Embracing World Class Standards Care To Learn, Learn To Care

Don Mariano Marcos Memorial State University
South La Union Campus

COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Tel. 072.682.0663/ichams.dmmmsu-sluc.com
Embracing World Class Standards Care to learn, Learn to care
SITUATION 1. Respiratory disease is a medical term that encompasses pathological

conditions affecting the organs and tissues that make gas exchange possible in higher
organisms, and includes conditions of the upper respiratory tract, trachea, bronchi,
bronchioles, alveoli pleura, and pleural cavity, and the nerves and muscles, of breathing.
Nurse Jima is assigned in the medical ward and caring for clients with various
respiratory disorders and clients vith various types of tubes.
1. Tonsillectomy or Adenoidectomy is indicated only if the patient has:

a. Repeated boutd of tonsillitis
b. Hypertrophy of adenoids and tonsils that can cause obstruction
c. Repeated attacks of purulent otitis media
d. All of the above
2. On entering the Emergency Department, a client is short of breath and appears frightened.
Nurse Jima beginning the assessment of the client would be aware that an early
manifestation often associated with asthma is
A. Cyanosis B. Hypercapnia C. Anxiety D. Bradycardia
3. A client receives a beta- adrenergic bronchodilator and supplemental oxygen when entering
the ED for treatment of Asthma, but the client’s condition remains unchanged. Nurse Jima
anticipates that the client :
a. Will be coached immediately in biofeedback techniques
b. Will increase the amount of oral fluids
c. Will undergo “stat” pulmonary function test
d. Will receive intervention (IV) steroids
4. Nurse Jima notices that the fluid of the second chamber of the Pleur-evac is not bubbling.
Which of the following nursing assumptions would be most invalid?
a. The tubing from the client to the chamber is blocked
b. There is a leak somewhere in the tubing system
c. The client’s affected lung has re-expanded
d. The tubing need not to be cleared of fluids
5. The parents of a child with cystic fibrosis ask what determines the prognosis of the disease.
Nurse Jima knows that the greatest determinant of this prognosis is:
a. The ability to maintain ideal weight
b. The secretion of lipase by the pancreas
c. The regulation of sodium and chloride secretion
d. The degree of the pulmonary involvement
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Prepared by:
Enrico del Rosario
Agoo, La Union
6. Nurse Jima is caring for a client with a chest tube turns the client to the side and the chest
tube accidentally disconnects from the water seal chamber. Which initial action should the
nurse Jima take?
a. Call the health care provider (HCP).
b. Place the tube in a bottle of sterile water.
c. Replace the chest tube system immediately.
d. Place a sterile dressing over the disconnection site.
e. Clamp the tube using a double rubber tip double clamps
tube accidentally disconnects from the water seal chamber. Which is the best action should
the nurse Jima take?
b. Place the tube in a bottle of sterile water.
d. Place a sterile dressing over the disconnection site.
e. Clamp the tube using a rubber tip double clamps
tube accidentally puuled-out. Which is the initial action should nurse Jima take?
b. Take a gloved hand and cover the hole.
d. Place a sterile vaselinized dressing over the disconnection site.
tube accidentally puled-out. Which is the best action should nurse Jima take?
b. Take a gloved hand and cover the hole.
d. Place a sterile vaselinized dressing over the disconnection site.
10. Nurse Jima is caring for a client with a pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the water seal chamber. What action is most
appropriate?
a. Do nothing, because this is an expected finding.
b. Check for an air leak, because the bubbling should be intermittent.
c. Increase the suction pressure so that the bubbling becomes vigorous.
d. Clamp the chest tube and notify the health care provider immediately.
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Prepared by:
Enrico del Rosario
Agoo, La Union
11. The nurse is assessing the functioning of a chest tube drainage system in a client who has
just returned from the recovery room following a thoracotomy with wedge resection. Which
are the expected assessment findings? Select all that apply.
a. Excessive bubbling in the water seal chamber
b. Vigorous bubbling in the suction control chamber
c. Drainage system maintained below the client’s chest
d. 50 mL of drainage in the drainage collection chamber
e. Occlusive dressing in place over the chest tube insertion site
f. Fluctuation of water in the tube in the water seal chamber during inhalation and
exhalation
_______________
12. Nurse Jima who is the head of the unit, assign nurse Hazel to assist a health care provider
with the removal of a chest tube. Nurse Hazel should instruct the client to take which action?
a. Stay very still.
b. Exhale very quickly.
c. Inhale and exhale quickly.
d. Perform the Valsalva maneuver.
13. While changing the tapes on a newly inserted tracheostomy tube, the client coughs and the
tube is dislodged. Which is the initial nursing action would Nurse Hazel do?
a. Call the health care provider to reinsert the tube.
b. Grasp the retention sutures to spread theopening.
c. Call the respiratory therapy department to reinsert the tracheotomy.
d. Cover the tracheostomy site with a sterile dressing to prevent infection.
14. Nurse Jima is caring for a client immediately after removal of the endotracheal tube. The
nurse should report which sign immediately if experienced by the client?
a. Stridor
b. Occasional pink-tinged sputum
c. Respiratory rate of 24 breaths/minute
d. A few basilar lung crackles on the right
15. Nurse Jima is preparing to administer medication using a client’s nasogastric tube. Which
actions should the nurse take before administering the medication? Select all that apply.
a. Check the residual volume.

