1. Randy has undergone kidney transplant, what assessment would prompt Nurse 8.

8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid
Katrina to suspect organ rejection? and electrolyte imbalances. The client is somewhat confused and complains of nausea
A. Sudden weight loss and muscle weakness. As part of the prescribed therapy to correct this electrolyte
B. Polyuria imbalance, the nurse would expect to:
C. Hypertension A. Administer Kayexalate
D. Shock B. Restrict foods high in protein
2. The immediate objective of nursing care for an overweight, mildly hypertensive C. Increase oral intake of cheese and milk.
male client with ureteral colic and hematuria is to decrease: D. Administer large amounts of normal saline via I.V.
A. Pain 9. Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of
B. Weight IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The
C. Hematuria nurse should set the flow to provide:
D. Hypertension A. 18 gtt/min
3. Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal B. 28 gtt/min
thyroidectomy is performed. The nurse is aware that this medication is given to: C. 32 gtt/min
A. Decrease the total basal metabolic rate. D. 36 gtt/min
B. Maintain the function of the parathyroid glands. 10.Terence suffered form burn injury. Using the rule of nines, which has the largest
C. Block the formation of thyroxine by the thyroid gland. percent of burns?
D. Decrease the size and vascularity of the thyroid gland. A. Face and neck
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute B. Right upper arm and penis
hypoglycemia also can develop in the client who is diagnosed with: C. Right thigh and penis
A. Liver disease D. Upper trunk
B. Hypertension 11. Herbert, a 45 year old construction engineer is brought to the hospital
C. Type 2 diabetes unconscious after falling from a 2-story building. When assessing the client, the nurse
D. Hyperthyroidism would be most concerned if the assessment revealed:
5. Tracy is receiving combination chemotherapy for treatment of metastatic A. Reactive pupils
carcinoma. Nurse Ruby should monitor the client for the systemic side effect of: B. A depressed fontanel
A. Ascites C. Bleeding from ears
B. Nystagmus D. An elevated temperature
C. Leukopenia 12. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker.
D. Polycythemia Which information given by the nurse shows her knowledge deficit about the artificial
6. Norma, with recent colostomy expresses concern about the inability to control the cardiac pacemaker?
passage of gas. Nurse Oliver should suggest that the client plan to: A. take the pulse rate once a day, in the morning upon awakening
A. Eliminate foods high in cellulose. B. May be allowed to use electrical appliances
B. Decrease fluid intake at meal times. C. Have regular follow up care
C. Avoid foods that in the past caused flatus. D. May engage in contact sports
D. Adhere to a bland diet prior to social events. 13.The nurse is ware that the most relevant knowledge about oxygen administration
7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The to a male client with COPD is
nurse would evaluate that the instructions were understood when the client states, “I A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
should: B. Hypoxia stimulates the central chemoreceptors in the medulla that makes
A. Lie on my left side while instilling the irrigating solution.” the client breath.
B. Keep the irrigating container less than 18 inches above the stoma.” C. Oxygen is administered best using a non-rebreathing mask
C. Instill a minimum of 1200 ml of irrigating solution to stimulate evacuation of D. Blood gases are monitored using a pulse oximeter.
the bowel.”
D. Insert the irrigating catheter deeper into the stoma if cramping occurs
during the procedure.”
14.Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest
tubes are inserted, and one-bottle water-seal drainage is instituted in the operating
room. In the postanesthesia care unit Tonny is placed in Fowler’s position on either
his right side or on his back. The nurse is aware that this position:
A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous return
15.Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect
afterward, the nurse’s highest priority of information would be:
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.
16.Nurse Tristan is caring for a male client in acute renal failure. The nurse should
expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to
treat:
A. hypernatremia.
B. hypokalemia.
C. hyperkalemia.
D. hypercalcemia.
17.Ms. X has just been diagnosed with condylomata acuminata (genital warts). What
information is appropriate to tell this client?
A. This condition puts her at a higher risk for cervical cancer; therefore, she
should have a Papanicolaou (Pap)
smear annually.
B. The most common treatment is metronidazole (Flagyl), which should
eradicate the problem within 7 to 10
days.
C. The potential for transmission to her sexual partner will be eliminated if
condoms are used every time they
have sexual intercourse.
D. The human papillomavirus (HPV), which causes condylomata acuminata,
can’t be transmitted during oral
sex.
18.Maritess was recently diagnosed with a genitourinary problem and is being
examined in the emergency department. When palpating the her kidneys, the nurse
should keep which anatomical fact in mind?
A. The left kidney usually is slightly higher than the right one.
B. The kidneys are situated just above the adrenal glands.
C. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾” to
1-1/8″) wide.
D. The kidneys lie between the 10th and 12th thoracic vertebrae.
19.Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is
aware that the diagnostic test are consistent with CRF if the result is:
A. Increased pH with decreased hydrogen ions.
B. Increased serum levels of potassium, magnesium, and calcium.
C. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
D. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion75%.
20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she
read her chart while the nurse was out of the room, Katrina asks what dysplasia
means. Which definition should the nurse provide?
A. Presence of completely undifferentiated tumor cells that don’t resemble cells
of the tissues of their origin.
B. Increase in the number of normal cells in a normal arrangement in a tissue
or an organ.
C. Replacement of one type of fully differentiated cell by another in tissues
where the second type normally
isn’t found.
D. Alteration in the size, shape, and organization of differentiated cells.
21. During a routine checkup, Nurse Mariane assesses a male client with acquired
immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the
most common AIDS-related cancer?
A. Squamous cell carcinoma
B. Multiple myeloma
C. Leukemia
D. Kaposi’s sarcoma
22.Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a
spinal (subarachnoid) block during surgery. In the operating room, the nurse positions
the client according to the anesthesiologist’s instructions. Why does the client require
special positioning for this type of anesthesia?
A. To prevent confusion
B. To prevent seizures
C. To prevent cerebrospinal fluid (CSF) leakage
D. To prevent cardiac arrhythmias
23.A male client had a nephrectomy 2 days ago and is now complaining of abdominal
pressure and nausea. The first nursing action should be to:
A. Auscultate bowel sounds.
B. Palpate the abdomen.
C. Change the client’s position.
D. Insert a rectal tube.
24.Wilfredo with a recent history of rectal bleeding is being prepared for a
colonoscopy. How should the nurse Patricia position the client for this test initially?
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor
25.A male client with inflammatory bowel disease undergoes an ileostomy. On the
first day after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How
should the nurse interpret this finding?
A. Blood supply to the stoma has been interrupted.
B. This is a normal finding 1 day after surgery.
C. The ostomy bag should be adjusted.
D. An intestinal obstruction has occurred.
26.Anthony suffers burns on the legs, which nursing intervention helps prevent
contractures?
A. Applying knee splints
B. Elevating the foot of the bed
C. Hyperextending the client’s palms
D. Performing shoulder range-of-motion exercises
27.Nurse Ron is assessing a client admitted with second- and third-degree burns on
the face, arms, and chest. Which finding indicates a potential problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).
28. Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to
move on his own. To help the client avoid pressure ulcers, Nurse Celia should:
A. Turn him frequently.
B. Perform passive range-of-motion (ROM) exercises.
C. Reduce the client’s fluid intake.
D. Encourage the client to use a footboard.
29.Nurse Maria plans to administer dexamethasone cream to a female client who has
dermatitis over the anterior chest. How should the nurse apply this topical agent?
A. With a circular motion, to enhance absorption.
B. With an upward motion, to increase blood supply to the affected area
C. In long, even, outward, and downward strokes in the direction of hair
growth
D. In long, even, outward, and upward strokes in the direction opposite hair
growth
30.Nurse Kate is aware that one of the following classes of medication protect the
ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation
is:
A. Beta -adrenergic blockers
B. Calcium channel blocker
C. Narcotics
D. Nitrates
31.A male client has jugular distention. On what position should the nurse place the
head of the bed to obtain the most accurate reading of jugular vein distention?
A. High Fowler’s
B. Raised 10 degrees
C. Raised 30 degrees
D. Supine position
32.The nurse is aware that one of the following classes of medications maximizes
cardiac performance in clients with heart failure by increasing ventricular contractility?
A. Beta-adrenergic blockers
B. Calcium channel blocker
C. Diuretics
D. Inotropic agents
33.A male client has a reduced serum high-density lipoprotein (HDL) level and an
elevated low-density lipoprotein (LDL) level. Which of the following dietary
modifications is not appropriate for this client?
A. Fiber intake of 25 to 30 g daily
B. Less than 30% of calories form fat
C. Cholesterol intake of less than 300 mg daily
D. Less than 10% of calories from saturated fat
34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days
ago with an acute myocardial infarction. Which of the following actions would breach
the client confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the telemetry unit
before transferring the client to that
unit
B. The CCU nurse notifies the on-call physician about a change in the client’s
condition
C. The emergency department nurse calls up the latest electrocardiogram
results to check the client’s progress.
D. At the client’s request, the CCU nurse updates the client’s wife on his
condition
35. A male client arriving in the emergency department is receiving cardiopulmonary
resuscitation from paramedics who are giving ventilations through an endotracheal
(ET) tube that they placed in the client’s home. During a pause in compressions, the
cardiac monitor shows narrow QRS complexes and a heart rate of beats/minute with a
palpable pulse. Which of the following actions
should the nurse take first?
A. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over
10 minutes.
B. Check endotracheal tube placement.
C. Obtain an arterial blood gas (ABG) sample.
D. Administer atropine, 1 mg L.V.
36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse
Katrina determines that mean arterial pressure (MAP) is which of the following?
A. 46 mm Hg
B. 80 mm Hg
C. 95 mm Hg
D. 90 mm Hg
37. A female client arrives at the emergency department with chest and stomach pain 44. Francis with leukemia has neutropenia. Which of the following functions must
and a report of black tarry stool for several months. Which of the following order frequently assessed?
should the nurse Oliver anticipate? A. Blood pressure
A. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase levels B. Bowel sounds
B. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split C. Heart sounds
product values. D. Breath sounds
C. Electrocardiogram, complete blood count, testing for occult blood, 45. The nurse knows that neurologic complications of multiple myeloma (MM) usually
comprehensive serum metabolic panel. involve which of the following body system?
D. Electroencephalogram, alkaline phosphatase and aspartate A. Brain
aminotransferase levels, basic serum metabolic B. Muscle spasm
panel C. Renal dysfunction
38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of D. Myocardial irritability
the following conditions is suspected by the nurse when a decrease in platelet count 46. Nurse Patricia is aware that the average length of time from human
from 230,000 ul to 5,000 ul is noted? immunodeficiency virus (HIV) infection to the development of acquired
A. Pancytopenia immunodeficiency syndrome (AIDS)?
B. Idiopathic thrombocytopemic purpura (ITP) A. Less than 5 years
C. Disseminated intravascular coagulation (DIC) B. 5 to 7 years
D. Heparin-associated thrombosis and thrombocytopenia (HATT) C. 10 years
39. Which of the following drugs would be ordered by the physician to improve the D. More than 10 years
platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)? 47. An 18-year-old male client admitted with heat stroke begins to show signs of
A. Acetylsalicylic acid (ASA) disseminated intravascular coagulation (DIC). Which of the following laboratory
B. Corticosteroids findings is most consistent with DIC?
C. Methotrezate A. Low platelet count
D. Vitamin K B. Elevated fibrinogen levels
40. A female client is scheduled to receive a heart valve replacement with a porcine C. Low levels of fibrin degradation products
valve. Which of the following types of transplant is this? D. Reduced prothrombin time
A. Allogeneic 48. Mario comes to the clinic complaining of fever, drenching night sweats, and
B. Autologous unexplained weight loss over the past 3 months. Physical examination reveals a single
C. Syngeneic enlarged supraclavicular lymph node. Which of the following is the most probable
D. Xenogeneic diagnosis?
41. Marco falls off his bicycle and injuries his ankle. Which of the following actions A. Influenza
shows the initial response to the injury in the extrinsic pathway? B. Sickle cell anemia
A. Release of Calcium C. Leukemia
B. Release of tissue thromboplastin D. Hodgkin’s disease
C. Conversion of factors XII to factor XIIa 49. A male client with a gunshot wound requires an emergency blood transfusion. His
D. Conversion of factor VIII to factor VIIIa blood type is AB negative. Which blood type would be the safest for him to receive?
42. Instructions for a client with systemic lupus erythematosus (SLE) would include A. AB Rh-positive
information about which of the following blood dyscrasias? B. A Rh-positive
A. Dressler’s syndrome C. A Rh-negative
B. Polycythemia D. O Rh-positive
C. Essential thrombocytopenia
D. Von Willebrand’s disease
43. The nurse is aware that the following symptoms is most commonly an early
indication of stage 1 Hodgkin’s disease?
A. Pericarditis
B. Night sweat
C. Splenomegaly
D. Persistent hypothermia
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning 57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm
chemotherapy. Hg; Pao2 46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which
50. Stacy is discharged from the hospital following her chemotherapy treatments. of the following conditions?
Which statement of Stacy’s mother indicated that she understands when she will A. Metabolic acidosis
contact the physician? B. Metabolic alkalosis
A. “I should contact the physician if Stacy has difficulty in sleeping”. C. Respiratory acidosis
B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”. D. Respirator y alkalosis
C. “My physician should be called if Stacy is irritable and unhappy”. 58. Norma has started a new drug for hypertension. Thirty minutes after she takes
D. “Should Stacy have continued hair loss, I need to call the doctor”. the drug, she develops chest tightness and becomes short of breath and tachypneic.
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The She has a decreased level of consciousness. These signs indicate which of the
best response for the nurse is: following conditions?
