BATTERY EXAMINATION

FOR CRITICAL TEST ANALYSIS

NURSING THERAPEUTICS

CASE SCENARIO: The nurse supervisor is observing the staff nurses in their hospital to see how the quality of care is provided
in preparation for their ISO accreditation.

1. Hygiene is a highly personal matter determined by individual values and practices. THERAPEUTIC BATHS are given for
physical effects, such as to soothe irritated skin or to treat an area (e.g., the perineum). A nurse is giving a bed bath to a
client who is on strict bed rest. To increase venous return, the nurse bathes the client’s extremities by using:
A. Firm circular strokes from proximal to distal areas
B. Short, patting strokes from distal to proximal areas
C. Smooth, light strokes back and forth from proximal to distal areas
D. Long, firm strokes from distal to proximal areas

2. Part of hygiene measures is mouth care by brushing the teeth thoroughly after meals and at bedtime. When performing oral
care on a comatose client the nurse should:
A. Apply lemon glycerin to the client’s lips at least every 2 hours
B. Brush the teeth with the client lying supine
C. Place the client in a side-lying position, with the head of the bed lowered
D. Clean the client’s mouth with hydrogen peroxide

CASE SCENARIO: Nurse Sarah, a newly hired nurse, is asked to take over an absent nurse in another unit. She will take care of
clients with various conditions.

3. Clients with acid-base imbalance are usually being scheduled for blood to be drawn from the radial artery for an arterial
blood gas (ABG) determination. Before the blood is drawn, an Allen’s test is performed to determine the adequacy of blood
supply in ULNAR ARTERY. The respiratory therapist is doing the Allen’s test erroneously if he performs which of the
following?
A. Applies direct pressure over the client’s ulnar and radial arteries simultaneously
B. While applying pressure, he asks the client to open and close the hand repeatedly
C. Releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity
distal to the pressure point
D. Withdraws blood if the pinkness of the hand returns within 9 seconds

4. In hyperventilation, rapid respirations may cause the blowing off of CO2, leading to a decrease in carbonic acid that could
predispose the accumulation of base without a comparable loss of base in the body fluids. Nurse Sarah reviews an ABG
result of her patient hooked to a mechanical ventilator and notes the following: pH-7.45, PCO2 of 30 mmHg, and HCO3 of
22mEq/L. Nurse Sarah analyzes these results as indicating:
A. Metabolic acidosis, compensated
B. Metabolic alkalosis, uncompensated
C. Respiratory alkalosis, compensated
D. Respiratory acidosis, uncompensated

5. A bronchoscopy is usually ordered for direct visual examination of the larynx, trachea and bronchi with a
BRONCHOSCOPE. Nurse Sarah is caring for a client after a bronchoscopy and biopsy. Which of the following signs if noted
in the client should be reported immediately to the physician?
A. Blood-streaked sputum C. Hematuria
B. Dry cough D. Bronchospasm
6. If a client’s complaint is related to a certain respiratory disorder, an initial radiographic diagnostic procedure being ordered is
CHEST X-RAY, which provides information regarding the anatomical location and appearance of the lungs. Nurse Sarah is
caring for a female client. Which of the following actions is the most essential that nurse Sarah must ensure prior to Chest x-
ray?
A. Remove all accessories and other metal objects from the chest area.
B. Assess the client’s ability to inhale and hold breath.
C. Ask about the first day of the last menstruation.
D. Ask the ability to hold arms above the head.

7. In obtaining sputum sample, ask the client to breathe deeply and then cough up 1 to 2 teaspoons (4 to 10 mL) of sputum.
Nurse Sarah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate
obtaining the specimen?
A. Limiting fluids
B. Having the client take three deep breaths
C. Asking the client to spit into the collection container
D. Asking the client to obtain the specimen after eating

8. Incentive spirometers measure the flow of air inhaled through the mouthpiece. It is used to improve pulmonary ventilation.
Nurse Sarah is conducting preoperative teaching with a client about the use of an incentive spirometer in the postoperative
period. Nurse Sarah would include which piece of information in discussion with the client?
A. Keep a loose seal between the lips and the mouthpiece
B. Inhale as rapidly as possible
C. After maximum inspiration, hold the breath for 15 seconds and exhale
D. The best results are achieved when the head of the bed is elevated 45 to 90 degrees

