RAD BLOCK EXAM NUR.

155

1. The nursing management of the patient with cholecystitis associated

with cholelithiasis is based on the knowledge that *
a. a low-fat diet is recommended.
b. gallstones once removed tend not to recur.
c. Meperidine (Demerol) is used in the management of colic pain.
d. the disorder can be successfully treated with oral bile salts that dissolve
gallstones in just a week.

2. The physician orders oral neomycin as well as a neomycin enema for a

client with cirrhosis. The nurse understands that the purpose of this therapy is
to: *
a. reduce abdominal pressure
b. block ammonia formation
c. prevent straining during defecation
d. reduce bleeding within the intestine

3. The nurse is caring for a patient with cirrhosis. The patient suddenly
presents confusion, agitation and asterixis. A diagnosis of Disturbed thought
processes is formulated. This is due to: *
a. massive ascites formation
b. fluid volume excess
c. increase serum ammonia
d. portal hypertension

4. Which of the following is NOT the major role of the kidneys in normal
healthy adults? *
a. Excretion of nitrogen-containing wastes
b. Maintenance of water and electrolyte balance in the blood
c. Conversion of ammonia to bicarbonate ion to maintain the normal pH of the
blood
d. Prevention of bleeding, infection, and anemia
!
5. A nurse interviews the parents of a child recently diagnosed with
glomerulonephritis. The nurse understands that which information collected
during the assessment is most often associated with the diagnosis of
glomerulonephritis? *
a. Streptococcal throat infection 2 weeks prior to diagnosis.
b. Child fell off a bike onto the handlebars.
c. Nausea and vomiting for the last 24 hours.
d. Urticaria and itching for 1 week prior to diagnosis.

6. You are caring for a woman who is on hemodialysis. She has an AVF.
0/1
Which of the following is expected when assessing the fistula? *
a. Ecchymotic area
b. Pulselessness
c. Redness
d. Enlarged veins

7. How do kidneys control Na+ and K+ levels? *

a. Kidneys release aldosterone which controls renin. Renin causes the
release of angiotensin. Angiotensin controls the levels of Na+ and K+.
b. The kidneys release renin, which controls angiotensin. The angiotensin
controls aldosterone. Aldosterone controls the levels of Na+ and K+.
c. The kidneys release renin which controls K+. The kidneys release
angiotensin which causes Na+ release.
d. None of the above.

8. The nurse helps the client develop a home diet plan with the goal of
helping him maintain adequate nutritional status. Which of the following diets
would be most APPROPRIATE for a client with chronic renal failure? *
a. High carbohydrate, high protein.
b. High calcium, high potassium, high protein.
c. Low protein, low sodium, low potassium.
d. Low protein, high potassium

9. A patient is admitted with electrolyte imbalance. He has carpopedal

spasm, ECG changes, and a positive Chvostek’s sign. The nurse suspects a
deficit of: *
a. calcium.
b. magnesium.
c. phosphorus.
d. sodium.

10. To prevent complications associated with hypercalcemia, which of

the following health teachings should the nurse instruct a patient with this
electrolyte imbalance? *
a. Monitoring the patient for signs of decreasing sensorium
b. Taking anti-diarrheals as prescribed to manage increased GI motility as
part of the disease process
c. Monitoring pain and inflammation
d. Increasing patient mobility as tolerated

11. A client receiving parenteral nutrition in the home setting has a weight

gain of 5 lbs. in 1 week. The nurse next assesses the client to detect the
presence of which of the following: *
a. Thirst
b. Decreased BP
c. Polyuria
d. Crackles on auscultation of the lungs
12. A nurse is assigned to care for a group of clients. On review of the
client's medical records, the nurse determines that which client is at risk for
deficient fluid volume? *
a. A client with a colostomy
b. A client with decreased kidney function
c. A client with congestive heart failure
d. A client receiving frequent wound irrigations

13. A postoperative patient is diagnosed with fluid volume overload.

Which of the following should the nurse assess in this patient? *
a. poor skin turgor
b. distended neck veins
c. decreased urine output
d. concentrated hemoglobin & hematocrit levels

14. The nurse is caring for a patient receiving a blood transfusion. The
nurse would observe which of the following if fluid overload occurred during
the transfusion? *
a. Decreased pulse rate, increased BP, decreased respirations
b. Increased pulse rate, increased BP, increased respirations
c. Increased pulse rate, increased BP, decreased respirations
d. Decreased pulse rate, decreased BP, increased respirations

