Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur
ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

Diagnostic Test: NCM 104

MULTIPLE CHOICE. Encircle the right answer. NO ERASURES/ALTERATIONS. GOOD LUCK!!!!
I. Perception and Coordination
1. If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse
would anticipate that the client has problems with:
a. Body temperature control
b. Balance and equilibrium
c. Visual acuity
d. Thinking and reasoning
Rationale: A. Body temperature control. The body’s thermostat is located in the hypothalamus;
therefore, injury to that area can cause problems of body temperature control. Option B: Balance and
equilibrium problems are related to cerebellar damage. Option C: Visual acuity problems would occur
following occipital or optic nerve injury.
Option D: Thinking and reasoning problems are the result of injury to the cerebrum
2. A female client admitted to an acute care facility after a car accident develops signs and symptoms of
increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to
help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering
which drug endotracheally before suctioning?
a. Phenytoin (Dilantin)
b. Mannitol (Osmitrol)
c. Lidocaine (Xylocaine)
d. Furosemide (Lasix)
Rationale: C. Lidocaine (Xylocaine). Administering lidocaine via an endotracheal tube may minimize
elevations in ICP caused by suctioning. Option A: Phenytoin doesn’t reduce ICP directly but may be used
to abolish seizures, which can increase ICP. However, phenytoin isn’t administered endotracheally.
Option B and D: Although mannitol and furosemide may be given to reduce ICP, they’re administered
parenterally, not endotracheally.
3. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the
emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be
the most dangerous for the client?
a. Give him a barbiturate
b. Place him on mechanical ventilation
c. Perform a lumbar puncture
d. Elevate the head of his bed
Rationale: C. Perform a lumbar puncture. The client’s history and assessment suggest that he may
have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn’t be done because
it can quickly decompress the central nervous system and, thereby, cause additional damage. Option A:
After a head injury, barbiturates may be given to prevent seizures. Option B: Mechanical ventilation may
be required if breathing deteriorates. Option D: Elevating the head of the bed may be used to reduce ICP.
4. When obtaining the health history from a male client with retinal detachment, the nurse expects the client
to report:
a. Light flashes and floaters in front of the eye
b. A recent driving accident while changing lanes
c. Headaches, nausea, and redness of the eyes
d. Frequent episodes of double vision
Rationale: A. Light flashes and floaters in front of the eye. The sudden appearance of light flashes and
floaters in front of the affected eye is characteristic of retinal detachment. Option B: Difficulty seeing cars
in another driving lane suggests a gradual loss of peripheral vision, which may indicate glaucoma. Option
C: Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Option D:
Double vision is common in clients with cataracts.
5. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?
a. Imbalanced nutrition: Less than body requirements
b. Ineffective airway clearance
c. Impaired urinary elimination
d. Risk for injury
Rationale: B. Ineffective airway clearance. In Parkinson’s crisis, dopamine-related symptoms are
severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is
at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction.
Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority.
Although the other options also are appropriate, they aren’t immediately life-threatening.
6. To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should:
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

