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SITUATION : Arthur, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway.

The old woman fell at the railway. Arthur rushed at the scene. 1. As a registered nurse, Arthur knew that the first thing that he will do at the scene is A. Stay with the person, Encourage her to remain still and Immobilize the leg while While waiting for the ambulance. B. Leave the person for a few moments to call for help. C. Reduce the fracture manually. D. Move the person to a safer place. 2. Arthur suspects a hip fracture when he noticed that the old woman¶s leg is A. Lengthened, Abducted and Internally Rotated. B. Shortened, Abducted and Externally Rotated. C. Shortened, Adducted and Internally Rotated. D. Shortened, Adducted and Externally Rotated. 3. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to A. Infection B. Thrombophlebitis C. Inflammation D. Degenerative disease 4. The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except A. Hypothyroidism B. End stage renal disease C. Cushing¶s Disease D. Taking Furosemide and Phenytoin. 5. Martha, The old woman was now

Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms? A. Tachycardia and Hypotension B. Fever and Bradycardia C. Bradycardia and Hypertension D. Fever and Hypertension SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis. 6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane A. On his left hand, because his right side is weak. B. On his left hand, because of reciprocal motion. C. On his right hand, to support the right leg. D. On his right hand, because only his right leg is weak. 7. You also told Mr. Rojas to hold the cane A. 1 Inches in front of the foot. B. 3 Inches at the lateral side of the foot. c. 6 Inches at the lateral side of the foot. D. 12 Inches at the lateral side of the foot. 8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him A. Moves the cane when the right leg is moved. B. Leans on the cane when the right leg swings through.

C. keeps the cane 6 Inches out to the side of the right foot. D. Holds the cane on the right side. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood 9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as A. PPD B. PDP C. PDD D. DPP 10. The nurse would inject the solution in what route? A. IM B. IV C. ID D. SC 11. The nurse notes that a positive result for Alfred is A. 5 mm wheal B. 5 mm Induration C. 10 mm Wheal D. 10 mm Induration 12. The nurse told Alfred to come back after A. a week B. 48 hours C. 1 day D. 4 days 13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse¶s next action? A. Call the Physician B. Notify the radiology dept. for CXR evaluation C. Isolate the patient

D. Order for a sputum exam 14. Why is Mantoux test not routinely done in the Philippines? A. It requires a highly skilled nurse to perform a Mantoux test B. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions D. Almost all Filipinos will test positive for Mantoux Test 15. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH? A. I B. II C. III D. IV 16. How long is the duration of the maintenance phase of his treatment? A. 2 months B. 3 months C. 4 months D. 5 months 17. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase? A. Rifampicin B. Isoniazid C. Ethambutol D. Pyridoxine 18. According to the DOH, the most hazardous period for development of clinical disease is during the first A. 6-12 months after B. 3-6 months after C. 1-2 months after D. 2-4 weeks after

23 Year old athlete taking long term Decadron therapy and anabolic steroids C. 23 Year old athlete taking illegal drugs and abusing substances D. which of the following item indicates that the nurse needs further A. Tertiary D. This is the name of the program of the DOH to control TB in the country A. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following? A. Ask for leaflets and contact numbers of ostomy support groups D. Stop the irrigation by clamping the tube B. 22. The maximum height of irrigation solution for colostomy is A. While irrigating the client¶s colostomy. Short Coursed Chemotherapy D. 5 inches B. The next day. Look at the ostomy site B. the nurse will assess Michiel¶s stoma.instruction? 19. The nurse noticed that a prolapsed stoma is evident if she sees which of the following? . Tell the client that cramping will subside and is normal D. Promises he will begin to listen the next day C. Secondary C. 24 inches 26. the nurse would A. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention? A. 6-8 inches D. Notify the physician 28. Ask to defer colostomy care to another individual B. As the nurse prepares the materials needed. Participate with the nurse in his daily ostomy care C. DOTS B. 1-2 inches B. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except A. Tap water D. Talk about his ostomy openly to the nurse and friends 23. Quarterly SITUATION: Michiel. The nurse plans to teach Michiel about colostomy irrigation. Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy? A. Agrees to look at the colostomy D. 18 inches D. 23 Year old athlete with diabetes insipidus B. Expanded Program for Immunization 20. Primary B. States that colostomy care is the function of the nurse while he is in the hospital 27. 3-4 inches C. Michiel suddenly complains of severe cramping. The nurse should insert the colostomy tube for irrigation at approximately A. A male patient diagnosed with colon cancer was newly put in colostomy. National Tuberculosis Control Program C. Irrigation sleeve 24. Plain NSS / Normal Saline B. Slow down the irrigation C. 12-18 inches 25. Undernourished and Underweight individual who undergone gastrectomy 21. 12 inches C. K-Y Jelly C. Initially.

if made by Wilma indicates that she is committing an error? A. His sister and a nurse is suctioning the tracheostomy tube of James. Insert the cone 4 cm in the stoma D. Michiel asked the nurse. If a Wall unit is used. Pale Pink SITUATION: James. who is 6 feet 5 inches in height and weighing approximately 145 lbs? A. 10-15 mmHg D. 18 34. Eat eggs B. Fr. What are the 2 equipment¶s at james¶ bedside that could help Wilma deal with this situation? A.000 ml NSS B. Suction the client every hour 33. Wilma. What size of suction catheter would Wilma use for James. A dusky and bluish stoma C. 50-95 mmHg B. Wilma is using a portable suction unit at home. 2-5 mmHg B. 95-110 mmHg C. Fr. 5-10 mmHg C. Which of the following. Use 500 ml to 1. Wilma places 2 fingers between the tie and neck B. Protruding stoma with swollen appearance 29. The nurse knew that the normal color of Michiel¶s stoma should be A. A sunken and hidden stoma B. What should be the suctioning pressure required by James? A. Applying suction during catheter withdrawal D.A. Instilling 3 to 5 ml normal saline to loosen up secretion C. Eat cucumbers C. A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema. A narrow and flattened stoma D. what foods will help lessen the odor of his colostomy. Wilma was shocked to see that the Tracheostomy was dislodged. The nurse best response would be A. Gray C. Sterile saline dressing 37. 20-25 mmHg 35. Fr. 5 B. The tracheotomy can be pulled slightly away from the neck C. 32. Wilma measures the tie from the nose to . Eat beet greens and parsley D. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed? A. Which of the following should be included in the nurse¶s teaching plan? A. Suspend the irrigant 45 cm above the stoma C. Brick Red B. Fr. Theophylline and Epinephrine C. Obturator and Kelly clamp D. James¶ neck veins are not engorged D. Hyperventilating James with 100% oxygen before and after suctioning B. Blue D. 100-120 mmHg D. Eat broccoli and spinach 30. If cramping occurs. Both the inner and outer cannulas was removed and left hanging on James¶ neck. slow the irrigation 31. 155-175 mmHg 36. The nurse will start to teach Michiel about the techniques for colostomy irrigation. New set of tracheostomy tubes and Oxygen tank B. What is the amount of suction required by James using this unit? A. 12 D. 10 C.