15. Serum phosphorus is inversely proportional to serum calcium and

causes a reciprocal drop in calcium when phosphorus increases. Which of the
following clinical manifestations would indicate hypocalcemia as a result of
phosphorus excess? *
a. Tetany & tingling sensations
b. Impaired vision
c. Decreased urine output
d. Anorexia, nausea & vomiting

16. An adult male patient has a history of Diabetes Insipidus. The nurse
understands that which of the following imbalances is most likely to develop if
this medical problem recurs? *
a. Hypernatremia
b. Hyperkalemia
c. Hyponatremia
d. Hypokalemia

17. The nurse is reviewing the laboratory result of the client. An arterial
blood gas report indicates that the client’s pH is 7.20, PCO2 is 35 mmHg and
HCO3 is 19 mEq/L. The results are consistent with: *
a. Metabolic acidosis
b. Respiratory acidosis
c. Metabolic alkalosis
d. Respiratory alkalosis

18. The nurse must be alert for signs of respiratory acidosis in the client
with emphysema because this individual has a long-term problem with oxygen
maintenance and: *
a. hyperventilation occurs, even if the cause is not physiologic.
b. there is a loss of carbon dioxide from the body’s buffer pool.
c. the carbon dioxide is not excreted.
d. localized tissue necrosis occurs as a result of poor oxygen supply to the
area.

19. Nurse Taylor, N.O.D. for the 2pm-10pm shift, receives Mr. Burke suffering
from anemia, infection and dehydration and under fluid replacement therapy.
She carefully monitors the patient’s I&O during her shift (see image). Nurse
Taylor calculates the intake and output as: *
 a.
Intake = 1210mL; Output = 1000 mL
b. Intake = 1300mL; Output = 1010 mL
c. Intake = 1300mL; Output = 910 mL
d. Intake = 1310mL; Output = 900 mL

20. During the compensated stage of shock, even the less vital organs
receive insufficient blood supply. Continuous hypoxemia to the
abdominal organs may cause the pancreas to release a depressant factor
resulting to: *
a. Increased peripheral resistance
b. Decreased partial pressure of carbon dioxide
c. Decreased cardiac contractility
d. Bradypnea

21. Shock is a medical emergency which affects all of the body systems
leading to serious damage to multiple organs. Which among the options
below describes the underlying pathophysiologic alteration in all types of
shock? *
a. Hemorrhage of blood or body fluids
b. Inadequate tissue perfusion
c. Decreased cardiac output
d. Vasodilation of vascular beds

22. This type of vasogenic shock results from interference with the SNS
resulting to a predominant functioning of the PNS. Consequently, the body
experiences a loss of vasomotor tone with generalized arteriolar and venous
dilation producing a hypotensive state. *
a. Neurogenic shock
b. Septic shock
c. Anaphylactic shock
d. Hemorrhagic shock

23. Cardiogenic shock results from the inability of the heart to pump
blood sufficiently to perfuse the cells of the body. It can be coronary or non-
coronary in origin. All of the following conditions would cause non coronary
cardiogenic shock, EXCEPT: *
a. Amyloidosis of the heart
b. Myocardial Infarction
c. Cardiac tamponade
d. Cardiomyopathy

24. Which of the following would be the best indication that fluid
replacement for the client in hypovolemic shock is adequate? *
a. Systolic blood pressure above 60 mmHg
b. Pitting edema is maintained at +2
c. Urine output of greater than .5 mL/kg/hr
d. Heart rate of less than 100 bpm

25. A patient was admitted to the E.R. because of severe chest pain. His
ECG recording shows an abnormality consistent with Acute Myocardial
Infarction. Which earliest symptom should the nurse be alert for as it implies
development of Cardiogenic Shock which is a common complication of AMI? *
a. Cyanosis
b. Presence of fourth heart sound
c. Decreased urine output
d. Altered level of consciousness

26. Andrew, a student nurse, was explaining about the heart’s activity.
Cardiac electrical activity is the result of the movement of ions across the cell
membrane. He mentioned repolarization. He would be correct if he said: *
a. Repolarization is the electrical activation of the cell.
b. Repolarization is the return of the cell to its resting state.
c. Repolarization transmit impulses to the largest chamber of the heart, the
left bundle branch bifurcates into the left anterior and left posterior bundle
branches.
d. Repolarization interaction between changes in membrane voltage and
muscle contraction.