a. Stay with the client and encourage him to eat

b. Help the client fill out his menu
c. Give the client privacy during meals
d. Fill out the menu for the client
Rationale: A. Stay with the client and encourage him to eat. Staying with the client and encouraging
him to feed himself will ensure adequate food intake. A client with Alzheimer’s disease can forget how to
eat. Options B, C, and D: Allowing privacy during meals, filling out the menu, or helping the client to
complete the menu doesn’t ensure adequate nutritional intake.
7. The nurse is performing a mental status examination on a male client diagnosed with a subdural
hematoma. This test assesses which of the following:
a. Cerebellar function
b. Intellectual function
c. Cerebral function
d. Sensory function
Rationale: C. Cerebral function. The mental status examination assesses functions governed by the
cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Option A:
Cerebellar function testing assesses coordination, equilibrium, and fine motor movement. Option B:
Intellectual functioning isn’t the only cerebral activity. Option D: Sensory function testing involves
assessment of pain, light-touch sensation, and temperature discrimination.
8. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status
epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer
the second dose of diazepam, if needed and prescribed:
a. In 30 to 45 seconds
b. In 10 to 15 minutes
c. In 30 to 45 minutes
d. In 1 to 2 hours
Rationale: B. In 10 to 15 minutes. When used to treat status epilepticus, diazepam may be given every
10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4
hours, if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours. Option A: The nurse must not
administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose can’t be repeated in 30 to 45
seconds because the first dose wouldn’t have been administered completely by that time. Option C:
Waiting longer than 15 minutes to repeat the dose would increase the client’s risk of complications
associated with status epilepticus.
9. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye.
Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from
acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician
prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine
sulfate belongs to which drug classification?
a. Parasympathomimetic agent
b. Sympatholytic agent
c. Adrenergic blocker
d. Cholinergic blocker
Rationale: D. Cholinergic blocker. Atropine sulfate is a cholinergic blocker. It isn’t a
parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker.
10. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They
tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a
hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We
intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual
resuscitation bag.” Which intervention by the nurse has the highest priority?
a. Assessing the left leg
b. Assessing the pupils
c. Placing the client in Trendelenburg’s position
d. Assessing level of consciousness
Rationale: A. Assessing the left leg. In the scenario, airway and breathing are established so the nurse’s
next priority should be circulation. With a compound fracture of the femur, there is a high risk of
profuse bleeding; therefore, the nurse should assess the site. O ption B and D: Neurologic assessment is a
secondary concern to airway, breathing, and circulation. Option C: The nurse doesn’t have enough data to
warrant putting the client in Trendelenburg’s position.
11. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with
water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he
receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of
both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in
the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:
a. Increasing the exudative reaction of ocular tissue
b. Decreasing leukocyte infiltration at the site of ocular inflammation
c. Inhibiting the action of carbonic anhydrase
d. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris
Rationale: B. Decreasing leukocyte infiltration at the site of ocular inflammation. Dexamethasone
exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This
reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. Options C and
D: Dexamethasone and other anti-inflammatory agents don’t inhibit the action of carbonic anhydrase or
produce any type of miotic reaction
12. Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the
following findings should the nurse consider abnormal?
a. More back pain than the first postoperative day
b. Paresthesia in the dermatomes near the wounds
c. Urine retention or incontinence
d. Temperature of 99.2° F (37.3° C)
Rationale: C. Urine retention or incontinence. Urine retention or incontinence may indicate cauda
equina syndrome, which requires immediate surgery. Option A: An increase in pain on the second
postoperative day is common because the long-acting local anesthetic, which may have been injected
during surgery, will wear off. Option B: While paresthesia is common after surgery, progressive
weakness or paralysis may indicate spinal nerve compression. Option D: A mild fever is also common
after surgery but is considered significant only if it reaches 101° F (38.3° C).
13. After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician
prescribes Pilocarpineophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the
nurse should teach the client or a family member to administer the drug by:
a. Instilling one drop of pilocarpine 0.25% into both eyes daily
b. Instilling one drop of pilocarpine 0.25% into both eyes four times daily
c. Instilling one drop of pilocarpine 0.25% into the right eye daily
d. Instilling one drop of pilocarpine 0.25% into the left eye four times daily
Rationale: B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. The
abbreviation “gtt” stands for drop, “i” is the apothecary symbol for the number 1, OU signifies both eyes,
and “q.i.d.” means four times a day. Therefore, one drop of pilocarpine 0.25% should be instilled into
both eyes four times daily.
14. A female client who’s paralyzed on the left side has been receiving physical therapy and attending
teaching sessions about safety. Which behavior indicates that the client accurately understands safety
measures related to paralysis?
a. The client leaves the side rails down
b. The client uses a mirror to inspect the skin
c. The client repositions only after being reminded to do so
d. The client hangs the left arm over the side of the wheelchair
Rationale: B. The client uses a mirror to inspect the skin. Using a mirror enables the client to inspect
all areas of the skin for signs of breakdown without the help of staff or family members. Option A: The
client should keep the side rails up to help with repositioning and to prevent falls. Option C: The
paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it if
needed. Option D: A client with left-side paralysis may not realize that the left arm is hanging over the
side of the wheelchair. However, the nurse should call this to the client’s attention because the arm can
get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too
long.
15. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse
asks the client to take a few steps; with each step, the client’s feet make a half circle. To document the
client’s gait, the nurse should use which term?
a. Ataxic
b. Dystrophic
c. Helicopod
d. Steppage
Rationale: C. Helicopod. A helicopod gait is an abnormal gait in which the client’s feet make a half
circle with each step. Option A: An ataxic gait is staggering and unsteady. Option B: In a dystrophic gait,
the client waddles with the legs far apart. Option D: In a steppage gait, the feet, and toes raise high off the
floor and the heel comes down heavily with each step.
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

16. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for
this client?
a. A private room down the hall from the nurses’ station
b. An isolation room three doors from the nurses’ station
c. A semi private room with a 32-year-old client who has viral meningitis
d. A two-bed room with a client who previously had bacterial meningitis
Rationale: B. An isolation room three doors from the nurses’ station. A client with bacterial
meningitis should be kept in isolation for at least 24 hours after admission. Option A: During the initial
acute phase, should be as close to the nurses’ station as possible to allow maximal observation. Option C:
Placing the client in a room with a client who has viral meningitis may cause harm to both clients because
the organisms causing viral and bacterial meningitis differ; either client may contract the other’s disease.
Option D: Immunity to Bacterial meningitis can’t be acquired; therefore, a client who previously had
bacterial meningitis shouldn’t be put at risk by rooming with a client who has just been diagnosed with
this disease.
17. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg
P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s
history. Which preexisting condition would contraindicate the use of pyridostigmine?
a. Ulcerative colitis
b. Blood dyscrasia
c. Intestinal obstruction
d. Spinal cord injury
Rationale: C. Intestinal obstruction. Anticholinesterase agents such as pyridostigmine are
contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or
hypersensitivity to anticholinesterase agents. Options A, B, and D: Ulcerative colitis, blood dyscrasia, and
spinal cord injury don’t contraindicate use of the drug
18. A female client is admitted to the facility for investigation of balance and coordination problems,
including possible Ménière’s disease. When assessing this client, the nurse expects to note:
a. Vertigo, tinnitus, and hearing loss
b. Vertigo, vomiting, and nystagmus
c. Vertigo, pain, and hearing impairment
d. Vertigo, blurred vision, and fever
Rationale: A. Vertigo, tinnitus, and hearing loss. Ménière’s disease, an inner ear disease, is
characterized by the symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo,
vomiting, and nystagmus suggests labyrinthitis. Ménière’s disease rarely causes pain, blurred vision, or
fever.
19. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window
undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the
stapedectomy, the nurse should provide which client instruction?
a. “Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours.”
b. “Try to ambulate independently after about 24 hours.”
c. “Shampoo your hair every day for ten (10) days to help prevent ear infection.”
d. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to
loud sounds for 30 days.”
Rationale: D. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose
yourself to loud sounds for 30 days.” For 30 days after a stapedectomy, the client should avoid air
travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes
(such as from high altitudes) Option A: Immediately after surgery, the client should lie flat with the
surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time.
Option B: The client’s first attempt at postoperative ambulation should be supervised to prevent falls
caused by vertigo and light-headedness. Option C: The client must avoid shampooing and swimming to
keep the dressing and the ear dry.
20. Nurse Marty is monitoring a client for adverse reactions to dantrolene(Dantrium). Which adverse reaction
is most common?
a. Excessive tearing
b. Urine retention
c. Muscle weakness
d. Slurred speech
Rationale: C. Muscle weakness. The most common adverse reaction to dantrolene is muscle weakness.
The drug also may depress liver function or cause idiosyncratic hepatitis. Options A and B: Although
excessive tearing and urine retention are adverse reactions associated with dantrolene use; they aren’t as
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

common as muscle weakness. Option D: Muscle weakness is rarely severe enough to cause slurring of
speech, drooling, and enuresis

