MEDICAL SURGICAL NURSING 1 CARE OF CLIENTS WITH CARDIOVASCULAR DISORDERS

MEDICAL SURGICAL NURSING 1
CARE OF CLIENTS WITH CARDIOVASCULAR DISORDERS

SITUATION: Basic knowledge about the physiology of the cardiovascular system will greatly help the nurse to
provide appropriate assessment and interventions. The key component of physical assessment includes a health
history, physical examination, and monitoring of variety of laboratory and diagnostic test results.
1. The pumping action of the heart is accomplished by the rhythmic contraction and relaxation of its muscular wall.
What change occurs during systole?
a. The chambers of the heart become smaller as the blood is ejected
b. The heart chambers fill with blood in preparation for subsequent ejection.
c. The heart chamber of the heart becomes bigger as it receives blood
d. The myocardium becomes thinner as it blood enter the chamber.
ANSWER: A
Rationale: As the blood coming from the systemic circulation enters the inferior and superior vena cava, the atrium
will receive the blood which makes the myocardium thin and enlarged. This occurs during diastole when the heart
relaxes as the chamber of the heart is filled with blood. During systole or contraction, the heart become smaller as the
blood is ejected to the circulation.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p.786
2. Cardiac conduction system generates and transmits electrical impulses that stimulate contraction of the
myocardium. Impulses come from two specialized electrical cells. What are the physiologic characteristics of the
electrical cell?
a. Automaticity, excitability, potentiality
c. Conductivity, potentiality, refractivity
b. Automaticity, conductivity, refractivity
d. Automaticity, conductivity, excitability
ANSWER: D
The two specialized electrical cells are the purkinje cells and the nodal cell that is physiologically characterized by its
automaticity, conductivity, and excitability.
3. Automaticity refers to:
a. Ability to transmit an electrical impulse from one cell to another
b. Ability to respond to electrical impulse
c. Ability to initiate an electrical impulse
d. Ability to automatically respond to electrical impulse
ANSWER: C
The two specialized electrical cells are the purkinje cells and the nodal cell that is physiologically characterized by it its
Automaticity, conductivity, and excitability. Automaticity refers to the ability to initiate an electrical impulse. Option A
refers to conductivity of the cell. Option B refers to excitability. Option D doesn’t refer to any of the three physiologic
characteristic of the electrical cell.
4. Cardiac output must be responsive to changes in the metabolic demand. You know that cardiac output can be
determined by:
a. Measuring the amount of blood ejected per heartbeat and multiplying it to the client’s heart rate.
b. Summing up the stroke volume with the client’s heart rate
c. Getting the heart rate of the client and the client’s stroke volume and BP
d. Getting the BP of the client multiply to the client’s heart rate
ANSWER: A
Rationale: Cardiac output refers to the amount of blood pumped by each ventricle during a given period. CO is
computed by multiplying the stroke volume by the heart rate. Stroke volume refers to the amount of blood ejected
per heartbeat.
5. Heart rate is stimulated by the following except:
a. Increased level of the catecholamine
c. The vagus nerve
b. Excess thyroid hormone
d. The sympathetic system
ANSWER: C
Rationale: The increase level of epinephrine and norepinephrine increases the contractility of the heart by stimulating
the sympathetic nervous system. Excess thyroid hormone like in patients with hyperthyroidism, where metabolic
demand is increased, you can observe an increase in the heart rate. Vagus nerve, which is the longest nerve, will
cause bradycardia when stimulated which can be a serious problem especially to patients with cardiac diseases.
6. One student nurse asks you how to determine the stroke volume of the heart. You will answer the question,
knowingly that stroke volume is determined by:
a. The degree of cardiac muscle strength
b. The intrinsic contractility of the cardiac muscle
c. The pressure gradient against which the muscle ejects blood during contraction
d. All of the above factors
ANSWER: D
Rationale: Stroke volume is primarily affected by three factors- preload, afterload and contractility. Option A refers to
contractility, option B is refers to preload, option C refers to afterload.
7. You know that there are factors that may bring changes in the cardiac structure associated with aging which
includes all of the following except:
a. Elongation of the aorta
c. Increased sensitivity to baroreceptors
b. Endocardial fibrosis
d. Increased size of left atrium
ANSWER: C
Rationale: The above changes are structural changes that occur as part of the aging process. Instead of increase in
baroreceptors sensitivity, the change that occurs is decrease in its sensitivity. Baroreceptors work under negative
feedback mechanism. When BP is elevated, it transmits impulses to the medulla to lower down the HR and BP and the
opposite.
8. How are you going to assess a client with postural hypotension? Arrange the following in order of execution.
i. Position the client supine and flat
ii. Do not remove the BP cuff between position changes but check to see if the BP is still correctly placed
iii. Supine measurements should be measured before checking the upright position
iv. Assess BP changes with client sitting on the edge of the bed with feet dangling and standing
v. Record HR and BP
a. i, ii, iii, iv, v
b. i, iii, ii, iv, v
c. i, iii, ii, v, iv
d. ii, i, iii, iv, v
ANSWER: B
Rationale: Postural hypotension or orthostatic hypotension occurs when the BP decreases significantly after the
patient assumes an upright posture. It is usually accompanied by dizziness, lightheadedness, or syncope. The proper
order in checking the BP changes should start by positioning the patient first and then measure first the BP in supine
position before an upright position but never remove the BP cuff to avoid any changes related to misplacing or
adjusting the cuff. Lastly document the HR and BP.
9. You assess a patient for postural hypotension and recognize the following are normal postural responses except:
a. An unchanged systolic pressure
c. An increase of 10 mm Hg in the reading
b. A heart rate of 5-20 bpm above the resting rate
d. An increase of 5 mm Hg in diastolic pressure
ANSWER: C
Rationale: Postural hypotension or orthostatic hypotension occurs when the BP decreases significantly after the
patient assumes an upright posture. It is usually accompanied by dizziness, lightheadedness, or syncope. Option C is
incorrect. For us to say that it is normal postural response, it should be a slight decrease of up to 10 mm Hg and not
an increase.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p.799.
10. You check the client’s chart and see on the assessment data that the client’s pulse strength is “left radial+2.”
Based on 0-4 rating scale, this means:
a. Diminished pulse and cannot be obliterated
b. Pulse is weak, thready, difficult to palpate and obliterated with pressure
c. Full pulse, easy to palpate, weak and thread
d. Strong and bounding pulse, may be abnormal
ANSWER: A
Rationale: Pulse is weak, thready, and difficult to palpate only if pressure is applied. 0: pulse not palpable or absent.
+1 Pulse is weak, thready, difficult to palpate and obliterated with pressure. +2 diminished pulse and cannot be
obliterated. +3 Full pulse, easy to palpate. +4 Strong and bounding pulse may be abnormal.
11. A nurse is explaining the anatomy and physiology of the heart to a group of adults participating in a wellness
program. When a participant asks for an explanation of the purpose of the superior vena cava, the nurse provides
which of the following information?
a. Returns blood from the body area above the diaphragm
b. Returns blood from the body below the diaphragm
c. Drains blood from the heart
d. Receives freshly oxygenated blood from the lungs through the pulmonary veins
The superior vena cava returns blood from the body area above the diaphragm, the inferior vena cava returns blood
from the body below the diaphragm, and the coronary sinus drains blood from the heart. The left atrium receives
freshly oxygenated blood from the lungs through the pulmonary veins.
SITUATION: Cardiovascular disease is the leading cause of death and showed in later studies that many of the
population, men and women of all racial and ethnic groups are seriously affected by these cardiac conditions.
12. When do coronary arteries primarily receive blood flow?
a. During inspiration
b. During diastole
c. During expiration
d. During systole
ANSWER: B
Although the coronary arteries may receive a minute portion of blood during systole, most of the blood flow to
coronary arteries is supplied during diastole. This is the relaxation of the muscle, the heart chambers fill with blood in
preparation for the subsequent ejection. Breathing patterns are irrelevant to blood flow.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 10th
Edition, Vol. 1. Page 647
13. Atherosclerosis impedes coronary blood flow by which of the following mechanisms?
a. Plaques obstruct the vein
c. Blood clots form outside the vessel wall
b. Plaques obstruct the artery
d. Hardened vessels dilate to allow blood to flow through
ANSWER: B
Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Atheresclerosis is a direct result of
plaque formation in the artery. Hardened vessels cannot dilate properly and therefore constrict blood flow.
14. A murmur is heard at the second left intercostals space along the left sternal border. Which valve area is this?
a. Aortic
b. Mitral
c. Pulmonic
d. Tricuspid
ANSWER: C
Abnormalities of the pulmonic valve are auscultated at the second left intercostals space along the left sternal border.
Option A – aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum.
Option B – mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line.
Option D – tricuspid valve abnormalities are heard at the third and fourth intercostals spaces along the sternal border.
15. What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein
distention?
a. High fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position
ANSWER: C
Jugular venous pressure is measure with a centimeter ruler to obtain the vertical distance between the sternal angle
and the point of highest pulsation with the head of the bed inclined between 15 and 30 degrees.
Option A – in high fowler’s position, the veins would be barely discernible above the clavicle.
Option B and D – increased pressure can’t be seen when the client is supine or when the head of the bed is raised 10
degrees because the point that marks the pressure level is above the jaw, therefore not visible.
16. After teaching a group of adults about modifiable risk factors for coronary artery disease (CAD), the community
health nurse knows that the group needs additional teaching if which finding is identified as one of these factors?
a. Cigarette smoking
b. Family history
c. Hypercholesterolemia
d. Hypertension
ANSWER: B
Family history is a risk factor for CAD, but it is a non-modifiable risk factor. Cigarette smoking, elevated cholesterol
levels (hypercholesterolemia), and hypertension are modifiable risk factors for CAD.
17. A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the
nurse best explains the procedure to the client?
a. "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter."
b. "PTCA involves cutting away blockages with a special catheter."
c. "PTCA involves passing a catheter through the coronary arteries to find blocked arteries."
d. "PTCA involves inserting grafts to divert blood from blocked coronary arteries."
ANSWER: A
PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque,
thereby opening a stenosed or blocked artery.
Option B - this is a description of an atherectomy.
Option C - this only describes a cardiac catheterization.
Option D - Inserting grafts to divert blood from blocked arteries describes coronary artery bypass graft surgery.
Edition, Vol. 1. Page 733-735
18. As initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given
sublingually. This drug’s principal effects are produced by:
a. Antispasmodic effects on the pericardium
c. Vasodilation of peripheral vasculature
b. Causing an increased myocardial oxygen
d. Improved conductivity in the myocardium
ANSWER: C
Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand.
Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the
heart.
Option A and D - nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.
Option B - nitroglycerin decreases myocardial oxygen demand.
19. A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is prescribed. Morphine is given
because it:
a. Eliminates pain, reduces cardiac workload, and increases myocardial contractility
b. Lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand
c. Raises the blood pressure, lowers myocardial oxygen demand, and eliminates pain
d. Increases venous return, lowers resistance, and reduces cardiac workload.
ANSWER: B
When given to treat acute MI, morphine sulfate eliminates pain, reduces venous return to the heart, reduces vascular
resistance, reduces myocardial workload, and reduces the oxygen demand of the heart.
Option A, C and D - Morphine sulfate doesn't increase myocardial contractility, raise blood pressure, or increase
venous return.
20. A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals
myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic indicates myocardial
ischemia?
a. Prolonged PR interval
b. Absent Q wave
c. Elevated ST segment
d. Widened QRS complex
ANSWER: C
Ischemic myocardial tissue changes cause elevation of the ST segment, a peaked or inverted T wave, and a
pathological Q wave.
Option A - a prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart
block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic
disturbances, rheumatic fever, or chronic degenerative disease of the conduction system.
Option B - an absent Q wave is normal; an MI may cause a significant Q wave.
Option D - a widened QRS complex indicates a conduction delay in the His-Purkinje system.
21. A client is admitted to the coronary care unit with a suspected diagnosis of acute myocardial infarction. To help
confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatinine
kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest
pain?
a. 30 minutes to 1 hour
b. 2 to 3 hours
c. 4 to 8 hours
d. 12 to 18 hours
ANSWER: C
Serum CK-MB levels can be detected 4 to 8 hours after the onset of chest pain. This will peak within 12 to 24 hours
and return to normal within 3 to 4 days.
22. Which of the following blood tests is most indicative of cardiac damage?
a. Lactate dehydrogenase
b. 2 to 3 hours
c. Troponin Ix
d. Creatine kinase (CK)
ANSWER: C
Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren’t detectable
in people without cardiac injury.
Option A - Lactate dehydrogenase (LDH) is present in almost all body tissues and not specific to heart muscle. LDH
isoenzymes are useful in diagnosing cardiac injury.
Option B - CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes.
Option D - Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac
injury.
23. A client is prescribed captopril (Capoten) to treat his hypertension. This drug is classified as:
a. Calcium channel blocker
b. ACE inhibitor
c. Beta blocker
d. Vasodilator
ANSWER: B
Captopril is an ACE inhibitor that works by blocking the conversion of angiotensin I to angiotensin II, which reduces
sodium and water retention and lowers blood pressure. It may also slow the progression of diabetic renal disease in
clients with associated renal insufficiency.
Edition
24. The nurse is caring for a client who is receiving captopril and spirinolactone. Which laboratory value will be most
important to monitor?
a. Blood urea nitrogen
b. Alkaline phosphatase
c. Sodium
d. Potassium
ANSWER: D
Hyperkalemia is a common adverse effect of both ACE inhibitors and potassium sparing diuretics. The other laboratory
values may be affected by these medications but are not as likely or as potentially life threatening.
Edition
25. Which signs and symptoms are present with a diagnosis of pericarditis?
a. Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
b. Low urine output secondary to left ventricular dysfunction
c. Lethargy, anorexia, and heart failure
d. Pitting edema, chest discomfort, and nonspecific ST-segment elevation
ANSWER: A
The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment
elevation, elevated ESR, and pericardial friction rub.
Option B, C and D - all other symptoms may result from acute renal failure.
26. Which signs and symptoms would alert the nurse to the possibility of a major complication in a client with
pericarditis?
a. Chest pain and diaphoresis
c. Hypotension and muffled heart sounds
b. Dyspnea and copious blood-tinged, frothy sputum
d. Tachycardia and oliguria
ANSWER: C
A major complication associated with pericarditis is pericardial effusion or cardiac tamponade manifested by
hypotension and muffled heart sounds.
Option A - Crushing chest pain and diaphoresis are signs of myocardial infarction.
Option B - Dyspnea and copious blood-tinged, frothy sputum are signs of acute pulmonary edema, a complication of
left-sided heart failure.
Option D - Tachycardia and oliguria are signs of hemorrhagic shock.
27. When obtaining the history of a client admitted with Endocarditis, which information from the client interview
would the nurse consider as significant?
a. Dental surgery in the recent past
c. History of marijuana use
b. History of coronary artery disease (CAD)
d. Prolonged use of steroid therapy
ANSWER: A
Dental surgery is one of the predisposing factors for the development of endocarditis because it may create a portal of
entry for microorganisms.
Option B, C and D - a history of valvular heart disease (not CAD), I.V. drug use (not marijuana use), and prolonged
I.V. antibiotic therapy (not steroid therapy) are predisposing factors for endocarditis.
28. Which clinical manifestation indicates the development of right-sided heart failure in a client with COPD?
a. Increased barrel chest
b. Diminished heart sounds
c. Dependent ankle edema
d. Pink, frothy sputum
ANSWER: C
Ankle edema is a manifestation of right-sided heart failure. There is a sluggish venous return due to failure of the
right ventricle.
Option A – is incorrect because barrel chest is a consequence of COPD.
Option B – is incorrect because in congestive heart failure, an additional abnormal heart sound (S3) is heard.
Option D – is incorrect because pink, frothy sputum is a symptom of pulmonary edema.
29. An 84-year-old male is returning from the operating room (OR) after inguinal hernia repair. The nurse notes that
he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which of the following signs
and symptoms indicates left-sided heart failure?
a. Jugular vein distention
b. Right upper quadrant pain
c. Bibasilar fine crackles
d. Dependent edema
ANSWER: C
Bibasilar fine crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload.
Option A, B and D - Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are
caused by right-sided heart failure, usually a chronic condition.
30. The physician prescribes dopamine (Inotropin) to improve the client’s hemodynamic status. The nurse knows that
this drug is prescribed to:
a. Decrease the oxygen demand of the heart
c. Decrease circulating blood volume
b. Decrease cardiac workload
d. Increase cardiac output and stroke volume
ANSWER: D
Dopamine increases cardiac output and stroke volume. It does not produce the effects mentioned in options a, b or c.
Edition. Page 303
31. Which outcome is the best indicator that digoxin has been effective?
a. Increased systolic and diastolic pressures
c. Decreased pulse rate and increased urinary output
b. Unlabored respirations and increased urinary output
d. Increased BP and decreased pulse rate
ANSWER: C
The best indicator that digoxin has been effective in strengthening cardiac contraction and increasing glomerular
filtration is a decrease in heart rate (vagal effect) and incrased uriary output. As a result of thse drugs, cardiac output
is improved, raising BP and decreasing pulmonary congestion.
Option A, B and D – are incorrect because it s only partially accurate.
SITUATION: Alma Almaden, a 42-year-old female visits the emergency department stating that she developed
severe chest pain radiating to her jaw while doing the laundry manually. She is concerned that she is having a heart
attack because his father died of a heart attack at the age of 61.Her blood pressure is 140/90, pulse 89bpm and
respiration.
32. After beginning an IV access and giving one aspirin to chew, the nurse administers a prescribed sublingual NTG
tablet to the client and starts oxygen by nasal cannula at 4L per minute. Within 30 minutes, the client states that his
pain is relieved. What type of angina pectoris Ms. Almaden is experiencing?
a. Stable angina
b. Unstable angina
c. Refractory angina
d. Prinzmetal’s angina
ANSWER: A
Rationale: Predictable and consistent pain that occurs on exertion which is relieved by rest and nitroglycerin is called
stable angina. Unstable angina is characterized by pain that occurs more frequently and last longer than stable
angina. Threshold for pain is lower, and pain may occur at rest. Refractory angina is a severe incapacitating chest
pain. Prinzmetal angina is pain at rest with reversible ST segment elevation caused by coronary artery vasospasm.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p. 867
33. Ms. Almaden heard from the other patient that her chest pain might be a crescendo angina. How will you explain
that her pain is different from crescendo angina? You will tell her that:
a. Crescendo angina occurs more frequently and last longer
b. Crescendo angina is severe that she will be incapacitated
c. Crescendo angina is a pain that occurs at rest
d. Crescendo angina is symptoms free
ANSWER: A
Rationale: Unstable angina or pre infarction angina or crescendo angina is characterized by pain that occurs more
frequently and last longer than stable angina. The threshold for pain is lower, and pain may occur at rest. Option B is
refractory angina which is a severe incapacitating chest pain. Option C is prinzmetal angina or variant angina which is
pain at rest with reversible ST segment elevation caused by coronary artery vasospasm. Option D is called silent
ischemia.
34. Nitroglycerine is prescribed to your patient. As part of the discharge planning, you will provide health teachings on
the proper use of NTG. Which statement by the client will help you determine that additional health teaching is
needed?
a. “I should place my NTG tablet on my buccal pouch.”
b. “I should crush NTG tablet if the pain is severe.”
c. “My mouth should be moist”
d. “I should keep my tongue still and swallow my saliva as NTG tablet dissolves.”
ANSWER: D
Rationale: NTG tablet must be place under the tongue or in the cheek because these areas have too many blood
vessels. The mouth should be moist so NTG will dissolve easily and fast. If the patient has a severe chest pain, tablet
can crushed or chew for faster absorption. Tongue should be keep still and do not swallow until NTG tablet is
completely dissolved.
35. Instructions should be given to the client before she goes home which includes all of the following, except?
a. Carry the medication at all times and stored in a dark glass bottle.
b. NTG should not be taken in anticipation of any activity that may produce pain.
c. NTG is highly volatile and is inactivated by heat, moisture, air, light, and time.
d. Renew the NTG supply every 6 months.
ANSWER: B
Rationale: A, C, and D are correct. NTG must be taken in anticipation of any activity that may produce pain because it
increases tolerance for exercise and stress when taken prophylactically, it is best taken before pain develops.
SITUATION: Manny Packman, a 46-year-old man, is brought to the emergency department after experiencing
crushing substernal chest pain, which is unrelieved by rest and NTG. He is pale, cool, clammy and diaphoretic. He
complains of inability to take a deep breath and nausea. His blood pressure is 105/80, HR 92bpm, RR 28 per minute.
36. Based from the above situation, Mr. Packman is probably suffering from what disorder?
a. Angina pectoris
b. Left-sided heart failure
c. Heart burn
d. Myocardial infarction
ANSWER: D
Rationale: A client with myocardial infarction is characterized by crushing substernal chest pain which is unrelieved by
nitroglycerine and rest. The client is pale, cool, clammy and diaphoretic. Angina pectoris can be like MI but is relieved
by nitro and rest. Heart burn sometimes mimics the pain of MI but is relieved by antacids. Left sided heart failure is
manifested by lung related signs and symptoms like coughing and dyspnea.
37. Everyone who is involved in the care of a patient should work collaboratively to achieve a better outcome. As you
attend to Mr. Packman, what should be your collaborative intervention that should be implemented first?
a. Prevent further myocardial damage
c. Prevent respiratory dysfunction
b. Relief pain or ischemic signs and symptoms
d. Maintain adequate tissue perfusion
ANSWER: B
Rationale: Client having an MI should be relieved from pain and other signs and symptoms of ischemia to prevent
potential complications. A, C, D are complications that may arise if ischemic signs and symptoms is not given with
proper interventions.
38. What would be your priority nursing diagnosis during the first 24 hours following an MI?
a. Impaired gas exchange
b. High risk for infection
c. Fluid volume deficit
d. Constipation
ANSWER: A
Rationale: Impaired gas exchange related to poor oxygenation and dysrhythmia is a major problem immediately
following MI therapy is directed toward improving CO and decreasing myocardial workload.
39. You provide drug teaching about the action of morphine sulfate to Mr. Packman in relation to his MI. You identify
that no further teaching is required if he states that the primary reason of morphine administration is:
a. To reduce his anxiety so oxygen demand will be minimized
c. To dilate his blood vessel
b. To control his pain
d. To reduce the workload of the heart
ANSWER: B
Rationale: The main purpose of Morphine administration is pain relief. Dilation of the blood vessel which will result to
reduce workload of the heart by decreasing both the cardiac filling pressure and the pressure against which the heart
muscle has to eject blood. And lastly, it reduces the client’s anxiety.
40. An intravenous infusion at a “keep vein open” rate would be ordered primarily to:
a. Help keep him well hydrated
c. Prevent kidney failure
b. Help keep him well nourished
d. Provide a route for emergency drugs
ANSWER: D
Rationale: A client with MI may develop complications, such as cardiac dysrhythmia, that requires prompt
intervention. An open IV allows a rapid administration of various agents as needed.
41. The client continues to have episodic chest pain during the first 8 hours, despite morphine administration. He is
started on continuous intravenous NTG (Tridil) infusion. Essential nursing action would include:
a. Obtaining an infusion pump for the medication
c. Monitoring urine output hourly
b. Monitoring the blood pressure hourly
d. Obtaining serum potassium levels daily.
ANSWER: A
Rationale: NTG infusion pump requires an infusion pump for precise control of the medication. Blood pressure
monitoring would be done in a continuous system. Hourly urine output is not always required for this client. Obtaining
a serum potassium level is not associated with NTG infusion.
42. If Mr. Packman develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
a. Pulmonary crackles
b. Bradycardia
c. Elevated blood pressure
d. Fever
ANSWER: A
Rationale: Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased UO, and a
sign of diminished blood flow to the brain, such as confusion, and restlessness, cold clammy skin, and tachynea with
respiratory crackles. Cardiogenic shock is a serious complication of myocardial infarction.
43. After his attack, Mr. Packman told you, “My father died of a heart attack when he was 60, and I suppose I will
too.” Which of the following responses would be the most appropriate?
a. “Tell me more of what you’re feeling.”
b. “Are you thinking that you won’t recover from this illness?”
c. “You have a fine doctor. Everything will be all right soon.”
d. “Would you agree that this would be very unlikely?”
ANSWER: A
Rationale: When a client makes a comment about their death, it is best for the nurse to help the client express their
feelings. Asking a question that requires more than yes or no answers is unlikely to elicit how the client really feels
and offers the client no support. Cliché are not helpful and even changing the topic.
Reference: Psychiatric Nursing by Sheila Videbeck, p. 112
44. 1 week post MI, he suddenly becomes agitated, restless and diaphoretic. Pulse pressure drops to 20 mm Hg.
Assessment also reveals faint radial and apical pulses that weaken significantly on inspiration. This patient is most
likely experiencing:
a. Mitral valve rupture
b. Pulmonary embolus
c. Cardiogenic shock
d. Cardiac tamponade
ANSWER: D
Rationale: The signs and symptoms of cardiac tamponade may begin with the patient reporting shortness of breath,
chest tightness and dizziness. The nurse may observe that the patient is becoming progressively more restless. The
cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous
pressure and distant heart sound.
Cardiogenic shock is manifested by tissue hypoperfusion and overall shock state. Pulmonary embolus is characterized
by sudden dyspnea and petecheal rash on the chest.
45. Lifestyle modification for Manny Packman during convalescence and healing period is necessary for faster
recovery. Which of the following statements of the client needs further teaching?
a. “I should avoid any activity that may cause me fatigue.”
b. “I should see to it that I will take a bath with warm water.”
c. “I should lose weight and stop smoking.”
d. “I should keep myself active by engaging into strenuous sports.”
ANSWER: D
Rationale: It is required for clients with M.I. to modify his lifestyle to prevent future attacks or further complications.
Clients should avoid those activities that may cause chest pain, extreme dyspnea, or undue fatigue but not all activity
should be withheld. Clients must avoid extreme heat and cold or walking against strong wind, therefore option B is
correct. Losing weight and smoking cessation is necessary to eliminate modifiable risk factors. Option D is incorrect,
clients should avoid activities that may cause stress and fatigue. Enrolling to workshops and too many activities might
put strain to heart.
46. Alteplase recombinant (TPA), a thrombolytic enzyme, is administered during the first 6 hours following onset of MI
to:
a. Control chest pain
c. Control the dysrhythmia associated with MI
b. Reduce coronary artery vasospasm
d. Revascularize the blocked coronary artery
ANSWER: D
Rationale: Alteplase recombinant (TPA), a thrombolytic agent administered IV, lyses the clot blocking the coronary
artery. The drug is most effective when administered within the first 6 hours following onset of myocardial infarction.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p. 1003, 2212
47. It is the second day of hospitalization of a client following a Myocardial Infarction. Which of the following is an
expected outcome?
a. Able to perform self-care activities without pain
c. Can recognize the risk factors of Myocardial Infarction
b. Severe chest pain
d. Can participate in cardiac rehabilitation walking program
ANSWER: A
By the 2nd day of hospitalization after suffering a Myocardial Infarction, clients are able to perform care without chest
pain.
48. A 64 year old male client, with a long history of cardiovascular problem including hypertension and angina, is to
be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Mimi should inform the
client that the primary purpose of the procedure is:
a. To determine the existence of CHD
c. To obtain the heart chambers pressure
b. To visualize the disease process in the coronary arteries
d. To measure oxygen content of different heart chambers
ANSWER: B
The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the
coronary arteries.
49. Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical
incision during postoperative period. Which of the following pharmaceutical agents should Nurse Mitch administer to
her?
a. Protamine Sulfate
b. Quinidine Sulfate
c. Vitamin C
d. Coumadin
ANSWER: A
Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery and is the
antidote for Heparin. Coumadin is warfarin and is used as anticoagulant, which will further cause bleeding if use.
Option C and D are unrelated options.
50. A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history
indicates that the infarction occurred ten hours ago. Which laboratory test result should the nurse expect this client to
exhibit?
a. Elevated LDH.
b. Elevated serum amylase.
c. Elevated CK-MB.
d. Elevated hematocrit.
ANSWER: C
The cardiac isoenzyme CK-MB (C) is the most sensitive and most reliable indicator of myocardial damage of all the
cardiac enzymes. It peaks within 12 to 20 hours after myocardial infarction (MI). (A) is a cardiac enzyme that peaks
around 48 hours after an MI. (B) is expected with acute pancreatitis. (D) would be expected in a client with a fluid
volume deficit, which is not a typical finding in MI.
SITUATION: Milagrosa, a female elderly client, is scheduled to undergo a mitral valve replacement for severe calcific
mitral stenosis and mitral regurgitation. Although the diagnosis was made during her childhood, she had been
asymptomatic until 4 years ago. Recently she noticed increased symptoms despite daily doses of digoxin and
furosemide.
51. During the initial interview of the client, you would most likely learn that the client’s childhood health history
included:
a. Chicken pox
b. Poliomyelitis
c. Rheumatic fever
d. Meningitis
ANSWER: C
Rationale: Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditic. Such
infectious diseases as chicken fox, poliomyelitis, and meningococcal meningitis are not associated mitral stenosis.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p. 917-918
52. Milagrosa undergoes a mitral valve replacement. Postoperatively, she develops multiple premature ventricular
contractions. The physician orders lidocaine hydrochloride infusion at 2 mg/min. The IV bag contains 2 g of lidocaine
in 500 ml of dextrose 5% in water. If the equipment used for administering the drug and solution indicates that 60
micro drops are equal to 1 ml, how many micro drops would provide 2 mg of lidocaine each minute?
a. 15
b. 30
c. 45
d. 60
ANSWER: B
Rationale: The solution to this problem is as follows:
2 grams=2000mg
2000mg: 500 ml:: 2mg: x ml
2000 x = 1000
X= 1000/2000 = 0.5 ml of solution/minute
0.5 ml x 60 (micro drops) = 30 micro drops/minutes
53. The physician orders pulmonary artery pressure monitoring including PCWP with a pulmonary catheter. The
purpose of this is to help assess the:
a. Degree of coronary stenosis
c. Pressure from fluid within the left ventricle
b. Blood pressure within the right ventricle
d. Oxygen and carbon dioxide pressure in the blood
ANSWER: C
Rationale: The pulmonary artery pressure is used o assess the heart’s ability to receive and pump blood. Pulmonary
capillary wedge pressure (PCWP) reflects the left ventricular and diastolic pressure and guides the physician in
determining fluid management for clients. Degree of coronary artery stenosis is assessed during the cardiac
catheterization.
54. As she recovers, the client asks the nurse to adjust the bed so that her knees will be supported in a flexed
position and she will not “slide down” in bed. You should explain to the patient that the position requested is
contraindicated, primarily because:
a. It places her feet in a dropped position
c. It causes stagnation of blood in her legs and feet
b. It causes her knees to freeze
d. It places pressure on the nerves under her knees
ANSWER: C
Rationale: Every effort should be made to prevent stagnation of blood in the lower extremities during the postoperative period.
Having the knees flexed by using a gatched bed or by placing pillow under the knees in the popliteal
area promotes stagnation of blood and is contraindicated. If the client wants someone support on the knees while
lying on her back or while in Fowler’s position, a small roll or small pillow maybe place under the lower thigh just
above the knees. This replacement prevents interference in the circulation in the legs.
55. After Milagrosa experiences some initial excitation, the nurse would judge that she is demonstrating a typical toxic
reaction to lidocaine hydrochloride when she complains of:
a. Palpitations
b. Tinnitus
c. Urinary frequency
d. Lethargy
ANSWER: B
Rationale: The desired effect of lidocaine hydrochloride is to depress automaticity in the His-purkinje fibers stimulation
threshold in the ventricles, thereby decreasing ectopic ventricular beats. Common adverse effect of lidocaine include
dizziness, tinnitus, blurred vision, tremors, numbness, and tingling of extremities, excess perspiration, hypotension,
convulsions, and finally coma may occur. Cardiac effects include slowed conduction and cardiac arrest.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p. 784-785,2601
SITUATION: An industrial health nurse at a large clinic printing plant finds a male employee’s blood pressure to be
elevated on two occasions one month apart and refers him to his private physician. The employee is about 25 pounds
overweight and smokes a pack of cigarettes daily for over 20 years.
56. During nursing assessment, the client says, “I don’t really know why I’m here; I feel fine and haven’t had any
symptoms.” The nurse would recognize the importance of explaining to the client that symptoms of hypertension
a. Are seldom present
c. Occur only with malignant hypertension
b. Signify a high risk of stroke
d. Appear after irreversible kidney damage has occurred
ANSWER: A
Rationale: Most people with hypertension are completely asymptomatic and may continue to be so even with
dangerous elevation with blood pressure. Therefore, the presence or absence of symptoms is not accurate of reflection
of person’s status. Symptoms are not directly related to the status of the kidney. The severity of HPN, rather than the
presence of/absence of symptoms determine the risk of complications such as stroke.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p. 986,1022-1023
57. The industrial health nurse monitor the client’s BP as he begins therapy of methyldopa (Aldomet) and
hydrochlorothiazide (hydroDIURIL). The nurse would know that the client must be monitored carefully during the first
days of therapy because methyldopa frequently causes:
a. Drowsiness
c. Nausea and facial flushing, tremors and incoordination
b. Inability to concentrate
d. Hyperexcitability and aggression
ANSWER: A
Rationale: Methyldopa commonly produces drowsiness and inability to concentrate during the first days of therapy or
whenever the dosage is adjusted. These effects can be extremely dangerous who drives or operate machineries and
must be closely monitored for.
58. The nurse teaches the client about his dietary restrictions, a low calorie, and low fat, low sodium diet. Which of
the following menu selections would best meet his needs?
a. Mixed green salad with blue cheese dressing crackers and cold cuts
b. Ham sandwich on rye bread and an orange
c. Baked chicken and apple and slice of white bread
d. Hotdogs, baked beans and celery and carrot sticks
ANSWER: C
Rationale: Processed and cured meat products such as cold cuts, ham, and hotdogs are high in both fat and sodium
and should be avoided on a low-calorie, low-fat, and low-salt diet. Dietary restrictions of all types are complex and
difficult to implement with clients who are basically asymptomatic.
59. The client’s job involves working in a warm, dry room, frequently bending and crouching to check the underside of
a high-speed press, and wearing eye guard. Given this information, which side effect of hydrochlorothiazide
(hydroDIURIL) should the nurse monitor?
a. Muscle aches
b. Thirst
c. Lethargy
d. Postural hypotension
ANSWER: D
Rationale: Possible dizziness from postural hypotension when rising from a crouched or bent position increases the
client’s risk of being injured by the equipment. The nurse should assess the client’s Bp in all 3 positions (sitting, lying,
and standing) at all routine visits. The other adverse effects listed could also cause complications in the work
environment, but are not as potentially as dangerous as postural hypotension.
60. The client asks whether he should begin an exercise program. When teaching him about appropriate exercise, the
nurse should emphasize which of the following instructions:
a. Avoid acute exercise; it will increase the heart’s workload to a dangerous level
b. Follow exercise session with soaks or steam baths to prevent muscle cramping
c. Perform isometric exercise to reduce the heart’s workload and improve blood flow
d. Practice muscle pumping exercises for the legs when standing for a prolong period
ANSWER: D
Rationale: A regular exercise program will be prescribed for the client to aid rate control and improve cardiac fitness.
The program initiated slowly to avoid heart damage. Isometric exercises increase muscle tone but do not improve
aerobic fitness. Postural hypotension is an ongoing problem that requires muscle pump exercises for standing. Steam
baths should be avoided because they can induce hypotensive fainting and injury.
61. The client realizes the importance of quitting smoking, and the nurse develops a plan to help him achieve his
goal. Which of the following nursing interventions should be the initial step in this plan?
a. Review the negative effects of smoking on the body.
b. Discuss the effects passive smoking on environmental pollution.
c. Establish the client’s daily smoking pattern.
d. Explain how smoking worsens high blood pressure.
ANSWER: C
Rationale: A plan to reduce or stop smoking begins with establishing the client’s personal daily smoking pattern and
activities associated with smoking. It is important that the client understands the associated health risk, but this
knowledge has not been shown to successfully help the client to change his smoking behavior.
SITUATION: Mario, a 60-year-old hospitalized client, had experienced an acute myocardial infarction (MI) three days
earlier. He was in a stable condition on a telemetry unit when he suddenly developed ventricular fibrillation, swiftly
followed by cardiac arrest. Following verification that the client had arrested, CPR was started immediately. You and
the other staff quickly responded to the emergency code and arrived at the client’s bedside with the crash cart.
62. Which of the following may predispose an individual to ventricular fibrillation based from the situation?
a. Severe myocardial damage
b. Electrolyte imbalances
c. Hypothermia
d. Hypoxia
ANSWER: A
Rationale: Ventricular fibrillation is a lethal dysrhythmia that usually results from all of the choices above but if you’ll
look back on the situation, the client had MI that leads to severe myocardial damage. Damage in the myocardium
results to damage in the nodal pathways also which is responsible in the transmission of the electrical impulse.
Disturbance in transmission of the electrical impulse will cause dysrhythmia.
Reference: Medical-Surgical by Joyce Black, 8th edition, p. 1467
63. During the CPR, the xyphoid process at the lower end of the sternum should not be deeply compressed when
performing external cardiac compression, due to the danger of lacerating the victim’s:
a. Liver
b. Lung
c. Stomach
d. diaphragm
ANSWER: A
Rationale: Because of the anatomical position of the liver, one must be careful not to break or fractured because it
may puncture the liver. Diaphragm and stomach is located lower or far from the xyphoid process.
64. When performing external chest compression on your patient during CPR, you will depress the sternum by:
a. ½” to 1”
b. 1” to 1 ½”
c. 1 ½” to 2”
d. 2” to 2 ½”
ANSWER: C
Rationale: An adult sternum must be depressed 1 ½” to 2” with each compression to ensure adequate heart
compression.
65. During rescue breathing, if the chest wall fails to rise with each inflation, the most likely reason is that the:
a. Airway is not clear
c. Inflations are being given at too rapid rate
b. Victim is beyond resuscitation
d. Rescuer is using inadequate force for cardiac massage
ANSWER: A
Rationale: If the airway is not clear, it is impossible to inflate the lungs during rescue breathing. A common sign of
airway obstruction is failure of the victim’s chest wall to rise with each inflation.
66. You have given defibrillation to your client knowing that the purpose of it in the treatment of cardiac arrest is:
a. To treat tachydysrhythmias
c. To synchronize with the client’s ECG
b. To terminate a tachydysrhythmias
d. To depolarize myocardial cell
ANSWER: D
Rationale: Defibrillation and cardioversion are used to treat tachydysrhythmias. Defibrillation acts by depolarizing the
myocardial cell immediately and it is unsynchronized unlike cardioversion. Option A is both the purpose of
defibrillation and cardioversion but the exact purpose of defibrillation based on the situation is to deliver a flow of
current to myocardium that cease to pump. Option B is the purpose of cardioversion and is done synchronous with the
client’s ECG.
SITUATION: Nar Ding is a 45-year-old businessman. Lately he has experienced frequent episodes of chest pain that
are relieved by rest. He visited at the out-patient clinic because of his concern that it might be a serious problem. The
doctor advises him to undergo a series of diagnostic procedures both invasive and non-invasive.
67. The physician ordered him for a treadmill stress test. Prior to the procedure, you obtain his baseline BP, PR and
rhythm strip. Mr. Nar Ding asks you why he needs to have this test. You answered him back knowingly that the test
has the following advantages except:
a. Client is not susceptible to infection because it is a non-invasive procedure.
b. It helps to determine the cause of the pain.
c. It can validate the effectiveness of antianginal or antiarrythmic medications.
d. It can identify the size, shape and motion of the cardiac status.
ANSWER: D
Rationale: All of the following options are correct except for option D because it is echocardiography.
68. Prior to Mr. Nar Ding treadmill stress test, what instructions should you not give to him?
a. Fast for 4 hours before the test
c. Wear a comfortable shirt and sneaker
b. Avoid stimulants, such as tobacco and caffeine
d. Continue to take beta-blockers
ANSWER: D
Rationale: The above instructions, A, B, and C are correct choices. The physician may instruct the client not to take
cardiac medication, such as beta-blocker before the test because it might alter the result of the test.
69. After the test, you instructed Mr. Nar Ding to:
a. Rest for a time
b. Avoid stimulants
c. Avoid extreme temperature changes
d. Do all of the above
ANSWER: A
Rationale: The client is instructed to take a rest for 10-15 minutes and once stable, he can return to his usual activity.
Option A and C are instruction in preparation to ECG stress testing.
70. Proper care of CVP insertion is a must because this is directly inserted to the blood stream. What nursing
intervention is not needed to prevent infection?
a. Dressing must be checked and kept dry at all times.
b. Use sterile technique in changing the dressing of the catheter.
c. Dressing must be air occlusive.
d. Observe the dressing for any discharge.
ANSWER: D
Rationale: A, B and C are correct answers that can prevent infection. Option D is part of nursing intervention but it
cannot prevent infection because it is assessment.
SITUATION: A 69-year-old female client has a history of congestive heart failure (CHF). Her physician recently
increased her daily digoxin (Lanoxin) and furosemide (Lasix) doses as her condition was deteriorating. Ten days ago,
the client stopped taking all her medications, which she blamed for her frequent headaches. She is now admitted to
the emergency department with CHF complicated by pulmonary edema. She is edematous and cyanotic, in acute
respiratory distress, extremely anxious, and complaining of nausea.
71. The client receives morphine sulfate IV soon after admission. When evaluating the client’s response to the
medication, the nurse should assess its effect on her?
a. Nausea
b. Crackles
c. Cyanosis
d. Anxiety
ANSWER: D
Rationale: Morphine sulfate is given to help alleviate the anxiety, common I clients suffering from acute pulmonary
edema and associated distress. The drug does not affect nausea, crackles, or cyanosis.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p. 283, 965
72. In which of the following positions should the nurse place the client?
a. Semi-sitting (low Fowler’s position)
c. Sitting nearly upright (high Fowler’s position)
b. Lying on her right side (Sims’ position)
d. Lying on her back with her head lowered (Trendelenburg’s position)
ANSWER: C
Rationale: Sitting nearly upright in bed with the feet and legs resting on the mattress decreases venous return to the
heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion.
73. The major goal of therapy for this client would be to:
a. Increase cardiac output.
c. Decrease peripheral edema.
b. Improve respiratory status.
d. Enhance comfort.
ANSWER: A
Rationale: Increasing cardiac output is the main goal of therapy for the client with congestive heart failure (CHF) or
pulmonary edema. Pulmonary edema is an acute emergency requiring immediate intervention. In the client with CHF
or pulmonary edema, improve respiratory status will occur when CO is improved. Peripheral edema is not typically
associated with pulmonary edema. Comfort will be improved when CO increase to a acceptable level.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p.952, 957
74. Which of the following would be a priority nursing diagnosis for the client with CHF and pulmonary edema?
a. High risk for infection related to stasis of secretions in alveoli.
b. Impaired skin integrity related to edema and pressure.
c. Activity intolerance related to imbalance between oxygen supply and demand.
d. Constipation related to immobility.
ANSWER: C
Rationale: Activity intolerance is a primary problem for clients with CHF and pulmonary edema. Clients frequently
complain of the dyspnea and fatigue.
75. This client requires careful skin care, primarily because an edematous client is prone to develop:
a. Itchy skin
b. Decubitus ulcers
c. Electrolyte imbalance
d. Distention of weakened veins
ANSWER: B
Rationale: Edematous areas are subject to decubitus ulcers because of interference with the proper blood supply to
the skin and underlying issues. The primary cause of Decubitus ulcer is unrelieved pressure over an area, which
results in poor oxygenation of cells.
SITUATION: The human heart, through rhythmic contraction, provides the pressure necessary to propel blood
through the body. Blood flow is essential to deliver nutrients to the tissues of the body and to transport metabolic
wastes for removal.
76. Mrs. Gomez, a 78 year old client, is admitted with a diagnosis of mild chronic heart failure. The nurse expects to
hear this sound when listening to client’s lungs:
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs
ANSWER: B
Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar
spaces and causes crackling sounds at the end of inspiration.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p.950-951
77. Which of the following is considered as a sign of digitalis toxicity that a nurse should teach a client?
a. Increased appetite
c. Skin rash over the chest and back
b. Elevated blood pressure
d. Visual disturbances such as seeing yellow spot
Answer: D
Seeing yellow spots and colored vision are common symptoms of digitalis toxicity. Other options are not related to
digitalis toxicity.
78. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to
help:
a. Retard rapid drug absorption
c. Prevent sleep disturbances during the night
b. Excrete excessive fluids accumulated at night
d. Prevention of electrolyte imbalance
Answer: C
When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently
at night.
79. What would be the primary goal of therapy for a client with pulmonary edema and heart failure?
a. Enhance comfort
c. Improve respiratory status
b. Increase cardiac output
d. Peripheral edema decreased
ANSWER: B
The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output.
Pulmonary edema is an acute medical emergency requiring immediate intervention.
80. A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and
vomiting, and is complaining of headache. Her pulse rate is 43 beats per minute. Which question is a priority for the
nurse to ask this client or her family on admission?
a. “Does the client have her own teeth or dentures?"
c. “Does the client takes nitroglycerin?"
b. Does the client takes aspirin and if so, how much?"
d. “Does the client takes digitalis?"
ANSWER: D
Elderly persons are particularly susceptible to digitalis intoxication (D) which manifests itself in such symptoms as
anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Although it is important to obtain a complete medication
history (B and C), the symptoms described are classic for digitalis toxicity, and assessment of this problem should be
made promptly. (A) is irrelevant.
81. The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in
electrical conduction in the ventricles?
a. T wave of 0.16 second.
c. QT interval of 0.34 second.
b. PR interval of 0.18 second.
d. QRS interval of 0.14 second.
ANSWER: D
The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS (D) indicates an electrical anomaly in the
ventricles. The T wave is normally 0.16 seconds (A). The PR interval range is 0.12 to 0.20 second (B). The QT interval
should be 0.31 to 0.38 second (C).
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p.808, 825-827
82. The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two
years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital
protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for
the nurse to implement?
a. Ask the client what he means by "heart trouble."
c. Notify surgery that the ECG is over two years old.
b. Call for an ECG to be performed immediately.
d. Notify the client's surgeon immediately.
ANSWER: B
Clients over the age of 40 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to
surgery, generally 24 hours to two weeks before. (B) should be implemented to ensure that the client's current
cardiovascular status is stable. Additional data might be valuable (A), but since time is limited, the priority is to obtain
the needed ECG. Documentation of vital signs is important, but does not replace the need for the ECG (C). The
surgeon only needs to be notified if the ECG cannot be completed, or if there is a significant problem (D).
83. A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In
determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which
medication is most likely the cause of the bradycardia?
a. propanolol (Inderal).
b. captopril (Capoten).
c. furosemide (Lasix).
d. dobutamine (Dobutrex).
ANSWER: A
Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither
(B), an ACE inhibitor, nor (C), a loop diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac
stimulant, which would increase the heart rate.
84. Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment
protocol?
a. Diuretic therapy.
b. Pacemaker implantation.
c. Anticoagulation therapy.
d. Cardiac catheterization.
ANSWER: C
The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy (C)
which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood
pooling in the fibrillating atria. (A, B, and D) are not indicated.
85. Francis who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse
explains that morphine:
a. Decrease anxiety and restlessness
c. Dilates coronary blood vessels
b. Prevents shock and relieves pain
d. Helps prevent fibrillation of the heart
ANSWER: B
Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction; it also
decreases apprehension and prevents cardiogenic shock.
86. During the first several hours after a cardiac catheterization, it would be most essential for Nurse Mimi to:
a. Elevate client’s bed at 45°
b. Instruct the client to cough and deep breathe every 2 hours
c. Frequently monitor client’s apical pulse and blood pressure
d. Monitor client’s temperature every hour
ANSWER: C
Blood pressure is monitored to detect hypotension which may indicate shock or haemorrhage. Apical pulse is taken to
detect dysrhythmias related to cardiac irritability.
87. A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse Patricia consults the physician about
withholding which regularly scheduled medication on the day before the surgery?
a. Potassium Chloride
b. Warfarin Sodium
c. Furosemide
d. Docusate
ANSWER: B
Rationale: In preoperative period, the nurse should consult with the physician about withholding Warfarin Sodium to
avoid occurrence of hemorrhage.
88. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial
infarction. Which of the following is the most essential nursing action?
a. Monitoring urine output frequently.
c. Obtaining serum potassium levels daily.
b. Monitoring blood pressure every 4 hours.
d. Gather an infusion pump.
ANSWER: D
Administration of Intravenous nitroglycerin infusion requires pump for accurate control of medication.
89. A client has been hospitalized with heart failure. He is receiving digoxin (Lanoxin) and furosemide (Lasix)
intravenously. He tells the nurse that he hears a continuous ringing in his ears and he has never had this problem
before. What is the appropriate action for the nurse to take at this time?
a. Obtain a digoxin level to check for toxicity.
b. Note the observation in the chart and plan to reassess in 2 hours.
c. Ask the client if he has been taking aspirin in addition to his other medications.
d. Discontinue the furosemide and notify the physician.
ANSWER: D
The nurse should recognize the ringing in the ears, or tinnitus, as a sign of ototoxicity probably caused by the
furosemide. The appropriate action is for the nurse to stop the furosemide and notify the physician. If the drug is
stopped soon enough, permanent hearing loss can be avoided and the tinnitus should subside. The nurse should note
the observation in the chart but should not delay action. Tinnitus is not a symptom of digoxin (Lanoxin) toxicity.
Aspirin can cause tinnitus, but the nurse should first investigate the obvious cause of tinnitus, which in this case is the
furosemide.
90. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in a
client with mitral stenosis, teaching plan should include proper use of:
a. Dental floss
b. Electric toothbrush
c. Manual toothbrush
d. Irrigation device
ANSWER: C
The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to
enter and increasing the risk of endocarditis.
91. Among the following signs and symptoms, which would most likely be present in a client with mitral regurgitation?
a. Altered level of consciousness
c. Increase creatine phospholinase concentration
b. Exceptional Dyspnea
d. Chest pain
ANSWER: B
Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral
regurgitation.
92. A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse knows
that the teachings are effective if the client states that:
a. I can eat celery sticks and carrots
c. I can eat shredded wheat cereal
b. I can eat broiled scallops
d. I can eat spaghetti on rye bread
ANSWER: C
Wheat cereal has low sodium content. Celery, carrots, scallop and rye bread are foods that are high in sodium.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p.960,961.
93. A 7-year-old child is admitted to the hospital with a medical diagnosis of acute rheumatic fever. Which of the
following diversional activities is least desirable to the child during the acute phase of the illness?
a. Reading a book to the father.
c. Watching the television with a sibling.
b. Playing with a doll with the nurse.
d. Playing checkers with a roommate.
ANSWER: D
School-age children enjoy board games and are commonly intense about following rules. Their play can become
emotional. Adequate rest is of utmost importance during the acute stage of rheumatic fever. Therefore, playing a
game with another child probably would be too strenuous. Such diversional activities as reading a book, playing with a
doll, and watching television would be more satisfactory.
94. A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the
nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important
to teach the client?
a. Facial flushing.
b. Fever.
c. Pounding headache.
d. Feelings of dizziness.
ANSWER: D
Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output (D). (A
and C) will not occur as the result of pacemaker failure. (B) may be an indication of infection postoperatively, but is
not an indication of pacemaker failure.
Reference: Medical-Surgical by Brunner and Suddarth’s, 11th edition, p.851-852.
95. A child with heart disease starts on oral digoxin (Lanoxin). When preparing to administer the medication, which of
the following should the nurse do first?
a. Check the last serum electrolyte results for the child.
b. Verify the dosage with a pharmacist who is working that day.
c. Ask the mother if she is willing to administer the medication.
d. Teach the mother how to measure the child’s heart rate.
ANSWER: A
It is most important to know the child’s serum potassium level when administering digoxin. Digoxin increases
contractility of the heart and increases renal perfusion, resulting in a diuretic effect with increased loss of potassium
and sodium. Hypokalemia increases the risk of digoxin toxicity. Verifying the dosage is specified by facility policy and
varies among facilities. Although the child may take the medication better from the mother than from the nurse,
asking the mother to give the medication is not necessary. In addition, this would be done after the nurse has
checked the electrolyte levels. Teaching the parent how to measure the child’s heart rate can be done at any time, not
necessarily when preparing to give digoxin.
96. A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive
care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level
is 4.5mEq/L. What action should the nurse implement?
a. Notify the healthcare provider.
c. Document the finding as the only action.
b. Decrease the IV solution flow rate.
d. Administer potassium replacement as prescribed.
ANSWER: C
Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric
suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid
dysrhythmias. Documentation of the normal finding (C) is indicated at this time. Continued monitoring of the client
should anticipate the onset of complications that may require (A, B, and C).
97. The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most
important for the nurse to include?
a. Safety precautions during activity.
c. Maintain a fluid intake of 3 to 4 L per day.
b. Assess for changes in size of lymph nodes.
d. Administer narcotic analgesic around the clock.
ANSWER: C
Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so
maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to promote excretion of serum
calcium. Although the client is at risk for pathologic fractures due to diffuse osteoporosis, mobilization and weight
bearing (A) should be encouraged to promote bone reabsorption of circulating calcium, which can cause renal
complications. (B) is a component of ongoing assessment. Chronic pain management (D) should be included in the
plan of care, but prevention of complications related to hypercalcemia is most important.
98. The doctor has prescribed nitroglycerin to a client with angina. The patient also has closed-angle glaucoma. The
nurse contacts the physician to discuss the potential problem, which is:
a. Decrease intraocular pressure.
c. Hypotension.
b. Increase intraocular pressure.
d. Hypertension.
ANSWER: B
Nitroglycerin causes vasodilation, which results in increase intraocular pressure. The vasodilatory effects of the
medication can trigger an attack, causing pain and loss of vision. Hypotension is a common side effect of nitroglycerin,
which dilates the blood vessels but is not a concern in the client with glaucoma.
99. A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms
of a febrile, nonhemolytic reaction. What assessment finding is most important for the nurse to identify?
a. Increased anxiety since the transfusion began.
c. Complaints of feeling cold.
b. Drowsiness after receiving diphenhydramine (Benadryl).
d. Flushed skin and headache.
ANSWER: D
The most common type of reaction is a febrile, nonhemolytic blood transfusion reaction related to leukocyte
incompatibility, which causes chills, fever, headache, and flushing (D). Some clients are anxious (A) about the risk of
blood-borne infections, but the client's response to the release of inflammatory and immunologic mediators can
potentially lead to bronchospasm and circulatory collapse. Drowsiness (B) is an expected symptom after
diphenhydramine administration. (C) is often a sensory response to environmental temperatures or the administration
of cold blood.
100. The nurse administers packed red blood cells (PRBCs) to a client. Which of the following nursing actions is
appropriate?
a. Discontinue the I.V. catheter if a blood transfusion reaction occurs.
b. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle.
c. Flush PRBCs with 5% dextrose and 0.45% normal saline solution.
d. Stay with the client during the first 15 minutes of infusion.
ANSWER: D
Blood transfusion reaction occurs during the first 15 minutes or first 50 ml of the infusion. If any BT reaction occurred,
it is imperative that an established IV is kept to administer medication to prevent or treat cardiovascular collapse. 19
gauge needle must be used and peripherally inserted central catheter line is not recommended to avoid slow flow.
Dextrose and LRS may cause hemolysis. NSS is the only compatible solution.
MEDICAL SURGICAL NURSING
CARE OF CLIENTS WITH DEGENERATIVE DISORDERS
SITUATION: A degenerative disease, also called neurodegenerative disease, is a disease in which the function or
structure of the affected tissues or organs will progressively deteriorate over time
1. Nurse Daniel is assessing a client who has a history of Parkinson's disease for the past 6 years. What
symptoms should this client most likely exhibit?
a. Extreme muscular weakness, easy fatigability, and ptosis
b. Propulsive gait, masklike facial expression, and tremors
c. Loss of short-term memory, facial tics and grimaces, and constant writhing movements
d. Numbness of the extremities, loss of balance, and visual disturbances
ANSWER: B
Option B are common clinical features of Parkinsonism. Option A of myasthenia gravis, option C are symptoms of
chorea, and option D of multiple sclerosis.
Reference: Brunner and Suddarth’s Medical Surgical Nursing 12th edition Page 1986
2. Nurse Gener is completing an admission interview and assessment on a client with a history of Parkinson's
disease. Which question should provide information relevant to the client's plan of care?
a. Have you experienced any weakness especially in the afternoon?
c. Do you have leg or arm stiffness?
b. Have you traveled to Africa??
d. Do you have throbbing headaches?
ANSWER: C
Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor
activities. They may even experience being rooted to the spot and unable to move (option C). Parkinson's disease
does not cause option A. Option B is incorrect. Option D: PD does not cause throbbing headaches
3. The client is on an anti-Parkinsonian medication which acts by releasing dopamine from the neuronal storage
sites. This anti-viral agent used early in Parkinson’s disease treatment is:
a. Artane
b. Benadryl
c. Elavil
d. Symmetrel
ANSWER: D
Amantadine hydrochloride (symmetrel) is an antiviral agent used early in Parkinson’s treatment to reduce
rigidity, tremor and bradykinesia. It is thought to act by releasing dopamine from the neuronal storage sites.
Studies suggest also that it may have antiglutamatergic properties.
Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing.
10th Edition, Vol. 2. Page 1982
4. A patient with parkinson’s disease is disheartened because his drug levodopa is no longer controlling his
symptoms. The nurse’s response that would be the most helpful information is that:
a. Other drugs can be combined with levodopa to increase its effectiveness
b. The effect of this drug has an uneven course; symptoms will begin to subside again soon
c. The drug can be given in higher doses to control the symptoms
d. Surgery will produce permanent improvement
ANSWER: A
Levodopa is the most effective agent and the mainstay of treatment. The beneficial effects of levodopa are most
pronounced in the first few years of treatment. Benefits begin to wane and adverse effects become more severe
over time. The addition of other drugs to L-dopa may improve the conversion of L-dopa to dopamine. Palliative
surgical implementations all have had little effect on controlling the symptoms. Increasing the dose would put the
client at risk for developing adverse effects
5. A family member asks the nurse what could be done to help the patient with parkinson’s disease (PD). Nurse
Hannah accurately responds by stating that an appropriate intervention for a patient with Parkinson’s disease
would be to:
a. Advise patient to practice walking to marching music
c. Help client practice rapid eating
b. Prepare thin liquids for easy swallowing
d. Use laxative for constipation
ANSWER: A
A progressive program of daily exercise will increase muscle strength, improve coordination and dexterity, reduce
muscular rigidity and prevent contractures that occur when muscles are not used. The patient is taught to
concentrate on walking erect, to watch the horizon, and to use a wide-based gait (e.g walking with the feet
separated). A conscious effort is made to swing the arms, raise the feet while walking, and use a heel to toe
placement of the feet with long strides. The patient is advised to practice walking to marching music, because
this provides sensory reinforcement. Option B: Thin liquids should be avoided, because it can cause aspiration.
Instead, give the client a semisolid diet with thick liquids, because it is easier to swallow than solids. Option C:
Rapid eating is discouraged. Clients with PD may take some time to finish their food. Option D: Use of laxatives
should be avoided in controlling constipation. Encourage the patient to follow regular bowel routine, increase fluid
intake and eat food with moderate fiber content.
Reference: Brunner and Suddarth’s Medical Surgical Nursing 12th edition Page 1990-1991
6. Which nursing diagnosis takes highest priority for a client with parkinsonian crisis?
a. Imbalanced nutrition: Less than body requirements
c. Impaired urinary elimination
b. Ineffective airway clearance
d. Risk for injury
ANSWER: B
In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A
client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling
increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway
clearance takes highest priority. Although the other options also are appropriate, they aren't immediately lifethreatening.
Reference: Brunner and Suddarth’s Medical Surgical Nursing 12th edition Page
7. When assessing the client with Parkinson's disease, the nurse would anticipate which of the following signs and
symptoms?
a. Dry mouth
b. Aphasia
c. An exaggerated sense of euphoria
d. A stiff, mask-like facial expression
ANSWER: D
Typical signs of Parkinson's disease include drooling; a low-pitched, monotonous voice; and a stiff, mask-like
facial expression.
Option A - Dry mouth is not associated with Parkinson's disease.
Option B - Aphasia is not a symptom of Parkinson's disease.
Option C - An exaggerated sense of euphoria would not be typical; more likely, the client would exhibit
depression, probably related to the progressive nature of the disease and the client's difficulties dealing with it.
10th Edition, Vol. 2. Page 1980-1981
8. A client has been placed on levodopa to treat his Parkinson's disease. Which of the following is a common side