30 seconds D. In the Choroids D. Nurse jet knew that Acute close angle glaucoma is caused by A. Obstruction in trabecular meshwork C. The Doctor orders pilocarpine. Snellen¶s Chart C. Gonioscopy 47. Relax the Ciliary muscle C. 43. There are frank blood suction from the tube D. Decrease production of Aqueous Humor 48. 8-21 mmHg B. There is an increase in IOP D. CONES [RETINA] 44. In the sub arachnoid space of the meninges B. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma? A. He is being seen by Nurse Jet. 2-7 mmHg c. James¶ Oxygen saturation is 91% C. In the Ciliary Body 45. Measures the Intra Ocular Pressure C. Sudden blockage of the anterior angle by the base of the iris B. 45 seconds SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. In the Lateral ventricles C. Wood¶s light D. It measures the peripheral vision remaining on the client B. Nurse Jet knows that Aqueous Humor is produce where? A. What test would Nurse Jet implement to measure CN II¶s Acuity? A. 38. Batumbakal. Gradual increase of IOP D. 40. Nurse Jet wants to measure Mr. There are moderate amount of tracheobronchial secretions 39. Nurse jet knows that the action of this drug is . 10 seconds B.the tip of the earlobe and to the xiphoid process. The Nurse notices that Mr. IRIS B. Wilma knew that James have an adequate respiratory condition if she notices that A. 20 seconds C. Pain 41. Batumbakal cannot anymore determine RED from BLUE. Slit lamp B. Nurse jet performed a TONOMETRY test to Mr. Contract the Ciliary muscle B. The doctor orders timolol [timoptic]. Nurse Jet knows that the normal IOP is A. 31-35 mmHg D. James¶ respiratory rate is 18 B. Nurse jet knows that the action of this drug is to A. The nurse knew that which part of the eye is affected by this change? A. What does this test measures A. Dilate the pupils D. An abrupt rise in IOP from 8 to 15 mmHg 42. RODS [RETINA] D. Batumbakal¶s CN II Function. Irreversible vision loss C. PUPIL c. Wilma knew that the maximum time when suctioning James is A. Loss of peripheral vision B. Determines the Tone of the eye in response to the sudden increase in IOP. 15-30 mmHg 46. Measures the Client¶s Visual Acuity D.

52. After mastoidectomy. Bending at the waist C. Which of the following should the nurse question? A. Atropine Sulfate B. Which statement if made by the client indicates that the teaching has been successful? . Naloxone Hydrochloride [Narcan] D. Indicates a CN VIII Dysfunction B. Relaxes the Ciliary muscle 49. Air. What activity is contraindicated immediately after procedure? A. Lying down C. what drug should always be available in any case systemic toxicity occurs? A. Pindolol [Visken] C. When caring for Mr. Anna noticed a rotary nystagmus towards the irrigated ear. Mr. What does this means? A. CN II C. Constrict the pupil D. Abnormal C. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. The physician orders the following for the client with Menieres disease. Aida. Diet and Nutrition D. Nurse John should be aware that the cranial nerve that is usually damage after this procedure is A. If Mr. The most appropriate method to administer the ear drops is A. Watching large screen TVs B. After instilling a warm water in the ear. Pull the pinna down and back and direct the solution towards the eardrum D. Nurse Anna is giving dietary instruction to a client with Menieres disease. Nurse Anna is doing a caloric testing to his patient. CN VI 56. Breathing. Pull the pinna up and back and direct the solution onto the wall of the canal 54. Love and Belongingness C. Batumbakal. Circulation B. Nurse Jenny is developing a plan of care for a patient with Menieres disease. Atropine sulfate C. Reduce production of Aquesous Humor C. Batumbakal is receiving pilocarpine. a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. Pull the pinna up and back and direct the solution towards the eardrum B. Diazepam [Valium] 57. What is the priority nursing intervention in the plan of care for this particular patient? A. CN I B.A. Jet teaches the client to avoid A. Reduce production of CSF B. Food. Ear drops are prescribed to an infant. Dipenhydramine [Benadryl] B. Mesoridazine Besylate [Serentil] SITUATION : Wide knowledge about the human ear. Reading newsprint B. Inconclusive 53. it¶s parts and it¶s functions will help a nurse assess and analyze changes in the adult client¶s health. Watching TV D. Pull the pinna down and back and direct the solution onto the wall of the canal C. Reading books D. Safety 55. CN VII D. Listening to the music 51. Out of bed activities and ambulation D. Going out in the sun 50. Normal D.