II. Inflammatory and Immunologic Response

1. An HIV-positive client who has been started on highly active antiretroviral therapy (HAART) came back
for a follow-up checkup. Which of the following will be the most helpful in determining the response to
the therapy?
a. Rapid HIV antigen test
b. Western Blot analysis
c. Viral Load Test
d. White Blood Cells
Rationale: C. Viral load test. A viral load test helps provide information on the health status and how
well antiretroviral therapy (ART – treatment with HIV medicines) is controlling the virus. Options A and
B monitors the presence of antibodies to HIV, so these tests will yield a positive result after the patient is
infected with HIV even if the drug therapy is effective. Option D will be used to assess the impact of HIV
on immune function but will not directly measure the effectiveness of the medicines.
2. A client with acquired immunodeficiency syndrome is prescribed with Zidovudine (Azidothymidine).
Which of the following laboratory results should the nurse monitor while on this medication?
a. Throat swab gram stain
b. Complete blood count
c. Random blood sugar
d. Blood uric acid
Rationale: B. Complete blood count. Zidovudine may decrease the number of a certain type of white
blood cell in the blood and cause anemia and muscle disorders. Options A, C, and D are not related to the
medication.
3. The client who is human immunodeficiency virus seropositive has been taking Saquinavir (Invirase). The
nurse provides medication instructions and advises the client to:
a. Take the medication in the morning before meals
b. Include a low-fat diet
c. Weight gain is expected
d. Avoid being exposed to sunlight
Rationale: D. Avoid being exposed to sunlight. Saquinavir (Invirase) is an antiviral medicine that
prevents human immunodeficiency virus (HIV) from multiplying in the body. This can cause
photosensitivity so the nurse should instruct the client to avoid sun exposure. Option A: The medicine is
taken with food or within 2 hours after eating a full meal. Option B: The medicine is best absorbed with a
high-fat meal. Option C: Weight loss instead is expected.
4. Stavudine (Zerit) is prescribed to a client with human immunodeficiency virus seropositive. The nurse
observes which of the following most closely while the client is taking the medication?
a. Orientation
b. Gag Reflex
c. Appetite
d. Gait
Rationale: D. Gait. One of the most serious side effects of Stavudine (Zerit) is peripheral neuropathy so
the nurse should monitor the client’s gait while taking this medication.
5. A nurse is evaluating an HIV – positive client who is prescribed with Pentamidine (Pentam) IV for the
treatment of Pneumocystis carinii pneumonia. Which of the following assessment after the administration
is the most important to relay to the physician?
a. Blood pressure of 100/62 mm/Hg
b. Redness and pain at the site of the infusion
c. Sudden sweating and hunger
d. Unusual taste or dryness in the mouth
Rationale: C. Sudden sweating and hunger. Pentamidine can cause fatal hypoglycemia, so symptoms
such as sudden sweating and hunger are indicative of a low blood sugar indicates a need for change in the
treatment. Option A: A low blood pressure may indicate the need of a slower infusion. Option B: Redness
and Pain is a sign for the nurse to establish a new IV line. Option D: Dryness and unusual taste may
happen at the start but do not need for an immediate notification of the physician.
6. A client is prescribed with Pentamidine (Pentam) IV for the treatment of Pneumocystis carinii
pneumonia. Suddenly, the client develops a temperature of 101.5°F. The nurse in charge knows that this
sign would mostly indicate on which of the following?
a. An overdosage of the medication
b. The need for an additional dosage
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