9. Post-abdominal surgery clients are encouraged to do deep breathing and coughing exercises to prevent ATELECTASIS,
which is the most common post-operative complication that develops during 1 to 2 days postoperative period from the
collapse of the alveoli with retained mucous secretions. Nurse Sarah must include all of the following proper instructions in
deep breathing and coughing exercises to post-operative clients except:
A. Instruct the client that a sitting position gives the best lung expansion
B. Instruct the client to breathe deeply 3 times, inhaling through the nostrils and exhaling slowly through pursed lips.
C. Instruct the client that the third breath should be held for 3 seconds; then the client should cough deeply 3 times.
D. The client should perform this exercise at least twice every shift.

10. In doing the pursed-lip breathing, purse your lips as if about to whistle, and breathe out slowly and gently, making a slow
'WHOOSHING' sound without puffing the cheeks. This creates a resistance to air flowing out of the lungs. Nurse Sarah
instructs a client to use the pursed-lip method of breathing and the client asks about the purpose of this type of breathing.
Nurse Sarah responds, knowing that the primary purpose of pursed-lip breathing is to:
A. Promote oxygen intake
B. Strengthen the diaphragm
C. Promote carbon dioxide elimination
D. Strengthen the intercostal muscles
11. The nurse must ensure chest physiotherapy every after nebulization by percussing over the thorax to loosen secretions in
the affected area of the lungs. It is important in loosening and mobilizing secretions. A nurse orientee states imperfectly to
nurse Sarah the proper way of doing chest physiotherapy (CPT) during their post-conference if she specifies:
A. “I should place a layer of gown between the hands and the client’s skin”.
B. “I should perform this in the morning on rising, 1 hour before meals, or 2 to 3 hours after meals”.
C. “If the client is receiving a tube feeding, finish the feeding and begin doing the CPT in high fowlers’ position”.
D. “I must stop CPT if pain occurs”.

12. Chest tubes may be inserted to drain fluid or air from any of the three compartments of the thorax. The
pleural space, located between the visceral and parietal pleura, normally contains 20ml or less of fluid, which helps lubricate
the visceral and parietal pleura. Nurse Sarah has assisted a physician with the insertion of a chest tube. Nurse Sarah
monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this
assessment, which of the following actions would be most appropriate?
A. Inform the physician
B. Encourage the client to deep breathe
C. Continue to monitor, for this is an expected finding
D. Reinforce the occlusive dressing

13. Surgical incision of the chest wall almost always causes some degree of pneumothorax (air accumulating in the pleural
space) or hemothorax (buildup of serous fluid or blood in the pleural space). Air and fluid collect in the pleural space,
restricting lung expansion and reducing gas exchange. Nurse Sarah is caring for a client with a chest tube. Nurse Sarah
turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:
A. Call the physician
B. Place the tube in a bottle of sterile water
C. Immediately replace the chest tube system
D. Place a sterile dressing over the disconnection site

14. If there is no fluctuation noted in the water seal chamber, the doctor will order chest radiograph to determine whether the
lung has reexpanded, as supported by increased breath sounds upon chest auscultation. Nurse Sarah is assisting a
physician with the removal of a chest tube. Nurse Sarah will appropriately instruct the client to:
A. Stay very still
B. Inhale and exhale quickly
C. Exhale slowly
D. Deep breathe, exhale, and bear down

15. In Metered Dose Inhaler (MDI), patients should wait 20-30 seconds before taking another dose of bronchodilator. Disinfect
the metered-dose inhaler mouthpieces weekly by soaking for 20 minutes in one pint of water with 2 ounces of vinegar
added. Nurse Sarah has an order to give a client Albuterol (Ventolin) two puffs, and Budesonide (Fulmicort), two puffs, by
MDI. Nurse Sarah administers the medication by giving the:
A. Budesonide first and then the Albuterol
B. Albuterol first and then the Budesonide
C. Alternating a single puff of each, beginning with the Budesonide
D. Alternating a single puff of each, beginning with the Albuterol
16. The nasal cannula (nasal prongs) is the most common and inexpensive device used to administer oxygen. It delivers a
relatively low concentration of oxygen (24% to 45%) at flow rates of 2 to 6 L/miti.Effective oxygen concentration can be
delivered to nose breathers with the use of a nasal cannula. An oxygen delivery system is prescribed for a client with
Chronic Obstructive Pulmonary Disease (COPD) to deliver a precise oxygen concentration. Which of the following types of
oxygen delivery systems would Nurse Sarah anticipates to be prescribed?
A. Venturi mask C. Face tent
B. Aerosol mask D. Tracheostomy collar