A. “Stacy looks very nice wearing a hat”. A. Asthma attack
B. “You should not worry about her hair, just be glad that she is alive”. B. Pulmonary embolism
C. “Yes it is upsetting. But try to cover up your feelings when you are with her C. Respiratory failure
or else she may be upset”. D. Rheumatoid arthritis
D. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule
be different in texture”. out cirrhosis of the liver:
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse 59. Which laboratory test indicates liver cirrhosis?
in-charge should: A. Decreased red blood cell count
A. Provide frequent mouthwash with normal saline. B. Decreased serum acid phosphate level
B. Apply viscous Lidocaine to oral ulcers as needed. C. Elevated white blood cell count
C. Use lemon glycerine swabs every 2 hours. D. Elevated serum aminotransferase
D. Rinse mouth with Hydrogen Peroxide. 60.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at
53. During the administration of chemotherapy agents, Nurse Oliver observed that the increased risk for excessive bleeding primarily because of:
IV site is red and swollen, when the IV is touched Stacy shouts in pain. The first A. Impaired clotting mechanism
nursing action to take is: B. Varix formation
A. Notify the physician C. Inadequate nutrition
B. Flush the IV line with saline solution D. Trauma of invasive procedure
C. Immediately discontinue the infusion 61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is
D. Apply an ice pack to the site, followed by warm compress. most common with this condition?
54. The term “blue bloater” refers to a male client which of the following conditions? A. Increased urine output
A. Adult respiratory distress syndrome (ARDS) B. Altered level of consciousness
B. Asthma C. Decreased tendon reflex
C. Chronic obstructive bronchitis D. Hypotension
D. Emphysema 62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose
55. The term “pink puffer” refers to the female client with which of the following p.o. every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:
conditions? A. “I’ll see if your physician is in the hospital”.
A. Adult respiratory distress syndrome (ARDS) B. “Maybe your reacting to the drug; I will withhold the next dose”.
B. Asthma C. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a
C. Chronic obstructive bronchitis day”.
D. Emphysema D. “Frequently, bowel movements are needed to reduce sodium level”.
56. Jose is in danger of respiratory arrest following the administration of a narcotic
analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the
paco2 to be which of the following values?
A. 15 mm Hg
B. 30 mm Hg
C. 40 mm Hg
D. 80 mm Hg
63. Which of the following groups of symptoms indicates a ruptured abdominal aortic 70. Arnold, a 19-year-old client with a mild concussion is discharged from the
aneurysm? emergency department. Before discharge, he complains of a headache. When offered
A. Lower back pain, increased blood pressure, decreased re blood cell (RBC) acetaminophen, his mother tells the nurse the headache is severe and she would like
count, increased white blood her son to have something stronger. Which of the following responses by the nurse is
(WBC) count. appropriate?
B. Severe lower back pain, decreased blood pressure, decreased RBC count, A. “Your son had a mild concussion, acetaminophen is strong enough.”
increased WBC count. B. “Aspirin is avoided because of the danger of Reye’s syndrome in children or
C. Severe lower back pain, decreased blood pressure, decreased RBC count, young adults.”
decreased RBC count, decreased C. “Narcotics are avoided after a head injury because they may hide a
WBC count. worsening condition.”
D. Intermitted lower back pain, decreased blood pressure, decreased RBC D. Stronger medications may lead to vomiting, which increases the intracarnial
count, increased WBC count. pressure (ICP).”
64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood 71. When evaluating an arterial blood gas from a male client with a subdural
under his buttocks. Which of the following steps should the nurse take first? hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses
A. Call for help. best describes the result?
B. Obtain vital signs A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure
C. Ask the client to “lift up” (ICP)
D. Apply gloves and assess the groin site B. Emergent; the client is poorly oxygenated
65. Which of the following treatment is a suitable surgical intervention for a client with C. Normal
unstable angina? D. Significant; the client has alveolar hypoventilation
A. Cardiac catheterization 72. When prioritizing care, which of the following clients should the nurse Olivia
B. Echocardiogram assess first?
C. Nitroglycerin A. A 17-year-old clients 24-hours postappendectomy
D. Percutaneous transluminal coronary angioplasty (PTCA) B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
66. The nurse is aware that the following terms used to describe reduced cardiac C. A 50-year-old client 3 days postmyocardial infarction
output and perfusion impairment due to ineffective pumping of the heart is: D. A 50-year-old client with diverticulitis
A. Anaphylactic shock 73. JP has been diagnosed with gout and wants to know why colchicine is used in the
B. Cardiogenic shock treatment of gout. Which of the following actions of colchicines explains why it’s
C. Distributive shock effective for gout?
D. Myocardial infarction (MI) A. Replaces estrogen
67. A client with hypertension ask the nurse which factors can cause blood pressure B. Decreases infection
to drop to normal levels? C. Decreases inflammation
A. Kidneys’ excretion to sodium only. D. Decreases bone demineralization
B. Kidneys’ retention of sodium and water 74. Norma asks for information about osteoarthritis. Which of the following
C. Kidneys’ excretion of sodium and water statements about osteoarthritis is correct?
D. Kidneys’ retention of sodium and excretion of water A. Osteoarthritis is rarely debilitating
68. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) B. Osteoarthritis is a rare form of arthritis
is administered to treat hypertension is: C. Osteoarthritis is the most common form of arthritis
A. It dilates peripheral blood vessels. D. Osteoarthritis afflicts people over 60
B. It decreases sympathetic cardioacceleration. 75. Ruby is receiving thyroid replacement therapy develops the flu and forgets to take
C. It inhibits the angiotensin-coverting enzymes her thyroid replacement medicine. The nurse understands that skipping this
D. It inhibits reabsorption of sodium and water in the loop of Henle. medication will put the client at risk for developing which of the following
69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus lifethreatening complications?
erythematosus (SLE) is: A. Exophthalmos
A. Elavated serum complement level B. Thyroid storm
B. Thrombocytosis, elevated sedimentation rate C. Myxedema coma
C. Pancytopenia, elevated antinuclear antibody (ANA) titer D. Tibial myxedema
D. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels
76. Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation
should the nurse report to the physician immediately?
A. Pitting edema of the legs
B. An irregular apical pulse
C. Dry mucous membranes
D. Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is admitted to the
intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises
above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory
findings support the nurse’s suspicion of diabetes insipidus?
A. Above-normal urine and serum osmolality levels
B. Below-normal urine and serum osmolality levels
C. Above-normal urine osmolality level, below-normal serum osmolality level
D. Below-normal urine osmolality level, above-normal serum osmolality level
78. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome
(HHNS) is stabilized and prepared for discharge. When preparing the client for
discharge and home management, which of the following statements indicates that
the client understands her condition and how to control it?
A. “I can avoid getting sick by not becoming dehydrated and by paying
attention to my need to urinate, drink,
or eat more than usual.”
B. “If I experience trembling, weakness, and headache, I should drink a glass
of soda that contains sugar.”
C. “I will have to monitor my blood glucose level closely and notify the
physician if it’s constantly elevated.”
D. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in
carbohydrates.”
79. A 66-year-old client has been complaining of sleeping more, increased urination,
anorexia, weakness, irritability, depression, and bone pain that interferes with her
going outdoors. Based on these assessment findings, the nurse would suspect which
of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about the
need to take fludrocortisone acetate and hydrocortisone at home. Which statement by
the client indicates an understanding of the instructions?
A. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
B. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
C. “I’ll take two-thirds of the dose when I wake up and one-third in the late
afternoon.”