c. The client has developed another infection

d. The client is experiencing the therapeutic effect of the medication
Rationale: C. The client has developed another infection. Pentamidine can cause low white blood cells
or low platelets in your blood, so the client is most likely developed another infection brought about these
side effects. Options A, B, and D are inappropriate interpretation.
7. While on Pentamidine (Pentam) infusion therapy. The nurse must anticipate doing which of the
following?
a. Secure a 12-lead ECG
b. Observe for signs of retinal damage
c. Instruct the client on a low potassium diet
d. Instruct the client on limit fluid intake
Rationale: A. Do a 12-lead ECG. Pentamidine may cause a condition that affects the heart rhythm (QT
prolongation). QT prolongation can rarely cause serious fast/irregular heartbeat and other symptoms (such
as severe dizziness, fainting) that need an urgent medical attention. Options B and D are not related to the
use of the medication. Option C: Low levels of potassium in the blood can increase the risk of QT
prolongation.
8. The nurse is monitoring a post-renal transplantation client taking Cyclosporine (Neoral). The nurse
observes an elevation in one of the client’s vital sign and the client is complaining of sweating and
headache. Which of the following vital sign is most likely increased
a. Respiratory rate
b. Pulse rate
c. Temperature
d. Blood pressure
Rationale: D. Blood pressure. Hypertension is one of the side effects of taking cyclosporine (Neoral)
and since the client is also complaining of sweating and headache, the blood pressure is the important sign
to be monitored closely.
9. A nurse is doing an assessment data while completing an admission for a patient with a history of liver
transplant who is receiving cyclosporine (Sandimmune), Prednisone (Orasone), and Azathioprine
(Imuran). Which of the following information will give the nurse the most attention?
a. The client has a soft non-tender lump in the shoulder
b. An increase cholesterol level
c. Grade 1+ pitting edema in the feet
d. Swollen and pinkish gums noted
Rationale: A. The client has a soft non-tender lump in the shoulder. A client taking
immunosuppressive medications are at risk for development of cancer. A soft non-tender lump will
indicate that the patient has lymphoma
10. A client is admitted to the emergency room complaints of a difficulty of breathing and upon auscultation,
the nurse noted that the patient has wheezes. An allergic reaction to penicillin was diagnosed. Which of
the following medications should the nurse expect to administer first?
a. Aminophylline (Theophylline)
b. Albuterol (Ventolin HFA)
c. Methylprednisolone (Solu-Medrol)
d. Pulmicort (Budesonide)
Rationale: B. Albuterol (Ventolin HFA). Albuterol (Ventolin HFA) is the most rapidly acting of the
medications among the choices. Option A is not the first line treatment for a bronchospasm. Options C
and D are corticosteroids that are used during allergic reaction but are not rapidly acting.
11. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency
syndrome who is receiving foscarnet (Foscavir). The nurse carefully monitors which of the following
laboratory test during the treatment with this medication, except?
a. Serum creatinine
b. Serum calcium
c. Serum magnesium
d. Serum sodium
Rationale: D. Serum sodium. Renal impairment is the major toxicity involve in Foscarnet (Foscavir);
This medicine also may cause decreased levels of calcium, magnesium, phosphorous, and potassium.
12. A client is recently diagnosed with HIV and a highly antiretroviral therapy is started. After the first week
of therapy, the patient complains of headaches, dizziness, and nightmares. Which one of the following
anti-retroviral drugs is most likely associated with these symptoms?
a. Lamizudine
b. Efavirenz
c. Tenofovir
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CAMARINES SUR POLYTECHNIC COLLEGES
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ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

d. Saquinavir
Rationale: B. Efavirenz. Efavirenz is a non-nucleoside reverse transcriptase inhibitor. Side effects
include rash, dizziness, confusion, headache, and nightmares. Options A and C: Lamivudine and
Tenofovir side effects includes headache, dizziness, nausea, diarrhea, or trouble sleeping. Option D:
Saquinavir can cause headache, nausea, diarrhea, and photosensitivity.
13. Sirolimus (Rapamune) is prescribed to a post-renal transplantation client. Upon the review of the chart,
the nurse expects which of the following laboratory results?
a. Elevated serum potassium
b. Decreased cholesterol level
c. Elevated platelet count
d. Elevated triglyceride level
Rationale: D. Elevated triglyceride level. Sirolimus (Rapamune) raises cholesterol and triglyceride
levels. This medication also causes a decrease in potassium and platelet count.
14. A post-kidney transplant client went to the health care facility to ask the nurse regarding vaccinations
while on Tacrolimus (Prograf) a medication used to prevent organ rejection. Which of the following is an
appropriate response of the nurse?
a. “Do not skip due doses of vaccination for this can help in your treatment”.
b. “You can have live vaccinations even without the approval of the physician”.
c. “Influenza can happen anytime, so a flu vaccine is a must”.
d. “Do not receive any live vaccinations while on this treatment”.
Rationale: D. “Do not receive any live vaccinations while on this treatment”. Tacrolimus may lower
your body’s resistance and the vaccine may not work as well or the client may get the infection the
vaccine is meant to prevent.
15. A nurse is giving instructions to a client who is receiving Mycophenolate mofetil (CellCept) and
Mycophenolic acid (Myfortic) after undergoing a heart transplant. The nurse tells the client to anticipate
the following side effects, except?
a. Insomnia
b. Vomiting
c. Hypertension
d. Diarrhea
Rationale: A. Insomnia. These medications can cause diarrhea, vomiting, sepsis, back pain, neutropenia
and hypertension.
16. Amikacin (Amikin) is given to a client with E-coli infection. The nurse advises the client to report which
of the following symptoms immediately?
a. Muscle pain
b. Constipation
c. Fatigue
d. Hearing loss
Rationale: D. Hearing loss. Amikacin is an aminoglycoside. Side effects of this medication includes
ototoxicity (Hearing loss), confusion, disorientation, gastrointestinal irritation, palpitations, blood
pressure changes and nephrotoxicity
17. A client went to the emergency room with complaints of abdominal pain, nausea, diarrhea and mucoid
stools. Upon the interview of the nurse, the client stated that he is taking Cefixime (Suprax) for the
treatment of urinary tract infection. The nurse determines that the client is most likely suffering from?
a. Crohn’s disease
b. Acute Gastroenteritis
c. Acute appendicitis
d. Pseudomembranous colitis
Rationale: D. Pseudomembranous colitis. Pseudomembranous colitis also called antibiotic-associated
colitis or C. difficile colitis, is the inflammation of the colon associated with an overgrowth of the
bacterium Clostridium difficile. This overgrowth of C. difficile is most often related to recent antibiotic
use such as ampicillin, clindamycin, fluoroquinolones, and cephalosporins.
18. Amphotericin B (Fungizone) IV is given to a client with aspergillosis, a fungal infection. In order to
prevent its side effects, the nurse anticipate administering which of the following prior, except?
a. Hydrocortisone
b. Ketoconazole
c. Diphenhydramine
d. Meperidine
Rationale: B. Ketoconazole. Azole antifungals (eg, ketoconazole) decreases the effectiveness of
amphotericin. Options A and C: Fever, shaking, chills, flushing, loss of appetite, dizziness, nausea,
vomiting, headache, shortness of breath, or fast breathing may occur 1 to 3 hours after the infusion is
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CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