17. A simple face mask is used to deliver oxygen concentrations from 40% to 60% at liter flows of 5 to 8 L/min, respectively for
short-term oxygen therapy or to deliver oxygen in an emergency. A minimal flow rate of 5L/min is needed to prevent the
rebreathing of exhaled air. Nurse Sarah is caring for a client with emphysema. The client is receiving oxygen. Nurse Sarah
assesses the oxygen flow rate to ensure that it does not exceed:
A. 1L/min C. 6L/min
B. 2L/min D. 10L/min

18. Suctioning is a sterile procedure performed to maintain a patent airway. It involves the removal of respiratory secretions that
accumulate in the tracheobronchial airway when the client is unable to expectorate secretions. Which nursing action by
nurse Sarah is essential to prevent hypoxemia during tracheal suctioning on her patient?
A. Removing oral and nasal secretions.
B. Encouraging the client to deep breathe and cough to facilitate removal of upper-airway secretions.
C. Administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
D. Auscultating the lungs to determine the baseline data to assess the effectiveness of suctioning.

19. The endotracheal tube needs to be moved to the opposite side of the mouth to prevent pressure and necrosis of the lips
and mouth area, nerve damage and cleaning of the mouth, and this should be done by two health care providers. Nurse
Sarah is caring for a client immediately after removal of the endotracheal tube following radical neck dissection. Nurse
Sarah reports which of the following signs immediately if experienced by the client?
A. Stridor
B. Occasional pink-tinged sputum
C. Respiratory rate 24 breaths per minute
D. A few basilar crackles on right

20. Tracheostomy tubes have an outer cannula that is inserted into the trachea and a flange that rests against the neck and
allows the tube to be secured in place with tape or ties. Nurse Sarah is changing the tapes on a tracheostomy tube. The
client coughs and the tube is dislodged. The initial nursing action is to:
A. Cover the tracheostomy site with a sterile dressing to prevent infection
B. Call the physician to reinsert the tube
C. Grasp the retention sutures to spread the opening
D. Call the respiratory therapy department to reinsert the tracheostomy

SITUATION: Proper food and nutrition are important factors that contribute to fast recovery and rehabilitation of patients. As
such, meeting the nutritional needs of patients must be a major part of the nursing care plan.

21. Barium swallow is an examination of the upper GI tract under fluoroscopy after the client drinks barium sulfate. The client
being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which
of the following instructions for the client to follow before the test?
 A. Fast for 8 hours before the test
B. Eat a regular supper and breakfast
C. Continue to take all oral medications as scheduled
D. Monitor own bowel movement pattern for constipation

22. Upper gastrointestinal fiberoscopy is usually being done for patients with chief complaint of melena and other signs and
symptoms related to upper gastrointestinal bleeding. Following sedation, an endoscope is passed down the esophagus to
view the esophagus, stomach and duodenum; issue specimens can be obtained. The client has undergone
esophagogastroduodenoscopy. The nurse places highest priority on which of the following items as part of the client’s care
plan?
A. Assessing for the return of the gag reflex
B. Giving warm gargles for a sore throat
C. Monitoring for temperature
D. Monitoring complaints of heartburn

23. Clients whose gastrointestinal tracts are severely dysfunctional or non-functional and are unable to process nutrients
normally require Total Parenteral Nutrition (TPN) administered through a central vein, such as subclavian vein. The nurse is
caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention specifically
would provide assessment data related to the most common complication related to TPN?
A. Weighing the client daily – fluid volume overload
B. Monitoring intake and output - fluid volume overload
C. Monitoring the temperature - infection
D. Monitoring the serum blood urea nitrogen – renal function

24. When TPN is anticipated for an extended period (greater than 4 weeks), a more permanent catheter, such as peripherally
inserted central catheter line, a tunnelled catheter, or an implanted vascular access device is used. A nurse is preparing to
change the TPN solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse
asks the client to do who of the following most essential items during the tubing change?
A. Take a deep breath, hold it, and bear down.
B. Exhale slowly and evenly.
C. Turn the head to the right.
D. Breathe normally.