Peachy is complaining of something buzzing into her ears. He might have a sensory hearing loss in the right hear. Irrigate the ear D. low fat. A low sodium . I will try to follow a 50% carbohydrate. Assessment disclosed: weak rapid pulse. and/or a sensory hearing loss in the left ear. This is Grossly abnormal and should be reported to the neurosurgeon D. Sensory perceptual alteration R/T Lens extraction and replacement C. furrows in his tongue. Nurse Joemar assessed peachy and found out It was an insect. I will make sure that I will clean my hair and face to prevent infection C. Body Image disturbance R/T the eye packing after surgery 62. which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions? A. D. What should be the first thing that Nurse Joemar should try to remove the insect out from peachy¶s ear? A. He might have a conductive hearing loss in the right ear. I should avoid air travel for a while 60. A client with Cataract is about to undergo surgery. high protein dietary intake C. Which of the following is a correct conclusion for nurse Josph to make? A. A high calorie. What typical dietary prescription would nurse Oca expect the doctor to prescribe? A. Nurse Oca is preparing plan of care. Pick out the insect using a sterile clean forceps 59. I will not eat turnips.5kg. red meat and raddish 58. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. Aling myrna has Menieres disease. acute weight loss of . low sodium and high calorie intake D. Conductive hearing loss is possible in the right ear C. Instill an antibiotic ear drops C. The client states that the fork is louder in the LEFT EAR.A. Peachy was rushed by his father.000 ml of fluids per day C. I will try to eat foods that are low in sodium and limit my fluid intake B. 30% fat and 20% protein diet D. I must drink atleast 3. Knowledge deficit R/T the pre operative and post operative self care D. low sodium and restricted fluid intake SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. He might have a sensory hearing loss in the left ear B. slow . high fluid intake B. Steven into the hospital admission. Use a flashlight to coax the insect out of peachy¶s ear B. Following an ear surgery. He instilled a cold water in the client¶s right ear and he noticed that nystagmus occurred towards the left ear. I will use straw for drinking D. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient? A. and/or a conductive hearing loss in the left ear. He placed the tuning fork in the patients forehead after tapping it onto his knee. Anxiety R/T to the operation and its outcome B. Indicating a Cranial Nerve VIII Dysfunction B. The test should be repeated again because the result is vague C. Nurse Joseph is performing a WEBERS TEST. What does this finding indicates? A. 63. This indicates an intact and working vestibular branch of CN VIII 61. Activities are resumed within 5 days B.

The patient was prescribed with levodopa. Forgetfulness C. Hereditary factors C. Fluid volume deficit R/T uncontrolled vomiting C.4 C. Increase dopamine availability B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting C. 2. Frequent oral care D. Temperature: 35. Mask like facial expression D. Activates dopaminergic receptors in the basal ganglia C.5 C 2. 50 ml B.8 C . The charge nurse is going to make an initial assessment. 500 ml D. Muscle atrophy 70. B. There was no infection. you will expect the patient to have 1. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting D. Offer large amount of oral fluid intake to replace fluid lost B. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.5kg? A. Which of the following is a characteristic of a patient with advanced Parkinson¶s disease? A. Approximately how much fluid is lost in acute weight loss of . The onset of Parkinson¶s disease is between 50-60 years old. Impairment of dopamine producing cells in the brain 71. Manifest normal skin turgor of skin and tongue 4.4 SITUATION: A 65 year old woman was admitted for Parkinson¶s Disease.4 D. Decrease acetylcholine availability D. Which of the following measures will not help correct the patient¶s condition A.3. 1. Drinks fluids as prescribed A. You are discussing with the dietician what food to avoid with patients taking levodopa? . Exhibit return of BP and Pulse to normal 3. Fluid volume deficit R/T furrow tongue B. 75 ml 66. Maintain body temperature at 36. Dehydration R/T subnormal body temperature D. 64. BUN Creatinine ratio : 10 : 1. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting 67.flattening of the skin was noted when the nurse released her pinch.3. Release dopamine and other catecholamine from neurological storage sites 72. Death of brain cells due to old age D. Give enteral or parenteral fluid C. 2. This disorder is caused by A. Which of the following is the appropriate nursing diagnosis? A. Injurious chemical substances B. What is the action of this drug? A. 750 ml C. 1. He also complains for postural hypotension. 69. Disturbed vision B. Dehydration R/T incessant vomiting 65. Give small volumes of fluid at frequent interval 68. Postural Hypotension is A.3 B. After nursing intervention.

Take the drug on empty stomach C. He suffers from: A. Walk erect with eyes on horizon C. I know the hallucinations are parts of the disease B. Dietary prescription SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders. I help her do some tasks he cannot do for himself D.A. What is the action of this drug? A. Agnosia D. The nurse will assess a loss of ability in which of the following areas? A. operating machineries etc. Aphasia 76. Balance B. Caffeine B. Thiamine rich food D. Dela Isla said he cannot comprehend what the nurse was saying. Ill turn off the TV when we go to another room 78. Lean and shout at the ear of the client B. Dissolve blockage of the urinary tract due to obstruction of cystine stones C. NSAID C. the patient complained of difficulty in walking. I¶ll get you a wheelchair D. Increases glandular secretion for clients affected with cystic fibrosis B. Acetaminophen D. What should the nurse caution the client when using this medication A. Which of the following drugs are not compatible when taking Probanthine? A. The nurse is aware that in communicating with an elderly client. Vitamin C rich food B. Speech D. 74. Your response would be A. One day. Which of the following is most important discharge teaching for Mr. Vitamin E rich food C. B. Mr. Dela Isla. Emergency Numbers B. Use a medium-pitched voice 77. Vitamin B6 rich food 73. Open mouth wide while talking to the client C. Stimulate peristalsis for treatment of constipation and obstruction 80. Relaxation technique D. Take with a full glass of water in treatment of Ulcerative colitis D. I told her she is wrong and I explained to her what is right C. Avoid hazardous activities like driving. a client with early Dementia exhibits thought process disturbances. Dela Isla. Insomnia B. Drug Compliance C. Alcohol . the nurse will A. 79. Endurance 75. Aphraxia C. Reduces secretion of the glandular organ of the body D. which of the following statement of the daughter will require the nurse to give further teaching? A. Use a low-pitched voice D. As the nurse talks to the daughter of Mr. Judgment C. Dela Isla A. Don¶t force yourself to walk SITUATION: Mr. You will need a cane for support B. I must take double dose if I missed the previous dose 81.