D. “I’ll take the entire dose at bedtime.”
81. Which of the following laboratory test results would suggest to the nurse Len that
a client has a corticotropin-secreting pituitary adenoma?
A. High corticotropin and low cortisol levels
B. Low corticotropin and high cortisol levels
C. High corticotropin and high cortisol levels
D. Low corticotropin and low cortisol levels
82. A male client is scheduled for a transsphenoidal hypophysectomy to remove a
pituitary tumor. Preoperatively, the nurse should assess for potential complications by
doing which of the following?
A. Testing for ketones in the urine
B. Testing urine specific gravity
C. Checking temperature every 4 hours
D. Performing capillary glucose testing every 4 hours
83. Capillary glucose monitoring is being performed every 4 hours for a client
diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular
insulin according to glucose results. At 2 p.m., the client has a capillary glucose level
of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect
the dose’s:
A. onset to be at 2 p.m. and its peak to be at 3 p.m.
B. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. onset to be at 4 p.m. and its peak to be at 6 p.m.
84. The physician orders laboratory tests to confirm hyperthyroidism in a female client
with classic signs and symptoms of this disorder. Which test result would confirm the
diagnosis?
A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes
during the TSH stimulation test
B. A decreased TSH level
C. An increase in the TSH level after 30 minutes during the TSH stimulation
test
D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine
(T4) as detected by radioimmunoassay
85. Rico with diabetes mellitus must learn how to self-administer insulin. The
physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane
insulin suspension (NPH) to be taken before breakfast. When teaching the client how
to select and rotate insulin injection sites, the nurse should provide which instruction?
A. “Inject insulin into healthy tissue with large blood vessels and nerves.”
B. “Rotate injection sites within the same anatomic region, not among
different regions.”
C. “Administer insulin into areas of scar tissue or hypotrophy whenever
possible.”
D. “Administer insulin into sites above muscles that you plan to exercise
heavily later that day.”
86. Nurse Sarah expects to note an elevated serum glucose level in a client with 93. A 62-year-old male client was in a motor vehicle accident as an unrestrained
hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory driver. He’s now in the emergency department complaining of difficulty of breathing
finding should the nurse anticipate? and chest pain. On auscultation of his lung field, no breath sounds are present in the
A. Elevated serum acetone level upper lobe. This client may have which of the following conditions?
B. Serum ketone bodies A. Bronchitis
C. Serum alkalosis B. Pneumonia
D. Below-normal serum potassium level C. Pneumothorax
87. For a client with Graves’ disease, which nursing intervention promotes comfort? D. Tuberculosis (TB)
A. Restricting intake of oral fluids 94. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
B. Placing extra blankets on the client’s bed A. The space remains filled with air only
C. Limiting intake of high-carbohydrate foods B. The surgeon fills the space with a gel
D. Maintaining room temperature in the low-normal range C. Serous fluids fills the space and consolidates the region
88. Patrick is treated in the emergency department for a Colles’ fracture sustained D. The tissue from the other lung grows over to the other side
during a fall. What is a Colles’ fracture? 95. Hemoptysis may be present in the client with a pulmonary embolism because of
A. Fracture of the distal radius which of the following reasons?
B. Fracture of the olecranon A. Alveolar damage in the infracted area
C. Fracture of the humerus B. Involvement of major blood vessels in the occluded area
D. Fracture of the carpal scaphoid C. Loss of lung parenchyma
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the D. Loss of lung tissue
development of this disorder? 96. Aldo with a massive pulmonary embolism will have an arterial blood gas analysis
A. Calcium and sodium performed to determine the extent of hypoxia. The acid-base disorder that may be
B. Calcium and phosphorous present is?
C. Phosphorous and potassium A. Metabolic acidosis
D. Potassium and sodium B. Metabolic alkalosis
90. Johnny a firefighter was involved in extinguishing a house fire and is being treated C. Respiratory acidosis
to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring D. Respiratory alkalosis
intubation and mechanical ventilation. He most likely has developed which of the 97. After a motor vehicle accident, Armand an 22-year-old client is admitted with a
following conditions? pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage
A. Adult respiratory distress syndrome (ARDS) system. Bubbling soon appears in the water seal chamber. Which of the following is
B. Atelectasis the most likely cause of the bubbling?
C. Bronchitis A. Air leak
D. Pneumonia B. Adequate suction
91. A 67-year-old client develops acute shortness of breath and progressive hypoxia C. Inadequate suction
requiring right femur. The hypoxia was probably caused by which of the following D. Kinked chest tube
conditions? 98. Nurse Michelle calculates the IV flow rate for a postoperative client. The client
A. Asthma attack receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion
B. Atelectasis set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s
C. Bronchitis IV to deliver how many drops per minute?
D. Fat embolism A. 18
92. A client with shortness of breath has decreased to absent breath sounds on the B. 21
right side, from the apex to the base. Which of the following conditions would best C. 35
explain this? D. 40
A. Acute asthma
B. Chronic bronchitis
C. Pneumonia
D. Spontaneous pneumothorax
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with
congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle
of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the
nurse administer to the child?
A. 1.2 ml
B. 2.4 ml
C. 3.5 ml
D. 4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the following
statements, if made by the client, indicates to the nurse that the teaching was
successful?
A. “I will wear the stockings until the physician tells me to remove them.”
B. “I should wear the stockings even when I am sleep.”
C. “Every four hours I should remove the stockings for a half hour.”
D. “I should put on the stockings before getting out of bed in the morning.”
 Answers and Rationales
1. Answer: (C) Hypertension. Hypertension, along with fever, and tenderness over
the grafted kidney, reflects acute rejection.
2. Answer: (A) Pain. Sharp, severe pain (renal colic) radiating toward the genitalia and
thigh is caused by uretheral distention and smooth muscle spasm; relief form pain is
the priority.
3. Answer: (D) Decrease the size and vascularity of the thyroid gland. Lugol’s
solution provides iodine, which aids in decreasing the vascularity of the thyroid gland,
which limits the risk of hemorrhage when surgery is performed.
4. Answer: (A) Liver Disease. The client with liver disease has a decreased ability
to metabolize carbohydrates because of a decreased ability to form
glycogen (glycogenesis) and to form glucose from glycogen.
5. Answer: (C) Leukopenia. Leukopenia, a reduction in WBCs, is a systemic effect
of chemotherapy as a result of myelosuppression.
6. Answer: (C) Avoid foods that in the past caused flatus. Foods that bothered a
person preoperatively will continue to do so after a colostomy.
7. Answer: (B) Keep the irrigating container less than 18 inches above
the stoma.” This height permits the solution to flow slowly with little force so that
excessive peristalsis is not immediately precipitated.
8. Answer: (A) Administer Kayexalate. Kayexalate,a potassium exchange resin,
permits sodium to be exchanged for potassium in the intestine, reducing the serum
potassium level.
9. Answer:(B) 28 gtt/min. 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)
10. Answer: (D) Upper trunk. The percentage designated for each burned part of the
body using the rule of nines: Head and neck 9%; Right upper extremity 9%;
Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right
lower extremity 18%; Left lower extremity 18%; Perineum 1%.