b. Aspirate the stomach contents.
c. Turn off the suction to the nasogastric tube.
d. Remove the tube and place it in the other nostril.
e. Test the stomach contents for a pH indicating acidity.
______________
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Prepared by:
Enrico del Rosario
Agoo, La Union
16. Nurse Jima is preparing to insert a nasogastric tube in an adult client. To determine the
accurate measurement of the length of the tube to be inserted, the nurse should take which
action?
a. Mark the tube at 10 inches (25.5 cm).
b. Mark the tube at 32 inches (81 cm).
c. Place the tube at the tip of the nose and measure by extending the tube to the earlobe
and then down to the xiphoid process.
d. Place the tube at the tip of the nose and measure by extending the tube to the earlobe
and then down to the top of the sternum.
17. The nurse checks for residual before administering a bolus tube feeding to a client with a
nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate
action for the nurse to take?
a. Hold the feeding and reinstill the residual amount.
b. Reinstill the amount and continue with administering the feeding.
c. Elevate the client’s head at least 45 degrees and administer the feeding.
d. Discard the residual amount and proceed with administering the feeding.
18. Nurse Jima is inserting a nasogastric tube in an adult client. During the procedure, the client
begins to cough and has difficulty breathing. What is the most appropriate action?
a. Insert the tube quickly.
b. Notify the health care provider immediately.
c. Remove the tube and reinsert it when the respiratory distress subsides.
d. Pull back on the tube and wait until the respiratory distress subsides.
19. Nurse Jima is preparing to administer medication through a nasogastric tube that is
connected to suction. To administer the medication, nurse Jima should take which action?
a. Position the client supine to assist in medication absorption.
b. Aspirate the nasogastric tube after medication administration to maintain patency.
c. Clamp the nasogastric tube for 30 to 60 minutes following administration of the
medication.
d. Change the suction setting to low intermittent suction for 30 minutes after medication
administration.
20. Nurse Jima is assessing for correct placement of a nasogastric tube. Nurse Jima aspirates
the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this
information, which action should the nurse take at this time?
a. Retest the pH using another strip.
b. Document that the nasogastric tube is in the correct place.
c. Check for placement by auscultating for air injected into the tube.
d. Call the health care provider to request a prescription for a chest radiograph.
21. Nurse Jima is preparing to obtain a sputum specimen from a client. Which of the following
actions will facilitate obtaining the specimen?
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Prepared by:
Enrico del Rosario
Agoo, La Union
a. Limiting fluids
b. Having client take three deep breaths.
c. Asking the client to spit into the collection container
d. Asking the client to obtain specimen after eating.
22. Nurse Jima is caring for a client after a bronchoscopy and biopsy. Which of the following
signs should nurse Jima be reported immediately to the physician?
a. Blood-streaked sputum
b. Dry cough
c. Hematuria
d. Bronchospasm
23. Nurse Jima is observing nurse Renz suction fluids from a client via tracheostomy tube.
When suctioning, the nurse Renz must limit the suctioning to a maximum of
a. 5 seconds
b. 10 seconds
c. 30 seconds
d. 1 minute
24. Nurse Elli together with Nurse Jima is caring for a client hospitalized with acute
exacerbation of COPD. Which of the following would they expect to note on assessment of
this client?
a. Increased O2 saturation with exercise
b. Hypocapnia
c. A hyperinflated chest on X-ray film
d. A widened diaphragm noted on X-ray film
25. An oxygen delivery system is prescribed for a client with COPD to deliver a precise oxygen
concentration. Which of the following types of oxygen delivery systems would the nurse
anticipate to prescribed?
a. Venturi mask
b. Aerosol mask
c. Face tent
d. Tracheostomy collar
26. The client is already for discharge, Nurse Jima is instructing her client with a diagnosis of
emphysema about measures that will enhance the effectiveness of breathing during
dyspneic period. Which of the following positions will the nurse instructs the client to
assume?
a. Side-lying in bed
b. Sitting in a recliner chair
c. Sitting up in bed
d. Sitting on the side of the bed and leaning on a overbed table
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Prepared by:
Enrico del Rosario
Agoo, La Union
27. Nurse Jima is conducting an educational session with some significant others regarding TB.
Nurse Jima tells the group that one of the first symptoms associated with TB is
a. A bloody, productive cough
b. A cough with expectoration of mucoid sputum
c. Chest pain
d. Dyspnea
28. Nurse Jima performs an admission on a client with the diagnosis of TB. She reviews the
result of which the diagnostic test that will confirm this diagnosis
a. Bronscopy
b. Chest X-ray film
c. Sputum culture
d. Tuberculin Skin test
29. A nursing instructor asks a nursing student to describe a route of transmission of