effect of levodopa that the nurse should include in the client's teaching plan?
a. Pancytopenia
b. Peptic ulcer
c. Postural hypotension
d. Weight loss
ANSWER: C
Postural hypotension resulting in lightheadedness, dizziness, and fainting is a common side effect of levodopa.
Clients should be taught to change positions slowly and dangle the legs before getting out of bed.
Option A - Levodopa does not commonly cause pancytopenia.
Option B - Levodopa does not commonly cause peptic ulcer formation.
Option D - Levodopa does not commonly cause weight loss.
Reference: Hayes, E. R. & Kee, J. L (2003) Pharmacology: A Nursing Process Approach. 4th Edition. Page 356
9. A patient who has been taking bromocriptine (Parlodel) and benztropine (Cogentin) for Parkinson’s disease is
experiencing a worsening of symptoms. The nurse will anticipate that patient may benefit from:
a. Complete drug withdrawal for a few weeks.
c. Withdrawal of anticholinergic therapy.
b. Use of levodopa (L-dopa)-carbidopa (Sinemet).
d. Increasing the dose of bromocriptine.
Answer: B
After the dopamine receptor agonists begin to fail to relieve symptoms, the addition of L-dopa with carbidopa can
be added to the regimen. Complete drug withdrawal will result in worsening of symptoms. Anticholinergic therapy
should be continued to help maintain the balance between the actions of dopamine and acetylcholine. Increasing
the dose of bromocriptine will increase the risk for toxic effects.
Reference: Lewis Medical Surgical Nursing 7th ed page 1551
10. When teaching a client about levodopa-carbidopa (Sinemet) therapy for Parkinson's disease, the nurse should
include which teaching?
a. "Report any eye spasms."
c. "Stop taking this drug when your symptoms disappear."
b. "Take this medication at bedtime."
d. "Be aware that your urine may appear darker than usual."
ANSWER: D
Levodopa-carbidopa, used to replace insufficient dopamine in clients with Parkinson's disease, may cause
harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision is an expected
adverse effect. The client should take levodopa-carbidopa shortly before meals, not at bedtime, and must
continue to take it for life.
11. The nurse is teaching a client about the nutritional modifications he will need to make in his diet because he
is taking levodopa for his Parkinson's disease. Which of the following dietary changes will he need to make?
a. Increase amount of potassium in the diet
c. Decrease the amount of protein in the diet
b. Increase the amount of sodium in the diet
d. Implement a 2-g sodium-restricted diet.
ANSWER: C
High protein meals can impair absorption and reduce the effectiveness of the medication.
There is no need to increase the amount of potassium and sodium in the diet.
There is no need to implement a sodium-restricted diet.
Reference: Springhouse Nurse’s Drug Guide (2005) 6th ed. Lippincott Williams and Wilkins
12. Parkinson’s disease, a progressive neurologic disorder is characterized by:
a. Bradykinesia
b. Tremors
c. Muscle rigidity
d. All of the above
ANSWER: D
Parkinson’s disease is a slowly progressing neurologic involvement disorder that eventually leads to disability. It
is the fourth most common degenerative disease. The three cardinal signs of this disease are tremor, rigidity and
bradykinesia.
13. The client is on an anti-Parkinsonian medication which acts by releasing dopamine from the neuronal storage
sites. This anti-viral agent used early in Parkinson’s treatment is:
a. Artane
b. Benadryl
c. Elavil
d. Symmetrel
ANSWER: D
Amantadine hydrochloride (symmetrel) is an antiviral agent used early in Parkinson’s treatment to reduce
rigidity, tremor and bradykinesia. It is thought to act by releasing dopamine from the neuronal storage sites.
Studies suggest also that it may have antiglutamatergic properties.
14. When assessing the client with Parkinson's disease, the nurse would anticipate which of the following signs
and symptoms?
a. A stiff, mask-like facial expression
c. Dry mouth
b. An exaggerated sense of euphoria
d. Aphasia
ANSWER: A
Typical signs of Parkinson's disease include drooling; a low-pitched, monotonous voice; and a stiff, mask-like
facial expression.
Option C - Dry mouth is not associated with Parkinson's disease.
Option D - Aphasia is not a symptom of Parkinson's disease.
Option B - An exaggerated sense of euphoria would not be typical; more likely, the client would exhibit
depression, probably related to the progressive nature of the disease and the client's difficulties dealing with it.
15. The nurse is teaching a client about the nutritional modifications he will need to make in his diet because he
is taking levodopa for his Parkinson's disease. Which of the following dietary changes will he need to make?
a. Increase amount of potassium in the diet
c. Decrease the amount of protein in the diet
b. Increase the amount of sodium in the diet
d. Implement a 2-g sodium-restricted diet.
ANSWER: C
High protein meals can impair absorption and reduce the effectiveness of the medication.
There is no need to increase the amount of potassium and sodium in the diet.
There is no need to implement a sodium-restricted diet.
Reference: Springhouse Nurse’s Drug Guide (2005) 6th ed. Lippincott Williams and Wilkins
16. The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a patient
with Parkinson’s disease. To assist the patient to ambulate safely, the nurse should:
a. Allow the patient to ambulate only with assistance.
b. Instruct the patient to rock from side to side to initiate leg movement.
c. Have the patient take small steps in a straight line directly in front of the feet.
d. Teach the patient to keep the feet in contact with the floor and slide them forward.
ANSWER: B
Rocking the body from side to side stimulates balance and improves mobility. The patient should initially be
ambulated with assistance but might not require continual assistance with ambulation. The patient should
maintain a wide base of support to help with balance. The patient should lift the feet and avoid a shuffling gait.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition page 1554
17. Which statement indicates that the family has a good understanding of the changes in motor movement
associated with Parkinson’s disease?
a. “I can never tell what he’s thinking. He hides behind a frozen face.”
b. “She drools all the time just so I can’t take her out anywhere.”
c. “I think this disease makes him nervous. He perspires all the time.”
d. “I can offer smaller meals with bite-size portions and a liquid supplement.”
ANSWER: D
A masklike face, drooling, and excess perspiration are common in clients with Parkinson’s disease. Changes in
facial expression or a masklike facies in a Parkinson’s disease client can be misinterpreted. Because chewing and
swallowing can be problematic, small frequent meals and a supplement are better for meeting the client’s
nutritional needs.
Reference: Ignatavicius. Medical Surgical Nursing 6th edition
18. A priority for Nurse Jose teaching a patient and his family about dietary practices related to Parkinson's
disease is to address the risk of:
a. Fluid overload and drooling
c. Choking and diarrhea
b. Aspiration and anorexia
d. Dysphagia and constipation
ANSWER: D
The patient may have severe problems with constipation. Among the factors causing constipation are weakness
of the muscles used in defecation, lack of exercise, inadequate fluid intake, and decreased autonomic nervous
system activity. The medications used for the treatment of the disease also inhibit normal intestinal secretions. A
regular bowel routine may be established by encouraging the patient to follow a regular time pattern, consciously
increase fluid intake, and eat foods with moderate fiber content. Laxatives should be avoided. Psyllium, for
example, decreases constipation but carries the risk for bowel obstruction. A raised toilet seat is useful because
the patient has difficulty in moving from a standing to a sitting position. Swallowing disorders can be due to poor
head control, tongue tremor, hesitancy in initiating swallowing, difficulty in shaping food into a bolus, and
disturbances in pharyngeal motility. To offset these problems, the patient should sit in an upright position during
mealtime. A semisolid diet with thick liquids is easier to swallow than solids; thin liquids should be avoided. It is
helpful for patients to think through the swallowing sequence. The patient is taught to place the food on the
tongue, close the lips and teeth, lift the tongue up and then back, and swallow. The patient is encouraged to
chew first on one side of the mouth and then on the other. To control the buildup of saliva, the patient is
reminded to hold the head upright and make a conscious effort to swallow. Massaging the facial and neck
muscles before meals may be beneficial.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical and Surgical Nursing 10th edition, Page 1984.
19. For which side effects in the client with Parkinson’s disease who has been taking a combination carbidopalevodopa drug
(Sinemet) for 3 years will the nurse monitor?
a. Constipation
b. Abnormal movements
c. Malabsorption syndrome
d. Increased resting heart rate
ANSWER: B
Following 3 or more years of treatment, about one third of clients develop involuntary movements that are
thought to be treatment-related.
Reference: Ignatavicius. Medical Surgical Nursing 6th edition page
20. Which teaching intervention is most appropriate for the client with Parkinson’s disease?
a. Universal precautions
b. Seizure precautions
c. Fall precautions
d. Isometric exercises
ANSWER: C
Rigidity in movement increases the risk of falls.
21. A patient with Parkinson’s disease has decreased tongue mobility and an inability to move the facial muscles.
The nurse recognizes that these impairments commonly contribute to the nursing diagnosis of:
a. Disuse syndrome related to loss of muscle control.
b. Self-care deficit related to bradykinesia and rigidity.
c. Impaired verbal communication related to difficulty articulating.
d. Impaired oral mucous membranes related to inability to swallow.
Answer: C
The inability to use the tongue and facial muscles decreases the patient’s ability to socialize or communicate
needs. Disuse syndrome is not an appropriate nursing diagnosis because the patient is continuing to use the
muscles as much as possible. There is no indication in the stem that the patient has a self-care deficit,
bradykinesia, or rigidity. The oral mucous membranes will continue to be moist and should not be impaired by
the patient’s difficulty swallowing.
22. The best time for Nurse Jose to assess for tremor in a patient with Parkinson's disease is when the patient is:
a. Resting
c. Preparing his meal tray to eat
b. Brushing his teeth
d. Participating in occupational therapy
ANSWER: A
Although symptoms are variable, a slow, unilateral, resting tremor is present in 70% of patients at the time of
diagnosis. Resting tremor characteristically disappears with purposeful movement but is evident when the
extremities are motionless. The tremor may present as a rhythmic, slow turning motion (pronation–supination) of
the forearm and the hand and a motion of the thumb against the fingers as if rolling a pill. Tremor is present
while the patient is at rest; it increases when the patient is walking, concentrating, or feeling anxious.
23. As Nurse Jose assesses Nicanor, who has been taking levodopa and carbidopa (Sinemet) for 7 years, which of
the following common side effects of the drug should be noted by him?
a. Pruritus
b. Dyskinesia
c. Lactose intolerance
d. Diarrhea
ANSWER: B
Levodopa (Dopar, Larodopa) is the most effective agent and the mainstay of treatment. Because levodopa is
thought to precipitate oxidation, which further damages the substantia nigra and eventually speeds disease
progression, physicians delay prescribing the medication or increasing the dosage for as long as possible.
Levodopa is converted to dopamine in the basal ganglia, producing symptom relief. The beneficial effects of
levodopa are most pronounced in the first few years of treatment. Benefits begin to wane and adverse effects
become more severe over time. Confusion, hallucinations, depression, and sleep alterations are associated with
prolonged use. Levodopa is usually given in combination with carbidopa (Sinemet), an amino acid decarboxylase
inhibitor that helps to maximize the beneficial effects of levodopa by preventing its breakdown outside the brain
and reducing its adverse effects. Within 5 to 10 years, most patients develop a response to the medication
characterized by dyskinesia (abnormal involuntary movements), including facial grimacing, rhythmic jerking
movements of the hands, head bobbing, chewing and smacking movements, and involuntary movements of the
trunk and extremities. The patient may experience an on–off syndrome in which sudden periods of near
immobility (“off effect”) are followed by a sudden return of effectiveness (“on effect”). Various adjunctive
therapies are used to minimize dyskinesias.
24. Gelai, a patient with Parkinson's disease, is experiencing difficulty when swallowing. Which of the following is
most appropriate to reduce the risk of aspiration?
a. Solid food with thin liquids
c. Semisolid food with thick liquids
b. Pureed food with water
d. Thin liquids only
ANSWER: C
Swallowing disorders can be due to poor head control, tongue tremor, hesitancy in initiating swallowing, difficulty
in shaping food into a bolus, and disturbances in pharyngeal motility. To offset these problems, the patient
should sit in an upright position during mealtime. A semisolid diet with thick liquids is easier to swallow than
solids; thin liquids should be avoided. It is helpful for patients to think through the swallowing sequence. The
patient is taught to place the food on the tongue, close the lips and teeth, lift the tongue up and then back, and
swallow. The patient is encouraged to chew first on one side of the mouth and then on the other. To control the
buildup of saliva, the patient is reminded to hold the head upright and make a conscious effort to swallow.
Massaging the facial and neck muscles before meals may be beneficial.
25. A priority for Nurse Jose teaching a patient and his family about dietary practices related to Parkinson's
disease is to address the risk of:
a. Fluid overload and drooling
c. Choking and diarrhea
b. Aspiration and anorexia
d. Dysphagia and constipation
ANSWER: D
The patient may have severe problems with constipation. Among the factors causing constipation are weakness
of the muscles used in defecation, lack of exercise, inadequate fluid intake, and decreased autonomic nervous
system activity. The medications used for the treatment of the disease also inhibit normal intestinal secretions. A
regular bowel routine may be established by encouraging the patient to follow a regular time pattern, consciously
increase fluid intake, and eat foods with moderate fiber content. Laxatives should be avoided. Psyllium, for
example, decreases constipation but carries the risk for bowel obstruction. A raised toilet seat is useful because
the patient has difficulty in moving from a standing to a sitting position. Swallowing disorders can be due to poor
head control, tongue tremor, hesitancy in initiating swallowing, difficulty in shaping food into a bolus, and
disturbances in pharyngeal motility. To offset these problems, the patient should sit in an upright position during
mealtime. A semisolid diet with thick liquids is easier to swallow than solids; thin liquids should be avoided. It is
helpful for patients to think through the swallowing sequence. The patient is taught to place the food on the
tongue, close the lips and teeth, lift the tongue up and then back, and swallow. The patient is encouraged to
chew first on one side of the mouth and then on the other. To control the buildup of saliva, the patient is
reminded to hold the head upright and make a conscious effort to swallow. Massaging the facial and neck
muscles before meals may be beneficial.
SITUATION: Nurse Marina is assigned to patients with Myasthenia Gravis, which is an auto-immune disease that
presents as muscular weakness and fatigue. Patients whom she handled in the Ward of Kalikasan Hospital have
varying queries regarding their condition.
26. As Nurse Marina is doing her routine ward rounds, a 28-year old female asks her about the most appropriate
schedule for her care? Being a competent nurse, she knows that it is best to do the care:
a. All at one time, to provide a longer rest period
c. In the morning, with frequent rest periods
b. Before meals, to stimulate her appetite
d. Before bedtime, to promote rest
ANSWER: C
The patient is also taught srategies to conserve energy. To do this, the nurse helps the patient identify the best
times for rest periods throughout the day. The patient is encouraged to schedule activities to coincide with peak
energy and strength levels. Since the patient has higher energy in the morning, most of the activities should be
scheduled during this time, of course, with frequent rest periods.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition, Page 1958.
27. Nurse Marina is caring for a recently diagnosed patient with myasthenia gravis. Which additional test can be
completed to help diagnose the disorder?
a. Passive range of motion of the neck
c. Application of painful stimuli to legs
B) Check of deep tendon reflexes
d. MRI
ANSWER: D
The thymus gland, which is a site of acetylcholine receptor antibody production, is enlarged in myasthenia gravis.
MRI demonstrates this enlargement in 90% of cases.
28. The physician has ordered a Tensilon test to rule out myasthenia gravis. Nurse Marina knows that which of
the following medications would be used to counteract the side effects of the Tensilon?
a. Baclofen (Lioresal)
b. Atropine (AtroPen)
c. Epinephrine (Adrenalin)
d. Narcan (Naloxone)
ANSWER: B
Atropine 0.4 mg should be available to control the side effects of Tensilon, which includes bradycardia, sweating,
and cramping. Baclofen, Epinephrine, and Narcan are not used to counteract this medication.
29. In evaluating laboratory data, the nurse correlates which results with the diagnosis of myasthenia gravis?
a. Elevated serum calcium level
c. Decreased complete blood count
b. Decreased thyroid hormone level
d. Elevated acetylcholine receptor antibody levels
ANSWER: D
Testing for acetylcholine receptor (AChR) antibodies is important, because 80% to 90% of clients with the
disease have elevated AChR antibody levels.
Reference: Ignatavicius. Medical Surgical Nursing 6th ed. Page 1017
30. The client suspected to have myasthenia gravis is about to undergo the Tensilon (edrophonium chloride) test.
Which drug will the nurse have available for complications of this test?
a. Epinephrine
b. Atropine sulfate
c. Diphenhydramine
d. Neostigmine bromide
ANSWER: B
Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate,
causing cardiac fibrillation or arrest. Atropine sulfate is an anticholinergic drug.
Reference: Ignatavicius. Medical Surgical Nursing 6th ed. Page
31. When assessing a patient with myasthenia gravis, the nurse would be correct in questioning the patient
regarding which of the following clinical manifestations?
a. Weakness associated with fatigue
c. Projectile vomiting without nausea
b. Headache that worsens at night
d. Diaphoresis
ANSWER: A
The initial manifestation of myasthenia gravis usually involves the ocular muscles. Diplopia (double vision) and
ptosis (drooping of the eyelids) are common. However, the majority of patients also experience weakness of the
muscles of the face and throat (bulbar symptoms) and generalized weakness. Weakness of the facial muscles will
result in a bland facial expression. Laryngeal involvement produces dysphonia (voice impairment) and increases
the patient’s risk for choking and aspiration. Generalized weakness affects all the extremities and the intercostal
muscles, resulting in decreasing vital capacity and respiratory failure. Myasthenia gravis is purely a motor
disorder with no effect on sensation or coordination.
Reference: Brunner. Medical Surgical Nursing 11th edition, Page 2285
32. Which of the following statements, if made by a patient who has myasthenia gravis would indicate correct
understanding of necessary adaptations to the disease?
a. “My activity tolerance will increase during the day.”
c. “I will avoid extremes in temperature.”
b. “My diet would include high-protein foods.”
d. I should avoid people who have colds.”
ANSWER: D
An expected outcome for the patient with myasthenia gravis is avoidance of situations that may predispose to
colds and infections and exacerbate symptoms. Option A: Activity tolerance is decreased due to fatigue. Option
B: Semi- solid foods may be easier to eat than solids or liquids. High- protein foods are not required, but a
balanced diet should be encouraged. Option C: Temperature is not identified as a problem for the patient with
myasthenia gravis.
33. The nurse is administering neostigmine (Prostigmin) P.O. to a client with myasthenia gravis. Which nursing
intervention should the nurse implement?
a. Give the medication with food or milk
b. Warn the client that he'll experience mouth dryness
c. Administer the medication anytime
d. Dosage is decreased gradually as prescribed until maximal benefits are obtained
ANSWER: A
Tell the client to take the medication with food or milk to prevent GI distress.
Option B - Adverse effects of the medication include increased salivation, bradycardia, sweating, nausea, and
abdominal cramps.
Option C - Neostigmine must be given at scheduled times to ensure consistent blood levels.
Option D – Dosage is increased (not decreased) gradually to until maximal benefits (improved strength and less
fatigue) are obtained.
Springhouse Nurse’s Drug Guide (2005) 6th ed. Lippincott Williams and Wilkins
34. The nurse must plan care for a 28-year-old female hospitalized with a diagnosis of myasthenia gravis. Which
of the following times would be most appropriate for procedures and care to be completed?
a. All at one time, to provide a longer rest period
c. In the morning, with frequent rest periods
b. Before meals, to stimulate her appetite
d. Before bedtime, to promote rest
ANSWER: C
Myasthenia gravis is characterized by extreme muscle weakness, which generally worsens after effort/activity
and improves with rest.
Option A - Procedures should be spaced to allow for rest in between.
Option B - Procedures should be avoided before meals, or the client may be too exhausted to eat.
Option D - Procedures should be avoided at bedtime.
35. In a client with myasthenia gravis, priority nursing care is directed to conserve the client's energy and:
a. Ensure a safe environment
c. Provide psychological support and reassurance
b. Maintain respiratory function
d. Promote comfort and relieve pain
ANSWER: B
In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and
swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure.
Option A - Providing a safe environment is a secondary goal.
Option C - Providing emotional support is a secondary goal.
Option D - Pain is not a problem with myasthenia gravis.
36. A nurse provided instructions to a client with a diagnosis of myasthenia gravis about home care measures.
Which client statement indicates the need for further instruction?
a. “I can change the time of my medication on the mornings when I feel strong.”
b. “I will reset each afternoon after my walk.”
c. “If I get abdominal cramps and diarrhea, I should call my doctor.”
d. “I should cough and deep breathe many times during the day.”
ANSWER: A
The client with myasthenia gravis and his or her family should be taught information about the disease and its
treatment. They should be aware of the adverse reactions of anticholinesterase medications and corticosteroids
and should be taught that timing of anticholinesterate medication is critical. It is important to instruct the cline to
administer the medication on time to maintain a chemical balance at the neuromuscular junction. If it is not given
time, the client may become too weak to even swallow.
Options B, C and D - include all of the necessary information that the client requires to understand how to
maintain health with this neurological degenerative disease.
37. After teaching a client about myasthenia gravis, the nurse would judge that the client has formed a realistic
concept of her condition when she says that by taking her medication and pacing her activities:
a. She will live longer, but ultimately the disease will cause her death.
b. Her symptoms will be controlled and eventually the disease will be cured.
c. She should be able to control the disease and enjoy a healthy lifestyle.
d. Her fatigue will be relieved, but she should expect occasional periods of muscle weakness.
ANSWER: C
With a well-managed regimen, a client with myasthenia gravis should be able to control symptoms, maintain a
normal lifestyle, and achieve a normal life expectancy.
Option A - Myasthenia gravis can be controlled and need not be a fatal disease.
Option B - Myasthenia gravis can be controlled, not cured.
Option D - Episodes of increased muscle weakness should not occur if treatment is well-managed.
38. Which of the following statements is incorrect about myasthenia gravis?
a. Women are affected more frequently than men
b. It is an autoimmune disorder by varying degrees of weakness of voluntary muscles
c. The initial manifestation generally involve the leg muscles
d. It is a purely motor disorder with no effect on sensation or coordination
ANSWER: C
Options a, b and d are all correct statements about myasthenia gravis. The initial manifestation usually involves
the ocular muscles. Diplopia and ptosis are common. It is in Guillian-barre’ that weakness begins in the leg
muscles and progresses upward.
39. The nurse is teaching a client recently diagnosed with myasthenia gravis about the disease. Which of the
following is true about myasthenia gravis?
a. Genetic dysfunction
c. There is involuntary muscle weakness that escalates with rest
b. Men are affected more frequently
d. The initial manifestation usually involves the ocular muscles
ANSWER: D
Myasthenia gravis is an autoimmune (not genetic) disorder affecting the myoneural junctions, affects more
women than men, there is voluntary muscle weakness that escalates with activity and the initial manifestation
usually involves the ocular muscles (e.g. diplopia and ptosis are common).
40. A test that is used to diagnose myasthenia gravis (MG) is ordered by the physician. Because the test involves
an injection of a drug that makes muscle strength improve for about five minutes the nurse realizes that this test
likely is:
a. Analysis of antiacetylcholine receptor antibodies
c. A computed tomography (CT) scan of the legs
b. A Tensilon test
d. A nerve stimulation study
Answer: B
The Tensilon test produces a five-minute increase in muscle strength. A computed tomography (CT) scan of the
legs is not indicated for this client. The nerve stimulation study and the analysis of antiacetylcholine receptor
antibodies are tests that can be done to help diagnose MG, but do not require a drug injection.
Reference: Lemone-Burke. Medical Surgical Nursing 4th edition
41. The nurse is assessing a client with myasthenia gravis. Which of the following is characteristic of this disease?
a. Great improvement occurs in muscle strength with physical therapy
b. No improvement occurs in muscle strength with any treatment
c. Visual problems may be an early symptom
d. Routine exercise provides an improvement in muscle strength
ANSWER: C
The manifestations of myasthenia gravis correspond to the muscles involved. Initially, the eye muscles are
affected and the client experiences either diplopia (unilateral or bilateral double vision) or ptosis (drooping of the
eyelid). Although treatments such as glucocorticoid and immunosuppressant therapy may result in an increase in
muscle strength, exercise tends to fatigue muscles, while rest will improve function.
42. The physician has ordered Edrophonium chloride test to rule out myasthenia gravis. Nurse Hannah knows
that which of the following medications would be used to counteract the side effects of the Edrophonium chloride?
b. Atropine (AtroPen)
c. Epinephrine (Adrenalin)
d. Narcan (Naloxone)
ANSWER: B
Atropine 0.4 mg should be available to control the side effects of Tensilon (Edrophonium chloride), which includes
bradycardia, sweating, and cramping. Baclofen, Epinephrine, and Narcan are not used to counteract this
medication.
43. The nurse recognizes which pathophysiologic change in the client diagnosed with myasthenia gravis?
a. The myelin sheath is destroyed by the immune system.
b. Myasthenia gravis is caused by antibodies to dopamine receptors.
c. There is evidence of central and peripheral nervous system disease.
d. There is a defect in the transmission of nerve impulses to the skeletal muscles.
ANSWER: D
The major pathologic defect in myasthenia gravis is that nerve impulses are not transmitted to skeletal muscles
at the neuromuscular junction.
Reference: Ignatavicius. Medical Surgical Nursing 6th edition page 1016
44. Which physical assessment finding does the nurse expect to observe in a client with myasthenia gravis?
a. Difficulty or inability to perform the six cardinal positions of gaze
c. Absent deep tendon reflexes
b. Lateralization to the affected side during the Weber test
d. Impaired stereognosis
ANSWER: A
The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the
extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the
cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed.
45. When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises
the patient to:
a. Anticipate the need for weekly plasmapheresis treatments.
b. Protect the extremities from injury due to poor sensory perception.
c. Do frequent weight-bearing exercise to prevent muscle atrophy.
d. Perform necessary physically demanding activities in the morning.
Answer: D
Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then.
Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for in situations where
corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy
does not occur because muscles are used during part of the day.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition page 1555-1557
46. The client with myasthenia gravis develops a sudden increase in weakness, accompanied by an increase in
heart rate from 76 to 100 beats/min and an increase in blood pressure from 122/72 to 152/82 mm Hg. Which
conclusion will the nurse reach from these findings?
a. The client is experiencing a mixed crisis.
c. The client is experiencing cholinergic crisis.
b. The client is experiencing myasthenic crisis.
d. The client’s condition is responding to treatment.
ANSWER: B
The client in myasthenic crisis experiences a rise in heart rate and blood pressure as well as an increase in
muscle weakness.
47. The client with myasthenia gravis in cholinergic crisis has been treated with atropine. Which nursing
intervention is a priority for this client?
a. Suctioning the client
c. Measuring urinary output ever 30 minutes
b. Turning and positioning the client
d. Administering anticholinergic drugs on time
ANSWER: A
Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a
ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility
of pneumonia are most important.
Reference: Ignatavicius. Medical Surgical Nursing 6th ed. Page
48. The patient with myasthenia gravis is to undergo plasmapheresis. Which of the following statements is
appropriate for a nurse to make when explaining the purpose of plasmapheresis?
a. “Excess red blood cells will be removed from our circulation.”
b. “Cells in your blood that attack your own tissue will be removed.”
c. “You will receive blood transfusions from a healthy donor.”
d. “Foreign organisms will be filtered from your blood.”
ANSWER: B
Plasmapheresis is a technique that permits selected removal of the patient’s plasma and plasma components.
Plasma exchange a temporary reduction is the titer of circulating antibodies. Myasthenia gravis is considered an
autoimmune disease in which antibodies directed against acetylcholine receptors impair neuromuscular
transmission. Plasmapheresis is does not involve receiving blood transfusions. The purpose of plasmapheresis for
the patient is the reduction of circulating antibodies, rather than red blood cells.
49. Nurse Isabelle must develop a plan of care for a 32-year-old female admitted with a possible diagnosis of
myasthenia gravis. Which of the following teachings should not be included?
a. Avoid emotional stress
b. Keep frequently used items in each floor, if the patient lives in a 2-storey home
c. Edrophonium chloride test is the first line of therapy for MG
d. Stress the importance of taking the medication on-time
ANSWER: C
Pyridostigmine bromide (Mestinon), an anticholinesterase medication, is the first line of therapy. It provides
symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of
available acetylcholine at the neuromuscular junction. Edrophonium chloride test is used to diagnose MG. Other
options are correct.
50. The most accurate in confirming the diagnosis of myasthenia gravis is:
a. Single fiber electromyography
b. Tensilon test
c. MRI
d. CT scan
ANSWER: A
A single fiber electromyography (EMG) detects a delay or failure of neuromuscular transmission. The exam itself
takes 1-3 hours to perform. A single fiber EMG is considered the best test, being positive in 95-99% of MG
patients. A Tensilon test is positive in many patients who have MG, but may actually be negative in 20-30%
patients with MG diagnosed by other methods.
Reference:
Brunner
and
Suddarth’s
Medical
Surgical
Nursing
12th
edition
Page
1964
51. A client is admitted to the hospital for diagnostic testing for possible myasthenia gravis. The nurse prepares
for intravenous administration of edrophonium chloride (Tensilon). What is the expected outcome for this client
following administration of this pharmacologic agent?
a. Progressive difficulty with swallowing
c. Improvement in generalized fatigue
b. Decreased respiratory effort
d. Decreased muscle weakness
ANSWER: D
Administration of edrophonium chloride (Tensilon), a cholinergic agent, will temporarily reduce muscle weakness,
the most common complaint of newly-diagnosed clients with myasthenia gravis. This medication is used to
diagnose myasthenia gravis due to its short duration of action. This drug would temporarily reverse (options A
and B), not increase these symptoms. Option C is not a typical complaint of clients with myasthenia gravis, but
weakness of specific muscles, especially after prolonged use, is a common symptom.
Reference:
Brunner
and
Suddarth’s
Medical
Surgical
Nursing
12th
edition
Page
1964
52. The healthcare provider prescribes pyridostigmine bromide (Mestinon) tablets for a client with myasthenia
gravis (MG). What instruction should the nurse provide this client?
a. Increase activity in the afternoon when the medication is most effective.
b. Take the medication 30 to 45 minutes before eating.
c. Use a PRN dose for increasing muscular weakness or fasciculations.
d. Give the client a dietary guide that describes low-protein foods.
ANSWER: B
Mestinon, an acetylcholinesterase inhibitor, increases the amount of neuromuscular transmitters to promote
muscular strength and swallowing, so the client should take the medication at least 30 minutes before meals.
Option A: Activity should be scheduled in the mornings and after drug administration when therapeutic responses
peak. Option C may reflect either under-dosing or over-dosing and requires differential diagnosis by the
healthcare provider. Option D: A low-protein diet is not part of the treatment protocol for MG.
Reference: Amy Karch Focus on Nursing Pharmacology 3rd edition
53. What is the priority nursing diagnosis during myasthenic crisis?
a. Fatigue
c. Ineffective breathing pattern
b. Deficient knowledge
d. Imbalanced Nutrition, less than body requirements
ANSWER: C
Respiratory distress and varying degrees of Dysphagia, dysarthria, eyelid ptosis, diplopia, and prominent muscle
weakness are symptoms of myasthenic crisis. Providing ventilator assistance takes precedence in the immediate
management of the patient with myasthenic crisis. Ongoing assessment for respiratory failure is essential.
54. A client with myasthenia gravis verbalizes complaints of feeling much weaker than normal. The physician
plans to implement a diagnosis test to determine if the client is experiencing myasthenic crisis. The physician
administer edrophonium (Tensilon). Which of the following would indicate that the client is experiencing a
myasthenic crisis?
a. Increasing weakness
c. An increase in muscle spasm
b. A temporary improvement in the condition
d. No change in the condition
ANSWER: A
A myasthenic crisis occurs when weakness affects the muscles that control breathing. This can create a medical
emergency requiring a respirator to help the person breathe or measures to prevent a person from taking in, or
aspirating, too much air into their lungs. In individuals whose respiratory muscles are weak, infection, fever, a
reaction to medication, or emotional stress can trigger a crisis.
55. A client with myasthenia gravis becomes increasingly weaker. The physician prepares to identify whether the
client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease
(myasthenic crisis). An injection of edrophonium (tensilon) is administered. Which of the following would indicate
that the client is in cholinergic crisis?
a. An improvement of weakness
c. No change in the condition
b. A temporary worsening of the weakness
d. Complaints of muscle spasm
ANSWER: C
Cholinergic crisis results from an excess of cholinesterase inhibitors (ie, neostigmine, pyridostigmine,
physostigmine) and resembles organophosphate poisoning. In this case, excessive ACh stimulation of striated
muscle at nicotinic junctions produces flaccid muscle paralysis that is clinically indistinguishable from weakness
due to MG. Injection of edrophonium (tensilon), also an cholinesterase inhibitor, would not change the client’s
condition.
SITUATION: Multiple Sclerosis is an immune-mediated disease of the CNS which can affect every facet of daily
living of patients. Karyle, 40 year-old businesswoman, is diagnosed with this disorder by her physician during her
consultation in Unciano Medical Center.
56. What basic information will Nurse Cassandra provide Karyle, who is recently diagnosed with multiple sclerosis
(MS)?
a. It is a degenerative disease of the nervous system.
c. It has an acute onset.
b. It usually occurs more frequently in men.
d. It is caused by a bacterial infection.
ANSWER: A
Degenerative neurologic disorders pose a great challenge to the client, the family, and the caregiver. By their
very nature, these disorders cause progressive decline in neurologic function. Multiple sclerosis is an immunemediated, progressive
demyelinating disease of the CNS. Demyelination refers to the destruction of myelin, the
fatty and protein material that surrounds certain nerve fibers in the brain and spinal cord; it results in impaired
transmission of nerve impulses. It occurs at any
Age but typically manifests in young adults between the ages of 20 and 40 years; it affects women more
frequently than men.
57. Which of the following nursing interventions would be included in the care plan for Karyle?
a. Encourage the patient to void 1 hour after drinking.
b. Order a low-residue diet.
c. Provide total assistance as needed with all activities of daily living.
d. Instruct the patient on daily muscle stretching.
ANSWER: D
The signs and symptoms of MS are varied and multiple, reflecting the location of the lesion (plaque) or
combination of lesions. The primary symptoms most commonly reported are fatigue, depression, weakness,
numbness, difficulty in coordination, loss of balance, and pain. Visual disturbances may also occur due to lesions
in the optic nerves or their connections may include blurring of vision, diplopia, scotoma and total blindness.
Spasticity of the extremities and loss of the abdominal reflexes result from involvement of the main motor
pathways of the spinal cord. Since muscle spasticity is common to patents with MS, daily exercise fro muscle
stretching are prescribed to minimize joint contractures. Special attention is given to the hamstrings,
gastrocnemius muscles, hip adductors, biceps, and wrist and finger flexors. A stretch-hold-relax routine is helpful
for relaxing and treating muscle spasticity. Swimming and stationary bicycling are useful, and progressive weight
bearing can relieve muscle spasticity in te legs. The patient should not be hurried in these activities, because
these often increases spasticity. A voiding schedule time is set up (every 1.5-2 hours) initially, with gradual
lengthening of interval. The patient is instructed to drink a measured amount of fluid every 2 hours and then
attempt to void 30 minutes after drinking. MS patients may suffer from constipation and fecal impaction,
adequate fluids and dietary fibers are recommended. Patients should not be provided with total assistance by the
nurse. Independence and self care should be enforced.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition, Page 2281-2283.
58. When teaching Karyle on how to reduce fatigue, Nurse Dong should tell her to:
a. Take a hot bath.
c. Increase the dose of muscle relaxants.
b. Rest in an air-conditioned room.
d. Avoid naps during the day.
ANSWER: B
The patient with MS is encouraged to work and exercise to a point just short of fatigue. Very strenous physical
exercise is not advisable, because it raises the body temperature and may aggrevate the symptoms. The patient
is advised to take short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation
of symptoms. Depression, heat, anemia, deconditioning, and medication may contribute to fatigue. Avoiding hot
temperatures, effective treatment of depression and anemia, and physical therapy may control fatigue. Resting in
air-conditioned rooms may prevent heat that may lead to its exacerbation. Taking a hot bath, increasing the dose
of muscle relaxants and avoiding naps would not reduce fatigue.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition, Page 2279, 2281.
59. Karlye has complaints of weakness, incoordination, dizziness, and loss of balance. As Nurse Dong is doing his
assessment, which of the following signs and symptoms revealed during the history and physical assessment is
typical of MS?
a. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes
b. Flexor spasm, clonus, and negative Babinski's reflex
c. Blurred vision, intention tremor, and urinary hesitancy
d. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
ANSWER: C
Symptoms of MS includes fatigue, depression, weakness ,numbnesss, difficulty in coordination, loss of balance,
and pain. Visual disturbances due to lesions in the optic nerves or their connections include blurring of vision,
diplopia, patchy blindness (scotoma), and total blindness. Spasticity of the extremities and loss of abdominal
reflexes result from involvement of the main motor pathways of the spinal cord. Disruption of the sensory axon
may produce sensory dysfunction (paresthesias, pain). Involvment of the cerebellum or basal ganglia can
produce ataxia (impaired coordination of movements) and tremor. Loss of control connections between the cortex
and the basal ganglia may occur and cause lability and euphoria. Bladder, bowel, and sexual dysfunctions are
common. Bladder symptoms involves inability to store urine, inability to empty the bladder completely or a
mixture of both types. There is no decrease or absent deep tendon reflex, negative Babinski reflex, or
hyperactive abdominal reflexes in patients with MS.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition, Pages 2278-2279.
60. A 37-year-old teacher is hospitalized with complaints of weakness, incoordination, dizziness, and loss of
balance. The diagnosis is multiple sclerosis (MS). Which of the following signs and symptoms, discovered during
the history and physical assessment, is typical of MS?
a. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes
b. Flexor spasm, clonus, and negative Babinski's reflex
c. Blurred vision, intention tremor, and urinary hesitancy
d. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
ANSWER: C
Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when
performing an activity). Nerve damage can cause urinary hesitancy.
Option A - In MS, deep tendon reflexes are increased or hyperactive.
Option B - A positive Babinski's reflex is found in MS.
Option D - Abdominal reflexes are absent with MS.
61.The client with multiple sclerosis sometimes exhibits signs or symptoms of emotional distress. The nurse
should be aware that clients with multiple sclerosis are most likely to exhibit:
a. Mood disorders
b. Thought disorders
c. Psychosomatic illnesses
d. Drug dependency problems
ANSWER: A
Clients with multiple sclerosis often experience psychological disturbances that are best described as mood
disorders. Suicide as the cause of death occurs 7.5 times more frequently among persons diagnosed with MS
than among the age-matched general population. Emotional instability is typical.
Option B - Thought disorders are not typical of clients with multiple sclerosis unless they present independently.
Option C - Psychosomatic illnesses are not typical of clients with multiple sclerosis unless they present
independently.
Option D - Drug dependency is not typical of clients with multiple sclerosis unless it presents independently.
62. A client with multiple sclerosis has been prescribed baclofen. The client asks the nurse about the action of the
drug. Which of the following is an accurate response regarding this drug's action?
a. "It is an antibiotic that will help treat your urinary tract infection."
b. "Baclofen will decrease your fatigue and help increase your energy levels."
c. "Taking this drug will help decrease the visual problems you have been having."
d. "Baclofen will help relieve the muscle spasms that you have been experiencing."
ANSWER: D
Baclofen is a central-acting skeletal muscle relaxant that is used to decrease the spasticity experienced by
individuals with multiple sclerosis.
Option A - Baclofen is not an antibiotic.
Option B - Baclofen does not decrease fatigue. Common side effects are fatigue and weakness.
Option C - Baclofen does not improve vision.
63. When developing a plan of home care for the client with multiple sclerosis, the nurse should teach the client
about which of the following complications most likely to occur?
a. Ascites
b. Contractures
c. Fluid volume overload
d. Myocardial infarction
ANSWER: B
Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections.
Nursing care should be directed toward the goal of preventing these complications.
Option A - Ascites is not associated with multiple sclerosis.
Option C - Fluid volume overload is not associated with multiple sclerosis.
Option D - Myocardial infarction is not associated with multiple sclerosis.
64. The client with multiple sclerosis tells the nurse that after the physical therapy she is too tired to take a bath.
Which of the following is the priority nursing diagnosis at this time?
a. Activity intolerance due to generalized weakness
b. Fatigue related to disease state
c. Impaired physical mobility related to neuromuscular impairment
d. Self-care deficit related to fatigue and neuromuscular weakness
ANSWER: D
At this time, based on the client’s statement, the priority is self-care deficit related to fatigue after a physical
therapy. The other three nursing diagnoses are appropriate to a client with MS but are not related to the client’s
statement.
65. Multiple sclerosis is a disease described as:
a. An immune-mediated progressive demyelinating disease of the CNS
b. An autoimmune disorder affecting the myoneural junction
c. A condition with paroxysm of pain in the area innervated by CN V
d. A condition due to the unilateral inflammation of the seventh cranial nerve
ANSWER: A
Multiple sclerosis is a disease described as An immune-mediated progressive demyelinating disease of the CNS.
Myasthenia gravis - An autoimmune disorder affecting the myoneural junction
Trigeminal neuralgia - A condition with paroxysm of pain in the area innervated by CN V
Bell’s Palsy - A condition due to the unilateral inflammation of the seventh cranial nerve
66. The nurse assesses for which clinical manifestation in the client with MS of the relapsing-remitting type?
a. Absence of periods of remission
c. Absence of active disease manifestations
b. Attacks becoming increasingly frequent
d. Gradual neurologic symptoms without remission
ANSWER: B
The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks.
67. Which clinical manifestations would serve to alert the nurse to the early onset of MS?
a. Hyperresponsive reflexes
b. Excessive somnolence
c. Nystagmus and ataxia
ANSWER: C
Early signs and symptoms of MS include changes in motor skills, vision, and sensation.
d. Heat intolerance
68. A patient with multiple sclerosis (MS) has a nursing diagnosis of urinary retention related to sensorimotor
deficits. An appropriate nursing intervention for this problem is to:
a. Decrease fluid intake in the evening.
b. Teach the patient how to use the Credé method.
c. Suggest the use of incontinence briefs for nighttime use only.
d. Assist the patient to the commode every 2 hours during the day.
ANSWER: B
The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder
emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs
and frequent toileting will not improve bladder emptying.
69. A client presents with an acute exacerbation of multiple sclerosis. Which drug will the nurse be prepared to
administer?
c. Dantrolene sodium (Dantrium)
b. Interferon beta-1b (Betaseron)
d. Methylprednisolone (Medrol)
ANSWER: D
Methylprednisolone is the drug of choice for acute exacerbations of the disease.
Reference: Ignatavicius. Medical Surgical Nursing page
70. A 30-year-old nurse who works on a busy medical-surgical unit has been diagnosed with multiple sclerosis
(MS). The priority for this client is to:
a. Leave employment as a nurse due to the need for complete bed rest.
b. Continue to work as scheduled without making changes.
c. Work as hard as possible now because later, it may not be possible.
d. Negotiate a regular schedule of working 8-hour dayshifts and consider applying for nursing positions that are
less stressful and demanding.
ANSWER: D
Multiple sclerosis (MS) is progressive and will be negatively affected by working long hours and enduring stressful
shifts. It is important for this client to plan a schedule that is less demanding and move now to a work
environment that is less stressful for adapting to life with MS.
71. A client who has multiple sclerosis develops total urinary incontinence. What initial treatment should the
nurse tell the client to expect?
a. Anticholinergic medications
c. Intermittent self-catheterization of the urinary bladder
b. Indwelling catheter to a collection bag
d. Surgery to create a permanent ileal conduit
ANSWER: B
A blocked urethra or bladder weakness may prevent normal emptying. When no urine is retained in the bladder,
it is termed total incontinence. Treatment includes an indwelling catheter attached to a collection bag.
Reference: White. Foundations of Nursing 4th edition
72. Which factor frequently precipitates exacerbations of a client’s symptoms of multiple sclerosis?
a. Paresthesia
c. Exposure to bright lights
b. Blind spots or flashing “lights” in one or both eyes
d. Periods of emotional or physical stress
ANSWER: D
Multiple sclerosis (MS) can affect the myelin sheath of brain or spinal cord tissue, or both. Manifestations of MS
vary according to the area of demyelination; the disease is characterized by remission and exacerbation due to
periods of emotional or physical stress. Symptoms include motor difficulties (e.g., decreased muscle strength,
spasticity, paralysis), sensory issues (e.g., visual disturbances, numbness, paresthesia), and other disturbances
(e.g., mood changes, sexual dysfunction).
Reference: White. Foundations of Nursing 4th edition
73. A 36-year old female reports double vision, visual loss, muscular weakness, numbness of the hands, fatigue,
tremors, and incontinence. Based on this report, what does the nurse suspect?
a. Parkinson’s disease
c. Amyotrophic lateral sclerosis
b. Myasthenia gravis
d. Multiple sclerosis
ANSWER: D
These are symptoms of MS, which is more common in women ages 20-40.
74. Baclofen (Lioresal) is prescribed for a client with multiple sclerosis. The nurse monitors the client, knowing
that the primary therapeutic effect of this medication is which of the following?
a. Increased muscle tone
c. Decreased local pain and tenderness
b. Decreased muscle spasms
d. Increased range of motion
ANSWER: B
Baclofen is used for treating spasm of skeletal muscles, muscle clonus, rigidity, and pain caused by disorders
such as multiple sclerosis. It is also injected into the spinal cord (intrathecal) for management of severe
spasticity. Reference: Reference: Brunner and Suddarth’s Medical Surgical Nursing 12th edition Page 1959
75. A client with multiple sclerosis is receiving diazepam (Valium), a centrally acting skeletal muscle relaxant.
Which of the following, if noted during the assessment of the client would indicate that the client is experiencing a
side effect related to this medication?
a. Headache
b. Increased salivation
c. Urinary retention
d. Drowsiness
ANSWER: D
The most frequent side effects of diazepam are drowsiness, fatigue, and ataxia (loss of balance). Rarely,
diazepam causes a paradoxical reaction with excitability, muscle spasm, lack of sleep, and rage. Confusion,
depression, speech problems, and double vision are also rare side effects of diazepam.
Reference: Amy Karch. Focus on Nursing Pharmacology 3rd edition Page
76. Nurse Isabelle is assessing a patient with multiple sclerosis scheduled for MRI. Due to the pathophysiology of
this disease process, she expects the MRI to reveal which of the following findings?
a. Enlarged thymus gland
c. Presence of multiple plaques
b. Presence of abscess
d. Presence of a tumor
ANSWER: C
The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI. Option A: seen
in MG. Option B: Brain abscess. Option D: Brain tumor
Reference: Amy Karch. Focus on Nursing Pharmacology 3rd edition Page 1959
77. Which of the following nursing interventions would not be included in the care plan for a patient admitted
with MS?
a. Encourage the patient to void 30 minutes after drinking
b. Encourage the patient to exercise to a point just short of fatigue
c. Encourage cold shower instead of hot shower
d. Instruct the patient on daily muscle stretching
ANSWER: C
Extreme cold and heat exposure may increase spasticity and should be discouraged. Option A: The patient is
instructed to drink a measured amount of fluid every two hours and then attempt to void 30 minutes after
drinking, to enhance bladder control. Option B: The patient is encouraged to work and exercise to a point just
short of fatigue. Very strenuous physical exercise is not advisable, because it raises the body temperature and
may aggravate symptoms. Option D: Stretching are prescribed to minimize joints contractures.
78. Which of the following clinical presentation can the nurse find when reviewing the history of a patient with
Guillain-Barre’ syndrome?
a. Decreased cognition due to cranial nerve demyelination, ascending paralysis
b. Miller-fisher variant
c. Descending paralysis, areflexia
d. Autonomic dysfunction, spasticity and ascending paralysis
ANSWER: B
Although the classic clinical features include areflexia and ascending weakness, variation in presentation occurs.
There may be a sensory presentation, with progressive sensory symptoms; an atypical axonal destruction; or the
Miller-fisher variant, which includes paralysis of the ocular muscles, ataxia, and areflexia. GBS does not affect
cognitive function or LOC.
79. The nurse knows that plasmapheresis is being utilized in the treatment of the patient with Guillain-Barre'
syndrome for which of the following reasons?
a. Removal of anti-acetylcholine receptor antibodies
b. Reduction in the number of bacteria in the bloodstream
c. Decrease in antibodies attacking peripheral nerve myelin
d. Removal of potassium and fluid
ANSWER: C
Plamapheresis and IVIG are used to directly affect the peripheral nerve myelin antibody level. Both therapies
decrease circulating antibody levels and reduce the amount of time the patient is immobilized and dependent on
mechanical ventilation.
80. 5. A client is newly diagnosed with Alzheimer's disease. When planning the client's care, the nurse should
focus on:
a. Helping the client recognize physical limitations
c. Providing a safe, structured environment
b. Helping to reverse the disease
d. Preventing loss of cognitive functions
ANSWER: C
Preventing injury is an important goal of care for a client with Alzheimer's disease and can be achieved by
providing a safe, structured environment. Other care goals include establishing effective communication with the
client and family to help them adjust to the client's altered cognitive abilities, offering emotional support,
teaching the client and family about the disease, and encouraging the client to exercise to help maintain mobility.
Alzheimer's disease can't be reversed. Cognitive losses can't be prevented because Alzheimer's disease is an
insidious, degenerative dementia that eventually causes disorientation; severe deterioration of memory,
language, and motor ability; emotional lability; and physical and intellectual disability.
81. Nurse Hannah is caring for an elderly patient who exhibits signs of dementia. The most common cause of
dementia in an elderly patient is:
a. Delirium
b. Depression
c. Excessive drug use
d. Alzheimer's disease
ANSWER: D
The two most common types of dementia are alzheimer’s disease and vascular or multi-infarct dementia.
82. The definitive diagnosis for Alzheimer’s disease is:
a. Autopsy
b. CT scan
c. MRI
d. CSF analysis
ANSWER: A
A definitive diagnosis of AD can be made only at autopsy but an accurate clinical diagnosis can be made in about
90% of cases. The most important goal is to rule out other causes of dementia. CT, MRI and CSF analysis may all
refute or support a diagnosis of probable AD
83. The adult child of a patient who has dementia of the Alzheimer type tearfully tells a nurse, “I can’t take this
another day. Now I’m being accused of stealing my mother’s underwear.” Which of the following responses by
the nurse would be most therapeutic?
a. “This must be difficult time for you and your mother.”
b. “Don’t take it personally. Your mother doesn’t mean it.”
c. “Have you tried discussing this with your mother.”
d. “Ask your mother where the under wear was last seen.”
ANSWER: A
Families with members who have dementia are under tremendous stresses. A goal for these individuals is that
they will be able to verbalize unacceptable feelings in a supportive environment. This option encourages
verbalization. Option B: This response discourages verbalization by the individual. Option C: The patient with
dementia does not have the capacity to discuss the issues. Option D: The patient with dementia has a loss of
short-term memory and will not recall where the underwear was last seen. This response also does not allow the
individual to ventilate.
84. The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of
dementia in an elderly client is:
a. Delirium
b. Depression
c. Excessive drug use
d. Alzheimer's disease
ANSWER: D
Alzheimer's disease is the most common cause of dementia in the elderly. Approximately 10% of people over age
65 have Alzheimer's disease; about 50% of people over age 85 have the disease.
Option A - Delirium, or acute confusion, is caused by an underlying disease and isn't itself a cause of dementia.
Option B - Depression is common in the elderly but, in many cases, manifests itself in apathy, self-deprecation,
or inertia; not dementia.
Option C - Excessive drug use, commonly stemming from the client seeing multiple physicians who are unaware
of drugs that other physicians have prescribed, can cause dementia. Although it's a problem among the elderly, it
isn't as common as Alzheimer's disease.
85. A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms:
difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and
occasional incontinence. This client is in what stage of Alzheimer's disease?
a. I
b. II
c. III
d. IV
ANSWER: B
Stage II (out of III) is exhibited by the above listed symptoms as well as communication difficulties, motor
disturbances, forgetfulness, and psychosis. This stage lasts 2 to 10 years.
Option A - Stage I, which lasts 1 to 3 years, is characterized by memory loss, poor judgment and problemsolving, difficulty adapting to
new environments and challenges, and agitation or apathy.
Option C - Stage III is characterized by loss of all mental abilities and the ability to care for self. Although there
are different staging systems (one characterizes the disease as mild, moderate, and severe), none includes stage
IV.
86. To encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:
a. Stay with the client and encourage him to eat
c. Give the client privacy during meals
b. Help the client fill out his menu
d. Fill out the menu for the client
ANSWER: A
Staying with the client and encouraging him to feed himself will ensure adequate food intake.
Option B - A client with Alzheimer's disease can forget how to eat.
Option C and D - Allowing privacy during meals, filling out the menu, or helping the client to complete the menu
doesn't ensure adequate nutritional intake.
87. A 78-year-old Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place
him closer to the nurses' station because of his tendency to:
a. Forget to eat
b. Not change his position often
c. Exhibit acquiescent behavior
d. Wander
ANSWER: D
A client with Alzheimer's disease is at risk for injury because of his tendency to wander. Placing him closer to the
nurses' station makes it easier to monitor him and ensure his safety should he begin to wander.
Option A, B and C - Placing the client closer to the nurses' station won't help the client remember to eat, change
his position often, or change his behavior
88. A family member is caring for a client diagnosed with Alzheimer's disease. Which of the following is most
likely to cause the caregiver depression and role strain?
a. The caregiver had a close relationship with the client before diagnosis of the illness.
b. The caregiver has no formal support, such as a visiting nurse or day care worker.
c. The caregiver understands the full reality of the disease and its inevitable progression.
d. The caregiver feels unable to control the client and unable to cope with caregiving.
ANSWER: D
The caregiver who feels unable to control the client's behavior and unable to cope with the responsibility of
caregiving is at the greatest risk for depression and role strain.
Option A - A close relationship with the client who has Alzheimer's disease doesn't place the caregiver at greater
risk for role strain and depression.
Option B - Absence of formal support may cause role strain and depression, but the effect may be mitigated by
the caregiver's coping mechanisms and skills.
Option C - A deeper understanding of the disease is unlikely to increase role strain or depression.
89. An 89-year-old client is suffering from Alzheimer's-type dementia. Which intervention would be most useful in
managing his dementia?
a. Provide a safe environment.
c. Avoid the use of touch.
b. Provide a stimulating environment.
d. Use restraints whenever necessary.
ANSWER: A
Providing a safe environment ensures safety when a client has poor judgment, memory loss, and an unsteady
gait. (Priority: Safety)
Option B - Overactivity and noise can overstimulate a client with Alzheimer's-type dementia by causing agitation.
Option C - The use of nonverbal communication techniques, such as touch, conveys acceptance to the client and
can be comforting.
Option D - The use of restraints can increase a client's agitation.
90. A nurse is preparing for the admission of a client with a suspected Guillain-Barre syndrome. When the client
arrives at the nursing unit, the nurse reviews the physician’s documentation. The nurse expects to note
documentation of which hallmark clinical manifestation of this syndrome?
c. Abrupt onset of a fever and headache
b. Multifocal seizures
d. Development of progressive muscle weakness
ANSWER: D
A hallmark clinical manifestation of Guillain-Barre syndrome is progressive muscle weakness that develops
rapidly.
Option A - Cerebral function, level of consciousness, and pupillary responses are normal.
Option B - Seizures are not normally associated with this disorder.
Option C - The client does not have symptoms such as a fever or headache.
91. A nurse reviews the physician’s orders for a client with Guillain-Barre syndrome. Which order written by the
physician should the nurse question?
a. Vital signs assessed every 2 to 4 hours
c. Passive-range-of-motion (ROM) exercises
b. Clear liquid diet
d. Bilateral calf measurements
ANSWER: B
Clients with Guillain-Barre syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear
liquids than thick or semisolid foods.
Option A - Because clients with Guillain-Barre syndrome are at risk for hypotension or hypertension, bradycardia,
and respiratory depression, frequent monitoring of vital signs is required.
Option C and D - Passive ROM exercises can help prevent contractures, and assessing calf measurements can
help detect deep vein thrombosis, for which these clients are at risk.
92. A nurse is performing an assessment on a client with Guillain-Barre syndrome. The nurse determines that
which of the finding would be of greatest concern?
a. A blood pressure (BP) decrease from 106/60 mmHg to 98/58 Hg
b. Lung vital capacity of 10ml/kg
c. Difficulty articulating words
d. Paralysis progressing from the toes to the waist
ANSWER: B
Respiratory compromise is a major concern in clients with Guillain-Barre syndrome. Clients often are intubated
and mechanically ventilated when the vital capacity is less than 15 ml/kg.
Option A - Although orthostatic hypotension is a problem with these clients, the BP drop in Option A is less than
10 mmHg and is not significant.
Option C and D - are expected depending on the degree of paralysis that occurs.
93. Which of the following is a correct statement regarding amyotrophic lateral sclerosis?
a. The disease is genetic
c. MRI is the ultimate diagnostic test for this disease
b. It affects more women than men
d. There is no specific therapy for this disease
ANSWER: D
ALS is a disease of unknown cause (idiopathic) in which there is a loss of motor neurons in the anterior horns of
the spinal cord and nuclei of the lower brain stem. It affects more men than women, there is no clinical or
laboratory test specific to this disease and is diagnosed on the basis of signs and symptoms. There is also no
specific therapy for ALS. The main focus of medical and nursing management is to improve function, well-being
and quality of life.
94. A nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On
assessment, the nurse notes that the client is severely dysphagic. Which of the following would be an
inappropriate component of the care plan for this client?
a. Allow the client sufficient time to eat
c. Provide oral hygiene after each meal
b. Provide a full liquid diet for ease in swallowing.
d. Maintain a suction machine at the bedside.
ANSWER: B
A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. Semisoft foods are
easiest to swallow and require less chewing.
Option A - The client should be given a sufficient amount of time to eat.
Option C - Oral hygiene is necessary after each meal.
Option D - Suctioning should be available for clients who experience dysphagia and are at risk for aspiration.
95. Guillain Bare’ is an autoimmune attack of the peripheral nerve myelin. The major precipitating factor or
predisposing event that may lead to this syndrome is a/an:
a. Change in weather
b. Exposure to allergens
c. Infection
d. Poor nutrition
ANSWER: C
In majority of the cases, there is a predisposing event, most often a respiratory or gastrointestinal infection. The
antecedent event usually occur 2 weeks before the symptoms begin. Weakness begins in the legs and progresses
upward for about a month. Complete functional recovery may take two years.
96. The drug of choice for a client with Alzheimer’s disease is:
a. Tensilon
b. Baclofen
c. Symmetrel
d. Aricept
ANSWER: D
The first drug introduced to treat the symptoms of this disease is Cognex. However they found out that this
medication can cause liver toxicity. It was not until 1997 that Donepezil (Aricept), an anticholinesterase inhibitor,
was introduced. This has a far fewer side-effects than the former and has been the drug of choice for this
disorder.
97. To encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:
a. Stay with the client and encourage him to eat
c. Give the client privacy during meals
b. Help the client fill out his menu
d. Fill out the menu for the client
ANSWER: A
Staying with the client and encouraging him to feed himself will ensure adequate food intake.
Option B - A client with Alzheimer's disease can forget how to eat.
Option C and D - Allowing privacy during meals, filling out the menu, or helping the client to complete the menu
doesn't ensure adequate nutritional intake.
98. A nurse is preparing for the admission of a client with a suspected Guillain-Barre syndrome. When the client
arrives at the nursing unit, the nurse reviews the physician’s documentation. The nurse expects to note
documentation of which hallmark clinical manifestation of this syndrome?
c. Abrupt onset of a fever and headache
b. Multifocal seizures
d. Development of progressive muscle weakness
ANSWER: D
A hallmark clinical manifestation of Guillain-Barre syndrome is progressive muscle weakness that develops
rapidly.
Option A - Cerebral function, level of consciousness, and pupillary responses are normal.
Option B - Seizures are not normally associated with this disorder.
Option C - The client does not have symptoms such as a fever or headache.
99. A nurse is performing an assessment on a client with Guillain-Barre syndrome. The nurse determines that
which of the finding would be of greatest concern?
a. A blood pressure (BP) decrease from 106/60 mmHg to 98/58 Hg
b. Lung vital capacity of 10ml/kg
c. Difficulty articulating words
d. Paralysis progressing from the toes to the waist
ANSWER: B
Respiratory compromise is a major concern in clients with Guillain-Barre syndrome. Clients often are intubated
and mechanically ventilated when the vital capacity is less than 15 ml/kg.
Option A - Although orthostatic hypotension is a problem with these clients, the BP drop in Option A is less than
10 mmHg and is not significant.
Option C and D - are expected depending on the degree of paralysis that occurs.
100. For a patient with Guillain-Barré syndrome, what nursing diagnoses would be most appropriate?
a. Risk for injury related to muscle weakness
b. Ineffective breathing pattern related to loss of respiratory muscle function
c. Risk for infection related to break in primary defenses
d. Pain related to swelling on the brain
ANSWER: B
Patients with Guillain-Barré often develop respiratory difficulties because of muscle weakness.
Reference: Brunner and Suddarth’s Medical Surgical Nursing 11th edition
CARE OF CLIENTS WITH CELLULAR ABERRATIONS (ONCOLOGIC NURSING) 1
SITUATION: Cancer is a broad term used to encompass several malignant diseases. There are over 100
different types of cancer, affecting various parts of the body. Each type of cancer is unique with its own causes,
symptoms, and methods of treatment.
1. The nurse would explain to the client that in contrast to malignant tumor, the following is characteristic of
benign tumor:
a. Invasive growth
c. Presence of metastasis
b. Immature, poorly differentiated tissue
d. Fully differentiated tissue
ANSWER: D
Difference between a Benign and Malignant Tumor
Benign Tumor
Malignant Tumor
Well-differentiated cells
Cells are undifferentiated
Smooth and round with a surrounding fibrous capsule.
Irregular shaped with no capsule.
Cells multiply slowly.
Cells multiply rapidly.
Tumor grows by expanding and pushing away and