27. The blood flow to the different parts of the body is generated by the
pumping actions of the heart. Among the statements below, which would
support the true mechanism of the muscle organ? *
a. At the end of diastole, pressure within the right and left ventricles rapidly
increases.
b. During systole, when the ventricles are relaxed and the AV valves are open,
blood returning from the veins flows into the atria and then into the ventricles.
c. Toward the end of the diastolic period, the atrial muscles contract in
response to an electrical impulse initiated by the SA node.
d. Atrial diastole augments ventricular blood volume by 15% to 25% and is
sometimes referred to as the “atrial kick”.

28. A client seeks medical attention for dyspnea, chest pain, syncope,
fatigue and palpitations. A thorough physical examination reveals an apical
systolic thrill and heave, along with a fourth heart sound (S4) and a systolic
murmur. Diagnostic tests reveal that the client has hypertrophic
cardiomyopathy (HCM). Which drug can be given to a patient with HCM to
decrease cardiac workload by decreasing force of cardiac contraction, rate
and conductivity? *
a. Atenolol
b. Diltiazem
c. Procainamide
d. Digoxin

29. A client newly diagnosed with angina pectoris has taken two
sublingual nitroglycerin tables for chest pain. The chest pain was relieved but
the client complains of a headache. The nurse interprets that this symptom
most likely represents: *
a. An allergic reaction to nitroglycerine
b. An expected side effect of the medication
c. An early sign of medication tolerance
d. An impending sign of cardiogenic shock

30. A client is admitted for the treatment of Prinzmetal’s angina. When

developing care plan, the nurse keeps in mind that this type of angina is
triggered by: *
a. Activities that increase myocardial oxygen demand.
b. An unpredictable amount of activity.
c. Coronary artery spasm.
d. The same type of activity that caused previous angina episodes.

31. During the past few months, a 56-year old woman has felt brief
twinges of chest pain while working in her garden and has had frequent
episodes of indigestion. She comes to the hospital after experiencing severe
anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of
stable angina pectoris. The woman says, “I really thought I was having a heart
attack. How can you tell the difference?” Which response by the nurse would
provide the client with the most accurate information about the difference
between the pain of angina and that of MI? *
a. “The pain associated with a heart attack is much more severe.”
b. “The pain associated with a heart attack radiates into the jaw and down the
left arm.”
c. “It is impossible to differentiate angina pain from that of a heart attack
without an ECG.”
d. “The pain of angina is usually relieved by resting or lying down.”

32. Alteplase, recombinant, or tissue plasminogen activator (tPA) is

administered during the first 6 hours after onset of Myocardial Infarction. The
nurse is knowledgeable that this is done to achieve which of the following
effects? *
a. Control chest pain.
b. Reduce coronary artery vasospasm.
c. Control the dysrhythmias associated with MI.
d. Revascularize the blocked coronary artery.

33. A nurse is taking history from a patient who has just been admitted to
the hospital with an acute myocardial infarction. Which of the following
questions would be most important for the nurse to ask? *
a. “At what time did the pain start?”
b. “When did you eat your last meal?”
c. “Have you experienced a pounding headache?”
d. “Did you feel fluttering in your chest?”

34. Mr. Uno was admitted to the E.R. because of shortness of breath
accompanied by edema and distended neck veins. The nurse intends to
check whether Mr. Uno is positive for hepatojugular reflux. To carry out this
assessment, the nurse should: *
a. Elevate the client’s head to 90 degrees.
b. Press the right upper abdomen.
c. Lay the client flat in bed.
d. Instruct the client to bear down.