tuberculosis. The instructor concludes that the student states that TB is transmitted by
a. Airborne route
b. Blood and body fluids
c. Fecal-oral route
d. Hand to mouth
30. A client with tuberculosis is being treated with isoniazid(INH) and rifampin(Rifadin). Nurse
Jima is preparing instructions for the client regarding these medications. Which of the
following statements should be included in the plan of care?
a. “You must discontinue the medications if gastrointestinal irritation occurs.”
b. “You must take the medications with meals.”
c. “The entire yearlong course needs to be completed.”
d. “Fluids must be increased while taking this medication to prevent renal failure.”
31. Charge Nurse Jima assigns Nurse Elli to care for a client with acute respiratory distress
syndrome. Which of the following would Nurse Elli expect to note in the client
a. Decreased respiratory rate
b. Pallor
c. Low arterial PaO2
d. An elevated arterial PaO2
32. Isonaiazid (INH) and rifampin (Rifadin) have been prescribed to a client with TB. Nurse Jima
reviews the medical record of the client. Which of the following, if noted in the client’s
history, would require physician notification.
a. Heart disease
b. Allergy to Penicillin
c. Hepatitis B
d. Rheumatic Fever
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Prepared by:
Enrico del Rosario
Agoo, La Union
33. A client is suspected of having a pulmonary embolus. Nurse Jima assesses a client,
knowing that which of the following is a clinical manifestation of pulmonary embolus?
a. Decreased respirations
b. Bradypnea
c. Dyspnea
d. Bradycardia
34. A female client is scheduled for a chest radiograph. Which of the following questions is of
most importance Nurse Jima assessing this client?
a. “Is there a possibility that you could be pregnant?”
b. “Are you wearing any metal chain or jewelry?”
c. “Can you hold your breath easily?”
d. “Are you able to hold your hands above your head”
35. A client has just returned to a nursing unit following a bronchoscopy. Nurse Jima would
implement which of the following nursing interventions for this client?
a. Encouraging additional fluids for 24 hrs.
b. Ensuring the return the gag reflex before offering food or fluid.
c. Administering atropine IV
d. Administering small doses of midazolam
Situation 2. Upon discharge, the client with COPD requires considerable patient and
family teaching
36. Nurse Jam instructs a client diagnosed with COPD to utilize pursed-lip breathing. The client
asks nurse Jam about the advantage of this kind of breathing. The nurse answers that the main
purpose of pursed-lip-breathing is to:
a. prevent bronchial collapse b. Strengthen the intercostal muscles
c. Achieve maximum inhalation d. allows Air trapping
37. Nurse Jam instructs a patient about the use of respiratory inhaler. Arrange the steps in using
an inhaler chronologically
1. Press the canister down with your fingers as you breathe in.
2. Wait one minute between puffs if more than one puff is prescribed
3. Inhale mist hold your breath at least 5-10 seconds before exhaling.
4. Remove the cap and shake the inhaler
a. 4, 1, 3, 2 b. 3,4,2,1 c. 4,1,2,3 d. 1, 2, 3, 4
38. The physician prescribed monitoring of client’s oxygen saturation of the blood. Which of the
following will you prepare
a. EKG c. Spirometer
b. Pulse oximeter d. BP apparatus
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Prepared by:
Enrico del Rosario
Agoo, La Union
39. Patients suffering from COPD taught to avoid shifts to temperature and humidity. It should
be emphasized that the heat increases body temperature and thereby raising the:
a. Risk for Infection c. Oxygen requirements
b. Fluid intake d. Anxiety level
40. COPD patients maybe taught the following pulmonary hygiene measures to improve
clearance of airway secretion, except
a. Measure fluid intake c. postural drainage
b. Effective coughing d. complete bed rest
41. Nurse Jam is caring for a client hospitalized with acute exacerbation of chronic obstructive
pulmonary disease. Which findings would the nurse expect to note on assessment of this
client? Select all that apply.
a. A low arterial PCo2 level
b. A hyperinflated chest noted on the chest x-ray
c. Decreased oxygen saturation with mild exercise
d. A widened diaphragm noted on the chest x-ray
e. Pulmonary function tests that demonstrate increased vital capacity
_____________________
42. The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse
concludes that the client understands the information if the client indicates to report which
early sign of exacerbation?
a. Fever
b. Fatigue
c. Weight loss
d. Shortness of breath
43. The nurse is taking the history of a client with occupational lung disease (silicosis). The
nurse should assess whether the client wears which item during periods of exposure to
silica particles?
a. Mask
b. Gown
c. Gloves
d. Eye protection
44. The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then
attempts to determine the cause of the alarm. If unsuccessful in determining the cause of
the alarm, the nurse should take what initial action?
a. Administer oxygen
b. Check the client’s vital signs
c. Ventilate the client manually
d. Start cardiopulmonary resuscitation
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Prepared by:
Enrico del Rosario
Agoo, La Union
45. The nurse is preparing a list ofhome care instructions for a client who has been hospitalized
and treated for tuberculosis. Which instructions should the nurse include on the list? Select
all that apply.
a. Activities should be resumed gradually.
b. Avoid contact with other individuals, except family members, for at least 6 months.
c. Asputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
d. Respiratory isolation is not necessary because family members already have been
exposed.
e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic
bags.
f. When 1 sputum culture is negative, the client is no longer considered infectious and
usually can return to former employment.
__________________________
Situation 3. Significant myocardial damage may cause inadequate cardiac output and the
heart cannot support the body’s need for blood, which is called heart failure (HF). HF is
often reffered to us as congestive heart failure(CHF), is the inability of the heart to pump
sufficient blood to meet the needs of the tissues for oxygen and nutrients. The following
questions apply to CHF and other different cardiovascular conitions.
46. Kassy, who has been diagnosed with left-sided heart failure, complains of increasing
shortness of breath, and is agitated, and coughing up of pink-tinged frothy sputum. Nurse
Tordel should recognize this as signs and sypmtoms of:
a. Cardiogenic shock c. Acute Pulmonary edema
b. Right-sided heart failure d. Pneumonia
47. The physician prescribes Digoxin (Lanoxin) for a client with heart failure. During Digoxin
therapy, which electrolyte imbalance may predispose the client to Digitalis toxicity?
a. Hypermagnesemia b. Hypercalcemia c. Hypernatremia d. Hypokalemia
48. Before administering Digoxin(Lanoxin), what is the most important action of nurse Tordel to
take?
a. Weigh the client daily c. Provide food high in potassium
b. Take an apical pulse d. Administer oxygen
49. Nurse Tordel is caring for Luela who has an acute pulmonary edema. To immediately
promote oxygenation and relief of dyspnea, nurse Tordel should first:
a. Perform chest physiotherapy c. Place Luela on High Fowler’s
b. Have her take deep breaths and cough d. Administer oxygen
50. Which signs and symptoms are present with a diagnosis of pericarditis?
a. Fever, chest discomfort, and elevated ESR
b. Low urine output secondary to left ventricular dysfunction
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Prepared by:
Enrico del Rosario
Agoo, La Union
c. Lethargy, anorexia, and heart failure