against surrounding tissue.
Tumor grows by invading and destroying surrounding

tissue.
Mass is mobile. Not attached to surrounding tissue.
Mass is fixed. Attached to surrounding tissue and deeply

fixed in surrounding tissue.
Never spread to other sites (metastasize).
Almost always spreads to other sites if not removed or

destroyed.
Easier to remove and does not recur after excision.
Difficult to remove and recurs after excision.
2. Identification of cancer risks is part of every nurse’s assessment skills. Some of the most common of these
signs and symptoms include:
a. Obvious change in the appearance skin area that look markedly unlike surrounding tissues
b. A scar formation from skin abrasions
c. Cough and colds that respond quickly to antibiotic
d. Non-compliance to monthly breast self-examination
ANSWER: A
Health promotion through self-knowledge and teaching of the public may lead to application measures of early
detection and treatment. The American Cancer Society has identified 7 symptoms which could be a sign of
cancer.
* A change in bowel or bladder habits
* A sore that does not heal
* Unusual bleeding or discharge from any place
* A lump in the breast or other parts of the body
* Chronic indigestion or difficulty in swallowing
* Obvious changes in a wart or mole
* Persistent coughing or hoarseness
Reference: Amercian Cancer Society
3. A patient tells Nurse Hannah that he has heard that certain foods can increase the incidence of cancer. Nurse
Hannah suggests to the patient that the following food selections can increase the incidence of cancer except:
a. Tinapa and green beans
c. Steamed tilapia and steamed vegetable
b. Grilled liempo and grilled talong
d. Tocino, onions, and mixed vegetables
ANSWER: C
Dietary factors are also linked to environmental cancers. The risk of cancer increases with long-term ingestion of
carcinogens. Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or
smoked meats, nitrate-containing foods, and red and processed meats.
4. It is recommended that breast self-examination (BSE) as a screening measure for every women must be
practiced by which population group?
a. >20, monthly
b. > 35 years, yearly
c. > 50 years, yearly
d. >55 years, weekly
ANSWER: A
Beginning in their early 20’s, women should be told about the benefits and limitations of BSE. The importance of
prompt reporting of any new breast symptoms to a health professional should be emphasized.
5. Nurse Isabelle is instructing a client self breast examinations. The client asks why it is advised to perform BSE
after menstruation. Nurse Isabelle would base her response on which of the following statements?
a. There is increased lumpiness before their menstrual period
b. As women ages, breasts become fattier
c. Mood swings before menstruation affects compliance
d. BSE is anxiety-producing activity
ANSWER: A
Variations in breast tissue occur during the menstrual cycle, pregnancy, and the onset of menopause. Normal
changes must be distinguished from those that may signal disease. Most women noticed increased tenderness
and lumpiness before their menstrual periods; therefore, BSE is best performed after menses (days 5 to 7,
counting the first day of menses as day 1). Also women have grainy-textured breast tissue, but these areas are
usually less nodular after menses. Option B: Though breasts become fattier as women ages, it is not the reason
why BSE should be performed after menses. Option C: Incorrect statement. Option D: Only 25 to 30% of women
performs BSE proficiently and regularly each month because women find BSE to be anxiety-producing .
6. The client’s deceased grandmother was diagnosed with breast cancer at age 48. She asks Nurse Hannah when
her 16-year old daughter should begin mammography. What is your best advice?
a. Age 18 years
b. Age 28 years
c. Age 35 years
d. Age 40 years
ANSWER: B
A general guideline is to begin mammography screening 10 years earlier than the age at which the youngest
family member developed breast cancer but not before 25 years of age. In families with history of breast cancer,
a downward shift in age of diagnosis of about 10 years is seen. (eg. Grandmother diagnosed with breast cancer
at 48 years of age, mother diagnosed with breast cancer at age 38 years of age, then daughter should begin
screening at age 28 years)
7. An addition that should be made in the nursing care plan when a diagnosis of breast cancer is first made at
stage T1 N0 M0 is:
a. “Risk for disturbed body image related to threats of anticipated changes.”
b. “Risk of anxiety related to outcome of treatments.”
c. “Risk for infection related to decreased white blood cell count.”
d. “Risk for ineffective coping related to husband’s expectations regarding anticipated treatments.”
ANSWER: B
Early stages of cancer create anxiety about the outcome of treatments for the patient
8. During a recent visit to the clinic, a woman tells Nurse Hannah that during palpation she felt a lump in her
right breast. The client is fearful that the she might have breast cancer. Signs and symptoms of breast cancer
would include:
a. Painful lump
c. Movable lump with regular borders
b. Non-tender and fixed lesion
d. Mild tenderness of breasts prior to menstruation
ANSWER: B
Breast cancers can occur anywhere in the breast but are usually found in the upper outer quadrant, where the
most breast tissue is located. Generally, the lesions are non-tender, fixed rather than mobile, and hard with
irregular borders.
9. A nurse is planning a community education presentation about testicular cancer. The target group should be
men aged:
a. 15 to 35 years
b. 30 to 40 years
c. 40 to 50 years
d. 65 years and older
ANSWER: A
Testicular cancer is the most common cancer diagnosed in men between 15 to 35 years of age.
10. Which of the following conditions, reported to a nurse by a 20- year- old male patient, would indicate a risk
for development of testicular cancer?
a. Prenatal exposure to diethylstilbesterol
b. Crytorchidism
c. Genital herpes
d. Hydrocele
ANSWER: B
Testicular tumors are much more common in males who have undescended testicles. Other predisposing factors
include a history of mumps, orchitis, inguinal hernia in childhood and testicular cancer in the contralateral testis.
Options A, C and D: Genital herpes, prenatal exposure to diethylstilbesterol and a hydrocele are not considered
contributory factors in the development of testicular cancer.
11. Nurse Hannah is performing an assessment to a client suspected of testicular cancer. Nurse Hannah would
expect which of the following symptoms as a significant finding for testicular cancer?
a. Painful inguinal area
c. Reddened scrotum
b. Weight loss and general weakness
d. Enlargement of the scrotum without pain
ANSWER: D
The symptoms appear gradually, with a mass or lump on the testicle and usually painless enlargement of the
testis. The patient may report heaviness in the scrotum.
12. Which of the following tumor markers is expected to elevate in testicular cancer?
a. PSA and CEA
b. BRCA 1 and BRCA 2
c. AFP and beta HCG
d. CEA and AFP
ANSWER: C
Alpha fetoprotein (AFP) can help diagnose and treat liver cancer. AFP is also higher in certain testicular cancers
(those containing embryonal cell and endodermal sinus types) and is used for follow-up of these cancers. An
elevated blood level of human chorionic gonadotropin (HCG) will also raise suspicions of cancer in certain
situations. For example, in a woman who still has a large uterus after pregnancy has ended, a high blood level of
this marker may be a sign of a cancer. This is also true of men with an enlarged testicle or anyone with a tumor
in their chest. Prostate specific antigen (PSA) is a tumor marker for prostate cancer. BRCA1 and BRCA2 are
human genes that belong to a class of genes known as tumor suppressors. Mutation of these genes has been
linked to hereditary breast and ovarian cancer
13. Nurse Isabelle is reviewing the patient's assessment chart. Which of the following assessment data does
Nurse Isabelle identify as a risk factor associated with colorectal cancer?
a. Family history of stomach cancer
c. Age greater than 50
b. History of bowel obstruction
d. Low-fat, low-protein, low-fiber diet
ANSWER: C
Incidence of colorectal cancer increases with age (the incidence is highest in people older than 85 years) and is
higher in people with family history of colorectal cancer and those with IBD or polyps. Other risk factors: High
consumption of alcohol, cigarette smoking, history of gastrectomy, High fat, high protein and low fiber diet,
obesity.
14. Colorectal cancer screening includes all the following, except:
a. Fecal occult blood testing (FOBT)
c. Radiographic barium contrast studies
b. Digital rectal examination (DRE)
d. Papanicolaou smears test
ANSWER: D
Along with an abdominal and rectal examination, the most important diagnostic procedures for cancer of the
colon are FOBT, barium enema, proctosigmoidoscopy, and colonoscopy. Carcinoembryonic antigen (CEA) studies
may also be performed. Although CEA may not be a highly reliable indicator in diagnosing colon cancer because
not all lesions secrete CEA, studies show that CEA levels are reliable prognostic predictors.
15. A patient suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?
a. Fecal occult blood test (FOBT)
c. Colonoscopy
b. Carcinoembryonic antigen (CEA)
d. Barium enema
ANSWER: C
The majority of colorectal cancer cases can be identified by colonoscopy with biopsy or cytology smears.
Carcinoembryonic antigen (CEA) studies may also be performed. Although CEA may not be a highly reliable
indicator in diagnosing colon cancer because not all lesions secrete CEA, studies show that CEA levels are reliable
prognostic predictors.
16. Nurse Daniel is interpreting the outcome of a biopsy from a patient with colorectal cancer. The results
indicate a positive nodes and a tumor that extends through entire bowel wall. Nurse Daniel recognizes that the
patient has which class of colorectal cancer based upon Dukes' Classification-Modified Staging System?
a. Class C1
b. Class C2
c. Class C3
d. Class D
ANSWER: B
The staging of colon cancer is relatively straightforward.
Class A
: The tumor penetrates into the mucosa of the bowel wall but no further.
Class B1
: Tumor extends thorugh the mucosa
Class B2
: Tumor penetrates through entire bowel wall into serosa, no nodal involvement
Class C1
: Positive nodes, tumor is limited to bowel wall
Class C2
: Positive nodes, tumor extends through entire bowel wall
Class D
: The tumor, which has spread beyond the confines of the lymph nodes (to organs such as the
liver, lung or bone).
17. Epstein-Barr virus is known to be associated with:
a. Hepatocellular carcinoma
b. Cervical cancer
c. Burkitt's lymphoma
d. T-cell leukemia
ANSWER: C
Burkitt’s lymphoma (or Burkitt Lymphoma) is an uncommon type of Non-Hodgkin Lymphoma (NHL). Burkitt’s
lymphoma commonly affects children. It is a highly aggressive type of B-cell lymphoma that often starts and
involves body parts other than lymph nodes. In spite of its fast-growing nature, Burkitt’s lymphoma is often
curable with modern intensive therapies. Although no common etiologic factors has been identified, the incidence
of NHL has increased in people with immunodeficiencies or autoimmune disorders; prior treatment for cancer;
prior organ transplant; viral infections (including Epstein-Barr virus and HIV); and exposure to pesticides,
solvents, dyes, or defoliating agents.
19. The client, who was diagnosed a while ago with Hodgkin lymphoma early stage, expresses concern for his
family. Which of the following statements best describes the management of the disease process?
a. “The disease has no cure, and often the patient is transferred to a hospice care”
b. “The potential development of a second malignancy should be addressed when treatment decisions are made”
c. “Organ transplant is necessary for complete recovery”
d. “The disease is already incurable when you experienced bleeding during urination”
ANSWER: B
The potential development of a second malignancy should be addressed with the patient when treatment
decisions are made. However, it is also important to tell patients that Hodgkin lymphoma is often curable. The
nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such
as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. Other options
are incorrect
20. A human papillomavirus (HPV) is a member of the papillomavirus family of viruses that is capable of infecting
humans. Like all papillomaviruses, HPVs establish productive infections only in the stratified epithelium of the
skin or mucous membranes. Human papilloma virus is known to be associated with:
a. Cervical cancer
b. Lymphoma
c. Hepatocellular cancer
d. Gastric cancer
ANSWER: A
Carcinoma of the cervix is predominantly squamos cell cancer. Cervical cancer is less common than it once was
because of early detection of cell changes by Pap smear. High-risk HPV can lead to cancers of the cervix, vulva,
vagina, and anus in women. In men, it can lead to cancers of the anus and penis.
21. A patient has been diagnosed with stage 0 cervical cancer. This stage describes cancer occurring in which of
the following areas?
a. Invasive cancer with tumor spreading to other parts of the body
b. Carcinoma is strictly confined to the cervix
c. Carcinoma limited to epithelial cells
d. Carcinoma extends beyond the cervix and upper two thirds of vagina
ANSWER: C
Stage 0 - Carcinoma in situ. Tumor is present only in the epithelium The covering of the internal and the external
organs of the body, as well as the lining of vessels, glands, and organs. It consists of cells bound together by
connective material, and it varies in the number of layers and the kinds of cells it contains. (cells lining the
cervix) and has not invaded deeper tissues.
Stage I - Invasive cancer with tumor strictly confined to the cervix.
Stage II - Invasive cancer with tumor extending beyond the cervix and/or the upper two-thirds of the vagina The
passage that connects the female reproductive organs to the outside., but not onto the pelvic wall.
Stage III - Invasive cancer with tumor spreading to the lower third of the vagina or onto the pelvic wall; tumor
may be blocking the flow of urine from the kidneys to the bladder.
Stage IV - Invasive cancer with tumor spreading to other parts of the body. This is the most advanced stage of
cervical cancer.
22. A patient tells the nurse that she is afraid of getting cervical cancer because her mother died of cervical
cancer. The most appropriate response by the nurse would be:
a. “You need to a have a pelvic examination every 6 months because of your history.”
b. “If you have regular Pap smears, cervical cancer is usually diagnosed early and cured.”
c. “There’s no need to worry so much. Cervical cancer does not run in families.”
d. “Cervical cancer is sexually transmitted. Don’t switch partners often and you don’t have to worry.”
ANSWER: B
For patients who have regular annual pelvic examinations and Papanicolaou (Pap) smears, cervical cancer is
usually diagnosed and treated in its early stage.
Reference: Brunner and Suddarth’s Medical Surgical Nursing 12th edition Page 344, 1457
23. Nurse Hannah is developing a teaching plan for a client who is at high risk for developing cervical cancer. This
would include:
a. Report thin watery vaginal discharge for further evaluation
c. Pap smear every 3 years
b. Report any pain after intercourse
d. PSA test annually
ANSWER: A
Early cervical cancer rarely produces symptoms. If symptoms are present, they may go unnoticed as a thin
watery vaginal discharged often unnoticed after intercourse or douching. When symptoms such as discharge,
irregular bleeding, or pain after sexual intercourse occur, the disease may be advanced. Pap smear should be
done annually. PSA test is done for prostate cancer.
24. A 30-year-old patient is being screened for ovarian cancer. The nurse would expect which of the following risk
factors as part of the teaching plan?
a. Infertility
b. Less than 40 years of age
c. Oral contraceptive use
d. Breastfeeding
ANSWER: A
Risk factors for ovarian cancer:
•
After age 40 and peaks in the early 80’s
•
Family history
•
Low parity
•
Obesity
Pregnancy and oral contraceptives decreases the risk
25. Which of the following history and assessment data would put the client at high risk for bladder cancer?
a. Cigarette smoking for 20 years
c. Urinary incontinence
b. High fat and low fiber diet
d. Physical inactivity
ANSWER: A
Tobacco use continues to be a leading risk factor for all urinary tract cancers. People who smoke develop bladder
twice as often as those who do not smoke.
SITUATION: Each type of cancer is unique with its own causes, symptoms, and methods of treatment.
26. The nurse includes which information about benign tumors when presenting an in-service on cancer?
a. They do not cause pain
c. They are often surrounded by a capsule
b. They are smaller than 2 cm in size
d. They cause the sensation of itching
ANSWER: C
Benign tumors are made up of normal cells growing in the wrong place or growing when they are not needed.
They grow by expansion rather than invasion and often are encapsulated. The size and the fact that it is painless
does not mean that the tumor is benign. Additionally, the presence of any sensation (such as itching) does not
rule out malignancy.
Reference: Brunner and Suddarth’s Medical Surgical Nursing 11th edition page 402
27. The nurse recognizes which biologic characteristic as specific to normal differentiated adult cells but not to
cancer cells?
a. Anaplasia
b. Hypertrophy
c. Aneuploidy
d. Loose adherence
ANSWER: B
Some normal tissues increase in size by having individual cells get larger, a process called hypertrophy. Cancer
cells are usually small and always grow by hyperplasia, not hypertrophy. The other characteristics are associated
with malignant cells or early embryonic cells.
28. The patient’s tumor was staged using the TNM system. The tumor was staged as T4,N1,Mx. Using the TNM
this would mean:
a. Tumor in situ, minimal node involvement, no presence of metastasis.
b. Large tumor, no node involvement, presence of metastasis.
c. Medium tumor, multiple nodes involvement, no presence of metastasis.
d. Large tumor, single node involvement, unable to assess metastasis.
ANSWER: D
The larger the number in the TNM staging system, the increasing involvement or larger size of the tumor, node,
and metastasis.
Reference: Brunner and Suddarth’s Medical Surgical Nursing 11th edition page
29. The nurse recognizes malignant cell growth as uncontrolled because of which action?
a. Cancer cells always divide more rapidly than normal cells.
b. The mitosis of malignant cells usually produces more than two daughter cells.
c. Malignant cells are able to bypass one or more phases of the cell cycle during cell division.
d. Malignant cells re-enter the cell cycle more frequently, making cell division a continuous process.
ANSWER: D
Although some malignant cells divide very rapidly, this is not true for all malignant cells. Malignant cells have
bypassed the normal control mechanisms that restrict entering the cell cycle, so they re-enter the cell cycle as
soon as they finish a round of cell division. Thus, cancer cell division is relentless.
30. An adult man who has a mother with breast cancer, a father with smoking-related lung cancer, a sister with
breast cancer, and a sister with ovarian cancer, asks if he should be concerned for his cancer risk. What is the
nurse’s best response?
a. “Your risk is not affected by this family history, because most of the cancers arose in female gender–
associated tissues.”
b. “You have two first-degree relatives and two second-degree relatives with cancer, which increases your
general risk for cancer.”
c. “Your risk for breast cancer is increased. However, your risk for lung cancer is not affected by this history.”
d. “Your risk for cancer is affected by your parents’ cancer development. Your sisters’ cancers have no bearing on
your risk.”
ANSWER: C
This man has four first-degree relatives with cancer, three of whom have cancers that are associated with a
genetic risk. The fact that the sisters and mother were diagnosed at relatively young ages increases the likelihood
of a genetic predisposition. The genetic association with these cancers also increases the risk for male members
of the family. Lung cancer has not been found to have a genetic association.
31. An older client says that she does not perform breast self-examination because there is no history of breast
cancer in her family. What is the nurse’s best response?
a. “You are correct. Breast cancer is an inherited type of malignancy and your family history indicates a low risk
for you to develop it.”
b. “Breast cancer can be found more frequently in families. However, the risk for general, nonfamilial breast
cancer increases with age.”
c. “Because your breasts are no longer as dense as they were when you were younger, your risk for breast
cancer is now decreased.”
d. “Examining your breasts once a year when you have your mammogram is sufficient screening for someone
with your history.”
ANSWER: B
The risks for all types of sporadic (noninherited, nonfamilial) cancers increase with age. Adults older than 60
years have immune systems that function at less than optimal levels. Therefore, this group has a higher
incidence of cancer compared with that of the general population.
32. During a recent visit to the clinic, a woman tells the nurse that during palpation she felt a lump in her right
breast. The client is fearful that the she might have breast cancer. Signs and symptoms of breast cancer would
include:
a. Painful lump
c. Movable lump with regular borders
b. Non-tender and fixed lesion
d. Mild tenderness of breasts prior to menstruation
ANSWER: B
Breast cancers can occur anywhere in the breast but are usually found in the upper outer quadrant, where the
most breast tissue is located. Generally, the lesions are non-tender, fixed rather than mobile, and hard with
irregular borders.
33. The middle-aged client with small cell lung cancer asks if his adult children are at increased risk of this
cancer. What is the nurse’s best response?
a. “This disease is a random event and there is no way to prevent it.”
b. “Because this disease is inherited as a dominant trait, your children have a 50% risk for developing it.”
c. “Cigarette smoking is the main cause of this disease, and helping your children not to smoke will decrease
their risk.”
d. “Lung cancer can be avoided by decreasing dietary intake of fats and increasing the amount of regular aerobic
exercise.”
ANSWER: C
Long-term cigarette smoking is the major risk factor for small cell lung cancer. Although some pulmonary
problems are associated with a genetic predisposition, none have been linked to lung cancer development.
34. A client who is newly diagnosed with cancer says to the nurse, "I don't want to spend my final days on earth
in a hospital bed." The best response by the nurse is:
a. "I know how you feel. It must be hard to know that you are dying."
b. "Why do you feel so negative about being in the hospital?"
c. "Please tell me more about how you are feeling right now."
d. "If I were you I would go home and enjoy the life you have left."
ANSWER: C
The nurse is in the unique position to provide physical as well as psychosocial support to the client diagnosed
with cancer. This nurse needs to learn more about the client's feelings and not discount or add to the client's
feelings of pending hospitalization.
Reference: Lemone-Burke. Contemporary Medical Surgical Nursing 4th edition
35. Which of the following conditions, reported to a nurse by a 20- year- old male patient, would indicate a risk
for development of testicular cancer?
a. Prenatal exposure to diethylstilbesterol
b. Crytorchidism
c. Genital herpes
d. Hydrocele
ANSWER: B
Testicular tumors are much more common in males who have undescended testicles. Other predisposing factors
include a history of mumps, orchitis, inguinal hernia in childhood and testicular cancer in the contralateral testis.
Options A, C and D: Genital herpes, prenatal exposure to diethylstilbesterol and a hydrocele are not considered
contributory factors in the development of testicular cancer.
36. The client with prostate cancer says that he is now having a lot of pain in his lower back and legs. The nurse
correlates this to which condition?
a. Arthritis
b. Urinary retention
c. Metastasis to the bone
d. Muscle atrophy from inactivity
ANSWER: C
The primary site of metastasis for prostate cancer is the bone of the spine and legs. Pain in these areas in a client
with prostate cancer is highly suggestive of cancer progression and metastasis.
37. Following a right mastectomy, a patient tells the nurse it feels like her nipple is still present. Which of the
following is the nurse's best explanation?
a. “The feeling of the nipple is related to the dressing.”
c. “Once the wound heals that feeling will go away.”
b. “The sensation will disappear in a few months.”
d. “I will call your doctor and see if that is normal.”
ANSWER: B
Because nerves in the skin and axilla are often cut or injured during breast surgery, patients experience a variety
of sensations. Common sensations include tenderness, soreness, numbness, tightness, pulling and twinges.
These sensations may occur along the chest wall, in the axilla, and along the side of the upper arm. After
mastectomy, some patients experience phantom sensations and report a feeling that the breast and or nipple are
still present. Sensations usually persists for several months and then begin to diminish, although some may
persist for as long as 2 years and possibly longer. Patient should be reassured that this is a normal part of
healing and that these sensations are not indicative of problem.
Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 1719
38. A non-antineoplastic agent that is given to a client receiving Ifosfamide (IFEX) or cyclophosphamide
(Cytoxan) to reduce the risk of hemorrhagic cystitis:
a. Fluorouracil
b. Tamoxifen
c. L-Asparaginase
d. Mesna
ANSWER: D
Some people who are given ifosfamide chemotherapy may get blood in their urine (haematuria). This can also
happen with higher doses of cyclophosphamide chemotherapy, but is less common. Both drugs can cause
irritation and bleeding from the lining of the bladder and the kidneys. Mesna helps to prevent this by protecting
your bladder and kidneys. Mesna is always given with ifosfamide, and normally only given with higher doses of
cyclophosphamide. While you are having this treatment, your urine is closely monitored and tested for any signs
of blood. If you have blood in your urine, you will be given extra mesna. Drinking as much water as possible can
help to flush through the chemotherapy.
39. Which of the following is an appropriate nursing intervention for a client receiving chemotherapy with a
nursing diagnosis of Imbalanced nutrition: less than body requirements?
a. Administer an antiemetic premedication prior to chemotherapy.
b. Offer frequent high-calorie, high-fat meals.
c. Instruct the client to drink a full glass of water before each meal.
d. Reinforce teaching regarding the reason for the nausea and vomiting.
ANSWER: A
The most common reason for altered nutrition is nausea and vomiting. Option B: This would increase nausea in
most clients. Option C: This will decrease their meal intake. Option D: This will not decrease the nausea and
vomiting.
Reference: Boyles. Pharmacologic aspects of nursing care 7th edition page 957, 959
40. A female client tells the nurse, "I want to stop taking birth control. I heard it causes cancer." Which of the
following responses can the nurse make to this client?
a. "You heard correctly. They do cause cancer."
b. “Some birth control pills with estrogen can increase the risk for breast cancer but they also decrease the risk
for ovarian cancer."
c. "Aspirin is more dangerous than a birth control pill."
d. "This is entirely wrong and I wouldn't stop taking them."
ANSWER: B
Estrogen-containing contraceptive pills have been implicated in breast cancer, but they also have been shown to
decrease the risk of ovarian cancer. Investigators have not reached a final conclusion about the cancer risk posed
by contraceptives.
41. A client is prescribed external radiation as part of his cancer treatment. Which of the following should be
included in this client's instructions?
1. Do not wash off the treatment marks.
3. Wash the skin with soap and water.
2. Use an electric razor to shave the treatment area.
4. Avoid applying heat or cold to the area.
a. 3 and 4
b. 1, 2, 4
c. 1 and 2
d. All except 1
ANSWER: B
Client teaching should include washing the skin with plain water, no soap; and do not apply deodorant, lotions,
medications, perfume, or powder to the site. Take care not to wash off the treatment marks. Do not rub, scratch,
or scrub treated skin areas. If necessary, use only an electric razor to shave the treated area. Apply neither heat
nor cold (e.g., heating pad or ice pack) to the treatment site.
42. While a patient is receiving intravenous doxorubicin hydrochloride, the nurse observes that there is swelling
and pain at the IV site. The nurse should do all of the following except:
a. Stop the administration of the drug immediately
c. Apply a cold compress to the site
b. Notify the patient's physician
d. Apply a warm compress to the site
ANSWER: D
If extravasation is suspected, the medication administration is stopped immediately, and dependent on the drug,
an attempt is made to aspirate any remaining drug from the extravasation site through the existing needle.
Application of heat or cold is very dependent on the drug administered. In general, cold compresses are indicated
for doxorubicin extravasation but are of no benefit for taxane or oxaliplatin extravasation. Warm compresses are
recommended for vinca alkaloid extravasation.
43. When caring for a client receiving a methotrexate infusion, the nurse should:
a. Administer leucovorin immediately after the infusion of methotrexate.
b. Increase the client’s intravenous fluids, if the specific gravity falls below 1.010.
c. Discontinue the infusion, if nausea and vomiting develop.
d. Premedicate the client with prednisone to prevent hemorrhagic cystitis.
ANSWER: A
This is the appropriate nursing action. Leucovorin competes with methotrexate at the cellular level to decrease
uric acid levels. Option B: This is not specific to methotrexate. Option C: The med should not be discontinued but
rather an antiemetic may be prescribed. Option D: Methotrexate is not associated with hemorrhagic cystitis.
Reference: Boyles. Pharmacologic aspects of nursing care 7th edition page 956
44. A male patient diagnosed with colon cancer was newly put in colostomy. Which of the following behaviors
show the best adaptation with the new colostomy:
a. Look at the ostomy site
b. Participate with the nurse in his daily ostomy care
c. Ask for leaflets and contact numbers of ostomy support groups
d. Talk about his ostomy openly to the nurse and friends
ANSWER: C
Actual participation conveys positive acceptance and adjustment to the altered body image. Although looking at
the ostomy site also conveys acceptance and adjustment, Participating with the nurse to his daily ostomy care is
the BEST adaptation a client can make during the first few days after colostomy creation.
45. Following a left modified radical mastectomy, which of the following nursing measures should be implemented
to prevent complications in the affected arm?
a. Using sequential comprehension devices on the arm.
c. Immobilizing the arm soaks to the arm
b. Applying warm soaks to the arm
d. Elevating the arm on two pillows
ANSWER: D
Positioning will help to promote venous lymphatic drainage. The affected arm is elevated to promote fluid
drainage via the lymphatic and venous pathways. Options A, B and C: Elevation of the arm so that it is level with
or above the heart, diuretics and isometric exercises may be recommended to reduce fluid volume in the arm.
The patient may need to wear an elastic pressure gradient sleeve during waking hours to maintain volume
reduction, but the initial action by the nurse would be elevating the arm.
46. Alvira is receiving internal radiation therapy for her cancer of the cervix. Her radiation source, a rod, becomes
dislodged. What will be the nurse’s first action?
a. Notify the radiation safety department at once and wait for further information
b. Use long-handled forceps to remove the rod and place in a lead container
c Apply two sets of rubber gloves and pick up the rod; place it in a white plastic biohazard for pick up
d. Use long-handled forceps to pick up the rod; clean with normal saline, and reinsert into client’s vagina,
stopping when the rod meets resistance. This indicates that it is against the cervix
ANSWER: B
Long-handled forceps and a lead-lined container must be kept in the room of any client receiving internal
radiation therapy for this very occurrence.
47. Epstein-Barr virus is known to be associated with:
a. Hepatocellular carcinoma
b. Cervical cancer
c. Burkitt's lymphoma
d. T-cell leukemia
ANSWER: C
Burkitt’s lymphoma (or Burkitt Lymphoma) is an uncommon type of Non-Hodgkin Lymphoma (NHL). Burkitt’s
lymphoma commonly affects children. It is a highly aggressive type of B-cell lymphoma that often starts and
involves body parts other than lymph nodes. In spite of its fast-growing nature, Burkitt’s lymphoma is often
curable with modern intensive therapies. Although no common etiologic factors has been identified, the incidence
of NHL has increased in people with immunodeficiencies or autoimmune disorders; prior treatment for cancer;
prior organ transplant; viral infections (including Epstein-Barr virus and HIV); and exposure to pesticides,
solvents, dyes, or defoliating agents.
48. Nurse Hannah suspects a client of having Hodgkin lymphoma on the basis of what clinical manifestation?
a. Enlarged painless lymph node on one side of the neck
c. Early morning sweats with fever
b. Enlarged painless lump in the neck
d. Painless hematuria
ANSWER: A
Hodgkin lymphoma usually begins as a painless enlargement of one or more lymph nodes on one side of the
neck. The individual nodes are painless, and firm but not hard. The most common sites for lymphadenopathy are
the cervical, supraclavicular, and mediastinal nodes; involvement of the iliac or inguinal nodes or spleen is much
less common.
SITUATION: Cancer is not a single disease; rather, it is a group of distinct diseases with different causes,
manifestations, treatments and prognosis. Cancer nurses must be prepared to support patients and families
through wide range of physical, emotional, social, cultural, and spiritual crisis.
49. When describing neoplasms that become progressively worse and often result in death to a client, the nurse
would be teaching about which type of neoplasm?
a. Benign
b. Leukemia
c. Malignant
d. Vesicles
ANSWER: C
Malignant neoplasms form irregularly shaped masses that have fingerlike projections. Because of their rapid
growth, cancer cells often spread from an initial site to other parts of the body via the blood or lymph systems;
this spread is known as metastasis and its progress depends on the type of cancer.
Reference: White. Foundations of Nursing 3rd ed
50. A client is diagnosed with cancer that occurs in the lymphatic system. The nurse is aware that this type of
cancer is:
a. Carcinoma
b. Leukemia
c. Lymphoma
d. Sarcoma
ANSWER: C
Cancers are named according to the site of the primary neoplasm or the type of tissue involved. The four main
classifications by tissue type include lymphomas, cancers occurring in lymphatic tissue and similar infectionfighting organs;
leukemias, cancers occurring in blood-forming organs such as bone marrow; sarcomas, cancers
occurring in connective tissue such as bone; and carcinomas, cancers occurring in epithelial tissue such as skin.
51. A nurse is teaching at a health fair about the early warning signs of cancer. Which of the following are early
warning signs?
1. A sore that does not heal
3. Family history
5. Obvious change in nevus
2. Change in bladder or bowel habits
4. Unusual discharge
a. 1, 2, and 4
b. All except 3
c. All except 5
d. All of the above
ANSWER: B
Early warning signs can be easily remember using the acronym CAUTION: C, change in bladder/bowel habits; A,
a sore that does not heal; U, unusual bleeding or discharge; T, presence of lump or “thickening”; I, indigestion;
O, obvious change in wart or mole; and N, nagging cough or hoarseness.
52. A patient has had a decrease in the tumor marker PSA. This would indicate that the patient:
a. No longer has the disease.
c. Is responding to treatment.
b. Has an increase in the severity of the disease process.
d. Should be retested.
ANSWER: C
A decrease in a tumor marker is important in the assessment of cancer, monitoring tumor response during
treatment strategies, and diagnosis of recurrence of disease.
53. A patient who has been told by the health care provider that the cells in a bowel tumor are poorly
differentiated asks the nurse what is meant by “poorly differentiated.” Which response should the nurse make?
a. “The cells in your tumor do not look very different from normal bowel cells.”
b. “The tumor cells have DNA that is different from your normal bowel cells.”
c. “Your tumor cells look more like immature fetal cells than normal bowel cells.”
d. “The cells in your tumor have mutated from the normal bowel cells.”
Answer: C
An undifferentiated cell has an appearance more like a stem cell or fetal cell and less like the normal cells of the
organ or tissue. The DNA in cancer cells is always different from normal cells, whether the cancer cells are well
differentiated or not. All tumor cells are mutations form the normal cells of the tissue.
Reference: Lewis. Medical Surgical Nursing 7th ed page 274
54. In reviewing the pathophysiology of a particular type of cancer, the nurse correlates the generation time for
cancer development with which description?
a. The rate at which cancer cells are able to migrate and metastasize to different sites
b. How long it takes for a malignant tumor to double in size by mitotic cell divisions
c. The period of time necessary for one cell to enter and complete one round of cell division by mitosis
d. The period of time between when a carcinogen damages the DNA of a cell and when that cell expresses
malignant characteristics
ANSWER: C
The definition of generation time is the period of time necessary for one cell to complete a round of cell division.
Reference: Ignatavicius. Medical Surgical Nursing 6th ed page 403
55. The client states that his brain tumor is benign and does not need to be removed. What is the nurse’s best
response?
a. “Because benign tumors continue to get larger, when they are in a place that could damage normal tissue,
they need to be removed.”
b. “Because benign tumors are composed of completely normal cells, removal is only done for cosmetic
purposes.”
c. “Because benign tumors can easily become malignant, they should be removed before cancer develops.”
d. “Because benign tumors can migrate, they should be removed before they spread.”
ANSWER: A
Even though benign tumors do not invade, they can compromise or even destroy surrounding normal tissue. This
is particularly a problem when a benign tumor arises in a location that does not expand to accommodate growth,
such as in the skull.
56. The nurse correlates “initiation” in cancer development to which action?
a. Inflicting mutations at specific sites on the exposed cell’s DNA
b. Increasing the transformed cell’s capacity for error-free DNA repair
c. Stimulating or enhancing cell division of cells damaged by a carcinogen
d. Making cancer cells appear more normal to escape immunosurveillance
ANSWER: A
The process of initiation induces changes in the genes that allow for the activation of proto-oncogenes to
oncogene status and to be expressed.
57. The nurse at the clinic is interviewing a 61-year-old woman who is 5 feet, 3 inches tall and weighs 125
pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and
has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about
cancer screening and decreasing cancer risk?
1. Pap testing
3. Sunscreen use
5. Colorectal screening
2. Tobacco use
4. Mammography
a. All except 1
b. 1, 3, 5
c. All except 5
d. All of the above
ANSWER: C
The patient’s age, gender, and history indicate a need for screening and/or teaching about colorectal cancer,
mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is
physically active, and her body weight is healthy.
Reference: Lewis. Medical Surgical Nursing 7th ed page 269-270
58. Based on the higher mortality rates in men from specific types of cancers, which question is most important
for the nurse to ask during annual health screenings?
a. “How much time do you spend in the sun?”
b. “How many servings of fruits and vegetables do you eat every day?”
c. “How often do you eat smoked meats?”
d. “Do you smoke cigarettes?”
ANSWER: D
Although prostate cancer has a higher incidence in men than lung cancer, more cancer deaths occur from lung
cancer in men compared with deaths from prostate cancer.
Reference: Ignatavicius. Medical Surgical Nursing 6th ed
59. The staging of the client’s cancer by the TNM classification is T1, N3, M1. What is the nurse’s interpretation of
this classification?
a. The client has two tumors that are nonresponsive to treatment.
b. The client has leukemia confined to the bone marrow.
c. The client has a 2-cm tumor with one regional lymph node involved and no distant metastasis.
d. The client has a small primary tumor, tumor extension into three lymph nodes, and one site of distant
metastasis.
ANSWER: D
T = primary tumor. T1 indicates that a primary tumor is detectable but still relatively small. N = regional lymph
nodes. N3 indicates that regional lymph nodes are involved. M = distant metastasis. M1 indicates that there is
evidence of distant metastasis in at least one site.
60. The nurse is caring for a client who has just received a diagnosis of advanced oral cancer and learned that he
will need to have a glossectomy with jaw resection. He states to the nurse, “I would rather die than have half of
my face removed. My life is over.” Which is the best description of the client’s response to the diagnosis?
a. The client is ready to die.
c. The client has accepted the diagnosis.
b. The client is in grief over the diagnosis.
d. The client is in denial about the diagnosis.
ANSWER: B
The client is grieving the loss of his health and present appearance.
61. The nurse is caring for a client who has just received a diagnosis of advanced oral cancer that will require
extensive surgery. Which statement by the client indicates that he has accepted his diagnosis?
a. “I don’t like it, but I have cancer and that’s the way it is.”
b. “The biopsy test results will be double-checked next week.”
c. “Of all the rotten things to happen to me, now I have cancer on top of it all.”
d. “If I can just live long enough to see my son get married, everything will be OK.”
ANSWER: A
The client has accepted the diagnosis. He is not happy about it, but has acknowledged the reality of the situation.
62. An older client with age spots is fearful of contracting skin cancer. The client asks the nurse if he is able to
continue his hobby of outdoor gardening. What is the nurse’s best response?
a. “Avoid staying outside.”
c. “You can grow plants indoors.”
b. “Use oil-based tanning lotion.”
d. “Wear a hat and gloves when gardening.”
ANSWER: D
Freckles, birthmarks, and age spots are caused by patches of melanin in the skin. Melanin protects against the
harmful effects of sun exposure. Hyperpigmentation can occur in sun-exposed areas and can lead to skin cancer.
63. A client has numerous skin lesions. Which one will the nurse evaluate first?
a. Beige freckles on the backs of both hands
b. Irregular blue mole with white specks on the lower leg
c. Large cluster of pustules in the right axilla
d. Raised, tubular, white, snake-like areas on the inner aspects of the wrists
ANSWER: B
This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an
indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome.
Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the
potentially cancerous lesion first.
64. A nurse inspects the site where a client’s basal cell carcinoma has been treated with cryosurgery and finds
that the area is red, with a blister in the center. Which action will the nurse take?
a. Culturing the site
c. Applying hydrocortisone cream
b. Notifying the surgeon
d. Continuing to assess
ANSWER: D
This skin reaction is the expected and normal response to cryosurgery. No other intervention is necessary other
than continued assessment.
65. Nurse Sarah is caring for a client who is receiving radiation therapy for treatment of oral cancer. The client
complains of a constant dry mouth. Which is the nurse’s best response?
a. “Massage the area just over the lower jaw twice a day.”
b. “Use lemon and glycerin swabs to clean your mouth and help keep it moist.”
c. “Suck on lemon slices to help increase saliva production.”
d. “Rinse your mouth out often with saline or cool water.”
ANSWER: D
Clients should avoid agents that can irritate the oral mucosa and should keep their mouth moist with frequent
rinses of saline or water.
66. Which factor would place a client at risk for esophageal cancer?
a. A high-stress occupation
c. A 20 pack-year smoking history
b. A preference for high-fat foods
d. A history of myocardial infarction
ANSWER: C
The two most important factors for the development of esophageal cancer are tobacco use and alcohol ingestion.
67. Nurse Hannah is performing an assessment of a client with suspected esophageal cancer. Which statement
made by the client is indicative of advanced disease?
a. “I have difficulty swallowing solids, particularly meat.”
c. “I have difficulty swallowing soft foods.”
b. “I usually have a sticking feeling in my throat.”
d. “I have difficulty swallowing liquids.”
ANSWER: D
Dysphagia does not usually present until the esophageal lumen is 60% occluded. It begins with a sticking
sensation in the throat and dysphagia for solids, followed by dysphagia for soft foods. The client with dysphagia
for liquids has the most advanced disease.
Reference: Ignatavicius. Medical Surgical Nursing 6th ed page
68. Which is the priority intervention in the care of a client with esophageal cancer?
a. Maintaining nutritional intake
b. Allowing grieving
c. Preventing aspiration
d. Managing pain relief
ANSWER: C
Although nutrition is high on the list of priorities, prevention of aspiration is the highest. When a client aspirates,
his or her respiratory system is compromised, thereby causing further deterioration, which increases nutritional
needs.
69. A client has undergone an esophagogastrostomy for cancer of the esophagus. How will the nurse best
support the client’s respiratory status?
a. Assessing the client’s breath sounds every 4 hours
c. Maintaining the client in a supine position
b. Performing chest physiotherapy every 6 hours
d. Administering analgesia regularly
ANSWER: D
Respiratory care is the highest postoperative priority. Incisional support and adequate analgesia are crucial for
effective coughing and deep breathing. As long as vital signs are stable, the nurse administers analgesia regularly
to assist the client in performing deep breathing, turning, and coughing routines.
70. The nurse is caring for a client with prostate cancer. Which laboratory finding indicates to the nurse that the
cancer has metastasized to the bone?
a. Serum calcium, 21.6 mg/dL
c. Alkaline phosphatase, 45 IU/mL
b. Creatine kinase, 45 U/mL
d. Lactate dehydrogenase, 66 U/L
ANSWER: A
Metastasis of tumor to bone results in release of calcium into the bloodstream, causing an elevation of the serum
calcium level (normal range, 9 to 10.5 mg/dL). The other laboratory values are within normal limits and do not
indicate metastasis to the bone.
71. The mother of a 16-year-old client diagnosed with Ewing’s sarcoma expresses concern that her son seems to
be angry at everyone in the family. How will the nurse respond?
a. “You need to set limits with your son.”
c. “He will be back to normal when he leaves the hospital.”
b. “This is a normal stage in the grieving process.”
d. “This is typical behavior for a teenager.”
ANSWER: B
Clients often experience a loss of control over their lives when a diagnosis of cancer (e.g., Ewing’s sarcoma) is
made. Clients may progress through the grieving process, which includes denial, followed by anger. Setting limits
without understanding the grieving process can make the client feel that he has no control. The behavior is not
typical of a teenager without the disease. It is part of the grieving process. The mother should not expect the son
to go back to “normal” when he goes home.
72. The nurse is teaching a health promotion class about preventing cancer. Which statement by a student
indicates understanding of gastric cancer development?
a. “I should skip my morning bacon and egg sandwich to reduce my risk of gastric cancer.”
b. “I have been lactose-intolerant for many years, so I should have a yearly test for gastric cancer.”
c. “I should switch from regular to decaffeinated coffee to reduce my risk of gastric cancer.”
d. “I am at low risk for developing gastric cancer because I am a vegetarian and I only eat organic produce.”
ANSWER: A
Regular consumption of processed foods with nitrates (including bacon) can increase risk for gastric cancer.
Lactose intolerance, coffee intake, and vegetarian diet are not factors for gastric cancer development.
73. The nurse is caring for a client who has just been diagnosed with end-stage pancreatic cancer. The nurse
assesses the client’s emotional response to the diagnosis. Which is the nurse’s initial action for the assessment?
a. Bringing the client to a quiet room for privacy
b. Pulling up a chair and sitting next to the client’s bed
c. Determining if the client feels like talking about his or her feelings
d. Reviewing the physician’s notes about the prognosis for the client
ANSWER: C
Before conducting an assessment about the client’s feelings, the nurse should determine if he or she is willing
and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an
alternative meeting space may be located.
74. What intervention will the nurse implement to prevent injury in the client with bone cancer?
a. Using a lift sheet when repositioning the client
b. Positioning client’s heels from touching the mattress
c. Providing small, frequent meals that are rich in calcium and phosphorus
d. Applying pressure for a full 5 minutes after any intramuscular injections
ANSWER: A
Bone metastasis of cancer can cause such bone destruction that grasping or pulling a client can result in a
pathologic fracture. Using a lift sheet spreads the client’s weight more evenly, preventing excessive force on any
one body area.
75. The client with lung cancer is scheduled to have a liver scan and asks why this procedure is being done. What
is the nurse’s best response?
a. “Cigarette smoking can also cause liver cancer.”
b. “It is best to test liver function first in case the treatment causes liver damage.”
c. “Treatment for lung cancer is different if it has spread to the liver.”
d. “An enlarged liver can interfere with cancer therapy.”
ANSWER: C
Surgery and radiation are considered local treatments for lung cancer confined to the chest. If cancer has spread
beyond the chest, systemic therapy (chemotherapy) is required to control the disease.
76. A client’s laboratory findings reveal an elevated serum acid phosphatase level and a high-normal prostatespecific antigen level.
How will the nurse interpret this information?
a. The client shows evidence of renal disease and should be evaluated further.
b. The client’s results may indicate prostate cancer. He should be further evaluated.
c. The client’s results are not abnormal. He does not need to be evaluated further.
d. The client’s results may indicate an infection. He should be evaluated further.
ANSWER: B
Both serum acid phosphatase and prostate-specific antigen levels will be elevated when the client has prostate
cancer. The results are not indicative of renal disease or infection, but they are abnormal, may indicate prostate
cancer, and should be further evaluated.
77. Which client statement indicates understanding about a transrectal ultrasound?
a. “This is performed to determine if the outlet of my bladder is obstructed.”
b. “This is performed to determine the amount of residual urine present.”
c. “This is performed to view the interior of the bladder and urethra.”
d. “This is performed to view the prostate and do a tissue biopsy.”
ANSWER: D
A transrectal ultrasound is performed to view the prostate and surrounding structures and possibly also to do a
tissue biopsy. A urodynamic pressure flow study will determine if the outlet of the client’s bladder is obstructed. A
bladder scan will determine the amount of residual urine that is present. A cytoscopy will allow the interior of the
bladder and urethra to be visualized
78. Which client diagnosed with prostate cancer would not be a candidate for watchful waiting?
a. A client with stage 0 cancer of the prostate
b. A client who is asymptomatic
c. A client who wants to avoid urinary incontinence as a result of treatment
d. A client who chooses not to be monitored with a digital rectal examination (DRE)
ANSWER: D
To participate in watchful waiting, the client must be monitored with a DRE and PSA testing. Clients who are
asymptomatic, have cancer at stage 0, and wish to avoid urinary incontinence from treatment would all be
excellent candidates for watchful waiting.
SITUATION: A breast disorder, whether benign or malignant can cause great anxiety and fear of potential
disfigurement, loss of sexual attractiveness, and even death. Nurses, therefore, must have experience in the
assessment and management of not only the physical symptoms but also the psychosocial symptoms of breast
disorder.
79. When instructing a patient on techniques to follow while performing a breast self-examination, Nurse Isabel
instructs the patient to:
a. Use 1 or 2 fingers to examine the breast
b. Perform the entire examination while standing in front of the mirror
c. Place a pillow or folded towel under the shoulder of the breast you are not examining
d. Palpate the breast in the shower while they are soapy and possible changes are easy to detect
ANSWER: D
Some women do the examination while in the shower, fingers glide easily over soapy skin, so it is more easy to
concentrate on feeling for changes inside the breast. For palpation, use palmar surface of the middle three fingers
and make a gentle rotation on the breast. The examination is performed not just standing but also while lying.
Place a pillow or folded towel under the shoulder of the breast you are examining.
: Kozier. Fundamentals of Nursing. 8th edition. Page 629
80. Nurse Mian notes from the physician's charting concern that the patient may have a malignant tumor in the
breast. Based upon assessment data, the mass when palpated is:
a. A regular shape
b. Nontender
c. Mobile tissue
d. A soft and regular shape
ANSWER: B
Malignant tumors in the breast are generally nontender, fixed rather than mobile, and hard with irregular
borders.
81. During an assessment, the client asks why the nurse is "feeling her armpit". Which of the following would be
an appropriate response for the nurse to make to this client?
a. "I'm assessing hair distribution in this area."
c. "Don't you feel your own armpits?"
b. "I'm counting the ribs."
d. "Breast tissue extends into this area."
Answer: D
Various palpation patterns may be used as long as every part of each breast is palpated, including the axillary
tail. The axillary tail is also called tail of Spence, which is the breast tissue that extends from the upper outer
quadrant toward and into the axillae.
Reference: Lemone-Burke Medical Surgical Nursing 4th ed
82. During a recent visit to the clinic, a woman who presents with erythema of the nipple and areola on the right
breast states that she discovered it several weeks ago and is fearful of what will be found. The nurse suspects:
a. Peau d' orange
b. Nipple inversion
c. Paget's disease
d. Acute mastitis
ANSWER: C
Paget disease of the breast accounts for 1% of diagnosed breast cancer cases. Symptoms typically include a
scaly, erythematosus, pruritic lesion of the nipple. Option A: orange-peel-appearance, a classical sign of
advanced breast cancer. Acute mastitis, is an inflammation or infection of breast tissue, occurs most commonly in
breastfeeding women, although it may also occur in nonlactating women.
Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 1710,1713
83. A woman who presents with dimpling of the right breast states that it occurred in the last two weeks. She has
not performed a breast self-examination. What assessment should the nurse make?
a. Evaluate the patient's milk production
c. Order an immediate mammogram
b. Palpate the area for a breast mass
d. Call the physician to schedule a biopsy
ANSWER: B
When a patient presents a breast problem the nurse conducts a general health assessment. Options A, C, and D
though important, assessment should be done first.
84. Which of these women are at greatest risk of developing breast cancer?
a. Those who breast-fed infants for more than 1 year
b. Those who experienced early menarche
c. Those who had their first full-term pregnancy after age 30
d. Those who have smoked for a year or more
ANSWER: C
The risk factors of the development of breast cancer include a family history (immediate female relatives), highfat diet, obesity after
menopause, early menarche, first child after 30, and postmenopausal hormone therapy.
Reference: Rick Daniels Medical Surgical Nursing
85. The nurse is teaching a postmenopausal patient with stage III breast cancer about the expected outcomes of
her cancer treatment. Which patient statement indicates that the teaching has been effective?
a. “After cancer has not recurred for 5 years, it is considered cured.”
b. “The cancer will be cured if the entire tumor is surgically removed.”
c. “Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and
radiation.”
d. “I will need to have follow-up examinations for many years after I have treatment before I can be considered
cured.”
ANSWER: D
The risk of recurrence varies by the type of cancer. For breast cancer in postmenopausal women the patient
needs at least 20 disease-free years to be considered cured. Some cancers are considered cured after a shorter
time span, or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.
Reference: Ignatavicius. Medical Surgical Nursing 6th ed page 271-272
86. Which comment made by the client with breast cancer indicates a need for clarification regarding cancer
causes and prevention?
a. “I will eat a low-fat diet from now on.”
b. “I know that nothing I did or didn’t do caused this cancer.”
c. “I hope my daughter doesn’t have this problem when she grows up.”
d. “I will have regular mammograms on my other breast to prevent cancer.”
ANSWER: D
Regular mammography can help detect breast cancer at an early stage, but does not prevent breast cancer.
High-fat diets have a slight connection to breast cancer development, as does obesity. For the most part, the
cause of breast cancer is unknown. Breast cancer has familial and hereditary forms. Having a mother with breast
cancer does increase a woman’s overall risk.
87. A female client is recovering from breast cancer surgery that included axillary node dissection. The nurse
realizes that this client is at risk for developing:
a. Postoperative wound infection.
b. Lymphedema.
c. Anemia.
d. Metastasis.
Answer: B
Axillary node dissection is generally performed during surgery for all invasive breast carcinomas to stage the
tumor. This surgery can cause lymphedema, nerve damage, and adhesions, as well as alter immune system
functioning. Removal of the lymph nodes does not increase risk of metastasis or anemia. Post operative wound
infection is a risk even if node dissection is not performed.
88. A client is having radiation therapy following a mastectomy. Client education should emphasize which of the
following?
a. Increasing dietary fiber
c. Prohibiting exercise for 6 months
b. Screening her sons for prostate cancer
d. Monitoring all female family members for breast cancer
ANSWER: D
The risk factors of the development of breast cancer include a family history (immediate female relatives), highfat diet, obesity after
menopause, early menarche, first child after 30, and postmenopausal hormone therapy.
89. The client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and
gown when he or she is giving the drugs to the client. What is the nurse’s best response?
a. “These coverings protect you from getting an infection from me.”
b. “I am preventing the spread of infection from you to me or any other client here.”
c. “The hospital policy is for any nurse giving these drugs to wear a gown, glove, and mask.”
d. “The clothing protects me from accidentally absorbing these drugs.”
ANSWER: D
Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, the health care
workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them.
Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and
Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing
protective clothing whenever preparing, giving, or disposing of chemotherapy drugs.
90. The client’s spouse reports that the last time the client received lorazepam (Ativan) before receiving
chemotherapy, the client didn’t remember the trip home. Which is the nurse’s best action?
a. Holding the dose of lorazepam for this round of chemotherapy
b. Explaining to the client and spouse that this is a normal response to the drug
c. Performing a Mini-Mental State Examination
d. Documenting the response as the only action
ANSWER: B
Lorazepam, a benzodiazepine, induces sedation and amnesia in addition to having antiemetic effects. Many
clients have little if any memory about events occurring within a few hours after receiving lorazepam. This is an
expected side effect and does not denote any permanent reduced cognition in the client. Both the client and
spouse should be aware of this effect so that the client is not at risk for injury. Driving, cooking, or operating
mechanical equipment should not be performed until the drug’s effects have worn off.
91. Which intervention is most important to teach the client who develops thrombocytopenia secondary to
chemotherapy?
a. “Eat a low-bacteria diet.”
c. “Use a soft-bristled toothbrush and do not floss.”
b. “Take your temperature daily.”
d. “Avoid using mouthwashes that contain alcohol.”
ANSWER: C
Thrombocytopenia means that the client’s platelets are greatly decreased in number, increasing the client’s risk
for prolonged bleeding in response to even minor injury, especially from highly vascular areas, such as the gums.
SITUATION: Cervical cancer is the second most prevalent cancer in women worldwide and fifth leading cause of
cancer deaths.
92. The client who is being treated with radiation for cervical cancer asks if she should have a mammogram.
What is the nurse’s best response?
a. “Although you should delay the mammogram until your therapy is finished, perform a breast self-examination
monthly.”
b. “Being treated for one kind of cancer does not prevent the development of another type of cancer. Have the
mammogram.”
c. “Absolutely do not have the mammogram this year, because you are already over the limit for safe exposure
levels to radiation.”
d. “The radiation therapy you are receiving will protect you against other cancer development, so it is okay to
skip the mammogram this year.”
ANSWER: B
Clients are encouraged to participate in their normal regular screening for other cancer types while they are
receiving some treatments for a different cancer type. The mammogram radiation exposure is very low and will
not interfere with the cervical cancer therapy. Also, the cervical cancer therapy will not interfere with the
mammogram.
93. A patient is receiving radiation therapy for squamous-cell carcinoma of the cervix. The nurse should be aware
of which of the following side effects of radiation therapy?
a. Migraine headaches
b. Severe pain
c. Abdominal cramping
d. Constipation
ANSWER: C
Radiation side effects are cumulative and tend to appear when the total dose exceeds body’s natural capacity to
repair the damage caused by radiation. Radiation enteritis, resulting in diarrhea and abdominal cramping and
radiation cystitis, manifested by urinary frequency, urgency, and dysuria may occur.
94. When the female patient undergoes intracavitary brachytherapy, the patient should be instructed to:
a. Stay on bed rest
c. Consume a high-residue diet.
b. Encourage her children to visit.
d. Keep the head of the bed no higher than 45 degrees.
ANSWER: A
The nurse need to explain that during the treatment:
• The patient must stay on absolute bed rest
• She may move from side to side with her back supported by pillow
• Head of bed raised to 15 degrees
• Flex and extend the feet to stretch the calf muscles promoting circulation and venous return
• Low residue diet to prevent frequent bowel movements
• Urinary catheter is in placed
• Allow no visitor who are pregnant, or who are younger than age 18 years of age to avoid radiation exposure
95. Which of the following safety guidelines is typically implemented when the patient undergoes internal
irradiation?
a. The patient is on bed rest with bathroom privileges.
b. The patient should remain perfectly still during treatment.
c. The nurse is responsible for removing the radioactive material.
d. Nurses who are or may be pregnant should not be involved in the care of this patient.
ANSWER: D
Nurses who are or maybe pregnant should not be involved in the immediate care of such patients.
96. After receiving change-of-shift report, which of these patients should the nurse assess first?
a. 35-year-old who has wet desquamation associated with abdominal radiation
b. 42-year-old who is sobbing after receiving a new diagnosis of ovarian cancer
c. 24-year-old who is receiving neck radiation and has blood oozing from the neck
d. 56-year-old who has a new pericardial friction rub after receiving chest radiation
ANSWER: C
Since neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the
neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not
immediately life threatening.
97. The client asks Nurse Isabel to explain the statement “the uncontrolled growth of malignant cells.” Nurse
Isabel would determine that the best term for this statement is:
a. Cancer
b. Diabetes mellitus
c. Hypertrophy
d. Cyst
ANSWER: A
Cancer cells are malignant neoplasms that develop rapidly, growing at the expense of healthy tissue.
Reference: White. Foundations of Nursing 3rd edition
98. When teaching the client regarding factors that can influence the cancer survival rate, Nurse Hannah
determines that the most significant factor would be:
a. Age of the client at initial diagnosis
c. Racial and ethnic background
b. Client’s response to diagnosis
d. Type of cancer
ANSWER: D
The type of cancer plays the largest role in the cancer survival rate. The remaining choices have minimal
significance to the growth rate of cancer cells.
99. When teaching a client about benign neoplasms, Nurse Daniel would state that:
a. They are able to multiply quickly and spread to distant body parts
b. They are irregular in shape with fingerlike projections
c. They are not cancerous and are usually harmless
d. They are usually found in infection-fighting organs such as lymphatic tissue
ANSWER: C
Benign neoplasms are nonmalignant growths that develop slowly; they are encapsulated and well-defined and do
not pose a major health problem unless they are found in areas that interfere with vital functions.
100. The client is diagnosed with malignant neoplasms that have multiplied quickly and spread to distant body
parts. The nurse is aware that this process is called:
a. Cellular transition
b. Metastasis
c. Osmosis
d. Transposition
ANSWER: B
Malignant neoplasms form irregularly shaped masses that have fingerlike projections. Because of their rapid
growth, cancer cells often spread from an initial site to other parts of the body via the blood or lymph systems;
this spread is known as metastasis and its progress depends on the type of cancer.
CARE OF CLIENTS WITH CELLULAR ABERRATIONS (ONCOLOGIC NURSING) 2
SITUATION: Cancer is primarily a disease of advancing age, although certain types of cancer occur
predominantly in younger age groups.
1. A client with colon cancer is discharged to home with morphine for pain management. He is having episodes of
nausea and vomiting. Which route of morphine administration would be most advantageous to use?
a. Oral
b. Rectal
c. Intravenous
d. Intramuscular
ANSWER: B
Rectal administration of opioids is recommended for clients who are NPO, nauseated, or at home. Oral agents are
the preferred route of analgesia in many cases. However, because of his nausea and vomiting, this client does
not have the functional gastrointestinal (GI) system needed for good absorption of oral agents. Intramuscular
agents are not recommended for cancer pain. Intravenous agents are recommended when oral or rectal routes
fail to provide pain control.
2. The nurse screens clients at a health fair. Which client is at highest risk for the development of colon cancer?
a. An older white female client with irritable bowel syndrome
b. A middle-aged African-American man who smokes four cigarettes a day
c. A middle-aged man who travels and eats out frequently
d. An older Chinese woman taking hormone replacement therapy
ANSWER: B
Colon cancer is more prevalent among African-American men and smokers. Irritable bowel syndrome, travel, and
hormone replacement therapy do not increase the risk for colon cancer.
3. The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become
withdrawn from family members. Which strategy will the nurse use to assist the client at this time?
a. Asking the physician for a psychiatric consult for the client
b. Explaining the improved prognosis for colon cancer with new treatment
c. Encouraging the client to verbalize feelings about the diagnosis
d. Allowing the client to remain withdrawn
ANSWER: C
The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to
verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric
consult is not appropriate for the client. The nurse should not brush aside the client’s feelings with a
generalization about cancer prognosis and treatment. The nurse should not ignore the client’s withdrawal
behavior.
4. Nurse Tentay is taching a group of clients about colorectal cancer. Nurse Tentay informs the group about the
most common symptom of colorectal cancer, that is:
a. Fatigue
b. Passage of blood in the stools
c. Change in bowel habits
d. Anorexia
ANSWER: C
The most common presenting symptom in colorectal cancer is a change in bowel habits. The passage of stool is
the second most common symptom. Symptoms may include unexplained anemia, anorexia, weight loss and
fatigue.
5. Mr. Ben, a client with colorectal cancer, is being prepared for surgery that will occur on the following day. The
nurse prepares to administer cephalexin (Keflex) to the patient and informs the patient that the goal of antibiotic
administration prior to surgery is to:
a. Treat any undiagnosed infections
c. Assist in digestion after surgery
b. Reduce the intestinal bacteria
d. Reduce abdominal distention
ANSWER: B
Antibiotics such as cephalexin (Keflex) is administered orally the day before the surgery to reduce intestinal
bacteria.
6. A client with colon cancer was referred to a general surgeon for bowel resection and needs to have a
colostomy bag as a result of his bowel surgery. The client is postoperative day three following a colostomy. Nurse
Hannah is changing the dressing and notes the stoma is dusky in color. What might this indicate?
a. Circulation to the stoma is compromised
c. This is a normal color postoperatively
b. The patient's oxygen saturation may be low
d. The stoma is blocked
ANSWER: A
The stoma should appear red, similar in color to the mucosal lining of the inner cheek and slightly moist. Very
pale or darker-colored stomas with a dusky bluish or purplish hue indicate impaired blood circulation to the area.
New stomas appear swollen but swelling generally decreases over 2 to 3 weeks or for as long as 6 weeks. Failure
of swelling to recede may indicate a problem, for example, blockage.
Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1346
7. When discussing risk factors of cancer with a client, Nurse Allan can best describe carcinogens as:
a. Biological agents used to treat certain cancers
b. Chemical substances that initiate or promote the development of cancer
c. Genetic predispositions that increase the risk of cancer
d. Organic substances that reduce the risk of some types of cancer
ANSWER: B
Risk factors for developing cancer can be classified as environmental, lifestyle, genetic, and viral. Environmental
factors include occupational exposure to various chemicals known to be carcinogenic (e.g., asbestos, vinyl
chloride, coal, tar, arsenic) or to substances such as radium or secondhand smoke. The effect of these factors
usually depends on the dose; the larger the dose or the longer the duration of exposure, the greater the risk of
cancer development.
8. Nurse Hannah is conducting a focused interview about a client's integumentary status. Which of the following
client characteristics would cause Nurse Hannah to focus on risk factors for skin cancer?
a. Is a child daycare worker
b. Female, age 35
c. Blond hair and blue eyes
d. Dark complexion
ANSWER: C
Risk factors for skin cancer include male gender, age over 50, family history of skin cancer, extended exposure to
sunlight, tendency to sunburn, light-colored hair or eyes, residence in high altitudes or near the equator, and
exposure to radiation, x-rays, or petroleum products.
9. A client thinks she has cancer because her last Pap smear identified cervical dysplasia. The best response by
the nurse is:
a. "This means the cells of your cervix have lost their useful function."
b. “This means the cells are normal."
c. "This means the cells are abnormal because of irritation."
d. "This confirms that the cells are cancerous."
ANSWER: C
Dysplastic cells show abnormal variation in size, shape, and appearance and a disturbance in their usual
arrangement. Examples of dysplasia include changes in the cervix in response to continued irritation, such as
from the human papillomavirus (HPV).
10. A client who is being treated for cancer says, "I thought the pain that I had before I was diagnosed with
cancer was bad. This is horrible." The nurse's best response is:
a. "The pain might be worse because of the cancer treatment."
c. "Pain is a frame of mind."
b. "The treatment for the cancer must not be working."
d. "Pain is the main indication of cancer."
ANSWER: A
Chronic pain may be related to treatment or may indicate progression of the disease. Identifying the pain as
treatment-related rather than tumor-related is extremely important because it has a definite effect on the client's
psychological outlook. There are other signs of cancer other than pain. In some instances, pain is a late
manifestation. There is not adequate data to indicate the treatment is ineffective. Pain is whatever the client
perceives it to be. The "frame of mind" does not determine pain.
11. Which of the following statements made by the patient during teaching for internal radiation does not indicate
the need for further teaching?
a. “My children can come visit me after school.”
b. “Individuals will need to keep at least 3 feet away when possible.”
c. “I will be sharing a room, near the nursing station.”
d. “The hospital staff will limit the amount of time in my room.”
ANSWER: D
General guidelines include assigning the patient to a private room; postradiation precaution signage; limiting the
amount of time in the room; observing a distance of at least 6 feet from the source when possible; and
prohibiting pregnant staff, family, and visitors and children from interacting or visiting with the patient.
Reference: Rick Daniels. Medical Surgical Nursing
12. The nurse understands that medications in this group of anti-neoplastics are cell-cycle nonspecific:
a. Antimetabolites
b. Mitotic inhibitors
c. Alkylating agents
d. Antibiotic agents
ANSWER: C
Alkylating agents are cell-cycle nonspecific. Antimetabolites are cycle-specific agents. Mitotic inhibitors exert their
primary effect on the G2 portion of the cell cycle. Antibiotic antineoplastic agents interfere with several portions
of the cell cycle.
13. For the client experiencing xerostomia, the nurse should:
a. Provide frequent lip lubrication with a water-soluble gel.
b. Increase the client’s IV fluids until specific gravity is greater than 1.010.