started. Medications such as acetaminophen, diphenhydramine, corticosteroids such as hydrocortisone)

may be necessary to prevent these side effects. Option D: Meperidine (25 to 50 mg IV) has been shown in
some patients to decrease the duration of shaking chills and fever that may accompany the infusion of
amphotericin B.
19. A nurse is giving instructions to a client taking Ciprofloxacin (Cipro) for the treatment of gonorrhea. The
nurse tells the client to?
a. Report any history of tendon problems
b. Resume daily exercise such as biking
c. Take an antacid 30 minutes prior
d. Take it with a yogurt as part of the treatment
Rationale: A. Report any history of tendon problems. Ciprofloxacin may cause swelling or tearing of a
tendon (the fiber that connects bones to muscles in the body), especially in the Achilles’ tendon of the
heel. This can happen during treatment or up to several months after the client stop taking ciprofloxacin.
20. Tetracycline has been prescribed for a client with Chlamydia trachomatis infection. Select the side effect
of the medication. Select all that apply.
a. Glossitis
b. Tremors
c. Urinary frequency
d. Discoloration of the nails
e. Photosensitivity
Rationale: A. Glossitis., D. Discoloration of the nails., E. Photosensitivity. Side effects of tetracycline
include glossitis, discoloration of the nails, photosensitivity, anorexia, nausea, vomiting, diarrhea, bulky
loose stools, stomatitis, sore throat, black hairy tongue,dysphagia,and hoarseness

III. Pain (with Perioperative Concept)

1. A chronic pain client reports to you, the charge nurse, that the nurse have not been responding to requests for
pain medication. What is your initial action?
a. Check the MARs and nurse’s notes for the past several days.
b. Ask the nurse educator to give an in-service about pain management.
c. Perform a complete pain assessment and history on the client.
d. Have a conference with the nurses responsible for the care of this client
Answer D- As charge nurse, you must assess for the performance and attitude of the staff in relation to this
client. After gathering data from the nurses, additional information from the records and the client can be
obtained as necessary. The educator may be of assistance if knowledge deficit or need for performance
improvement is the problem.
2. Family members are encouraging your client to “tough it out” rather than run the risk of becoming addicted to
narcotics. The client is stoically abiding by the family’s wishes. Priority nursing interventions for this client
should target which dimension of pain?
a. Sensory
b. Affective
c. Sociocultural
d. Behavioral
e. Cognitive
Answer C- The family is part of the sociocultural dimension of pain. They are influencing the client should
be included in the teaching sessions about the appropriate use of narcotics and about the adverse effects of
pain on the healing process. The other dimensions should be included to help the client/family understand
overall treatment plan and pain mechanism.
3. A client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is not
responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of
pain?
a. Amitriptyline [Elavil]
b. Corticosteroids
c. Methylphenidate [Ritalin]
d. Lorazepam [Ativan]
Answer A- Antidepressants such as amitriptyline can be given for a diabetic neuropathy. Corticosteroids are
for pain associated with inflammation. Methylphenidate is given to counteract sedation if the client is on
opioids. Lorazepam is an anxiolytic.
4. Which client is most likely to receive opioids for extended periods of time?
a. A client with fibrolyalgia
b. A client with phantom limb pain
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c. A client with progressive pancreatic cancer