25. A client on TPN is usually being monitored for blood glucose levels every 4-6 hours to monitor for possible complication
signs of hyperglycemia or hypoglycemia. A nurse is making initial rounds at the beginning of the shift. The TPN bag of an
assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until
another TPN solution is mixed and delivered to the nursing unit?
A. 5% dextrose in water
B. 5% dextrose in 0.9% sodium chloride
C. 5% dextrose in Ringers lactate
D. 10% dextrose in water

26. A stroke patient suffering from dysphagia is usually being given a bolus feeding through the use of nasogastric tube, this
feeding resembles a normal feeding pattern which consists of 300 to 400 mL of formula every 3 to 6 hours. A nurse is
inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty of
breathing. Which of the following is the most appropriate nursing action?
A. Remove the tube and reinsert when the respiratory distress subsides
B. Pull back on the tube and wait until the respiratory distress subsides
C. Quickly insert the tube
D. Notify the physician immediately
27. Nasogastric tubes are used for feeding clients who have adequate gastric emptying, and who require short-term feedings.
They are not advised for feeding clients without intact gag and cough reflexes since the risk of accidental placement of the
tube into the lungs is much higher in those clients. The nurse checks for residual before administering a bolus tube feeding
to a client with nasogastric tube and obtains a residual amount of 150 mL. What is the appropriate action for the nurse to
take?
A. Hold the feeding.
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.

28. Obtaining capillary blood glucose by skin puncture is an alternative for self-management of diabetes mellitus. The procedure
is less painful than venipuncture, and the ease of the skin puncture method makes it possible for patients to perform this
procedure. A diabetes nurse educator is providing health teaching regarding the proper method of blood glucose
determination through skin puncture. The nurse needs to reinforce the teaching if the client identifies which of the following
statements?
A. “I should perform hand hygiene before the procedure”.
B. “I should clean the site with antiseptic swab, and allow it to dry completely”.
C. “I should wipe away the first droplet of blood with cotton ball”.
D. “I should select the central tip of the finger which has more dense blood supply”.

29. A stoma is the surgical creation of an opening into the colon that allows for drainage of fecal matter from the colon to the
outside of the body. The nurse is assessing a stoma prolapse in a client with colostomy. The nurse would observe which of
the following if the stoma prolapsed occurred?
A. Sunken and hidden stoma
B. Dark- and bluish-colored stoma
C. Narrowed and flattened stoma
D. Protruding stoma

30. Patients with colostomy must be instructed to avoid foods that cause excess gas formation and odor. The client with a new
colostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse teaches the client to include which
of the following foods in the diet to reduce odor?
A. Yogurt C. Cucumbers
B. Broccoli D. Eggs

31. The normal stool of patients with an ileostomy is liquid. The client has just had surgery to create an ileostomy. The nurse
assesses the client in the immediate post-operative period for which of the following most frequent complication of this type
of surgery?
A. Intestinal obstruction
B. Fluid and electrolyte imbalance
C. Malabsorption of fat
D. Folate deficiency

32. Cleansing enemas uses a variety of solutions. Hypotonic solutions (e.g tap water) exert osmotic pressure, which draws fluid
from the interstitial space into the colon. A client has an order for “enemas until clear” before major bowel surgery. After
preparing the equipment and solution, the nurse assists the client into which of the following positions to administer the
enema?
 A. Right side-lying with the head of the bed elevated 45 degrees.
B. Left-lateral sim’s position
C. Right-lateral sim’s position
D. Left side-lying with the head of the bed elevated 45 degrees.

