .. :, E .: B. Lithotomy
:. .TI: . LE: Transurethral resection of the prostate surgery or TURP is done in
the Iithotomy position in order for the surgeon to have an ease in the performance of
surgery since a scope and a resectoscope is inserted into the clients urethra.
2. . TURP is a surgery that can- be performed in around 1-2 hours. The role of an
anesthesia?
/ú . Local lnfiltration
/ú . General lnhalation
ú ú :. Subarachnoid block
/ [. General lntravenous
:. .TI: . LE: Subarachnoid block , The area of surgery is in the pelvic area
hence subarachnoid block or spinal anesthesia can be utilized for procedures below
the thoracic nerve or at the Ievel of the diaphragm and will Iast for Iess than 3-4
hours.
B. Pfannensteil incision
C. Inguinal incision
D. no incision
CORRECT ANSWER: D. no incision
RATIONALE: TURP or transurethral resection of the prostate is a surgery that does not require a
surgical incision since a scope and a resectoscope is inserted in the client's urethra only.
5. After the TURP , the Scrub Nurse anticipates that she needs to prepare which of the following
supplies to help prevent bleeding in the post- op period and to allow the drainage of excess blood clots
and retained prostatic fragments?
C. heparinized syringe
RATIONALE: The 3-way foley catheter will be used post op for cystoclysis (Continous bladder
irrigation) to prevent bleeding by increasing the flow of the fluid into the bladder and to flush blood clots
and prostatic fragments from the operative site which can stimulate bladder spasm that leads to bleeding.
Option B, nelaton catheter, is not used since this is only used as a single straight catheter to drain urine. If
used frequently it can cause irritation and further increase the risk for bleeding. Option C heparin will
further cause bleeding due to its anti-coagulant property. Option D. Levine tube is not related since this is
the tube used for gastric decompression.
6. Antonio, a 69 year old client was admitted with a chief complaint of gross hematuria and severe
lumbar pain. He was diagnosed to have stones in the renal pelvis .
What do you call the surgical removal of stones in the renal pelvis using an open approach?
A. Cystolithotomy
B. Pyelolithotomy
C. Nephrectomy
D. Pelvic laparotomy
RATIONALE: Pyel- stands for the renal pelvis and lithotomy is the suffix used for the surgical removal
of a stone, Cysto stands for the urinary bladder and nephrectomy is for the removal of a kidney. Pelvic
laparotomy is a surgery done to explore the pelvic organs such as the Uterus, ovaries and fallopian tubes
7. Another approach for removing stones is with the use of a non invasive procedure called ESWL,
ESWL stands for?
RATIONALE: This surgery is a non invasive procedure which crushes stones with the use of shock
waves , and the stones, after being crushed, are then voided by the client. The client after the procedure
is encourage to increase his fluid intake to flush out the stone sediments.
8. Antonio opted to have the open approached surgery for the removal of his kidney stones. In
performing the open surgery, the client will be placed in a lumbotomy position. Which of the following
positioning equipment is not needed in performing the procedure?
A. Axillary roll
B. shoulder roll
C. pillow rolls
D. "donut"
RATIONALE: SHOULDER ROLL is not needed. This is usually used for neck surgeries to
hyperextend the neck part. In doing lumbotomy position the client will be placed on a side lying position
therefore an axillary roll will be needed to prevent undue pressure on the dependent axilla, pillow rolls can
be used in front and at the back to immobilize the patient and the donut will be placed on the clients head.
9. In performing the Open surgery for the removal of urinary stones , the surgeon may need a knife to
cut through tubular structures such as the renal pelvis or ureters. Which of the following blades is the
most appropriate to aid the surgeon in performing the said surgery?
A. Blade 10
B. Blade 11
C. Blade 12
D. Blade 15
RATIONALE: Blade 12 is also called hooked knife and is usually used to cut through tubular
structures and for oropharyngeal surgeries. Blade 10 and 20 are the usual blades used to cut the skin;
Blade 15 is the smallest belly and is used for making small and curvilinear incisions; Blade 11 is used for
stabbing and puncturing tissues.
10. Antonio was placed on Epidural anesthesia and was given Morphine sulfate along with
Sensorcaine (Marcaine) . The anaesthesiologist noted a marked decrease on the clients SaO2 and the
RR was down to 8 breaths per minute. She is suspecting opioid toxicity. The circulating nurse anticipates
that she needs to prepare an appropriate Antidote to counteract the effects of the morphine. Which of the
following drugs should the circulating nurse prepare?
A. nalbuphine (nubain)
B. Naloxone (narcan)
C. Neostigmine (Prostigmine)
RATIONALE: Naloxone (Narcan) is a narcotic antagonist which can help counter act the effects of an
opioid narcotic. A. Nalbuphine (nubain) is incorrect since it is a narcotic agonist-antagonist thus can
further aggravate the toxicity, option C Neostigmine (prostigmine) is an Acetylcholinesterase inhibitor
which can be used for excess muscle relaxation brought about by neuro muscualr junction blocking
agents or myasthenia gravis and option D vecuronium bromide is an example of a neuro-muscular
junction blocking agent used as an adjunct drug for general anesthesia.
11. Erlinda a 40 year old female client was admitted due to right upper quadrant pain accompanied by
jaundice , She was diagnosed to have cholelithiasis .
A. Carbon Dioxide
B. Nitrous oxide
C. Oxygen
D. Helium
RATIONALE: Carbon dioxide is the common gas utilized to insufflate the peritoneal cavity since it can
be absorbed in the surrounding tissues and expelled through the respiratory tract. Oxygen is not used
because it supports combustion and can cause burns or fire when cautery is used. Nitrous Oxide is
usually used as an anesthetic agent. While helium is commonly used to inflate party balloons
12. Because of the need for insufflation, clients who will undergo laparoscopic cholecystectomy need
to undergo the procedure under General Inhalation anesthesia. During the administration of anesthesia
when stage II or stage of excitement is reached, the circulating nurse can note the following responses
from the client:
C. pupils are smaller but the eyelid reflex along with other reflexes are lost
RATIONALE: Loses consciousness but is still sensitive to external stimuli, is a characteristic sign of
the second stage of anaesthesia. Other signs may include irregular respiration but with increased muscle
tone and involuntary responses. It is therefore very important that at this stage the OR suite must be quiet
to prevent undue stimulation. Choice A speaks of stage I or induction , Choice C is noted in stage III
which is the surgical anaesthesia and Choice D describes the danger stage or stage IV where medullary
paralysis occurs.
13. A client is scheduled for an Open Cholecystectomy and the surgeon will utilize a Kocher incision.
The circulating nurse therefore must do skin preparation. This will cover what skin areas?
RATIONALE: From nipple line to anterior 1/3 of the thigh. Kochers incision is also called Right
subcostal incision therefore this incision must be prepared covering the mentioned areas
14. After doing the initial incision, the surgeon cuts through the subcutaneous layers and asks for a
retractor. Which of the following instruments should the scrub nurse hand to the surgeon?
A. Balfour
B. Senn retractor
C. Army-navy retractor
D. Gelpi retractor
RATIONALE: The Army Navy retractor, also known as parabeau or skin retractor, is usually used to
retract the first two layers of the abdomen and other areas in surgery; a balfour is used as a self retaining
retractor to retract the peritoneum; a senn retractor is used for retracting tissues in minor surgeries; and
gelpi is a self retaining retractor used to retract superficial wounds especially in neuro surgeries.
15. Upon reaching the fascia the surgeon asked for a scissor to cut through this tough tissue layer.
Which of the following cutting instruments is most appropriate to be handed over by the scrub nurse?
A. Iris scissor
C. Potts scissor
RATIONALE: The Mayo curve scissor is used to cut through tough tissues such as skin, fascia and
muscles. Mayo straight scissors are used to cut sutures and supplies used in the surgery, Potts scissor is
an angulated scissor used to cut delicate tissues and blood vessels and an iris scissor is used for plastic
surgeries and cutting fine tissues.
16. In doing the open cholecystectomy, the surgeon reached the peritoneum and has located the gall
bladder and its surrounding blood vessels. He clamps the cystic artery using 2 mixters, and then asks for
a scissor. The scrub nurse should give the surgeon what instrument?
C. metzembum
D. bandage scissor
RATIONALE: Metzembum is used to cut through delicate tissues such as blood vessels. , mayo
curve scissor is used to cut through tough tissues such as skin, fascia and muscles. Mayo straight
scissors are used to cut sutures and supplies used in the surgery. Bandage scissor is used for general
cutting of supplies, dressings and bandages.
17. Before closing the peritoneum the surgeon asked for a T-tube to allow the drainage of bile and
allow the inflammation in the Common bile duct to subside. The surgeon then informs the scrub nurse to
prepare a stay suture. Which of the following is the most appropriate to be used as the stay suture?
RATIONALE: Silk 2-0 on a cutting needle. Cutting needles are used to suture through tough tissues
such as the skin. Silk is a non-absorbable suture which can be used for the said purpose.
18. Jenna, a 21 year old fashion model underwent excision of subcutaneous mass at her right cheek.
She is very much anxious about how the surgical wound will look like after the surgery.
To minimize scarring, the scrub nurse knows that she must prepare a thin suture such as Nylon 5-0
loaded on which of the following needles?
A. Intestinal needle
B. dura needle
C. reverse cutting needle
D. atraumatic needle
RATIONALE: Atraumatic needles, also known as eyeless needles, leave less trauma to tissues thus
can minimize the potential of scarring and keloid formation.. Reverse cutting is a traumatic needle which
can bring about more scars though it can also be used to suture the skin. Intestinal and dura needles are
inappropriate to be used in the skin since they are thin and tapered.