d. Pitting edema, chest discomfort, and non ST segment elevation
Situation 4: Nurse Steve is assigned to a medical unit and tasked to obtained data about
his patients
51. Nurse Steve performs blood pressure screening at the local community center. Which of the
following clients is most likely to develop essential hypertension?
a. A 30-year old man who is an account executive of a large company
b. A 40-year ;old man who jogs 3 miles three times a week
c. A 55-year old man whose father dies at age 60 due to CVA
d. A 70-year old man who supplemts his diet with vitamins B and C
52. To a client schedule for anhiography, the nurse would state that:
a. “The general hospital consent you signed will permit the procedure.to numb ”
b. “The procedure will take place to the operating theatre.”
c. “A local anesthetic will be used to numb the area before catheter insertion
d. “You can eat and drink until the time you leave the unit after the procedure.”
53. For a client with Cardiomyopathy, the most important nuirsing diagnosis is:
a. Decreased cardiac output related to reduced myocardial contractility
b. Excessive fluid volume related to fluid retention and altered compensatory mechanisms
c. Anxiety related to actual threat to health status
d. Ineffective individual coping related to fear of debilitating illness
54. Which client diagnosis indicates a high risk for thrombotic stroke?
a. Atrial fibrillation c. Diabetis insipedus
b. Hypotension d. Mycardial infarction 25 years ago
55. Nurse Annie is reviewing the health care providers order for a new client. The client has just
returned from surgery for aortic aneurysm repair. He is in NPO, he has an NGT and vital
signs are stable. Which order would the nurse question?
a. 1000 ml D5W with 40 mEq potassium to infuse at 100 mL/hr
b. Cefoxitin(Mefoxin) 1gm IV in 50mL D5W over 15 minutes
c. 1000mL DL ½ NaCl to infuse 125ml/hr
d. 20 mEq Potassium IV push
56. When instructing a client in the proper administration of sublingual nitroglycerin (NTG),
Nurse Annie include in the teaching plan that the client should:
a. Take an Aspirin before each dose of NTG
b. Store NTG tablets in the refrigerator
c. Repeat the dosage every five minutes to three time if pain is not relieved
d. Assess blood pressure for reactive hypertension after each dose
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Prepared by:
Enrico del Rosario
Agoo, La Union
57. Nurse Annie understands that the purpose of bed rest following a myocaridial infarction is to:
a. Facilitate accurate cardiac monitoring
b. Promote a restful atmosphere
c. Decrease workload on the heart
d. Allow regeneration of the myocardium
58. Nurse lea is caring for a patient admitted to the unit with a diagnosis of acute Myocardial
Infarction. Lea understands that a caridiac monitor is attached to this patient for which of the
following reasons?
a. To monitor client’s conditi0n closely without having to wake her up
b. To prevent another, more serious heart attack from occurring
c. To verify the diagnosis of MI
d. To detect any life threatening changes in the heart rhythm
59. Later in the acute phase of MI; which of the following would appear as a first sign of tissue
death?
a. ST segment suppression c. Prolonged PR interval
b. Short T wave d. Pathologic q wave
60. Which symptom distinguished myocardial infarction from angina?