35. A man is admitted for treatment of heart failure. The physician orders
an IV of 125 mL for normal saline per hour and central venous pressure (CVP)
readings every 4 hours. Sixteen hours after admission, the client’s CVP
reading is 3 cmH2O. Which of the following evaluations of the
client’s fluid status, if made by the nurse, would be most accurate? *
a. “The client has received enough fluid.”
b. “The client’s fluid status remains unaltered.”
c. “The client has received too much fluid.”
d “The client needs more fluid ”

36. Several months after being diagnosed with Coronary Artery Disease,
Mr. Atom had a heart attack. To revascularize portions of his myocardial wall,
he was scheduled for CABG. Which of the following is done in this surgery: *
a. Atherosclerotic plaque is vaporized using photodynamic laser.
b. A cardiac catheter is inserted to dilate the clogged coronary arteries.
c. A graft is used to reroute blood flow through the heart.
d. Device made from titanium is placed in the affected arteries to hold them
open

37. The nurse coming on duty receives the report from the nurse going
off duty. Which client should the on-duty nurse assess first? *
a. The 58-year-old client who was admitted 2 days ago with heart failure,
blood pressure of 126/76 mmHg, and a respiratory rate of 22 breaths/minute.
b. The weeping 10-year-old girl with cyanotic congenital heart defect who is
with her mother
c. The 89-year old client with end-stage right-sided heart failure, blood
pressure of 78/50mmHg, and with a "Do not resuscitate" order
d. The 62-year old client who was admitted 1 day ago with thrombophlebitis
and is receiving I.V. heparin

38. Casey Lucas, a pre-school child previously diagnosed of Tetralogy of

Fallot, is rushed to the ER due to cyanosis precipitated by crying. Her mother
observed that after playing, he gets tired. Which of the following nursing care
goals should the nurse consider as most appropriate for patient Casey? *
a. Promote normal growth and development
b. Decrease hypoxic spells
c. Prevent infection
d. Hydrate adequately

39. Who among these clients with congenital heart diseases should be
care for first by the nurse? *
a. The child with coarctation of aorta with elevated blood pressure in the
upper extremity.
b. The child with partial anomalous venous return with clubbing of fingers and
elevated red blood cells.
c. The child with tricuspid atresia who experiences fatigue after feeding.
d. The child with ventricular septal defect who murmurs on auscultation of the
chest

40. A client with high blood pressure is receiving an antihypertensive

drug. The nurse knows that antihypertensive drugs commonly cause fatigue
and dizziness, especially on rising. When developing a client teaching plan to
minimize orthostatic hypotension, the nurse should include which instruction?
*
a. “Avoid drinking alcohol and straining at stool, and eat a low-protein snack at
night.”
b. “Wear elastic stockings, change positions quickly and hold onto a stationary
object when rising.”
c. “Flex your calf muscles, avoid alcohol, and change positions slowly.”
d. “Rest between demanding activities, eat plenty of fruits and vegetables,
and drink 6 to8 cups of fluid daily.”

41. The senior nurse is orienting a new graduate registered nurse to an

oncology unit where blood product transfusions are frequently administered.
In discussing ABO compatibility, the senior nurse presents several
hypothetical scenarios. A well-informed new graduate would know the
greatest likelihood of an acute hemolytic reaction would occur when giving: *
a. A-positive blood to an A-negative client.
b. O-negative blood to an O-positive client
c. O-positive blood to an A-positive client
d. B-positive blood to an AB-positive client

42. A serum bilirubin is performed on a client who is weak and dyspneic

and jaundiced. A bilirubin level above 2 mg/100mL (hyperbilirubinemia) blood
volume could indicate which of the following conditions? *
a. Hemolytic anemia
b. Pernicious anemia
c. Decreased rate of red cell destruction
d. Low oxygen-carrying capacity of erythrocytes

43. The nurse is assessing a client with polycythemia vera. The nurse
should conduct a focused assessment because this client is at risk for which
of the following? *
a. Hair loss
b. Thrombus formation
c. Clotting
d. Iron-deficiency

44. Which of the following interventions aims to maintain adequate

ventilation and oxygenation to clients with acute respiratory failure? *
a. Oxygen therapy
b. Intubation and mechanical ventilation
c. Verbalization of feelings
d. ABG analysis

45. The RN needs further teaching when she states the following
regarding PEEP: *
a. PEEP improves functional residual capacity
b. PEEP improves oxygenation by enhancing gas exchange
c. PEEP closes the alveoli, thus preventing atelectasis
d. PEEP reverses V/Q mismatch

46. An RN is caring for the following group of clients on the clinical

nursing unit. The RN interprets that which of the following is most at risk for
the development of DVT and pulmonary embolism? *
a. A 65-year old man out of bed 1 day after prostate resection
b. A 73-year old woman who has just had a pinning of hip fracture
c. A 38-year old man with pulmonary contusion after an automobile accident d.
A 25-year old woman with diabetic ketoacidosis

47. Urokinase is being administered to a patient with pulmonary

embolism. The nurse understands that the primary purpose of this medication
is to: *
a. Inhibit further clot formation
b. Reduce oxygen demand
c. Prevent platelet aggregate
d. Dissolve the thrombus
j
48. A client has sustained a blunt trauma injury to the chest. An
assessment finding that would be most indicative of further respiratory
complications would be: *
a. Complaints of increasing pain over the affected area.
b. Oximetry reading consistently around 90%.
c. Diminished breath sounds on the affected side.
d. Fever of 38 degree Celsius and increasing sputum production.