19. During the skin closure, the surgeon asked for pick up forceps to grasp the skin . Which of the
following is most appropriate to be given by the scrub nurse?
A. Thumb forceps
B. Debakey forceps
D. Russian forceps
RATIONALE: Adson forceps with teeth is used for grasping skin layers during closure. Debakey is
used to grasp delicate tissues such as blood vessels. Thumb forceps used to grasp delicate tissues.
Russian forceps is used to grasp tough tissues in the peritoneal cavity.
20. Victoria a 70 year old diabetic client is experiencing Chronic Renal failure due to DM nephropathy
and has an IJ catheter as port for her hemodialysis. She has a non healing wound at her left foot with
signs of gangrene.
Victorina was scheduled for an AVF creation to create a more permanent access for her hemodialysis.
AVF stands for ___
A. Atrio-ventricular fistula
B. Arterio-venous fistula
C. Atrio-venous fistula
D. Arterio-ventricular fistula
RATIONALE: Arterio-venous fistula (AVF) is a surgical procedure where an abnormal connection will
be created between an artery and a vein and will be connected through surgical anastomosis.
21. After the incision on the clients forearm the doctor tried to locate for the suitable blood vessels to
be anastomosed . The surgeon then asked for a pick up forceps. Which of the following is most suitable
to be used to grasp the blood vessels?
B. tissue forceps
C. debakey forceps
D. ureteral forceps
RATIONALE: The Debakey forceps is used to grasp delicate tissues especially blood vessels. Adson
forceps are used grasping tissues during wound closure. Tissue forceps are used to grasp tough tissues
and the Uretheral forceps are used to grasp the ureter.
22. After identifying the blood vessels, the surgeon is now ready to perform surgical anastomosis on
the artery and vein. Which of the following sutures is most appropriate to be used as suture for the blood
vessels?
B. polypropelene (Prolene)
C. silk ( Mersilk)
D. Stainless steel ( Ethicon)
RATIONALE: Polypropelene (Prolene) is a non absorbable suture which is usually used for plastic
and cardiovascualr surgeries . Silk can be used to ligate blood vessels but is not appropriate to be used
for anastomosis of blood vessels. Surgical gut can be used for general closure. Stainless steel can be
used to close or connect bones and bony structures.
23. In doing the anastomosis of vessels the surgeon asked for a 6-0 suture which is just appropriate to
the size of the blood vessels to be sutured. He then asked for a needle holder to hold the very small
needle. Which of the following suturing instruments should the scrub nurse anticipate to give?
B. Castroviejo
C. halsted clamp
D. thumb forceps
RATIONALE: Needles should be handled with appropriate needle holders and a Castroviejo is a self
locking needle holder used for fine or very small needles. A mayo-hegar needle holder is the common
needle holder in use for basic abdominal surgeries. A halsted clamp is a small clamp but should not be
used to hold needles. The thumb forceps is not used to hold needles
24. During the Creation of the AVF , the surgeon also asked for heparin diluted with normal Saline
solution to heparinize the blood vessels. Heparin can be used during cardiovascualr surgeries to__
RATIONALE: Heparin is an anti coagulant which prevents blood clots. During anastomosis, the blood
supply at the sutured area is temporarily cut off thus increasing the risk of developing clots at the site.
Having clots at the anastomosis site will defeat the purpose of the surgery.
25. After the AVF creation, the client also underwent wound debridement. The wound was a little deep
and was infected thus the surgeon opted to suture the site, though it is infected, to prevent the risk of
bleeding at the site. Which of the following sutures is best suited to be used to close an infected surgical
site?
B. silk
C. cotton
D. surgical guts
RATIONALE: Synthetic monofilament sutures, are the best choice to close these types of wound.
Because it causes less reaction than the other braided sutures . Surgical guts can be used to close
infected wounds but it is more reactive thus might not be able to sustain the wound closure until it heals.
Cotton and Silk sutures are more often associated with inflammation and irritation thus can cause delay in
wound healing.
26. Carlos, a 21 year old registered nurse, has been recently assigned in the operating room for
orientation and training for 1 month. He is very much excited and eager to learn a lot during this pre-
employment phase.
On Carlos first day of exposure, he was tasked by the Nurse Supervisor to observe the different surgical
procedures in the area . He entered an OR suite where Myrna, an 18 year old client, was being prepped
for surgery. He was then asked by the circulating nurse about the purposes of doing the skin prep. All of
the following are appropriate responses of Carlos except:
A. Skin prep is done to render the skin sterile prior to the procedure
B. Skin prep is done to reduce the resident and transient flora in the skin
C. Skin prep is done to minimize the risk for post operative wound infections
D. Skin prep is done to prepare the area of not just the preferred incision but also possible sites
drain placements.
CORRECT ANSWER: A. Skin prep is done to render the skin sterile prior to the procedure
RATIONALE: This is incorrect since the skin can not be sterilized no matter how it is prepped.
27. After the Skin Prep, the surgeon remembered and instructed the nurses to prepare a mono polar
electrosurgical pencil so he can perform the surgery faster . The senior nurse asked a nurse-orientee to
place the dispersive pad or return electrode on the client. Which of the following actions of the nurse-
orientee is inappropriate whenever a dispersive pad is placed?
A. he applies the pad in complete contact to an area with good vascular and muscular tissues
B. he cuts the pad to adjust its size to fit appropriately to the patient
CORRECT ANSWER: B. he cuts the pad to adjust its size to fit appropriately to the patient
RATIONALE: This is an inappropriate action. Cautery pads should not be cut to fit to the size of the
area where you intend to place it since cutting can alter the electrical connections and insulation of the
pad.
28. During the surgery, a nurse-orientee was very excited and observant on the things that were
happening during the surgery. He noted that after reaching the peritoneum, the Surgeon asked for a
grasping instrument that he will use to locate and grasp the appendix. The nurse-orientee knows that this
grasping instrument is__
A. Kocher
B. tissue forceps
C. Babcock
D. allis
CORRECT ANSWER: C. Babcock
RATIONALE: Babcock is a non toothed grasping instrument which is used to hold delicate tissues
such as the fallopian tubes and portions of the intestine. All the other options are toothed instruments and
are therefore not used to hold delicate tissues such as the intestines.
29. After removing the appendix the surgeon is already checking for any bleeders. The scrub nurse
anticipates that the first counting during closure must be performed when:
RATIONALE: Initial counting must be performed during the closure of the first layer therefore in this
scenario the counting must be done before the closure of the peritoneum. Counting is a responsibility of
OR nurses and is therefore should not be done based on the Surgeons instructions only.
30. After 2 weeks of orientation Carlos, the OR nurse-orientee was given the opportunity to do his first
independent scrub to assist a caesarean section delivery. He is very much excited and nervous in doing
his tasks. He reviews the basic principles of asepsis and knows a violation has occurred when:
B. Gowns are considered sterile by members of the team in front up to the sleeves and axillary
areas.
CORRECT ANSWER: B. Gowns are considered sterile by members of the team in front up to the
sleeves and axillary areas.
RATIONALE: This is a violation on asepsis. Remember gowns are sterile in the sleeves only. 2
inches above the elbows, the axillary region are considered unsterile since it can accumulate moisture
which can contaminate sterile areas. All the other options upholds the principles of asepsis.
31. After the sterile draping, while the circulating nurse was moving the sterile back table, some sterile
water from the basin filled with sterile water spilled on the sterile table. What will be the most appropriate
action of Carlos in this scenario:
B. Renders the entire back table unsterile and asks for a new set of instruments and supplies
C. Asks for a spare towel and covers the wet area before proceeding with the surgery
D. Renders the part unsterile and avoids placing instruments and supplies only at that area.
CORRECT ANSWER: C. Asks for a spare towel and covers the wet area before proceeding with the
surgery
RATIONALE: One basic principle on asepsis is doing remedy if contamination occurs. Option A is a
clear violation since anything wet leaves room for contamination thus needing immediate action, Option B
is incorrect since it is not cost effective and will put of a lot of hassle and will be a waste of time since the
wet area is the only part that requires immediate remedy. Option D is incorrect though you will not place
sterile instruments at that area, one important principle on asepsis is keeping only sterile objects to come
in contact with sterile objects. It is therefore inappropriate to combine sterile and unsterile areas on one
table.
32. Even though Carlos is just new in the practice of operating room nursing, being a registered nurse
makes him responsible for his actions as a professional. Since Carlos assisted on a ceasarian section
delivery, which of the following actions could exhibit a potential risk of negligence on the part of Carlos
and his circulating nurse?
B. Informs the surgeon of a lacking sponge and insists on locating it first before closing the body
cavity
RATIONALE: Counting during the closing of the peritoneum can put them at risk of doing a negligent
act. Remember that in caesarean section there is an open cavity within a cavity which is the uterus. It is
important to note that an additional counting is needed to be performed whenever a surgery involves a
cavity within a cavity. All the other options are appropriate actions and can ensure safe and competent
practice in the Operating Room.
33. Jane, an obese 32 year old, is admitted to the hospital after a vehicular accident. She has multiple
skin lacerations and a fractured hip. She is brought to the OR for surgery.
After surgery, Joy is to receive a piggy-back of Cefuroxime Sodium 500 mg in 50 ml of D5W. The
piggyback is to infuse in 20 minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set the
piggyback to flow at:
A. 25 gtt/min
B. 30 gtt/min
C. 35 gtt/min
D. 45 gtt/min
RATIONALE: To get the correct flow rate: multiply the amount to be infused (50 ml) by the drop factor
(10) and divide the result by the amount of time in minutes (20
34. A 25 year old, female, obese client becomes concerned about her weight. She asks their office
nurse how she might lose weight. Before answering her question, the nurse should bear in mind that long-
term weight loss best occurs when:
RATIONALE: For weight reduction to occur and be maintained, a new dietary program, with a
balance of foods from the basic four food groups, must be established and continued. This will require
altering eating habits/behaviors.