33. In carminative enema, the solution is instilled into the rectum releases gas, which in turn distends the rectum and the colon,
thus stimulating peristalsis. For an adult, 60-180 ml of fluid is instilled. A nurse has administered approximately half of a high
cleansing enema when the client complains of pain and cramping. Which nursing action is the most appropriate?
A. Discontinuing the enema and notifying the physician.
B. Raising the enema bag so that the solution can be completed quickly.
C. Clamping the tubing for 30 seconds and restarting the flow at a slower rate.
D. Reassuring the client and continuing the flow.

CASE SCENARIO: Nurse July is assigned to patient SM who undergone Open-Heart Surgery. The patient’s central venous
catheter is hooked to a central venous pressure monitor.

34. In measuring the CVP, the zero point on the manometer needs to be at the level of the phlebostatic axis. The client needs
to be supine, with the head of bed at 45 degrees. To measure the CVP of patient S.M., nurse July should manipulate the 3
way stopcock to which of the following?
A. Turn the 3 way stopcock OFF to the patient
B. Turn the 3 way stopcock ON to the patient and ON to the manometer
C. Turn the 3 way stopcock ON to the saline solution and ON to the manometer
D. Turn the 3 way stopcock ON to the saline solution and ON to the patient

35. The Einthoven's triangle was derived from Willem Einthoven a Dutch doctor and physiologist who invented the first practical
electrocardiogram. It refers to an imaginary inverted equilateral triangle centered on the chest and the points being the
standard leads on the arms and legs. Patient SM suddenly complains of severe chest pain, nurse July immediately hooked
her to the cardiac monitor. Nurse July is correct in placing the 3 leads if:
A. The white lead is placed on the right arm, the black lead is at the left arm, and the red lead is placed on the left leg
B. The white lead is placed on the left arm, the black lead is at the left arm, and the red lead is placed on the left leg
C. The white lead is placed on the right leg, the black lead is at the right arm, and the red lead is placed on the left arm
D. The white lead is placed on the right arm, the black lead is at the left arm, and the red lead is placed on the right leg

36. Pulse oximetry is a noninvasive test that registers the saturation of the client’s hemoglobin. As nurse July made her rounds
for 12NN, she noticed that the SaO2 is recorded as 90% on the pulse oximeter hooked on patient SM’s finger. Which of the
following actions should you expect that nurse July will do initially?
A. Immediately press the call light and call for the code blue
B. Check the client status and sensor placement
C. Transfer the sensor to other location such as the earlobe or forehead
D. Continue monitoring as the SaO2 reading is within normal limits

37. Cardiac catheterization involves insertion of catheter into the heart and surrounding vessels. It obtains information about the
structure and performance of the heart valves and circulatory system. Patient SM is now scheduled for cardiac
catheterization using a radiopaque dye due to persistence of chest heaviness. Which of the following assessments is most
critical before the procedure?
A. Intake and output C. Height and weight
B. Baseline peripheral pulse rates D. Allergy to shellfish
38. Cardiac catheterization is an invasive diagnostic procedure which imposes that the nurse must monitor vital signs and
cardiac rhythm for dysrhythmia at least every 30 minutes for 2 hours initially. Nurse July now receives patient SM from the
catheterization laboratory. In the first few hours after cardiac catheterization, which nursing measure would be most
essential?
A. Checking pedal pulse in the extremity used for the cut-down
B. Encouraging the client to cough and deep breathe hourly
C. Keeping the client sedated to maintain the pressure dressing
D. Monitoring the client’s urine output

CASE SCENARIO: Patient EA, a 35-year old female was brought to the emergency room due to a decrease in the level of
consciousness. In the assessment made by nurse PM his VS revealed the following: HR=135, RR= 29, BP=80/50, T=35.9 0C. He
is pale-looking, profusely sweating and cold to touch. An IV insertion was immediately ordered by the resident doctor.