11. Answer: (C) Bleeding from ears. The nurse needs to perform a thorough
assessment that could indicate alterations in cerebral function, increased intracranial
pressures, fractures and bleeding. Bleeding from the ears occurs only with basal
skull fractures that can easily contribute to increased intracranial pressure and brain
herniation.
12. Answer: (D) may engage in contact sports. The client should be advised by the
nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker
generator.
13. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic
stimulus for breathing. COPD causes a chronic CO2 retention that renders
the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the
client then becomes the stimulus for breathing. Giving the client oxygen in low
concentrations will maintain the client’s hypoxic drive.
14. Answer: (B) Facilitate ventilation of the left lung. Since only a partial
pneumonectomy is done, there is a need to promote expansion of this remaining Left
lung by positioning the client on the opposite unoperated side.
15. Answer: (A) Food and fluids will be withheld for at least 2 hours. Prior to
bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize
the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client
food and drink after the procedure without checking on the return of the gag reflex
can cause the client to aspirate. The gag reflex usually returns after two hours.
16. Answer: (C) hyperkalemia. Hyperkalemia is a common complication of acute renal
failure. It’s life-threatening if immediate action isn’t taken to reverse it.
The administration of glucose and regular insulin, with sodium bicarbonate
if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells
and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and
hypercalcemia don’t usually occur with acute renal failure and aren’t treated with
glucose, insulin, or sodium bicarbonate.
17. Answer: (A) This condition puts her at a higher risk for cervical
cancer; therefore, she should have a Papanicolaou (Pap) smear
annually. Women with condylomata acuminata are at risk for cancer of the cervix
and vulva. Yearly Pap smears are very important for early detection. Because
condylomata acuminata is a virus, there is no permanent cure. Because condylomata
acuminata can occur on the vulva, a condom won’t protect sexual partners. HPV can
be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.
18. Answer: (A) The left kidney usually is slightly higher than the right one. The
left kidney usually is slightly higher than the right one. An adrenal gland lies atop each
kidney. The average kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm
(2″ to 2¼”) wide, and 2.5 cm (1″) thick. The kidneys are located retroperitoneally, in
the posterior aspect of the abdomen, on either side of the vertebral column. They
lie between the 12th thoracic and 3rd lumbar vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5
mg/dl. The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine
level ranges from 0.7 to 1.5 mg/dl. The test results in option C are abnormally
elevated, reflecting CRF and the kidneys’ decreased ability to remove nonprotein
nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen
ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and
phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl
falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with
the normal range of 60% to 75%.
20. Answer: (D) Alteration in the size, shape, and organization of differentiated
cells. Dysplasia refers to an alteration in the size, shape, and organization of
differentiated cells. The presence of completely undifferentiated tumor cells that don’t
resemble cells of the tissues of their origin is called anaplasia. An increase in the
number of normal cells in a normal arrangement in a tissue or an organ is called
hyperplasia. Replacement of one type of fully differentiated cell by another in
tissues where the second type normally isn’t found is called metaplasia.
21. Answer: (D) Kaposi’s sarcoma. Kaposi’s sarcoma is the most common cancer
associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia
may occur in anyone and aren’t associated specifically with AIDS.
22. Answer: (C) To prevent cerebrospinal fluid (CSF) leakage. The client receiving
a subarachnoid block requires special positioning to prevent CSF leakage and
headache and to ensure proper anesthetic distribution. Proper positioning doesn’t help
prevent confusion, seizures, or cardiac arrhythmias.
23. Answer: (A) Auscultate bowel sounds. If abdominal distention is accompanied by
nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the
nurse should suspect gastric or small intestine dilation and these findings must be
 reported to the physician. Palpation should be avoided postoperatively with abdominal
distention. If peristalsis is absent, changing positions and inserting a rectal tube won’t
relieve the client’s discomfort.
24. Answer: (B) Lying on the left side with knees bent. For a colonoscopy, the
nurse initially should position the client on the left side with knees bent. Placing the
client on the right side with legs straight, prone with the torso elevated, or bent over
with hands touching the floor wouldn’t allow proper visualization of the large intestine.
25. Answer: (A) Blood supply to the stoma has been interrupted. An ileostomy
stoma forms as the ileum is brought through the abdominal wall to the surface skin,
creating an artificial opening for waste elimination. The stoma should appear cherry
red, indicating adequate arterial perfusion. A dusky stoma suggests decreased
perfusion, which may result from interruption of the stoma’s blood supply and may
lead to tissue damage or necrosis. A dusky stoma isn’t a normal finding. Adjusting the
ostomy bag wouldn’t affect stoma color, which depends on blood supply to the area.
An intestinal obstruction also wouldn’t change stoma color.
26. Answer: (A) Applying knee splints. Applying knee splints prevents leg
contractures by holding the joints in a position of function. Elevating the foot of the
bed can’t prevent contractures because this action doesn’t hold the joints in a position
of function. Hyperextending a body part for an extended time is
inappropriate because it can cause contractures. Performing shoulder range-of-
motion exercises can prevent contractures in the shoulders, but not in the legs.
27. Answer: (B) Urine output of 20 ml/hour. A urine output of less than 40 ml/hour
in a client with burns indicates a fluid volume deficit. This client’s PaO2 value falls
within the normal range (80 to 100 mm Hg). White pulmonary secretions also
are normal. The client’s rectal temperature isn’t significantly elevated and probably
results from the fluid volume deficit.
28. Answer: (A) Turn him frequently. The most important intervention to prevent
pressure ulcers is frequent position changes, which relieve pressure on the skin
and underlying tissues. If pressure isn’t relieved, capillaries become
occluded, reducing circulation and oxygenation of the tissues and resulting in
cell death and ulcer formation. During passive ROM exercises, the nurse moves each
joint through its range of movement, which improves joint mobility and circulation to
the affected area but doesn’t prevent pressure ulcers. Adequate hydration is
necessary to maintain healthy skin and ensure tissue repair. A footboard prevents
plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.
29. Answer: (C) In long, even, outward, and downward strokes in the direction
of hair growth. When applying a topical agent, the nurse should begin at
the midline and use long, even, outward, and downward strokes in the direction of
hair growth. This application pattern reduces the risk of follicle irritation and skin
inflammation.
30. Answer: (A) Beta -adrenergic blockers. Beta-adrenergic blockers work by
blocking beta receptors in the myocardium, reducing the response to catecholamines
and sympathetic nerve stimulation. They protect the myocardium, helping to reduce
the risk of another infraction by decreasing myocardial oxygen demand. Calcium
channel blockers reduce the workload of the heart by decreasing the heart rate.
Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease
anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular
end diastolic pressure (preload) and systemic vascular resistance (afterload).
31. Answer: (C) Raised 30 degrees. Jugular venous pressure is measured with a
centimeter ruler to obtain the vertical distance between the sternal angle and the
point of highest pulsation with the head of the bed inclined between 15 to
30 degrees. Increased pressure can’t be seen when the client is supine or when the
head of the bed is raised 10 degrees because the point that marks the pressure level
is above the jaw (therefore, not visible). In high Fowler’s position, the veins would be
barely discernible above the clavicle.