c. Instruct the client not to use aspirin.
d. Provide the client with a soft-bristled toothbrush.
ANSWER: A
Xerostomia is a dry mouth that benefits from frequent lip lubrication. Other options are incorrect.
14. When caring for a client experiencing thrombocytopenia secondary to chemotherapy, the nurse should:
a. Use aseptic technique when changing IV lines.
c. Apply pressure for three to five minutes following injections.
b. Eliminate offensive odors in the environment.
d. Administer pegfilgrastim as prescribed.
ANSWER: C
Thrombocytopenia places the client at increased risk for bleeding. Option A: This action is related to leukopenia.
Option B: This action is related to nausea and vomiting. Option D: This action is related to leukopenia.
Reference: Boyles. Pharmacologic aspects of nursing care 7th edition page 957-958
15. In treating cancer, the primary purpose of administering drugs according to a protocol or regimen of several
drugs at a time is:
a. There is a more pronounced effect of the drugs on the cancer than if the drugs were used alone.
b. The drugs have different side effects that counteract each other, thereby decreasing toxicity.
c. Since there is no definitive cure for cancer, it is best to use several at once to try to find one that will work.
d. This type of intense treatment gets the toxicities over in a shorter period of time than giving the drugs sequentially.
ANSWER: A
This increases the effectiveness of therapy and decreases the risk of cancer cells becoming resistant to therapy.
Option B: This is not true as stated. Option Ct: This is not the rationale for combination therapy. Option D: This is
not the rationale for combination therapy.
16. When teaching the client and family how to prevent the development of stomatitis and ulceration, which
client response indicates a need for further explanation?
a. “I need to do mouth care every four hours.”
c. “Rinsing my mouth after meals will help.”
b. “I should use a soft bristle toothbrush.”
d. “Commercial mouthwashes are best to use.”
ANSWER: D
Commercial mouthwashes (with alcohol) can be drying and irritating and should be avoided. Other options
indicate client understanding.
17. A nursing student teaching a client about risk factors for colorectal cancer would include:
a. Heavy alcohol consumption
c. Eating a high-fiber diet
b. Exposure to secondhand smoke
d. History of rectal polyps
ANSWER: D
The link between dietary intake and the development of some types of colorectal cancer continues to be
investigated; obesity, dietary fiber intake, history of polyps, and certain food additives are currently considered to
be risk factors.
18. A client has recently lost her mother to colon cancer. Which of the following should the nurse suggest to this
client?
a. “Have you considered being checked for the same condition?"
b. "You should make sure you get checked monthly."
c. "Have you talked with a psychologist about your loss?"
d. "Is your father still alive?"
ANSWER: A
Colon cancer is one of the most common inherited cancer syndromes. Monthly checking would be too frequent.
There is no indication the client has abnormal or unresolved psychological concerns related to the loss of her
mother. The father's current status is not the primary concern for this client's preventative health plan.
19. A patient with metastatic cancer of the colon experiences severe vomiting following each administration of
chemotherapy. An important nursing intervention for the patient is to:
a. Teach about the importance of nutrition during treatment.
b. Have the patient eat large meals when nausea is not present.
c. Administer prescribed antiemetics 1 hour before the treatments.
d. Offer dry crackers and carbonated fluids during chemotherapy.
ANSWER: C
Treatment with antiemetics before chemotherapy may help to prevent anticipatory nausea. Although nausea may
lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should
eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition Page 295, 297
20. A client is scheduled for a mastectomy. As she is about to receive the preoperative medication, she tells the
nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicates
that the nurse is acting as a client advocate?
a. Telling the client that her surgeon is excellent and knows what is best for her condition
b. Calling the surgeon to come and explain all treatment options to the client
c. Holding the client’s hand and offering to pray with her for a good outcome to the surgery
d. Arranging for a postoperative visit from a cancer survivor
ANSWER: B
Clients have the right to be fully informed about their treatment plans and to change their minds. A client
expressing doubt, uncertainty, or a change of feeling about a treatment plan should be supported by the nurse,
heard by the health care provider, and be an active participant in treatment planning. The nurse would be
functioning best as a client advocate by notifying the surgeon that the client wants a different treatment option.
The nurse would not be acting as a client advocate by providing vague reassurance, arranging for a cancer
survivor to come meet with the client, or offering to pray with the client because none of these options would
address the client’s desire for a different treatment option.
Reference: Iganatavicius. Medical Surgical Nursing 6th edition
21. The client who has just had a mastectomy is crying. When the nurse asks about her crying, the client
responds, “I know I shouldn’t cry because this surgery may well save my life.” What is the nurse’s best response?
a. “It is all right to cry. Mourning this loss is important for getting past this.”
b. “I know this is hard, but your chances of survival are better now.”
c. “Would you like to talk to someone who also has had a mastectomy?”
d. “How have you coped with difficult situations in the past?”
ANSWER: A
Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or grieving for a body
image alteration is a healthy part of adapting or adjusting to a new image. Discussing survival, talking with
someone else who has undergone mastectomy, and asking about prior coping behaviors do not address the
client’s feelings about loss of the breast.
22. The client scheduled to undergo radiation therapy for breast cancer asks why 6 weeks of daily treatment are
necessary. What is the nurse’s best response?
a. “Your cancer is widespread and requires more than the usual amount of radiation treatment.”
b. “The cost of giving larger doses of radiation for a shorter period of time is unjustified by the results.”
c. “Research has shown that more cancer cells are killed if the radiation is given in smaller doses over a longer
time period.”
d. “It is less likely that your hair will fall out or that you will become anemic if the radiation is given in small
doses over a longer time period.”
ANSWER: C
Because of varying responses of all cancer cells within a given tumor, small doses of radiation are given on a
daily basis for a set period of time. This method allows multiple opportunities to destroy cancer cells while
minimizing damage to normal tissues.
23. A client is receiving brachytherapy with a sealed radiation source for cervical cancer. Which nurse will be
assigned to provide personal care to this client while the radiation source is in the client?
a. The new nurse who has no exposure with radiation from brachytherapy
b. The pregnant nurse with expertise in oncology
c. The experienced nurse assigned to care for two other clients receiving brachytherapy
d. The nurse who is experienced with brachytherapy
ANSWER: D
The client is emitting radioactivity and poses a radiation hazard to others at this time. Anyone who is pregnant
should not enter the room. Individual care providers should wear a lead apron and should not spend more than
30 minutes a day in the room with the client receiving brachytherapy.
24. Which statement made by the client who has recently had a mammogram indicates a need for clarification
regarding the importance or purpose of this procedure?
a. “Now that I have had a mammogram, my risk for getting breast cancer is reduced.”
b. “Now that I’ve had a mammogram, I will still do a breast self-examination monthly.”
c. “Yearly mammograms can reduce my risk of dying from breast cancer.”
d. “The amount of radiation exposure from a mammogram is very low.”
ANSWER: A
Regular or yearly mammography does not decrease the incidence of breast cancer. It only assists in early
detection and diagnosis and decreases the mortality rate from breast cancer. The client should be instructed that
the mammogram uses a very small amount of radiation in the test, and that consistent scheduling of a
mammogram, along with a breast self-examination performed at least monthly, can reduce the client’s risk of
dying from breast cancer.
25. The client who has discovered a lump in her breast becomes tearful when scheduling a mammogram. Which
is the nurse’s best response?
a. “It is a good thing you called. All lumps are considered cancerous until proven otherwise.”
b. “Unless you have a relative with breast cancer, this lump is probably benign.”
c. “Diagnosing cancer at this early stage is most likely to result in a cure.”
d. “Many women have breast lumps, and 90% of the lumps are benign.”
ANSWER: D
The finding of a breast lump or mass is a frightening experience. Clients should be reassured, until they can be
seen or testing is done, that 90% of all breast lumps or masses are benign. It is inaccurate for the nurse to state
that all lumps are considered cancerous until proven benign, the lump is probably benign unless the client has a
relative with breast cancer, or diagnosing cancer at an early stage usually results in a cure.
26. A nurse empties 40 mL of sanguineous drainage from the Jackson-Pratt drain in the client’s incision on the
first day after a mastectomy and axillary node dissection. Which other actions regarding the drain will be high
priority for the nurse?
a. Flushing the tubing with urokinase to ensure patency
b. Compressing and close the drain to ensure suction
c. Advancing the tubing 1/2 inch from the insertion site
d. Clamping the drain for 2 hours and releasing the clamp for 2 hours
ANSWER: B
The Jackson-Pratt drain removes fluid from the wound through closed suction. The drain must be compressed
and closed to create suction as it slowly re-expands. The drain should never be flushed with urokinase, tubing
should not be advanced, and the drain should not be clamped and released for 2 hours.
27. Which clinical manifestation in a client with invasive cervical cancer alerts the nurse to the possibility of
metastasis?
a. Amenorrhea
b. Weight gain
c. Breast tenderness
d. Swelling of the left leg
ANSWER: D
Leg pain or unilateral swelling of a leg is a symptom of disease progression as the tumor enlarges, presses on the
sciatic nerve, and impedes venous return.
28. Why are the death rates from ovarian cancer so high?
a. The causative oncovirus is resistant to chemotherapy or radiation.
b. There are no obvious symptoms or problems during the early stages of this disorder.
c. Radiation therapy is ineffective because the ovaries are located so deep within the pelvis.
d. Ovarian cancer occurs primarily in women over age 70 who also have other complicating health problems.
ANSWER: B
Ovarian cancer is poorly detected in its early stages, when the chances for cure or control are better.
29. Which intervention is essential for the nurse to perform for the client who is receiving radiation for vaginal
cancer?
a. Assessing for perineal hypopigmentation
c. Assessing for vaginal stenosis
b. Monitoring for the onset of spontaneous menopause
d. Teaching exercises to prevent urinary incontinence
ANSWER: C
Radiation treatment causes local inflammation, leading to the development of fibrotic tissue changes that cause
adhesions and/or stenosis. Without intervention, these changes can decrease the size and elasticity of vaginal
tissues, limiting or inhibiting vaginal intercourse.
30. A patient has undergone a transurethral resection of the prostate (TURP). He has a continuous bladder
irrigation system to a three-way Foley. The patient states he has to void. What nursing intervention should the
nurse perform?
a. Call the physician
c. Irrigate the catheter.
b. Increase the flow of the irrigant
d. Tell the patient to void.
ANSWER: C
After a TURP, clots that can occlude the catheter and create a sensation to void in the patient are common. The
nurse should irrigate the catheter to allow the urine to flow.
31. A patient is 12 hours postoperative after a transurethral resection of the prostate (TURP). The patient uses
the call light to call the nurse. The patient is concerned about the blood clots in the catheter and Foley bag. How
should the nurse respond?
a. “I need to call your physician.”
b. “I will need to stop the bladder irrigation.”
c. “Blood clots are common during this time frame and will start to decrease in a day.”
d. “You need to stop moving and irritating the catheter.”
ANSWER: C
Blood clots are common during the first 36 hours following a TURP. The irrigant should not be stopped because it
is flushing the clots out the urinary system. A large amount of bright red blood would have been an indication of
hemorrhage.
32. A patient in a physician’s office is being screened for prostate cancer. What tests would be completed at this
time?
a. Digital rectal examination and transrectal ultrasonography
b. Biopsy of the prostate and magnetic resonance imagery
c. Complete blood cell count and prostate-specific antigen
d. Prostate-specific antigen (PSA) and digital rectal examination
ANSWER: D
Early screening for prostate cancer includes the digital rectal examination and a PSA test. Other test may be
ordered for confirmation of diagnosis.
33. A patient has been prescribed flutamide (Eulexin) for the treatment of prostate cancer. He asks the nurse
what information he needs to know about the medication. The nurse correctly states that:
a. “Incontinence can occur occasionally”
c. “Weight gain and loss can fluctuate”
b. “Mild insomnia and excitability can occur”
d. “A side effect is greenish urine”
ANSWER: D
Greenish urine and photosensitivity are side effects of flutamide.
Reference: Amy Karch. Focus on Nursing Pharmacology. 3rd edition. Page 208
34. The nurse has taught a 20-year-old how to perform a testicular self-examination. The statement by the
patient that indicates he understands the teaching is:
a. “It’s not necessary to feel the testes, just look at them in a mirror.”
b. “The best time to do a self-exam is after a shower, when my body is warm.”
c. “It doesn’t really matter when I do it, just do it sometime.”
d. “The physician is really the best person to check this for me.”
ANSWER: B
Testicular self-examination (TSE) is to be performed once a month. The test is neither difficult nor time
consuming. A convenient time is usually after a warm bath or shower when the scrotum is more relaxed.
35. The nurse is caring for a patient who has been diagnosed with testicular cancer. After the patient’s wife
leaves the room, the nurse notices the man looking down and squeezing his hands. Which of the following
nursing actions would assist in decreasing the patient’s anxiety?
a. Leave the room and locate the patient’s wife
c. Sit quietly on the chair in the room
b. Leave the room and pull the door closed
d. Complete your assessment as quickly as possible
ANSWER: C
You can help the patient through active listening, providing information, and referring him for counseling as
needed. Other options are not therapeutic and does not address the issue of decreasing the patient’s anxiety.
Reference: Adrian Linton. Introduction to Medical Surgical Nursing. 4th edition. Page 1101
36. The nurse is teaching a male patient to perform monthly testicular self-examinations. Which of the following
points would be appropriate to emphasize?
a. Testicular cancer is a highly curable type of cancer.
b. Testicular cancer is very difficult to diagnose.
c. Testicular cancer is the number one cause of cancer deaths in males.
d. Testicular cancer is more common in older men.
ANSWER: A
Testicular cancer is the most common cancer in men 15 to 35 years of age. Although testicular cancer occurs
most often between the ages of 15 and 40, it can occur in males of any age. It is a highly treatable and usually
curable form of cancer. Lung cancer is the number one cause of cancer death in males. Prostate cancer is
common in older men.
Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 382, 1770
37. The nurse assesses the patient on Adriamycin very carefully when the patient complains of:
a. Nausea
b. Visual disturbances
c. Headache and dizziness
d. Rapid heart beat
ANSWER: D
Adriamycin is cardiotoxic and can cause heart failure; a rapid heart would warrant an immediate assessment.
Other side effects include complete but reversible alopecia, nausea and vomiting, mucositis, red urine,
mylesuppression, fever, chills and rash.
38. To counteract the adverse effect of Doxorubicin, Nurse Hannah should do which of the following?
a. Administer Leucoverin (Wellcovorin) orally during therapy as ordered
b. Administer Dexrazoxane (Zinecard) IV 30 minutes before doxorubicin is administered as ordered
c. Administer Aprepitant (Emend) before therapy as ordered.
d. Administer erythropoietin (EPO) after therapy as ordered
ANSWER: B
Dexrazoxane (Zinecard) is a cardioprotective drug that interferes with the cardiotoxic effects of doxorubicin
(Adriamycin). Dexrazoxane is given IV 30 minutes before the doxorubicin is administered. Leucoverin is given
orally or IV to combat the adverse effect of methotrexate therapy. Aprepitant (Emend) is given to prevent nausea
and vomiting during chemotherapy. Myelosuppression is a side effect of most chemotherapeutic agents,
Erythopoietin (EPO) is given to simulate RBC production, thus decreasing the symptoms of chronic anemia and
reducing the need for blood transfusion.
Reference: Amy Karch. Focus on Nursing Pharmacology. 3rd edition. Page 199, 202
: Brunner. Medical Surgical Nursing. 11th edition. Page 400-401
39. The patient is scheduled to receive Ifosfamide for leukemia. Nurse Hannah would expect the doctor to order
which of the following drug to reduce the incidence of cyclophosphamide’s adverse effect?
a. Amifostine (Ethyol)
b. Leucoverin (Wellcovorin)
c. Mesna (Mesnex)
d. Ondansetron (Zofran)
ANSWER: C
Mesna (Mesnex) is a cytoprotective drug agent that is used to reduce the incidence of hemorrhagic cystitis
caused by ifosfamide or cyclophosphamide. Mesna, which is known to react chemically with urotoxic metabolites
of ifosfamide, is given IV at the time ifosfamide injection and is repeated 4 hours and 8 hours afterward.
Amifostine (Ethyol) is a cytoprotective drug that protect the healthy cells from toxic effects of Cisplatin.
Leucoverin is for methotrexate toxicity. Ondansetron (Zofran) is an antiemetic drug for nausea and vomiting
induced by chemotherapy.
Reference: Amy Karch. Focus on Nursing Pharmacology. 3rd edition. Page 193, 197, 199
SITUATION: Cancer is not a single disease; rather, it is a group of distinct diseases with different causes,
manifestations, treatments and prognosis. Cancer nurses must be prepared to support patients and families
through wide range of physical, emotional, social, cultural, and spiritual crisis.
40. A patient tells the nurse that he has heard that certain foods can increase the incidence of cancer. The nurse
informs the patient that certain foods appear to increase the risk of cancer. Which of the following menu
selections would be the best choice for reducing the risk of cancer?
a. Smoked salmon and green beans
c. Baked apricot chicken and steamed broccoli
b. Pork chops and fried green tomatoes
d. Liver, onions, and steamed peas
ANSWER: C
Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats,
nitrate and nitrite-containing foods. A high caloric diet intake is also associated with an increased cancer risk.
Consumption of high fiber foods (such as fruits, vegetables and whole grain cereals) and cruciferous vegetables
(such as cabbage, broccoli, cauliflower) appears to decrease the risk of cancer.
41. Which of the following would be an example of primary prevention?
a. Yearly Papanicolaou tests
c. Teaching patients to wear sunscreen
b. Testicular self-examination
d. Screening mammogram
ANSWER: C
Primary prevention is reducing cancer risks by helping patients avoid known carcinogens. In primary prevention
nurses can use their teaching and counseling skills to encourage patients to participate in cancer prevention
programs and adopt healthy lifestyles. Secondary prevention is early detection and prompt treatment. Options A,
B and D are secondary preventions.
Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 388-389
42. A patient has a cancer that has been staged as T3 N2 M3. He has a PRN order of morphine, 4 mg, IM q3-4hr.
He requests another pain shot about 2 hours and 45 minutes after the last one. An appropriate nursing action
would be to:
a. Inform the patient that this narcotic may be given only every 4 hours to prevent addiction
b. Ignore the call bell for 20 minutes, and then take at least 10 minutes to prepare and administer the injection
c. Give the morphine; evaluate the results of pain relief. Arrange for the physician to evaluate for breakthrough pain
d. Ask the family to assist in helping the patient accept waiting longer to receive an addicting medication such as
morphine
ANSWER: C
Terminal care does not include concerns about morphine addiction. Medication may be given 15 minutes before
or after an allotted time. The occurrence of breakthrough pain is a real concern for this patient.
Reference: Adrian Linton. Introduction to Medical Surgical Nursing. Page 371
43. The nurse assesses beginning acceptance of the diagnosis of cancer when the patient:
a. Begins to act in a cheerful manner
c. Cries over loss of health
b. Inquires about support groups
d. Actively interacts with his or her family
ANSWER: C
Directed planning for support for the diagnosis is indicative of acceptance. Crying and a cheerful manner are not
necessarily positive. Interaction with the family is not indicative of acceptance.
Reference: Adrian Linton. Introduction to Medical Surgical Nursing. Page 391
SITUATION: A breast disorder, whether benign or malignant can cause great anxiety and fear of potential
disfigurement, loss of sexual attractiveness, and even death. Nurses, therefore, must have experience in the
assessment and management of not only the physical symptoms but also the psychosocial symptoms of breast
disorder.
44. When instructing a patient on techniques to follow while performing a breast self-examination, the nurse
instructs the patient to:
a. Use 1 or 2 fingers to examine the breast
b. Perform the entire examination while standing in front of the mirror
c. Place a pillow or folded towel under the shoulder of the breast you are not examining
d. Palpate the breast in the shower while they are soapy and possible changes are easy to detect
ANSWER: D
Some women do the examination while in the shower, fingers glide easily over soapy skin, so it is more easy to
concentrate on feeling for changes inside the breast. For palpation, use palmar surface of the middle three fingers
and make a gentle rotation on the breast. The examination is performed not just standing but also while lying.
Place a pillow or folded towel under the shoulder of the breast you are examining.
: Kozier. Fundamentals of Nursing. 8th edition. Page 629
45. The nurse notes from the physician's charting concern that the patient may have a malignant tumor in the
breast. Based upon assessment data, the mass when palpated is:
a. Nontender
b. A regular shape
c. A soft and regular shape
d. Mobile tissue
ANSWER: A
Malignant tumors in the breast are generally nontender, fixed rather than mobile, and hard with irregular
borders.
46. The nurse instructing a group of high school girls on the importance of breast self-examination informs the
teenagers that the best time to perform a breast self-examination is:
a. Every other month
b. On the last day of menstruation
c. On the first day of menstruation
d. 5 to 7 days after menses, counting the first day of menses as day 1
ANSWER: D
Most women notice increased tenderness and lumpiness before their menstrual periods; therefore, BSE is best
performed after menses (day 5 to day 7, counting the first day of menses as day 1).
47. When planning patient education for a woman diagnosed with breast cancer, the nurse recognizes that the
patient has an increased risk for developing:
a. Breast cancer
b. Cervical cancer
c. Ovarian cancer
d. Lung cancer
ANSWER: C
A woman with breast cancer has an increased for ovarian cancer and a woman with ovarian cancer has threefold
to fourfold increased for breast cancer.
48. The patient is a 39-year-old woman with a family history of breast cancer. A breast-tumor marking test is
done, and the results are positive. The patient is requesting a bilateral mastectomy. This surgery is an example
of which of the following?
a. Salvage surgery
b. Palliative surgery
c. Prophylactic surgery
d. Reconstructive surgery
ANSWER: C
Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer.
Colectomy, mastectomy, and oophorectomy are examples of prophylactic surgery. Recent developments in the
ability to identify genetic markers indicative of a predisposition to develop some types of cancer may play a role
in decisions concerning prophylactic surgeries. Option B: When cure is not possible, the goal of treatment are to
make the patient as comfortable as possible and to promote a satisfying and productive life for as long as
possible. Palliative surgeries are performed in attempt to relieve complications of cancer such as ulcerations,
obstructions, hemorrhage, pain, and malignant effusion. Option D: Reconstructive surgery may follow curative or
radical surgery and is carried out in attempt to improve function or obtain a more desirable cosmetic effect.
Option A: No such thing as salvage surgery.
49. When instructing the patient on breast self-examinations, the nurse tells the patient to raise her arms and
inspect the breast in the mirror. The patient asks the nurse why she needs to do this. The nurse's best response
is:
a. “It will give you greater visibility.”
c. “It will help to observe for dimpling.”
b. “If you feel pain you will need to inspect it.”
d. “Everyone is different in assessing the breast.”
ANSWER: C
To elicit skin dimpling or retraction that may otherwise go undetected, the examiner instructs the patient to raise
both arms overhead. This maneuver normally elevates both breasts equally.
50. During a community lecture, the nurse is instructing women on self breast examinations. One of the
participants asks why her breasts become tender. Prior to explaining the cause of the pain, the nurse should
ascertain whether:
a. The pain occurs prior to her menstrual period
c. She has given birth to children
b. She has dimpling in any breast site
d. She exercises daily or occasionally
ANSWER: A
Most women notice increased tenderness and lumpiness before their menstrual periods; therefore, BSE is best
performed after menses (day 5 to day 7, counting the first day of menses as day 1).
51. A male patient states my mother, grandmother, and sister died of breast cancer. What information should the
nurse provide to the patient?
a. “Men do not get breast cancer; only women are affected.”
b. “The fact your relatives had breast cancer has no affect on you.”
c. “I wouldn't worry about your risk of breast cancer.”
d. “It is true that men with a family history are at risk for cancer.”
ANSWER: D
Breast cancer can occur in men. Family history of breast cancer can put the client at risk with breast cancer.
52. A woman who was diagnosed with breast cancer at age 48 asks the nurse when her teenage daughters
should begin mammography. What is your best advice?
a. Age 28 years
b. Age 35years
c. Age 38 years
d. Age 40 years
ANSWER: C
A general guideline is to begin screening ten years earlier than the age at which the youngest family member
developed breast cancer but not before 25 years of age. In families with a history of breast cancer, a downward
shift in age of diagnosis of about 10 years is seen (e.g. Mother diagnosed with breast cancer at age 48, then
daughter should begin screening at age 38)
53. A woman visits the clinic and tells the nurse she has had a bloody drainage from her right nipple. Which of
the following diagnostic tests would the nurse expect the physician to order on this patient?
a. Ultrasound
b. Mammogram
c. Computer-assisted detection
d. Galactography
ANSWER: D
Galactography is performed to evaluate abnormality within the duct when the patient has bloody nipple discharge
on expression, spontaneous nipple discharge, or a solitary dilated duct noted on mammography.
54. A patient voices concerns of repeated exposure to radiation with her upcoming mammogram. The nurse
teaches the patient that a mammogram:
a. Does not use radiation
b. Is a risky procedure and the benefits and risks must be carefully considered
c. Uses radiation that may cause skin cancer
d. Is equivalent to an hour of sunlight
ANSWER: D
Patients scheduled for a mammogram may voice concern about exposure to radiation. The radiation exposure is
equivalent to about 1 hour of exposure to sunlight, so patients would have to have many mammograms in a year
to increase their cancer risk.
55. A 52-year-old woman admitted to the same-day surgical unit for wire needle localization and biopsy states,
“My surgeon explained the need for putting a wire in my breast, but I don't remember exactly why I need to have
it.” What is the nurse's best response?
a. “I have not seen it done before but I understand that it is for aspirating the fluid.”
b. “The wire is used to locate the mass using an x-ray and it will establish the location.”
c. “You will have a core biopsy with the use of the MRI to find the mass.”
d. “You will have a portion of the mass removed and then the surgeon will decide the treatment.”
ANSWER: B
Wire needle localization is a technique used to locate nonpalpable masses or suspicious calcium deposits detected
on mammogram, ultrasound, or MRI that require an excisional biopsy. The radiologist inserts a long, thin wire
through a needle, which is then inserted into the area of abnormality using x-ray. The wire remains in place after
the needle is withdrawn to ensure precise location.
56. Following a right mastectomy, a patient tells the nurse it feels like her nipple is still present. Which of the
following is the nurse's best explanation?
a. “The feeling of the nipple is related to the dressing.”
c. “Once the wound heals that feeling will go away.”
b. “The sensation will disappear in a few months.”
d. “I will call your doctor and see if that is normal.”
ANSWER: B
Because nerves in the skin and axilla are often cut or injured during breast surgery, patients experience a variety
of sensations. Common sensations include tenderness, soreness, numbness, tightness, pulling and twinges.
These sensations may occur along the chest wall, in the axilla, and along the side of the upper arm. After
mastectomy, some patients experience phantom sensations and report a feeling that the breast and or nipple are
still present. Sensations usually persists for several months and then begin to diminish, although some may
persist for as long as 2 years and possibly longer. Patient should be reassured that this is a normal part of
healing and that these sensations are not indicative of problem.
57. The nurse performing discharge planning with a patient who has undergone a total mastectomy and axillary
dissection instructs the patient that she should report which of the following signs or symptoms to the physician
immediately?
a. Tightness and tingling across the chest wall
b. Temperature of 98.5° F
c. Gross swelling and a large amount of output from the drainage device
d. Swelling in the arm on the side of the mastectomy
ANSWER: C
Hematoma formation may occur after either mastectomy or breast conservation and usually develops within the
first 12 hours after surgery. The nurse assesses for signs and symptoms of hematoma at the surgical site, which
may include swelling, tightness, pain, and bruising of the skin. The surgeon should be notified immediately for
gross swelling or increased bloody output from the drain.
58. A radical mastectomy and axillary node dissection have been performed on a patient. Which of the following
should be included in patient education regarding hand and arm care of the affected side?
a. Avoid lifting objects greater than 20 pounds.
c. Avoid venipuncture.
b. Keep cuticles clipped.
d. Use a sunscreen with an SPF of 4 to 8.
ANSWER: C
Hand and arm care after Axillary Lymph Node Dissection
•
Avoid BP, injections and blood draws in the affected extremities
•
Use sunscreen (higher than SPF 15)
•
Apply insect repellant
•
Wear gloves for gardening
•
Use cooking mitt for removing objects from oven
•
Avoid cutting cuticles; push them back during manicures
•
Use electric razor for shaving armpit
•
Avoid lifting objects greater than 5 to 10 pounds
SITUATION: Cervical cancer is the second most prevalent cancer in women worldwide and fifth leading cause of
cancer deaths.
59. A nurse working in a health clinic for women cares for numerous patients daily. Based upon the patients
receiving care on this particular day, which of the following would be at the greatest risk for developing cervical
cancer?
a. An 18-year-old woman with no children, with multiple sex partners
b. A 17-year-old girl who is a smoker
c. A 43-three-year-old smoker who had her first child at age 16
d. A 32-year-old woman who had her first child at age 30 and quit smoking 3 years ago
ANSWER: C
Risk factors for cervical cancer includes:
•
Mutiple sex partner
•
Early age at first coitus (20 year old below)
•
Sex with uncircumcised male
•
Sexual contact with males whose partners have had cervical cancer
•
Early childbearing
•
Family history of cervical cancer
•
Overweight status
•
Exposure to HPV
•
Smoking and exposure to second hand smoke
60. The nurse is developing a teaching plan for a patient being screened for cervical cancer. When discussing risk
factors of cervical cancer, the nurse would be correct in identifying which of the following as the most important
risk factor?
a. Late childbearing
c. Postmenopausal bleeding
b. Human papillomavirus (HPV)
d. Obesity
ANSWER: B
Most cervical cancers are often due to exposure to HPV. Other risk factors for Cervical cancer includes:
•
Mutiple sex partner
•
Early age at first coitus (20 year old below)
•
Sex with uncircumcised male
•
Sexual contact with males whose partners have had cervical cancer
•
Early childbearing
•
Family history of cervical cancer
•
Overweight status
•
Smoking and exposure to second hand smoke
61. A patient is receiving radiation therapy for squamous-cell carcinoma of the cervix. The nurse should be aware
of which of the following side effects of radiation therapy?
a. Migraine headaches
b. Severe pain
c. Abdominal cramping
d. Constipation
ANSWER: C
Radiation side effects are cumulative and tend to appear when the total dose exceeds body’s natural capacity to
repair the damage caused by radiation. Radiation enteritis, resulting in diarrhea and abdominal cramping and
radiation cystitis, manifested by urinary frequency, urgency, and dysuria may occur.
62. When the female patient undergoes intracavitary brachytherapy, the patient should be instructed to:
a. Encourage her children to visit.
c. Consume a high-residue diet.
b. Deep breathe and cough every 2 hours.
d. Keep the head of the bed no higher than 45 degrees.
ANSWER: B
The nurse need to explain that during the treatment:
•
The patient must stay on absolute bed rest
•
She may move from side to side with her back supported by pillow
•
Head of bed raised to 15 degrees
•
She should be encouraged to practice deep breathing and coughing exercise
•
Flex and extend the feet to stretch the calf muscles promoting circulation and venous return
•
Low residue diet to prevent frequent bowel movements
•
Urinary catheter is in placed
•
Allow no visitor who are pregnant, or who are younger than age 18 years of age to avoid radiation
exposure
63. The patient is receiving carmustine, a chemotherapy agent. A side effect of this medication is
thrombocytopenia. What symptom will the nurse likely assess in the patient with thrombocytopenia?
a. Interrupted sleep pattern
b. Hot flashes
c. Nosebleed
d. Increased weight
ANSWER: C
Thrombocytopenia, a decrease in the circulating platelet count, is the common cause of bleeding in patients with
cancer and is usually defined as a platelet count of less than 100,000/mm3.
64. When preparing to administer an antineoplastic agent to a hospitalized patient, the nurse should:
a. Chemotherapy calculations should be checked by a single nurse
b. Prime the tubing with the chemotherapy drug
c. Use clean gloves and a lab coat
d. Use Luer-Lok fittings on all intravenous tubing used to deliver chemotherapy
ANSWER: D
Preparation of chemotherapy drugs: Before administering consult with the pharmacist, Chemotherapy
calculations and drugs should be checked by two nurses against written orders to prevent errors that may result
from misplacement of decimal point or dispensing the wrong drug, Prepare under vented, laminar flow cabinet
with the blower operated around the clock, wash hands before and after administration, Use Luer-Lok on all IV
tubings, Prime the tubing before adding chemotherapy to IV bag, dispose in hazardous waste receptacles, wear
surgical gloves and disposable long-sleeved gown when preparing and administering chemotherapy drug
: Joyce Black. Medical Surgical Nursing. 8th edition. Page 279
: Donna Gauwitz. NSNA. NCLEX Review. Page 532
65. A female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of
disturbed body image and situational low self-esteem. Which of the following actions best indicates that the
patient is meeting the goal of improved body image and self-esteem?
a. The patient requests that her family bring her makeup and wig.
b. The patient begins to discuss the future with her family.
c. The patient reports less disruption from pain and discomfort.
d. The patient cries openly when discussing her disease.
ANSWER: A
For many patients, hair loss is a major assault on body image, resulting in depression, anxiety, anger, rejection
and isolation. The patient is encouraged to acquire wig or hairpiece before hair loss occurs so that the
replacement matches the patient’s own hair; option A exhibits interest in appearance by requesting aids
appropriately.
66. Patients receiving chemotherapy are at risk for adverse effects related to the therapy. To combat the most
common adverse effects of chemotherapy, the nurse would administer an:
a. Antiemetic
b. Antimetabolite
c. Tumor antibiotic
d. Anticoagulant
ANSWER: A
Nausea and vomiting are most common side effects of chemotherapy and may persist for as long as 24 to 48
hours after its administration. To minimize discomfort, some antiemetic medications are necessary for the first
week at home after chemotherapy. Medications that can decrease nausea and vomiting include metoclopramide
(Reglan).
67. Nurse Hannah is preparing a class on chemotherapy administration for a group of student nurses. Which of
the following routes of administration should Nurse Hannah include in the class?
I. Intramuscularly
III. Rectal
V. Oral
II. Intravenous
IV. Intrathecal
VI. Topical
a. II, IV, V
b. All except III
c. All except I
d. All of the above
ANSWER: B
The IV and oral routes are the most common routes for chemotherapy administration for the majority of cancers.
The intrathecal route may be used to circumvent the blood brain barrier when cancer involves the CNS. The
rectal route is not used for chemotherapy administration.
68. Which of the following is a priority for Nurse Isabelle to monitor for a client receiving ifosfamide (Ifex) for
testicular cancer?
a. Hemorrhagic cystitis
b. Alopecia
c. Phlebitis
d. Liver dysfunction
ANSWER: A
Ifosfamide is an alkylating antineoplastic drug used in the treatment of testicular cancer. It must always be
administered with mesna (Mesnex), the antidote for ifosfamide toxicity. Ifex is metabolized to products that
cause hemorrhagic cystitis. At least two liters of oral or IV fluids should be given with mesna (Mesnex) to prevent
bladder toxicity. Other less serious side effects include alopecia, phlebitis, and liver dysfunction.
:Amy Karch. Focus on Nursing Pharmacology.3rd edition. Page 193
69. Which of the following is a priority for the nurse to monitor in a client who is receiving mitoxantrone
(Novantrone) for leukemia?
a. Pneumonia
b. Amenorrhea
c. Mucositis
d. Congestive heart failure
ANSWER: D
Mitoxantrone (Novantrone) is an antineoplastic drug used in the treatment of leukemia. It can cause a potentially
fatal congestive heart failure. Other less serious side effects include amenorrhea, mucositis and pneumonia.
: Amy Karch. Focus on Nursing Pharmacology.3rd edition. Page 201
70. Nurse Miannie is caring for a 31-year old female with ovarian cancer who is receiving cisplatin (Platinol).
Which of the following is a priority to include in this client’s plan of care?
a. Monitor BUN and creatinine
c. Instruct the client to use a reliable method of birth control
b. Instruct the client to report tinnitus
d. Maintain IV hydration
ANSWER: C
It is a priority to instruct a client who is of childbearing age and receiving cisplatin (Platinol) to take reliable
method of birth control. Testicular and ovarian function can be affected by chemotherapeutic agents, resulting in
possible sterility. Reproductive cells may be damaged during treatment rsulting in chromosomal abnormalities on
offspring. Banking of sperm is recommended for men before treatments are initiated to protect against sterility or
any mutagenic damage to sperm. Options A, B and D are all appropriate interventions but not the priority.
71. Nurse Daniel is teaching a class on the various types of chemotherapy agents. Which of the following
examples of chemotherapy agents should the nurse include in the cell cycle specific group?
I. Cyclophosphamide
III. Doxorubicin
V. Methotrexate
II. Cisplatin
IV. 5-flurouracil
VI. Vincristine
a. I, II, III
b. IV, V, VI
c. III, IV, V, VI
d. All except III
ANSWER: B
5-FU, methotrexate and Vincristine are all cell cycle specific chemotherapeutic drugs.
72. Prior to initiating chemotherapy administration for a client, the nurse should consider which of the following
principles?
a. All chemotherapy drugs must be administered by an infusion pump
b. Vesicant drugs should be infused before non-vesicant drugs
c. The client’s arm should be elevated throughout the administration
d. The IV line should be flushed with 20 ml of D5W between drugs
ANSWER: B
Vesicant chemotherapy agents should be administered before non-vesicant drugs if two such drugs are ordered in
combination. This is due to the fact that the best blood flow, condition of the vein, and site are desired for
administration of a potentially tissue damaging drug (vesicant). Since these factors could deteriorate during
administration, the nurse should start with the vesicant. Some chemotherapy agents should be administered with
an infusion pump, but others should not. The client’s arm should be in natural, relaxed position during
administration. The IV line should be flushed approximately 10 ml of normal saline between administrations of
chemotherapy drugs.
Reference: Joyce Black. Medical Surgical Nursing. 8th edition. Page 279
:Donna Gauwitz. NSNA. NCLEX Review. Page 533
73. In planning care of a client experiencing fatigue related to chemotherapy, which of the following is the most
appropriate nursing intervention?
a. Prioritize and administer nursing care throughout the day
b. Accomplish all the nursing cares early in the day so the client can rest the remainder of the day
c. Perform all nursing cares during the evening shift when the client is most rested
d. Limit the number of visitors, promoting a maximum opportunity for sleep
ANSWER: A
Client should be taught to pace their activities throughout the day in order to conserve energy; therefore nursing
cares should be placed as well. While adequate sleep is important, maximal sleep will not completely resolve
clinical manifestations. Completely restricting visitors does not promote healthy coping and may result in
isolation.
74. Six days after receiving chemotherapy, the client reports that, “My mouth feels like it’s on fire!” Which of the
following is the priority nursing action?
a. Encourage rinsing mouth several times per day with an OTC mouthwash
b. Administer analgesic as ordered
c. Assess the oral mucosa for signs of infection and tissue breakdown
d. Instruct the client to eat small, frequent meals of soft food
ANSWER: C
Adverse reactions of chemotherapy include stomatitis and mucositis in some clients. The nurse should always
first assess the client’s oral mucosa for signs of breakdown and infection. Pain medication may be necessary to
administer, but this is not the first action the nurse should take. Rinsing the oral mucosa is encouraged, but with
salt or soda solution, not OTC mouthwashes, which can be drying. Clients should eat small, frequent meals of
soothing foods after chemotherapy, but usually this is not required after the first week, and again, the nurse
should perform an assessment before implementing a plan of care.
75. A nurse who is caring for an adult patient who develops a mild oral yeast infection following chemotherapy
should encourage the patient to:
a. Avoid the use of a lip lubricant
b. Scrub the tongue with a firm-bristled toothbrush
c. Avoid the use of dental floss until the stomatitis is resolved
d. Rinse the mouth with normal saline
ANSWER: D
Mild yeast infection is managed by rinsing the mouth with normal saline every two hours while awake; every 6
hours at night to remove debris and thick secretions. Lip lubricant is used to keep them from drying. Tongue is
scrubbed with soft toothbrush. Avoid commercial mouthwashes. Flossing may be performed unless it causes pain
or unless platelet levels are less than 40,000/mm3.
Reference: Brunner. Medical Surgical Nursing. 11th edition. Page 406, 427
76. A senior female college student has had a melanoma of the forehead surgically removed and given a course
of chemotherapy. Which of the following comments that she has made demonstrate her appropriate
understanding of the treatments and prognosis?
a. “Why did you bring me this shampoo? You guys took all my hair, so I don’t have anything to wash or fix.”
b. “Why don’t my friends from school come to visit? Did you tell them to stay away?”
c. “My Prom dance is only 3 weeks away. Do you think I could find a wig to cover my head where the hair fell out
from the chemo?”
d. “Well, this looks like the end of the problem for me, thank goodness! I won’t have to bother that doctor again
until I graduate in a couple of years because all my shots must be up to date now.”
ANSWER: C
Acceptance of the diagnosis, treatments, side effects, and prognosis by the patient are important so that the
nurse can judge their understanding and acceptance by the patient. To help the patient retain control and
positive self-esteem, it is important to encourage independence and continued participation in self care and
decision making. Option C demonstrates acceptance and participation.
SITUATION: Mr. Ben was 35 when his doctor told him the grim news: He had advanced colon cancer. As far as
he knew, Mr. Ben had no family history of the disease. But after checking, Mr. Ben learned that several aunts and
uncles had died of colon cancer at an early age.
77. Nurse Daniel is reviewing the patient's chart and is asking questions related to risk factors for colorectal
cancer. Which of the following does Nurse Daniel identify as a risk factor associated with colorectal cancer?
a. Age greater than 50
c. Family history of stomach cancer
b. History of bowel obstruction
d. Low-fat, low-protein, low-fiber diet
ANSWER: A
The exact cause of colon and rectal cancer is still unknown, but risks factors have been identified.
•
Increasing age
•
Family history of colon cancer or polyps
•
Previous colon or adenomatous polyps
•
History of inflammatory bowel disease
•
High fat, high protein, low fiber diet
•
Genital cancer (endometrial cancer, ovarian cancer) or breast cancer (in women)
78. The nurse is interviewing a patient about his past medical history. Which preexisting condition may lead the
nurse to suspect that a patient has colorectal cancer?
a. Duodenal ulcers
b. Hemorrhoids
c. Weight gain
d. Polyps
ANSWER: D
•
Increasing age
•
•
•
•
•
79. The nurse is conducting a screening for colorectal cancer. The patient with the highest risk of colorectal
cancer is a:
a. 52-year-old man with a family history of polyposis
b. 32-year-old woman with a history of skin cancer
c. 61-year-old man with a history of gastric ulcers
d. 42-year-old man following a low-fat, 1800-calorie diet
ANSWER: A
•
Increasing age
•
•
•
•
•
80. When teaching a group of patients about colorectal cancer, the nurse informs the group that the most
common symptom is:
a. Passage of blood in the stools
c. Anorexia
b. Fatigue
d. A change in bowel habits
ANSWER: D
The most common presenting symptom in colorectal cancer is a change in bowel habits. The passage of stool is
the second most common symptom. Symptoms may include unexplained anemia, anorexia, weight loss and
fatigue.
82. Mr. Ben was referred to a general surgeon for bowel resection and needs to have a colostomy bag as a result
of his bowel surgery. Mr. Ben is postoperative day three following a colostomy. The nurse is changing the
dressing and notes the stoma is dusky in color. What might this indicate?
a. This is a normal color postoperatively
c. Circulation to the stoma is compromised
b. The patient's oxygen saturation may be low
d. The stoma is blocked
ANSWER: C
The stoma should appear red, similar in color to the mucosal lining of the inner cheek and slightly moist. Very
pale or darker-colored stomas with a dusky bluish or purplish hue indicate impaired blood circulation to the area.
New stomas appear swollen but swelling generally decreases over 2 to 3 weeks or for as long as 6 weeks. Failure
of swelling to recede may indicate a problem, for example, blockage.
Reference: Kozier. Fundamentals of Nursing. 8th edition. Page 1346
83. Which of the following should be included in the teaching about dietary management for a patient who has a
colostomy?
a. Experiment with an irritating food several times before eliminating it
b. Fluid intake should be decreased to prevent diarrhea
c. Diet should be high in fiber
d. Cabbage should be included to aid in digestion
ANSWER: A
The nurse advises the patient to experiment with an irritating food several times before restricting it, because an
initial sensitivity may decrease with time. The patient avoids that cause excessive odor and gas, including foods
in the cabbage family, eggs, fish, beans, and high cellulose products such as peanuts. Fluids is encouraged for
diarrhea. Low fiber to prevent diarrhea.
SITUATION: A cancer is an abnormal growth of cells (usually derived from a single cell). The cells have lost
normal control mechanisms and thus are able to expand continuously, invade adjacent tissues, migrate to distant
parts of the body, and promote the growth of new blood vessels from which the cells derive nutrients. Cancerous
(malignant) cells can develop from any tissue within the body.
84. The nurse includes in the teaching plan that malignant tumors are similar to benign tumors because both:
a. Contain cells that closely resemble those in the tissue of origin
b. Travel quickly to invade and destroy other tissues and organs
c. Always grow and multiply very rapidly, competing for space and nutrients and causing severe pain
d. May press on nearby surrounding tissues, such as nerves and blood vessels, causing pain
ANSWER: D
Both benign and malignant tumor depending on the location may press surrounding tissues, such as nerves and
blood vessels causing pain. Option A is for benign tumor. Option B and C are characteristic of a malignant tumor
Reference: Adrian Linton. Introduction to Medical Surgical Nursing. 4th edition. Page 370
85. Which of the following actions if made by a client with cancer indicates a need for further teaching by the
nurse?
a. Brushing teeth with a soft bristle toothbrush
c. Avoiding hard or spicy foods
b. Lubricating lips with petroleum jelly
d. Rinsing with an alcohol-based mouthwash
ANSWER: D
Rinsing with an alcohol-based mouthwash will dry and break down oral tissue. Option A is incorrect because a
soft toothbrush will prevent oral trauma. Option B is incorrect because lubricating lips will soften them and
prevent cracking. Answer C is incorrect because
avoiding hard or spicy foods helps to prevent irritation.
86. A client with cancer is admitted with fever of 103.4° F and a platelet count of 18,000/mm3. Nurse Hannah
can expect in doctor’s order to include:
a. Aspirin every four hours while febrile
c. Restriction in some activities
b. Seizure precautions
d. Tracheostomy set at bedside
ANSWER: C
Prevention of injury, bruising, and bleeding is highest priority when the platelet count is low. Normal platelet
count is 150,000–500,000/mm3. Option A is incorrect because ASA is contraindicated in bleeding disorders.
Option B is incorrect because seizure precautions are not indicated unless the client’s temperature exceeds 105°
F. Option D is incorrect because there is no risk for airway based on the information provided.
87. A client with neutropenia has been admitted from the Emergency department. What is the priority nursing
intervention at this time?
a. Thorough hand-washing before client contact
c. Give pain medication as ordered
b. Start two or more large-bore IVs
d. Request hypoallergenic sheets from the laundry
ANSWER: A
The client with neutropenia is at high risk for infection due to low white blood cell count; therefore, hand-washing
is the first-line barrier that will protect them from infection. Options B, C, and D can be done at another time, but
are not priorities, so they are incorrect.
88. A cancer patient has been given a 6-month prognosis and would like to die at home. The patient's care needs
are unable to be met in a home environment. What might the nurse suggest as an alternative?
a. A rehabilitation hospital
b. A personal care home
c. Acute care
d. Hospice care
ANSWER: D
For many years, society was unable to cope appropriately with patients in the most advanced stages of cancer,
and patients died in acute care settings rather than at home or in facilities designed to meet their needs. The
needs of patients with terminal illnesses are best met by a comprehensive multidisciplinary program that focuses
on quality of life, palliation of symptoms, and provision of psychosocial and spiritual support for the patient and
family when cure and control of the disease are no longer possible. The concept of hospice best addresses these
needs.
89. A 58-year-old male is hospitalized for a wedge resection of the left lower lung lobe. A routine chest x-ray
shows carcinoma. The patient is anxious and asks if he can smoke. Which of the following statements by the
nurse would be most therapeutic?
a. "Smoking is the reason you're here."
b. "The doctor left orders for you not to smoke."
c. "You're anxious about the surgery. Do you see smoking as helping?"
d. "Smoking is OK right now, but after your surgery it's contraindicated."
ANSWER: C
Patients often experience distress related to the underlying cancer or treatments. These symptoms may interfere
with work and quality of life. The nurse assesses for these problems and helps the patient identify strategies for
coping with them. Other options are not therapeutic.
SITUATION: Disorders of the male reproductive system include a wide variety of conditions that usually affect
both urinary and reproductive systems.
90. The nurse cautions that the most common site of cancer in adult men is the:
a. Colon
b. Lung
c. Pancreas
d. Prostate
ANSWER: D
Prostate cancer accounts for 33% of estimated new cases of types of cancer in men. Lung cancer accounts for
13%. Colon cancer 12%. Pancreatic cancer 2%.
91. Which of the following men should receive teaching regarding the genetic predisposition of prostate cancer?
a. Native Americans
b. European Americans
c. African Americans
d. Asian Americans
ANSWER: C
Prostate cancer rates are twice as high in African American men than in Caucasian men, and African American
men are more likely to die of prostate cancer than men in any other racial or ethnic group.
92. A community health nurse is providing a cancer prevention class at a local church. The nurse informs the
class that digital rectal examination (DRE) used to screen for cancer of the prostate is recommended for every
man:
a. Abstaining from sexual activity
b. Over age 18
c. Over age 35
d. Over age 50
ANSWER: D
When prostate cancer is detected early, the likelihood of cure is high. Every man older than 50 years of age
should have an annual DRE and PSA test as part of his regular health checkup. These test are recommended for
younger men (40-45 years of age) if they are at high risk for prostate cancer.
93. When the progress notes reflect that digital rectal examination (DRE) revealed extensive hardening in the
posterior lobe of the prostate gland, the nurse recognizes that the observation typically indicates:
a. A normal finding
c. Evidence of a more advanced lesion
b. A sign of early prostate cancer
d. Metastatic disease
ANSWER: B
Routine repeated rectal palpation of the gland (preferably by the same examiner) is important because early
cancer may be detected as a nodule within the substance of the gland or as an extensive hardening in the
posterior lobe. The more advanced lesion is “stony hard” and fixed. Normal prostate is small (about the size of a
chestnut), smooth, mobile, and
median sulcus is palpable.
:Delmar. Fundamentals of Nursing. 2nd edition. Page 614
94. A hospitalized patient is placed on diethylstilbestrol (DES) for prostate cancer. The nurse explains the
possible side effects of the medication, which is:
a. Gynecomastia
b. Pruritus
c. Constipation
d. Tinnitus
ANSWER: A
DES relieves symptoms of advanced prostate cancer, reduces tumor size, decreases pain from metastatic
nodules, and promotes well-being. However, DES significantly increases the risk for thromboembolism,
pulmonary embolism, myocardial infarction, and stroke. Other side effects of estrogen therapy include impotence,
decreased libido, difficulty in achieving orgasm, decreased sperm production, and gynecomastia (enlargement of
breasts in men)
95. A patient has been prescribed flutamide (Eulexin) for the treatment of prostate cancer. He asks the nurse
what information he needs to know about the medication. The nurse correctly states that:
a. “Incontinence can occur occasionally”
c. “Weight gain and loss can fluctuate”
b. “Mild insomnia and excitability can occur”
d. “A side effect is greenish urine”
ANSWER: D
Greenish urine and photosensitivity are side effects of flutamide.
96. What information should the nurse provide to a 53-year-old male on prevention and early detection of
prostate cancer?
a. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
b. Have a transrectal ultrasound every 5 years
c. Perform monthly testicular self-examinations, especially after age 50
d. Have a complete blood count (CBC) yearly (including blood urea nitrogen [BUN] and creatinine assessment)
ANSWER: A
When prostate cancer is detected early, the likelihood of cure is high. Every man older than 50 years of age
should have an annual DRE and PSA test as part of his regular health checkup. These tests are recommended for
younger men (40-45 years of age) if they are at high risk for prostate cancer. Transrectal ultrasound (TRUS)
studies may be performed in patients with abnormalities detected by DRE or those with elevated PSA levels. TSE
is done to detect testicular cancer. Complete blood count including BUN and creatinine assessment is unrelated.
97. The patient who had a prostatectomy 1 year ago now has elevation in serum acid phosphatase. The nurse is
aware that this is an indication of:
a. Reduction of cancer risk
c. Testicular cancer
b. Orchitis
d. The cancer has metastasized
ANSWER: D
Elevations of these three tests indicate metastasis.
Reference: Joyce Kee. A look at Laboratory and Diagnostic tests with nursing implications. 7th edition. Page 12
98. The patient is postoperative following a prostatectomy. The nurse notes urine leakage around the suprapubic
tube. The nurse should:
a. Give meticulous aseptic care to and around the suprapubic tube
b. Call the urologist immediately
c. Remove the suprapubic tube
d. Administer antispasmodic drugs as ordered
ANSWER: A
One disadvantage of a suprapubic approach is the leakage of urine around the suprapubic tube. This managed
with meticulous aseptic care to the area and around the suprapubic tube to prevent skin irritation and infection.
Option D is for bladder spasm. Options B and C are incorrect
99. The nurse teaches the post-prostatectomy patient which of the following general guidelines regarding
urination?
a. Increased urine output should be reported.
b. Dribbling will continue for the remainder of your life.
c. Blood in the urine should be reported to the physician immediately.
d. Urine control will return immediately.
ANSWER: C
The patient undergoing prostatectomy may be discharged within several days. The patient and family require
instructions about how to manage the drainage system, how to assess for complications, and how to promote
recovery. They are informed about signs and symptoms that should be reported to the physician (eg, blood in
urine, decreased urine output, fever, change in wound drainage, calf tenderness). As the patient recovers and
drainage tubes are removed, he may become discouraged and depressed because he cannot regain bladder
control immediately. He may continue to “dribble” after being discharged from the hospital, but the dribbling
should gradually diminish.
100. The discharge teaching plan for a postoperative prostatectomy patient would include instructions relative to:
I. Remedy for bladder spasm.
IV. Perineal exercises
II. Catheter care
V. Avoidance of heavy lifting
III. Delay of sexual activity for 3 months
VI. Report calf tenderness
a. All except VI
b. All except III
c. All except I
VI. All of the above
ANSWER: B
Instruction relative to bladder spasm relief, catheter care, perineal exercises to help reduce incontinence, and
avoidance of heavy lifting is appropriate. Patients undergoing prostatectomy have high incidence of DVT (calf
tenderness is a hallmark sign). Sexual activity is usually resumed in 6 weeks.
CARE OF CLIENTS WITH ENDOCRINE DISORDERS
SITUATION: When conducting a focused endocrine assessment in a patient, begin with a thorough history of their
chief complaints. You will need to elicit information about any experienced signs or symptoms of endocrine disease or
disorders. Endocrine disorders and diseases usually manifest according to which endocrine hormone is being
overproduced and secreted or underproduced and secreted. The key to discovering the nature of the symptoms lies in
your understanding of the functions of the endocrine hormones.
1. What is the effect on the client’s hormone response to a naturally occurring hormone if the client takes a drug that
blocks that hormone’s receptor site?
a. Greater hormone metabolism
c. Increased hormone activity
b. Decreased hormone activity
d. Hormone response would be unchanged
ANSWER: B
Hormones cause an activity in the target tissues by binding with their specific cellular receptor sites, thereby changing
the cell’s activity. When the receptor sites are occupied by other substances that block hormone binding, the cell’s
response is the same as when there is a decreased level of the hormone.
Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition Page 1413
2. The ovaries of an older woman are producing only minimal amounts of estrogen. How will this affect other hormone
production?
a. Increased gonadotropin-releasing hormone (Gn-RH), increased follicle-stimulating hormone (FSH)
b. Increased Gn-RH, decreased FSH
c. Decreased Gn-RH, increased FSH
d. Decreased Gn-RH, decreased FSH
ANSWER: A
The trigger for Gn-RH is decreased circulating levels of estrogen. As a woman’s ovarian production of estrogen
decreases, the circulating levels of estrogen also decrease, stimulating the hypothalamus to increase production and
release of Gn-RH. This stimulates the anterior pituitary gland to increase production and release of FSH.
Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition Page
3. Which will the nurse assess next in a male client who begins to have fluid secretion from his breasts?
a. Posterior pituitary hormones
c. Anterior pituitary hormones
b. Adrenal medulla functioning
d. Parathyroid functioning
ANSWER: C
Breast fluid and milk production are induced by the presence of prolactin, secreted from the anterior pituitary gland.
The hypothalamus regulates secretion of prolactin through the activity of prolactin-inhibiting hormone. A problem in
the hypothalamus or the anterior pituitary gland can cause lactation in men or women.
4. Which is the expected clinical manifestation for a client who has excessive production of melanocyte-stimulating
hormone?
a. Hypoglycemia and hyperkalemia
c. Increased urine output
b. Irritability and insomnia
d. Darkening of the skin
ANSWER: D
Melanocyte-stimulating hormone increases the size of melanocytes in the skin and increases the amount of pigment
(melanin) that they produce.
5. The release of oxytocin is controlled by:
a. Positive feedback
b. Negative feedback
c. Nervous feedback
d. Reverse feedback
ANSWER: A
Even though most of the hormones in the endocrine system are under a negative feedback mechanism, oxytocin is
not one of those hormones. Oxytocin is controlled by a positive feedback mechanism.
Reference: Rick Daniels Contemporary Medical Surgical Nursing
6. Aging affects the endocrine system in many ways. Which of the following are age-related changes?
1. Increased estrogen in women
4. Increased pancreatic secretion of insulin
2. Increased production of antidiuretic hormone
5. Smaller thyroid gland
3. Decreased testosterone in men
a. 2, 3, 4
b. 2, 3, 5
c. 3, 4, 5
d. All except 1
ANSWER: B
Age-related changes include a decreasing basal metabolic rate as a result of a smaller thyroid gland. There is an
increased production of antidiuretic hormone, resulting in more dilute urine and polyuria. Other changes are that the
pancreas secretes less insulin, estrogen decreases in women, and testosterone decreases in men.
7. Which safety measure will the nurse use for the adult client who has growth hormone deficiency?
a. Avoiding intramuscular medications
c. Using a lift sheet to reposition the client
b. Placing the client in protective isolation
d. Assisting the client to move slowly from a sitting to a standing position
ANSWER: C
In adults, growth hormone is necessary to maintain bone density and strength. Adults with growth hormone deficiency
have thin, fragile bones. Avoiding IM medications, using protective isolation, and assisting the client as he or she
moves from sitting to standing will not serve as safety measures when the client is deficient in growth hormone.
8. The client just diagnosed with acromegaly is scheduled for a hypophysectomy. Which statement made by the client
indicates a need for clarification regarding this treatment?
a. “I will drink whenever I feel thirsty after surgery.”
b. “I’m glad there will be no visible incision from this surgery.”
c.“I hope I can go back to wearing size 8 shoes instead of size 12.”
d. “I will wear slip-on shoes after surgery so I don’t have to bend over.”
ANSWER: C
Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism,
skeletal changes and organ enlargement are not reversible. It will be appropriate for the client to drink as needed
postoperatively, avoid bending over, and reassured that the incision will not be visible.
9. Which statement made by Mr. Delima who is going home after a trans-sphenoidal hypophysectomy indicates an
adequate understanding of actions to prevent complications from this treatment?
a. “I will wear dark glasses whenever I am outdoors.”
b. “I will keep food on upper shelves in the refrigerator so that I do not have to bend over.”
c. “I will wash the incision line every day with peroxide and redress it immediately.”
d. “I will remember to cough and deep breathe at least every 2 hours while I am awake.”
ANSWER: B
After this surgery, the client must take care to avoid activities that can increase intracranial pressure. They should
avoid bending from the waist and should not bear down, cough, or lie flat.
10. A patient is receiving medical treatment for acromegaly after surgery. Which of the following prescriptions would
the nurse expect to see?
a. Bromocriptine mesylate (Parlodel) 100 mg PO daily
c. Cortisone acetate (Cortone) 100 mg PO three times a day
b. Cabergoline (Dostinex) 1 mg PO twice a week
d. Octreotide (Sandostatin) 20 mg IM every four weeks
ANSWER: D
Cortone is used to treat adrenocorticotropic dysfunction, and Dostinex is used to treat hyperprolactinemia.
Sandostatin is used for residual growth hormone hypersecretion following surgery. Parlodel is alternative medication
for growth hormone hypersecretion following surgery; the dosage listed is incorrect.
11. A client presents with elevations in triiodothyronine (T3) and thyroxine (T4), and a decrease in thyroid stimulating
hormone levels (TSH). Which is the nurse’s priority intervention?
a. Monitor the apical pulse.
c. Administer liothyronine (Cytomel).
b. Administer levothyroxine (Synthroid).
d. Assess for Trousseaus’ sign.
ANSWER: A
The client’s laboratory findings suggest that the client is experiencing hyperthyroidism. The reduction in TSH comes as
a negative feedback from the elevated thyroid hormone levels and elevated metabolic rate. The increased metabolic
rate can cause an increase in the client’s heart rate and the client should be monitored for the development of
dysrhythmias. Placing the client on telemetry monitory might also be a precaution.
12. A woman comes into the clinic with a progressively enlarging neck. The client mentions that she has been in a
foreign country for the previous 3 months and that she did not eat much while she was there because she did not like
the food. The client also mentions that she becomes dizzy when lifting her arms to do normal household chores or
when dressing. What endocrine disorder would the nurse expect the physician to diagnose?
a. Diabetes mellitus
b. Goiter
c. Diabetes insipidus
d. Cushing's syndrome
ANSWER: B
A goiter can result from inadequate dietary intake of iodine associated with changes in foods or malnutrition. It's
caused by insufficient thyroid gland production and depletion of glandular iodine. Signs and symptoms of this
malfunction include enlargement of the thyroid gland, dizziness when raising the arms above the head, dysphagia,
and respiratory distress. Signs and symptoms of diabetes mellitus include polydipsia, polyuria, and polyphagia. Signs
and symptoms of diabetes insipidus include extreme polyuria (4 to 16 L/day) and symptoms of dehydration (poor
tissue turgor, dry mucous membranes, constipation, dizziness, and hypotension). Cushing's syndrome causes buffalo
hump, moon face, irritability, emotional lability, and pathologic fractures.
13. A patient is diagnosed with Graves’ disease. Which one of the following nursing interventions would the nurse
complete?
a. Administer a stool softener
c. Provide frequent meals.
b. Provide extra blankets
d. Restrict the caloric intake.
ANSWER: C
Some nursing interventions for Graves’ disease (hyperthyroidism) include offering frequent, high-calorie meals;
medicating for diarrhea; providing a fan or decreasing the temperature on an air conditioner; and taking daily weight
measurements.
14. A pregnant patient is receiving treatment for hyperthyroidism. Which of the following medications would Nurse
Daniel expect to see?
a. Levothyroxine
b. Methimazole
c. Propylthiouracil
d. Radioactive iodine
ANSWER: C
Propylthiouracil (PTU) is the drug of choice for treating hyperthyroidism in a pregnant or breastfeeding patient.
Radioactive iodine and methimazole are treatments for nonpregnant patients with hyperthyroidism. Levothyroxine is
for hypothyroidism.
15. In planning the care of the client receiving thyroid medication, Nurse Isabel would identify which of the following
as an appropriate nursing diagnosis:
a. Risk for injury related to altered calcium levels.
b. Disturbed sleep pattern related to thyroid dysfunction.
c. Decreased knowledge related to effects of deficiency of thyroid hormone.
d. Pain related to ulcerogenic effects of thyroid hormone preparations.
ANSWER: B
Insomnia is a manifestation of hyperthyroidism and can result in clients with hypothyroidism receiving thyroid
replacement therapy. Option A: This would be more appropriate for a client with parathyroid disease. Option C: This is
not a NANDA (North American Nursing Diagnosis Association) nursing diagnosis. Option D: Thyroid preparations are
not ulcerogenic.
Reference: Bonita E. Broyles Pharmacological Aspects of Nursing Care, 7th Edition page 799
16. A patient is in the emergency department complaining of an ongoing fever. The patient has had an infection and is
restless, diaphoretic, and agitated. Vital signs are as follows: temperature 106° F, pulse 114, blood pressure 180/80
mm Hg. Which of the following disorders is the patient most likely to have?
a. Addisonian crisis
b. Goiter
c. Myxedema
d. Thyroid crisis
ANSWER: D
Thyroid crisis is a serious form of hyperthyroidism that is life threatening. It is most likely to occur in persons who
have been inadequately treated or undiagnosed. Infection, stress or emotional trauma, pregnancy, and medications
may precipitate the event. Myxedema and addisonian crisis would not produce a severe increase in blood pressure.
Goiter tends to interfere with swallowing and breathing.
17. Which client statement alerts the nurse to the possibility of hypothyroidism?
a. “My sister has thyroid problems.”
c. “Food just doesn’t taste good without a lot of salt.”
b. “I seem to feel the heat more than other people.”
d. “I am always tired, even with 10 or 12 hours of sleep.”
ANSWER: D
Clients with hypothyroidism usually feel tired or weak and often report an increase in time spent sleeping, sometimes
up to 14 to 16 hours daily.
18. A nurse is administering levothyroxine to a client. The nurse should monitor the client for which adverse effects of
this agent?
a. Constipation
b. Tachycardia
c. Lethargy
d. Weight gain
ANSWER: B
Tachycardia is a manifestation of hyperthyroidism, an adverse effect of thyroid replacement therapy. Options A, C and
D: These are manifestations of the hypothyroidism that the medication is treating.
19. A few hours after returning to the surgical nursing unit, a patient who has undergone a subtotal thyroidectomy
develops laryngeal stridor and a cramp in the right hand. The nurse anticipates that intervention will include:
a. Administration of IV morphine.
c. Endotracheal intubation with mechanical ventilation.
b. Administration of IV calcium gluconate.
d. Immediate tracheostomy and manual ventilation.
ANSWER: B
The patient’s clinical manifestations are consistent with tetany caused by hypocalcemia resulting from damage to the
parathyroid glands during surgery. Tracheostomy may be needed if the calcium does not resolve the stridor. There is
no indication that morphine is needed. Endotracheal intubation may be done, but only if calcium is not effective in
correcting the stridor.
20. A client being treated with medication for a seizure disorder is scheduled for a serum T3 and T4 level. Nurse
Hannah realizes that this client's results might be:
a. Falsely reduced
c. Normal
b. Falsely elevated
d. Indicative of pending parathyroid hormone disease
ANSWER: A
The value of T3 and T4 blood levels might be decreased by certain medications including phenytoin (Dilantin), which is
a medication commonly prescribed for seizure disorders. Measurement of T3 and T4 levels are not indicative of
parathyroid disease.
Reference: Lemone-Burke Medical Surgical Nursing 4th edition
21. What hormone is released when serum calcium levels are low?
a. Calcitonin
b. Cortisol
c. Parathyroid hormone
d. Thyroxine
ANSWER: C
Parathyroid hormone is secreted when serum calcium levels are low. Calcitonin is released when serum calcium levels
are high. Cortisol and thyroxine are not related to calcium.
22. Which client is at greatest risk for hyperparathyroidism?
a. The client with pregnancy-induced hypertension
b. The client receiving dialysis for end-stage kidney disease
ANSWER: B
c. The older adult client with moderate heart failure