39. Intravenous therapy provides a vascular route to sustain clients who are unable to take substances orally to replace water,
electrolytes, and nutrients more rapidly. Patient EA is hypovolemic, and plasma expanders are not available. Nurse PM
anticipates that which of the following solutions available on the nursing unit will be prescribed by the physician?
A. 5% dextrose in water
B. 0.9% sodium chloride
C. 0.45% sodium chloride
D. 5% dextrose in 0.45% sodium chloride

40. In adding of medication to an intravenous line, the expiry date of the medication and solution should be assessed, and the
medication must be ensured that it can be mixed in soft plastic because some medications absorb into the soft plastic and
should be mixed only in glass. Nurse PM has an order to hang an IV bag of 1L 5% dextrose in water with 20 mEq KCl.
Nurse PM should plan to do which of the following immediately after injecting the potassium chloride into the port of the IV
bag?
A. Attach the tubing to the client
B. Check the solution for yellowish discoloration
C. Rotate the bag gently
D. Place the time tape on the IV
41. Immunocompromised clients have a high risk to develop infection which occurs from the entry of microorganisms into the
body through the venipuncture site. Patient EA has a 1L bag of 5% dextrose in 0.9% NaCl hung at 3PM. Nurse PM is
making rounds at 3:45PM finds the client to be complaining of a pounding headache and to be dyspneic, experiencing chills,
apprehensive, and with increased pulse rate. The IV bag has 400 mL remaining. Nurse PM should take which of the
following actions first?
A. Sit the client up in bed C. Slow the IV infusion
B. Call the physician D. Remove the IV catheter
CASE SCENARIO: Nurse Marica is a medical-surgical nurse taking care of patient CKD who is suffering from Chronic Renal
Failure. Two units of packed red blood cells were ordered to be transfused for 4-6 hours each unit.

42. Before blood transfusion, the recipient’s ABO type and Rh type are identified. An antibody screen is done to determine the
presence of antibodies other than anti-A and anti-B. Crossmatching is done, in which donor red blood cells are combined
with recipient’s serum and Coomb’s serum; crossmatch is compatible if no red blood cell clumping occurs. Nurse Marica
measured the temperature of patient CKD before hanging the packed red blood cells and it was found to be 100.6 0F orally.
Nurse Marica must do which of the following as the most appropriate nursing action?
A. Administer diphenhydramine as ordered and begin the transfusion
B. Administer two tablets of paracetamol and begin the transfusion
C. Begin the transfusion as prescribed
D. Delay hanging the blood and notify the physician

43. Blood products should be infused through administration sets designed specifically for blood; use straight tubing blood
administration set that contains an in-line blood filter designed to trap fibrin clots and other debris that accumulate during
 blood storage. Nurse Marica overhears a physician stating that another client is in hypovolemic shock and requires plasma
expansion. Nurse Marica anticipates receiving an order to transfuse which of the following blood products to this client?
A. Cryoprecipitate C. Albumin
B. Packed red blood cells D. Platelets

CASE SCENARIO: Ms. GS is a newly hired staff nurse in the emergency room. She enrolled herself to Basic Life Support (BLS)
and Advance Cardiac Life Support (ACLS) certification as these are required for the said position.

44. Defibrillation is an asynchronous countershock used to terminate pulseless ventricular tachycardia or ventricular fibrillation.
During the defibrillation, be sure that no one is touching the bed or the client when delivering the countershock. Ms. GS is
preparing to defibrillate a client in ventricular fibrillation during the return demonstration. Ms. GS places the paddles
correctly on the client’s chest if:
A. The first paddle is placed on the left sternum at 2 nd intercostal space, and the second on the right anterior axillary line
at 5th intercostal space.
B. The first paddle is placed on the right sternum at 2 nd intercostal space, and the second on the left anterior axillary line
at 5th intercostal space.
C. The first paddle is placed on the right sternum at 5th intercostal space, and the second on the left anterior axillary line
at 2nd intercostal space.
D. The first paddle is placed on the left sternum at 5th intercostal space, and the second on the right anterior axillary line
at 5th intercostal space.

45. Cardioversion involves the delivery of a “timed” electrical current to terminate a tachydysrhythmia. In cardioversion, the
defibrillator is set to synchronize with the ECG on a cardiac monitor so that the electrical impulse discharges during
ventricular depolarization (QRS complex. A lower amount of energy is used than with defibrillation. If the defibrillator were
not synchronized, it would discharge on the T wave and cause ventricular fibrillation. Ms. GS is evaluating a client’s
response to cardioversion on their return demonstration. Which of the following observations would be of highest priority to
the nurse?
A. Oxygen flow rate C. Blood pressure
B. Status of airway D. Level of consciousness

CASE SCENARIO: Student nurse GH is a sophomore student. She is reviewing the important concepts about proper food and
nutrition for their upcoming preliminary examination.