49. The following are the functions of water- seal bottle system. (Select
All That Applies) *
a. It futhers pnemothorax
b. It drains the pleural space

c. It facilitates re-expansion of the lung

d. It corrects positive pressure in the lung

50. Jeremaine Sales has been diagnosed with Bronchiectasis. As a

student nurse, the following statements are true to patients with
Bronchiectasis (Select all that apply) *
a. They are less prone to respiratory infection since they have good
resistance.
b. They should avoid crowds and report early signs of infection in case they
acquire one.
c. They can perform strenuous exercises up to their
limits. d. They may have stasis of secretions.
e. They may be given anti- microbial therapy for bacterial infection.

51. Which laboratory test is not included in making the diagnosis of

myocardial infarction? *
a. AST
b. Troponin
c. CK-MB
d. Myoglobin

52. A nurse is caring for a client with a myocardial infarction. The nurse
recognizes that the most common complication in the client following a
myocardial infarction is: *
a. Right ventricular hypertrophy
b. Cardiac dysrhythmia
c. Left ventricular hypertrophy
d. Hyperkalemia

53. Which activity is suitable for a client who suffered an uncomplicated

myocardial infarction (MI) two days ago? *
a. Sitting in the bedside chair for 15 minutes three times a day
b. Remaining on strict bed rest with bedside commode privileges
c. Ambulating in the room and hall as tolerated
d. Sitting on the bedside for five minutes three times a day with assistance

54. Which of the following lipid abnormalities is a risk factor for the
development of atherosclerosis and peripheral vascular disease? *
a. Low concentration of triglycerides.
b. High levels of high-density lipid (HDL) cholesterol.
c. High levels of low-density lipid (LDL) cholesterol.
d. Low levels of LDL cholesterol.

55. During an initial assessment of a client diagnosed with vasospastic

disorder (Raynaud's phenomenon), the nurse notes a sudden color change
from pink to white in the fingers. The nurse should first assess: *
a. Appearance of cyanosis.
b. Radial pulse.
c. SpO2 of the affected fingers.
d. Blood pressure.

56. The primary goal for the client with Buerger's disease is to prevent: *0/1
a. Embolus formation.
b. Fat embolus formation.
c. Thrombus formation.
d. Thrombophlebitis.

57. A client with angina is experiencing migraine headaches. The

physician has prescribed Sumatriptan succinate (Imitrex). Which nursing
action is most appropriate? *
a. Call the physician to question the prescription order.
b. Try to obtain samples for the client to take home.
c. Perform discharge teaching regarding this drug.
d. Consult social services for financial assistance with obtaining the drug.

58. The physician has ordered Nitrostat (nitroglycerin SL) tablets for
a client with stable angina. The medication: *
a. Slows contractions of the heart
b. Dilates coronary blood vessels
c. Increases the ventricular fill time
d. Strengthens contractions of the heart

59. The physician has prescribed nitroglycerin sublingual tablets as

needed for a client with angina. The nurse should tell the client to take the
medication: *
a. After engaging in strenuous activity
b. Every four hours to prevent chest pain
c. As soon as he notices signs of chest pain
d. At bedtime to prevent nocturnal angina

60. The physician orders Zestril (lisinopril) and Lasix (furosemide) to be

administered at the same time to a client with hypertension. The nurse should:
*
a. Question the order
b. Administer the medications as ordered
c. Administer the medications separately
d. Contact the pharmacy

61. The nurse is providing dietary teaching for a client with hypertension.
Which food should be avoided by the client on a sodium restricted diet? *
a. Dried beans
b. Swiss cheese
c. Peanut butter
d. Colby cheese