35. The nurse teaches an obese, diabetic client, the value of aerobic exercises in her weight reduction
program. The nurse would know that this teaching was effective when the client says that exercise will:
RATIONALE: Increased exercise builds skeletal muscle mass and reduces excess fatty tissue.
Exercise increases the metabolism of the body and thus increases the heart rate.
36. The physician orders non-weight bearing with crutches for a client, who had surgery for a fractured
hip that was incurred during a football game. The most important activity to facilitate walking with crutches
before ambulation is begun is:
D. Using the trapeze frequently for pull-ups to strengthen the biceps muscles
CORRECT ANSWER: A. Exercising the triceps, finger flexors, and elbow extensors
RATIONALE: These sets of muscles, flexors and extensors, are used when walking with crutches
and therefore need strengthening prior to ambulation. The weight of the body in crutch walking is
supported by the arms and palms therefore the strength of the upper extremities must be assured. Doing
pull-ups limits strengthening only for the biceps.
37. The nurse recognizes that a client understood the demonstration of crutch walking when she
places her weight on:
RATIONALE: The palms and not the axilla should bear the clients weight to avoid damage to the
nerves in the axilla (brachial plexus). The crutch length should be measured to be two inches below the
axilla to prevent this damage.
38. A 46 year-old radio commentator is admitted to the ER because of severe chest pain. He is 5 feet,
8 inches tall and weighs 190 pounds. He is diagnosed with a myocardial infarct. Morphine sulfate,
Diazepam (Valium) and Lidocaine are prescribed.
The physician orders 8 mg of Morphine Sulfate to be given IV. The vial on hand is labeled 1 ml/ 10 mg.
The nurse should administer:
A. 8 minims
B. 10 minims
C. 12 minims
D. 15 minims
RATIONALE: 1 ml = 15 minims Desired is 8 mg; stock is 10 mg/ml Using ratio and proportion: 8
mg/10 mg = X minims/15 minims 10 X= 120 X = 12 minims The nurse will administer 12 minims
intravenously equivalent to 8mg Morphine Sulfate
39. A client asks the nurse why he is receiving the injection of Morphine after he was hospitalized for
severe anginal pain. The nurse replies that it:
C. Decreases anxiety
RATIONALE: Morphine is a specific central nervous system depressant used to relieve the pain
associated with myocardial infarction. It also decreases anxiety and apprehension that help decrease
myocardial oxygen demand.
40. A client is admitted to the hospital because of a complaint of dyspnea and chest pain. Oxygen
3L/min by nasal cannula is prescribed. The nurse institutes safety precautions in the room because
oxygen:
C. Supports combustion
D. Is flammable
RATIONALE: The nurse should know that Oxygen is necessary to produce fire, thus precautionary
measures are important regarding its use. It is not flammable.
41. A client is ordered laboratory tests after she is admitted to the hospital for angina. The isoenzyme
test that is a reliable early indicator of a myocardial infarction is:
A. SGPT
B. LDH
C. CK-MB
D. Myoglobin
RATIONALE: The cardiac marker, Creatinine phosphokinase (CK) isoenzyme levels, especially the
MB sub-unit which is cardio-specific, begins to rise in 3-6 hours, peak in 12-18 hours and is elevated 48
hours after the occurrence of the infarct. Myoglobin begins to rise earlier in one hour but is not cardio-
specific. The other markers mentioned rise later and are not cardio-specific as well. The CK-MB therefore
is most reliable in assisting with early diagnosis. The cardiac markers elevate as a result of myocardial
tissue damage. The nurse needs to note, during initial assessment, the time the pain started so the
appropriate cardiac marker can be evaluated.
42. An early finding in the EKG of a client with an infarcted myocardium would be:
A. Disappearance of Q waves
B. Elevated ST segments
C. Absence of P wave
D. Flattened T waves
RATIONALE: This is a typical early finding after a myocardial infarct because of the altered
contractility of the heart. The insufficient oxygen to the myocardium leads to anaerobic metabolism of the
myocardial cells. Lactic acids are produce and deplete the ATP, which is the energy source of the cells.
Without ATP, there is free movement of ions across the plasma membrane causing a change in
membrane potential as sodium moves into the cell and potassium moves out. This inhibits conduction of
electrical impulses that leads to decrease myocardial contractility. The ST segment can be elevated as
much as 10 mm or more. The other EKG findings that may be associated with MI are a large Q wave and
inversion of the T wave. The other options are not typical of MI.
43. A client, who had a myocardial infarction 3 days earlier, has been complaining to the nurse about
a lot of issues related to his hospital stay. The best initial nursing response would be to:
A. Allow him to release his feelings and then leave him alone to allow him to regain his
composure
B. Allow him to verbalize and then refocus the conversation on his fears, frustrations and anger
about his condition
C. Explain how his being upset dangerously disturbs his need for rest
CORRECT ANSWER: B. Allow him to verbalize and then refocus the conversation on his fears,
frustrations and anger about his condition
RATIONALE: This provides the opportunity for the client to verbalize feelings underlying behavior and
helpful in relieving anxiety. Anxiety can be a stressor which can activate the sympatho-adrenal response
causing the release of catecholamines that can increase cardiac contractility and workload. This can
further increase myocardial oxygen demand.
44. Twenty four hours after admission for an Acute MI, the clients temperature is noted at 39.3 C. The
nurse monitors him for other adaptations related to the fever, including:
A. Shortness of breath
B. Chest pain
RATIONALE: Fever causes an increase in the bodys metabolism, which results in an increase in
oxygen consumption and demand. This need for oxygen increases the heart rate, which is reflected in the
increased pulse rate. Increased BP, chest pain and shortness of breath are not typically noted in fever.
45. A client who is admitted to the hospital for chest pain, asks the nurse, Is it still possible for me to
have another heart attack if I watch my diet religiously and avoid stress? The most appropriate initial
response would be for the nurse to:
A. Suggest he discuss his feelings of vulnerability with his physician.
B. Tell him that he certainly needs to be especially careful about his diet and lifestyle.
C. Avoid giving him direct information and help him explore his feelings
D. Recognize that he is frightened and suggest he talk with the psychiatrist or counselor.
CORRECT ANSWER: C. Avoid giving him direct information and help him explore his feelings
RATIONALE: To help the patient verbalize and explore his feelings, the nurse must reflect and
analyze the feelings that are implied in the clients question. The focus should be on collecting data to
minister to the clients psychosocial needs.
46. A 55 year- old, female, is admitted to the hospital to rule out pernicious anemia. A Schilling test is
ordered. The nurse recognizes that the primary purpose of the Schilling test is to determine the clients
ability to:
RATIONALE: Pernicious anemia is caused by the inability to absorb vitamin B12 in the stomach due
to a lack of intrinsic factor in the gastric juices. In the Schilling test, radioactive vitamin B12 is
administered and its absorption and excretion can be ascertained through the urine.
47. Ana, who underwent subtotal gastrectomy 6 months earlier, is diagnosed to have Pernicious
anemia. The physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM. Available is a vial of the drug
labeled 1 ml= 100 mcg. The nurse should administer:
A. 0.5 ml
B. 1.0 ml
C. 1.5 ml
D. 2.0 ml
RATIONALE: The desired is 0.2 mg; the stock is 100mcg/1ml First convert milligrams to micrograms
and then use ratio and proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : 1 ml 100 X= 200 X = 2
ml. Inject 2 ml. to give 0.2 mg of Cyanocobalamin.
48. Health teachings to be given to a client with Pernicious Anemia regarding his therapeutic regimen
concerning Vit. B12 will include:
RATIONALE: Deep IM injections bypass B12 absorption defect in the stomach due to lack of intrinsic
factor, the transport carrier component of gastric juices. A monthly dose is usually sufficient since it is
stored in active body tissues such as the liver, kidney, heart, muscles, blood and bone marrow
49. The nurse knows that a client, who had total gastrectomy and with Pernicious Anemia,
understands the teaching regarding the vitamin B12 injections when she states that she must take it:
RATIONALE: With the absence of gastric secretions related to gastrectomy, the intrinsic factor does
not return even with therapy. B12 injections will be required for the remainder of the clients life. B12
injection is made available to the body without the need for the intrinsic factor from the gastric secretions.
50. A 45 year old artist diagnosed with colorectal Ca has recently had an abdomino-perineal resection
and colostomy. He accuses the nurse of being uncomfortable during a dressing change, because his
wound looks terrible. The nurse recognizes that the client is using the defense mechanism known as:
A. Reaction Formation
B. Sublimation
C. Intellectualization
D. Projection
RATIONALE: Projection is the attribution of unacceptable feelings and emotions to others which may
indicate the clients non-acceptance of his condition. This has to be explored further by the nurse to help
the client cope with his condition.
51. When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should
plan to perform the procedure:
CORRECT ANSWER: A. When the client would have normally had a bowel movement
RATIONALE: Irrigation should be performed at the time the client normally defecated before he had
the colostomy to maintain continuity in lifestyle and usual bowel function/habit. This is an aspect that
needs to be considered in the rehabilitation of the client.
52. When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse
notes that he needs more teaching if he:
B. Lubricates the tip of the catheter before inserting it into the stoma
C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion
D. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled.
CORRECT ANSWER: C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion
RATIONALE: The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes
hook is too high which can create increase pressure and sudden intestinal distention. This leads to
abdominal cramping and discomfort to the client. The main purpose of the irrigation is for bowel training to
stimulate peristalsis for the return of regular bowel activity and not to cleanse the bowels. This should be
done at the same time each day. 1000 ml of solution is used for the purpose.
