4.
A 42 year old woman has an
MS II MT1
1. Normal saline 0.9%1000mL IV
solution is prescribed for the client. The
IV is to run at 100 mL per hour. The
nurse understands that which of the
following is not a characteristic of this
type of solution?
a. Is isotonic with the plasma and other
body fluids
b. Is hypotonic with the plasma and other
body fluids
c. Does not affect the plasma osmolarity
d. Is the same solution as sodium chloride
0.9%
2. Lactated Ringer’s solution (LR) is
prescribed for the postoperative client. A
nursing student is caring for the client.
The nursing instructor asks the students
about the tonicity of the prescribed IV
solution. Which of the following is
correct regarding the tonicity of the
solution?
a. Isotonic
b. Normotonic
c. Hypotonic
d. Hypertonic
3. The nurse is caring for a client
with a fluid volume deficit. Which of the
following client is at risk for fluid volume
deficit?
a. A client with cirrhosis
b. A client with congestive heart failure
c. A client with decreased kidney function
d. A client with a colostomy
abdominal resection for colon cancer.
The patient is returned to her room with
Jackson-Pratt drain. The nurse
understands that the purposes of the
drain is to:
a. Irrigate the incision with a saline solution
b. Prevent bacterial infection of the incision
c. Prevent accumulation of drainage in the
wound
d. Measure the amount of fluid lost after
surgery
5. A patient with upper GI bleeding
underwent gastroscopy. The nursing
care plan after the procedure includes
which of the following?
a. Administering meperidine for pain
b. Positioning the client on left side
c. Keeping patient NPO until gag reflex
returns
d. Observing client for melena
6. The client underwent Billroth I for
gastric ulcer. Postoperatively, the
drainage from the NGT is thick and the
volume of secretion has dramatically
reduced in the last 2 hours and the client
feels like vomiting. The most appropriate
nursing action is to:
a. Reposition the NGT by advancing it gently
b. Notify the MD of your finding
c. Irrigate the NGT with 50cc of sterile NSS
d. Discontinue the low-intermittent
suctioning
7. An effective strategy for
preventing constipation in an elderly
client is:
a. Reducing fluid intake to encourage bulk
formation in the intestinal lumen
b. Use of laxative daily to establish a regular
elimination pattern
c. A regimen of exercise directed at toning
the abdominal muscles
d. Setting a routine for bowel elimination
just before bedtime
8. The client has developed
peritonitis related to a perforated
duodenal ulcer. The nurse would find in
her assessment:
a. Decreased or absent bowel sound
b. Colicky abdominal pain
c. High-pitched bowel sound
d. Alternating episodes of constipation and
diarrhea
9. A nursing diagnosis appropriate
for a client with ulcerative colitis is:
a. Abdominal pain related to decreased
peristalsis
b. Diarrhea related to hyperosmolar
intestinal content
c. Fluid volume excess related to increased
H2O absorption by the intestinal mucosa
d. Activity intolerance related to fatigue
10. The nurse is assisting with the
admission of a client who is the victim of
gang violence. The client's underwear is
bloody and contains a hole where a
bullet passed through after it exits from
the body. The physician wants the
underwear removed immediately so an
assessment can be done. Which of the
following actions by the nurse would be
best?
a. Get assistance to remove the underwear
intact, then place it in a paper bag and label
it
b. Remove the underwear in the quickest
manner and send it home with the family
c. Cut the underwear off as quickly as
possible and dispose of it using a biohazard
bag
d. Cut the underwear off and put it in a
plastic bag with the rest of the client's
belongings
11. In order to educate clients, the nurse
should understand that the most
common site of cancer for a female is
the
a. vagina
b. uterine body
c. uterine cervix
d. fallopian tube
12. Which of the following procedures is
considered essential in diagnosing
breast cancer and determining whether
it is benign or malignant?
a. X-ray film
b. Core-needle biopsy
c. Mammography
d. Ultrasonography
13.  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
14.  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.