62. The nurse is caring for a client scheduled for a surgical repair of an
abdominal aortic aneurysm. Which assessment is most crucial during the
preoperative period? *
a. Assessment of the client’s level of anxiety
b. Evaluation of the client’s exercise tolerance
c. Identification of peripheral pulses
d. Assessment of bowel sounds and activity

63. The nurse is caring for a client scheduled for repair of an abdominal
aortic aneurysm. Which pre-op assessment is most important? *
a. Level of anxiety
b. Exercise tolerance
c. Quality of peripheral pulses
d. Bowel sounds

64. A home health nurse is making preparations for morning visits. Which
one of the following clients should the nurse visit first? *
a. A client with a stroke with tube feedings
b. A client with a history of congestive heart failure complaining of nighttime
dyspnea
c. A client with a thoracotomy six months ago
d. A client with Parkinson’s disease

65. A client with congestive heart failure has been receiving digoxin
(Laxoxin). Which finding indicates that the medication is having a desired
effect? *
a. Increased urinary output
b. Stabilized weight
c. Improved appetite
d. Increased pedal edema

66. A client with congestive heart failure has been receiving digoxin
(Laxoxin). Which finding indicates that the medication is having a desired
effect? *
a. Increased urinary output
b. Stabilized weight
c. Improved appetite
d. Increased pedal edema

67. A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to

treat Type II diabetes mellitus. Which statement indicates the need for further
teaching? *
a. “I will keep candy with me just in case my blood sugar drops.”
b. “I need to stay out of the sun as much as possible.”
c. “I often skip dinner because I don’t feel hungry.”
d. “I always wear my medical identification.”

68. The glycosylated hemoglobin of a 40-year-old client with diabetes

mellitus is 2.5%. The nurse understands that: *
a. “I will keep candy with me just in case my blood sugar drops.”
b. “I need to stay out of the sun as much as possible.”
c. “I often skip dinner because I don’t feel hungry.”
d. “I always wear my medical identification.”

69. A client with diabetes mellitus has a prescription for Glucotrol XL

(glipizide). The client should be instructed to take the medication: *
a. At bedtime
b. With breakfast
c. Before lunch
d. After dinner

70. The physician has prescribed NPH insulin for a client with diabetes
mellitus. Which statement indicates that the client knows when the peak
action of the insulin occurs? *
a. “I will make sure I eat breakfast within two hours of taking my insulin.”
b. “I will need to carry candy or some form of sugar with me all the time.”
c. “I will eat a snack around three o’clock each afternoon.”
d. “I can save my dessert from supper for a bedtime snack.”

71. A left-lower lobectomy is performed on a client with lung cancer. The

nurse should expect postoperative care to include: *
a. A closed chest drainage system
b. Bed rest for 48 hours
c. Positioning supine or right-side lying
d. Chest physiotherapy

72. A client’s admission history reveals complaints of fatigue, chronic

sore throat, and enlarged lymph nodes in the axilla and neck. Which exam
would assist the physician to make a tentative diagnosis of leukemia? *
a. A complete blood count
b. An x-ray of the chest
c. A bone marrow aspiration
d. A CT scan of the abdomen

73. A client with breast cancer is returned to the room following a right
total mastectomy. The nurse should: *
a. Elevate the client’s right arm on pillows.
b. Place the client’s right arm in a dependent sling.
c. Keep the client’s right arm on the bed beside her.
d. Place the client’s right arm across her body.

74. A caregiver providing care to a client receiving chemotherapy for

breast cancer asks the nurse, “What can I do to prevent or relieve nausea and
vomiting for her?” The nurse would include which measures in the response?
*
a. “Make sure she eats, but not immediately before her chemotherapy
treatment.” b. “Let her suck on hard candy or soda crackers.”
c. “Try to control environmental strong, smelly foods.”
d. All of the above

75. A client with a right lobectomy is being transported from the

intensive care unit to a medical unit. The nurse understands that the client’s
chest drainage system: *
a. Can be disconnected from suction if the chest tube is clamped
b. Can be disconnected from suction, but the chest tube should remain
unclamped
c. Must remain connected by means of a portable suction
d. Must be kept even with the client’s shoulders during the transport

76. A client with a history of systemic lupus erythematosus was admitted

with a severe viral respiratory tract infection and diffuse petechiae. Based on
these data, it is most important that the nurse further evaluate the client’s
recent: *
A. Quality and quantity of food intake.
B. Type and amount of fluid intake.
C. Weakness, fatigue, and ability to get around.
D. Length and amount of menstrual flow

77. The nurse is preparing a teaching plan about increased exercise for a
female client who is receiving long-term corticosteroid therapy. What type of
exercise is most appropriate for this client? *
A. Floor exercises.
B. Stretching.
C. Running.
D. Walking.