53. When doing colostomy irrigation at home, a client with colostomy should be instructed to report to
his physician :
RATIONALE: Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be
reported to the physician. Forcing the tube in could lead to intestinal perforation. Abdominal cramps and
passage of flatus can be expected during colostomy irrigations. The cramps could be due to high
pressure, rapid flow of solution or the use of a cold solution. The procedure may take longer than half an
hour.
54. A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of
his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:
RATIONALE: As long as no one else confirms the presence of the stoma and the client does not
need to adhere to a prescribed regimen, the clients denial is supported. Denial is the first stage anyone
goes through in illness. The nurse and the clients significant others will have to help him through this.
55. The nurse would know that dietary teaching had been effective for a client with colostomy when he
states that he will eat:
B. Everything he ate before the operation but will avoid those foods that cause gas
D. Soft foods that are more easily digested and absorbed by the large intestines
CORRECT ANSWER: B. Everything he ate before the operation but will avoid those foods that cause
gas
RATIONALE: There is no special diet for clients with colostomy. These clients can eat a regular diet.
Only gas-forming foods and foods that the client observes that cause distention and discomfort should be
avoided.
56. A 40 year-old truck driver, is brought to the emergency room after a vehicular accident. He has
suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be
amputated.
When Eddie arrives in the emergency room, the assessment that assume the greatest priority are:
RATIONALE: Respiratory and cardiovascular functions are essential for oxygenation. These are top
priorities to trauma management. There is a need to maintain or reestablish basic life functions. In this
type of case, we expect a lot of blood loss which can lead to decrease circulating volume or hypovolemia
and the client can go into hypovolemic shock. Hypovolemia leads to decrease tissue perfusion which
leads to tissue hypoxia organs of the body that can eventually lead to organ dysfunctions thus multi-organ
failure. When we perform initial assessment, we always start with our ABC's - airway, breathing (note the
quality of the breathing and its rate), and circulation (Check pulses! Not BP. The pulse is more important
at this point to indicate circulation/perfusion.A BP is well appreciated only if there is a good pulse. Don't
waste your time checking on the BP if the pulse is not there.). The ABCs are the primary physiologic /life
functions and needs of the body as these are essential for oxygenation. Without Oxygen, a person dies.
After assessing the ABC and we see that there is a problem in any of these areas , we immediately
proceed to re-establish for the ABC. This is fundamental in nursing assessment and intervention.
Checking out for pain and relieving pain comes later.
57. A client with acute airway obstruction undergoes endotracheal intubation and positive pressure
ventilation. The most immediate nursing intervention for him at this time would be to:
RATIONALE: It is a primary nursing responsibility to evaluate effect of interventions done to the client
particularly if the airway is involved. Nothing is achieved if the equipment is working and the client is not
responding.
58. A chest tube with water seal drainage is inserted to a client following a multiple chest injury
causing a hemothorax on the L lung. A few hours later, the clients chest tube seems to be obstructed.
The nurse observes the long tube in the water-sealed bottle is not fluctuating. The most appropriate
nursing action would be to:
CORRECT ANSWER: B. Assess the client's respiration and auscultate for breath sounds
RATIONALE: Prompt and accurate assessment will direct the nurse to the next most appropriate
action to take. Absence of fluctuation in the water seal bottle at this time indicates the presence of
obstruction especially in the case of a hemothorax and because the tube has just been inserted only a
few hours earlier. Blood clots can clog the tube and cause further lung collapse and respiratory distress.
Absence or diminished breath sounds indicate lung collapse. In this event, the MD should be notified
immediately. Clamping the tube is NOT done as this can further cause obstruction that can lead to further
lung collapse and mediastinal shift.
59. The observation that indicates a desired response to thoracostomy drainage of a client with chest
injury is:
RATIONALE: The chest tube normalizes intrathoracic pressure and restores negative intra-pleural
pressure, drains fluid and air from the pleural space, and improves pulmonary function. Breath sounds
indicate the free passage of air in the air passages. Increased breath sounds indicate better lung
expansion. Constant bubbling indicates an air leak. Crepitus may indicate subcutaneous emphysema . An
increased RR indicates respiratory distress & hypoxia.
60. In the evaluation of a clients response to fluid replacement therapy, the observation that indicates
adequate tissue perfusion to vital organs is:
RATIONALE: A rate of at least 30 ml/hr is considered adequate that indicates good perfusion of
kidney, heart and brain. A CVP 0f 2cm indicates decreased circulatory volume, and options C & D are
indications of decreasing cardiac output and tissue perfusion that leads to hypoxia. Hypoxia is initially
indicated by restlessness and tachycardia.
61. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He
begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is
diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse
should emphasize in his teaching plan the:
CORRECT ANSWER: D. Presence of abdominal drains for several days after surgery
RATIONALE: Drains are usually inserted into the splenic bed to facilitate removal of fluid in the area
that could lead to abscess formation. The rest of the options are for the doctor to discuss with the client.
62. To promote continued improvement in the respiratory status of a client following chest tube
removal after a chest surgery for multiple rib fracture, the nurse should:
A. Encourage bed rest with active and passive range of motion exercises
RATIONALE: This nursing action prevents collection of respiratory secretions that can lead to
atelectasis and respiratory infection. It also promotes adequate lung re-expansion and gas exchange.
63. A client undergoes below the knee amputation following a vehicular accident. Three days
postoperatively, the client is refusing to eat, talk or perform any rehabilitative activities. The best initial
nursing approach would be to:
A. Give him explanations of why there is a need to quickly increase his activity
B. Emphasize repeatedly that with as prosthesis, he will be able to return to his normal lifestyle
D. Accept and acknowledge that his withdrawal is an initially normal and necessary part of
grieving
CORRECT ANSWER: D. Accept and acknowledge that his withdrawal is an initially normal and
necessary part of grieving
RATIONALE: Grief is noted whenever a significant part of the body is severed. The manifestations
presented by the client is noted in the stage of depression of grieving. This withdrawal provides time for
the client to assimilate what has occurred and integrate the change in the body image. Acceptance of the
clients behavior is an important factor in the nurses intervention.
64. A laboratory technician is diagnosed as having myelocytic leukemia and is admitted to the hospital
for chemotherapy. He discusses his recent diagnosis of leukemia by referring to statistical facts and
figures. The nurse recognizes that he is using the defense mechanism known as:
A. Reaction formation
B. Sublimation
C. Intellectualization
D. Rationalization
RATIONALE: People use defense mechanisms to cope with stressful events. Intellectualization is the
use of reasoning and thought processes to avoid the emotional upsets.
65. The laboratory results of the client with leukemia indicate bone marrow depression. The nurse
should encourage the client to:
RATIONALE: Suppression of red bone marrow activity increases bleeding susceptibility associated
with thrombocytopenia, decreased platelets. The use of soft toothbrush and electric razor decreases the
potential for any injury that can lead to bleeding. Anemia and leukopenia are the two other problems
noted with bone marrow depression.
66. While receiving blood transfusion, a client develops flank pain, chills, fever and hematuria. The
nurse recognizes that the client is probably experiencing:
RATIONALE: A Hemolytic transfusion reaction results from a recipients antibodies that are
incompatible with transfused RBCs that leads to RBC hemolysis. This is also called Type II
hypersensitivity. The manifestations result from RBC hemolysis, agglutination, and capillary plugging that
can damage renal function, thus the flank pain and hematuria and the other manifestations
67. A client cracks jokes about his leukemia even though he is becoming more ill and weaker. The
nurses most therapeutic response would be:
RATIONALE: This non-judgmentally, on the part of the nurse, points out the client's behavior.
69. During an 8 hour shift, the client drinks two 6 oz. cups of tea and vomits 125 ml of fluid. During this
8 hour period, his fluid balance would be:
A. +55 ml
B. +137 ml
C. +235 ml cccccccccccccchhhhhhhhhhhhhaaaaaaaaaannnnnnnnngggggggggeeeeeeee
D. +485 ml
RATIONALE: The clients intake was 180 ml (6oz x 30 ml) and loss thru the vomitus was 125 ml of
fluid; loss is subtracted from intake
70. A 65-year old male teacher is admitted to the hospital with a diagnosis of Left-sided CHF. In the
assessment, the nurse should expect to find:
B. Dyspnea on exertion
RATIONALE: Dyspnea upon exertion is a manifestation of pulmonary congestion and edema that
occur because of fluid extravasation from the pulmonary capillary bed, resulting in difficult breathing. Left-
sided heart failure creates a backward effect on the pulmonary system that leads to pulmonary
congestion. The other manifestations are typical of right-sided heart failure. Its symptoms reflect systemic
venous congestion.
71. The physician orders on a client with CHF a cardiac glycoside, a vasodilator, and furosemide
(Lasix). The nurse understands Lasix exerts is effects in the:
A. Distal tubule
B. Collecting duct
C. Glomerulus of the nephron
RATIONALE: This is the site of action of Lasix being a potent loop diuretic. Lasix decreases the
preload or venous return thus decreasing the cardiac workload. Use of diuretics is one of the essential
elements in the management of CHF
72. The client weighs 210 lbs on admission to the hospital. After 2 days of diuretic therapy he weighs
205.5 lbs. The nurse could estimate that the amount of fluid he has lost is:
A. 0.5 L
B. 1.0 L
C. 2.0 L
D. 3.5 L
RATIONALE: One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5 lbs weight loss equals
approximately 2 Liters.
73. A client has been receiving Digitalis, Lasix, and Isordil tablets for his CHF. He is on bedrest with
bathroom privileges. His apical pulse rate is 44. The nurse concludes that his pulse rate is most likely the
result of the:
A. Lasix
B. Isordil
C. Bed-rest regimen
D. Digitalis
CORRECT ANSWER: D. Digitalis
RATIONALE: A cardiac glycoside such as digitalis increases force of cardiac contraction, decreases
the conduction speed of impulses within the myocardium and slows the heart rate. These effects results
in a more effective and increased the cardiac output that will greatly lessen the congestion of the heart.