Which of the following can best prevent its occurrence? A. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Coherence and sense of hearing D. WBC : 12. What should the nurse tell clients when taking Probanthine? A. which of the following is most important to include in preparing Franco¶s bedside equipment? A. Franco. Franco? A. 87. B. Make sure you limit your fluid intake to 1L a day D. He was rushed to the hospital unconscious. Patency of airway and adequacy of respiration 85. Ulcerative Colitis D. Level of awareness and response to pain B. Franco¶s conditions.mm. Ernie jerks even on slight pressure. 84. One of the complications of prolonged bed rest is decubitus ulcer. Upon palpation of his abdomen.mm 90. Considering Mr. D. Pre op care would include all of the following except? A. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder? A. Stat appendectomy was indicated. The affected lobe in the patient is the Right lobe C.000 cu. mm. Diagnosis is acute appendicitis. Franco¶s Right side is weak. His diagnosis was CVA. The client will have problems in judging distance and proprioception D. What should be the most accurate analysis by the nurse? A. Complained of severe right iliac pain. Use special water mattress D. The tactile stimulation during mouth care will hasten return to consciousness D. Urinary retention B. Hgb : 13 to 14 gm/dl. Consent signed by the father B. Never swim on a chlorinated pool C. 70 years old. Glaucoma SITUATION : Mr. Clients orientation to time and space will be much affected SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Platelets : 250. Franco frequent mouth care? A. Mouth breathing is used by comatose patient and it¶ll cause oral mucosa dying and cracking. Turn frequently every 2 hours C. Expressive aphasia is prominent on clients with right sided weakness B.000/cu.000 to 13. Massage reddened areas with lotion or oils B. C. What is the rationale for giving Mr. Keep skin clean and dry 88. Blood test was ordered.82. RBC : 4.5 TO 5 Million / cu. Avoid hot weathers to prevent heat strokes B. 89. To remove dried blood when tongue is bitten during a seizure C. Footboard and splint D. suddenly could not lift his spoons nor speak at breakfast. He will be thirsty considering that he is doesn¶t drink enough fluids B.000 to 500. Suction machine and gloves 86. Avoid cold weathers to prevent hypothermia 83. Papillary reflexes and response to sensory stimuli C. Which result of the lab test will be significant to the diagnosis? A. If Mr. Enema STAT . Sandbag and trochanter rolls C. Hand bell and extra bed linen B. Peptic Ulcer Disease C.

Memory deficit B. Is progressive and reversible C. Disorientation C. Use sterile technique in irrigating the tube C. Deep breathing and leg exercise 94. Occurs suddenly and irreversible 100. What do you call a STROKE that manifests a bizarre behavior? A. The main difference between chronic and organic brain syndrome is that the former A. Irrigate the tube with saline as ordered B. Occurs suddenly and reversible B. Abdomen is soft and patient asks for water C. Inorganic Psychoses C. Reduce pain C. weakness and diaphoresis 3. Inappropriate affect . Organic Stroke D. Organic Psychoses 99. Ruptured colon 96. tends to be progressive and irreversible D. electrolyte imbalance 2. Early ambulation B. Common anesthesia for appendectomy is A. Skin prep of the area including the pubis D. 2 and 3 C. Hemorrhage D. When do you think the NGT tube be removed? A. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to : A. 1. Which behavior results from organic psychoses? A. Abdomen is soft and flatus has been expelled D. Offer some ice chips to wet lips 97. what would be the most suspected complication? A. B and C only Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital.C. All of the above 95. Prevent vomiting D. and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home. When patient requests for it B. NGT was connected to suction.3 D. Intussusception B. rigidity of the abdominal wall 4. advance the tube every hour to avoid kinks D. Elevated temperature. General C. Impaired Judgement D. Post op care for appendectomy include the following except A. Inorganic Stroke B. Peritonitis may occur in ruptured appendix and may cause serious problems which are 1.2. Caudal D. Remove the jewelries 91. If after surgery the patient¶s abdomen becomes distended and no bowel sounds appreciated. Hypovolemia. Paralytic Ileus C. 98. Hypnosis 93. Diet as tolerated after fully conscious C. Nasogastric tube connect to suction D. Pallor and eventually shock A. the nurse must A. Allay anxiety and apprehension B. 1 and 2 B. Relax abdominal muscle 92. In caring for the patient with NGT. Nausea and vomiting. Spinal B.

Snack tables d. Middle . A patient who has kaposis sarcoma has all of the following nursing diagnoses." b. "Let's talk about your options. The nurse assesses the client's home environment for the safe use crutches. "What does your family want you to do. 6. Wheezes on auscultation d. Inability to cough c. Diet high in fat 3.brimmed heat when I am in the sun" 5. 20 to 39 years b. "You need to follow the doctor's advice." c.´ b. A 4-year old cocker spaniel b. Diet high in fat b. The patient asks the nurse.1. Which one would indicate a risk factor for developing cancer of cervix? a.aged men d. Which of these groups should a nurse target when planning a community education presentation about testicular cancer? a." c. related to inability to control disease process 4. Gradual 2. 40 to 49 years . Which of the following statements. would indicate to the nurse the need for further instruction? a. Altered with maintenance related to non compliance c. "I will use tanning booths rather than sunbathing from now on. Exposure to pesticides c." d. "I will wear a broad . High . "I wouldn't have the surgery done without a second opinion. Senior citizens c." d. A nurse is planning a community education presentation about testicular cancer. To which one should the nurse give priority? a. A woman reports all of the following data when giving his history to a nurse. A patient who has a diagnosis is metastatic cancer of the kidney is told by the physician that the kidney needs to be removed. "What does your family want you to do. "I wouldn't have the surgery done without a second opinion.school students 7. Loud crowing when attempting to speak b. Scatter rugs c. Altered thought processes related to lesions b. "What should I do?" Which of the following responses by the nurse would be most therapeutic? a. if made by a patient who has had a basal cell carcinoma removed." 8. The large groups should be men aged: a. "I will use sunscreen with at least a sun protection factor (SPF) of 15. An observation consistent with complete-airway obstruction is: a. Hopelessness. "I will stay out of the sun between 10:00 AM and 2:00 PM" d. Defensive coping related to loss of boundaries d. Which one of the following would pose the greatest hazard to the client's safe use of crutches at home? a. Day care providers b.