d. A client with trigeminal neuralgia
Answer C- Cancer pain generally worsens disease progression and the use of opioids is more generous.
Fibromyalgia is more likely to be treated with non-opioid and adjuvant medications. Trigeminal neuralgia is
treated with anti-seizure medications such as carbamezapine (Tegretol). Phantom limb pain usually subsides
after ambulation begins.
5. As the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The
RN has correctly charted dose and time of medication, but there is no documentation regarding non-
pharmaceutical measures. What action should you take first?
a. Make a note in the nurse’s file and continue to observe clinical performance
b. Refer the new nurse to the in-service education department.
c. Quiz the nurse about knowledge of pain management.
d. Give praise for the correct dose and time and discuss the deficits in charting.
Answer D- In supervising the new RN, good performance should be reinforced first and then areas of
improvement can be addressed. Asking the nurse about knowledge of pain managements also an option;
however, it would be a more indirect and time consuming approach. Making an ote and watching do not help
the nurse to correct the immediate problem. In service might be considered if the problem persists.
6. In caring for a child with pain, which assessment tool is the most useful?
a. Simple description pain intensity scale
b. 0-10 numeric pain scale
c. Faces pain- rating scale
d. McGill-Melzack pain questionnaire
Answer C- The Faces Pain rating scale (depicting, smiling, neutral, frowning, crying, etc.) is appropriate for
young children who may have difficulty describing pain or understanding the correlation of pain to numerical
or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and use of advanced
vocabulary.
7. In applying the principles of pain treatment, what is the first consideration?
a. Treatment is bases on client goals.
b. A multidisciplinary approach is needed.
c. The client must believe about perceptions of own pain.
d. Drug side effects must be prevented and managed.
Answer C- The client must be believed and his or her experience of pain must be acknowledged as valid. The
data gathered via client reports can then be applied to other options to other options in developing the treatment
plan.
8. Which route of administration is preferred if immediate analgesia and rapid titration are necessary?
a. Intraspinal
b. Patient- controlled analgesia [PCA]
c. Intravenous
d. Sublingual
Answer C- the IV route is preferred as the fastest and most amenable titration. A PCA bolus can be delivered
unless; however, the pump will limit the dosage that can be delivered unless the parameters are changed.
Intraspinal administration requires special catheter placement and there are more potential complications with
this route. Sublingual is reasonably fast, but not a good route for titration, medication variety in this form is
limited.
9. When titrating an analgesic to manage pain, what is the priority goal?
a. Administer smallest dose that provides relief with the fewest side effects.
b. Titrate upward until the client is pain free.
c. Titrate downwards to prevent toxicity.
d. Ensure that the drug is adequate to meet the client’s subjective needs.
Answer A- the goal is to control pain while minimizing side effects. For sever pain the medication can be
titrated upward until pain is controlled. Downward titration occurs when the pain begins to subside. Adequate
dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs.
10. In educating clients about non-pharmaceutical alternatives, which topic could you delegate to an experienced
LPN/LVN, who will function under your continued support and supervision?
a. Therapeutic touch
b. Use of heat and cold applications
c. Meditation
d. Transcutaneous electrical nerve stimulation (TENS)
Answer B- Use of heat and cold applications is a standard therapy with guidelines for safe use and predictable
outcomes, and an LPN/LVN will be implementing this therapy in the hospital, under the supervision of an RN.
Therapeutic touch requires additional training and practice. Meditation is not acceptable to all clients and an
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assessment of spiritual beliefs should be conducted. Transcutaneous electrical stimulation is usually applied by
a physical therapist.
11. Place the examples of drugs in the order of usage according to the World Health Organization (WHO) analgesic
ladder.
a. Morphine, hydromorphone, acetaminophen and lorazepam
b. NSAIDs and corticosteroids
c. Codeine and oxycodene
d. Diphenhydramine
Answer B, C, A- Step 1 includes non-opioids and adjuvant drugs. Step 2 includes opioids for mild pain plus
Step 1 drugs are adjuvant drugs as needed. Step 3 includes opioids for severe pain (replacing Step 2 opioids)
and continuing. Step 1 drugs and adjuvant drugs as needed.