But a heart rate of less than 60/min can indicate toxicity from Digitalis and must be reported to the MD.
74. The diet ordered for a client with CHF permits him to have a 190 g of carbohydrates, 90 g of fat
and 100 g of protein. The nurse understands that this diet contains approximately:
A. 2200 calories
B. 2000 calories
C. 2800 calories
D. 1600 calories
RATIONALE: There are 9 calories in each gram of fat and 4 calories in each gram of carbohydrate
and protein. Fat: 90g X 9 = 810 Protein: 100g X 4= 400 CHO: 190 X 4= 760 TOTAL: 1970 calories
75. After the acute phase of congestive heart failure, the nurse should expect the dietary management
of the client to include the restriction of:
A. Magnesium
B. Sodium
C. Potassium
D. Calcium
RATIONALE: Restriction of sodium reduces the amount of water retention that reduces the cardiac
workload. Reducing the cardiac workload improves cardiac performance with the improvement in cardiac
output. For severe restriction, the client is allowed 200-500mg/day.
76. A 40-year old male attendant diagnosed with a previous history of SLE develops GI bleeding while
on duty and is admitted to the hospital. An important etiologic clue for the nurse to explore while taking his
history would be:
RATIONALE: Some medications, such as aspirin and prednisone, irritate the stomach lining and may
cause gastric bleeding with prolonged use.
77. The meal pattern that would probably be most appropriate for a client recovering from GI bleeding
is:
RATIONALE: Presence of food in the stomach at regular intervals interacts with HCl limiting acid
mucosal irritation. Mucosal irritation can lead to bleeding.
78. A client with a history of recurrent GI bleeding is admitted to the hospital for a gastrectomy.
Following surgery, the client has a nasogastric tube to low continuous suction. He begins to
hyperventilate. The nurse should be aware that this pattern will alter his arterial blood gases by:
A. Increasing HCO3
B. Decreasing PCO2
C. Decreasing pH
D. Decreasing PO2
RATIONALE: Hyperventilation results in the increased elimination of carbon dioxide from the blood
that can lead to respiratory Alkalosis seen in the ABG result as decreased pCO2, normal HCO3 and a ph
>7.45.
79. Routine postoperative IV fluids are designed to supply hydration and electrolyte and only limited
energy. Because 1 L of a 5% dextrose solution contains 50 g of sugar, 3 L per day would apply
approximately:
A. 400 Kilocalories
B. 600 Kilocalories
C. 800 Kilocalories
D. 1000 Kilocalories
RATIONALE: Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4 kcal/g = 600 kcal; only
about a third of the basal energy need
80. Thrombus formation is a danger for all postoperative clients. The nurse should act independently
to prevent this complication by:
RATIONALE: Inactivity causes venous stasis, hypercoagulability, and external pressure against the
veins, all of which lead to thrombus formation. Early ambulation or exercise of the lower extremities
reduces the occurrence of this phenomenon
81. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story
building. When assessing the client, the nurse would be most concerned if the assessment revealed:
A. Reactive pupils
B. A depressed fontanel
D. An elevated temperature
RATIONALE: The nurse needs to perform a thorough assessment that could indicate alterations in
cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs
only with basal skull fractures that can easily contribute to increased intracranial pressure and brain
herniation.
82. An unconscious client is admitted to the ICU. IV fluids are started and an indwelling catheter is
inserted. With an indwelling catheter, urinary infection is a potential danger. The nurse can best plan to
avoid this problem by:
RATIONALE: Promoting hydration maintains urine production at a higher rate. The increase urine
volume flushes the bladder and prevents urinary stasis and possible infection.
83. The nurse performs full range of motion on a bedridden clients extremities. When putting his ankle
through range of motion, the nurse must perform:
RATIONALE: These movements include all possible range of motion for the ankle joint.
84. A client has been in a coma for 2 months. The nurse understands that to prevent the effects of
shearing force on the skin, the head of the bed should be at an angle of:
A. 30 degrees
B. 45 degrees
C. 60 degrees
D. 90 degrees
RATIONALE: Shearing force occurs when 2 surfaces move against each other. When the bed is at
an angle greater than 30 degrees, the torso/trunk tends to slide and causes this phenomenon. Shearing
forces are good contributory factors of pressure sores. Frequent change of position at least every two
hours and special attention to pressure areas will further help prevent the problem.
85. Transurethral resection of the prostate (TURP) is performed on a client with BPH. Following the
surgery, nursing care should include:
RATIONALE: The primary nursing responsibility in a client with a cystoclysis following a TURP is to
maintain the patency of the 3-way catheter. This promotes bladder decompression, which prevents
distention and bleeding. Continuous flow of fluid through the bladder limits clot formation; promotes
hemostasis and also promotes drainage of retained prostatic fragments. The presence of blood clots and
retained prostatic fragments in the bladder can induce bladder spasms that also can induce bleeding.
There is no incision in TURP thus dressing and wound infection cannot be expected.
86. In the early postoperative period following a transurethral surgery, the most common complication
the nurse should observe for is:
A. Sepsis
B. Hemorrhage
RATIONALE: After transurethral surgery, hemorrhage is common because of venous oozing and
bleeding from many small arteries in the prostatic bed. Also, retained prostatic tissue and blood clots can
cause bladder spasms that can lead to bleeding.
87. Following prostate surgery, the doctor may order the retention catheter to be secured to the clients
leg causing slight traction of the inflatable balloon against the prostatic fossa. This is done to:
A. Limit discomfort
B. Provide hemostasis
RATIONALE: The pressure of the balloon against the small blood vessels of the prostate creates a
tampon-like effect that causes them to constrict thereby preventing bleeding.
88. Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal
discomfort. The nurse notes that the catheter drainage has stopped. The nurses initial action should be
to:
RATIONALE: To check for the patency of the catheter tubing, note for kinks or dependent loops or
that the client could be lying on the tube. Milking of the tube may be done to dislodge any obstruction and
allow for drainage. A physicians order is not necessary for a nurse to check catheter patency. The
irrigation and removal of the catheter, in this instance, is not done by the nurse but by the physician
89. The nurse would know that a post-TURP client understood his discharge teaching when he says I
should:
A. Get out of bed into a chair for several hours daily
RATIONALE: Urethral mucosa in the prostatic area is damaged during surgery and strictures may
form with healing that causes partial or even complete urinary obstruction. Obstruction to the urinary flow
is manifested by decrease in the urinary stream.
90. A 30 year old female teacher is admitted to the surgical unit for a subtotal thyroidectomy. She is
diagnosed with Graves Disease. When assessing the client, the nurse would expect to find:
RATIONALE: Classic signs associated with hyperthyroidism are weight loss and restlessness
because of increased basal metabolic rate. Exopthalmos is due to peribulbar edema.
91. A client undergoes Subtotal Thyroidectomy for Graves Disease. In planning for the clients return
from the OR, the nurse would consider that in a subtotal thyroidectomy:
RATIONALE: Subtotal thyroidectomy allows some thyroid tissue to remain. This may provide enough
hormone for normal function. Total thyroidectomy is generally done in clients with Thyroid Ca.
92. Before a post- thyroidectomy client returns to her room from the OR, the nurse plans to set up
emergency equipment, which should include:
RATIONALE: Acute respiratory obstruction in the post-operative period can result from edema,
subcutaneous bleeding that presses on the trachea causing an airway obstruction. Hypocalcemia and
tetany, caused by accidental removal of the parathyroid gland, may also cause a laryngospasm which
also contributes to airway obstruction
93. When a post-thyroidectomy client returns from surgery the nurse assesses her for unilateral injury
of the laryngeal nerve every 30 to 60 minutes by:
RATIONALE: If the recurrent laryngeal nerve is injured during surgery, the client will be hoarse and
have difficult speaking
94. On a post-thyroidectomy clients discharge, the nurse teaches her to observe for signs of surgically
induced hypothyroidism. The nurse would know that the client understands the teaching when she states
she should notify the physician if she develops:
A. Intolerance to heat
RATIONALE: Dry skin is most likely caused by decreased glandular function and fatigue caused by
decreased metabolic rate. Body functions and metabolism are decreased in hypothyroidism. The other
options are classic of hyperthyroidism.
95. A clients exopthalmos continues inspite of thyroidectomy for Graves Disease. The nurse teaches
her how to reduce discomfort and prevent corneal ulceration. The nurse recognizes that the client
understands the teaching when she says: I should:
96. Clara is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her
entire right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is
compromised, and she is in pain and anxious.
Performing an immediate appraisal, using the rule of nines, the nurse estimates the percent of Claras
body surface that is burned is:
A. 4.5%
B. 9%
C. 18 %
D. 22.5%
RATIONALE: The entire right lower extremity is 18%, the anterior portion of the right upper extremity
is 4.5% giving a total of 22.5%
97. The nurse applies mafenide acetate (Sulfamylon cream) to a client who has second and third
degree burns on the right upper and lower extremities, as ordered by the physician. This medication will:
RATIONALE: Sulfamylon is effective against a wide variety of gram positive and gram negative
organisms including anaerobes.