a. Chest pain that is not affected by coronary vasodilators
b. Arrhythmias
c. Hypotension, distended jugular veins and muffled heart sounds
d. EKG changes
61. The nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects
pulmonary edema. The nurse immediately asks another nurse to contact the health care
provider and prepares to implement which priority interventions? Select all that
apply.
a. Administering oxygen
b. Inserting a Foley catheter
c. Administering furosemide
d. Administering morphine sulfate intravenously
e. Transporting the client to the coronary care unit
f. Placing the client in a low Fowler’s side-lying position
________________________
62. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger,
and begins coughing frothy, pink-tinged sputum. Which finding would the nurse Pacio
anticipates when auscultating the client’s breath sounds?
a. Stridor
b. Crackles
c. Scattered rhonchi
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Prepared by:
Enrico del Rosario
Agoo, La Union
d. Diminished breath sounds
63. Nurse Pacio is about to administer Amlodipine(Norvasc) to client who was admitted due to
hypertension. Nurse Pacio knows when not to administer this drug if the blood pressure is:
a. 110/80 mmHg b. 140/90 mmHg c. 90/60 mmHg d. 110/60 mmHg
64. A client with myocardial infarction is developing cardiogenic shock. Because of the risk of
myocardial ischemia, what condition should the nurse carefully assess the client for?
a. Bradycardia
b. Ventricular dysrhythmias
c. Rising diastolic blood pressure
d. Falling central venous pressure
65. A client with variant angina is scheduled to receive an oral calcium channel blocker twice
daily.Which statement by the client indicates the need for further teaching?
a. “I should notifymy doctor ifmy feet or legs start to swell.”
b. “My doctor told me to call his office if my pulse rate decreases below 60.”
c. “Avoiding grapefruit juice will definitely be a challenge for me, since I usually
drink it every morning with breakfast.”
d. “My spouse told me that since I have developed this problem, we are going to
stop walking in the mall every morning.”
66. The nurse is assessing the neurovascular status of a client who returned to the surgical
nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm,
and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from
admission. How should the nurse correctly interpret the client’s neurovascular status?
a. The neurovascular status is normal because of increased blood flow through the
leg.
b. The neurovascular status is moderately impaired, and the surgeon should be
called.
c. The neurovascular status is slightly deteriorating and should be monitored for
another hour.
d. The neurovascular status is adequate from an arterial approach, but venous
complications are arising.
67. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat
cardiac tamponade. Which observation would indicate that the procedure was effective?
a. Muffled heart sounds
b. A rise in blood pressure
c. Jugular venous distention
d. Client expressions of dyspnea
68. The nurse is caring for a client who had a resection of an abdominal aortic aneurysm
yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged
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Enrico del Rosario
Agoo, La Union
for the last 10 hours. The client’s urine output for the last 3 hours has been 90, 50, and 28
mL (28 mL is most recent). The client’s blood urea nitrogen level is 35 mg/dL (12.6 mmol/L)
and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which
nursing action is the priority?
a. Check the urine specific gravity.
b. Call the health care provider (HCP).
c. Put the IV line on a pump so that the infusion rate is sure to stay stable.
d. Check to see if the client had a blood sample for a serum albumin level drawn.
69. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse
sees no electrocardiographic complexes on the screen. Which is the priority nursing action?
a. Call a code.
b. Call the health care provider.
c. Check the client’s status and lead placement.
d. Press the recorder button on the electrocardiogram console
70. A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour
for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output
for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea
nitrogen level is 45 mg/dL(16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194
mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk
for which problem?
a. Hypovolemia
b. Acute kidney injury
c. Glomerulonephritis
d. Urinary tract infection
Situation 5. Nurse Diane is assigned at the Medical Surgical unit and is taking care of
patients with gastrointestinal conditions. The following questions apply.
71. Nurse Diane is providing care for a client diagnosed with GERD. Which of the following
measures would be inappropriate to include in the client’s discharge instruction?
a. Divide meals into small feeding c. avoid food high in caffeine
b. Sleep with head of the bed elevated d. Ensure a high calorie and high protein diet
72. The nurse is caring for a client with gastroenteritis. Which of the following measures should
receive the priority in the client’s plan of care?
a. Provides assistance when the client is washing hands and face prior to eating meals
b. Maintain a clean environment free from odor
c. Encourage intake of fluids and continuously monitor intake and output