the nurse plans to: a. Teach the procedure for irrigation of the stoma d. Blocking the action of cholinesterase c. Integumentary b. Internal rotation with flexion of the knee and hip c. When evaluating for major complications of this disease. External rotation with flexion of the knee and hip d. Stimulating the cerebral cortex b. Preoperatively. Accelerating transmission along neural swaths . the nurse plans to: a. A 10-year-old boy who is in the terminal stages of Duchenne muscular dystrophy is being cared for at home. Intramedullary nailing is used in the treatment of: a. Measles d. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). Limit fluid intake for 24 hours b. Genital Herpes b. Preoperatively. Neurological c. Provide cleansing enemas and laxatives as ordered 14. External rotation with extension of the knee and hip 16.c. Teach muscle tightening exercises c. an external shunt may be used for clients who require hemodialysis. Hydrocele 11. Respiratory d. Fracture of the neck of the femur d. Provide cleansing enemas and laxatives as ordered 12. Septicemia b. Intertrochanteric fracture of the femur 15. The most serious problem with an external shunt is. A client has been diagnosed as having bladder cancer. Clot-formation c. reported to a nurse by a 20 year old male patient. Teach muscle-tightening exercises d. The nurse should know that. Sclerosis of vessels 13. Slipped epiphysis of the femur b. 50 to 64 years d. This drug acts by: a. Fracture of shaft of the femur c. and a cystectomy and an ileal conduit are scheduled. would indicate a risk for development of testicular cancer? a. Gastrointestinal 10. a. 65 years and older 9. Teach the procedure for irrigation of the stoma c. Replacing deficient neurotransmitters d. A client has been diagnosed as having bladder cancer. Which of the following conditions. Undescended testicle c. Limit fluid intake for 24 hours b. Exsanguination d. and a cystectomy and an ileal conduit are scheduled. following a fracture of the neck of the femur. To gain access to a vein and an artery. Internal rotation with extension of the knee b. the desirable position for the a. a nurse would give priority to assessing which of the following body systems? a.

The nurse bases the reply on the knowledge that there is: a. A genetic in the production acetylcholine b. Multiple petechiae c. Using a sterile syringe to remove it from clamped. An inhibition of the enzyme ACHE leaving the end plates folded 18. Pruritic lesions b. scaly lesions d. Erythematous macules 23. A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. the nurse should assess for signs of respiratory complications because the: a. Impaired digestion 21. which would be evidenced by: . Wiping the catheter with alcohol and draining it into a sterile test tube d. Adjust the TENS dial until the client perceives pain relief and comfort d. Avoiding exposure to the sum b. The nurse assess the client with cholecystitis for the development of obstructive jaundice. Disconnecting the catheter and draining it into a clean container b. Length of time required for surgery is prolonged c. Shiny.17. Following an abdominal cholecystectomy. A decreased number of functioning acetylcholine receptor sites d. The nurse must help the client with pemphigus vulgaris deal with the resulting: a. Topical application of steroids c. Infertility b. Skin lesions d. Bloodstream is invaded by microorganisms from the biliary tract 25. Incision is in close proximity to the diaphragm b. A client with myasthenia gravis ask the nurse why the disease has occurred. Ocular motility c. Paralysis c. A reduced amount of neurotransmitter acetylcholine c. Turn the machine several times a day for 10 to 20 minutes c. The nurse should explain to the client with psoriasis that treatment usually involves: a. Debridement of necrotic plaques 22. Client's resistance is lowered because of bile in the blood d. Potassium permanganate baths d. Defective sebaceous gland formation 20. The nurses should assess a client with psoriasis a. Autoimmunity b. Increased amino acid metabolism d. Although no cause has been determined for scleroderma. When operating the TENS unit the nurse should a. it is thought to be caused by: a. Apply the color-coded electrodes anywhere it is comfortable for the client 19. cleansed catheter 24. A urine specimen for ketones should be removed from a client's retention catheter by: a. Maintain the same dial setting everyday b. Cleansing the drainage valve and removing it from the catheter bag c.

An increased level of epinephrine 32. Following a bilateral lumbar sympathectomy a client has a sudden drop in blood pressure but no. The occurrence of chronic illness is greatest in: a. care of the donor site includes immediately reporting. Adolescents c. Straw-colored urine. itchy skin d. Paradoxical respiration c. Bile flow into the intestine is obstructed c. Cleanse the site with an antiseptic solution d. Position the client on the affected side b. Scoliosis b. a. The liver is manufacturing inadequate bile d. the client may develop: a. a. The life-threatening problem that can develop postoperatively is: a. Light amber urine. A reallocation of the blo6d supply d. Clients with fractured mandibles usually have them immobilized with wires. Bleeding oral ulcerations 28. Small amount of yellowish green oozing b. immediately after the procedure. Infection b. Osteomyelitis d. A client with full-thickness burns on the chest has a skin graft. There is inadequate closure of the Ampulla of Vater 27. Hernation of the diaphragm 30. Fatty foods are hard to digest b. yellow sclerae 26. An inadequate fluid intake b. Shortness of breath c. As a result of fractured ribs. putty-colored stools. clay colored stools. Shoulder discomfort d. During the 1s124 hours after a skin graft. The nurse recognizes that this is most likely caused by: a. Epithelialization under the nonadherent dressing d. Bronchospasm 29. Middle-aged adults 33. Young children d. Older adult b. The chief complaint in a client with Vincent's Angina is: a. evidence of bleeding. the nurse should: a. Vomiting c. A client with cholelithiasis experience discomfort after ingesting fatty foods because. Dark-colored urine. Separation of the edges of the nonadherent dressing 34. Briefly apply pressure over the aspiration site 31. The after effects of anesthesia c. Chest pain b. Inadequate absorption of fat-soluble K b. Obstructive lung-disease d. A client has a bone marrow aspiration performed. A moderate area of serosanguinous oozing c. Begin frequent monitoring of vital signs c. During peritoneal dialysis the nurse observes that drainage of dialysate from the peritoneal cavity . yellow skin c. dark brown stools.a.