d. The older adult on home oxygen therapy
Clients who have chronic kidney disease do not completely activate vitamin D and poorly absorb calcium from the
gastrointestinal (GI) tract. They are chronically hypocalcemic, which triggers overstimulation of the parathyroid
glands.
23. When taking the blood pressure of a client after a parathyroidectomy, the nurse notes that the client’s hand has
gone into flexion contractions. Which does the nurse determine may be the cause of this symptom?
a. Hypokalemia
b. Hyperkalemia
c. Hypercalcemia
d. Hypocalcemia
ANSWER: D
Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of
hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions (Trousseau’s sign) occurring
during blood pressure measurement are indicative of hypocalcemia.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition page
24. Following the intravenous infusion of calcium, Nurse Allan should:
a. Instruct the client to not to get out of bed without assistance
c. Monitor the client for muscle spasms
b. Place the client on an ECG monitor
d. Administer oral etidronate disodium
ANSWER: A
Following IV calcium infusion clients may experience syncope, placing them at risk for falls. Option B: The client
should have been on an ECG monitor during infusion. Option C: This is a manifestation of hypoparathyroidism and can
be used as a measure of effectiveness of calcium infusion, but this is not the best answer. Option D: This is used to
treat hyperparathyroidism.
25. A client comes into the clinic demonstrating symptoms of hypocalcemic tetany. Which of the following
assessments did the nurse conduct to determine the client's condition?
a. Measure capillary blood.
b. Tap a finger in front of the client's ear at the angle of the jaw.
c. Measure the client's blood pressure.
d. Place a tuning fork over one of the client's fingers.
ANSWER: B
The nurse most likely assessed the client for Chvostek's sign by tapping a finger in front of the client's ear at the angle
of the jaw. Decreased calcium levels will cause the client's lateral facial muscles to contract. This demonstrates tetany.
Placing a tuning fork over the client's finger evaluates the client's ability to perceive vibrations, but does not evaluate
the muscle response of tetany. Blood pressure measurement may give the nurse valuable information about the
client's fluid and electrolyte status, but does not evaluate tetany. A capillary blood level for serum calcium would give
a measurement, but does not assess for the clinical symptoms of tetany.
Reference: Lemone-Burke Medical Surgical Nursing 4th edition
26. Normally the antidiuretic hormone (ADH) influences kidney function by stimulating the:
a. Nephron tubules to reabsorb water
c. Glomerulus to withhold the proteins from the urine
b. Nephron tubules to reabsorb glucose
d. Glomerulus to control the quantity of fluid passing through it
ANSWER: A
A – The antidiuretic hormone aids the body in retaining fluid by causing the nephrons to reabsorbed water.
References: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 10th
Edition, Vol. 2. Page 1208.
27. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would
anticipate which of the following assessment findings?
a. Lethargy
b. Heat intolerance
c. Diarrhea
d. Skin eruptions
ANSWER: A
A – In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen consumption,
decreasing oxidation of nutrients for energy, and producing less body heat. Therefore, the nurse can expect the client
to complain of constipation, lethargy and inability to get warm
28. A 30-year-old woman is receiving levothyroxine sodium (Synthroid) 0.1 mg PO daily. Which of the following
findings would indicate to the nurse that the client is getting favorable results from the medication?
a. Decreased blood pressure
c. Decreased pulse rate
b. Increased urine output
d. Increased respiratory rate
ANSWER: B
B – Medication increases metabolic processes of body, including glomerular filtration, edema will decrease as water is
excreted
A, C– Characteristic of hypothyroidism, would indicate that medication is not working
D – Respiratory rate may or may not be affected by medication
29. A physician has prescribed propylthiouracil (PTU) for a client with hyperthyroidism and the nurse develops a plan
of care for the client. A priority nursing assessment to be included in the plan regarding this medication is to assess
for:
a. Relief of pain
c. Signs and symptoms of hyperglycemia
b. Signs of renal toxicity
d. Signs and symptoms of hypothyroidism
ANSWER: D
D – Excessive dosing with propylthiouracil (PTU) may convert the client from a hyperthyrpoid state to a hypothyroid
state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required.
Propylthiouracil is not used for pain and does not cause hyperglycemia or renal toxicity.
30. A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism.
Which of the following, if found by the nurse at the patient’s bedside, is nonessential?
a. Potassium chloride for IV administration
c. Tracheostomy set-up
b. Calcium gluconate for IV administration
d. Suction equipment
ANSWER: A
A – Hypokalemia is not expected after this surgery
B – Used to treat tetany resulting from possible damage to parathyroid glands
C – Essential equipment to provide for airway
D – Needed to maintain a patent airway
31. The nurse is obtaining a history on a client with hyperthyroidism. The nurse should report which of the following
assessments to the physician?
a. Anxiety with extreme nervousness
c. Cool, clammy skin
b. Slow, sluggish pulse
d. Husky, slow speech
ANSWER: A
A – Signs and symptoms of hyperthyroidism are related to an increased metabolic rate
B, C, D – Related to a decreased metabolic rate
32. Which symptom in the patient with a goiter should the nurse report to the physician immediately?
a. Weight gain of 2 pounds
b. Stridor
c. Excessive thirst
d. Nausea
ANSWER: B
B – Be careful to assess the effect of the goiter on breathing and swallowing. Stridor, a whistling sound, may be heard
if the airway is obstructed. Stridor is an ominous sign and should be reported to the physician immediately. If the
patient experiences difficulty swallowing, notify the physician and collaborate with the dietitian to provide soft foods or
liquid nutrition. A swallowing study might be ordered, which can assist a speech pathologist or other expert to make
specific recommendations for safe swallowing
References: Hopper P.D. and Williams L.S.(2003). Understanding Medical-Surgical Nursing. 2nd edition. Page 636.
33. The nurse plans care for a 36-year-old woman with Graves’ disease. The nurse knows that which of the following
foods or fluids should be restricted for this client?
a. Milk
b. Apples
c. Orange juice
d. Tea
ANSWER: D
D – Stimulant that would increase metabolic rate
A, B, C – Not limited for Graves’ disease
34. The physician diagnoses Graves’ disease for a 28-year-old woman seen in the clinic. The nurse would expect the
client to exhibit which of the following symptoms?
a. Lethargy in the early morning.
c. Weight loss of 10 lb in 3 weeks.
b. Sensitivity to cold.
d. Reduced deep tendon reflexes.
ANSWER: C
C – Increased metabolic rate causes weight loss even with increased appetite
A – Patient will be restless
B – Patient will have heat intolerance due to increased metabolic rate
D – Patient’s reflexes will be hyperactive
Edition, Vol. 2. Page 1221-1222.
35. The client is exhibiting symptoms of myxedema. The nursing assessment should reveal:
a. Increased pulse rate
c. Fine tremors
b. Decreased temperature
d. Increased radioactive iodine uptake level
ANSWER: B
B – With myxedema there is a slowing of all body functions
A – Pulse will decrease
C, D – Associated with hyperthyroidism
36. A client is admitted to the hospital with myxedema coma. The most critical nursing intervention for the patient at
this time is:
a. Administering an oral dose of levothyroxine (Synthroid)
b. Warming the patient with a warming blanket
c. Measuring and recording intake and output accurately
d. Maintain a patient airway
ANSWER: D
D – Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing
intervention. Ventilator support is usually needed. Although myxedema coma is associated with severe hypothermia, a
warming blanket shouldn’t be used because it may cause vasodilation and shock. Gradual warming with blankets
would be appropriate. Thyroid replacement will be administered IV, and although intake and input is important, it isn’t
critical at this time.
37. The nurse is caring for a client admitted with acute hypoparathyroidism. It is MOST important for the nurse to
have which of the following items available?
a. Tracheostomy set
b. Cardiac monitor
c. IV monitor
d. Heating pad
ANSWER: A
A – Tracheostomy set is the most important for the client’s safety due to risk for laryngospasm
B, C – Cardiac monitor and IV monitor would be nice to have, but not the most important
D – This is unnecessary
38. The nurse is caring for a client receiving treatment for hypoparathyroidism. The nurse determines that treatment
has been successful if which of the following was observed?
a. The client’s output is 1500 cc of clear straw-colored urine
c. The client denies numbness and tingling
b. The client is unable to state his name
d. The client loses 3 pounds in one week
ANSWER: C
C – Tetany is major sign of hypoparathyroidism
A – Important to monitor, but are not top priority
B – Confusion and decreased memory are symptoms of hypercalcemia
D – Most frequently observed with hyperparathyroidism
39. Which of the following types of foods should the nurse encourage in the diet of a client with hypoparathyroidism?
a. High in phosphorus
b. High in calcium
c. Low in sodium
d. Low in potassium
ANSWER: B
B – Diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium
balance
A – Diet should be low in phosphorus
C, D – Not regulated by the parathyroid
40. The nurse is caring for a patient with hyperparathyroidism. Which symptom is MOST important for the nurse to
report to the next shift?
a. Abdominal discomfort
b. Hematuria
c. Muscle weakness
d. Diaphoresis
ANSWER: B
B – Hematuria is a sign of renal calculi; 55% of hyperparathyroid clients have renal stones
A, C, D – Sign of hyperparathyroidism but does not require reporting
41. While preparing a client to teach a client about hyperparathyroidism, the nurse knows that parathyroid hormone
(PTH) has what effect in the kidney?
a. PTH stimulates calcium reabsorption and phosphate excretion
b. PTH stimulates phosphate reabsorption and calcium excretion
c. PTH increases absorption of vitamin D and excretion of vitamin E
d. PTH increases absorption of vitamin E and excretion of vitamin D
ANSWER: A
A – PTH stimulates the kidneys to reabsorb calcium and excrete phosphate. PTH converts vitamin D to its active form,
1,25-dihydroxyvitamin D. PTH doesn’t have a role in the metabolism of vitamin E
42. Which of the following is true regarding Cushing’s disease?
a. Overproduction of adrenal medulla hormone occurs
b. Women ages 20-40 years are five times more likely than men to develop Cushing’s syndrome
c. It is characterized by muscle weakness, anorexia and dark skin pigmentation
d. Depletion of sodium and water occurs
ANSWER: B
Cushing’s syndrome is commonly caused by use of corticosteroid medications and is infrequently due to the excessive
corticosteroid production by the adrenal cortex. The classic picture of Cushing’s syndrome in the adult is that of
central-type obesity, with a fatty buffalo hump in the neck, heavy trunk and thin extremities. Option C refers to
Addison’s disease. Women ages 20-40 years are five times more likely than men to develop this disease. Retention of
water occurs as a result of increased mineralocorticoid activity producing hypertension and heart failure.
43. A client is admitted for a series of tests to verify the diagnosis of Cushing’s syndrome. Which of the following
assessment findings, if observed by the nurse, would support this diagnosis?
a. Buffalo hump, hyperglycemia, and hypernatremia.
c. Lethargy, weight gain, and intolerance to cold.
b. Nervousness, tachycardia, and intolerance to heat.
d. Irritability, moon face, and dry skin.
ANSWER: A
A – Cushing’s syndrome is characteristic of these assessments, as are weight gain, moon face, purple striae,
osteoporosis, mood swings, and high susceptibility to infections
B – Symptoms of hyperthyroidism
C – Symptoms of hypothyroidism (myxedema)
D – Symptoms of hypoparathyroidism
44. The nursing care plan for a client with decreased adrenal function should include:
a. Encouraging activity
c. Limiting visitors
b. Placing client in reverse isolation
d. Measures to prevent constipation
ANSWER: C
C – Any exertion, either physical or emotional, places additional stress on the adrenal glands which could precipitate
an addisonian crisis. The plan of care should protect this client from the physical and emotional exertion of visitors.
45. Which of the following is a characteristic manifestation of a client with Addison’s disease?
a. Moon face
b. Buffalo hump
c. Dark skin pigmentation
d. Truncal obesity
ANSWER: C
Options a, b and d are all clinical manifestations of a client with Cushing’s disease. Option C is a clinical manifestation
of a client with Addison’s disease.
46. The drug of choice for a client with Addison’s disease is:
a. Levothyroxine
b. PTU
c. Hydrocortisone
d. Methotrexate
ANSWER: C
Hydrocortisone is administered intravenously followed with 5% dextrose in normal saline. This is used to treat shock
and adrenal insufficiency. The client will require additional supplementary therapy with glucocorticoids during stressful
procedures or significant illnesses to prevent Addisonian crisis.
47. The priority nursing diagnosis for a client with Addison’s disease is:
a. Fluid volume deficit
b. Fluid volume excess
c. Impaired skin integrity
d. Impaired activity tolerance
ANSWER: A
Clients with Addison’s disease have a disturbance of sodium and potassium metabolism. In severe cases this may lead
to a severe marked depletion of sodium and water and severe, chronic dehydration. Immediate treatment is directed
toward restoring blood circulation, restoring fluid balance by administering fluids, corticosteroids, monitoring vital
signs. To provide information about the fluid balance and adequacy of the hormone replacement the nurse assesses
the client’s skin turgor, mucous membranes and weight while instructing the client to report increased thirst. The
nurse also encourages the client to consume food and fluids that will assist in restoring fluid and electrolyte balance.
Options C and D may be present in a client with Addison’s disease but it not the priority.
48. The nurse is teaching diet restrictions for a client with Addison's disease. The client would indicate an
understanding of the diet by stating:
a. "I will increase sodium and fluids and restrict potassium."
b. "I will increase potassium and sodium and restrict fluids."
c. "I will increase sodium, potassium and fluids."
d. "I will increase fluids and restrict sodium and potassium."
ANSWER: A
A – The manifestation of Addison''s disease due to mineralocorticoid deficiency resulting from renal sodium wasting
and potassium retention include dehydration, hypotension, hyponatremia, hyperkalemia and acidosis.
49. The following are signs and symptoms seen in a client with syndrome of inappropriate diuretic hormone (SIADH)
secretion, except:
a. Dilute urine
b. Confusion
c. Weakness
d. Muscle cramps
ANSWER: A
The syndrome of inappropriate anti-diuretic hormone (SIADH) secretion includes excessive ADH secretion from the
pituitary gland even in the face of subnormal serum osmolality. Clients with this disorder cannot excrete dilute urine.
They retain fluids and develop a sodium deficiency known as dilutional hyponatremia. Anorexia, nausea, and malaise
are the earliest findings, followed by headache, irritability, confusion, muscle cramps, weakness, obtundation,
seizures, and coma. These occur as osmotic fluid shifts result in cerebral edema and increased intracranial pressure.
Dilute urine is seen in clients with Diabetes insipidus.
Key feature: concentrated urine and hyponatremia
50. Nursing management for a client with SIADH include all of the following, except:
a. Close monitoring of daily weight
c. Close monitoring of intake and output
b. Increasing fluid intake
d. onitoring neurologic status
ANSWER: B
Eliminating the underlying cause if possible and restricting fluid intake (not increasing) are typical interventions for
managing this syndrome. Diuretics may be used along with fluid restriction if severe hyponatremia is present. Close
monitoring of intake and output, daily weight, urine and blood chemistries and neurologic status is indicated for the
client with SIADH.
51. After several diagnostic tests, a client is diagnosed with diabetes insipidus. A nurse performs an assessment on
the client, knowing that which symptom is most indicative of this order?
a. Fatigue
b. Diarrhea
c. Polydipsia
d. Weight gain
ANSWER: C
C – Polydispia and polyuria are classic symptoms of diabetes insipidus. The urine is pale, and the specific gravity is
low. Anorexia and weight loss occur. Option 1 is a vague symptom. Options 2 and 4 are not specific to this disorder.
52. The nurse is caring for a patient admitted two days ago with a diagnosis of closed head injury. If the patient
develops diabetes insipidus, the nurse would observe which of the following symptoms?
a. Decerebrate posturing, BP 160/100, pulse 56.
b. Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004.
c. Glucosuria, osmotic diuresis, loss of water and electrolytes.
d. Weight gain of 5 lb, pulse 116, serum sodium 110 mEq/L.
ANSWER: B
B – Signs of dehydration, increased output, low specific gravity, normal 1.010-1.030
A – Late signs of increased intracranial pressure or brain damage
C – Signs of hyperglycemia due to diabetes mellitus
D – Symptoms of SIADH (syndrome of inappropriate antidiuretic hormone) are opposite of diabetes insipidus
53. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the
client during the conversation is most predictive of a potential for impaired skin integrity?
a. "I give my insulin to myself in my thighs."
b. "Sometimes when I put my shoes on I don't know where my toes are."
c. "Here are my up and down glucose readings that I wrote on my calendar."
d. "If I bathe more than once a week my skin feels too dry."
ANSWER: B
B – Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients do not feel pressure and/or
pain and are at high risk for skin impairment.
54. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an emergency room. Which finding
would a nurse expect to note as confirming this diagnosis?
a. Comatose state
c. Increased respirations and an increased in pH
b. Decreased urine output
d. Elevated blood glucose level and low plasma bicarbonate level.
ANSWER: D
D – In DKA, the arterial pH is lower than 7.35, plasma bicarbonate is lower than 15mEq/l, the blood glucose level is
higher than 250 mg/dL, and ketones are present in theblood and urine. The client would be experiencing polyuria, and
Kussmaul’s respirations would be present. A comatose state may occur if DKA is hot treated, but coma would not
confirm the diagnosis.
55. During a visit, a client with a diagnosis of type 1 diabetes mellitus consults a nurse. The client relates a history of
vomiting and diarrhea and tells the nurse that no food has been consumed for 36 hours. Which additional statement
by the client indicates a need for further teaching?
a. “I need to stop my insulin.”
c. “I need to monitor my blood glucose every 3 to 4 hours.”
b. “I need to increase my fluid intake.”
d. “I need to call the physician because of these symptoms.”
ANSWER: A
A – When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the
prescribed insulin or oral medication. The client should consume additional fluids and should notify the physician. The
client should notify the physician. The client should monitor the blood glucose level every 3 to 4 hours.
56. The visiting nurse evaluates the progress of a client recently diagnosed with insulin-dependent diabetes mellitus
(IDDM). As part of the treatment plan, the client receives Humulin N 32 units and Humulin R 8 units each morning.
Which of the following actions, if performed by the client while preparing the morning insulin injection, would require
an intervention by the nurse?
a. After the client draws up 8 units of Humulin R, she adds Humulin N to the syringe for a total of 40 units.
b. The client draws up 32 units of the cloudy insulin followed by 8 units of clear insulin for a total of 40 units.
c. Initially, the client injects air into the Humulin N vial without drawing up any insulin.
d. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn.
ANSWER: B
B – Humulin R is clear and drawn up first, only 8 units are ordered, Humulin N is cloudy
A – Clear insulin always drawn up first
C, D – Allows you to withdraw medication later
57. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques
to a newly diagnosed client with diabetes?
a. Give written pre and post tests
c. Allow another diabetic to assist
b. Ask questions during practice
d. Observe a return demonstration
ANSWER: D
D – Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique
58. A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a
discharge teaching plan regarding the insulin and plan to reinforce which of the following concepts?
a. Always keep insulin vials refrigerated.
b. Ketones in the urine signify a need a need for less insulin.
c. Increase the amount of insulin before unusual exercise.
d. Systematically rotate insulin injections within one anatomic site.
ANSWER: D
D – Insulin doses should not be adjusted nor increased before unusual exercise. If ketones are found in the urine, it
possibly may indicate the need for additional insulin. To minimize the discomfort associated with insulin injections,
insulin should be administered at room temperature. Injection sites should be rotated systematically within one
anatomic site.
59. The two main problems related to insulin in type II diabetes are:
a. Lipodistrophy and lipoatrophy
c. Lipohytrophy and lypoatrophy
b. Insulin resistance and impaired insulin secretion
d. Local and systemic reactions
ANSWER: B
The two main problems related to insulin in type II diabetes are insulin resistance and impaired insulin secretion.
Insulin resistance refers to a decreased tissue sensitivity to insulin. Despite the impaired insulin secretion that is
characteric of type II diabetes, there is enough insulin present to prevent the breakdown of fats and the
accompanying production of ketone bodies. Therefore, DKA does not typically occure in Type II diabetes.
60. A nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The
client demonstrates an understanding of the teaching by stating that glucose will be taken if which of the following
symptoms develops?
a. Polyuria
b. Shakiness
c. Blurred vision
d. Fruity breath odor
ANSWER: B
B – Shakiness is a sign of hypoglycemia and would indicate the need for food or glucose. A fruity breath odor, blurred
vision, and polyuria are signs of hyperglycemia.
Edition, Vol. 2. Page 1181, 1183.
61. A nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The priority nursing
diagnosis would be:
a. Fluid volume deficit
c. Nutrition: less than body requirements, imbalanced
b. Family processes, dysfunctional
d. Knowledge, deficient: disease process and treatment
ANSWER: A
A – An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is
accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be
replaced when it becomes severe. Options 2,3,and 4 are not related specifically to the subject of the question.
62. After hypophysectomy, a client complains of being thirsty and having to urinate frequently. The initial nursing
action is to:
a. Increased fluid intake
c. Assess for urinary glucose
b. Document the complaints
d. Assess urine specific gravity
ANSWER: D
D – After hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone deficiency. This
deficiency is related to surgical manipulation. The nurse should assess the specific gravity of the urine and notify the
physician if the result is lower than 1.006. Although options 1 and 2 may be components of the plan of care, they are
not initial actions. Additionally, the physician will prescribe increased fluids. Option 3 is unrelated to the client’s
condition.A –
63. A nurse is caring for a client after hypophysectomy. The nurse notices clear nasal drainage from the client’s
nostril. The initial nursing action would be to:
a. Lower the head of the bed
c. Obtain a culture of the drainage
b. Test the drainage for glucose
d. Continue to observe the drainage
ANSWER: B
B – After hypophysectomy, the client should be monitored for rhinorrhea which could indicate a cerebrospinal fluid
leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. The head of
the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the
need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.
64. The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic
syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
a. Elevated serum acetone level
c. Serum alkalosis
b. Elevated serum acetone level
d. Below-normal serum potassium level
ANSWER: D
A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the
hyperosmolar, hyperglycemic state caused by the relative insulin deficiency.
Option A and B - An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis.
Option D - Metabolic acidosis, not serum alkalosis, may occur in HHNS.
65. A client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing
the result with the client, the nurse would be most accurate in stating:
a. "The test needs to be repeated following a 12-hour fast."
b. "It looks like you aren't following the prescribed diabetic diet."
c. "It tells us about your sugar control for the last 3 months."
d. "Your insulin regimen needs to be altered significantly."
ANSWER: C
The glycosylated Hb test provides an objective measure of glycemic control over a 3-month period.
Option A - The test helps identify trends or practices that impair glycemic control, and it doesn't require a fasting
period before blood is drawn.
Option B and D - The nurse can't conclude that the result occurs from poor dietary management or inadequate insulin
coverage.
66. Regular insulin was administered at 8:00am. The insulin will reach its peak around:
a. 9:00 am
b. 11:00 am
c. 2:00 pm
d. 8:00 pm
ANSWER: B
Short acting insulin or regular insulin have an onset of 30 minutes to 1 hour, peak action of 2-3 hours and duration of
4-6 hours.
Option A-is the peak if the insulin taken was rapid acting
Option C- is the peak if the insulin taken was intermediate acting
Option D- is the peak if the insulin taken was long acting
67. How long does the peak effect last for Novolin NPH, an intermediate-acting insulin?
a. 15 minutes to 1 hour
b. 2 to 3 hours
c. 6 to 12 hours
d. 12 to 16 hours
ANSWER: C
Novolin NPH has a peak effect of 6 to 12 hours. The peak effect of short-acting insulin is 2 to 3 hours. Long acting
insulin has a peak effect of 12 to 16 hours. The onset of rapid-acting insulin is 15 minutes to 1 hour.
68. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should
anticipate which laboratory test result?
a. Decreased serum sodium level
c. Increased hematocrit
b. Decreased serum creatinine level
d. Increased blood urea nitrogen (BUN) level
ANSWER: A
In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water
excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia.
Option B and C - In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within
normal limits.
Option D - Typically, the hematocrit and BUN level decrease.
69. A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result
best supports a diagnosis of Addison's disease?
a. Blood urea nitrogen (BUN) level of 12 mg/dl
c. Serum sodium level of 134 mEq/L
b. Blood glucose level of 90 mg/dl
d. Serum potassium level of 5.8 mEq/L
ANSWER: D
Addison's disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid
losses, an increased serum potassium level, and hypoglycemia. Therefore, an elevated serum potassium level of 5.8
mEq/L best supports a diagnosis of Addison's disease.
Option A and B - A BUN level of 12 mg/dl and a blood glucose level of 90 mg/dl are within normal limits.
Option C - In a client with Addison's disease, the serum sodium level would be much lower than 134 mEq/L, a nearly
normal level.
70. The nurse is caring for a patient following a right adrenalectomy. During the immediate postoperative period, it is
MOST important for the nurse to observe for which of the following?
a. Fluid and electrolyte imbalance
c. Respiratory atelectasis
b. Temperature fluctuation
d. Blood pressure alteration
ANSWER: D
D – Decrease in blood pressure may indicate shock
A, B, C – Severity of this complication is not as life-threatening as that of shock
71. A male patient is diagnosed with hyperprolactinemia. Which of the following clinical manifestations occurs less
frequently in men?
a. A decrease in testosterone
b. Erectile dysfunction
c. Gynecomastia
d. Infertility
ANSWER: C
In men, hyperprolactinemia causes a decrease in testosterone secondary to an inhibition of gonadotropin secretion,
leading to decreased facial and body hair, erectile dysfunction, decreased libido, small testicles, and infertility.
Gynecomastia occurs less frequently in men.
72. Which of the following clinical manifestations would not be associated with hyperprolactinemia in women?
a. Excessive estrogen
b. Hirsutism
c. Osteoporosis
d. Weight gain
ANSWER: A
Hyperprolactinemia is associated with a decrease in estrogen, resulting in symptoms of vaginal dryness, hot flashes,
osteopenia, and osteoporosis. The patient may also experience weight gain, irritability, hirsutism, anxiety, and
depression.
73. A patient arrives at the physician’s office complaining of weight gain. The patient has thin extremities, a “buffalo
hump,” and a protruding abdomen. This patient is most likely to be diagnosed with which disease process?
a. Addison’s disease
b. Cretinism
c. Cushing’s syndrome
d. Obesity
ANSWER: C
Even though the patient has gained weight (obesity), the distribution of that weight is characteristic for the disease
process of Cushing’s syndrome. Cretinism and Addison’s disease do not exhibit those symptoms.
74. A patient is being treated for Cushing’s syndrome. Which of the following instructions would the nurse not give?
a. Monitor glucose levels
c. Wear medical identification
b. Implement safety precautions
d. Volunteer at the hospital to prevent depression
ANSWER: D
A patient diagnosed with Cushing’s syndrome is predisposed to falls, injury, and increased glucose levels. The patient
should wear an identification bracelet indicating his or her disease process. The patient should avoid crowds and
persons with infections.
75. Which effects does the nurse expect daily cortisol therapy to have on a client’s circulating levels of
adrenocorticotropic hormone (ACTH) and aldosterone?
a. Increased ACTH, increased aldosterone
c. Decreased ACTH, increased aldosterone
b. Increased ACTH, decreased aldosterone
d. Decreased ACTH, decreased aldosterone
ANSWER: D
Taking exogenous cortisol increases the blood levels of cortisol, causing the negative feedback loops to be inhibited.
The elevated cortisol levels will suppress hypothalamic secretion of corticotropin-releasing hormone (CRH). Low levels
of CRH suppress the anterior pituitary production of ACTH. Elevated blood levels of cortisol cause increased sodium
retention and water reabsorption, inhibiting aldosterone synthesis.
76. The nurse evaluates no need for further instruction for self-care for the patient with Cushing’s syndrome who
states:
a. “I know I should add salt to everything I eat.”
c. “I avoid being exposed to anyone with an infection.”
b. “I make a point to avoid excessive exposure to sun.”
d. “I am careful to wear well-fitting shoes.”
ANSWER: C
Patients with Cushing’s syndrome are especially prone to infection so this statement is correct. Option A – Adding salt
would increase the fluid retention. Options B, D: Sun and well-fitting shoes are not significant for Cushing’s.
Edition, Vol. 2. Pages 1239.
77. A patient is admitted to the hospital in Addisonian crisis 1 month after a diagnosis of Addison’s disease. The nurse
identifies the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of
management of condition when the patient says:
a. “I double my dose of hydrocortisone on the days that I go for a run.”
b. “I had the stomach flu earlier this week and couldn’t take the hydrocortisone.”
c. “I frequently eat at restaurants, and so my food has a lot of added salt.”
d. “I do yoga exercises almost every day to help me reduce stress and relax.”
ANSWER: B
Rationale: The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs
to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given.
The other patient statements indicate appropriate management of the Addison’s disease.
78. Nurse Hannah is admitting a patient with hyperaldosterism. Which of the following would take the least priority
during this period?
a. Assessment of breath sounds
c. Assistance with activities of daily living (ADLs)
b. Cardiac monitoring
d. Review of electrolyte levels
ANSWER: C
The first priority for the nurse is to monitor cardiac and respiratory status. Cardiac status can be impaired because of
changes in potassium, and fluid balance can be impaired because of sodium, affecting the respiratory status.
79. A patient is admitted with possible SIADH. Which information obtained by the nurse is most important to
communicate rapidly to the physician?
a. The patient complains of a severe headache
c. The patient has a urine specific gravity of 1.025
b. The patient complains of severe thirst
d. The patient has a serum sodium level of 119 mEq/L
ANSWER: D
A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid
correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition Page 1295
80. A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse will monitor carefully for
a. Rapid and unexpected weight loss.
c. Decreased serum sodium level.
b. Increased total urinary output.
d. Elevation of serum hematocrit.
ANSWER: C
SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and
elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition Page 319, 322, 325-326
81. A patient calls for a refill of water. Four empty water pitchers are on the bedside table. The patient’s urine output
is 3500 mL in an eight-hour period. The patient has had recent surgery on the pituitary gland. What endocrine
disorder is the patient most likely to have?
a. Diabetes insipidus
c. Myxedema
b. Diabetes mellitus
d. Syndrome of inappropriate antidiuretic hormone secretion
ANSWER: A
Diabetes insipidus and diabetes mellitus both cause increased urine output, but diabetes insipidus is related to a
problem with antidiuretic hormone; diabetes mellitus is a problem with glucose. Myxedema is caused by a thyroid
hormone imbalance. Syndrome of inappropriate antidiuretic hormone secretion causes fluid retention.
82. In order to diagnose if patient has Diabetic insipidus, the physician ordered a Fluid Deprivation Test. The nurse will
perform this test by:
a. Withholding fluids for 2-4 hours or until 1%-2% of the body weight is lost
b. Withholding fluids for 8-12 hours or until 3%-5% of the body weight is lost
c. Provide an I.V fluid, then withhold oral fluids for 24 hours
d. Provide an I.V fluid, then withhold oral fluids for 8 hours
ANSWER: B
The Fluid deprivation test is carried out by withholding fluids for 8-12 hours or until 3%-5% of the body weight is lost.
The patient is weight frequently during the test. Options A, C, and D are incorrect.
83. Laboratory results of a patient with diabetes insipidus would demonstrate a:
a. Low specific gravity of urine and increased serum osmolality
b. Low specific gravity of urine and decreased serum osmolality
c. High specific gravity of urine and increased serum osmolality
d. High specific gravity of urine and decreased serum osmolality
ANSWER: A
A patient who has diabetes insipidus has the inability to increase the specific gravity and the osmolality of the urine.
The patient continues to excrete large volumes of urine with low specific gravity and experiences weight loss,
increasing serum osmolality, and elevated serum sodium levels.
84. A patient with diabetes insipidus is treated with Desmopressin. Nurse Isabel should instruct the patient to
administer the drug:
a. Intranasally
b. Orally
c. Subcutaneously
d. Intravenously
ANSWER: A
Desmopressin is administered intranasally; the patient sprays the solution into the nose through a flexible calibrated
plastic tube. One or two administrations usually control the symptoms. Intramuscular administration of ADH,
vasopressin tannate in oil, is used if the intranasal route is not possible.
85. The patient clarifies to the nurse the difference between diabetes insipidus and mellitus. It is correct for the nurse
to say that:
a. D.I is a disorder of the posterior lobe of the pituitary gland characterized by a deficiency of aldosterone while D.M.
is a disorder characterized by a destruction of the beta cells
b. D.I. is a disorder of the posterior lobe of the pituitary gland characterized by a deficiency of ADH while D.M. is a
disorder characterized by a destruction of the beta cells
c. D.M. is a destruction of the alpha cells while D.I. is a disorder of the posterior lobe of the pituitary gland
characterized by a deficiency in ADH
d. D.M. is a destruction of the alpha cells while D.I. is a disorder of the posterior lobe of the pituitary gland
characterized by a deficiency in aldosterone
ANSWER: B
The correct answer is Option B. Option A is incorrect because D.I. is a deficiency of ADH and not aldosterone. Option C
is incorrect because D.M. type 1 is the destruction of beta cells and not alpha cells. Option D is incorrect because D.M.
type 1 is a destruction of beta cells while D.I. is not characterized by a deficiency of aldosterone.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition, Pages 1378, 1447.
86. A 42-year old-male patient presents with complaints of palpitation, chest pain, anxiety, and nausea. The blood
pressure is 235/110 mm Hg. Which endocrine disorder is the patient most likely to have?
a. Pheochromocytoma
b. Addison’s disease
c. Diabetes insipidus
d. Hypopituitarism
ANSWER: A
Pheochromocytoma may occur at any age, but its peak incidence is between ages 40 and 50 years. The typical triad
of symptoms comprises headache, diaphoresis, and palpitations. Hypertension and other cardiovascular disturbances
are common. During these attacks, the patient is extremely anxious, tremulous, and weak. The patient may
experience headache, vertigo, blurring of vision, tinnitus, air hunger, and dyspnea.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition
87. A patient at the clinic understands about type 2 diabetes mellitus when she explains:
a. “It happens to everyone who has gained weight.”
c. “I will have to take insulin.”
b. “I have to watch what I eat and exercise.”
d. “The cells that make insulin were destroyed.”
ANSWER: B
Persons with type 2 diabetes control their blood glucose levels with diet, exercise, and medications. Type 1 diabetes
mellitus is characterized by a destruction of beta cells. Not every person who gains weight develops diabetes mellitus.
Insulin is not generally necessary for the patient with type 2 diabetes unless the person is ill or the diabetes is poorly
controlled.
88. A patient at the clinic has a random plasma glucose drawn. The result is 203 mg/dL. The nurse knows that the
patient:
a. Has diabetes.
c. Will have a fasting plasma glucose drawn.
b. Will be prescribed oral medications.
d. Will need to test her glucose for two consecutive days.
ANSWER: C
A patient with a random plasma glucose greater than 200 should have a fasting glucose the next day. A diagnosis of
diabetes requires that the patient have two occasions of hyperglycemia.
89. The nurse explains that type 1 diabetes mellitus is a disease in which the body does not produce enough insulin so
the blood glucose is elevated because of:
a. Prolonged elevation of stress hormone levels (cortisol, epinephrine, glucagon, growth hormone).
b. Malfunction of the glycogen-storing capabilities of the liver.
c. Destruction of the beta cells in the pancreas.
d. Insulin resistance of the receptor cells of the muscle tissue.
ANSWER: C
Type 1 diabetes mellitus is a disease characterized by an absence of insulin production and secretion from
autoimmune destruction of the beta cells. Options A, B, D – Although these factors affect insulin production and
secretion, they are not the cause of type 1 diabetes mellitus.
Edition, Vol. 2. Pages 1151, 1153.
90. Which of the following is the correct procedure for mixing two types of insulin in the same syringe?
a. Withdraw the regular insulin prior to any other type of insulin
b. Withdraw the regular insulin after other types of insulin
c. Draw each insulin in a separate syringe, then combine the two
d. Two types of insulin should not be mixed in the same syringe
ANSWER: A
Regular insulin always should be drawn up before any other type of insulin. Option B: Regular insulin always should
be drawn up first. Option C: This is not the appropriate technique. Option D: Although true with a few insulins, it is
not characteristic of most.
91. When evaluating the electrolyte levels of a client experiencing diabetic ketoacidosis (DKA), the nurse would be
most concerned about which finding?
a. Sodium level > 145 mEq/L
c. Potassium 3.1 mEq/L
b. Sodium level 133 mEq/L
d. Potassium 5.2 mEq/L
ANSWER: C
Hypokalemia is the most serious electrolyte imbalance associated with DKA and this level is significant when
compared to the normal level of 3.5-5 mEq/L. Option A: This is highly unlikely to occur in this client. Option B:
Although indicative of hyponatremia, the level is not far from the normal. Option D: This is highly unlikely to occur in
this client.
92. The nurse correlates which assessment finding in the client with diabetes mellitus with decreasing renal function?
a. Ketone bodies in the urine during acidosis
c. Protein in the urine during a random urinalysis
b. Glucose in the urine during hyperglycemia
d. White blood cells in the urine during a random urinalysis
ANSWER: C
Urine should not contain protein. The presence of proteinuria in a diabetic marks the beginning of renal problems
known as diabetic nephropathy, which progresses eventually to end-stage kidney disease. Chronically elevated blood
glucose levels cause renal hypertension and excess kidney perfusion, with leakage from the renal vasculature. The
excess leaking allows larger substances, such as proteins, to be filtered into the urine.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition
93. A patient tells the nurse that she eats “huge” amounts of food but stays hungry most of the time. The nurse
explains that hunger experienced by persons with type 1 diabetes is caused by the:
a. Excess amount of glucose
b. Need for additional calories to correct the increased metabolism.
c. Fact that the cells cannot use the blood glucose.
d. Need for exercise to stimulate insulin secretion.
ANSWER: C
The cells cannot use the glucose without insulin, so the diabetic client still feels hungry although there is abundant
glucose circulating in the blood.
Edition, Vol. 2. Pages 1151-1153.
94. When the type 2 diabetic patient says, “Why in the world are they looking at my hemoglobin? I thought my
problem was with my blood sugar.” The nurse responds that the level of hemoglobin A1c:
a. Shows how a high glucose level can cause a significant drop in the hemoglobin level.
b. Shows what the glucose level has done for the last 3 months.
c. Indicates a true picture of the patient’s nutritional state.
d. Reflects the effect of high glucose levels on the ability to produce red blood cells.
ANSWER: B
By analyzing the amount of glucose bound to the hemoglobin, the level of blood glucose can be evaluated for the last
3 months, because the glucose stays bound to the hemoglobin for the life of the red blood cell (RBC).
95. A client who has type 2 diabetes is prescribed to take an oral sulfonylurea agent to maintain control of blood
glucose levels. Which precautions does the nurse need to include in the teaching plan related to this medication?
a. “Change positions slowly.”
b. “Avoid taking nonsteroidal anti-inflammatory drugs.”
c. “Do not skip the medication, even if you are unable to eat.”
d. “Discontinue the medication if you develop an infection.”
ANSWER: B
Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition
96. On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the
nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a
life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance
most commonly follows thyroid surgery?
a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia
ANSWER: A
Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of
hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium,
potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid;
however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid
surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and
magnesium, not thyroid surgery.
97. The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
a. insulin.
b. furosemide (Lasix).
c. potassium chloride.
d. vasopressin (Pitressin).
ANSWER: D
Vasopressin is given subcutaneously in the acute management of diabetes insipidus. Insulin is used to manage
diabetes mellitus. Furosemide causes diuresis. Potassium chloride is given for hypokalemia.
98. The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and
aberrant behavior. The client is still conscious. The nurse should first administer:
a. I.M. or subcutaneous glucagon.
c. 15 to 20 g of a fast-acting carbohydrate such as orange juice.
b. I.V. bolus of dextrose 50%.
d. 10 U of fast-acting insulin.
ANSWER: C
This client is having a hypoglycemic episode. Because the client is conscious, the nurse should first administer a fastacting
carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should
administer either I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer
insulin to a client who's hypoglycemic; this action will further compromise the client's condition.
99. A client with type 1 diabetes mellitus takes 15 U of Humulin N insulin before breakfast and 8 U before dinner.
During a follow-up visit, the nurse reevaluates the client's knowledge about insulin therapy and self-administration
skills and learns that the client is unaware that certain over-the-counter (OTC) preparations and other medications
may interact with insulin. The nurse should advise the client to avoid which OTC preparations?
a. Antacids
c. Vitamins with iron
b. Salicylate-containing preparations
d. Acetaminophen-containing preparations
ANSWER: B
Salicylates may interact with insulin, causing hypoglycemia. Antacids, vitamins with iron, and acetaminophen aren't
known to interact with insulin.
100. Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is
experiencing complications?
a. Tetanic contractions
b. Neck vein distention
c. Weight loss
d. Polyuria
ANSWER: B
SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause
such complications as vascular fluid overload, signaled by neck vein distention. This syndrome isn't associated with
tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).
CARE OF CLIENTS WITH FLUIDS AND ELECTROLYTES DISTURBANCES
SITUATION: The fluids and electrolytes must be maintained to promote normal function. Potential and actual
problems of fluid and electrolytes happen in all health care settings, in every disorder and with a variety of changes
that affect homeostasis
1. The most important electrolyte of intracellular fluid is:
a. sodium
b. Calcium
c. Chloride
d. potassium
ANSWER: D
D – The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a
critical factor in the cell’s ability to function
A – Sodium is the most abundant cation of the extracellular compartment
B – Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones
C – Chloride is an extracellular anion
2. The nurse evaluates the laboratory reports on electrolyte values carefully to assess the balance between positive
and negative ions, which is regulated by the process of:
a. Adaptation
b. Diffusion
c. Homeostasis
d. Osmosis
ANSWER: B
B – Diffusion allows the ions to support homeostatic balance.
A – Adaptation is the preferential survival of members of a species because of a phenotype that gives them an
enhanced capacity to withstand the environment.
C – Homeostasis is the the state of equilibrium (balance between opposing pressures) in the body with respect to
various functions and to the chemical compositions of the fluids and tissues.
D – Osmosis is the passage of solvent through a semi permeable membrane from an area of lesser solute
concentration to one of greater solute concentration
3. The nurse instructs a family that the blood being brought by the incoming capillaries into the kidney, which
contains nitrogenous substances to be excreted as waste, involves a process of:
a. Active transport
b. Diffusion
c. Filtration
d. Osmosis
ANSWER: C
B – Capillary blood from the renal arteries filters into the kidney for processing as the first step.
A – Active transport is the movement of substances across cell membranes against the concentration gradient
C – Filtration is the process whereby fluid and solutes move together across a membrane from an area of high
pressure to one of lower pressure
D – Osmosis is the passage of solvent through a semi permeable membrane from an area of lesser solute
concentration to one of greater solute concentration
4. All the following are isotonic solutions, except:
a. 0.9% NaCl
b. Lactated Ringer’s solution
c. D5W
d. 0.45% NaCl
ANSWER: D
0.9% NaCl- also called normal saline, this is an isotonic solution that expands the ECF volume
Lactated Ringer’s solution- an isotonic solution that contains multiple electrolytes
D5W-an isotonic solution that supplies 170 calories/L and free water to aid in renal excretion of solutes
0.45% NaCl- or half strength saline. This is a hypotonic solution
5. A nurse is assigned to care for a group of clients. On review of the client’s medical records, the nurse determines
that which client is at risk for deficient fluid volume?
a. A client with a colostomy
c. A client with decreased kidney function
b. A client with congestive heart failure
d. A client receiving frequent wound irrigations
ANSWER: A
A – Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or
increased urinary output, insufficient IV fluid replacements, draining fistulas, and the presence of an ileostomy or
colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound
irrigations, is at risk for excess fluid volume.
6. A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a
deficient fluid volume. Which assessment finding would be nurse note in a client with this condition?
a. Lung congestion
c. Increased blood pressure
b. Decreased hematocrit
d. Decreased central venous pressure (CVP)
ANSWER: D
D – Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate,
decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine
volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal
CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment findings in options 1, 2,
and 3 are seen in a client with excess fluid volume.
7. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130
mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development
of a sodium value at this level?
a. The client with renal failure
c. The client with hyperaldosteronism
b. The client who is taking diuretics
d. The client who is taking corticosteroids
ANSWER: B
B – Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client
taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for
hypernatremia.
8. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On
assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep
tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client
if hyponatremia were present?
a. Dry skin
c. Hyperactive bowel sounds
b. Decreased urinary output
d. Increased specific gravity of the urine
ANSWER: C
C – Hyperactive bowel sounds indicate hyponatremia. Options 1, 2, and 4 are signs of hypernatremia. In
hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in
deficient fluid volume.
9. Which clinical manifestation would the nurse expect to assess in a client with hypernatremia?
a. Muscle weakness and paresthesia
c. Muscle twitching and tetany
b. Fruity breath and Kussmaul’s respirations
d. Tented skin turgor and thirst
ANSWER: D
D – Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L typically, the client exhibits
tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy and restlessness.
A – Muscle weakness and paresthesia are associate with hypokalemia fruity breath is associated with diabetic
ketoacidosis.
B, C – Muscle twitching and tetany may be seen with hypocalcemia or hyperphosphatemia.
10. Which of the following is a contributing factor in the development of hypernatremia?
a. SIADH
b. Diabetes insipidus
c. Loss of GI fluids
d. Adrenal insufficiency
ANSWER: B
Hypernatremia or sodium excess is a state where serum sodium is greater than 145 mEq/L. Options a, c and d are all
contributing factors of hyponatremia since there following conditions promote sodium deficit. Diabetes insipidus, a
deficiency of the ADH from the posterior pituitary gland leads to hypernatremia if the patient cannot respond to thirst
or if fluids are excessively restricted.
11. A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and
determines that the client was at risk for developing the potassium deficit because the client:
a. Has renal failure
c. Has a history of Addison’s disease
b. Requires nasogastric suction
d. Is taking a potassium-sparing diuretic
ANSWER: B
B – Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for
hypokalemia. The client with renal failure or Addison’s disease and the client taking a potassium-sparing diuretic are
at risk for hyperkalemia.
12. A nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of
the following would the nurse note on the electrocardiogram as a result of the laboratory value?
a. U waves
b. Absent P waves
c. Elevated T waves
d. Elevated ST segment
ANSWER: A
A – A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte
imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment
depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia.
13. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with
hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states
that which of the following is part of the plan for preparation and administration of the potassium?
a. Obtaining a controlled IV infusion pump
c. Diluting in appropriate amount of normal saline
b. Monitoring urine output during administration
d. Preparing the medication for bolus administration
ANSWER: D
D – Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or
controller. The usual concentration of IV potassium chloride in 20 to 40 mEq/L. Potassium chloride is never given by
bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is
recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting.
The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored
closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary
output during administration and contacts the physician if the urinary output is less than 30 ml/hr.
14. The nurse assesses for hyperkalemia in a client with which of the following problems?
a. Renal failure
b. Nausea and vomiting
c. Excessive laxative use
d. Loop diuretic use
ANSWER: A
Renal failure results in the inability of the kidneys to excrete potassium and that leads to hyperkalemia. Nausea,
vomiting, excessive laxative use, and loop diuretic use will cause hypokalemia.
15. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical
manifestations would the nurse expect to note in the client?
a. Twitching
c. Hypoactive bowel sounds
b. Negative Trousseau’s sign
d. Hypoactive deep tendon reflexes
ANSWER: A
A – Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a
positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability,
muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased
gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
16. A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the
electrocardiogram?
a. Widened T wave
b. Prominent U wave
c. Prolonged QT interval
d. Shortened ST segment
ANSWER: C
C – Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A
shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia.
17. Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?
a. Muscle pain and acute rhabdomyolysis
c. Hot, flushed skin and diaphoresis
b. Soft-tissue calcification and hyperreflexia
d. Increased respiratory rate and depth
ANSWER: C
C – Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit hypotension,
lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are indicative of
hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia. Increased
respiratory rate and depth are associated with metabolic acidosis
18. A nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus level is 2.0 mg/dL.
Which condition most likely caused this serum phosphorus level?
a. Alcoholism
b. Renal insufficiency
c. Hypoparathyroidism
d. Tumor lysis syndrome
ANSWER: A
A – The normal serum phophorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative
factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids.
Malnutrition is associated with alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are
causative factors of hyperphosphatemia.
19. The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result
in metabolic acidosis?
a. Severe diarrhea for 24 hours
c. Alternating constipation and diarrhea
b. Nausea with anorexia
d. Vomiting for over 48 hours
ANSWER: A
A – Severe diarrhea is the only problem listed that can lead to metabolic acidosis if untreated.
20. Which of the following would indicate that your client is in metabolic acidosis?
a. High pH, high HCO3
b. Low pH, low pCO2
c. Low pH, low HCO3
d. High pH, low pCO2