12. Which client is at greater risk for respiratory depression while receiving opioids analgesia?
a. An elderly chronic pain client with a hip fracture
b. A client with a heroin addiction and back pain
c. A young female client with advanced multiple myeloma
d. A child with an arm fracture and cystic fibrosis
Answer D- at greatest risk are elderly clients, opiate naïve clients, and those with underlying pulmonary
disease. The child has two of the three risk factors.
13. A client appears upset and tearful, but denies pain and refuses pain medication, because “my sibling is a drug
addict and has ruined out lives”. What is the priority intervention for this client?
a. Encourage expression of fears on past experiences
b. Provide accurate information about use of pain medication
c. Explain that addiction is unlikely among acute care clients
d. Seek family assistance in resolving this problem.
Answer A- This client has strong beliefs and emotions related to the issue of sibling addiction. First
encourage expression. This indicated to the client that the feelings are real and valid.It is also an opportunity
to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is
important, bearing in mind that their beliefs about drug addiction may be similar to those of the client.
14. A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. Hat is one of the first
signs of withdrawal?
a. Fever
b. Nausea
c. Diaphoresis
d. Abdominal cramps
Answer C- Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever, nausea, and
abdominal cramps are late signs that occur between 48 and 72 hours.
15. In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant?
a. Assist the client with preparation of a sitz bath.
b. Monitor the client for signs of discomfort while ambulating
c. Coach the client to deep breathe during painful procedures
d. Evaluate relief after applying a cold application.
Answer A- The nursing assistant is able to assist the client with hygiene issues and knows the principles of
safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are
nursing responsibilities.
16. The physician has ordered a placebo for a chronic pain client. You are a newly hired nurse and you feel
uncomfortable administering the medication. What is the first action you should take?
a. Prepare the medication and hand it to the physician
b. Check the hospital policy regarding use of the placebo.
c. Follow a personal code of ethics and refuse to give it.
d. Contact the charge nurse for advice.
Answer D- the charge nurse is a resource person who can help locate and review the policy. If the physician
is insistent, he or she could give the placebo personally, but delaying the administration does not endanger the
health or safety of the client. While following one’s own ethical code is correct, you must ensure that the
client is not abandoned and that care continues.
17. For a cognitively impaired client who cannot accurately report pain, what is the first action that you should
take?
a. Closely assess for nonverbal signs such as grimacing or rocking
b. Obtain baseline behavioral indicators from family members.
c. Look at the MAR and chart, to note the time of the last dose and response.
d. Give the maximum PRS dose within the minimum time frame for relief.
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ISO 9001:2008 COLLEGE OF HEALTH CARE TECHNOLOGY

Answer B- Complete information from the family should be obtained during the initial comprehensive
history and assessment. If this information is not obtained, the nursing staff will have to rely on observation of
nonverbal behavior and careful documentation to determine pain and relief patterns.
18. Which route of administration is preferable for administration of daily analgesics( if all body systems are
functional)?
a. IV
b. IM or subcutaneous
c. Oral
d. Transdermal
Answer C- If the gastrointestinal system is function, the oral route is preferred for routine analgesics because
of low cost and ease administration. Oral route is also less painful and less invasive than the IV, IM,
subcutaneous, or PCA routes. Transdermal route is slower and medication availability is limited compared to
oral forms.
19. A first day post- operative client on a PCA pump reports that the pain is inadequate. What is the first action you
should take?
a. Deliver the bolus dose per standing order.
b. Contact the physician to increase the dose
c. Try non-pharmacological comfort measures.
d. Assess the pain for location, quality and intensity.
Answer D- Assess the pain for changes in location, quality, and intensity, as well as changes in response to
medication. This assessment will guide the next steps.
20. Which non-pharmacological measure is particularly useful for a client with acute pancreatitis?
a. Diversional therapy, such as playing cards or board games.
b. Massage of back and neck with warmed lotion
c. Side-lying position with knees to chest and pillow against abdomen
d. Transcutaneous electrical nerve stimulation (TENS)
Answer C- The side-lying knee chest position opens retroperitoneal space and provides relief. The pillow
provides a splinting action. Diversional therapy is not the best choice for acute pain, especially if the
activity requires concentration. TENS is more appropriate for chronic muscular pain. The additional
stimulation of massage may be distressing to the client.