46. Nutrition is the sum of all interactions between an organism and the food it consumes. Nutrients are organic and inorganic
substances found in foods that are required for body functioning. GH is taking care of a bulimic client who stated that she is
overweight. Upon assessment, GH determined that her BMI is 17.5. This means that the patient’s BMI is considered a/an:
A. Normal weight C. Overweight
B. At risk D. Underweight

47. Low-purine diet is used to treat gout. Purine is a precursor for uric acid that forms stones and crystals. In developing a
dietary plan for patients with gout, GH must plan to include which item on a list of foods to be avoided?
A. Liver C. Carrots
B. Chocolate D. Broccoli

48. Enteral feedings are administered through nasogastric and small-bore feeding tubes, or through gastrostomy or jejunostomy
tubes. It is used for clients with swallowing problems, burns, major trauma, or severe malnutrition. A client who recently has
been started on enteral feedings begins to complain of abdominal cramping, followed by the passage of two liquid stools.
 Student nurse GH notes that the client has abdominal distention as well. GH reviews the nutritional content on the label of
the can of feeding to see if it has which of the following ingredients?
A. Maltose C. Sucrose
B. Lactose D. Fructose

CASE SCENARIO: BJ has recently passed the board exam and was assigned to the medical ward of Sulu Medical Center. As a
competent nurse, it is essential that she knows the basic procedure when providing care for the patient.

49. Some urine examinations require collection of all urine produced and voided over a specific period of time, ranging from 1 to
2 hours to 24 hours. Urine osmolality is a measure of the solute concentration of urine that is a more exact measurement of
urine concentration than specific gravity. The physician has ordered a 24-hour urine specimen. After explaining the
procedure to the client, nurse BJ collects the first specimen. This specimen is then:
A. Tested, then discarded
B. Placed in a separate container and later added to the collection
C. Discarded, then the collection begins
D. Saved as part of the 24-hour collection

50. Renal biopsy is the insertion of a needle into the kidney to obtain a sample of tissue for examination. During the procedure,
the client must be placed on prone with pillow under the abdomen and shoulders. Nurse BJ is caring for the client who has
had a renal biopsy. Which of the following interventions would nurse BJ avoid in the care of the client after this procedure?
A. Encouraging fluids to at least 3L in the first 24 hours
B. Administering narcotics as needed
C. Testing serial samples with dipsticks for occult blood
D. Ambulating the client in the room and hall for short distances

51. Intravenous pyelogram is performed to identify abnormalities in the renal system. It is vital to inform the client about possible
throat irritation, flushing of the face, warmth, or a salty taste during the test. The client is scheduled for intravenous
pyelogram. Before the test the priority action of nurse BJ would be to:
A. Administer an oral preparation of radiopaque dye
B. Restrict fluids
C. Determine history of allergies
D. Administer a sedative

52. Renal angiography involves the injection of a radiopaque dye through a catheter for examination of the renal artery. Inform
the client about the possible burning feeling or the feeling of heat along the vessel when dye is injected. Nurse BJ is caring
for the client who has undergone renal angiography using the left femoral artery for access. Nurse BJ evaluates that the
client is experiencing a complication of the procedure if which of the following observations is made?
A. Urine output 50 mL/hour
B. Absence of hematoma in the left groin
C. Blood pressure 110/74 mmHg
D. Pallor and coolness of the left leg

CAE SCENARIO: Nurse AB is assigned to take care of a group of elderly patients. Pain and urinary incontinence are their
common concerns. Nurse AB should be able to address their concerns in a holistic manner.