Practicing under guidelines of the Nurse Practice Act c. into the diuretic phase. To limit these spasms the nurse should: a. Advance the catheter to relieve the pressure against the prostatic fossa 37. Hypovolemia b. The nurse checks for hypocalcemia by placing a blood pressure cuff on a client's arm and inflating it. irrigate the Foley catheter with 60 ml of normal saline c. Periodically rotate the catheter 35. After a prostatectomy. After 1 week a client with acute renal failure moves. A nurse stops at the scene of an accident and finds a man with a deep laceration on his hand. Legally. After about 3 minutes the client develops carpopedial spasm. a client complains of painful bladder spasms. Protected for these actions. Turn from side to side b. An early response that may be associated with possible damage to the motor branch of the facial nerve is: a. Encourage the client not to contract his muscles as if he were voiding d. An inability to wrinkle the forehead 36. Hydrogen peroxide .has ceased before the required amount has drained out The nurse should assist the client to: a. Homan's sign b. and abdominal pain. A client has ear surgery. a fractured am and leg. The nurse is: a. Treating a health problem that can and should be handled by a physician 40. Administer a narcotic every 4 hours b. Deep breathe and cough d. During this phase the client must be carefully assessed for signs of: a. in most states. the client may not sign the operative consent if: a. Ambivalent feelings regarding operation are present b. Metabolic acidosis d. Chvostek's skin d. Trosseau's sign 39. A discussion of alternative with 2 physicians have not been performed and recorded d. Dryness of the lips and mouth c. Romberg sign c. Which one of the following solution is normally used for continuous or intermittent bladder and catheter irrigations? a. buy the Good Samaritan Law d. A complete history and physical have not been performed 41. Chronic renal failure 38. The nurse records this finding as a positive: a. Any sedative type of medication has recently been administration c. Drink 8 ounces of water c. The nurse is assigned to check a client's continuous bladder irrigation. Negligent and can be sued for malpractice b. A bitter metallic state b. Hyperkalemia c. A sensation of pain behind the ear d. A client is scheduled for a below-the-knee amputation of the right leg. The nurse wraps the man's hand in soiled cloth and drives him to the nearest hospital.

To keep the drainage to light pink 43. Immediately before going to bed c. Which of the following can be stated as a probably cause of cancer of the penis? a. A flat disk is placed on the abdomen d. Which of the following statements might place the client more at ease and willing to give a. Cannot be detected by laboratory tests d. Immediately after getting out of bed in the morning b. "Why do you think you have a problem?" c. A nurse is assigned to instruct a client in the method of testicular self-examination. He .b. The anal area is washed at a separate time b. A client is scheduled for an ultrasound examination of the prostate. Plain water 42. The nurse is assigned to give perineal care to an uncircumcised male client. In the morning after breakfast d. A probe will be inserted into the rectum c. The nurse is assigned to teach a class in health behaviors to young man. The foreskin is retracted and the area beneath the foreskin is cleansed c. the nurse should plan to relate that: a. The scrotum is carefully washed with sterile normal saline 45. "When dud you first notice this problem? b. Which of the following is correct? a. Sterile normal saline d. Mr. Exercise d. The instruction should include mention that the best time to perform this task is: a. Rarely metastasizes b. The foreskin should not be retracted except by a physician d. To effectively teach men the importance of testicular selfexamination. history of his problem? a. the nurse should know that testicular carcinoma: a. According to the client's oral intake c. To describe the procedure to the client. "Do you think you sexual dysfunction is psychological?" d. Bacteriostatic water c. Poor personal hygiene c. A female nurse is assigned to obtain a history from & client with a urinary tract problem an sexual dysfunction. After a warm bath or shower 49. This procedure uses x-rays to produce a visual image 47. "Does your sexual dysfunction seem to be related to your urinary tract problem?" 46. A diet high in acidic foods b. The procedure is performed using a cystoscope b. the rate of flow is adjusted: a. When continuous bladder irrigation is used following prostate surgery. Must first be biopsied to confirm the diagnosis 48. Has a high incidence of early metastasis c. Dorn has vasectomy. To run at 60 drops per minutes b. Circumcision 44. To maintain an output of 500 ml every 8 hours d.

Milton perineal care. Urethra and bladder 51. Side to side across the labia majora b. Prom the urinary meatus to the vagina . Insert the applicator approximately ½ inch and depress the plunger 55. The nurse is participating in a health class for young women. Insert the applicator tip gently and with an upward and forward motion d. Drug therapy usually helps control the collection of fluid 52. Some live sperm will be present in the ejaculatory fluid for a period of time d. Upward from the anus to the pubic area d. One subject is cancer of the ovary.asks the nurse why he just use a method of birth control because today he. the cotton ball or wash cloth is gently directed: a. Intensive vaginal and perineal itching c. Chemotherapy is not used for treating ovarian cancer d. Nurse assistant attending a nursing conference hears that one of her clients has hydrocele. Even though a vasectomy is performed. Ask the client to void prior to inserting the suppository b. The most correct answer is: a. A client is scheduled for a cystectomy and asks the nurse what the physician will be able to see during the procedure. Prostate and ureters d. The nurse is assigned to give Ms. The nurse is asked to discuss the signs and symptoms of vaginitis caused by the fungus candida albicans with Ms. Which one of the following is correct? a. had a sterilization procedure. which is inserted by means of a special applicator supplied with the drug. Kidney and ureters b. Which of the following statements is correct? a. The sperm count will not be negative until his testosterone level decrease b. The most prominent early symptoms is an irregular menstrual cycle 53. Lubricate the tip of the suppository with petroleum jelly c. She asks the nurse how this condition is treated. Wearing a scrotal support usually corrects She problem d. When cleansing the perineum. High fever 54. This type of cancer has a high cure rate c. Downward from the pubic area to the anus c. The most common response is: a. Pain high in the abdomen b. Which one of the following is a usual sign and symptoms of this infection? a. a condom is still recommended for 1 to 2 years 50. The most correct reply is the: a. Decrease in urinary output d. Surgery may be necessary to correct the problem c. Early symptoms of cancer of the ovary are vague b. Some minor surgery usually is necessary to ensure sterilization c. Barrows. Usually the problem requires more medical or surgical intervention b. Bladder and rectum c. Edwards a vaginal suppository. The nurse prepares to give Ms.