ANSWER: C
Normal ABG pH is 7.35 to 7.45 and a normal bicarbonate level is 22 to 26 mEq/L. A low pH would indicate a client is
in an acidotic state and the low bicarbonate would indicate a metabolic cause for the acidosis. The pCO2 level is an
indicator of the respiratory component of the client’s acid-base balance.
21. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client,
knowing that the client is at risk for which acid-base disorder?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANSWER: B
B – Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of
hydrochloric acid. Options 1, 3, and 4 are incorrect.
22. A nurse reviews the blood gas results of a client with Guillain-Barre syndrome. The nurse analyzes the results and
determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse’s findings?
a. pH 7.25, Pco2 of 50 mm Hg
c. pH 7.50, Pco2 of 52 mm Hg
b. pH 7.35, Pco2 of 40 mm Hg
d. pH 7.52, Pco2 of 28 mm Hg
ANSWER: A
A – The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased
and the Pco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition. Option 4
identifies respiratory alkalosis.
23. A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to
experience what type of acid-base imbalance?
ANSWER: C
C – Respiratory acidosis is most often caused by hypoventilation. Chronic respiratory acidosis is most commonly
caused by chronic obstructive pulmonary disease. In end-stage disease, pathological changes lead to airway collapse,
air trapping, and disturbance of ventilation-perfusion relationships. Option 1, 2, and 4 are incorrect options.
24. A nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acidbase disorder?
ANSWER: A
A – Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes or an ileostomy, or
with diarrhea. These conditions result in metabolic acidosis. Options 2, 3, and 4 are incorrect because they do not
occur in the client with an ileostomy.
25. A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess:
a. Trousseau's sign
b. Homans' sign
c. Hegar's sign
d. Goodell's sign
ANSWER: A
This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign
(carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on
dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's
sign (cervical softening) are probable signs of pregnancy.
26. For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid
volume?
a. Cool, clammy skin
b. Distended neck veins
c. Increased urine osmolarity
d. Decreased serum sodium level
ANSWER: C
In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose
particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing
deficient fluid volume. Cool, clammy skin; distended neck veins; and a decreased serum sodium level are signs of
fluid volume excess, the opposite imbalance.
27. A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which
test result is most significant?
a. BUN level of 29 mg/dl
c. Urine specific gravity of 1.025
b. Serum sodium level of 132 mEq/L
d. Serum potassium level of 3 mEq/L
ANSWER: D
A serum potassium level of 3 mEq/L is below normal, indicating hypokalemia. Because hypokalemia may cause
cardiac arrhythmias and asystole, it's the most significant finding. In a client with a potential fluid volume imbalance,
such as from vomiting, the other options are expected and none is as life-threatening as hypokalemia. A BUN level of
29 mg/dl indicates slight dehydration, probably caused by vomiting. A serum sodium level of 132 mEq/L is slightly
below normal but not life-threatening. A urine specific gravity of 1.025 is normal.
28. A 78-year-old client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dL;
BUN: 12 mg/dL; Creatinine: 0.9 mg/dL; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33
mEq/L. Which result should the nurse identify as critical and report immediately?
a. CO2
b. Sodium
c. Chloride
d. Potassium
ANSWER: D
A normal potassium level is 3.8 to 5.5mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly
leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose
level is above normal (normal is 75 to 110 mg/dL) and the chloride level is a bit low (normal is 100 to 110 mEq/L).
Although these levels should be reported, neither is life-threatening. The BUN (normal is 8 to 26 mg/dL) and
creatinine (normal is 0.8 to 1.4 mg/dL) are within normal range.
29. Which organ is the most vital to the regulation of fluid and electrolyte balance?
a. Kidneys
b. Pancreas
c. Parathyroid
d. Liver
ANSWER: A
The kidneys control the excretion of sodium and potassium through the countercurrent mechanism. It regulates the
amount of ECF volume and osmolality by selective retention and excretion of body fluids. It also regulates the
electrolyte levels in the ECF, regulates the pH and responsible for the excretion of metabolic wastes and toxic
substances.
30. On a nursing assessment, the nurse finds the client with a weak and rapid heart rate, increase in temperature and
decrease skin turgor. The nurse should continue an assessment for what problem?
a. Sodium imbalance.
b. Altered renal function.
c. Fluid volume deficit.
d. Hyperkalemia.
ANSWER: C
With dehydration or fluid deficit, there is a loss of body fluids. This is manifested by rapid heart rate, increase in
temperature, flattened neck veins, decreased skin turgor, oliguria, concentrated urine, cool clammy skin related to
peripheral vasoconstriction, thirst, anorexia, muscle weakness and cramps.
31. Which problem can result the client has a fever?
a. Hypovolemia
b. Hypercalcemia.
c. Hypokalemia.
d. Hypervolemia
ANSWER: A
The body’s response to fever is to bring fluid to the surface areas, which have increased temperature, creating a
diaphoretic state and thus a loss of body fluids or hypovolemia.
32. A client is experiencing difficulty with edema and fluid overload. What nursing intervention would be the most
accurate in evaluating the client’s fluid balance?
a. Measure the intake and output.
c. Evaluate changes in daily weight.
b. Check for first and tissue turgor.
d. Evaluate vital signs every 3 hours.
ANSWER: C
The priority assessment for client with fluid problems is to obtain the daily weight. Weight gain and loss are the most
accurate measurements of fluid gain and loss.
33. The client is admitted with hypokalemia. An intravenous fluid of NSS is infusing at 80 ml / hour with 10 meq of
KCl / hour. Before beginning the IV infusion, the nurse should:
a. Check the sodium level b. Check the magnesium level c. Check the creatinine level d. Check the calcium level
ANSWER: C
A client receiving potassium needs to be evaluated for renal function because regulation of potassium is primarily
done within the kidneys. Options A, B and D are incorrect.
34. An elderly client is admitted to the unit with a temperature of 37.8 0 C, urine specific gravity of 1.032 and a dry
tongue. The nurse should anticipate an order for:
a. An antibiotic
b. An IV of normal saline
c. An analgesic
d. A diuretic
ANSWER: B
The client is hypovolemic and hyponatremic. The slight elevation in temperature might be related to the dehydration.
The normal specific gravity of urine is 1.010 – 1.020 therefore, the client’s finding shows urinary concentration. There
is not enough data to support that the client needs options A, C or D so they are incorrect.
35. The nurse made her diagnosis for a client who is having a shock, Fluid Volume Deficit related to decreased plasma
volume. Which of the following supports her diagnosis?
a. Shallow respirations with some bubbling crackling sounds.
c. Bounding post-tibial pulses
b. Some pitting edema found in the ankles.
d. Flattened neck veins, which are obvious upon lying in
ANSWER: D
Normally, check veins are distended when the client is in the supine position. These veins flatten as the client moves
to a sitting position. The other three responses are characteristics of Fluid Volume Excess.
Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 23.
36. If a client had a diagnosis of Syndrome of Inappropriate Anti-diuretic Hormone (SIADH), which of the following
electrolyte should a nurse watchful for?
a. Decreased sodium
b. Increased sodium
c. Increased potassium
d.Decreased potassium
ANSWER: A
SIADH causes a relative sodium deficit due to excessive retention of water.
Reference: LaCharity, Linda. Prioritization, Delegation, and Assignment. 2006. p. 24.
37. Which of the following would the nurse suspect if the client’s ECG waveform is tall-tented T waves?
a. Hyperkalemia
b. Hypercalcemia
c. Hypokalemia
d. Hypocalcemia
ANSWER: A
An ECG waveform showing a shortened QT interval and bradycardia suggests hypercalcemia. The ECG pattern
typically associated with hyperkalemia reveals tall-tented T waves, a prolonged PR interval and QRS duration, absent
P waves, and ST depression. The ECG associated with hypocalcemia typically shows a prolonged QT interval. With
hypokalemia, the ECG reveals a flattened T wave, prominent U wave, depressed ST segment, and prolonged PR
interval.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed., 2001. p. 66.
38. Which of the following clinical manifestations signifies hyperphosphatemia?
a. Increased respiratory rate
b. Diaphoresis, flushed skin
c. Hyperreflexia
d. Rhabdomyolysis and muscle pain
ANSWER: C
Soft tissue calcification and hyperreflexia are indicative of hypermagnesemia. Increased RR and depth are associated
with metabolic acidosis. Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. Muscle pain and acute
rhabdomyolysis are indicative of hypophosphatemia.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed., 2001. p. 66.
39. Foods high in potassium should be avoided in which of the following anomalies?
a. Renal disease
b. Colostomy
c. Ileostomy
d. Metabolic alkalosis
ANSWER: A
Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Clients receiving
diuretics, with ileostomies, or with metabolic alkalosis may be hypokalemic and should be encouraged to eat foods
high in potassium.
Reference: Huttel, Ray. Lippincott’s Review Series: Medical Surgical Nursing. 3rd ed. 2001. p. 65.
40. ICF as opposed to ECF has higher concentration of which of the following electrolyes?
a.Magnesium and potassium
b.Sodium and calcium
c.Calcium and potassium
d.Chloride and potassium
ANSWER: A
ICF has higher concentrations of magnesium, potassium, protein, phosphate, and sulfate, and lower concentrations of
sodium, calcium, chloride and bicarbonate.
Reference: Bates, Rita. Straight A’s in Anatomy and Physiology. 2007. p. 341.
41. The nurse is in the telemetry unit. The monitor watcher informs the nurse that the client has developed prominent
U waves in the ECG strip. Which laboratory value should the nurse check immediately?
a. Calcium
b. Magnesium
c. Sodium
d. Potassium
ANSWER: D
The nurse should check the serum potassium level. The client may have hypokalemia. ECG changes include flat T
waves or inverted T waves suggesting ischemia. Moreover, an elevated U wave is specific to hypokalemia.
Reference: Smeltzer, S.C. et al. (2004) Brunner and Suddarth’s Medical Surgical Nursing. 10th ed. Lippincott Williams
and Wilkins. Page 266
42. A client, admitted with aspirin intoxication, has the following results: pH=7.50, PaCO2=32, HCO3=24. This
client’s blood gas values indicate which of the following acid-base disturbances?
a. Respiratory Alkalosis
c. Respiratory Alkalosis, Compensated
b. Metabolic Alkalosis
d. Metabolic Alkalosis, Uncompensated
ANSWER: A
This is common due hyperventilation, which causes blowing off CO2 and hence a decrease in plasma carbonic acid
content. This should be uncompensated because the bicarbonate is normal.
Reference: Hoefler, Patricia. The Complete Q&A Book for the NCLEX/CAT-RN. 1994. p. 159.
43. Which of the following would indicate that your client is in metabolic acidosis?
b. Low pH, low pCO2
c. Low pH, low HCO3
d. High pH, low pCO2
a. High pH, high HCO3
ANSWER: C
Normal ABG pH is 7.35 to 7.45 and a normal bicarbonate level is 22 to 26 mEq/L. A low pH would indicate a client is
in an acidotic state and the low bicarbonate would indicate a metabolic cause for the acidosis. The pCO2 level is an
indicator of the respiratory component of the client’s acid-base balance.
44. The client is being weaned from a ventilator. Arterial blood gases drawn prior to extubation reveal: pH 7.32; PaO2
75 mmHg; PaCO2 56 mmHg; HCO3 26 mEq/L. The nurse calls the physician with these results because they indicate
that the client is in a state of:
a. Metabolic alkalosis
b. Respiratory alkalosis
d. Metabolic acidosis
ANSWER: C
Evaluate the pH first to determine acidosis or alkalosis. Then evaluate PaCO2 as the respiratory component and HCO
as the metabolic component. The client’s pH < 7.35 and PaCO2 > 45mm Hg indicate a state of respiratory acidosis
and indicates that the client is not tolerating the weaning process. Metabolic alkalosis would be indicated by a pH >
7.45 and a HCO 26 mEq/L. Respiratory alkalosis would be seen in a client with a pH > 7.45 with a PCO2 < 35 mmHg.
Metabolic acidosis would be indicated in a client with a pH < 7.35 with a HCO < 21 mEq/L.
SITUATION: The nurse needs to understand the physiology of fluid and electrolyte balance and acid–base balance to
anticipate, identify, and respond to possible imbalances in each. The nurse also must use effective teaching and
communication skills to help prevent and treat various fluid and electrolyte disturbances.
45. Nurse Isabel obtains all of the following assessment data about a patient with fluid-volume deficit caused by a
massive burn injury. Which of the following assessment data will be of greatest concern?
a. Oral fluid intake is 100 ml for the last 8 hours
c. Urine output is 30 ml over the last hour
b. The blood pressure is 90/40 mm Hg
d. There is prolonged skin tenting over the sternum
ANSWER: B
The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will
require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral
intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not
as urgently as the hypotension.
46. When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected
except:
a. Crackles
b. A bounding pulse
c. Engorged peripheral veins
d. An elevated hematocrit level
ANSWER: D
An elevated hematocrit would be expected with a deficit of body fluid in the intravascular compartment. When an
excess of body fluid exists in the intravascular compartment, a decreased hematocrit would be expected. Crackles (in
lungs) are consistent findings with fluid volume excess. An assessment finding associated with fluid volume excess is a
bounding pulse. An engorged peripheral veins may be seen with fluid volume excess.
Reference: Perry and Potter Fundamentals of Nursing 6th edition page 1144
47. Following bowel surgery 2 days ago, a patient has been receiving normal saline intravenously at 100 ml/hr, has a
nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that indicates a need to call the
doctor immediately is a:
a. Weight gain of 2 pounds above the preoperative weight
c. Gradually decreasing level of consciousness (LOC)
b. An oral temperature of 100.1° F with bibasilar lung crackles
d. Serum sodium level of 138 mEq/L (138 mmol/L)
ANSWER: C
The patient’s history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular
fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic
information will be ordered by the health care provider to determine the cause of the change in LOC and the
appropriate interventions. A weight gain of 2 pounds (<1 kg) since surgery would not be clinically significant unless
associated with other symptoms. The oral temperature elevation and crackles would initially be addressed by having
the patient cough and deep breathe. The sodium level is within the normal range of 135 to 145 mEq/L.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition page 322-325, 338
48. A patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. The
laboratory data that will be of most concern to the nurse is:
a. Potassium level of 3.4 mEq/L
c. Sodium level of 154 mEq/L
b. Calcium level of 7.8 mg/dl
d. Phosphate level of 4.8 mg/dl
ANSWER: C
The elevated serum sodium level is consistent with the patient’s neurologic symptoms and indicates a need for
immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary
slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the
normal parameters.
49. Which of the following reasons represents the main reason nurses and others need to offer older clients water
throughout the day?
a. The thirst mechanism declines with age so older adults are more vulnerable to dehydration
b. Older adults are more apt to forget to drink water during the day
c. The skin loses more water with aging and older adults need to drink more to tone their skin.
d. Most older adults have a taste for sweets and plain water does not appeal to them
ANSWER: A
Older adults experience a number of age-related changes that can affect fluid, electrolyte, and acid-base imbalances.
They have decreased thirst sensation which may affect their oral intake of fluids. The kidneys have a decrease in
glomerular filtration rate and in the number of filtering nephrons. These changes can mean that in the presence of
sodium depletion or overload the older adult may be unable to maintain homeostasis and the imbalance is instead
worsened.
Reference: Potter and Perry. Fundamentals of Nursing 6th edition Page 1148
50. Nurse Daniel is reviewing the client’s chart. He finds in the documentation that the client’s CVP was 7 mm Hg.
Which of the following categories would this reading fall into?
a. Low
b. Normal
c. Slightly elevated
d. High
ANSWER: C
CVP is a measurement of the pressure in the vena cava or right atrium. Since the pressure in the vena cava, right
atrium, and right ventricle are equal at the end of diastole, the CVP reflects the filling pressure of the right ventricle
(preload). The normal CVP is to 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an elevated right ventricular
preload. There are many problems that can cause an elevated CVP, but the most common is due to hypervolemia or
right sided HF.
51. Because women have more body fat than men, their percentage of body water relative to their total body weight
is:
a. The same as that fat of men
c. Lower than that of men
b. Higher than that of men
d. The same as their percentage of body fat
Answer: C
Because body fat, or adipose tissue, doesn’t retain water well, women have a lower percentage of body water relative
to their total body weight (45% to 50%) compared with that of men (50% to 60%).
Reference: Barbara Kozier, Fundamentals of Nursing 11th edition, Page 1434.
52. When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse
to obtain is:
a. Mental status
b. Skin turgor
c. Capillary refill
d. Heart sounds
ANSWER: A
Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing
confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also
be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as
immediate an impact on patient outcomes.
53. Nurse Daniel is infusing a hypotonic solution to a client. He knows that this type of solution will affect the client’s
fluid status by:
a. Decreasing water content in the blood vessel
c. Increasing water content in the blood vessel
b. Not changing water content in the blood vessel
d. Drawing water into the blood vessel
ANSWER: A
Because of hypotonic solution is less concentrated solution, fluid will be drawn from the hypotonic solution in the
blood vessels to the more concentrated solutions in the cells, thereby reducing water content in the blood vessels.
Reference: Suzanne Smeltzer, Brunner and Suddarth’s Medical Surgical Nursing 11th edition, Pages 1340, 1455.
54. A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the
most important assessment for the nurse to monitor is:
a. Peripheral pulses
b. Lung sounds
c. Peripheral edema
d. Urinary output
ANSWER: B
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles
in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess
listed. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when
administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
55. A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will
teach the patient to report symptoms of adverse effects such as:
a. Generalized weakness
b. Facial muscle spasms
c. Frequent loose stools
d. Personality changes
ANSWER: A
Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur
with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with
electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.
56. A client is currently taking furosemide (Lasix) and digoxin. As a result of the medication regimen, Nurse Mon is
alert to the presence of:
a. Cardiac dysrhythmias
b. Severe diarrhea
c. Hyperactive reflexes
d. Peripheral cyanosis
ANSWER: A
Furosemide (Lasix) is a non–potassium-sparing diuretic. Without a potassium supplement, the client may become
hypokalemic. Hypokalemia increases the risk for digoxin toxicity. Both hypokalemia and digoxin toxicity can cause
cardiac dysrhythmias. Option B: Clients with hypokalemia from diuretic use may experience intestinal distention and
decreased bowel sounds. Severe diarrhea may be a cause, not a result, of hypokalemia. Option C: Clients with
hyperactive reflexes may have hypocalcemia. Furosemide (Lasix) and digoxin do not predispose a client to
hypocalcemia. Option D: Peripheral cyanosis is not a potential problem related to the client’s medication regimen.
57. The K+ laboratory report shows a level of 6.2 mEq/L. Nurse Rachel will assess the patient closely for:
a. Excessive thirst
b. Irregular heartbeat
c. Swelling of ankles
d. Frightening hallucinations
ANSWER: B
Arrhythmias can be triggered by hyperkalemia.
58. A client is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be
administered:
a. Directly into the venous access line
c. Mixed in the prescribed intravenous fluid
b. Via intramuscular injection
d. Via a rectal suppository
ANSWER: C
The intravenous route is the recommended route for undiluted potassium. Never administer undiluted potassium
directly into a vein.
59. A 28-year-old male client is admitted with diabetic ketoacidosis. The nurse realizes that this client will have a need
for which of the following electrolytes?
a. Magnesium
b. Sodium
c. Calcium
d. Potassium
ANSWER: A
One risk factor for hypomagnesemia is an endocrine disorder, including diabetic ketoacidosis. The client's levels of
sodium, potassium, and calcium are not the primary needs of this client.
60. An elderly client with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that
which of the following symptoms can indicate hypermagnesemia?
a. Hyperreflexia
c. Hypotension, warmth, and sweating
b. Nausea and vomiting
d. Excessive urination
ANSWER: C
Elevations in magnesium levels is accompanied by hypotension, warmth, and sweating. Lower levels are associated
with nausea and vomiting, hypertension, and hyperreflexia. Urinary changes are not noted.
61. To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for hypocalcemia, an early sign of
hypocalcemia the nurse should assess for is:
a. Weak hand grips
b. Confusion
c. Constipation
d. Lip numbness
ANSWER: D
Numbness and tingling around the lips or in the fingers are early signs of hypocalcemia. Muscle weakness, confusion,
and constipation may also occur, but these are later signs of low calcium levels.
62. A client is diagnosed with hyperphosphatemia. The nurse realizes that this client might also have an imbalance of
which of the following electrolytes?
a. Sodium
b. Chloride
c. Calcium
d. Potassium
ANSWER: C
Excessive serum phosphate levels cause few specific symptoms. The effects of high serum phosphate levels on nerves
and muscles are more likely the result of hypocalcemia that develops secondary to an elevated serum phosphorus
level. The phosphate in the serum combines with ionized calcium, and the ionized serum calcium level falls. There is
no direct correlation between levels of phosphorus and that of sodium, potassium or chloride.
63. Which nursing intervention is most appropriate for a client with hypercalcemia?
a. Ambulate the client as soon as possible
c. Maintain the client on strict bed rest
b. Encourage compliance with fluid restrictions
d. Encourage the consumption of green, leafy vegetables
ANSWER: A
The client with hypercalcemia should be ambulated as soon as possible to prevent bones from releasing calcium and
increasing serum levels. The client should increase fluid intake to promote calcium excretion from the kidneys and to
prevent the risk of calculi formation. Green, leafy vegetables are calcium-rich foods and should be avoided by the
client with hypercalcemia.
64. For a child who has ingested the remaining contents of an aspirin bottle, is breathing rapidly, and has a blood pH
of 7.47, the nurse suspects signs and symptoms consistent with:
ANSWER: D
A salicylate overdose may cause respiratory alkalosis due to hyperventilation. Option A: Metabolic acidosis may occur
with salicylate poisoning, but the pH demonstrates an alkalosis state. Option B: Metabolic alkalosis is not consistent
with aspirin overdose. Option C: An aspirin overdose does not cause respiratory acidosis.
65. Arterial blood gases are obtained for the client. The client’s results of pH, 7.48; CO2, 42; HCO3, 32; indicates
which one of the following acid-base imbalances?
b. Respiratory acidosis
c. Respiratory alkalosis
ANSWER: D
The client’s pH is elevated at 7.48 (normal, 7.35 to 7.45), the CO2 is normal at 42 (normal, 35 to 45 mm Hg), and the
bicarbonate is elevated at 32 (normal, 19 to 25 mEq/L). The client is experiencing metabolic alkalosis. Option A: In
metabolic acidosis, the client’s pH would be below 7.35, and the bicarbonate would be below 22 mEq/L. The client is
not experiencing metabolic acidosis. Option B: In respiratory acidosis, the client’s pH would be below 7.35, and the
CO2 would be elevated above 45 mm Hg. The client is not experiencing respiratory acidosis. Option D: In respiratory
alkalosis, the client’s pH would be above 7.45, and the CO2 would be below 35 mm Hg. The client is not experiencing
respiratory alkalosis.
66. The physician orders 1000 ml of D5RL with 20 mEq KC1 to run for 8 hours. With an infusion set with a drop factor
of 15 gtt/ml, the nurse calculates the flow rate to be:
a. 12 drops per minute
b. 22 drops per minute
c. 32 drops per minute
d. 42 drops per minute
ANSWER: C
1000 ml/8 hr = 125ml/hr; 15 gtt/ml
60 min x 125 ml = 32 gtts/min
67. A client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client’s
respiratory rate has increased. What is your best response?
a. “It’s common for clients with uncomfortable procedures such as nasogastric tubes to have a higher rate of breathing”
b. “The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a
compensatory mechanism”
c. “Whenever a client develops a respiratory acid-base problem, increasing the respiratory rate helps correct the problem”
d. “The client is hyperventilating because of anxiety and we will have to stay alert for development of a respiratory acidosis”
ANSWER: B
Nasogastric suctioning can result in a decrease in acid components and a metabolic alkalosis. The client’s increase in
rate and depth of ventilation is an attempt to compensate by blowing off CO2. The first response may be true but
does not address all the components of the question. The third and fourth answers are inaccurate.
68. When a client has arterial blood gasses drawn, the nurse most needs to assure that which of the following actions
are carried out?
a. The client is instructed to lie down and remain lying down for at least 20 minutes
b. The client's blood pressure is taken every five minutes for fifteen minutes
c. Firm pressure is applied to the site for at least five minutes
d. The blood sample is kept in a cool location until the laboratory runs the tests
ANSWER: C
After the arterial blood sample has been drawn, firm pressure must be applied to the site for 5 minutes to prevent
bleeding into surrounding tissues.
Reference: Potter and Perry. Fundamentals of Nursing 6th edition
69. A client has intravenous therapy for the administration of antibiotics and is stating that the “IV site hurts and is
swollen.” Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to
infiltration?
a. Intensity of the pain
c. Amount of subcutaneous edema
b. Warmth of integument surrounding the IV site
d. Skin discoloration of a bruised nature
ANSWER: B
Signs of phlebitis may include increased temperature over the vein, erythema, pain and edema. With phlebitis, the
area is warm to the touch; with infiltration, the area is cool to the touch. Option A: The intensity of pain is not a
differentiating factor between phlebitis and infiltration. Pain may occur with both. Option C: The amount of
subcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema may occur with both.
Option D: Skin discoloration of a bruised nature is not the best way to differentiate phlebitis from infiltration. With
phlebitis, the area is typically reddened. With infiltration, the area is typically pale.
Reference: Potter and Perry. Fundamentals of Nursing 6th edition page 1189
70. The nurse explains that when oxygen is directed out of the arteries and into the capillaries, this process is:
a. Active transport
b. Diffusion
c. Filtration
d. Osmosis
ANSWER: B
Diffusion is the movement from areas of higher concentration to areas of lower concentration. Examples of diffusion
are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of
sodium concentration is high, to the ICF, where its concentration is low.
71. The patient’s IV has been infusing at a very high rate and now the patient appears to be in fluid volume overload,
as indicated by:
a. Hypotension
b. Tachycardia
c. Pulmonary edema
d. Kidney failure
ANSWER: C
An IV infusing at a high rate is used to increase intravascular fluid volume, but there is an equalization level, after
which the patient goes into fluid overload; this results in pulmonary edema.
72. The nurse explains that fluids carrying nutrients and wastes on a random basis throughout the body are carried
primarily by:
a. Filtrates
b. Extracellular fluid
c. Intracellular fluid
d. Osmolytes
ANSWER: B
The blood and lymph are the main media for transport of nutrients and wastes in the body.
73. Both the intracellular and extracellular fluids are made up of many different electrolytes, but the most abundant
intracellular positively charged electrolyte is:
a. Calcium
b. Chloride
c. Potassium
d. Sodium
ANSWER: C
K+ is the most abundant electrolyte in the cell.
74. Which of the following reasons represents the main reason nurses and others need to offer older clients water
throughout the day?
a. The thirst mechanism declines with age so older adults are more vulnerable to dehydration
b. Older adults are more apt to forget to drink water during the day
c. The skin loses more water with aging and older adults need to drink more to tone their skin.
d. Most older adults have a taste for sweets and plain water does not appeal to them
ANSWER: A
Older adults experience a number of age-related changes that can affect fluid, electrolyte, and acid-base imbalances.
They have decreased thirst sensation which may affect their oral intake of fluids. The kidneys have a decrease in
glomerular filtration rate and in the number of filtering nephrons. These changes can mean that in the presence of
sodium depletion or overload the older adult may be unable to maintain homeostasis and the imbalance is instead
worsened.
75. Nurse Hannah is reading the client’s chart. She finds in the documentation that the client’s CVP was 7 mm Hg.
Which of the following categories would this reading fall into?
a. Low
b. Normal
c. Slightly elevated
d. High
ANSWER: C
CVP is a measurement of the pressure in the vena cava or right atrium. Since the pressure in the vena cava, right
atrium, and right ventricle are equal at the end of diastole, the CVP reflects the filling pressure of the right ventricle
(preload). The normal CVP is to 2 to 6 mm Hg. A CVP greater than 6 mm Hg indicates an elevated right ventricular
preload. There are many problems that can cause an elevated CVP, but the most common is due to hypervolemia or
right sided HF
76. The nurse is monitoring hourly urine output as well as the intake of an assigned client who is comatose and has a
foley catheter. The nurse finds that the client is putting out 20-25 cc of urine an hour. After checking to make sure
there are no kinks in the foley catheter and that the catheter is patent and finds that there are no problems with the
catheter, which of the following things does the nurse most need to do next?
a. Continue to observe the output closely
c. Irrigate the catheter with sterile water
b. Give the client an IV fluids
d. Report these findings to the doctor
ANSWER: D
Urine output of less than 30 cc per hour is an indication of poor kidney perfusion and presents a risk for kidney failure.
This finding needs to be reported to the primary care provider.
77. Nurse Hannah is caring for a client who has a diagnosis of hypernatremia. The physician orders .45% NaCl IV
solution, a diuretic, and a low sodium diet. The usual goal of treatment for hypernatremia is to reduce the
hypernatremia within which of the following time frames?
a. 8-12 hours
b. 36 hours
c. 48 hours
d. 24 hours
ANSWER: C
The hypernatremia is corrected slowly over a 48-hour period due to the danger of a rebound cerebral edema as water
shifts back into dehydrated brain cells.
Reference: Burke, Lemon. Medical Surgical Nursing Chapter 5
78. The nurse is caring for a client who has been NPO for several days, is on antibiotics, and a corticosteroid. This
client is most at risk for life-threatening cardiac dysrhythmias resulting from which of the following conditions?
a. Hyperkalemia
b. Hypomagnesemia
c. Hypernatremia
d. Hypokalemia
ANSWER: D
The client is at risk for hypokalemia due to not eating. Almost all foods contain potassium and this client is not eating.
Potassium needs to be replaced every day. Corticosteroids and some antibiotics contribute to hypokalemia.
Hypokalemia affects transmission of nerve impulses and the contractility of cardiac muscles and may lead to lifethreatening cardiac
dysrhythmias.
79. The K+ laboratory report shows a level of 6.2 mEq/L. The nurse will assess the patient closely for:
a. Excessive thirst
b. Irregular heartbeat
c. Swelling of ankles
d. Frightening hallucinations
ANSWER: B
Arrhythmias can be triggered by hyperkalemia.
80. Older adults are at risk for dehydration because of reduced thirst and aging kidneys. The nurse monitors for the
early indicator of dehydration, which is:
a. Reduced skin turgor
b. Constipation
c. Concentrated urine
d. Disorientation
ANSWER: B
Because older adults have poor skin turgor and urine concentration is difficult to assess, constipation is the earliest
indicator of fluid deficit.
Reference: Adrian Linton. Introduction to Medical surgical Nursing 4th edition
81. The nurse is aware that extracellular fluid osmolarity is primarily maintained by:
a. Chloride
b. Magnesium
c. Potassium
d. Sodium
ANSWER: D
Sodium is the most abundant electrolyte in the ECF; its concentration ranges from 135 to 145 mEq/L and it is the
primary determinant of ECF volume and osmolality
82. A patient with no other medical condition presents to the hospital complaining of being frequently thirsty. The
nurse assesses this symptom as:
a. Too much sodium and too much water in the body
c. Too much sodium and too little water in the body
b. Too little sodium and too much water in the body
d. Too little sodium and too little water in the body
ANSWER: C
A primary characteristic of hypernatremia is thirst. Normal thirst is the body’s way of calling for an increase in fluid
volume, which could mean that there is too much sodium and too little water.
83. When a client has arterial blood gasses drawn, the nurse most needs to assure that which of the following actions
are carried out?
a. The client is instructed to lie down and remain lying down for at least 20 minutes
b. The client's blood pressure is taken every five minutes for fifteen minutes
c. Firm pressure is applied to the site for at least five minutes
d. The blood sample is kept in a cool location until the laboratory runs the tests
ANSWER: C
After the arterial blood sample has been drawn, firm pressure must be applied to the site for 5 minutes to prevent
bleeding into surrounding tissues.
Reference: Potter and Perry. Fundamentals of Nursing 6th edition
84. Your client with renal failure is most at risk for which of the following acid-base imbalances?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
ANSWER: C
In renal failure, excess hydrogen ions are not sufficiently excreted and bicarbonate is not formed or inadequately
formed which leads to metabolic acidosis.
85. As the body of a client with metabolic alkalosis attempts to compensate for metabolic alkalosis, which of following
manifestations is most likely to be present?
a. Increased loss of water through the skin
c. Depressed respiratory rate and depth
b. Pounding peripheral pulses
d. Increased urine output
ANSWER: C
Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and the depth of the
respirations.
86. Which of the following nursing interventions would most help the client with chronic respiratory acidosis?
a. Enforce strict bedrest except to get up to the commode
b. Restrict fluids to 1000 cc per day
c. If ordered, encourage client to use oxygen
d. Teach and encourage the client to use pursed-lip breathing
ANSWER: D
Pursed lip breathing helps keep the airways open throughout exhalation, and this promotes carbon dioxide
elimination. Fluids up to 3000 cc per day also help liquefy secretions and hydrate the mucous membranes of the
respiratory system which promotes airway clearance so you would not restrict fluids.
87. In an assessment of a patient who has been receiving IV fluids for the last 6 hours, the nurse finds that the pulse
is now bounding, the blood pressure is more than 15 mm Hg higher than the last reading, and there is distended neck
vein. The nurse evaluates these signs as associated with:
a. Infiltration of the IV site
c. Pulmonary air embolism
b. Vascular fluid volume excess
d. Phlebitis of the leg veins
ANSWER: B
FVE may be related to simple fluid overload or diminished function of the homeostatic mechanisms responsible for
regulating fluid balance. Clinical manifestations of FVE stem from expansion of the ECF and include edema, distended
neck veins, and crackles (abnormal lung sounds). Other manifestations include tachycardia; increased blood pressure,
pulse pressure, and central venous pressure; increased weight; increased urine output; and shortness of breath and
wheezing.
88. The physician has written the following orders for the client with Excess Fluid Volume. The client’s morning
assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles
bilaterally. Which order takes priority at this time?
a. Weigh client every morning
c. Restrict fluid to 1500 mL per day
b. Maintain accurate intake and output
d. Administer furosemide (Lasix) 40 mg IV push
ANSWER: D
Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop
diuretic that will help mobilize the fluid in the lungs. The other orders are important but not urgent.
89. The client’s potassium level is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your
supervision?
a. Administer Kayexalate 15 g orally
c. Assess ECG strip for tall T waves
b. Administer spironolactone 25 mg orally
d. Administer potassium 10 mEq orally
ANSWER: A
The client’s potassium is high (normal range 3.5-5.0). Kayexalate removes potassium from the body through the
gastrointestinal system. Spirolactone is a potassium-sparing diuretic that may cause the client’s potassium level to go
even higher. The nursing student may not have the skill to assess ECG strips and this should be done by the nurse.
90. You are reviewing a client’s morning laboratory results. Which of these results is of most concern?
a. Serum potassium 5.0 mEq/L
c. Serum calcium 10.2 mg/dL
b. Serum sodium 138 mEq/L
d. Serum magnesium 0.8 mg/dL
ANSWER: D
While all of these laboratory values are outside of the normal range, the magnesium is most outside of normal. With a
magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrythmias.
91. A client with respiratory failure is receiving mechanical ventilation and continues to produce ABG results indicating
respiratory acidosis. Which action should you expect to correct this problem?
a. Increase the ventilator rate from 6-10 per minute
c. Increase the oxygen concentration from 30% to 40%
b. Decrease the ventilator rate from 10 to 6 per minute
d. Decrease the oxygen concentration from 40% to 30%
ANSWER: A
The blood gas component responsible for respiratory acidosis is CO2 (carbon dioxide). Increasing the acidosis.
Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.
92. A client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client’s
respiratory rate has increased. What is your best response?
a. “It’s common for clients with uncomfortable procedures such as nasogastric tubes to have a higher rate of
breathing”
b. “The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a
compensatory mechanism”
c. “Whenever a client develops a respiratory acid-base problem, increasing the respiratory rate helps correct the
problem”
d. “The client is hyperventilating because of anxiety and we will have to stay alert for development of a respiratory
acidosis”
ANSWER: B
Nasogastric suctioning can result in a decrease in acid components and a metabolic alkalosis. The client’s increase in
rate and depth of ventilation is an attempt to compensate by blowing off CO2. The first response may be true but
does not address all the components of the question. The third and fourth answers are inaccurate.
93. A client’s arterial blood gases are pH 7.35; PCO2 40 mmHg, HCO3 20 mEq/L. The patient has:
a. Normal ABG values
c. Compensated metabolic acidosis
b. Uncompensated metabolic acidosis
d. Respiratory acidosis
ANSWER: A
Normal ABG values: pH 7.35 - 7.45; PACO2 35 – 45 mm Hg; HCO3 19 – 25 mEq/L.
94. The nurse identifies which set of blood gas values as consistent with a diagnosis of respiratory acidosis in a client?
a. pH 7.0; PCO2 43
b. pH 7.46; PCO2 38
c. pH 7.35; PCO2 44
d. pH 7.32; PCO2 48
ANSWER: D
The nurse would expect to see a decreased pH and increased PCO2 in a client with respiratory acidosis. Normal pH is
7.35 to 7.45, and normal PCO2 is 35 to 45 mm Hg.
95. When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for Nurse
Joyce to obtain is:
a. Mental status.
b. Skin turgor.
c. Capillary refill.
d. Heart sounds.
ANSWER: A
Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing
confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also
be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as
immediate an impact on patient outcomes.
Reference: Lewis, Medical Surgical Nursing, 7th edition, pp. 322-323
96. A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops
nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L (125 mmol/L). Nurse
Joyce reviews the physician’s postoperative medication and IV orders. Which of the following orders should the nurse
question?
a. Administer 3% saline if serum sodium drops to less than 128 mEq/L.
b. IV morphine sulfate 4 mg every 2 hours prn.
c. Infuse 5% dextrose in water at 125 ml/hr.
d. Give IV metoclopramide (Reglan) 10 mg every 6 hours prn nausea.
ANSWER: C
Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte
replacement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders
are appropriate for a postoperative patient with gastric suction.
Reference: Lewis, Medical Surgical Nursing, 7th edition, pp. 326, 338-340
97. A patient with renal insufficiency develops lethargy and somnolence with a blood pressure of 100/60, pulse 62,
and respirations 10. Nurse Joyce notes that the patient has been taking an aluminum hydroxide/magnesium
hydroxide suspension (Maalox) for indigestion. She anticipates that management of the patient will include IV
administration of:
a. Magnesium sulfate.
b. Potassium chloride.
c. Calcium gluconate.
d. Sodium chloride.
ANSWER: C
The patient has a history and symptoms consistent with hypermagnesemia, so calcium gluconate or calcium chloride
will be the initial therapy to oppose the effects of excess magnesium on cell function. Magnesium sulfate infusion is
contraindicated because it will increase the serum magnesium level. Potassium chloride and sodium chloride will not
impact the patient’s symptoms and should be avoided in a patient with renal insufficiency.
Reference: Lewis, Medical Surgical Nursing, 7th edition, pp. 332-333
98. While caring for an elderly client, Nurse Joyce notes that the patient has a low serum protein level. She will plan
to assess for:
a. Confusion.
b. Restlessness.
c. Edema.
d. Pallor.
ANSWER: C
Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues,
causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.
Reference: Lewis, Medical Surgical Nursing, 7th edition, p. 319
99. A postoperative patient with a nasogastric tube connected to low, intermittent suction is complaining of anxiety
and severe incisional pain. The patient has a respiratory rate of 32 breaths per minute. The arterial blood gases (ABG)
are pH 7.50, PaO2 90 mm Hg, PaCO2 30 mm Hg, and HCO3 23 mm Hg. Which intervention is most appropriate for
the nurse to implement?
a. Disconnect the nasogastric tube until the pH is within the normal range.
b. Administer the prescribed sodium bicarbonate 50 mEq intravenously.
c. Teach the patient about the importance of taking slow, deep breaths.
d. Give the patient the ordered morphine sulfate 4 mg intravenously.
ANSWER: D
The ABGs indicate respiratory alkalosis, which is caused by the increased respiratory rate. Because the increased
respirations are most likely caused by the incisional pain, the first action by the nurse should be to medicate the
patient for pain. The nasogastric tube is needed for postoperative gastric decompression and should remain connected
to suction. Sodium bicarbonate administration will further increase the pH. Teaching the patient to take slow, deep
breaths may be helpful, but it is unlikely to be effective until the pain level is decreased.
Reference: Lewis, Medical Surgical Nursing, 7th edition p. 335
100. A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the
most important assessment for the nurse to monitor is
a. Peripheral pulses.
b. Lung sounds.
c. Peripheral edema.
d. Urinary output.
ANSWER: B
Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles
in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess
listed. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when
administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
Reference: Lewis, Medical Surgical Nursing, 7th edition pp. 339-340
CARE OF CLIENTS WITH GASTROINTESTINAL DISORDERS
SITUATION: Assessment of the gastrointestinal system in a critically ill patient provides essential information. Early
identification and treatment of gastrointestinal disorders is necessary and serves as a foundation for developing a
holistic plan of care for the patient.
1. A client is seen coughing immediately after swallowing a bit of food. The nurse realizes that this client might have
an impairment of:
a. The tongue.
b. The hard palate.
c. The esophagus.
d. The soft palate.
Answer: D
The soft palate is primarily muscle that contracts when swallowing food. The hard palate is primarily bone. Neither the
tongue nor the esophagus are issues associated with this client's coughing when swallowing food.
2. A client states, "My mouth is always dry!" The nurse realizes that this client might experience an inability to break
down carbohydrates because:
a. The saliva includes a hormone that is needed for carbohydrate breakdown.
b. The saliva includes a vitamin that is needed for carbohydrate breakdown.
c. The saliva includes a mineral that is needed for carbohydrate breakdown.
d. The saliva includes an enzyme needed for carbohydrate breakdown.
Answer: D
Saliva provides enzymes, such as amylase, that begin the chemical breakdown of starches while food is still in the
mouth.
3. Which information collected by the nurse when caring for a patient who has just arrived in the recovery area after
an upper endoscopy is most important to communicate to the health care provider?
a. The patient has no gag reflex.
c. The patient complains of a sore throat.
b. The oral temperature is 100.6° F.
d. The apical pulse is 104 beats/min.
Answer: B
A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal
immediately after the procedure.
Reference: Lewis Medical Surgical Nursing 7th edition page 943
4. A client has been taking naproxen (Naprosyn) for several months. Which assessment question is important for the
nurse to ask?
a. “Have you experienced any constipation?”
c. “Have you had any difficulty swallowing?”
b. “Have you had any stomach pain or indigestion?”
d. “Have you noticed any weight loss lately?”
ANSWER: B
Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic pain can precipitate peptic ulcer
formation through the inhibition of prostaglandins. The client should be assessed for stomach pain or indigestion. This
medication does not typically cause constipation or difficulty swallowing. Weight loss would not be related to this
medication.
5. Nurse Mishal learns that an elderly client with ill-fitting dentures has been using an over-the-counter preparation
for a gum sore over the last month. Which of the following should the nurse instruct this client?
a. Stop wearing the dentures.
c. Continue to use the preparation.
b. Change the preparation.
d. Make an appointment to see the physician.
Answer: D
The nurse should instruct the client to seek medical attention for any oral lesion that does not heal within one week.
Because the current over-the-counter (OTC) remedy is not effective, the client should see the physician before using a
different OTC preparation. Not wearing the dentures can lead to nutritional problems and social isolation.
6. A client who is in need of a radical neck dissection for cancer continues to delay the surgery. Which of the following
nursing diagnoses would best describe the reason for this client's delay?
a. Imbalanced Nutrition: Less than Body Requirements
c. Disturbed Body Image
b. Risk for Ineffective Airway Clearance
d. Impaired Verbal Communication
Answer: C
Radical surgery of the head or neck seriously affects body image. An altered speech pattern and any disfigurement
affect the ability to feel attractive or effective in work or social roles. Clients may defer lifesaving surgery to postpone
disfiguring interventions or therapies. Impaired verbal communication, imbalanced nutrition, and risk for ineffective
airway clearance are all potential postoperative diagnoses for this client but they do not address the reason for delay
of the surgery.
7. Nurse Isabel is caring for a client who has just had abdominal surgery. When auscultating the client’s abdomen,
Nurse Isabel does not hear any bowel sounds. Which is the Nurse Isabel’s best action?
a. Notifying the physician
c. Documenting the finding
b. Percussing the abdomen
d. Inserting a nasogastric tube
ANSWER: C
Absent bowel sounds are expected immediately following abdominal surgery. The finding should be noted in the
client’s record for later reference. The absent bowel sounds are an expected finding so the physician does not need to
be notified. The nurse should insert a nasogastric tube if ordered by the physician if the ileus persists. Percussion may
be performed but may be uncomfortable for the client and will not determine the cause of the ileus.
8. The nurse assesses dullness at the left anterior axillary line. The nurse is concerned about which condition that the
client may have?
a. Cirrhosis
b. Splenomegaly
c. Bowel obstruction
d. Abdominal aortic aneurysm
ANSWER: B
Dullness in front of the tenth intercostal space, at the left anterior axillary line, is indicative of splenomegaly, which is
commonly seen with mononucleosis. Cirrhosis would be noted with percussion in the client’s left upper quadrant. The
nurse may note tympanic sounds with bowel obstruction. Percussion would not be used to assess abdominal aortic
aneurysm.
9. An overweight client tells the nurse, "Every Monday at work we have spaghetti. I can't stop myself! Sometimes I
eat three full plates!" The nurse realizes that this client is describing:
a. Extreme hunger.
c. Appetite stimulation by external cues.
b. Carbohydrate addiction.
d. Metabolic syndrome.
Answer: C
Most overweight people are stimulated to eat by external cues, such as the proximity to food and the time of day. In
contrast, hunger and satiety are the cues that regulate eating in adults of normal weight. The client's reports involve
eating with no mention of hunger. There is no information provided to support the presence of any addiction or
metabolic disorder.
10. An overweight female client states, "I'm trying to stick to my diet and exercise plan but my husband tells me that
I'm fine the way I am." An appropriate nursing diagnosis for this client would be:
a. Ineffective Therapeutic Regimen Management.
c. Imbalanced Nutrition: More than Body Requirements.
b. Chronic Low Self-Esteem.
d. Activity Intolerance.
Answer: A
Family and social support is critical to successful adherence to the therapeutic regimen. There is no information
provided to support the client's lack of adherence to the dietary plan. There is not information provided to support
activity intolerance or the lack of self-esteem.
11. A high-calorie, high-protein diet is provided for a patient with a fractured hip and severe protein-calorie depletion,
but the patient eats only about 50% of each meal tray and then complains of feeling tired. The nurse will plan to
a. Arrange for smaller portions to be served on patient trays.
b. Serve multiple small feedings of high-calorie, high-protein foods.
c. Give continuous tube feedings of liquid nutritional supplements.
d. Administer intravenous feeding with parenteral nutrition solutions.
Answer: B
Eating small amounts of food frequently throughout the day is less fatiguing and will improve the patient’s ability to
take in more nutrients. Smaller serving sizes will not improve patient nutritional intake. Tube feedings or parenteral
nutrition (PN) may be needed if the patient is unable to take in enough nutrients orally, but increasing the oral intake
should be attempted first.
12. Which characteristic puts a client at risk for gastroesophageal reflux disease?
a. Drinking decaffeinated beverages
c. Taking oral hypoglycemic agents
b. Losing weight
d. Nasogastric tube
ANSWER: D
A nasogastric tube keeps the cardiac sphincter open, allowing acidic contents from the stomach to enter the
esophagus.
13. Which is the priority assessment of a client experiencing regurgitation?
a. Auscultating lungs for crackles
c. Palpating the cervical lymph nodes
b. Inspecting the oral cavity
d. Culturing the throat for bacterial infection
ANSWER: A
The client with regurgitation is at risk of aspiration, pneumonia, and bronchitis. The nurse should auscultate the lungs
for crackles, an indication of aspiration.
14. Which client response to the Bernstein test would confirm the diagnosis of esophagitis?
a. Dysphagia during the test
c. No symptoms during the test
b. Heartburn during the test
d. Painful swallowing during the test
ANSWER: B
Clients with esophagitis will experience heartburn as the acidic solution is infused, with a positive Bernstein test result.
15. Nurse Julien is preparing the morning medications for a client with gastroesophageal reflux disease (GERD). Which
of the following nursing interventions would be appropriate for this client's medications?
a. Hold the antacids for at least two hours after oral medications are taken.
b. Provide the antacids first and then follow with the oral medications.
c. Provide all prescribed medications at 10:00 a.m.
d. Provide the antacids only at the hour of sleep.
Answer: A
Antacids interfere with the absorption of many drugs given orally and should be separated by at least two hours.
16. A patient with deep partial-thickness (second-degree) burns over 70% of the body experiences severe pain
associated with nausea and occasional vomiting during dressing changes. To promote relief of the patient’s nausea
and vomiting, the nurse should:
a. Administer the prescribed morphine sulfate before dressing changes.
b. Avoid performing dressing changes close to the patient’s mealtimes.
c. Keep the patient NPO for 2 hours before and after dressing changes.
d. Give the ordered prochlorperazine (Compazine) before dressing changes.
Answer: A
Because the patient’s nausea and vomiting are associated with severe pain, it is likely that they are precipitated by
stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse
should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times should also
be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an
adverse effect on the patient’s nutrition. Administration of antiemetics is not the best choice for a patient with nausea
caused by pain.
17. A client who has undergone Nissen fundoplication for GERD is ready for discharge home. Which statement made
by the client indicates understanding of the disease?
a. “I will no longer need any medication.”
b. “I will avoid spicy foods because they can irritate the suture line.”
c. “I should take antireflux medications when I eat a large meal.”
d. “I will need to continue to watch my diet and take my medication.”
ANSWER: D
There is a high percentage of recurrence of reflux after this type of surgery, so clients are encouraged to continue
antireflux regimens of medication and diet control.
18. Which symptom indicates a need for immediate intervention in the client with a rolling hernia?
a. Reflux
b. Vomiting
c. Pneumonia
d. Obstruction
ANSWER: D
A rolling hernia causes the fundus and portions of the stomach’s greater curvature to roll into the thorax next to the
esophagus, predisposing the client to volvulus, obstruction, and strangulation.
19. Which statement indicates that the client understands the management of his or her hiatal hernia?
a. “I will lie flat for 30 minutes after each meal.”
b. “I will remain upright for several hours after each meal.”
c. “I will have my blood count done in 2 weeks to check for anemia.”
d. “I will sleep at night lying on my left side to prevent nighttime reflux.”
ANSWER: B
Clients with hiatal hernia experience GERD. Positioning is an important intervention. The client should be taught to
sleep with the head of the bed elevated, to remain upright after meals for 2 to 3 hours, and to avoid straining or
restrictive clothing.
20. Which is the first intervention that the nurse will take for the client post–sliding hernia repair to prevent
complications?
a. Range-of-motion exercises to the lower extremities
c. Monitoring of input and output
b. Elevation of the head of the bed to 30 degrees
d. Assessment of bowel sounds
ANSWER: B
The prevention of respiratory complications is the primary focus of postoperative care. The high incision makes taking
deep breaths extremely painful for this client. By elevating the head of the bed to at least 30 degrees, the nurse
promotes lung expansion in the client.
21. Most of the work of changing raw fuel forms of carbohydrates to the refined usable fuel glucose is accomplished
by enzymes located in the:
a. Mouth
b. Small intestine
c. Large intestine
d. Stomach mucosa
ANSWER: B
B – Pancreatic amylase (which enters the small intestine at the sphincter of Oddi) and sucrose, lactase, and maltase
(which are released by epithelial cells covering the villi in the small intestine) are responsible for carbohydrate
digestion
A – Because ptyalin is present in saliva, some starch digestion occurs in the mouth
C – Digestion of carbohydrates is completed before their arrival in the large intestine, which is concerned primarily
with fluid re-absorption
D – Limited carbohydrate digestion occurs in the stomach; pepsin begins the digestion of proteins.
22. Amino acids are involved in total body metabolism building and rebuilding various tissues. Of these, a number are
essential amino acids. This means that:
a. These amino acids can be made by the body because they are essential to life
b. These amino acids are essential in body processes and the remaining amino acids are not
c. The body cannot synthesize these amino acids and thus they must be obtained from the diet
d. After synthesizing these amino acids, the body uses them in key processes essential for growth
ANSWER: C
C – These amino acids are needed to maintain life and are not produced by the body
A – The essential amino acids cannot be made by the body
B – All amino acids are needed for metabolism; however, arginine and histidine are necessary for growth, but not
during adulthood.
D – The body does not synthesize these amino acids; they must be ingested in the diet.
23. In colonoscopy, how should the nurse position the client?
a. Left side lying
b. Right side lying
c. Trendelenburg
d. Prone
ANSWER: A
A – With the patient in the left lateral position, this procedure allows the water to flow straight down into the
descending colon through the 'collapsed' lumen, and the scope to be easily negotiated through the straightened rectosigmoid colon
and sigmoid-descending colon junction with minimum discomfort.
(ACTUAL BOARD QUESTION)
24. A client is scheduled for a colonoscopy and asks the nurse what will be determined from the test. The nurse
should respond that colonoscopy would:
a. Evaluate whether there is a tumor or other problem in the large intestine
b. Determine the presence of blood in the abdominal cavity
c. Evaluate the presence of and possible sclerosed esophageal varices
d. Assess the effectiveness of treatment of a peptic ulcer
ANSWER: A
A colonoscopy is the insertion of a flexible tube into the lower GI tract for evaluation and treatment of conditions of
the lower bowel. An evaluation of the esophagus and stomach would require an approach from the upper GI tract such
as an esophagogastroduodenoscopy (EGD). The presence of blood in the abdominal cavity would require an abdominal
ultrasound.
25. The nurse is planning care for the client scheduled for gastroduodenoscopy and barium swallow. What will the
nursing plan include?
a. Anticipating the client will receive a low-residue diet in the evening and then receive nothing by mouth (NPO status)
6 to 12 hours before the test
b. Discussing with the client the nasogastric tube and the importance of gastric drainage of 24 hours the test.
c. Explaining to the client that he will receive nothing by mouth (NPO status) for 24 hours after the test to make sure
his stomach can tolerate his food
d. Discussing the general anesthesia and explaining that he will wake up in the recovery room
ANSWER: A
NPO status before a barium swallow and a gastroduodenoscopy and low-residue diet the evening before the
procedures are routine orders for these test. The other options are inappropriate.
26. A flat plate radiograph of the abdomen is ordered. The nurse recognizes that the client should receive:
a. No special preparation
c. Nothing by mouth for 8 hours
b. A low soapsuds enema
d. A laxative the evening before the x-ray
ANSWER: A
A – A flat plate film of the abdomen visualizes abdominal organs as they are
B, D – No bowel preparation is indicated
C – The client may eat and drink as tolerated
27. This test permits the visualization of structures that could once be seen only during laparotomy. The examination
is carried out using a fiberoptic endoscope.
a. Abdominal x-ray
b. Ultrasonography
c. Cholecystography
d. ERCP
ANSWER: D
ERCP or endoscopic retrograde cholangiopancreatography permits direct visualization of structure that could once be
seen only during laparotomy. The examination is carried out using a fiberoptic endoscope inserted into the esophagus
to the descending duodenum. Multiple position changes are required during the procedure beginning in the left
semiprone position to pass the endoscope.
28. The nurse is performing an abdominal assessment and inspects the skin on the abdomen. The nurse performs
which assessment technique next?
a. Palpates the abdomen for size
c. Listens to bowel sounds in all four quadrants
b. Palpates the liver at the right rib margin
d. Percusses the right lower abdominal quadrant
ANSWER: C
C – The appropriate sequence for abdominal examination inspection, auscultation, percussion, and palpation (I-A-PP). Auscultation is
performed after inspection to ensure that the motility of the bowel sounds is not altered by
percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel
sounds.
29. The nurse teaches the client which information regarding home collection of a stool specimen for blood occult
testing?
a. Three simultaneous specimens should be sent to lab
b. Diet should be low in fiber and low in residue to quiet the bowel
c. Any slide “positive” finding requires additional evaluation
d. Any red color on or near the specimen is considered positive
ANSWER: C
C – Three consecutive specimens should be acquired and sent. Diet should be high residue. A blue color is positive.
30. The client has just had a liver biopsy. Which of the following nursing actions would be the priority after the
biopsy?
a. Monitor pulse and blood pressure every 30 minutes until stable and then hourly for up to 24 hours
b. Ambulate every 4 hours for the first day as long as client can tolerate this
c. Measure urine specific gravity every 8 hours for the next 48 hours
d. Maintain NPO status for 24 hours post-biopsy
ANSWER: A
Complications of liver biopsy include hemorrhage or accidental penetration of biliary canniculi. The nurse should
assess for signs of hemorrhage (increased pulse, decreased blood pressure) every 30 minutes for the first few hours
and then hourly for 24 hours. The client should be monitored for fever every 4 hours and remain on bedrest for 24
hours.
Edition, Vol. 1. Page
SITUATION: The vague nature of many gastrointestinal symptoms makes diagnosis of GI problems quite difficult. A