32. Answer: (D) Inotropic agents. Inotropic agents are administered to increase the
force of the heart’s contractions, thereby increasing ventricular contractility
and ultimately increasing cardiac output. Beta-adrenergic blockers and
calcium channel blockers decrease the heart rate and ultimately decreased
the workload of the heart. Diuretics are administered to decrease the overall vascular
volume, also decreasing the workload of the heart.
33. Answer: (B) Less than 30% of calories form fat. A client with low serum HDL
and high serum LDL levels should get less than 30% of daily calories from fat. The
other modifications are appropriate for this client.
34. Answer: (C) The emergency department nurse calls up the
latest electrocardiogram results to check the client’s progress. The
emergency department nurse is no longer directly involved with the client’s care and
thus has no legal right to information about his present condition. Anyone directly
involved in his care (such as the telemetry nurse and the on-call physician) has the
right to information about his condition. Because the client requested that the nurse
update his wife on his condition, doing so doesn’t breach confidentiality.
35. Answer: (B) Check endotracheal tube placement. ET tube placement should be
confirmed as soon as the client arrives in the emergency department. Once the
airways is secured, oxygenation and ventilation should be confirmed using an end-
tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make
sure L.V. access is established. If the client experiences symptomatic bradycardia,
atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3
mg. Then the nurse should try to find the cause of the client’s arrest by obtaining an
ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation
and atrial flutter – not symptomatic bradycardia.
36. Answer: (C) 95 mm Hg. Use the following formula to calculate MAP
 MAP = systolic + 2 (diastolic) /3
 MAP=[126 mm Hg + 2 (80 mm Hg) ]/3
 MAP=286 mm HG/ 3
 MAP=95 mm Hg
37. Answer: (C) Electrocardiogram, complete blood count, testing for
occult blood, comprehensive serum metabolic panel. An electrocardiogram
evaluates the complaints of chest pain, laboratory tests determines anemia, and the
stool test for occult blood determines blood in the stool. Cardiac monitoring, oxygen,
and creatine kinase and lactate dehydrogenase levels are appropriate for a
cardiac primary problem. A basic metabolic panel and alkaline phosphatase
and aspartate aminotransferase levels assess liver function. Prothrombin time, partial
thromboplastin time, fibrinogen and fibrin split products are measured to verify
bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.
38. Answer: (D) Heparin-associated thrombosis and
thrombocytopenia (HATT). HATT may occur after CABG surgery due to heparin
 use during surgery. Although DIC and ITP cause platelet aggregation and bleeding,
neither is common in a client after revascularization surgery. Pancytopenia is a
reduction in all blood cells.
39. Answer: (B) Corticosteroids. Corticosteroid therapy can decrease antibody
production and phagocytosis of the antibody-coated platelets, retaining more
functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used
to treat an excessive anticoagulate state from warfarin overload, and ASA decreases
platelet aggregation.
40. Answer: (D) Xenogeneic. An xenogeneic transplant is between is between human
and another species. A syngeneic transplant is between identical twins, allogeneic
transplant is between two humans, and autologous is a transplant from the same
individual.
41. Answer: (B). Tissue thromboplastin is released when damaged tissue comes in
contact with clotting factors. Calcium is released to assist the conversion of factors X
to Xa. Conversion of factors XII to XIIa and VIII to VIII a are part of the intrinsic
pathway.
42. Answer: (C) Essential thrombocytopenia. Essential thrombocytopenia is linked to
immunologic disorders, such as SLE and human immunodeficiency vitus. The disorder
known as von Willebrand’s disease is a type of hemophilia and isn’t linked to
SLE. Moderate to severe anemia is associated with SLE, not polycythermia. Dressler’s
syndrome is pericarditis that occurs after a myocardial infarction and isn’t linked to
SLE.
43. Answer: (B) Night sweat. In stage 1, symptoms include a single enlarged lymph
node (usually), unexplained fever, night sweats, malaise, and generalized pruritis.
Although splenomegaly may be present in some clients, night sweats are generally
more prevalent. Pericarditis isn’t associated with Hodgkin’s disease, nor is
hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms. Persistent
hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease.
44. Answer: (D) Breath sounds. Pneumonia, both viral and fungal, is a common cause
of death in clients with neutropenia, so frequent assessment of respiratory rate
and breath sounds is required. Although assessing blood pressure, bowel sounds, and
heart sounds is important, it won’t help detect pneumonia.
45. Answer: (B) Muscle spasm. Back pain or paresthesia in the lower extremities may
indicate impending spinal cord compression from a spinal tumor. This should
be recognized and treated promptly as progression of the tumor may result
in paraplegia. The other options, which reflect parts of the nervous system, aren’t
usually affected by MM.
46. Answer: (C)10 years. Epidermiologic studies show the average time from
initial contact with HIV to the development of AIDS is 10 years.
47. Answer: (A) Low platelet count. In DIC, platelets and clotting factors are
consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen
levels decrease and the prothrombin time increases. Fibrin degeneration products
increase as fibrinolysis takes places.
48. Answer: (D) Hodgkin’s disease. Hodgkin’s disease typically causes fever night
sweats, weight loss, and lymph mode enlargement. Influenza doesn’t last for
months. Clients with sickle cell anemia manifest signs and symptoms of
chronic anemia with pallor of the mucous membrane, fatigue, and
decreased tolerance for exercise; they don’t show fever, night sweats, weight loss
or lymph node enlargement. Leukemia doesn’t cause lymph node enlargement.
49. Answer: (C) A Rh-negative. Human blood can sometimes contain an inherited D
antigen. Persons with the D antigen have Rh-positive blood type; those lacking
the antigen have Rh-negative blood. It’s important that a person with
Rhnegative blood receives Rh-negative blood. If Rh-positive blood is administered to
an Rh-negative person, the recipient develops anti-Rh agglutinins, and sub sequent
transfusions with Rh-positive blood may cause serious reactions with clumping and
hemolysis of red blood cells.
50. Answer: (B) “I will call my doctor if Stacy has persistent vomiting
and diarrhea”. Persistent (more than 24 hours) vomiting, anorexia, and diarrhea
are signs of toxicity and the patient should stop the medication and notify the health
care provider. The other manifestations are expected side effects of chemotherapy.
51. Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-
6 months, but may be different in texture”. This is the appropriate response.
The nurse should help the mother how to cope with her own feelings regarding the
child’s disease so as not to affect the child negatively. When the hair grows back, it is
still of the same color and texture.
52. Answer: (B) Apply viscous Lidocaine to oral ulcers as needed. Stomatitis can
cause pain and this can be relieved by applying topical anesthetics such as lidocaine
before mouth care. When the patient is already comfortable, the nurse can proceed
with providing the patient with oral rinses of saline solution mixed with equal part of
water or hydrogen peroxide mixed water in 1:3 concentrations to promote
oral hygiene. Every 2-4 hours.
53. Answer: (C) Immediately discontinue the infusion. Edema or swelling at the IV
site is a sign that the needle has been dislodged and the IV solution is leaking into the
tissues causing the edema. The patient feels pain as the nerves are irritated by
pressure and the IV solution. The first action of the nurse would be to discontinue
the infusion right away to prevent further edema and other complication.