This procedure requires the consent of the sexual partner 62. Douche the next day to remove debris and blood cloth b. Ms. Which of the following position is normally used for this type of examination? a. Left lateral position 59. The irrigation is best administered with the client standing in a bathtub b. One topic the nurse plans to includes is the importance of the Pap test. Before inserting. The nozzle is inserted downward and backward within the vagina 57.d. Return in bed for the next 5 days 56. Applies heat to the legs and alters the desired effect of heat directed to the pelvic region d. The physician will prescribe an antiviral drug as a pregnancy is confirmed b. Stay in bed for the next 5 days 60. Hull to: a. a sitz bath. The nurse is asked to plan a health teaching program for women of child-bearing age with genital herpes. Which of the following is correct? a. Which of the following is part of a correct explanation of this procedure? a. The nurse is assigned to teach health-seeking behaviors to young women. Genital herpes in the mother-has no effect on the infant c. Two small abdominal incisions are made to introduce the instrument b. who has had an abdominal hysterectomy. The physician asks the nurse to position a client for a vaginal examination. Which one of the following should the nurse include in a teaching session? a. the nozzle is lubricated with petroleum jelly c. Patency of the fallopian tube c. Ovarian cyst b. This procedure is performed vaginally d. The nurse is assigned to administer a vaginal irrigation (douche). Cervical cancer d. The physician asks the nurse to describe the laparoscopy procedure for sterilization to Ms. Wait until the infection has been . Uterine infections 58. Dorsal recumbent position d. Following the procedure the nurse should instruct Ms. Is more slippery and is dangerous when used for surgical clients b. Avoid straining and heavy lifting until the physician permits this activity c. The temperature of the solution should be between 80°F and 84°F d. Bruce. The nursing assistant is assigned to give Ms. Hull has had an electrocauterization of her cervix for chronic cervicitis. She asks the nurse why the regular bath tub cannot be used. Sim's position c. Hospitalization for 4 to 5 days is normally required c. Cannot supply water that is of the desired temperature for this procedure c. Bailey. Cannot be kept as clean as a special sitz bath tub 61. Lithotomy position b. She is instructed to use the special sitz bath tub. The most correct reply is based on the fact that a regular bath tab: a. which is used mainly to detect: a.

preferably in the evening b. Which one of the following suggestions can be included in this teaching session? a. Do not drink coffee or alcoholic beverages for 2 days before this test c. It will be necessary to fast from midnight the night before the test d. The most correct response-is based on the fact that genital warts: a. If pregnant. If Ms. Are started on the first day of menstruation d. 3 days b. Can be prevented of the individual takes birth control pills d. Manning? a. Which one of the following instructions should the nurse give to Ms. in form the physician of a history of genital herpes 63.papilloma-virus-infection. Appear to increase the risk of cancer of the vulva. Sheppard.cured before becoming pregnant d. 14 days d. Reeves has a normal menstrual cycle. Ms. Reeves who states that she usually has symptoms when she ovulates. how many days after ovulation should menstruation begin? a. 21 days 65. Void immediately before the examination c. Manning is scheduled for Papanicolaou test (Pap Smear) at the time of the next visit to the physician's office. Douche the day before the examination d. Bring a sanitary napkin with you because bleeding usually occurs after this week 64. Can be treated with an antibiotic. 7 days c. Are of no danger and need not be treated 67. Self-administer an enema or take a laxative for 2 nights prior to the examination b. Must be taken on an empty stomach c. vagina. Which of the following solutions would be best for the nurse to use . and cervix c. Avoid the use of large sanitary pads d. Are taken at the same time each day. Do not eat or drink fluids after midnight 68. The nurse is assigned to teach young women attending a gynecology clinic. Dodd has been told by her physician that she has genital warts. Avoid using super absorbed tampons b. The nurse should instruct Ms. Sheppard that oral contraceptive: a. The nurse obtains a health history from Ms. Take a diuretic at the onset of menstruation c. The physician suggests that the nurse include explaining ways to prevent toxic shock syndrome. Use a tampon on(y during the night 69. She asks the nurse if there is any danger or problems associated with this condition. Which of the following are included in the instructions for a client having a pelvic examination? a. Do not douche for 2 to 3 days before this test b. The physician asks the nurse to discuss the use of an oral contraceptive with Ms. which are caused by a human . Ms. Are best taken in the morning before breakfast 66. such as penicillin or tetracycline b.

Which of the following would indicate to the nurse that the stationary thrombus in Ms. If Ms. Lynch's skin for areas of psoriasis. Wrap the pack in several thick towels b. Patches of redness covered with silvery scales c. Heywood must be taught principles f good body mechanics. Betty Lynch. Hydrogen peroxide d. Place a pillow between hint and the . Encourage quadriceps setting exercises 71. to the client's lower back. Which of the following nursing action would be best a. Leg cramps c. Heywood that when he picks up something. Sara Fleming develops a slightly elevated temperature and swelling in the right call of her leg. The physician prescribes warm moist compresses for the client's affected leg. Covers the wet gauze with a towel 74. Uses a sterile technique c. Providone-iodine 70. Rub skin lotion over the back area c. Ms. Bend from the waist 76. Following a total abdominal hysterectomy Ms. A rash characterized by raised. Consequently. Mr. Inspect the skin every 4 hours d. Heats the water to 120°F b. Swelling of the knee 73. Elevate her feet on a stool 72. To reduce the potential for a thermal injury the nurse should plan to: a. Help to change positions to achieve comfort c. Ambulate with him at frequent intervals d. Fleming suddenly develops? a. Apply a hot water bottle b Use an electric heating pad c. holes that she has recently developed a skin problem and makes an appointment to be seen in a clinic specializing diagnosis of psoriasis is made by the physician. Perform passive range of motion during each shift b. Which of the following nursing actions is correct when applying the warm moist compress? The nurse: a. Sodium hydrochloride c. age 29. Wrap them in a warm blanket d. Weeping lesions on the trunk of the body b. Drake tells the nurse her feet are cold. When examining Mr. IsopropyI alcohol b.when cleaning the inner cannula of a tracheostomy tube? a. The nurse observes that the client's knee is swollen and painful. Areas of redness surrounded by crusts d. Lift with arms extended d. he should: a. pusfilled lesions 75. Keep his feet together c. called a hydrocollator. Chest pains b. The nurse applies a commercially made hot moist pack. The nurse would be correct in telling Mr. Numbness in the foot d. Flex both his knees b. which one of the following nursing measures should be carried out? a. the nurse should look for: a. Before being discharged.