complete patient history and an adequate physical examination are necessary in order to gather as much information
as possible. Although this is routinely done by the admitting physician, a nursing assessment must be completed as
well.
31. Which sound is normal to elicit when percussing in the seventh right intercostal space at the midclavicular line
over the liver?
a. Dullness
b. Tympany
c. Resonance
d. Hyperresonance
ANSWER: A
The liver is located in the right upper quadrant and would elicit a dull percussion note.
Reference: Kozier and Erb’s Fundamentals of Nursing 8th edition
32. The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is:
a. Increased salivation
c. Increased esophageal emptying
b. Decreased peristalsis
d. Decreased gastric acid secretion
ANSWER: D
As one ages, salivation decreases, esophageal emptying is delayed, and peristalsis is thought to remain fairly
constant. Gastric acid secretion decreases with aging. Decreased peristalsis may result from decreased bulk in diet,
decreased fluid intake, or laxative abuse.
Reference: Carolyn Jarvis. Physical examination and health assessment. 5th edition Page 562
33. The main reason auscultation precedes percussion and palpation of the abdomen is to:
a. Determine areas of tenderness before using percussion and palpation.
b. Prevent distortion of bowel sounds that might occur after percussion and palpation.
c. Allow the patient more time to relax and therefore be more comfortable with the physical examination.
d. Prevent distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation.
ANSWER: B
This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of
bowel sounds.
Reference: Carolyn Jarvis. Physical examination and health assessment. 5th edition Page 569
34. An elderly patient tells the nurse that the food she eats has no taste. The best response the nurse could give
would be:
a. “Eating larger meals will give you more food to taste.”
b. “Chewing your food longer will keep the food in your mouth longer to give you more taste.”
c. “As you get older, your taste buds decrease; try using different spices and flavors for taste.”
d. “You will start receiving nutrition via a nasogastric tube.”
ANSWER: C
As you get older, saliva, which helps dissolve food in the mouth, and the taste buds decrease. These changes
decrease the taste of food. The flavor of food may be helped by using different spices and flavors while cooking.
Reference: Rick Daniels. Contemporary Medical Surgical Nursing
35. The nurse knows that to assess bowel sounds, he must listen to all four quadrants. The nurse has determined the
patient has absent bowel sounds. The nurse must listen for:
a. Two minutes
b. Three minutes
c. Four minutes
d. Five minutes
ANSWER: D
The nurse must listen for five minutes before concluding the patient has absent bowel sounds.
Reference: Perry and Potter Fundamentals of Nursing 6th edition Page 743
36. The nurse is caring for a client who just completed a computed tomography (CT) scan with oral barium contrast.
Which instructions will the nurse provide to the client?
a. “Drink plenty of fluids over the next few days.”
b. “Do not eat or drink anything for 6 hours after the test.”
c. “You may not drive or operate heavy machinery today.”
d. “Do not take any blood thinners for 24 hours after the test.”
ANSWER: A
The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the barium from the colon.
There is no reason to limit the diet as the dye is being cleared. The test will not make the client drowsy, so there is no
reason to limit driving. Similarly, blood thinners will not affect the client.
Reference: Ignatavicius. Medical-Surgical Nursing, 6th Edition
37. The nurse is preparing the client for a CT scan of the abdomen with IV contrast. Which question will the nurse ask
the client prior to the examination?
a. “Are you allergic to shrimp or shellfish?”
b. “Have you had anything to eat or drink in the past 12 hours?”
c. “Did you finish taking all the prescribed laxatives?”
d. “Can you tolerate being tilted from side to side?”
ANSWER: A
Allergies to iodine or seafood can cause a cross-allergic reaction to the contrast dye used for CT scans. Clients
reporting such allergies should be scheduled for CT without contrast to avoid anaphylactic reactions. The client does
not need to be NPO for this test, and need not take laxatives. The client is not tilted during the CT scan.
38. The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells
the nurse that her mouth is very dry after the procedure. Which is the nurse’s best action?
a. Keep the client NPO.
c. Offer the client sips of clear liquids.
b. Check the client’s gag reflex.
d. Provide the client with a few ice chips.
ANSWER: B
The back of the throat is numbed for the EGD, impairing the gag reflex. The nurse should check the gag reflex prior to
offering any type of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex has
returned.
39. An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the
nurse include when the patient has completed the test?
a. Stool will be yellow for the first 24 hours post-procedure
b. The barium may cause diarrhea
c. Fluids must be increased to facilitate the evacuation of the stool
d. This series includes analysis of gastric secretions
ANSWER: C
X-rays can delineate the entire GI tract after the introduction of a contrast agent. A radiopaque liquid (eg, barium
sulfate) is commonly used. The patient ingests this tasteless, odorless, nongranular, and completely insoluble (hence,
not absorbable) powder in the form of a thick or thin aqueous suspension for the purpose of studying the upper GI
tract (upper GI series or barium swallow). The upper GI series enables the examiner to detect or exclude anatomic or
functional derangement of the upper GI organs or sphincters. The nurse administers an enema or laxative after the
tests to facilitate barium removal. Increasing fluid intake also will assist in eliminating the barium. As with any barium
study, the nurse monitors the patient for complete elimination of the barium.
40. A patient is scheduled for a gastroscopy and needs to be prepared for the procedure. What preparation is needed?
a. Insert a nasogastric tube
c. Have the patient lie in a dorsal position
b. Administer a micro Fleet enema
d. Spray or gargle the back of the throat with local anesthetic
ANSWER: D
This procedure also can be used to evaluate esophageal and gastric motility and to collect secretions and tissue
specimens for further analysis. The patient should not eat or drink for 6 to 12 hours before the examination. Patient
preparation includes helping the patient spray or gargle with a local anesthetic, and administering midazolam (Versed)
intravenously just before the scope is introduced. Midazolam is a sedative that provides moderate sedation and
relieves anxiety during the procedure.
41. A patient is scheduled to have a fecal occult blood test. Before the test, the nurse should instruct the patient to
avoid all of the following except:
a. Labanos
b. Sardinas
c. Vitamin C supplement
d. Tilapia
ANSWER: A
Fecal occult blood testing is one of the most commonly performed stool tests. It can be useful in initial screening for
several disorders. It tests only for the presence of blood, so other follow-up testing is required. The test is not perfect,
because certain factors interfere with its sensitivity and specificity. False-positive results may occur if the patient has
eaten rare meat, liver, poultry, turnips, broccoli, cauliflower, melons, salmon, sardines, or horseradish within 7 days
before testing. Medications that can cause gastric irritation, such as aspirin, ibuprofen, indomethacin, colchicine,
corticosteroids, cancer chemotherapeutic agents, and anticoagulants, may also cause false-positive results. Extensive
research has demonstrated that therapeutic doses of iron preparations do not cause false-positive results. Ingestion of
vitamin C from supplements or foods can cause false-negative results. Therefore, a careful assessment of the patient’s
diet and medication regimen is essential to reduce incorrect interpretation of results.
SITUATION: The upper gastrointestinal system includes the mouth, the stomach, the esophagus, and the inferior
esophageal sphincter. A variety of disorders in this system can cause discomfort, pain, nausea, and vomiting.
42. For patients who have swallowing difficulties, what type of diet would be ordered?
a. Regular diet
b. Clear liquid diet
c. Mechanical soft diet
d. Low-fat diet
ANSWER: C
Some patients may have difficulty swallowing thin liquids and foods that are tough. Some patients may need a pureed
diet or mechanical soft diet, especially if their swallowing difficulty is with the oral phase.
43. The nurse is caring for a client who has just received a diagnosis of advanced oral cancer that will require
extensive surgery. Which statement by the client indicates that he has accepted his diagnosis?
a. “The biopsy test results will be double-checked next week.”
b. “Of all the rotten things to happen to me, now I have cancer on top of it all.”
c. “If I can just live long enough to see my son get married, everything will be OK.”
d. “I don’t like it, but I have cancer and that’s the way it is.”
ANSWER: D
The client has accepted the diagnosis. He is not happy about it, but has acknowledged the reality of the situation.
44. The nurse is caring for a client who is being discharged following surgery for oral cancer. Which sign will the client
be instructed to watch for that indicates possible metastasis of the cancer?
a. Fragile gums that bleed easily
b. White patches on the tongue and back of the throat
c. Painful ulcerated lesions on the gums or inside of the cheek
d. Small hard lumps on the side of the neck or under the chin
ANSWER: D
Cervical lymph nodes that become hardened, enlarged, and fixed in position are indications of metastatic disease.
45. Which information about a patient who has just been admitted to the hospital with nausea and vomiting will
require the most rapid intervention by the nurse?
a. The patient has been vomiting several times a day for the last 4 days.
b. The patient is lethargic and difficult to arouse.
c. The patient’s chart indicates a recent resection of the small intestine.
d. The patient has taken only sips of water.
ANSWER: B
A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk.
The other information is also important to collect, but it does not require as quick action as the risk for aspiration.
46. Which of these nursing actions should the nurse working in the emergency department delegate to a nursing
assistant who is helping with the care of a patient who has been admitted with nausea and vomiting?
a. Assess for signs of dehydration
c. Auscultate the bowel sounds
b. Ask the patient what precipitated the nausea
d. Assist the patient with oral care after vomiting
ANSWER: D
Oral care is included in nursing assistant education and scope of practice. The other actions are all assessments that
require more education and a higher scope of nursing practice.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition Page 992-995
47. The nurse is admitting a patient who has been diagnosed with squamous cell carcinoma of the buccal mucosa.
When interviewing the patient for the health history, the nurse will ask about:
a. Any use of tobacco by the patient
c. Chronic overexposure to the sun
b. Any history of streptococcal throat infection
d. Recurrent herpes simplex (HSV) infections
ANSWER: A
Tobacco use greatly increases the risk for oral cancer. History of acute infections such as strep throat is not a risk
factor for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not
increase the risk for cancers of the buccal mucosa. Human papillomavirus infection (HPV) infection may be associated
with increased risk, but HSV infection is not a risk factor for oral cancer.
48. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing
discomfort. Which patient statement indicates that additional patient education about GERD is needed?
a. “I take antacids between meals and at bedtime each night.”
b. “I quit smoking several years ago, but I still chew a lot of gum.”
c. “I sleep with the head of the bed elevated on 4-inch blocks.”
d. “I eat small meals throughout the day and have a bedtime snack.”
ANSWER: D
GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at
bedtime. The other patient actions are appropriate to control symptoms of GERD.
49. Which statement will be included in the nurse’s teaching about oral care for the client with stomatitis?
a. “Rinse your mouth out twice a day with mouthwash.”
b. “Clean your mouth three times a day with a gentle foam sponge.”
c. “Use lemon-glycerin swabs to clean your mouth after meals and at bedtime.”
d. “Suck on ice cubes to minimize the discomfort.”
ANSWER: B
During painful, acute episodes of stomatitis, gentle mouth care using a gauze sponge dipped in either normal saline or
normal saline plus baking soda is most appropriate. Commercial mouthwashes containing alcohol, acidic foods or
other harsh solutions, and techniques that may cause bleeding should be avoided.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition Page
50. Which instruction will the nurse give the client to prevent nighttime reflux?
a. “Sleep in the right lateral decubitus position.”
c. “Have alcoholic beverages early in the evening.”
b. “Have a light evening snack before bedtime.”
d. “Elevate the head of the bed 6 to 8 inches for sleep.”
ANSWER: D
Elevation of the head of the bed 6 to 8 inches for sleep is helpful in preventing nighttime reflux episodes related to the
recumbent position. Wooden blocks or foam wedges can be used to achieve this level of elevation.
Reference: Sharon Lewis Medical Surgical Nursing 7th edition Page
51. The common symptom in clients with GERD is:
a. Pyrosis
b. Dyspepsia
c. Regurgitation
d. All of the above
ANSWER: D
Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis or a motility
disorder. Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation,
dysphagia, odynophagia, hypersalivation and esophagitis.
52. Management of a patient with GERD begins with teaching the client to avoid situations that decrease the lower
esophageal sphincter pressure such the following, except:
a. Eat a low-fat diet
c. Lie supine after eating to avoid reflux
b. Avoid eating or drinking 2 hours before bedtime
d. Avoid tight fitting clothes
ANSWER: C
Options a, b and d are all correct ways to decrease the lower esophageal sphincter pressure. Option C is incorrect
since the client should elevate the head of the bead 6-8 inches or to elevate the upper body on pillows to avoid reflux.
53. A client has gastroesophageal reflux disease (GERD). Which recommendation made by the nurse would be most
helpful to the client?
a. Avoid liquids unless a thickening agent is used
c. Maintain a diet of soft foods and cooked vegetables
b. Sit upright for at least 30 minutes after eating
d. Avoid eating 2 hours before going to sleep
ANSWER: D
D – Avoid eating 2 hours before going to sleep enhances the regurgitation of stomach contents which have increased
acidity into the esophagus. Maintaining an upright posture should be for about 2 hours after eating to allow for the
stomach emptying. The options A and C are interventions for clients with swallowing difficulties and not for GERD.
Nursing interventions for GERD:
• Coffee and alcohol stimulate gastric acid secretion. Taking these before bedtime can cause evening reflux.
• Antacids based on calcium carbonate (but not aluminum hydroxide) were found to actually increase the acidity of
the stomach. However, all antacids reduced acidity in the lower esophagus, so the net effect on GERD symptoms may
still be positive.
• Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these may help. Fat
also delays stomach emptying.
• Eating within 2–3 hours before bedtime
• Large meals. Having smaller, more frequent meals reduces GERD risk, as it means there is less food in the
stomach at any one time.
• Carbonated soft drinks, chocolate and peppermint.
• Acidic foods: tomatoes and tomato-based preparations; citrus fruits and citrus juices.
54. Which of the following is a priority for the nurse to administer to a client with GERD?
a. Antibiotics
b. Anticholinergics
c. Proton pump inhibitors
d. Cytoprotectors
ANSWER: C
Drugs used to promote healing the tissues damaged by acid reflux include antacids and anti secretory drugs such as
proton pump inhibitors and histamine 2 receptor antagonists. Cytoprotective/antipeptics, antibiotics and
anticholinergics are primarily used for peptic ulcer disease.
55. The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the
client’s record would the nurse question?
a. Digoxin (Lanoxin)
b. Furosemide (Lasix)
c. Indomethacin (Indocin)
d. Propranolol hydrochloride (Inderal)
ANSWER: C
C – Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug can cause ulceration of the esophagus, stomach,
or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a
loop diuretic.
A – Digoxin is a cardiac medication.
B – Propranolol (Inderal) is beta-adrenergic blocker.
D – Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders.
56. The nurse evaluates that the medication teaching is effective when the client with gastritis states that ranitidine
(Zantac):
a. Changes hormonal levels
b. Decreases gastric acid levels
c. Increases pepsin levels
d. Decreases pH levels
ANSWER: B
Ranitidine (Zantac) is a histamine 2 receptor antagonist which suppresses gastric acid secretion. Changing hormonal
levels is not a primary action of ranitidine. Cimetidine (Tagamet) suppresses pepsin production. Zantac also reduces
hydrogen ion concentration which will increase pH levels.
57. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that
this client is at risk for which vitamin deficiency?
a. Vitamin A
b. Vitamin B12
c. Vitamin C
d. Vitamin E
ANSWER: B
B – Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function
of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This
leads to the development of pernicious anemia.
A, C, D – The client is not at risk for vitamin A, C, or E deficiency.
Edition, Vol. 1. Pages 1012,1014.
58. The nurse is caring for a client who has a bleeding duodenal ulcer. The nurse identifies what assessment data is
indicative of a gastric perforation?
a. Increasing abdominal distention and tight abdomen
b. Decreasing hemoglobin and hematocrit with bloody stools
c. Diarrhea with increased bowel sounds and hypovolemia
d. Decreasing blood pressure with tachycardia and disorientation
ANSWER: A
Perforation is characterized by increasing distention and “board-like” abdomen. The other option may be seen with
hemorrhage.
59. There are different surgical procedures for peptic ulcer disease. Which procedure involves the removal of the lower
portion of the stomach as well as a small portion of the duodenum and pylorus and the remaining segment is
anastomosed to the duodenum?
a. Vagotomy
b. Pyloroplasty
c. Billroth I
d. Billroth II
ANSWER: C
Vagotomy-severing of the vagus nerve
Pyloroplasty – a longitudinal incision is made to the pylorus and transversely sutured closed to enlarge the outlet and
relax the muscle
Billroth I- involves the removal of the lower portion of the stomach as well as a small portion of the duodenum and
pylorus and the remaining segment is anastomosed to the duodenum
Billroth II- involves the removal of the lower portion of the stomach as well as a small portion of the duodenum and
pylorus and the remaining segment is anastomosed to the jejunum
SITUATION: Gastrointestinal Disorder (GI) is a digestive disorder that interferes with the workings of the intestine.
60. The health care provider orders IV ranitidine (Zantac) for a patient with an acute exacerbation of chronic peptic
ulcer disease. When teaching the patient about the effect of the medication, which information will the nurse include?
a. “Ranitidine constricts the blood vessels in the stomach and decreases bleeding.”
b. “Ranitidine decreases secretion of gastric acid.”
c.“Ranitidine neutralizes the acid in the stomach.”
d. “Ranitidine covers the ulcer with a protective material which promotes healing.”
ANSWER: B
Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response
beginning, “Ranitidine constricts the blood vessels” describes the effect of vasopressin. The response beginning
“Ranitidine neutralizes the acid” describes the effect of antacids. And the response beginning “Ranitidine covers the
ulcer” describes the action of sucralfate (Carafate).
61. A 36 year old male client has been hospitalized with PUD. He is being treated with a histamine receptor
antagonist ( Ranitidine ), antacids and diet. The nurse doing discharge planning will teach him that the action of
Ranitidine is to
a. Reduce gastric acid output
c. Inhibit the production of hydrochloric acid
b. Protect the ulcer surface
d. Inhibit vagus nerve stimulation
ANSWER: A
62. After a subtotal gastrectomy for severe and perforated PUD, patient Joherm Primo develops dumping syndrome.
The nurse understands that dumping syndrome refers to:
a. Nausea due to a full stomach
c. Rapid passage of osmotic fluid into the jejunum
b. Reflux of intestinal contents into the esophagus
d. Build up of feces and gas within the large intestine
ANSWER: C
63. Which of the following is an appropriate nursing intervention for patient with dumping syndrome?
a. Offer the patient with fluid or chilled solution
c. Provide small frequent feedings
b. Diet high in CHO and sugar
ANSWER: C
d. Position patient in semi fowler’s after each feeding
64. The patient who is suspected with appendicitis was complaining of severe pain and is asking for a medication for
her condition. The nurse best response to the patient is
a. “ I will ask the doctor to prescribe mefenamic acid for you sir”
b. ” I will ask the doctor to prescribe Demerol for you sir”
c. “ Your pain is a usual reaction sir, so please bear with it. Your appendix is swelling so it is just natural that pain is present ”
d. “ I can’t give you analgesic sir, it may mask pain which may indicate an impending rupture of your appendix”
ANSWER: D
65. The type of cell responsible in the production of HCL acid in the stomach is known as,
a. Chief cells
b. Parietal cells
c. gastric cells
ANSWER: B
d. mucous neck cells
66. Patient was admitted in the hospital complaining of pain 30 mins after meals, pain in the epigastric area, vomitus
is with blood and has loss of weight. The nurse suspects that the patient might have?
a. Gastric ulcer
b. Jejunal ulcer
c. duodenal ulcer
d. ileostomal ulcer
ANSWER: A
67. A patient with a peptic ulcer who has an NG tube develops sudden, severe upper abdominal pain, diaphoresis, and
a very firm abdomen. Which action should the nurse take next?
a. Irrigate the NG tube
b. Obtain the vital signs
c. Give the ordered antacid
d. Listen for bowel sounds
ANSWER: B
The patient’s symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock.
Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the
stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not
the first action that the nurse should take.
68. Nurse Daniel is caring for a client with peptic ulcer disease. The client vomits a large amount of undigested food
after breakfast. Which intervention will Nurse Daniel prepare to do for the client?
a. Administer a soap suds cleansing enema
c. Insert a nasogastric (NG) tube to low intermittent suction
b. Change the client’s diet to clear liquids only
d. Administer prochlorperazine (Compazine) 10 mg IM
ANSWER: C
Symptoms of abdominal distention and nausea and vomiting of undigested food signal pyloric obstruction. Treatment
is aimed at decompression of the stomach by an NG tube and restoration of fluid and electrolyte balance. The client
should remain NPO and a soap suds cleansing enema is not indicated.
Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition
69. A client with peptic ulcer disease says, "I feel so much better now that I've stopped eating." The nurse realizes
that this client is at risk for:
a. Sleep Pattern Disturbance
c. Imbalanced Nutrition: Less than Body Requirements
b. Fluid Volume Overload
d. Pain
Answer: C
In an attempt to avoid discomfort, the client with peptic ulcer disease (PUD) may gradually reduce food intake, and
sometimes jeopardize nutritional status. Anorexia and early satiety are additional problems associated with PUD. The
client is not at increased risk for pain, sleep pattern disturbance, or fluid volume overload due to this action.
70. Nurse Mon is caring for a client who has recently undergone a Billroth I procedure. He notes that the client’s
reflexes are slowed and the client reports tingling in his feet and hands. Which dietary recommendations will he make
for this client?
a. “Avoid nuts and other legumes.”
c. “Eat more shellfish, beef, and salmon.”
b. “Avoid grapefruit and orange juices.”
d. “Eat more leafy, dark green vegetables.”
ANSWER: C
The client has developed pernicious anemia caused by reduced stomach area and vitamin B12 deficiency. The client
should be encouraged to eat foods that are high in vitamin B12, including shellfish, beef, and salmon.
71. A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this
client's stools to be:
a. Coffee-ground-like
b. Clay-colored
c. Black and tarry
d. Bright red
ANSWER: C
Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of
digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffeeground-like. Clay-
colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract
bleeding.
72. The nurse is caring for a client who has recently undergone a Billroth II procedure. The client states that whenever
he eats, he becomes dizzy and sweaty, with heart palpitations. The client tells the nurse that he is now afraid to eat
anything. Which is the nurse’s best response?
a. “You should drink at least 6 ounces of fluid before each meal.”
b. “You should go back to a clear liquid diet for the next few days.”
c.“You might be lactose-intolerant now. Try avoiding dairy products.”
d. “You should avoid eating foods that contain large amounts of sugar.”
ANSWER: D
The client’s symptoms are consistent with dumping syndrome, which can be minimized by avoiding intake of foods
with high sugar content. A clear liquid or lactose-free diet is not appropriate for this client. Clients should avoid
drinking fluids with meals to prevent dumping syndrome.
73. A patient who is nauseated and vomiting up blood streaked fluid is admitted to the hospital with acute gastritis.
When obtaining the admission health history, it will be most important for the nurse to ask the patient about:
a. Frequency of nonsteroidal antiinflammatory drug (NSAID) use.
c. Recent weight gain or loss.
b. Family history of gastric problems.
d. The amount of fat in the diet.
ANSWER: A
Rationale: Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis.
Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.
74. The nurse finds a positive Blumberg’s sign in a client with abdominal pain. Which action will the nurse plan?
a. Have the client be NPO in preparation for surgery.
b. Document this normal finding in the client’s record.
c. Immediately auscultate the client’s abdomen for bowel sounds.
d. Repeat the maneuver with the client in a supine position, with the knees flexed.
ANSWER: A
A positive Blumberg’s sign (rebound tenderness) is indicative of peritoneal inflammation, which commonly
accompanies appendicitis. The client should be made NPO in preparation for surgery to remove the appendix. The
maneuver should not be repeated with the client in the supine position. The nurse should perform auscultation prior to
percussion for the abdominal assessment.
75. The nurse informs the student nurse that loperamide (Imodium) prescribed for a client who is experiencing
diarrhea has which of the following actions?
a. Consolidates the stool in the intestine
b. Distends the intestine by osmotic retention of the fluid
c. Lowers the surface tension, allowing more water into the stool
d. Inhibits the peristaltic ability of the intestinal muscles
ANSWER: D
Loperamide (Imodium) inhibits the peristaltic ability of the intestinal muscles which results in decreased
gastrointestinal motility. Consolidating stool in the intestine describes pectin, which is a component of the
antidiarrheal Kaopectate. Lowering the surface tension allows more water into the stool which describes surfactant
laxatives or stool softeners. Distending the intestine by osmotic retention of fluid describes the action of saline or
osmotic laxatives.
76. Which acid-base imbalance could a client develop as a result of diarrhea?
a. Respiratory acidosis
b. Metabolic acidosis
c. Carbonic acid deficit
ANSWER: B
B – Diarrhea causes the body to lose bicarbonate, which may cause metabolic acidosis. Respiratory acidosis is caused
by alveolar hypoventilation. Carbonic acid excess occurs with respiratory alkalosis. Vomiting could lead to metabolic
alkalosis.
77. The nurse should teach the client to prevent constipation by doing the following, except:
a. Establishing a regular schedule of exercise
c. Consume a low residue, bland diet
b. Have fluid intake of at least 2L/day
d. Establishing a regular time for bowel elimination
ANSWER: C
Goals for the patient with constipation include restoring or maintaining a regular pattern of elimination, ensuring high
intake of fluids and high fiber food –high residue and establishing a regular schedule of exercise.
78. When teaching a client to include more bulk in the diet, the nurse recognizes that the action of bulk to promote
defecation is a consequence of the:
a. Irritating effect of fiber on the bowel wall
c. Direct chemical stimulation of colonic musculature
b. Action of the multiflora of the large intestine
d. Tendency of smooth muscle to contract when stretched
ANSWER: D
D – Fiber absorbs water, swells, and consequently stretches the bowel wall, promoting peristalsis, mass movements,
and defecation. Smooth muscle tends to contract when stretched because of the reflex activity of stretch receptors.
A – Bulk caused by fiber does not irritate the bowel wall
B – Bacterial action is not involved in the process by which bulk stimulates defecation
C – There is no chemical stimulation
79. Pain in appendicitis is located at
a. Mc Burney’s point
b. Murphy’s point
c. Levigne’s point
d. Cullen’s point
ANSWER: A
A –McBurney's point is the name given to the point over the right side of the abdomen that is one-third of the
distance from the anterior superior iliac spine to the umbilicus (the belly button). This point roughly corresponds to
the most common location of the base of the appendix where it is attached to the cecum.
(ACTUAL BOARD QUESTION JUNE 2009)
80. Measures to provide comfort in appendicitis:
a. Apply hot compress
b. Apply cold compress
c. Frequent ambulation
d. Palpation of abdomen
ANSWER: B
B – The patient with suspected appendicitis is given nothing by mouth until a diagnosis is confirmed, in case surgery is
necessary. Ice to the site of pain and maintaining semi-Fowler’s position may help reduce pain while the diagnosis is
being made. The patient is often readied for an appendectomy by emergency department staff, so time for
preoperative teaching is limited.
81. Which of the following positions will provide comfort to the client during acute pain attacks of appendicitis?
a. Flat on bed with small pillow on had and with the knees flexed
c. Lying on either side
b. Semi Fowler’s position
d. Trendelenburg position
ANSWER: B
B – The patient with suspected appendicitis is given nothing by mouth until a diagnosis is confirmed, in case surgery is
necessary. Ice to the site of pain and maintaining semi-Fowler’s position may help reduce pain while the diagnosis is
being made. The patient is often readied for an appendectomy by emergency department staff, so time for
preoperative teaching is limited.
82. Which of the following pain medications should the nurse anticipate that the doctor will order for a client following
appendectomy?
a. Anticholinergic
b. Demerol
c. Morphine
d. Aspirin
ANSWER: C
C – After surgery, the nurse places the patient in a semi-Fowler position. This position reduces the tension on the
incision and abdominal organs, helping to reduce pain. An opioid, usually morphine sulfate, is prescribed to relieve
pain. When tolerated, oral fluids are administered. Any patient who was dehydrated before surgery receives
intravenous fluids. Food is provided as desired and tolerated on the day of surgery.
83. A patient is admitted with appendicitis. One of the laboratory tests the nurse would expect to see ordered is:
a. Serum sodium
c. Hemoglobin (Hgb) and hematocrit (Hct).
b. White blood cell (WBC) count
d. Bilirubin Level
ANSWER: B
Infection often accompanies the inflammation of the appendix. The nurse would be looking for an elevated WBC
count.
84. A patient is admitted to the emergency department for evaluation of right lower-quadrant abdominal pain with
nausea and vomiting. The patient has a white blood cell count (WBC) of 14,000/mm3 with a shift to the left. Which of
these actions is appropriate for the nurse to take?
a. Encouraging the patient to take sips of clear liquids
c. Checking for rebound tenderness every 30 minutes
b. Applying an ice pack to the right lower quadrant
d. Teaching the patient how to cough and deep breathe
ANSWER: B
The patient’s clinical manifestations are consistent appendicitis, and application of an ice pack will decrease
inflammation at the area. The patient should be NPO in case immediate surgery is needed. Checking for rebound
tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough
and deep breathe postoperatively, but coughing will increase pain and the patient is not likely to retain information at
this point.
85. A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how
would the nurse position the client?
a. Prone
b. Dorsal recumbent
c. Semi-Fowler’s
d. Supine
ANSWER: C
C – The semi-Fowler position assists drainage and prevents spread of infection throughout the abdominal cavity.
86. Which nursing action best demonstrates the nurse’s understanding of one of the primary complications of
peritonitis?
a. Providing small, frequent meals
c. Assessing skin integrity regularly
b. Performing frequent respiratory assessments
d. Evaluating stools for color and consistency
ANSWER: B
B – Because of the proximity of the diaphragm to the abdominal cavity, the client is at high risk for respiratory
complications. The severe pain associated with peritonitis interferes with maximal lung expansion, further increasing
the client’s risk for respiratory distress. Because paralytic ileus commonly occurs, feeding a client with peritonitis and
assuming that diarrhea will occur are inappropriate. Impaired skin integrity is not a primary potential complication
specific to this disease. Rather, it can occur in any client on bed rest.
87. A client is admitted with a diagnosis of acute diverticulitis. What nursing intervention is appropriate for this client?
a. Instruct the client to remain NPO
c. Administer cholinergic medications to reduce pain
b. Encourage ambulation at least four times daily
d. Encourage coughing and deep breathing every 2 hours
ANSWER: A
A – During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to
subside. The client remains NPO and is placed on bed rest. Pain occurs from bowel spasms and increased
intraabdominal pressure may precipitate an attack.
88. A 93-year-old client with a history of diverticulitis is admitted with severe abdominal cramping pain, anorexia,
nausea, vomiting for 24 hours, a markedly elevated temperature, and increased WBCs. The primary reason for
performing surgery is most likely that:
a. Surgery is usually indicated for clients with a diagnosis of diverticulitis
b. The symptoms exhibited by the client on admission are life-threatening
c. In some instances diverticulits is difficult to differentiate from carcinoma except surgically
d. The client’s age indicates that immediate correction of the potentially fatal condition is needed
ANSWER: B
B – The client’s status requires immediate intervention; to delay treatment may prove dangerous because symptoms
indicate possible perforation
A – Diverticulitis can in most cases be treated by diet, rest, and antibiotic therapy
C – This is not true with diagnostic techniques presently available.
D – Age is not the factor; the symptoms indicate possible peritonitis
89. The nurse is providing medications to a client with diverticular disease. Which of the following medications should
the nurse question for this client?
a. Trimethoprim-sulfamethoxazole (Bactrim)
c. Bisacodyl (Dulcolax) suppository
b. Metronidazole (Flagyl)
d. Docusate (Colace)
ANSWER: C
Although a stool softener such as docusate (Colace) may be prescribed, it is important to note that laxatives can
further increase intraluminal pressure in the colon and should be avoided for the client with diverticular disease.
Systemic broad-spectrum antibiotics effective against usual bowel flora are prescribed to treat acute diverticulitis. Oral
antibiotics such as metronidazole (Flagyl) and ciprofloxacin (Cipro) or trimethoprim-sulfamethoxazole (Septra,
Bactrim) may be prescribed if manifestations are mild.
90. When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will:
a. Administer IV fluids
c. Give stool softeners
b. Order a diet high in fiber and fluids
d. Prepare the patient for colonoscopy
ANSWER: A
A patient with acute diverticulitis will be NPO with parenteral fluids. A diet high in fiber and fluids will be implemented
before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented
later in the hospitalization. The patient with acute diverticulitis will not have colonoscopy because of the risk for
perforation and peritonitis.
91. The nurse is conducting discharge dietary teaching for a client with diverticulosis who is recovering from an acute
episode of diverticulosis. The nurse would determine that the client understood his dietary teaching by which
statement?
a. “I will need to increase my intake of protein and complex carbohydrates to increase healing.”
b. “Peanuts, fruits, and vegetables with seeds can cause problems, and I should avoid them.”
c. “I will not put any added salt on my food, and I will decrease intake of foods that are high in saturated fat.”
d. “Milk and milk products can cause lactose intolerance. If this occurs, I need to decrease my intake of these products.”
ANSWER: B
The primary problem with diverticula is food or indigestible fiber that gets caught in the pouches. The client should
avoid this type of fiber.
92. The nurse is reviewing the record of a client with Crohn’s disease. Which tool characteristic should the nurse
expect to note documented in the client’s record?
a. Diarrhea
c. Constipation alternating with diarrhea
b. Chronic constipation
d. Stool constantly oozing from the rectum
ANSWER: A
A – Crohn’s disease is characterized by non-bloody diarrhea of usually not more than four to five stools daily. Over
time, the diarrhea episodes increase in frequency, duration, and severity.
93. The nurse is aware that the manifestation that is found more in ulcerative colitis than in Crohn’s disease is:
a. Inclusion of transmural involvement of the small bowel wall
b. Correlation with increased malignancy because of the malabsorption syndrome
c. Involvement beginning proximally with intermittent plaques found along the colon
d. Involvement starting distally with rectal bleeding and spreading continuously up the colon
ANSWER: D
D – In ulcerative colitis, pathology is usually in the descending colon (left side) and rectum; in Crohn’s disease, it is
primarily in the terminal ileum, cecum and ascending colon on the right side. (page 1041)
A – Ulcerative colitis, as the name implies, affects the colon, not the small intestine
B – There is no direct correlation of colitis with malignancy of the bowel, although psychological, environmental,
genetic, and nutritional factors, as well as preexisting disease, appear to be influential in malignancy
C – Involvement is in the distal portion of the colon, not the proximal portion
94. The client is admitted to the hospital with ulcerative colitis. The nurse should assess the client for which common
complication of the disease?
a. Anemia
b. Steatorrhea
c. Cholelithiasis
d. Thrombocytopenia
ANSWER: A
Ulcerative colitis is a disease that spans the entire length of the colon and involves only the mucosa and submucosa of
the large intestine. The disease usually starts in the rectum and distal colon, spreading upward beyond the
rectosigmoid valve to involve most of the sigmoid and the descending colon. Hemorrhage and bleeding is a common
feature of ulcerative colitis, and over time this can lead to significant loss of RBCs. The client should be assessed for
possible anemia. Anemia and nutritional deficiencies are the most common complications of IBD’s (Ulcerative colitis
and anemia) They should be corrected nutritionally or with supplements.
95. The nurse has instructed the client about sulfasalazine (Azulfidine) which was prescribed for her ulcerative colitis.
The nurse evaluates which of the following statements made by the client indicates that the client understood the
instructions?
a. Azulfidine will decrease intestinal gas production
b. I may notice my urine turns blue
c. I should chew the tablets thoroughly and drink a sip of water
d. Nausea, vomiting and abdominal pain are adverse reactions to this drug
ANSWER: D
Sulfasalazine (Azulfidine) is an anti-inflammatory agent and sulfonamide which reduces gastrointestinal motility,
inflammation and microbial flora. Nausea, vomiting and abdominal pain are adverse reactions. Decreasing gas
formation is the action of simethicone. The tablets are not chewed and it should be administered with a full glass of
water. The skin and urine may turn yellow-orange, not blue.
96. The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding if noted on
assessment of the client would the nurse report to the physician?
a. Hypotension
b. Bloody diarrhea
c. Rebound tenderness
d. A hemoglobin level of 12 mg/dl
ANSWER: C
C – Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of
the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis
must be reported to the physician.
97. A patient diagnosed with irritable bowel syndrome (IBS) tells the nurse, “My friends tell me this problem is all in
my head.” In caring for the patient, the nurse should:
a. Discuss the new medications that are available to treat the condition.
b. Inform the patient that IBS has a specific, identifiable cause.
c. Explain that modifications to increase dietary fiber can control the symptoms.
d. Encourage the patient to express feelings and ask questions about IBS.
ANSWER: D
Because psychologic and emotional factors can impact on the symptoms for IBS, encouraging the patient to discuss
emotions and ask questions is an important intervention. Although new medications are available, discussion of these
medications does not address the patient’s concerns with what friends think or say. There is no specific cause for IBS.
Modifications in fiber intake may help some patients but might also increase bloating and gas pain. In addition,
discussion of fiber does not address the patient’s feelings.
98. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and
crampy abdominal pain associated with the diarrhea. The nurse will plan to:
a. Place the patient on NPO status.
c. Start bowel preparation for colonoscopy.
b. Administer Cobalamin (vitamin B12) injections.
d. Administer IV metoclopramide (Reglan).
ANSWER: A
An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the
patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. It is not
appropriate to administer laxatives needed for colonoscopy to a patient with diarrhea. Metoclopramide increases
peristalsis and will worsen symptoms.
99. While obtaining a nursing history from a patient with IBD, the nurse recognizes that the patient most likely has
ulcerative colitis rather than Crohn’s disease when the patient reports experiencing:
a. Weight loss.
b. Bloody stools.
c. Abdominal pain and cramping.
d. Disease onset at age 20.
ANSWER: B
Because ulcerative colitis affects the colon, blood in the stools is more common with this form of IBD. Weight loss,
abdominal pain and cramping, and onset at age 20 are consistent with both Crohn’s disease and ulcerative colitis.
100. Nurse Isabel is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the
highest priority?
a. Skin integrity
b. Blood pressure
c. Heart rate and rhythm
d. Abdominal percussion
ANSWER: C
Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk of
cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her
or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an
important part of physical assessment but has lower priority than heart rate and rhythm for this client.
CARE OF CLIENTS WITH GENITOURINARY DISORDERS
SITUATION: The urinary system comprises the kidneys, ureters, bladder, and urethra. A thorough understanding of
the urinary system is necessary for assessing individuals with acute or chronic urinary dysfunction and implementing
appropriate nursing care.
1. Which of the following is not an age-related change seen in the renal system?
a. Decreased glomerular filtration rate
b. Decreased muscle tone and elasticity in the ureters, bladder, and urinary sphincter
c. Prostatic hypoplasia in the male
d. Nocturia
ANSWER: C
Prostatic hyperplasia, not hypoplasia, is the age-related change often seen in elderly male patients resulting in urinary
retention.
2. What substance is produced by the kidneys that assists in blood pressure control?
a. Antidiuretic hormone
b. Erythropoietin
c. Renin
d. Vitamin D
ANSWER: C
Antidiuretic hormone is produced by the posterior pituitary. Erythropoietin stimulates the production of red blood cells.
Vitamin D is activated by the kidneys and influences calcium metabolism. Renin is produced by the kidneys and helps
control blood pressure.
3. A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of
the following changes in the pattern of urinary elimination normally occur with aging?
a. Decreased frequency
b. Incontinence
c. Sphincter reflexes decrease
d. Formation of bladder stones
ANSWER: B
B – Ureters, bladder, and urethra loose muscle tone results in stress and urge incontinence
A – Frequency increases because bladder capacity decreases
C – Decrease in sphincter reflexes is caused by the change in the pattern of urinary elimination, not a change in
pattern
D – related to fluid intake, diet, and activity, not age
4. The nurse prepares a 67-year-old man for an intravenous pyelogram (IVP). The client asks the nurse to explain the
reason why the procedure is performed. The nurse’s response should be based on the knowledge that the primary
purpose of an IVP is to
a. Observe the renal pelvis directly.
c. Examine the urinary tract by x-ray.
b. Assess glomerulofiltration rate.
d. Inject medication into the urinary system.
ANSWER: C
C – X-rays of entire urinary tract taken, evaluates kidney function
A – Would involve invasive procedure, such as cystoscopy
B, D – Not primary purpose
5. The nurse prepares a 67-year-old man for an intravenous pyelogram (IVP). Which of the following information is
MOST important for the nurse to obtain before the procedure?
a. The date of the client’s last EKG
c. A list of the client’s allergies
b. The time of the client’s last meal
d. A list of the medications the client takes at home
ANSWER: C
C – Involves injection of radiopaque dye, used to identify lesions and assess function, allergy to iodine is lifethreatening
A – Electrical activity of heart, not most important
B – Should be NPO for 6–8 h, not most important
D – Not most important
6. New orders indicate a urine specimen is needed. The patient is not catheterized. Which of the following instructions
would the nurse give the patient?
a. “Decrease your water intake to make the sample will be more concentrated.”
b. “I will need to catheterize you to obtain urine.”
c. “Please use the wipe and cup for the sample.”
d. “When you use the urinal, please call so that I can get the sample.”
ANSWER: C
A urine specimen obtained from a non-catheterized patient should be collected using a specimen cup and by using the
proper cleansing technique.
7. The nurse is reviewing medications that can be potentially nephrotoxic. Which of the following medications can be
nephrotoxic?
1. Amphotericin B
3. Erythromycin
5. Tobramycin
2. Chloroquine
4. Gentamicin
6. Vancomycin
a. 1 and 2
b. 1, 2, 4, 6
c. 1, 4, 5, 6
d. All except 3
ANSWER: C
Potentially nephrotoxic drugs are amikacin, gentamicin, amphotericin B, sulfonamides, tobramycin, vancomycin,
chemotherapeutic agents, contrast medium, ethylene glycol, nonsteroidal anti-inflammatory drugs (NSAIDs), gold,
and other heavy metals.
8. Nurse Isabel is collecting a 24-hour urine sample. Which of the following are steps for collecting the sample?
1. Discard the first void and save all subsequent urine for 24 hours
4. Save all urine in a 24-hour period
2. Discard the last void
5. Save the first void
3. Record the first void as the beginning time
6. Save all urine voided except the last specimen
a. 4 only
b. 1 and 3
c. 6 only
d. 3 and 4
ANSWER: B
The 24-hour urine collection procedure would include discarding the first void and recording the time as the start time.
Each subsequent void would be collected and saved until the 24-hour period ends. This includes the last void.
9. A client is schedule to have a kidney, ureter, and bladder (KUB) radiograph. Which of the following would be
ordered to prepare him for his radiograph?
a. Fluid and food will be withheld the morning of the examination
b. A tranquilizer will be given before examination
c. An enema will be given before the examination
d. No special preparation is required for the examination
ANSWER: D
A KUB radiograph examination ordinarily requires no preparation. It is usually done while the client lies supine and
does not involve the use of radiopaque substances.
10. After an intravenous pyelogram (IVP), the nurse should anticipate incorporating which of the following measures
into the client’s plan of care?
a. Maintain bed rest
c. Assessing the hematuria
b. Encouraging adequate fluid intake
d. Administering a laxative
ANSWER: B
After an IVP, the nurse should encourage fluids to decrease the risk of renal complication caused by the contrast
agent. There is no need to place the client on bed rest or administer laxative. An IVP would not cause hematuria.
11. Which of the following groups of laboratory tests is most important for assessing the client’s renal status?
a. Serum sodium and potassium
c. Serum blood urea nitrogen (BUN) and creatinine level
b. Arterial blood gases and hemoglobin
d. Urinary and urine culture
ANSWER: C
Serum BUN and creatinine are the test most commonly used to assess renal function, with creatinine being the most
reliable indicator. Nonrenal factors may affect BUN levels as well as serum sodium and potassium levels. Arterial blood
gases and hemoglobin are not used to assess renal status. Urinalysis is a general screening test, and a urine culture is
used to detect urinary tract infection.
12. A patient is being evaluated for a lower urinary tract infection. Which of the following symptoms would the nurse
expect to find?
a. Cloudy urine
b. Flank pain
c. Nausea
d. Temperature 102.9° F
ANSWER: A
Symptoms of a lower urinary tract infection include dysuria, frequency, urgency, hesitancy, cloudy urine, lower
abdominal pain, chills, malaise, and mild fever (less than 101° F). The other options are symptoms of upper urinary
tract infection.
13. Certain age groups do not show the classic symptoms of a urinary tract infection. Which of the following age
groups can show hypothermia, poor appetite, and a change in mental status when a urinary tract infection is present?
a. Newborns
b. Infants
c. Children
d. Elderly
ANSWER: D
The elderly tend to have symptoms of fever or hypothermia, poor appetite, lethargy, and a change in mental status.
Infants and children tend to have fevers and not hypothermia. Newborns can be hypothermic and feed poorly but can
also exhibit jaundice.
14. Clients taking phenazopyridine (Pyridium) for the treatment of a urinary tract infection should be told:
a. To limit their fluid intake.
c. That their urine may decrease in volume.
b. To avoid the use of acidic juices
d. That their urine may turn orange-red.
ANSWER: D
Phenazopyridine normally causes the client’s urine to turn orange-red, which may frighten the client (who may believe
there is bleeding). Option A: Clients taking antimicrobial agents for any type of infection should be encouraged to
consume 3,000-4,000 mL of fluid/day. Option B: Clients with urinary tract infections should be encouraged to drink
acidic fluids to acidify the urine. Option C: Phenazopyridine does not decrease urine output.
Reference: Amy Karch Focus on Nursing Pharmacology 4th edition
15. The hospitalized client with a urethral retention catheter has cystitis. Which is the priority nursing diagnosis for
this client?
a. Risk for Infection
c. Risk for Impaired Skin Integrity
b. Disturbed Body Image
d. Risk for Urge Urinary Incontinence
ANSWER: A
The most common cause of sepsis in hospitalized clients is a urinary tract infection. Ascending infections from cystitis
with an indwelling catheter is a major source of such infections. Although the other diagnoses are important, they
would not have life-threatening implications for the client.
16. The nurse monitors for which complication in the client with large renal calculi?
a. Chronic hypertension
b. Polyuria
c. Dysuria
d. Hydroureter
ANSWER: D
A hydroureter is most commonly caused by obstruction in the mid to upper portion of the urinary system. Large
kidney stones (renal calculi) can block the flow of urine in the renal pelvis or ureter. The kidney continues to make
urine and the volume backs up into the kidney.
17. Which client is at highest risk for developing a renal calculus?
a. An older man with diabetes mellitus
c. A middle-aged woman with mild congestive heart failure
b. A young woman who is 6 months pregnant
d. A young man who had a renal calculus 1 year ago
ANSWER: D
Age and the other conditions listed do not contribute to the formation of renal calculi. The greatest risk factor for
calculus formation is a history of a previous stone.
18. Which prevention strategy will the nurse teach the client with a risk for renal calculi?
a. “Drink at least 3 to 4 L of fluid every day.”
c. “Avoid aspirin and aspirin-containing products.”
b. “Avoid dairy products and other sources of calcium.”
d. “Start taking antibiotics at the first sign of a stone.”
ANSWER: A
Dehydration contributes to the precipitation of minerals to form a stone. Ingestion of calcium or aspirin does not cause
a stone. Antibiotics neither prevent nor treat a stone.
19. The client with a renal calculus has just returned from an extracorporeal shock wave lithotripsy procedure and the
nurse finds an ecchymotic area on the client’s right lower back. Which is the nurse’s priority intervention?
c. Placing the client in the prone position
b. Applying ice to the site
d. Documenting the observation as the only action
ANSWER: B
The shock waves can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the
extent and discomfort of the bruising.
20. The nurse completes which assessment in the client with acute glomerulonephritis and periorbital edema?
a. Auscultating breath sounds
c. Measuring deep tendon reflexes
b. Checking blood glucose levels
d. Testing urine for the presence of protein
ANSWER: A
Acute glomerular nephritis can cause sodium and water retention. When clients have edema, they may also have
circulatory overload with pulmonary edema.
21. Which dietary modification will the nurse teach to the client with nephrotic syndrome and a normal glomerular
filtration rate?
a. Decreased intake of protein
c. Decreased intake of carbohydrates
b. Increased intake of protein
d. Increased intake of carbohydrates
ANSWER: B
In nephrotic syndrome, the renal loss of protein is significant, leading to hypoalbuminemia and edema formation. If
glomerular filtration is normal or near-normal, the increased protein loss should be matched by an increased intake of
protein.
22. Common risk factors of pyelonephritis include all but the following:
a. Urinary retention
b. Urinary calculi
c. Prostate gland hypertrophy
d. Orthostatic hypotension
ANSWER: D
One of the causes of pyelonephritis is urinary retention. Causes of urinary retention are prostate gland hypertrophy,
masses, urinary calculi, or ureteral obstruction.
20. The nurse monitors for which clinical manifestation in a client with renal impairment associated with polycystic
kidney disease?
a. Flank pain
b. Periorbital edema
c. Bloody and cloudy urine
d. Enlarged or protruding abdomen
ANSWER: D
A protruding and distended abdomen is common because the cystic kidneys swell and push abdominal contents
forward and displace other abdominal organs.
23. A patient with chronic renal failure is admitted to the medical unit. A diet low in protein is ordered. The rationale
for this diet is that:
a. Protein sources are broken down and converted to urea, which is then filtered by the kidney.
b. Protein sources are of low biological value.
c. Protein increases calcium and sodium levels.
d. Deficit protein metabolism breaks down muscle tissue.
ANSWER: A
Protein in the diet increases the amount of nitrogen waste the kidney must handle.
24. Mang Ben is diagnosed by his physician to have an acute renal failure. As a nurse, you know that this is the most
common initial manifestation of acute renal failure:
a. Dysuria
b. Anuria
c. Hematuria
d. Oliguria
ANSWER: D
Acute renal failure is a reversible clinical syndrome where there is sudden and almost complete loss of kidney function
over a period of hours to days with failure to excrete nitrogenous products and to maintain fluid and electrolyte
homeostasis. Oliguria is the most common initial symptom of acute renal failure. Anuria is rarely the initial symptom.
Dysuria and hematuria are not associated with acute renal failure.
25. A patient has an external cannula inserted in the forearm for hemodialysis. Which of the following nursing
measures is appropriate for her care?
a. Use the unaffected arm for blood pressure measurements
c. Percuss the cannula for bruit each shift
b. Draw blood for the cannula for routine laboratory work
d. Inject heparin into the cannula each shift
Answer: A
The unaffected arm should be used for blood pressure measurement. The external cannula must be handled carefully
and protected from damage and disruption. In addition, a tourniquet or clamps should be kept at bedside because
dislodgement of the cannula would cause arterial hemorrhage. The arm with the cannula is not used for blood
pressure measurement, I.V. therapy, or venipuncture. Patency is assessed by auscultating for bruits every shift.
Heparin is not injected into the cannula to maintain patency. Because it is part of the general circulation, the cannula
cannot be heparinized.
26. A patient with chronic renal failure asks the nurse, “What’s the difference between hemodialysis and peritoneal
dialysis?” Which of the following statements best explains the difference?
a. “Hemodialysis is done three times a week and lasts three to four hours; peritoneal dialysis is done daily.”
b. “Hemodialysis uses a graft or fistula and pumps blood through a semipermeable membrane in a hemodialyzer as
the filter. Peritoneal dialysis uses the peritoneal lining of the abdominal cavity as the filter.”
c. “Hemodialysis and peritoneal dialysis use different equipment.”
d. “There are different dietary requirements for hemodialysis and peritoneal dialysis.”
ANSWER: B
All are differences between hemodialysis and peritoneal dialysis; however, “Hemodialysis uses a graft or fistula and
pumps blood through a semipermeable membrane in a hemodialyzer as the filter. Peritoneal dialysis uses the
peritoneal lining of the abdominal cavity as the filter” explains the mechanism between hemodialysis and peritoneal
dialysis.
27. Which is an initial priority intervention for the client with stress incontinence?
a. Beginning medication teaching
b. Having the client sign an informed consent form for surgery
c. Assisting the client in finding a supplier of absorbent pads and undergarments
d. Instructing the client to maintain a diary that records times of urine leakage, activities, and diet
ANSWER: D
Maintaining a diary detailing times of urine leakage, activities, and foods eaten will aid in the diagnostic process by
showing if there is a connection between specific factors that seem to trigger the incontinent episodes. Use of
medication, surgical procedures, and absorbent pads or undergarments may be used as part of the physician’s
treatment plan at some point, but more conservation interventions should be implemented first.
28. Which of the following is the priority nursing diagnosis for a client with urinary tract infection (UTI)?
a. Anxiety
b. Disturbed sleep pattern
c. Disturbed body image
d. Pain
ANSWER: D
Pain is the most common sign of UTI and is usually the most distressing symptom for the client. The pain may be
caused by the inability to void or by bladder spasms. The client may have manifestations of the other nursing
diagnoses as well, but pain is of the highest priority.
29. The nurse is instructing a patient how to prevent a urinary tract infection. Which of the following statements, if
made by the patient to the nurse, requires further investigation?
a. “I can go all day without emptying my bladder.”
c. “I do not use bubble bath.”
b. “I drink 2 liters of fluid every day.”
d. “I drink cranberry juice.
ANSWER: A
Should empty the bladder very four hours even if there is no urge.
Option B – appropriate behavior.
Option C – bubble bath, nylon underwear, and scented toilet tissue are irritating, wear loose-fitting cotton underwear.
Option D – will make urine acidic, which decreases incidence of infection.
Edition, Vol.2. Page 1312-1315
30. A 24-year-old female client comes to an ambulatory care clinic in moderate distress with a probable diagnosis of
acute cystitis. Which of the following symptoms should the nurse expect the client to report during the assessment?
a. Fever and chills
b. Frequency and burning on urination
c. Flank pain and nausea
d. Hematuria
ANSWER: B
B – The classic symptoms of cystitis are severe burning on urination, urgency, and frequent urination. Systemic
symptoms, such as fever and nausea and vomiting, are more likely to accompany pyelonephritis than cystitis.
Hematuria may occur, but it is not as common as frequency and burning.
31. A client complains of inability to inhibit urine flow long enough to reach the toilet. The nurse documents the
presence of which type of urinary incontinence?
a. Stress
b. Reflex
c. Urge
d. Functional
ANSWER: C
This type of incontinence is called urge incontinence or detrussor overactivity, caused by a hypertonic or overactive
detrussor muscle that leads to increased pressure within the bladder. Stress incontinence is loss of urine with
abdominal pressure. Reflex incontinence refers to loss of urine at somewhat predictable intervals when a specific
bladder volume is reached. Functional incontinence is an involuntary, unpredictable passage of urine.
32. A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse
include in a bladder retraining program?
a. Establishing a predetermined fluid intake pattern for the client
b. Encouraging the client to increase the time between voidings.
c. Restricting fluid intake to reduce the need to void
d. Assessing present elimination patterns
ANSWER: D
The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and
reasons for each accidental voiding.
Option A and C - Lowering the client's fluid intake won't reduce or prevent incontinence. The client should actually be
encouraged to drink 1.5 to 2 L of water per day.
Option B - A voiding schedule should be established after assessment.
Edition, Vol.2. Page 1275
33. The RN is doing initial discharge teaching to a 65 year-old female client with renal calculi. Which of the following
should be included as dietary recommendations to prevent recurrence?
a. Consume foods high in vitamin E
c. Increase sources of vitamin C
b. Reduce dietary calcium
d. Increase protein levels
ANSWER: B
B – Dietary restrictions of calcium and purines aid in the prevention of recurrence of renal calculi. Dietary
recommendations for prevention of kidney stones include restricting protein to 60 g/day to decrease urinary excretion
of calcium and uric acid. There is no evidence that increasing vitamins E or C affects or prevents the formation of
urinary stones.
34. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain
and nausea. The client’s temperature is 38.2 degrees Celsius. The priority nursing goal for this client is
a. Maintain fluid and electrolyte balance
c. Manage pain
b. Control nausea
d. Prevent urinary tract infection
ANSWER: C
C – The immediate goal of therapy is to alleviate the client’s pain
35. A middle-aged adult is seen in the emergency room for complaints of severe right-flank pain. The client is twenty
pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi four years ago. Which of the following
actions, if performed by the nurse, is MOST important?
a. Ensure that the client has nothing to eat or drink
c. Provide warm packs to relieve discomfort
b. Obtain a “clean-catch” urine specimen for analysis
d. Measure and strain the client’s urine
ANSWER: D
D – Will document passage of stone and allow composition to be analyzed
A – Should force fluids to 3,000/day to assist client pass stone
B – Not most important, used to identify infection
C – Not most important, analgesics given to reduce discomfort
36. Which of the following symptoms would most likely indicate pyelonephritis?
a. Ascites
b. Costovertebral angle (CVA) tenderness
c. Polyuria
ANSWER: B
d. Nausea and vomiting