54. Answer: (C) Chronic obstructive bronchitis. Clients with chronic obstructive
bronchitis appear bloated; they have large barrel chest and peripheral edema,
cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely
short of breath and frequently need intubation for mechanical ventilation and
large amount of oxygen. Clients with asthma don’t exhibit characteristics of chronic
disease, and clients with emphysema appear pink and cachectic.
55. Answer: (D) Emphysema. Because of the large amount of energy it takes to
breathe, clients with emphysema are usually cachectic. They’re pink and
usually breathe through pursed lips, hence the term “puffer.” Clients with ARDS are
usually acutely short of breath. Clients with asthma don’t have any particular
characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic
in appearance.
56. Answer: D 80 mm Hg. A client about to go into respiratory arrest will have
inefficient ventilation and will be retaining carbon dioxide. The value expected
would be around 80 mm Hg. All other values are lower than expected.
57. Answer: (C) Respiratory acidosis. Because Paco2 is high at 80 mm Hg and the
metabolic measure, HCO3- is normal, the client has respiratory acidosis. The pH
is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as
 possibilities. If the HCO3- was below 22 mEq/L the client would have metabolic
acidosis.
58. Answer: (C) Respiratory failure. The client was reacting to the drug with
respiratory signs of impending anaphylaxis, which could lead to eventually respiratory
failure. Although the signs are also related to an asthma attack or a
pulmonary embolism, consider the new drug first. Rheumatoid arthritis
doesn’t manifest these signs.
59. Answer: (D) Elevated serum aminotransferase. Hepatic cell death causes
release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase
(AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic
and irreversible disease of the liver characterized by generalized inflammation and
fibrosis of the liver tissues.
60. Answer: (A) Impaired clotting mechanism. Cirrhosis of the liver results in
decreased Vitamin K absorption and formation of clotting factors resulting in impaired
clotting mechanism.
61. Answer: (B) Altered level of consciousness. Changes in behavior and level of
consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is
caused by liver failure and develops when the liver is unable to convert protein
metabolic product ammonia to urea. This results in accumulation of ammonia
and other toxic in the blood that damages the cells.
62. Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2 to 4
stools a day”. Lactulose is given to a patients with hepatic encephalopathy to reduce
absorption of ammonia in the intestines by binding with ammonia and promoting
more frequent bowel movements. If the patient experience diarrhea, it indicates over
dosage and the nurse must reduce the amount of medication given to the patient.
The stool will be mashy or soft. Lactulose is also very sweet and may cause cramping
and bloating.
63. Answer: (B) Severe lower back pain, decreased blood pressure, decreased
RBC count, increased WBC count.Severe lower back pain indicates an aneurysm
rupture, secondary to pressure being applied within the abdominal cavity.
When ruptured occurs, the pain is constant because it can’t be alleviated until the
aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the
aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood
pressure wouldn’t increase. For the same reason, the RBC count is decreased – not
increased. The WBC count increases as cell migrate to the site of injury.
64. Answer: (D) Apply gloves and assess the groin site. Observing standard
precautions is the first priority when dealing with any blood fluid. Assessment of the
groin site is the second priority. This establishes where the blood is coming from and
determineshow much blood has been lost. The goal in this situation is to stop
the bleeding. The nurse would call for help if it were warranted after the assessment
of the situation. After determining the extent of the bleeding, vital signs assessment is
important. The nurse should never move the client, in case a clot has formed. Moving
can disturb the clot and cause rebleeding.
65. Answer: (D) Percutaneous transluminal coronary angioplasty (PTCA). PTCA
can alleviate the blockage and restore blood flow and oxygenation. An
echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual
medication. Cardiac catheterization is a diagnostic tool – not a treatment.
66. Answer: (B) Cardiogenic shock. Cardiogenic shock is shock related to ineffective
pumping of the heart. Anaphylactic shock results from an allergic reaction.
Distributive shock results from changes in the intravascular volume distribution and
is usually associated with increased cardiac output. MI isn’t a shock state, though a
severe MI can lead to shock.
67. Answer: (C) Kidneys’ excretion of sodium and water. The kidneys respond to
rise in blood pressure by excreting sodium and excess water. This response ultimately
affects sysmolic blood pressure by regulating blood volume. Sodium or water
retention would only further increase blood pressure. Sodium and water travel
together across the membrane in the kidneys; one can’t travel without the other.
68. Answer: (D) It inhibits reabsorption of sodium and water in the loop
of Henle. Furosemide is a loop diuretic that inhibits sodium and water reabsorption in
the loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause
dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and
decreasing blood pressure. Adrenergic blockers decrease sympathetic
cardioacceleration and decrease blood pressure. Angiotensin-converting enzyme
inhibitors decrease blood pressure due to their action on angiotensin.
69. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA)
titer. Laboratory findings for clients with SLE usually show pancytopenia, elevated
ANA titer, and decreased serum complement levels. Clients may have elevated BUN
and creatinine levels from nephritis, but the increase does not indicate SLE.
70. Answer: (C) Narcotics are avoided after a head injury because they
may hide a worsening condition. Narcotics may mask changes in the level of
consciousness that indicate increased ICP and shouldn’t acetaminophen is strong
enough ignores the mother’s question and therefore isn’t appropriate. Aspirin
is contraindicated in conditions that may have bleeding, such as trauma, and for
children or young adults with viral illnesses due to the danger of Reye’s syndrome.
Stronger medications may not necessarily lead to vomiting but will sedate the client,
thereby masking changes in his level of consciousness.
71. Answer: (A) Appropriate; lowering carbon dioxide (CO2)
reduces intracranial pressure (ICP). A normal Paco2 value is 35 to 45 mm Hg
CO2 has vasodilating properties; therefore, lowering Paco2 through
hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation
is evaluated through Pao2 and oxygen saturation. Alveolar hypoventilation would be
reflected in an increased Paco2.
72. Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-
Barre syndrome . Guillain-Barre syndrome is characterized by ascending paralysis
and potential respiratory failure. The order of client assessment should follow client
priorities, with disorder of airways, breathing, and then circulation. There’s no
information to suggest the postmyocardial infarction client has an arrhythmia or other
complication. There’s no evidence to suggest hemorrhage or perforation for the
remaining clients as a priority of care.
73. Answer: (C) Decreases inflammation. Then action of colchicines is to decrease
inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine
doesn’t replace estrogen, decrease infection, or decrease bone demineralization.
74. Answer: (C) Osteoarthritis is the most common form of
arthritis. Osteoarthritis is the most common form of arthritis and can be extremely
debilitating. It can afflict people of any age, although most are elderly.
75. Answer: (C) Myxedema coma. Myxedema coma, severe hypothyroidism, is a life-
threatening condition that may develop if thyroid replacement medication isn’t
taken. Exophthalmos, protrusion of the eyeballs, is seen with
hyperthyroidism. Thyroid storm is life-threatening but is caused by severe
hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower
leg, is associated with hypothyroidism but isn’t life-threatening.