d. Provide food preffered by the client and allow plenty of time meals
73. Nurse Diane is going to receive a newly admitted client who is infected with E. coli. What
contact precaution should Nurse Diane initiate?
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Enrico del Rosario
Agoo, La Union
a. Universal b. Standard c. Contact d. Droplet
74. When admitting a client as this infected through enteric route, what type of room should be
prepared?
a. Negative air flow room c. Private room
b. Ordinary room
75. When taking care of a client infected with cholera infections, which actions should be
observed, select all that apply
a. Nurse should wear gloves in contact with the client
b. Disposable utensils are used
c. Frequent handwashing
d. Reusable spoons and forks
____________________________
76. A client schedule for a vagotomy asks the nurse what the procedure is about. Which of the
following statements the nurse describes the purpose of vagotomy?
a. “It decreases food transit time in the stomach”
b. “It regenerates gthe gastric mucosa”
c. “It reduces the stimulus of acid secretion”
d. “it stops stress-related reactions”
77. After gastrectomy, a client is monitored for signs of Dumping Syndrome. Which of the
following Nurse Diane Should evaluate as early clinical manifestation associated with this
condition?
a. Hematemesis c. Rigidity of abdominal muscles
b. Decreasing Heart rated. Dizziness and hypotension
78. Nicole, a 24-year old engineer is admitted to the unit due to diverticulosis. The nurse is
preparing the plan of care for Nicole, which of the following diets would be essential to
include?
a. Low fiber diet
b. Low fat, high carbohydrate, and high residue diet
c. Low fat, high carbohydrate, and high calorie diet
d. Diet high in protein and calories, low residue and milk free
79. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who
is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal
pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended
and bowel sounds are diminished. Which is the most appropriate nursing intervention?
a. Notify the health care provider (HCP).
b. Administer the prescribed pain medication.
c. Call and ask the operating room team to perform surgery as soon as possible.
d. Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
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Prepared by:
Enrico del Rosario
Agoo, La Union
80. A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being
assessed by the nurse. Which assessment findings would be consistent with acute
pancreatitis? Select all that apply.
a. Diarrhea
b. Black, tarry stools
c. Hyperactive bowel sounds
d. Gray-blue color at the flank
e. Abdominal guarding and tenderness
f. Left upper quadrant pain with radiation to the back
___________________
81. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which
of these clinical manifestations support this diagnosis? Select all that apply.
a. Fever
b. Positive Cullen’s sign
c. Complaints of indigestion
d. Palpable mass in the left upper quadrant
e. Pain in the upper right quadrant after a fatty meal
f. Vague lower right quadrant abdominal discomfort
____________________
82. A client is diagnosed with viral hepatitis, complaining of “no appetite” and “losing my taste
for food.” What instruction should the nurse give the client to provide adequate nutrition?
a. Select foods high in fat.
b. Increase intake of fluids, including juices.
c. Eat a good supper when anorexia is not as severe.
d. Eat less often, preferably only 3 large meals daily.
83. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses
the client for which expected assessment finding?
a. Malaise
b. Dark stools
c. Weight gain
d. Left upper quadrant discomfort
84. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for
this client? Select all that apply.
a. Administer stool softeners as prescribed.
b. Instruct the client to limit fluid intake to avoid urinary retention.
c. Encourage a high-fiber diet to promote bowel movements without straining.
d. Apply cold packs to the anal-rectal area over the dressing until the packing is
removed.
e. Help the client to a Fowler’s position to place pressureon the rectal area and
decreasebleeding.
15
Prepared by:
Enrico del Rosario
Agoo, La Union
______________________
85. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about
substances to avoid. Which items should the nurse include on this list? Select all that apply.
a. Coffee
b. Chocolate
c. Peppermint
d. Nonfat milk
e. Fried chicken
f. Scrambled eggs
_____________
86. A client has undergone esophagogastroduodenoscopy. The nurse should place highest
priority on which item as part of the client’s care plan?
a. Monitoring the temperature
b. Monitoring complaints of heartburn
c. Giving warm gargles for a sore throat
d. Assessing for the return of the gag reflex
87. The nurse has taught the client about an upcoming endoscopic retrograde
cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs
further information if the client makes which statement?
a. “I know I must sign the consent form.”
b. “I hope the throat spraykeepsme from gagging.”
c. “I’m glad I don’t have to lie still for this procedure.”
d. “I’m glad some intravenous medication will be
e. given to relax me.”
Situation 6. Appendicitis is a medical emergency characterized by inflammation of the