15.   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
16. Among the following population
group, who has a higher risk in the
development of prostate cancer?
a. Caucasian
b. African-American
c. Asian
d. Hispanics
17. Who among these women is at most
risk for breast cancer?
a. Over age 60 years, married, multiple
sexual partners at a young age
b. Over age 40 years, never married, with a
family history of lung cancer
c. Over age 65 years, married, younger than
16 years at first pregnancy
d. Over age 55, never married, with a family
history of cancer
18. The ABCD method offers one way to
assess skin lesions for possible skin
cancer. What does the A stand for?
a. Asymmetry
b. Assessment
c. Actinic
d. Arcus
19. In the Philippines, the use of this
method is strongly suggested and
recommended than any other methods
to decrease death due to breast cancer:
a. BSE
b. Breast biopsy
c. Surgery
d. Mammography
20. The nurse is teaching a group of
women to perform breast self-
examination. The nurse should explain
that the main purpose of performing this
examination is to discover:
a. Changes from previous self-examinations
b. Fibrocystic masses
c. Areas of thickness or fullness
d. Cancerous lumps
21. A client has just received report from
her physician that describes a tumor that
was recently biopsied. If the result she
receives is listed as T0, N0 and M0, the
client will know that she has
a. a primary tumor and regional nodes
involved
b. no evidence of a primary tumor, lymph
node involvement and metastasis
c. no primary tumor, but evidence of a
degree of distant metastasis.
d. carcinoma in situ
22.  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)
23. The nurse is caring for a client with
neutropenia. Which of the following
blood tests would indicate to the nurse
the desired response to treatment?
a. Decreased platelet count
b. Normal hemoglobin
c. Increased granulocytes
d. Liver functions above normal
24. The nurse manager on the oncology
units is assessing the knowledge level of
the staff in regard to safety requirements
for the patient receiving internal
radiation therapy. Which observation by
the nurse manager indicated that further
instruction is necessary?
a. The physical therapist is ambulating the
patient in the hall
b. The nurse uses rubber gloves when
emptying the bedpan
c. The dietician provides a low residue diet
for the patient
d. The housekeeping staff calls the
radiation Safety personnel to inspect the
room before the patient is discharged.
25.  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)
26. The type of chemotherapeutic agent
that interferes with DNA replication is
known as a(n):
a. Radioactive Iodine
b. Antimetabolites
c. Alkylating agents
d. Hormonal inhibitor
27.  A nurse is caring for a patient who
is being discharged after treatment for
acute leukemia.  To manage mucositis
and painful mucous membranes, the
nurse should instruct the patient to eat:
A. Soft textured food, such as meatloaf
B. Raw fruits, such as apples
C. Raw vegetables such as eggplant
D. Foods with vitamin C, such as
grapefruits.
28. After cancer chemotherapy, a client
experiences nausea and vomiting. The
nurse should assign highest priority to
which intervention?
a. Administering metoclopramide (Reglan)
and dexamethasone (Decadron) as
prescribed
b. Encouraging rhythmic breathing
exercises
c. Withholding fluids for the first 4 to 6
hours after chemotherapy administration
d. Serving small portions of bland food
29. The nurse is interviewing a client
about his past medical history. Which
preexisting condition may lead the nurse
to suspect that a client has colorectal
cancer?
a. Hemorrhoids
b. Duodenal ulcers
c. Polyps
d. Weight gain
30.  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 the 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.”
31.  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.”
32. Mr. Jojo is receiving
chemotherapeutic agents in the
treatment of his cancer. He is suffering
from thrombocytopenia secondary to
chemotherapy. As his nurse, part of your
nursing intervention is:
a. Avoiding administering injections
b. Administering platelet transfusions as
ordered
c. Providing for periods of rest
d. Administering antiemetics before meals
33.  A 42-year-old male complains of
extreme fatigue and weakness after his
first week of radiation therapy.  Which of
the following responses by the nurse
would best reassure him?
A. “These symptoms usually result from
radiation therapy; however we will continue
to monitor your laboratory and x-ray
studies.’
B. “These symptoms are part of your
disease and can’t be helped.”
C. “Don’t be concerned about these
symptoms. Everybody feels this way after
having radiation therapy.”
D. “This is a good sign. It means that only
the cancer cells are dying
34. A priority nursing intervention for the
care of a terminally ill patient diagnosed
with metastatic cancer is
a. maintaining bowel function
b. alleviating and relieving pain
c. preventing respiratory arrest
d. managing chemotherapy
35. What would the nurse tell an
adolescent receiving chemotherapy
about alopecia?
a. “Don’t worry. Most chemotherapy does
not cause hair loss.”
b. “When your hair grows back, it may have
a different color or texture.”
c. “Your hair will grow back right after
completing all your chemotherapy.”
d. “Aren’t you lucky! The bald look is in
now.”