76. Answer: (B) An irregular apical pulse. Because Cushing’s syndrome causes
aldosterone overproduction, which increases urinary potassium loss, the disorder
may lead to hypokalemia. Therefore, the nurse should immediately report signs and
symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema
is an expected finding because aldosterone overproduction causes sodium and fluid
retention. Dry mucous membranes and frequent urination signal dehydration, which
isn’t associated with Cushing’s syndrome.
77. Answer: (D) Below-normal urine osmolality level, above-normal
serum osmolality level. In diabetes insipidus, excessive polyuria causes dilute
urine, resulting in a below-normal urine osmolality level. At the same time, polyuria
depletes the body of water, causing dehydration that leads to an above-normal serum
osmolality level. For the same reasons, diabetes insipidus doesn’t cause above-normal
urine osmolality or below-normal serum osmolality levels.
78. Answer: (A) “I can avoid getting sick by not becoming dehydrated and
by paying attention to my need to urinate, drink, or eat more than
usual.” Inadequate fluid intake during hyperglycemic episodes often leads to HHNS.
By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and
increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda
would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral
antidiabetic agents usually doesn’t need to monitor blood glucose levels. A
highcarbohydrate diet would exacerbate the client’s condition, particularly if fluid
intake is low.
79. Answer: (D) Hyperparathyroidism. Hyperparathyroidism is most common in older
women and is characterized by bone pain and weakness from excess
parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria.
While clients with diabetes mellitus and diabetes insipidus also have polyuria, they
don’t have bone pain and increased sleeping. Hypoparathyroidism is characterized by
urinary frequency rather than polyuria.
80. Answer: (C) “I’ll take two-thirds of the dose when I wake up and one-
third in the late afternoon.” Hydrocortisone, a glucocorticoid, should be
administered according to a schedule that closely reflects the body’s own secretion
of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken
in the morning and one-third in the late afternoon. This dosage schedule reduces
adverse effects.
81. Answer: (C) High corticotropin and high cortisol levels. A corticotropin-
secreting pituitary tumor would cause high corticotropin and high cortisol levels. A
high corticotropin level with a low cortisol level and a low corticotropin level with a low
cortisol level would be associated with hypocortisolism. Low corticotropin and high
cortisol levels would be seen if there was a primary defect in the adrenal glands.
82. Answer: (D) Performing capillary glucose testing every 4 hours. The nurse
should perform capillary glucose testing every 4 hours because excess cortisol may
cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone
testing isn’t indicated because the client does secrete insulin and, therefore, isn’t at
risk for ketosis. Urine specific gravity isn’t indicated because although fluid balance
can be compromised, it usually isn’t dangerously imbalanced. Temperature regulation
may be affected by excess cortisol and isn’t an accurate indicator of infection.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.. Regular
insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of
2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would
be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH)
level after 30 minutes during the TSH stimulation test. In the TSH test, failure
of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH
level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and
T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level
also occurs in malnutrition and liver disease and may result from administration of
phenytoin and certain other drugs.
85. Answer: (B) “Rotate injection sites within the same anatomic region,
not among different regions.” The nurse should instruct the client to rotate
injection sites within the same anatomic region. Rotating sites among different
regions may cause excessive day-to-day variations in the blood glucose level; also,
insulin absorption differs from one region to the next. Insulin should be injected only
into healthy tissue lacking large blood vessels, nerves, or scar tissue or other
deviations. Injecting insulin into areas of hypertrophy may delay absorption. The
client shouldn’t inject insulin into areas of lipodystrophy (such as hypertrophy or
atrophy); to prevent lipodystrophy, the client should rotate injection sites
systematically. Exercise speeds drug absorption, so the client shouldn’t inject insulin
into sites above muscles that will be exercised heavily.
86. Answer: (D) Below-normal serum potassium level. A client with HHNS has an
overall body deficit of potassium resulting from diuresis, which occurs secondary to
the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An
elevated serum acetone level and serum ketone bodies are characteristic of diabetic
ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
87. Answer: (D) Maintaining room temperature in the low-normal range. Graves’
disease causes signs and symptoms of hypermetabolism, such as heat intolerance,
diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance
and diaphoresis, the nurse should keep the client’s room temperature in the low-
normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not
restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat
intolerance would cause discomfort. To provide needed energy and calories, the nurse
should encourage the client to eat high-carbohydrate foods.
88. Answer: (A) Fracture of the distal radius. Colles’ fracture is a fracture of the
distal radius, such as from a fall on an outstretched hand. It’s most common in
women. Colles’ fracture doesn’t refer to a fracture of the olecranon, humerus, or
carpal scaphoid.
89. Answer: (B) Calcium and phosphorous. In osteoporosis, bones lose calcium and
phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture.
Sodium and potassium aren’t involved in the development of osteoporosis.
90. Answer: (A) Adult respiratory distress syndrome (ARDS). Severe hypoxia after
smoke inhalation is typically related to ARDS. The other conditions listed aren’t
typically associated with smoke inhalation and severe hypoxia.
91. Answer: (D) Fat embolism. Long bone fractures are correlated with fat emboli,
whichcause shortness of breath and hypoxia. It’s unlikely the client has developed
asthma or bronchitis without a previous history. He could develop atelectasis but it
typically doesn’t produce progressive hypoxia.
92. Answer: (D) Spontaneous pneumothorax. A spontaneous pneumothorax occurs
when the client’s lung collapses, causing an acute decreased in the amount of
functional lung used in oxygenation. The sudden collapse was the cause of his chest
pain and shortness of breath. An asthma attack would show wheezing breath sounds,
and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds
over the area of consolidation.
93. Answer: (C) Pneumothorax. From the trauma the client experienced, it’s unlikely
he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds
with TB would be heard.
94. Answer: (C) Serous fluids fills the space and consolidates the region. Serous
fluid fills the space and eventually consolidates, preventing extensive mediastinal shift
of the heart and remaining lung. Air can’t be left in the space. There’s no gel that can
be placed in the pleural space. The tissue from the other lung can’t cross the
mediastinum, although a temporary mediastinal shift exits until the space is filled.
95. Answer: (A) Alveolar damage in the infracted area. The infracted area produces
alveolar damage that can lead to the production of bloody sputum, sometimes in
massive amounts. Clot formation usually occurs in the legs. There’s a loss of lung
parenchyma and subsequent scar tissue formation.
96. Answer: (D) Respiratory alkalosis. A client with massive pulmonary embolism will
have a large region and blow off large amount of carbon dioxide, which crosses
the unaffected alveolar-capillary membrane more readily than does oxygen and
results in respiratory alkalosis.
97. Answer: (A) Air leak. Bubbling in the water seal chamber of a chest drainage
system stems from an air leak. In pneumothorax an air leak can occur as air is pulled
from the pleural space. Bubbling doesn’t normally occur with either adequate or
inadequate suction or any preexisting bubbling in the water seal chamber.
98. Answer: (B) 21. 3000 x 10 divided by 24 x 60.
99. Answer: (B) 2.4 ml. .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
100. Answer: (D) “I should put on the stockings before getting out of bed in the
morning. Promote venous return by applying external pressure on veins.