Feels cool and clammy d. Heywood is to remain in bed for the time being. Tell him to get control of himself d." b. Rumsey reacts from the anesthesia. Call the hospital chaplain for him 84. Stay with him quietly in the room at his bedside c. "Move your upper body first then legs. Leave the room until he has worked through his anger b. On his back with his head and knees straight 81. rushed to surgery where his arm is amputated above the elbow. the nurse explains that this medication is also used to: a. Reduce emotional depression b. An air mattress c. "Hold your breath as you are turning. Heywood to wash his back. Which of the following is the best action the nurse can take at this time? a. he has some numbness and tingling in his legs. Mr. "Curl up in a ball before you move. In what position should the .i. Relax skeletal muscles c. A bed board d. While assessing the disk to indicate that the pain is increased when: a. Which position would the nurse find gives Mr. a construction worker. Now. Heywood's coccyx is becoming impaired? The skin: a. A foam square 80. has been experiencing periodic bouts of law back pain. Which one of the following observations would most indicate to the nurse that the skin over Mr. Sneezing c. Position the client on rubber ring 77." 79. Is moist and warm 78. The physician suspects that Mr. he sees that his forearm is missing. Mr. "Avoid twisting your body while moving. Resting d. which instruction should the nurse provide to minimize his discomfort? a. Mr. Heywood has a herniated intervertebral disk in the lumbar spine. A sheep skin pad b." c. Eating b. Promote restful sleep d. When Mr.d. Urinating 83. Rumsey. in addition to the pain that radiates into his buttocks. On his side with hips and legs straight c.back d. Mr. Appears red when pressure in relieved c." d. Heywood is receiving 10 mg of Diazepam (Vatium) orally t. Besides diminishing anxiety. He screams obscenities and sobs uncontrollably. On his abdomen with his head to the side d. On his back with the head and knees elevated b. Before turning Mr. Barry Heywood. Looks shiny over boy prominences b. Heywood the most comfort? a. Which of the following should the nurse use to provide support to Mr. who has not regained consciousness. Heywood's spine? a. Relieve inflammation 82.

Elevate the foot c. Steve Rumsey's arm gets caught in a corn auger. Supine extended c. Across the phalanges d. The physician tells Ms. Rumsey to the hospital in shock? The client would have: a. She wears a cotton sock 89. Her hands and spine are involved. The physician directs the nurse to wrap Ms. Before Ms.nurse place Mr. Elkins that she has severely sprained ankle. Rumsey while continuing with his assessment and care? a. Below the knee b. She is told to remove it for approximately 20 minutes and re-apply it three times a day. His lower left arm and band are crushed. She' has pelvic-belt traction. . Elkins foot with an elastic roller bandage referred to by some as an Ace bandage. When the nurse helps Ms. Her toes appear swollen d. Elkins to loosen-the bandage if: a. which she uses intermittently throughout the day. Angela Freeman has acute low back pain. Her toes feel fairly warm b. Following an injury in which Ms. she experiencing immediate swelling of her ankle and pain on movement. Ramos was barbecuing outdoors when the gas tank exploded. During a farming accident Mr. Elkin's lower leg? a. Stabbing hand pain d. Rizal is most likely to tell the nurse that the first symptoms that caused her to seek health care was: a. Just below the ribcage b. Level with the iliac crest d. Decreasing blood pressure c. Immobilize the foot SITUATION: Mr. Rizal has acute rheumatoid arthritis. it would be best to place the top of the belt: a. Elkins leaves the emergency department. the nurse demonstrates hew to apply the roller bandage. Dangle the foot b. Ms. On his back with his legs elevated d. Prone b. Where should the nurse begin applying the bandage? a. sore joints b. Decreased heart rate b. The x-ray reveals that the bones are intact. At the metatarsals 90. Stiff. Freeman apply the pelvic traction. Generalized fatigue c. Where it is most comfortable 87. Above the knee c. Which on of the following nursing measures would be most helpful for relieving the swelling while preparing to obtain the x-ray of Ms. On his side with his neck 85. Increasing urine output 86. Ms. When the nurse admits Ms. Her physician has sent her to the hospital for x-ray. Increasing bowel sounds d. Leona Elkins while climbing stairs. Exercise the foot d. Her ankle feels painful c. Even with her waistline c. Disuse of fingers 88. It is essential that the nurse tells Ms. Which of the following assessments would the nurse typically find when the paramedics bring Mr.

Apply tomato juice and ointment over the area 92. Water-seal chest drainage involves attaching the chest tube to a: a. 96. At the emergency room. The patient is placed on bed post-operatively in what position? a. Right side d. The doctor orders MAFENIDE for application over the bum area. C02 tension 94. 45% c. Dark and scant urine output b. the upper half of his anterior trunk and the anterior and posterior portions of his left lower extremity. It causes lactic acidosis b. Do nothing as this is expected b. The nurse is administering the prescribed IVF. Prone b. Bradycardia and hypotension d. If the nurse sees fluid moving up and down during inspiration and expiration on the water seal bottle. Call the physician immediately and damp the chest tube . she suspected fluid overload because of which finding? a. .blood value determinations is most likely be useful to evaluate the adequacy of the fluid replacement? a. It has minimal eschar penetration d. Based on the rules of nine. Suction machine directly b. Which of the following is the BEST estimate of the burn? a. Creatinine levels b. Rubber tube/glass tube that is submerged underwater c. Blood urea nitrogen c. 27% d. A closed drainage bottle with sterile water and no external opening 98. The BEST initial management of burns that can be employed at the scene is generally which of the following: a. When she evaluated the patient. It is bacteriostatic SITUATION: MARK Lester had been diagnosed with Stage 1 bronchogenic cancer. 36% b. Which one of the following . Moist rates c. He had undergone lobectomy on the left lower lung.' 91. Hematocrit level d. the nurse assessed the extent of the burn on the patient's body. Immediately check the bottle for leaks c. Trendelenburg c. Left side 97.He sustained second degree and third degree burns of the anterior portion of BOTH arms. Rinse the area with mild soap and water d. A two-bottle drainage system is inserted. Rubber tube that is left open to air d. she should: a. Pour cold water over the burned areas b. It must be constantly applied c. Apply clean dressing to the affected area c. 54% 93. Facial flushing and twitching 95. The nurse understands that one disadvantage of this drug is that: a.

Administer oxygen to the patient c. Attempt to change a new bottle d. If the nurse sees vigorous and continuous bubbling in the second bottle. Cover the wound with wet sterile gauze and send someone to calf the physician 99. Obtain a new set of tubing and submerge the tube on the water c. she should: a. If the tube accidentally displaces from the chest of the patient. the nurse should do which action first? a. Apply vaselinized gauze to the opening . Attempt to reinsert the tube d. Clamp the tube with the use of forceps b.d. Momentarily clamp the tube to note for air leak b. Pull the chest tube out to remove the air leak 100.