appendix, many cases of which require the removal of the appendix. Mr. Jefferson
Eigenman, a client admitted 2 hours ago, presents with low grade fever, nausea,
vomiting, and vague pain in the abdominal region. The physician suspects that he has
appendicitis.
88. The major complication of appendicitis is the perforation of the appendix which generally
occur 24 hours after the onset of pain. Nurse Justin knows that which of the following is a
symptom of a possible perforation?
a. Fever and increasing abdominal distension c. Fatigue
b. Malaise and pallor d. Jaundice
89. Teresa, a client recovering from chronic pancreatitis is ordered for discharge. Which of the
following measures would be essential to include in the discharge instruction?
a. Weight reduction and exercise program
b. Bowel refraining program including daily laxative administration
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Prepared by:
Enrico del Rosario
Agoo, La Union
c. Diet modification avoiding high-fat foods, caffeine and alcohol

d. Relaxati0on techniques and stress management
90. Marian, a nurse in the PACU discovered that Malinda, 50 kilos who is 3 hours post
cholecystectomy was in severe pain. Upon checking the chart, she found out that Malinda
had demerol100mg PRN for pain. Which of the following nust Nurse Marian take next?
a. Verify the order from the attending physician
b. Inject Demerol IM to Malinda
c. Report the situation to the Nurse Supervisor and discuss the situation
d. Administer the recommended dose which is 50 mg because Malinda only weighs 50kg
91. While conversing with a client with end-stage liver disease, Nurse Mary noticed the client
was unable to stay awake and seemed to fall asleep in middle of a sentence. Nurse Mary
rcognizes these symptoms to be indicative of which condition?
a. Elevated blood sugar c. increase blood ammonia levels
b. Increased bile production d. hypocalcemia
92. A patient with liver disease asked Nurse Lauro she easily gets bruised. Which of the
following should nurse Lauro include in his response?
a. “your liver is unable to build the proteins that are needed in making clotting factors.”
b. “Your liver can no longer metabolize drugs making them inactive”
c. “your liver is breaking down blood cells to rapidly”
d. Your liver can’t store Vitamin C anymore”
93. A patient with liver encephalopathy is expected to have high blood ammonia level. Nurse
Lauro expect that which example of drug is listed on the medication order?
a. Metoprolol b. Ativan c. Cefuroxime d. Neomycin
94. Nurse Lauro knows that the route of aminoglycoside which has been prescribed prior to
scheduled Abdominoperineal Resection is
a. IV b. IM c. Oral d. Sublingual
95. The purpose of prescribing aminoglycoside prior to surgery is to