36. Shortly after arriving for the evening
shift, the triage nurse evaluates several
clients who have come into the
emergency department. Which client
should receive highest priority?
a. An elderly woman complaining of a loss
of appetite and fatigue for the past week
b. A basketball player limping and
complaining of pain and swelling in the right
ankle
c. A middle-aged man, diaphoretic and
complaining of severe chest pain radiating
to his jaw
d. A mother with a 5-year-old boy, who says
her son has been complaining of nausea
and has vomited once since noon
37. Systematic approach to effectively
establish and treat health priorities
includes the primary survey/ secondary
survey approach. The ABCD method is
used by the emergency staff in the
a. Secondary survey approach
b. Both Primary and Secondary survey
approach
c. Primary survey approach
d. None of the above
SITUATION: A rescuer is called to a
neighbor’s home after a 56-year-old
man collapses. After quickly assessing
the victim, the rescuer determines that
the victim is unresponsive.
38. To determine unresponsiveness, the
rescuer can:
a. Call the victim’s name and gently shake
the victim.
b. Perform the chin-tilt to open the victim’s
airway
c. Feel for any air movement from the
victim’s nose or mouth.
d. Watch the victim’s chest for respirations.
39. A maintenance man falls from a
ladder into the unit hall, striking his head
on some equipment. The man is
unconscious and not breathing; the
Code Team has already been paged
and is on its way. The nurse should:
a. Wait for the team to start CPR.
b. Open airway with a jaw thrust.
c. Start chest compressions.
d. Give two rescue breaths after extending
the neck.
40. A client encountered a vehicular
accident and sustained multiple
fractures. The nurse saw the patient
which she thinks has neck injury. The
most appropriate maneuver to give
airway and breathing resuscitation in
this client is:
a. Head tilt- chin lift `
b. Jaw thrust maneuver
c. Cricothyroidectomy
d. Tracheostomy
41. The nurse understands that the
estimated maximum time a person can
be without cardiopulmonary function and
still not experience permanent brain
damage is:
a. 1 to 2 minutes
b. 4 to 6 minutes
c. 8 to 10 minutes
d. 12 to 15 minutes
42. The position of rescuers in a two-
person rescue is:
a. The two rescuer faces the victim,
kneeling perpendicular to chest/sternum
b. The two rescuer faces victim on opposite
sides facing chest
c. One rescuer faces victim, kneeling
perpendicular to victims head; 2nd rescuer
on opposite side facing the victim, kneeling
perpendicular to sternum
d. One faces victim, kneeling in front of his
chest, the 2nd rescuer facing victim, parallel
to his head
43.  Chest compressions in CPR for a
pulseless toddler are:
A. 1 to 1 ½ inches in depth
B. ¼ to ½ inch in depth
C. ½ to 1 inch in depth
D. 1 ½ to 2 inches in depth
44. Proper hand placement for chest
compressions during cardiopulmonary
resuscitation (CPR) is essential to
reduce the risk of which of the following
complications?
a. Gastrointestinal bleeding
b. Emesis
c. Myocardial infarction
d. Rib fracture
45. While performing chest
compression, the rescuer realized that
the patient sustained rib fractures. What
will be the next step to do?
a. Stop chest compression
b. Continue chest compression
c. Splint the chest of the patient and stop
compression
d. Stop chest compression and wait until a
physician arrives
46.  The rescuer attempts to palpate the
carotid pulse of a client after 5 minutes
of CPR and finds that it is not palpable.
The rescuer should:
A. Discontinue CPR
B. Increase the rate of compressions.
C. Check the position of the hands
D. Increase the ratio of compression to
breaths.
47. During rescue breathing in CPR, the
victim will exhale by:
a. normal relaxation of the chest
b. gentle pressure of the rescuer’s hand on
the upper chest
c. the pressure of cardiac compressions
d. turning the head to the side
48. Which of the following drugs is most
commonly used to treat cardiogenic
shock?
a. Furosemide (Lasix)
b. Dopamine (Inotropin)
c. Enalapril (Vasotec)
d. Metoprolol (Lopressor)
49. The position that would enhance
cerebral blood flow to counteract the
symptoms of compensatory shock is:
a. Side-lying
b. Fowler’s
c. Trendelenburg
d. Gravity neutral
50. An elderly patient may have
sustained a basilar skull fracture after
slipping and falling on an icy sidewalk.