B – Common symptoms of pyelonephritis include CVA tenderness, burning on urination, urinary urgency or frequency,
chills, fever, and fatigue. Ascites, polyuria, and nausea and vomiting are not indicative of pyelonephritis.
37. The nurse is planning to teach the client with acute glomerulonephritis about dietary restrictions. The nurse should
include in the plan to make which of the following dietary changes?
a. Limit fluid intake to 500 mL per day
b. Restrict protein intake by limiting meats and other high-protein foods
c. Increase intake of high-fibre foods, such as bran cereal
d. Increase intake of potassium-rich foods such as bananas or melon
ANSWER: B
A client with glomerulonephritis should eat a diet that is high in calories but low in protein to inhibit protein
catabolism, and allow the kidneys to rest by diet (since they have fewer nitrogenous wastes to clear). It is important
to protect the kidneys while they are recovering their function. The other responses are incorrect.
38. Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parent’s remark: “We just
don’t know how he caught the disease!” The nurse's response is based on an understanding that:
a. AGN is a viral infection that involves the ureters
b. The disease is easily transmissible in schools
c. The illness is usually associated with chronic respiratory infections
d. It is not "caught" but is a response to a previous Group A- Beta hemolytic strep infection
ANSWER: D
D – AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of
2-3 weeks prior, and is considered as a non-infectious renal disease. Sometimes, this may also follow impetigo and
acute viral infections. This is an inflammation of the glomerular capillaries of the kidneys.
39. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute
glomerulonephritis?
a. Assess for generalized edema
c. Encourage rest during hyperactive periods
b. Monitor for increased urinary output
d. Note patterns of increased blood pressure
ANSWER: D
D – Hypertension is a key assessment in the course of the disease
40. The nurse admits a 50 year-old client with a 3 day history of fever, flank pain, and elevated blood pressure. Which
of the following data obtained in the admission interview alerts the nurse that this may be acute glomerulonephritis?
a. Travel to a foreign country
c. Type 1 diabetes since age 15
b. Sore throat 3 weeks ago
d. History of mild hypertension
ANSWER: B
B – In the majority of cases of acute glomerulonephritis there is a history of a group beta streptococcal infection of
the throat preceding the onset by 2-3 weeks. The other options do not suggest acute glomerulonephritis
41. The major manifestation of nephrotic syndrome is:
a. Hematuria
b. Pain on urination
c. Urgency
d. Edema
ANSWER: D
Nephrotic syndrome is a primary glomerular disease characterized by marked increase of protein in the urine,
decrease albumin in the blood and high serum cholesterol and low density lipoproteins. The major manifestation of
nephritic syndrome is edema. It is usually soft and pitting most commonly occurs around the eyes, in dependent area
and in the abdomen.
42. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the
relationship between edema formation and:
a. Increased retention of albumin in the vascular system
b. Decreased colloidal osmotic pressure in the capillaries
c. Fluid shift from interstitial spaces into the vascular space
d. Reduced tubular reabsorption of sodium and water
ANSWER: B
B – The increased glomerular permeability to protein causes a decrease in serum albumin which results in decreased
colloidal osmotic pressure
43. In planning diet teaching for a child in the early stages of nephrotic syndrome, the nurse should discuss with the
parents which of the following dietary changes?
a. Adequate protein intake, low sodium
c. Low-potassium, low-calorie intake
b. Low-protein, low-potassium intake
d. Limited-protein, high-carbohydrate intake
ANSWER: A
A – The patient is placed on a low-sodium, liberal potassium diet to enhance the sodium-potassium pump mechanism,
thereby assisting in the elimination of sodium to reduce edema. They are also given an adequate amount of protein
with emphasis on high biologic value proteins.
B – High protein, high potassium
C – Does not address protein need at all
D – May be appropriate only if the child cannot tolerate protein intake
44. Which of the following urinary symptoms is the most common initial manifestation of acute renal failure?
a. Anuria
b. Dysuria
c. Oliguria
d. Hematuria
ANSWER: C
Acute renal failure is a sudden and almost complete loss of kidney function over a period of hours to days. Oliguria or
less than 400 ml/day of urine is the most common clinical situation seen in clients with ARF. The other options are not
as common.
45. Your client has been diagnosed with renal failure. What serum laboratory value would be the best indicator of
renal function?
a. Potassium level
b. Blood urea nitrogen (BUN)
c. Creatinine level
d. Specific gravity
ANSWER: C
Creatinine levels are more sensitive and specific for renal disease. Although the BUN level is used to assess renal
function, it can also be affected by diet and fluid status. The potassium level can be affected by many factors as well.
Specific gravity is not a blood test, but rather is performed on the urine itself.
46. The client’s blood urea nitrogen (BUN) and creatinine is elevated in acute renal failure. This is known as:
a. Bacteriuria
b. Pyuria
c. Azotemia
d. Asterixis
ANSWER: C
The BUN levels rises steadily at a rate dependent on the degree of catabolism (breakdown of protein), renal perfusion
and protein intake. Serum creatinine rises in conjunction with glomerular damage. This is referred to as azotemia. It is
the retention of urea and other nitrogenous wastes in the blood.
47. In the oliguric phase of acute renal failure, the nurse should anticipate the development of which of the following
complications?
a. Hypokalemia
b. Hyperkalemia
c. Pulmonary edema
d. Hypomagnesemia
ANSWER: B
There are four clinical phases of ARF: initiation, oliguria, diuresis and recovery. In the oliguric phase of acute renal
failure, it is accompanied by a rise in the serum concentration of the substances usually excreted by the kidneys
(urea, creatinine, uric acid, potassium, magnesium) The minimum amount of urine needed to rid the body of normal
metabolic waste products is 400 ml. In this phase, uremic symptoms first appear and conditions such as hyperkalemia
develop.
48. A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities. Which of the
following nursing observations would indicate a therapeutic response to therapy for the edema?
a. Serum potassium 4.0 mEq/L
c. Increased specific gravity of the urine
b. Plasma glucose 140 mg/dL
d. Weight loss of 5 lb over last two days
ANSWER: D
D – Edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective
A, B – No relation to edema
C – Urine specific gravity may be decreased as client begins to lose some edema fluid
49. When caring for a client diagnosed with end-stage renal disease (ESRD), which of the following diets should the
nurse recommend?
a. Increased protein, decreased carbohydrates
c. Increased potassium and sodium
b. Restricted protein, increased carbohydrates
d. Restricted phosphorus and magnesium
ANSWER: B
With end-stage renal disease the kidneys have difficulty excreting protein and the build-up of toxins in the system
causes systemic problems. Clients must usually restrict dietary protein while increasing carbohydrate intake to meet
energy needs and prevent tissue breakdown. Potassium and sodium are restricted in clients with end-stage renal
failure. Protein-rich foods are also high in phosphorus, which is restricted to avoid osteodystrophy. Magnesium is not
specifically restricted.
50. The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for
patency in a fistula used for hemodialysis?
a. Observe for edema proximal to the site
c. Palpate for a thrill over the fistula
b. Irrigate with 5 ml of 0.9% Normal Saline
d. Check color and warmth in the extremity
ANSWER: C
C – To assess for patency in a fistula or graft, the nurse auscultates for a bruit and palpates for a thrill. Other options
are not related to evaluation for patency.
51. The nurse is caring for a homebound client with a urinary catheter. The client’s husband states that he thinks the
catheter is obstructed. Which of the following observations would confirm this suspicion?
a. The nurse notes that the bladder is distended
c. The nurse notes that the urine is concentrated
b. The client complains of a constant urge to void
d. The client complains of a burning sensation
ANSWER: A
A – bladder distention is one of the earliest signs of obstructed drainage tubing
B, D – seen with a urinary tract infection
C – seen with dehydration
52. In preadmission planning with a client who is to have a renal transplant, the client should be educated by the
nurse regarding the need to:
a. Remind family and friends that there is restricted visiting for at least 72 hours postoperatively
b. Arrange all live plants received postoperatively in one section of the room
c. Continue intermittent peritoneal dialysis for three months following surgery
d. Limit consumption of sodium-free liquids for one year postoperatively
ANSWER: A
A – Transplant clients require protective isolation following surgery
B – Can’t have live plants in their room at all
C – No need for dialysis following transplant
D – Need to force fluids, not restrict them
53. The nurse is caring for a client with chronic renal failure on hemodialysis 3 times a week. The client becomes
confused and irritable 6 hours before his next treatment. Which of these items might explain the reason for the
client’s behavior?
a. Elevated blood urea nitrogen (BUN)
b. Potassium loss
c. Calcium depletion
ANSWER: A
A – Confusion and irritability are signs of renal encephalopathy secondary to elevated levels of BUN and creatinine in
the blood. Other options do not explain the client’s behavior. Potassium levels are generally high in renal failure. Side
effects of calcium depletion manifest as abdominal and muscle cramping and hyperactive reflexes. Metabolic acidosis
not alkalosis is seen in renal failure.
54. If the nurse notes cloudy drainage 2 days post insertion of a Tenckhoff catheter for peritoneal dialysis, what other
data does the nurse need to collect before reporting this finding?
a. Bowel sounds
b. Breath sounds
c. Temperature
d. Urine output
ANSWER: C
C – This finding indicates potential infection so temperature is essential to evaluate before notification of the care
provider.
55. A client is admitted for hemodialysis. Which abnormal lab value would the nurse anticipate not being improved by
hemodialysis?
a. Low hemoglobin
b. Hypernatremia
c. High serum creatinine
d. Hyperkalemia
ANSWER: A
A – Although hemodialysis improves or corrects electrolyte imbalances it has not effect on improving anemia.
56. The nurse is planning care for a client who had surgery for an ileal conduit two days ago. It is MOST important for
the nurse to take which of the following actions?
a. Remove the appliance regularly and clean the skin with antiseptic solution.
b. Apply a close-fitting drainage bag to the stoma.
c. Massage the skin around the stoma with an emollient.
d. Expose the area around the stoma to air twice a day.
ANSWER: B
B – Primary preventative measure to prevent urine from contacting the skin
A – Soap and water should be used to clean the skin, not an antiseptic solution
C – Would hinder the application of the bag for urine collection
D – Unnecessary; would not help prevent skin breakdown
57. The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is:
a. Drink 3000 to 4000 cc of fluid each day for one month
c. Increase intake of citrus fruits to three servings per day
b. Limit fluid intake to 1000 cc each day for one month
d. Restrict milk and dairy products for one month
ANSWER: A
A – Drinking three to four quarts (3000 to 4000 cc) of fluid each day will aid passage of fragments and help prevent
formation of new calculi
58. A female client reports to the nurse that she experiences a loss of urine when she jogs. The nurse's assessment
reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse
explains to the client that this type of problem is called:
a. functional incontinence
b. reflex incontinence
c. stress incontinence
d. total incontinence
ANSWER: C
Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running,
laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional
incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine.
Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached.
Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.
59. A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar
region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and
appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate
abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
a. Kidney
b. Ureter
c. Bladder
d. Urethra
ANSWER: A
The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or
without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder,
and urethra are less common sites of renal calculi formation.
60. Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding
signals a significant problem during this procedure?
a. Blood glucose level of 200 mg/dl
c. Potassium level of 3.5 mEq/L
b. White blood cell (WBC) count of 20,000/mm3
d. Hematocrit (HCT) of 35%
ANSWER: B
An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by
insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its
ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client.
Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily
treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the
dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low
because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack
of erythropoietin.
61. A client with suspected renal dysfunction is scheduled for excretory urography. The nurse reviews the history for
conditions that may warrant changes in client preparation. Normally, a client should be mildly hypovolemic (fluid
depleted) before excretory urography. Which history finding would call for the client to be well hydrated instead?
a. Cystic fibrosis
b. Multiple myeloma
c. Gout
d. Myasthenia gravis
ANSWER: B
Fluid depletion before excretory urography is contraindicated in clients with multiple myeloma, severe diabetes
mellitus, and uric acid nephropathy — conditions that can seriously compromise renal function in fluid-depleted clients
with reduced renal perfusion. If these clients must undergo excretory urography, they should be well hydrated before
the test. Cystic fibrosis, gout, and myasthenia gravis don't necessitate changes in client preparation for excretory
urography.
62. A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which
instruction?
a. "Take your temperature every 4 hours."
b. "Increase your fluid intake to 2 to 3 L per day."
c. "Apply an antibacterial dressing to the incision daily."
d. "Be aware that your urine will be cherry-red for 5 to 7 days."
ANSWER: B
Increasing fluid intake flushes the renal calculi fragments through — and prevents obstruction of — the urinary
system. Measuring temperature every 4 hours isn't needed. Lithotripsy doesn't require an incision. Hematuria may
occur for a few hours after lithotripsy but should then disappear.
63. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure,
an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra–high-frequency sound
waves to shatter renal calculi. The nurse should instruct the client to:
a. limit oral fluid intake for 1 to 2 weeks.
b. report the presence of fine, sandlike particles through the nephrostomy tube.
c. notify the physician about cloudy or foul-smelling urine.
d. report bright pink urine within 24 hours after the procedure.
ANSWER: C
The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be
instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual
stone products. Hematuria is common after lithotripsy.
64. After trying to conceive for a year, a couple consults an infertility specialist. When obtaining a history from the
husband, the nurse inquires about childhood infectious diseases. Which childhood infectious disease most significantly
affects male fertility?
a. Chickenpox
b. Measles
c. Mumps
d. Scarlet fever
ANSWER:C
Mumps is the childhood infectious disease that most significantly affects male fertility. Chickenpox, measles, and
scarlet fever don't affect male fertility.
65. The nurse suspects that a client with a temperature of 103.6° F (39.8° C) and an elevated white blood cell count
is in the initial stage of sepsis. What is the most common cause of sepsis in hospitalized clients?
a. Respiratory infection
b. Urinary tract infection (UTI)
c. Vasculitis
d. Osteomyelitis
ANSWER: B
Sepsis most commonly results from a UTI caused by gram-negative bacteria. Other causes of sepsis include infections
of the biliary, GI, and gynecologic tracts. Respiratory infection, vasculitis, and osteomyelitis rarely cause sepsis in
hospitalized clients.
66. The nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions,
and sodium bicarbonate to be used to treat:
a. hypernatremia.
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.
ANSWER: C
Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to
reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily
prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels.
Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with
glucose, insulin, or sodium bicarbonate.
67. A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral
resection of the prostate. In addition to balloon inflation, the functions of the three lumens include:
a. continuous inflow and outflow of irrigation solution.
b. intermittent inflow and continuous outflow of irrigation solution.
c. continuous inflow and intermittent outflow of irrigation solution.
d. intermittent flow of irrigation solution and prevention of hemorrhage.
ANSWER: A
When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three
lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.
68. A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should
collect a urine specimen for culture and sensitivity by:
a. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container.
b. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle.
c. draining urine from the drainage bag into a sterile container.
d. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.
ANSWER: B
Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of
introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break
in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be
fresh and may contain bacteria, giving false test results. When there is no urine in the tubing, the catheter may be
clamped for no more than 30 minutes to allow urine to collect.
69. A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for:
a. enuresis.
b. drug toxicity.
c. lethargy.
d. insomnia.
ANSWER:B
Acute renal failure is characterized by oliguria and rapid accumulation of nitrogen waste in the blood. Kidneys excrete
medications, so the nurse should monitor the client closely for drug toxicity. With decreased urinary output or no
output, enuresis shouldn't occur. The client will most likely feel lethargic, but this isn't as serious a problem as drug
toxicity. The client isn't likely to have insomnia, but, may instead want to sleep most of the time.
70. A client requires hemodialysis. Which type of drug should be withheld before this procedure?
a. Phosphate binders
b. Insulin
c. Antibiotics
d. Cardiac glycosides
ANSWER: D
Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte
shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity.
Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some
antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects.
The nurse should check a formulary to determine whether a particular antibiotic should be administered before or
after dialysis.
71. A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are
consistent with CRF?
a. Increased pH with decreased hydrogen ions
b. Increased serum levels of potassium, magnesium, and calcium
c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl
d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%
ANSWER: C
The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test
results in option 3 are abnormally elevated, reflecting CRF and the kidneys' decreased ability to remove nonprotein
nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also
increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric
acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the
normal range of 60% to 75%.
72. A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the
client's risk of:
a. water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
b. a decreased serum phosphate level secondary to kidney failure.
c. an increased serum calcium level secondary to kidney failure.
d. metabolic alkalosis secondary to retention of hydrogen ions.
ANSWER: A
A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention
if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys'
inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF
may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
73. When a client with an indwelling urinary catheter insists on walking to the hospital lobby to visit with family
members, the nurse teaches him how to do this without compromising the catheter. Which client action indicates an
accurate understanding of this information?
a. The client sets the drainage bag on the floor while sitting down.
b. The client keeps the drainage bag below the bladder at all times.
c. The client clamps the catheter drainage tubing while visiting with the family.
d. The client loops the drainage tubing below its point of entry into the drainage bag.
ANSWER: B
To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to
flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because it
could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the
flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry
into the drainage bag.
74. The nurse correctly identifies a urine sample with a pH of 4.3 as being which type of solution?
a. Neutral
b. Alkaline
c. Acidic
d. Basic
ANSWER: C
Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic
solution. A pH of 7.0 is considered neutral.
75. The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal?
a. Specific gravity of 1.03
b. Urine pH of 3.0
c. Absence of protein
d. Absence of glucose
ANSWER: B
Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from
1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin,
bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per
high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.
76. A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for
prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the
surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland
removal?
a. Transurethral resection of the prostate (TURP)
c. Suprapubic prostatectomy
b. Retropubic prostatectomy
d. Transurethral laser incision of the prostate
ANSWER: A
TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially
suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic
prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common
procedures; they all require an incision
77. Which statement best describes the therapeutic action of loop diuretics?
a. They block reabsorption of potassium on the collecting tubule.
b. They promote sodium secretion into the distal tubule.
c. They block sodium reabsorption in the ascending loop and dilate renal vessels.
d. They promote potassium secretion into the distal tubule and constrict renal vessels.
ANSWER: C
Loop diuretics block sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. They also
dilate renal vessels. Loop diuretics block potassium reabsorption, but this isn't a therapeutic effect. Thiazide diuretics
promote sodium secretion into the distal tubule.
SITUATION: A thorough history and examination is essential in the assessment of all patients presenting with
genitourinary symptoms.
78. A patient’s urine dipstick indicates a large amount of protein in the urine. The next action by the nurse should be
to:
a. Check which medications the patient is currently taking.
b. Ask the patient about any family history of chronic renal failure.
c. Send a urine specimen to the laboratory to test for ketones and glucose.
d. Obtain a clean-catch urine for culture and sensitivity testing.
Answer: A
Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive
readings. The other actions by the nurse may be appropriate, but checking for medications that may affect the
dipstick accuracy should be done first.
Reference: Lewis Medical Surgical Nursing 7th ed
79. A client is admitted with an infection of the ureters. The nurse realizes that this infection could include which of
the following structures of the kidney?
a. Adrenal glands
b. Medulla
c. Cortex
d. Pelvis
Answer: D
The renal pelvis is continuous with the ureters. The cortex and medulla are deeper within the renal tissue and not an
extension of the ureters as is the case of the renal pelvis. The adrenal glands are located just above the kidneys, but
are not considered a part of the urinary system.
80. A client is experiencing a sudden decrease in systemic blood pressure. Which of the following will occur within the
kidney to help control this blood pressure drop?
a. Renal vessels will dilate
c. Hydrostatic pressure will increase
b. Juxtaglomerular cells will release renin
d. Glomerular filtration rate (GFR) will increase
Answer: B
A drop in systemic blood pressure often triggers the juxtaglomerular cells to release renin. Renin acts on
angiotensinogen to release angiotensin I, which is in turn converted to angiotensin II. Angiotensin II activates
vascular smooth muscle throughout the body, which causes systemic blood pressure to rise. Thus, the reninangiotensin mechanism is
a factor in renal autoregulation, even though its main purpose is the control of systemic
blood pressure. Increased glomerular filtration rate (GFR), dilation of renal vessels, and increased hydrostatic
pressure will all cause a further drop in blood pressure.
81. While assessing a patient’s urinary system, the nurse cannot palpate either kidney. Which action should the nurse
take next?
a. Ask the patient about any history of recent sore throat.
b. Obtain a urine specimen to check for hematuria.
c. Ask the health care provider about scheduling a renal ultrasound.
d. Document the information on the assessment form.
Answer: D
The kidneys are protected by the abdominal organs, ribs, and muscles of the back and may not be palpable under
normal circumstances, so no action except to document the assessment information is needed. Asking about a recent
sore throat, checking for hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal
problems for some patients, but there is nothing in the stem to indicate that they are appropriate for this patient.
82. The nurse uses auscultation during assessment of the urinary system to:
a. Determine the position of the kidneys.
c. Check for ureteral peristalsis.
b. Assess for bladder distension.
d. Identify renal artery or aortic bruits.
Answer: D
The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm.
Auscultation would not be helpful in assessing for the other listed urinary tract information.
83. The client reports the regular use of all the following medications. Which one alerts the nurse to the possibility of
renal impairment when used consistently?
a. Antacids
c. Antihistamine nasal sprays
b. Penicillin
d. Nonsteroidal anti-inflammatory drugs (NSAIDs)
ANSWER: D
NSAIDs inhibit prostaglandin production and decrease blood flow to the nephrons. They can cause an interstitial
nephritis and renal impairment.
84. Which of the following principles of catheter care should the nurse consider before catheterizing a client?
a. Place a urinary catheter in a client who is geriatric to prevent urinary incontinence.
b. Use a catheterization as a last resort.
c. Keep the catheter bag on t he bed and at the level of the bladder.
d. Sprinkle powder in the perineal area and around the catheter insertion site.
ANSWER: B
Catheterization may be used as a last resort after all noninvasive measure to promote urination, such as encouraging
ambulation and fluids, have failed. Catheterization should not be used for clients who are geriatric to prevent urinary
incontinence. The catheter bag should always be kept below the level of the bladder. Applying powder to the perineal
area and around the catheter insertion site should never be used, because this practice promotes infection.
Reference: Brunner and Suddarth. Medical-Surgical Nursing, 11th edition, pages 1952
85. Nurse Hannah identifies who among the following hospitalized clients to be at greatest risk for the development of
a nosocomial urinary tract infection?
a. A 75-year-old male who has pancreatic cancer.
b. A 48-year-old suspected of Parkinson’s disease who had been jogging prior to admission.
c. A 34-year-old male who drinks 2500 ml of fluids daily, following a fracture of a fibula.
d. A 60-year-old obese female with cholecystitis
ANSWER: A
Although nosocomial urinary infections may occur in any hospitalized client, the incidence is significantly impacted by
the client’s overall state of health. A client who is male, older, and has a terminal cancer receiving chemotherapy is
immunosuppressed and at greatest risk.
Reference: Brunner and Suddarth. Medical-Surgical Nursing, 11th edition, pages 1570-1571
86. The nurse correctly collects urine by which of the following methods to establish the diagnosis of urethritis?
a. Obtain a specimen in the beginning and in the middle of the urine flow.
b. Obtain the first voided specimen in the morning.
c. Collect all the urine for 24 hours.
d. Collect any voided specimen during the day.
ANSWER: A
Obtaining a urine specimen in the beginning and again in the middle of the urine flow (split urine collections) for the
purpose of performing a culture is the correct procedure for diagnosing urethritis.
Reference: Brunner and Suddarth. Medical-Surgical Nursing, 11th edition, pages
87. Which of the following should the nurse include to correctly collect a timed urine specimen?
a. Instruct the client to save the first voided specimen when the urine collection time starts.
b. Instruct the client on the importance of continuing to save all urine even if one specimen is missed.
c. Place the collection container in a location that is room temperature and away from accidental spillage.
d. Encourage the client to empty the bladder and save the specimen at the end of the collection time.
ANSWER: D
The first voided specimen for a timed urinary test should be discarded. The collection container should be kept in the
refrigerator or an ice in the bathroom. If a urine specimen is missed, the whole timed test must start again. It is
helpful to have a sign on the bathroom door and above the toilet to save all urine. At the conclusion of the test, the
client should be encouraged to empty the bladder and save this specimen.
Reference: Brunner and Suddarth. Medical-Surgical Nursing, 11th edition, pages 1577
88. The female client’s urinalysis shows all the following results. Which should the nurse document as abnormal?
a. pH 5.6
c. Specific gravity of 1.030
b. Ketone bodies present
d. Two white blood cells per high-power field
ANSWER: B
Ketone bodies are byproducts of incomplete metabolism of fatty acids. Normally, there are no ketones in urine.
Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy.
89. Which client is at greatest risk for development of a bacterial cystitis?
a. Older female client not taking estrogen replacement
b. Older male client with mild congestive heart failure
c. Middle-aged female client who has never been pregnant
d. Middle-aged male client who is taking cyclophosphamide for cancer therapy
ANSWER: A
Females at any age are more susceptible to cystitis than men because of the shorter urethra in women.
Postmenopausal women who are not on hormone replacement therapy are at an increased risk for bacterial cystitis
because of changes in the cells of the urethra and vagina.
The middle-aged female client who has never been pregnant would not have a risk potential as high as the older
female client who is using hormone replacement therapy.
90. The client with severe bacterial cystitis is prescribed to take cefadroxil (Duricef) and phenazopyridine (Pyridium).
What will the nurse teach this client regarding the drug regimen?
a. “Do not take these drugs with food or milk.”
c. “Do not be alarmed by the discoloration of your urine.”
b. “Stop these drugs if you think you are pregnant.”
d. “Drink a liter of cranberry juice every day.”
ANSWER: C
Phenazopyridine discolors urine most commonly to a deep reddish orange. Many clients think they have blood in their
urine when they see this. In addition, the urine can permanently stain clothing.
91. Which client statement indicates understanding regarding antibiotic therapy for recurrent urinary tract infections?
a. “If my urine becomes lighter and clear, I can stop taking my medicine.”
b. “Even if I feel completely well, I should take the medication until it is gone.”
c. “When my urine no longer burns, I will no longer need to take the antibiotics.”
d. “If my temperature goes above 100° F (37.8° C), I should take twice as much medicine.”
ANSWER: B
Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the
prescribed medication for the entire course and not just when symptoms are present. The other statements
demonstrate that additional teaching is needed for the client.
92. To relieve the symptoms of a lower UTI for which the patient is taking prescribed antibiotics, the nurse suggests
that the patient use the OTC urinary analgesic phenazopyridine (Pyridium) but cautions the patient that this
preparation
a. Contains methylene blue, which turns the urine blue or green.
b. Should be taken on an empty stomach for maximum effect.
c. Causes the urine to turn reddish orange and can stain underclothing.
d. Frequently causes allergic reactions and should be stopped if a rash occurs.
Answer: C
Patients should be taught that Pyridium will color the urine deep orange and stain underclothing. Urised may turn the
urine blue or green. The medication can cause gastrointestinal distress and should be taken with food. Although an
allergic reaction may occur, this is not common.
93. A patient with nephrotic syndrome develops flank pain. The nurse will anticipate treatment with:
a. Antibiotics.
b. Antihypertensives.
c. Anticoagulants.
d. Corticosteroids.
Answer: C
Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are
used to treat a patient with flank pain caused by pyelonephritis. Antihypertensives are used if the patient has high
blood pressure. Corticosteroids may be used to treat nephrotic syndrome but will not resolve a thrombosis.
94. A patient who is diagnosed with nephrotic syndrome has 3+ ankle and leg edema and ascites. Which nursing
diagnosis is a priority for the patient?
a. Fluid-volume excess related to low serum protein levels
b. Altered nutrition: less than required related to protein restriction
c. Activity intolerance related to increased weight and fatigue
d. Disturbed body image related to peripheral edema and ascites
Answer: A
The patient has massive edema, so the priority problem at this time is the excess of fluid volume. The other nursing
diagnoses are also appropriate, but the focus of nursing care should be resolution of the edema and ascites.
Reference: Lewis Medical Surgical Nursing 7th ed page 1167-1168
95. A patient is admitted to the hospital with nephrotic syndrome after taking an OTC nonsteroidal antiinflammatory
drug (NSAID) a week earlier. Which assessment data will the nurse expect to find related to this illness?
a. Low blood pressure
b. Recent weight gain
c. Poor skin turgor
d. High urine ketones
Answer: B
The patient with a rapid-onset nephrotic syndrome will have rapid weight gain associated with edema. Hypertension is
a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high.
96. Which statement made by the client who has kidney stones from secondary hyperoxaluria indicates correct
understanding of the role of dietary therapy for this condition?
a. “No modifications are needed because this type of stone is not caused by diet.”
b. “I will avoid dark green leafy vegetables, chocolate, and nuts.”
c. “I will avoid all dairy products and vitamin D.”
d. “I will avoid wine, meat, and shellfish.”
ANSWER: B
Secondary hyperoxaluria is caused by an excessive ingestion of foods containing large amounts of oxalate, such as
spinach, rhubarb, Swiss chard, collard greens, cocoa, beets, wheat germ, pecans, peanuts, okra, chocolate, and lime
peel.
97. The client with a renal calculus has just returned from an extracorporeal shock wave lithotripsy procedure and the
nurse finds an ecchymotic area on the client’s right lower back. Which is the nurse’s priority intervention?
c. Placing the client in the prone position
b. Applying ice to the site
d. Documenting the observation as the only action
ANSWER: B
The shock waves can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the
extent and discomfort of the bruising.
98. Which drug will the nurse administer to the client diagnosed with renal calculi from hyperuricemia?
a. Allopurinol (Zyloprim)
b. Captopril (Capoten)
c. Chlorothiazide (Diuril)
d. Phenazopyridine (Pyridium)
ANSWER: A
Allopurinol inhibits the enzyme that converts purine metabolites into uric acid, thereby reducing the amount of uric
acid present for precipitation into stones. The other drugs listed would not be effective.
99. The client who has undergone a nephrolithotomy procedure 24 hours ago now has a fever of 101° F (38.3° C).
Which is the nurse’s priority intervention?
a. Applying a cooling blanket
c. Notifying the physician
b. Straining the urine
d. Documenting the finding as the only action
ANSWER: C
The elevated temperature indicates a possible infection. Treatment must be initiated as soon as possible to prevent
septic complications.
100. A nurse is providing dietary teaching to a client who was just started on hemodialysis. Which instruction will the
nurse provide to this client regarding protein intake?
a. “Your protein needs will not change, but you may take more fluids.”
b. “You will need more protein now, because some protein is lost by dialysis.”
c. “Your protein intake will be adjusted according to your predialysis weight.”
d. “You no longer need to be on protein restriction.”
ANSWER: B
When renal disease has progressed and requires treatment with dialysis, increased protein is required in the diet to
compensate for protein losses through dialysis.

MEDICAL SURGICAL NURSING 1 CARE OF CLIENTS WITH CARDIOVASCULAR DISORDERS

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MEDICAL SURGICAL NURSING 1 CARE OF CLIENTS WITH CARDIOVASCULAR DISORDERS

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MEDICAL SURGICAL NURSING 1

CARE OF CLIENTS WITH CARDIOVASCULAR DISORDERS

Cells are undifferentiated

Smooth and round with a surrounding fibrous capsule.

Irregular shaped with no capsule.

Cells multiply slowly.

Cells multiply rapidly.

Tumor grows by expanding and pushing away and

Tumor grows by invading and destroying surrounding

Mass is mobile. Not attached to surrounding tissue.

Mass is fixed. Attached to surrounding tissue and deeply

Never spread to other sites (metastasize).

Almost always spreads to other sites if not removed or

Easier to remove and does not recur after excision.

Difficult to remove and recurs after excision.

Smoking and exposure to second hand smoke

c. The older adult client with moderate heart failure

d. High pH, low pCO2

d. Position patient in semi fowler’s after each feeding

d. mucous neck cells

d. Nausea and vomiting

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