78. Twenty-four hours after a bone marrow aspiration, the nurse

evaluates which of the following as an appropriate client outcome? *
The client maintains bed rest.
B. There is redness and swelling at the aspiration site.
C. The client requests morphine sulfate for pain.
D. There is no bleeding at the aspiration site.

79. When the nurse talks with a client with multiple sclerosis who has
slurred speech, which nursing intervention is contraindicated? *
A. Encouraging the client to speak slowly.
B Encouraging the client to speak distinctly
C. Asking the client to repeat indistinguishable words.
D. Asking the client to speak louder when tired

80. The nurse is preparing a client with multiple sclerosis (MS) for
discharge from the hospital to home. The nurse should tell the client: *
A. “You will need to accept the necessity for a quiet and inactive lifestyle.”
B. “Keep active, use stress reduction strategies, and avoid fatigue.” \
C. “Follow good health habits to change the course of the disease.”
D. “Practice using the mechanical aids that you will need when future
disabilities arise.”

81. A client with multiple sclerosis (MS) is receiving baclofen (Lioresal).

The nurse determines that the drug is effective when it achieves which of the
following? *
A. Induces sleep.
B. Stimulates the client’s appetite.
C. Relieves muscular spasticity.
D. Reduces the urine bacterial count

82. A client with multiple sclerosis (MS) lives with her daughter and 3-
year-old granddaughter. The daughter asks the nurse what she can do at
home to help her mother. Which of the following measures would be most
beneficial? *
A. Psychotherapy.
B. Regular exercise.
C. Day care for the granddaughter.
D. Weekly visits by another person with MS.

83. Which of the following is not a typical clinical manifestation of

multiple sclerosis (MS)? *
A. Double vision.
B. Sudden bursts of energy.
C. Weakness in the extremities.
D. Muscle tremors.

84. The nurse is reviewing the care plan of a client with Multiple Sclerosis.
Which of the following nursing diagnoses should receive further validation? *
A. Impaired mobility related to spasticity and fatigue.
B. Risk for falls related to muscle weakness and sensory loss.
C. Risk for seizures related to muscle tremors and loss of myelin.
D. Impaired skin integrity related bowel and bladder incontinence

85. A male client with human immunodeficiency virus (HIV) infection

becomes depressed and tells the nurse: “I have nothing worth living for now.”
Which of the following statements would be the best response by the nurse? *
A. “You are a young person and have a great deal to live for.”
B. “You should not be too depressed; we are close to fi nding a cure for
AIDS.” C. “You are right; it is very depressing to have HIV.”
D. “Tell me more about how you are feeling about being HIV-positive.”

86. A client with human immunodeficiency virus (HIV) infection is taking

zidovudine (AZT). The expected outcome of AZT is to: *
A. Destroy the virus.
B. Enhance the body’s antibody production.
C. Slow replication of the virus.
D. Neutralize toxins produced by the virus.

87. The primary reason that a herpes simplex virus (HSV) infection is a
serious concern to a client with human immunodeficiency virus (HIV) infection
is that it: *
A. Is an acquired immunodeficiency virus (AIDS)–defining illness.
B. Is curable only after 1 year of antiviral therapy.
C. Leads to cervical cancer.
D. Causes severe electrolyte imbalances.

88. A nurse is planning care for a 25-year-old female client who has just
been diagnosed with human immunodeficiency virus (HIV) infection. The
client asks the nurse, “How could this have happened?” The nurse responds
to the question based on the most frequent mode of HIV transmission, which
is: *
A. Hugging an HIV-positive sexual partner without using barrier precautions. B.
Inhaling cocaine.
C. Sharing food utensils with an HIV-positive person without proper cleaning
of the utensils.
D. Having sexual intercourse with an HIV positive person without using a
condom.

89. A client has been hospitalized with a diagnosis of myasthenia gravis.

A friend is visiting the client during lunch. The nurse enters the room after the
client recovered from choking on lunch. What should the nurse do next? *
A. Instruct the client to sit at a 30-degree angle in bed when eating.
B. Tell the client to swallow when her chin is tipped down on her chest.
C. Remind the client to rest after eating.
D. Encourage the client to eat alone.