98. Eight hours after a burn injury, the physician orders for the client 2 liters of IV fluid to be
administered q 12h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
A. 18 gtt/min
B. 28 gtt/min
C. 32 gtt/min
D. 36 gtt/min
RATIONALE: This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop
factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)
99. A burn client receives a temporary heterograft (pig skin) on some of his burns. These grafts will:
RATIONALE: The graft covers nerve endings, which reduces pain and provides a framework for
granulation that promotes effective healing. Covering the wounds will also prevent infection which is so
common in burn clients. The other options are irrelevant
100. A client with burns on the chest has periodic episodes of dyspnea. The nurse knows that the
position that would provide for the greatest respiratory capacity for the client would be the:
A. Semi-fowler's position
B. Sims' position
C. Orthopneic position
D. Supine position
RATIONALE: The orthopneic position lowers the diaphragm and provides for maximal thoracic
expansion. Close supervision of the client when deep breathing must be done to ensure effectiveness of
his ventilatory effort.
101. A 20- year old college student is admitted to the hospital with a tentative diagnosis of myasthenia
gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon
test. In preparing her for this procedure, the nurse explains that her response to the medication will
confirm the diagnosis if Tensilon produces:
RATIONALE: Tensilon acts systemically to increase muscle strength; with a peak effect in 30
seconds, It lasts several minutes. A positive Tensilon test indicates further assessment to confirm MG. A
negative result demands further exploration as to the cause of the muscle weakness
102. The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her
hospitalization would be to:
RATIONALE: Until diagnosis is confirmed, primary goal should be to maintain adequate activity to
maintain muscle strength and prevent muscle atrophy. The nurse should note for any weakness of the
thoracic muscles with can affect ventilation.
103. The most significant initial nursing observations that need to be made about a client with
myasthenia include:
RATIONALE: Muscle weakness of the respiratory muscles can lead to respiratory failure that will
require emergency intervention and inability to swallow may lead to aspiration.
104. The newly admitted client with myasthenia gravis, begins to experience increased difficulty in
swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:
D. Coordinate her meal schedule with the peak effect of her medication, Mestinon
CORRECT ANSWER: D. Coordinate her meal schedule with the peak effect of her medication,
Mestinon
RATIONALE: Dysphagia is minimized during peak effect of Mestinon, thereby decreasing the
probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow. The
client can be scheduled her meals at this time.
105. A client with myasthenia gravis, is concerned about her fluctuating physical condition and
generalized weakness. In planning for her care it would be most important to:
RATIONALE: Spacing activities will encourage maximal functioning within the limits of the clients
strength and fatigue. Preventing fatigue by allowing sufficient rest in between will greatly affect also the
clients self-worth and ability for self care.
106. A 65 years old, female meat vendor has a history of hypertension for the past 10 years. She has
mild dyspnea on exertion and pedal edema.
RATIONALE: Hypertension causes the heart to compensate for increased peripheral vascular
resistance that increases cardiac workload by LV hypertrophy. This results in the failing left ventricles
inability to pump blood effectively out of the heart and to accept blood returning from the lungs. This
results in increased vascular pressure in the lungs or pulmonary congestion manifested by dyspnea upon
exertion.
107. Hydrochlorothiazide (HydroDIURIL) 50 mg bid is ordered for a hypertensive client. The nurse
would know that the client understands the side effects of HydroDIURIL when he says, I should call the
physician if I develop:
A. Insomnia
B. A stuffy nose
C. Increased thirst
D. Generalized weakness
108. The physician orders potassium supplements to a client receiving diuretic. The nurse recognizes
that the client understands the teaching about potassium when she indicates that she should:
RATIONALE: Hyperkalemia manifests itself with an increase in GI motility such as colic and explosive
diarrhea. K imbalances need to be closely monitored as they can lead to cardiac irregularities and arrest.
109. The dietary practice that will help a hypertensive client reduce his dietary intake of sodium is:
RATIONALE: A lot of people prefer to drink carbonated beverages. Carbonated beverages are
generally high in sodium and should be avoided. Sauces and dairy products contain some amount of
sodium but not as much as carbonated drinks.
110. A most beneficial teaching plan for a client with HPN should include having the client:
RATIONALE: Rest decreases demand on the heart and will also prevent fatigue and physical stress
that helps maintain a normal blood pressure.
111. A hypertensive client arrives for another appointment and tells the nurse, My feet are killing me.
These shoes got so tight. The nurses best initial action is to:
RATIONALE: Shoes that become too tight may indicate pedal edema, which is a sign of fluid
retention. Weight gain is a good indicator of fluid retention which is common in clients with hypertension.
2.2 lbs weight gain is equal to one liter of fluid retained.
112. A 63-year old carpenter, is admitted to the hospital with upper right quadrant discomfort,
jaundice, and a recent 25- pound weight loss. After a diagnostic workup, carcinoma of the pancreas is
suspected and an exploratory laparotomy is scheduled.
Before surgery, meperidine (Demerol) is ordered for pain. Morphine sulfate is contraindicated for the
client because it:
RATIONALE: Morphine sulfate is spasmogenic and increases spasms of smooth muscle and is
contraindicated in all conditions in which there is obstruction of smooth muscle ducts. In its place,
Meperidine is preferred.
113. The physician orders atropine sulfate preoperatively. After administering the atropine to the
client, the nurse should be particularly observant for the occurrence of:
A. Polyuria
B. Diarrhea
C. Murmurs
D. Tachycardia
RATIONALE: Vagal stimulation slows the heart. Atropine, a vagolytic drug blocks vagal innervation,
and thereby increased heart rate can occur. The nurse must check for the heart rate before giving the
drug. The drug is withheld if the heart rate is more than 100/min.
114. A Whipple procedure is performed on the client with Pancreatic Ca. When the client returns from
surgery, the nurse should expect him to have a:
A. Chest tube
B. Intestinal tube
C. Nasogastric tube
D. Gastrostomy tube
RATIONALE: This surgery involves the stomach, duodenum, pancreas and common bile duct. A
nasogastric tube connected to suction or gravity drainage removes gastric secretions and prevents
abdominal distention.
115. After surgery, a client should be encouraged to turn from side to side and to carry out deep
breathing exercises. These activities are essential to prevent:
A. Metabolic Acidosis
B. Metabolic Alkalosis
C. Respiratory Acidosis
D. Respiratory Alkalosis
RATIONALE: Shallow respirations, bronchial tree obstruction and atelectasis compromise ventilation
and eventually gas exchange in the lungs. This causes an elevated carbon dioxide level due to CO2
retention that leads to respiratory acidosis.
116. The spouse of a client, who underwent Whipples surgery, asks the nurse about preparing meals
for her husband. The statement that the nurse should include in teaching about the diet would be:
A. Meals should be low fat because of interference with the fat digestion mechanism.
B. Meals should be restricted in calories and CHON because of compromised liver function.
C. The diet should be low in calories to prevent taxing the diseased pancreas.
CORRECT ANSWER: A. Meals should be low fat because of interference with the fat digestion
mechanism.
RATIONALE: Whipple procedure leads to malabsorption because of impaired delivery of bile to the
intestine. Fat metabolism is interfered with that causes dyspepsia.
117. A long term complication that a post pancreatectomy client must be made aware of is his
hypoinsulinism. The nurse would know that the client understands the teaching about hypoinsulinism
when he indicates that he should seek medical supervision if he has:
A. Oliguria
B. Anorexia
C. Weight gain
D. Increased thirst
118. Situation: After a partial nephrectomy, the client returns to the Urology unit with a nephrostomy
tube in place.
An acute life threatening complication that the nurse should assess the client for in the early post
operative period is:
A. Sepsis
B. Renal failure
C. Hemorrhage
D. Paralytic ileus
RATIONALE: The kidney, an extremely vascular organ receives a large percentage of blood from the
aorta via the renal artery. Blood that goes to the kidneys is cleared of toxic wastes through glomerular
filtration in the highly vascular glomerulus. Any injury to the kidney can lead to bleeding.
119. The nurses post operative plan of care for Gary after a partial nephrectomy includes:
B. Leaving the original dressing in place for at least the first 48 hours
CORRECT ANSWER: B. Leaving the original dressing in place for at least the first 48 hours
RATIONALE: Turning facilitates drainage from the operative site and also promotes adequate lung
expansion and ventilation.
120. A post partial nephrectomy client still has residual obstruction to urine flow and is being
discharged with the nephrostomy tube in place. The nurse should instruct him to:
RATIONALE: The dressing will need to be changed at home because drainage can persist for several
weeks. Unchanged dressings can lead to infection. To prevent further infection and promote urinary flow,
fluids are encouraged and the client needs to ambulate. The nephrostomy tube can only be irrigated by
the doctor.
121. A client has been taught how to care for his nephrostomy tube and how to change his dressing.
On the day of discharge he states, I hope I can handle all this at home. Its a lot to remember. The best
response by the nurse would be:
122. Natalia, 70 years old, comes to the community health center complaining of increased thirst and
appetite and weight loss.
Diabetes mellitus is diagnosed, and the physician prescribes Glucophage. While taking this medication,
Natalia should be taught to observe for:
A. Hypoglycemia
B. Diabetic coma
C. Weight loss
D. Ketonuria
RATIONALE: Oral antihyperglycemic agents can decrease serum glucose levels. The other options
relate to increase in blood glucose level.
123. Preoperative teaching for a client who is to undergo cataract surgery should include the
importance of :
RATIONALE: It is important that increase in intraocular pressure be avoided after cataract surgery.
Bending activity increases intraocular pressure and must be avoided by the client.
124. Safety is a nursing concern for a client following a cataract surgery. The nurse can provide for
this by:
CORRECT ANSWER: A. Putting the side rails up while the client is in bed
RATIONALE: Safety is a nursing priority after cataract surgery. Putting up the side rails will keep the
client from falling out of bed and will provide a sense of security. The other options are irrelevant.
Restraints are not used and not indicated.