The nurse knows that basilar skull
fractures:
a. Are the least significant type of skull
fracture
b. May cause cerebrospinal fluid (CSF)
leaks from the nose or ears
c. Have no characteristic findings
d. Are always surgically repaired
51. Your barkada decided to do
mountain hiking after your course audit
examination. The next day you went
with your barkada to Tanay. In the
middle of your hiking experience, one of
your friends accidentally stepped on a
snake and was bitten. As a nursing
student what should you do?
a. Remove any constrictive items such as
rings and loosen the client dress if tight
b. Immobilized the injured part above the
level of the heart
c. Remove the venom by sipping your
friends wound
d. Get a tourniquet and apply it to the part
52.  A client is to receive antivenin
following a snake bite. Before
administering the antivenin, the nurse
should give priority to :
A. Administering a local anesthetic
B. Checking for an allergic response
C. Administering an anxiolytic
D. Withholding fluids for 6-8 hours.
53. You are walking in the Garden of
Eden. In the middle of your wandering,
you were stung by a bee. You
experienced difficulty of breathing and
stridor. You were rushed to the hospital
and was diagnosed to have anaphylactic
shock. What drug would you anticipate
the doctor will order?
a. Hydrocortisone
b. Diphenhydramin
c. Epinephrine
d. Atropine Sulfate
54.  The nurse giving discharge
instructions to the patient who is
severely allergic to insect stings would
caution the patient  to :
A. Wear bright colors to repel insects.
B. Apply perfume liberally as a protection
C. Dress in sleeveless, easily removable
garments
D. Obtain an emergency treatment Kit.
55. A geriatric client confined to bed in a
nursing home develops bronchitis and
atelectasis of the right lower lobe. When
discussing the treatment regimen with
the client, the nurse includes the need
to:
a. Lie on the affected side to relieve chest
pain
b. Lie on the affected side to promote
drainage
c. Sleep on the position of most comfort to
promote rest
d. Sleep with the head elevated to stimulate
deep breathing
56. Nurse RY evaluates that LA, his
male client, understands the instruction
about an appropriate breathing
technique for chronic obstructive
pulmonary disease, when he:
a. Inhales through the mouth
b. Increase the respiratory rate
c. Holds each breath for a second at the end
of inspiration
d. Progressively increases the length of the
inspiration as tolerated
57. Patient PY has left upper lobectomy
to remove a cancerous lesion. After the
surgery, which of the following is the
most life threatening complication that
Nurse R should monitoring for?
a. Dyspnea due to increased intrathoracic
pressure
b. Hemothorax due to decreased thoracic
drainage
c. Decreased cardiac output due to
mediastinal shift
d. Pneumothorax due to increased
abdominal pressure
58. DY has just regained consciousness
after right pneumonectomy, MY, the
PACU nurse, should do which of the
following now:
a. Assess the pain
b. Remove the airway
c. Encourage the deep breathing exercises
d. Place the DY on his left side
59. What is the most common
complication of myocardial infarction
(MI)?
A. Cardiogenic shock
B. Heart Failure
c. Arrhythmias
d. Pericarditis
60. After recovery from an episode of
acute pulmonary edema, why would an
angiotensin-converting enzyme (ACE)
inhibitor be administered?
a. . To promote diuretics
b. To increase contractility
c. To decrease contractility
d. To reduce blood pressure
61. Acute pulmonary edema caused by
heart failure is usually a result of
damage to which of the following areas
of the heart?
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
62. Which of the following groups of
symptoms indicates a ruptured
abdominal aortic aneurysm?
a. Lower back pain, increased blood
pressure, decreased red blood cell (CBC)
count, increased white blood cell (WBC)
count
b. Severe lower back pain, decreased blood
pressure, decreased RBC count, increased
WBC count
c. Severe lower back pain, decreased blood
pressure, decreased RBC count, Decreased
WBC count
d. Intermittent lower back pain, decreased
blood pressure, decreased RBC count,
Increased WBC count
63. A client with partial and full thickness
burns over 25% of the total body surface
area (TBSA) is hospitalized in the burn
unit. A large bore central venous line is
inserted to permit rapid administration of
fluids and electrolytes. The large
amounts of lactated Ringer’s solution
and 5% dextrose in saline are
administered to:
a. Replace electrolytes lost
b. Maintain blood volume
c. Expand the plasma
d. Prevent fluid shifts
64. When the exposure method of
treatment is used for burns, the nurse
explains to the client that:
a. Bathing will not be permitted
b. Dressing will be changed daily
c. Isolation precautions will be required
while hospitalized
d. Room temperatures should be kept at
minimum of 72˚F
65. A nurse understands that a
temporary heterograft is used to treat
burns because this graft will:
a. Debride necrotic tissue
b. Promote rapid epithelialisation
c. Be sutured in place for better adherence
d. Be used concurrently with a topical
66. A client with burns is progressing
through the emergent/resuscitative
phase of burn care into the acute stage.