90. When caring for a client with myasthenia gravis who is receiving
anticholinesterase drug therapy, the nurse must be able to distinguish
cholinergic crisis from myasthenic crisis. Which of the following symptoms is
not present in cholinergic crisis? *
A. Improved muscle strength after I.V. administration of edrophonium chloride
(Tensilon).
B. Increased weakness.
C. Diaphoresis.
D. Increased salivation

91. A 9-year-old child with Guillain-Barré syndrome requires mechanical

ventilation. Which action should the nurse take? *
A. Maintain the child in a supine position to prevent unnecessary nerve
stimulation.
B. Transfer the child to a bedside chair three times a day to prevent postural
hypotension.
C. Engage the child in vigorous passive rangeof-motion exercises to prevent
loss of muscle function.
D. Turn the child slowly and gently from side to side to prevent respiratory
complications.

92. The nurse asks a school-age child with Guillain-Barré syndrome to

cough and also assesses the child’s speech for decreased volume and clarity.
The underlying rationale for these assessments is to determine which of the
following? *
A. Inflammation of the larynx and epiglottis.
B. Increased intracranial pressure.
C. Involvement of facial and cranial nerves.
D. Regression to an earlier developmental phase.

93. Which of the following actions should be the priority when caring for
a school-age child admitted to the pediatric unit with the diagnosis of Guillain -
Barré syndrome? *
A. Assessing the child’s ability to follow simple commands.
B. Evaluating the child’s bilateral muscle strength.
C. Making a game of the range-of-motion exercises.
D. Providing the child with a diversional activity.

94. After teaching the client with severe rheumatoid arthritis about
prescribed methotrexate (Rheumatrex), which of the following statements
indicates the need for further teaching? *
A. “I will take my vitamins while I’m on this drug.”
B. “I must not drink any alcohol while I’m taking this drug.”
C. “I should brush my teeth after every meal.”
D. “I will continue taking my birth control pills.”
95. The nurse teaches a client about heat and cold treatments to manage
arthritis pain. Which of the following client statements indicates that the client
still has a knowledge deficit? *
A. “I can use heat and cold as often as I want.”
B. “With heat, I should apply it for no longer than 20 minutes at a time.”
C. “Heat-producing liniments can be used with other heat devices.”
D. “Ten to 15 minutes per application is the maximum time for cold
applications.”

96. After teaching a group of clients with osteoarthritis about using

regular exercise, which of the following client statements indicates effective
teaching? *
A. “Performing range-of-motion exercises will increase my joint mobility.”
B. “Exercise helps to drive synovial fluid through the cartilage.”
C. “Joint swelling should determine when to stop exercising.”
D. “Exercising in the outdoors year-round promotes joint relaxation.”

97. The client diagnosed with osteoarthritis states, “My friend takes
steroid pills for her rheumatoid arthritis. Why don’t I take steroids for
my osteoarthritis?” Which of the following is the best explanation? *
A. Intra-articular corticosteroid injections are used to treat osteoarthritis.
B. Oral corticosteroids can be used in osteoarthritis.
C. A systemic effect is needed in osteoarthritis.
D. Rheumatoid arthritis and osteoarthritis are two similar diseases.

98. A high-carbohydrate, low-protein diet is prescribed for the client with

acute renal failure. The intended outcome of this diet is to: *
A. Act as a diuretic.
B. Reduce demands on the liver.
C. Help maintain urine acidity.
D. Prevent the development of ketosis.

99. The nurse assesses the client who has chronic renal failure and notes
the following: crackles in the lung bases, elevated blood pressure, and weight
gain of 2 lb in 1 day. Based on these data, which of the following nursing
diagnoses is appropriate? *
A. Excess fluid volume related to the kidney’s inability to maintain fluid
balance.
B. Ineffective breathing pattern related to fluid in the lungs.
C. Ineffective tissue perfusion related to interrupted arterial blood flow.
D. Ineffective therapeutic regimen management related to lack of knowledge
about therapy.

100. Which of the following nursing interventions should be included in

the client’s plan of care during dialysis therapy? *
A. Limit the client’s visitors.
B. Monitor the client’s blood pressure.
C. Pad the side rails of the bed.
D. Keep the client on nothing-by-mouth (NPO) status.