125. The physician orders 30 U of insulin to be added to a diabetic clients IV infusion of glucose and
water. The nurse understands that the only insulin that can be used is:
A. Lente insulin
B. NPH Insulin
C. Regular Insulin
D. Ultralente insulin
RATIONALE: Regular insulin is the only insulin that acts rapidly and is compatible with intravenous
solutions.
126. A client who had eye surgery complains of nausea after surgery. The nurse should:
RATIONALE: Nausea and vomiting is a discomfort following surgery related to the use of anesthesia.
They should be avoided as they can increase intraocular pressure. Administering the ordered antiemetic
will prevent nausea and vomiting. Deep breathing will relax the client but cannot give the assurance of
preventing vomiting in a client.
127. A client who had eye surgery is being taught how to administer his own eye drops before
discharge. The nurse approves his technique when he :
D. Holds the dropper tip above the eye towards the conjunctival sac.
CORRECT ANSWER: D. Holds the dropper tip above the eye towards the conjunctival sac.
RATIONALE: To protect against physical injury and infection, the dropper tip should not touch the eye
and that the medicine is instilled at the conjunctival sac
128. A client with lymphocytic lymphoma develops pancytopenia during the course of chemotherapy.
The client asks the nurse why this has occurred. The nurse should explain that:
CORRECT ANSWER: D. Cancer cells are the primary target of the drugs but normal cells are also
susceptible to the effects of chemotherapeutic drugs
RATIONALE: Chemotherapy can destroy actively proliferating cells in the body. The bone marrow is
an area of active cellular proliferation. This causes bone marrow depression and destroys indiscriminately
normal erythrocytes, WBC, platelets along with the neoplastic cells.
129. A client who develops pancytopenia during the chemotherapy should be taught to:
RATIONALE: Pancytopenia causes a decrease in blood cells. The reduced platelets increase the
likelihood of uncontrolled bleeding. The reduced lymphocytes increase susceptibility to infection.
Aggressive mouth care implies using strong mouthwashes that can further irritate the oral mucous
membranes. Fluid intake is encouraged as the clients uric acid level increases with chemotherapy.
130. A 30 year-old female social worker has had a variety of vague complaints for the past 6 months.
The physician suspects multiple sclerosis and plans to complete neurologic assessment.
When testing the trigeminal nerve, the nurse should expect the physician to evaluate:
RATIONALE: The afferent sensory branch of the trigeminal nerve innervates the cornea
131. The client is suspected of having multiple sclerosis. The nurse will expect her to complain about
the most common initial symptom associated with multiple sclerosis, which is:
A. Diarrhea
B. Headaches
C. Skin infection
D. Visual disturbances
RATIONALE: Visual disturbances such as diplopia and blurred vision are common initial symptoms
from impaired CN dysfunction and conduction deficits to the optic nerve.
132. A client diagnosed of Multiple Sclerosis asks the nurse Will I experience pain? The nurses best
response would be:
C. Lets make a list of the things you need to ask your doctor
RATIONALE: This is a truthful answer that provides hope for the client. Pain is a common source of
fear among clients regardless of the diagnosis.
133. A client appears obviously upset with his diagnosis of Multiple sclerosis and asks, Am I going to
die? The nurses best response would be:
B. Is your family here? I would like to explain your disease to all of you
D. Why dont you speak with your doctor who can give you more details about your disease?
CORRECT ANSWER: C. The prognosis is variable, most individuals experience remissions and
exacerbations
RATIONALE: This is a truthful answer that provides some realistic hope. With compliance to the
medical regimen, the client can be on remission for a long time.
134. During an exacerbation of Multiple Sclerosis, the client complains of urinary urgency and
frequency. The initial nursing action should be to:
RATIONALE: Assessment is the priority. The nurse should determine if the symptoms are caused by
a full bladder.
135. A client is given a diagnosis of cystitis. The nurse recognizes that Escherichia Coli is a common
causative agent in cystitis. The reason for this is that it is:
RATIONALE: It is a fact that E. coli is commonly found in the bowel and because of close anatomic
proximity and improper hygiene after bowel movements, the microorganism may spread to the nearby
urethra and thus the bacteria gains its way into the urinary system. This infection can best be prevented
by good and proper perineal hygiene
136. A 40 year old salesman, is admitted to the hospital with a tentative diagnosis of duodenal peptic
ulcer.
When performing the initial history and physical assessment the nurse would expect him to describe the
pain as:
CORRECT ANSWER: B. Gnawing, dull, aching epigastric pain or boring pain in the back
RATIONALE: Classic symptoms include gnawing, boring, or dull pain located in the mid epigastrium
or back. The pain is caused by irritation and erosion of the mucosal lining related to hypersecretion of
HCl. Option A is caused by biliary colic. Option D is related to gastric reflux disorder.
137. A clients peptic ulcer is confirmed by a gastroscopy and upper GI series. The physician orders
ranitidine (Zantac) 150 mg bid with meals. The nurse should check this order with the physician because:
RATIONALE: It is necessary to clarify the route of administration because the medication can be
given po, IV or IM. The other options are irrelevant.
138. A client hospitalized for peptic ulcer vomits his undigested antacids and complains of severe
epigastric pain. The nursing assessment reveals absence of bowel sounds, pulse rate of 134, and shallow
respirations of 32 per minute. In addition to calling the physician, the nurse should:
CORRECT ANSWER: D. Keep the client NPO in preparation for any possible surgery
RATIONALE: These are classic indicators of perforated peptic ulcer for which immediate surgery is
indicated. Assessing for possible complications should be part of the nursing assessment.
139. Subtotal gastrectomy (Billroth I) is performed on a client with peptic ulcer. The client recovers
from surgery and begins to eat more food in varied forms. After meals he experiences a cramping
discomfort and a rapid pulse with waves of weakness, which are frequently followed by nausea and
vomiting. The nurse recognizes that this response is known as dumping syndrome and is caused by:
CORRECT ANSWER: C. Rapid passage of hyperosmolar food solution into the small intestine
RATIONALE: Without an adequate stomach reservoir, the hypertonic oncentrated food mass from the
stomach dumps into the small intestine, drawing fluid from surrounding blood and tissue and causing
hypovolemia and typical shock symptoms. The initial manifestations of this complications are brought
about by hypovolemia.
140. About 2 hours after the initial post-meal attack of the dumping syndrome, the client experiences a
second period of discomfort, feeling somewhat shaky. This later follow-up effect, which is precipitated by
the dumping syndrome, is caused by:
B. Hyperglycemia from a rapidly absorbed glucose load, which overwhelms the insulin-adjusting
mechanism
C. The increased fat content and larger amount of seasoned food, creating digestive discomfort
D. The increased use of simple carbohydrates in meals, creating a more prolonged glucose rise
CORRECT ANSWER: A. Mild hypoglycemia from an overproduction of insulin that occurs in response
to the postprandial blood glucose rise
RATIONALE: The rapid absorption of sugars from the food mass causes elevation of blood sugar,
and the aggressive insulin response to bring the blood sugar to normal often causes transient
hypoglycemic symptoms.
141. The nurse understands that when a diabetic client undergoes surgery, his Insulin requirements
postoperatively will:
A. Decrease immediately
B. Fluctuate widely
C. Increase sharply
D. Remain elevated
RATIONALE: Emotional and physical stress related to surgery leads to hyperglycemia and cause
insulin requirements to remain elevated in the postoperative period
142. The nurse understands that, for a client who undergoes pelvic surgery, his plan of care must
include the prevention of postoperative deep vein thrombosis. This can be achieved by increasing the:
RATIONALE: Because venous stasis is the major predisposing factor of pulmonary emboli, venous
flow velocity should be increased like the application of anti-embolic stockings or elastic bandages to the
lower extremities and encouraging early ambulation
143. To prevent bleeding after prostatectomy, the client should be instructed to avoid straining on
defecation. The nurse knows that he understands the related teaching when he says he must increase his
intake of:
A. Milk products
B. Ripe bananas
C. Creamed potatoes
D. Green Vegetables
144. The most observable change caused by osteoporosis will occur in:
A. Facial bones
RATIONALE: Compression fractures of the vertebrae are the most frequent fractures in clients with
osteoporosis; a gradual collapse of vertebrae may be asymptomatic and only observed as kyphosis.
145. The physician applies Bucks extension (traction) on a client who recently had a hip fracture until
surgery can be performed to replace the head of the femur with a prosthesis. When checking the clients
Bucks extension, the nurse should be aware that:
A. Tape must cover the malleoli to adequately secure the weights to the leg
RATIONALE: Elevating the foot of the bed will provide counter traction. This will also keep the client
from being pulled down to the foot of the bed by the traction weight.
146. The nurse would recognize that a post-operative client is using the spirometer correctly when he:
A. Inhaled deeply, sealed her lips around the mouthpiece and exhaled
B. Coughed twice before inhaling deeply through the mouthpiece
C. Inhaled deeply through the mouthpiece, relaxed for a few seconds and then exhaled
CORRECT ANSWER: C. Inhaled deeply through the mouthpiece, relaxed for a few seconds and then
exhaled
RATIONALE: These are correct techniques; deep inhalation promotes alveolar expansion, and
exhalation promotes lung recoil. The other options are irrelevant.
147. A nurse is taking care of a client, who has received doctors orders on her 10th post-operative
day after left hip replacement surgery, to sit for short periods. When getting her out of bed the nurse
should place her in a:
C. Firm chair with her left foot flat on the floor's surface
D. Soft chair with enough pillows to keep the hip at a right angle
CORRECT ANSWER: C. Firm chair with her left foot flat on the floor's surface
RATIONALE: This action puts the least strain on the prosthesis, and the hip may be flexed to 90
degrees 10 days after surgery. No Hip flexion beyond 90 degrees is allowed as this might dislodge the
prosthesis.