53. Urinary catheterization is the introduction of a catheter into the urinary bladder. For adult female clients, use a 22-cm
catheter; for adult male clients, a 40-cm catheter is used. Nurse AB is inserting an indwelling urinary catheter into a male
client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, nurse BJ:
A. Immediately inflates the balloon
B. Withdraws the catheter approximately 1 inch and inflates the balloon
 C. Inserts the catheter until resistance is met and inflates the balloon
D. Inserts the catheter 2.5 to 5 cm and inflates the balloon

54. Nurses in a health care facility or clients in the home setting can use commercially prepared kits to test abnormal
constituents in the urine. Urine specific gravity is an indicator of urine concentration, or the amount of solutes present in the
urine. Nurse AB has an order to obtain a urinalysis from a client with an indwelling catheter. The nurse avoids which of the
following, which could contaminate the specimen?
A. Clamping the tubing of the drainage bag
B. Aspirating a sample from the port on the drainage bag
C. Wiping the port with an alcohol swab before inserting the syringe
D. Obtaining the specimen from the urinary drainage bag

55. An irrigation is a flushing or washing-out with a specified solution. The CLOSED method is the preferred technique for
catheter or bladder irrigation because it is associated with a lower risk of urinary tract infection. A client has had a
Transurethral Resection of the Prostate (TURP). What is the most important nursing intervention that must be observed by
nurse BJ in the first 24 hours?
A. Assess urinary output
B. Irrigate the bladder every 2 hours
C. Assess for haemorrhage
D. Force fluids

56. Benign Prostatic Hyperplasia (BPH) is the slow enlargement of the prostate gland, which causes narrowing of the urethra
and results in partial or complete obstruction. The client with BPH undergoes a transurethral resection of the prostate.
Postoperatively, the client is receiving continuous bladder irrigations (CBI). Nurse BJ assesses the client for signs of
transurethral resection syndrome. Which of the following assessment data would indicate the onset of this syndrome?
A. Bradycardia and confusion
B. Tachycardia and diarrhea
C. Decreased urinary output and bladder spasms
D. Increased urinary output and anemia

CASE SCENARIO: Nurse Kris is assigned to patient AT, a 65 year old male, diagnosed with Chronic Renal Failure for 1 year
and undergoes hemodialysis 3x/week via a left AVF.

57. Internal arteriovenous fistula provides the access of choice for chronic dialysis patients. The fistula is created surgically by
anastomosis of a large artery and a large vein in the arm. Its maturity takes about 6-12 weeks and it is required before the
fistula can be used so that the engorged vein can be punctured with a large-bore needle for the dialysis procedure. Nurse
Kris is assessing the patency of an arteriovenous fistula in the left arm of patient AT. Which finding indicates that the fistula
is patent?
A. Absence of bruit on auscultation of the fistula
B. Palpation of a thrill over the fistula
C. Presence of a radial pulse in the left wrist
D. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

58. Internal arteriovenous graft is used primarily for chronic dialysis patients who do not have adequate ________ for the
creation of a fistula. An artificial graft made of Gore-Tex is used to create an artificial vein for blood flow. Patient AT has a
left arm fistula and is at risk for steal syndrome. Nurse Kris assesses patient AT for which of the following manifestations?
A. Warmth, redness, and pain in the left hand
B. Pallor, diminished pulse, and pain in the left hand
C. Edema and reddish discoloration of the left arm
D. Aching pain, pallor, and edema of the left arm
59. Hemodialysis is the movement of dissolved particles from one fluid compartment into another across a semipermeable
membrane. Knowing that patient AT is at risk for disequilibrium syndrome, nurse Kris assesses the client during
hemodialysis for:
A. Hypertension, tachycardia, and fever
B. Hypotension, bradycardia, and hypothermia
C. Restlessness, irritability, and generalized weakness
D. Headache, deteriorating level of consciousness, and twitching

CASE SCENARIO: Nurse KE is assigned at the emergency room. Patient KK, a 76-year old female, came in due to a chief
complaint of difficulty of breathing. Latest laboratory exams revealed: K=7.8, Crea=3.6, BUN=145, Na=160. The doctor
immediately ordered for Emergency Tenchkhoff catheter insertion instead of the Femoral catheter insertion.

60. Peritoneal dialysis works on the principles of diffusion and osmosis, and the dialysis occurs via the transfer of fluid and
solute from the bloodstream through the peritoneum. Nurse KE is reviewing the list of components consisted in the
peritoneal dialysis solution with the client. Patient KK asks the nurse about the purpose of the glucose contained in the
solution. The nurse bases the response knowing that the glucose:
A. Prevents excess glucose from being removed from the client
B. Decreases the risk of peritonitis
C. Prevents disequilibrium syndrome
D. Increases osmotic pressure to produce ultrafiltration