a. Prophylaxis
b. Sterilize the bowel
c. Treat the underlying condition
d. No purpose. The physician just prescribed it.
96. The nurse receives a telephone call from the postanesthesia care unit stating that a client is
being transferred to the surgical unit. The nurse plans to take which action first on arrival of
the client?
a. Assess the patency of the airway.

b. Check tubes or drains for patency.
c. Check the dressing to assess for bleeding.
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Prepared by:
Enrico del Rosario
Agoo, La Union
d. Assess the vital signs to compare with preoperative measurements.
97. A nurse conducted preoperative teaching for a client scheduled for surgery in 1 week. The
client has a history of arthritis and has been taking Acetylsalicylic acid (Aspirin). The nurse
determines that the client needs additional teaching if the client states?
a. “i need to continue the Aspirin as prescribed until the day of the surgery”
b. “Aspirin can cause bleeding after surgery”
c. “ Aspirin can cause my ability to clot blood to be abnormal”
d. “I need to discontinue the aspirin 48hrs before the scheduled surgery”
98. A nurse assesses the client’s surgical inscision for the signs of infection. Which finding by
the nurse would be interpreted as a normal finding at the surgical site?
a. Red, hard skin
b. Purulent drainage
c. Serous drainage
d. Warm, tender skin
99. A client who had abdominal surgery complains of feeling as though “something gave way” in
the incicional site.the nurse removes the dressing end notes the presence of a loop of bowel
protruding through the incision. Select all that apply
a. Place the client in a supine position without pillow under the head
b. instruct the client to remain quiet
c. Place a sterile saline dressing and ice packs over the wound
d. Contact the surgeon
e. prepare the client for wound closure
___________________
100. A client with a perforated gastric ulcer is scheduled for ‘E’ surgery. The client cannot
sign the operative consent form because of sedation from narcotic analgesics that have
been administered. The nurse should take which of the following most appropriate actions in
the care of this client?
a. Obtain a telephone consent from a family member and have the consent witnessed
by two persons.
b. Obtain a court order for the surgery.
c. Send the client to surgery without the consent form being signed.
d. Have the hospital chaplain sign the informed consent immediately.
18
Prepared by:
Enrico del Rosario
Agoo, La Union
19
Prepared by:
Enrico del Rosario

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Embracing World Class Standards Care To Learn, Learn To Care

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Don Mariano Marcos Memorial State University

South La Union Campus

SITUATION 1. Respiratory disease is a medical term that encompasses pathological

1. Tonsillectomy or Adenoidectomy is indicated only if the patient has:

a. Check the residual volume.

29. A nursing instructor asks a nursing student to describe a route of transmission of

c. Lethargy, anorexia, and heart failure

60. Which symptom distinguished myocardial infarction from angina?

d. Diminished breath sounds

a. Universal b. Standard c. Contact d. Droplet

Situation 6. Appendicitis is a medical emergency characterized by inflammation of the

c. Diet modification avoiding high-fat foods, caffeine and alcohol

95. The purpose of prescribing aminoglycoside prior to surgery is to

a. Assess the patency of the airway.

d. Assess the vital signs to compare with preoperative measurements.

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