148. A menopausal client can best limit further progression of her osteoporosis by:
RATIONALE: Research demonstrates that women past menopause need 1500 mg of Calcium a day
which is almost impossible to obtain through dietary sources because the average daily consumption of
calcium is 300-500 mg. Thus the need for supplements. Vitamin D promotes the deposition of calcium
into the bone
149. A client returns from the bronchoscopy procedure. The nurse should withhold food and fluid for
several hours to prevent:
A. Abdominal distention
B. Aspiration of food
D. Projectile vomiting
RATIONALE: To allow for the insertion of the bronchoscope, throat muscles are anesthetized using
an anesthetic spray. This diminishes the protective gag reflex. The nurse therefore needs to keep the
client on NPO until the gag reflex has returned.
150. Cancer of the lung is diagnosed in the client and a pneumonectomy is performed. When
inspecting the clients dressing, the nurse observes some puffiness of the tissue around the area. When
the area is palpated, the tissue feels spongy with crackles. In charting, the nurse should describe this
observation as:
A. Chest distention
B. Crepitus
C. Pitting edema
D. Stridor
CORRECT ANSWER: B. Crepitus
RATIONALE: There is air in the tissues and palpation results in a crackling sound referred to as
crepitus. This may indicate the presence of subcutaneous emphysema.
151. A client who underwent Right pneumonectomy is observed on the first post-operative day to
have suddenly sat straight up in bed. His respirations are labored, and he is making a crowing sound. His
skin is pale, cool and moist. Immediately the nurse should:
RATIONALE: Assessment of the airway takes priority after chest surgery. Mediastinal shift with
airway obstruction may occur because pressure from retained secretions can build up on the operative
side, causing the trachea to deviate toward the unoperative side. This can lead to airway obstruction.
Auscultation of the unoperated side will help determine the presence of obstruction. Chest tubes are not
usually noted following pneumonectomy since there is no more lung to re-expand
152. When turning a client who underwent left pneumonectomy, the nurse should plan the use of:
RATIONALE: Lying on the operative side permits ventilation of the remaining lung and prevents fluid
from draining into the sutured bronchial stump and into the unaffected lung
153. After pneumonectomy, irradiation to the chest wall has been prescribed for the client with lung
cancer on an outpatient basis. In teaching him about skin care, the nurse should emphasize:
CORRECT ANSWER: C. Keeping the skin dry and protected from abrasions
RATIONALE: The skin is the first line of defense and keeping it dry and safe from injury promotes
skin integrity. Skin applications and frequent washings are avoided.
154. The characteristics that would alert the nurse that a client is at increased risk of developing
gallbladder disease would be:
RATIONALE: All these characteristics are well-established risk factors for gallbladder disease
(female, fat, forty and fertile
155. A client is to undergo an oral cholecystogram in the morning. As part of the preparation for this
test, the nurse should tell her client:
CORRECT ANSWER: D. A low-fat supper should be eaten the night before the test
RATIONALE: A low fat dinner is given so that large amounts of bile is stored in the gallbladder when
the test is done that can promote good radiographic visualization.
156. The presence of gallstones is confirmed and a client is given the diagnosis of Cholelithiasis.
Cholecystectomy with common bile duct exploration is scheduled. In the immediate postoperative period,
the nursing action that should assume the highest priority is:
RATIONALE: Self splinting of the incision site that clients do to control the post-operative pain results
in shallow breathing which does not aerate the lungs adequately, particularly the lower right lobe. Clients
need to be given pain relievers as ordered and encouraged deep breathing and coughing activities.
157. A hypertensive client is to be released from the hospital on regimen of Chlorothiazide and
Aldomet. The nurse should instruct the client to:
A. Avoid eating fruits and vegetables because they limit the liver's effect on digestion
C. Modify her diet to compensate for the pharmacologic effects of her medication on electrolyte
levels.
CORRECT ANSWER: C. Modify her diet to compensate for the pharmacologic effects of her
medication on electrolyte levels.
RATIONALE: Diuril is both a sodium & potassium excreting diuretic. The client must increase dietary
intake of potassium because of potassium loss associated with Diuril
158. The physician orders TPN 1L q12 hours for 2 days to a client with Colitis. The primary nursing
responsibility should be to monitor the clients
A. Electrolytes
B. Urinary output
C. Administration rate
RATIONALE: The solution is hyperosmolar and a very concentrated source of glucose. Too rapid
infusion can cause hyperglycemia that can easily contribute to circulatory overload. An infusion pump
should be used to ensure accurate infusion. At the same time, the clients blood glucose levels should be
monitored.
159. The nurse should be aware that clients receiving only IV fluids lose weight because of:
RATIONALE: IV fluids supply minimal calories not enough to meet daily nutritional requirements. A
client on only IV therapy will eventually lose weight and become malnourished.
160. A client develops an infection at the IV catheter insertion site. The nurse uses the term iatrogenic
when describing this infection because it resulted from:
C. A therapeutic procedure
161. A client is admitted with severe left flank pain, nausea, and hematuria. The tentative diagnosis is
a ureteral calculus. When he is first admitted, the initial nursing action is to:
RATIONALE: The pain of renal colic is excruciating and caused by spasms of the smooth muscles to
release the obstruction in the urinary tract. Unless relief is obtained the client will be unable to cooperate
with other therapy.
162. When taking the admitting history of a client with possible Left ureteral calculus, the nurse would
expect him to report:
CORRECT ANSWER: D. Spasmodic pain on the left side radiating to the suprapubis
RATIONALE: The pain with ureteral stones is caused by muscle spasm of the ureters in an attempt to
dislodge the obstruction and is excruciating and intermittent that follows the path of the ureter to the
bladder.
163. A 45 year-old jeepney driver is scheduled for an Intravenous Pyelogram (IVP). The nurse
explains to him that on the day before the IVP he must:
RATIONALE: The urinary system is located retroperitoneally. Laxatives remove feces and flatus,
providing better visualization of the urinary system.
164. The clients serum Calcium is elevated and the Intravenous Pyelogram (IVP) confirms the
presence of a ureteral calculus. If his blood tests indicated an elevated uric acid level instead of an
elevated calcium level, the nurse would recognize that the doctor may consider the presence of:
A. BPH
B. Gout
C. Rheumatoid Arthritis
D. Tetany
RATIONALE: Elevated serum uric acid is noted in the assessment of clients with Gout. The
accumulation of uric acid can contribute to the occurrence of acid urinary calculi
165. A client is admitted to the hospital with a history of ureterolithiasis, lower third. His urinary output
is noted to be much less than his intake. When it is noted that his bladder is not distended, the nurse
should suspect the development of:
A. Shock
B. Hydroureter
C. Urinary retention
D. Pulmonary congestion
RATIONALE: Calculi may obstruct the flow of urine to the bladder, allowing the urine to distend the
ureter causing hydroureter. Urinary retention presents itself with a distended bladder, even after voiding,
with an increase in residual urine.
166. Before a client with a history of urinary calculi is discharged, the nurse needs to discuss the need
to avoid UTI. The nurse knows that he understands signs of infection when he says he will report:
RATIONALE: These occur with a urinary tract infection because of bladder irritability. Burning on
urination and fever are additional signs of UTI
167. To facilitate micturation, a nurse should instruct a client with difficulty to voiding to:
RATIONALE: This uses gravity to allow urine to exert pressure on the area of the urinary trigone,
initiating relaxation of the urinary sphincter, and facilitating micturition.
168. A priority nursing action during the first 48 hours after admission of a client with jaundice and
pedal edema, and a history of excessive alcohol intake for the last five years, will be to:
RATIONALE: A history of excessive alcohol intake for the last five years will surely manifest itself with
alcohol withdrawal. A clients vital signs, especially the pulse and temperature will rise before the client
demonstrates any of the more severe symptoms of withdrawal from alcohol.
169. The nurse, aware of a clients history of excessive alcohol use, would expect his physical
assessment to reveal a :
A. Type A Hepatitis
RATIONALE: Scar tissue that forms as cirrhosis progresses, due to the hepatotoxic damage of
alcohol, causes the liver tissue to contract, making the liver small with a rough surface. Nodules are
formed as scar tissue pulls the liver at certain points.
170. A client with a liver disorder reports that his gums bleed spontaneously. In addition, the nurse
notes small hemorrhagic lesions on his face. The nurse recognizes that he needs additional:
A. Vitamin A
B. Bile salts
C. Vitamin K
D. Folic Acid
RATIONALE: Petechiae are evidences of capillary bleeding. The diseased liver is no longer able to
metabolize vitamin K which is necessary in the formation of prothrombin.
171. When the physician schedules a paracentesis on a client, the nurse should:
RATIONALE: The site of puncture for paracentesis is between the umbilicus and the symphysis
pubis. Instructing the client to void before paracentesis keeps the bladder in the pelvic area and prevents
its accidental puncture when the abdominal cavity is entered.
172. Dexamethasone (Decadron) is ordered for the early management of a client with cerebral edema
related to left intracerebral hemorrhage. This treatment is effective because it:
RATIONALE: Corticosteroids act to decrease inflammation which decreases the cerebral edema.
This can decrease the increased intracranial pressure of the client
173. During the time that a client is receiving Dexamethasone, the nurse should observe for the
development of negative side effect by:
174. The neuromuscular status and decreased mobility of a client with Stroke must be assessed early.
It is important for the nurse to consider any restrictions or abnormalities that are observed because:
CORRECT ANSWER: B. Shortening and eventual atrophy of the muscles will occur
RATIONALE: Shortening and eventual atrophy of muscles occurs due to lack of use, resulting in
contractures
175. A client is noted to manifest right hemianopsia as a result of his CVA. The nurse should:
RATIONALE: This client has lost vision from the right visual field. Scanning his environment
compensates for the loss allowing for better visualization.