Which of the following is a priority for
nursing care during the acute phase of
burns?
a. Care for the burn wounds
b. Promote the client coping with altered
body image
c. Restore maximal functional ability
d. Prevent hypothermia
67. Mr. T’s burns include the face and
neck, whole anterior trunk and anterior
surfaces of both upper arms. Using the
rule of nine, what is the TBSA?
a. 27%
b. 31%
c. 31.5%
d. 27.5%
68. A client has been admitted to the
burn unit with extensive full-thickness
burns. Which of the following
considerations has priority?
a. Fluid status
b. Body image
c. Level of pain
d. Risk of infection
69. The nurse is performing a full
physical examination of the client. Which
of following items is used to test the
function of cranial nerve II (optic):
a. Flashlight
b. Ophthalmoscope
c. Reflex hammer
d. Snellen chart
70. The client with trigeminal neuralgia
asks the nurse what causes the painful
episodes associated with the condition.
The nurse’s response is based on the
understanding that the symptoms can
be triggered by:
a. A local reaction to nasal stuffiness
b. A hypoglycaemic effect in the cranial
nerve
c. Stimulation of the affected nerve by
pressure and temperature
d. Release of catecholamines with infection
or stress
71. A client is receiving a radiation
implant for the treatment of bladder
cancer. Which of the following
interventions is appropriate?
a. Flush all urine down the toilet
b. Restrict the client’s fluid intake
c. Place the client in a semi-private room
d. Monitor the client for signs and
symptoms of cystitis
72. A client had transurethral
prostatectomy for benign hypertrophy.
He’s currently being treated with a
continuous bladder irrigation and is
complaining of an increase in severity of
bladder spasms. Which of the following
interventions should be done first?
a. Administer an oral analgesic
b. Stop the irrigation and call the physician
c. Administer a belladonna and opium
suppository as ordered by the physician
d. Check for the presence of clots, and
make sure the catheter is draining properly
73. Proper maintenance of a continuous
bladder irrigation system includes which
of the following interventions:
a. Regulate irrigant flow to maintain red
urine
b. Regulate irrigant flow to maintain a good
outflow of pink urine
c. Maintain a slow flow rate of irrigant to
prevent bladder distention
d. Stop the irrigation if there is leakage of
large amounts of urine around the catheter.
74. A client is admitted with severe
nausea, vomiting, and diarrhea and is
hypotensive. She’s noted to have severe
oliguria with elevated blood urea
nitrogen (BUN) and creatinine levels.
The physician will likely write an order
for which of the following treatments?
a. Force oral fluids
b. Give furosemide 20mg IV
c. Start hemodialysis after a temporary
access is obtained
d. Start IV fluid or normal saline solution
bolus followed by a maintenance dose
75. A client has a history of chronic renal
failure and receives hemodialysis
treatments three times a week through
arteriovenous (AV) fistula in the left arm.
Which of the following intervention is
included in this client’s care?
a. Keep the AV fistula site dry
b. Keep the AV fistula wrapped in gauze
c. Take the blood pressure in the left arm
d. Assess the AV fistula for a bruit and thrill
76. Which of the following clients is at
greater risk for developing acute renal
failure?
a. A dialysis client who gets influenza
b. A teenager who has an appendectomy
c. A pregnant woman who has a fractured
femur
d. A client with diabetes who has a heart
catheterization
77. Which of the following interventions
would be done for a client with urinary
calculus?
a. Save any calculi larger than 0.25cm
b. Strain the urine, limit oral fluids, give pain
medication
c. Encourage fluid intake, strain the urine,
give pain medication
d. Insert an indwelling urinary catheter,
check intake and output, give pain
medication
78. A client at the eye clinic is newly
diagnosed with glaucoma. Client
teaching includes the need to take his
medication because non-compliance
may lead to which of the following
conditions?
a. Diploma
b. Permanent vision loss
c. Progressive loss of peripheral vision
d. Pupillary constriction
79. Pilocarpine, 2 gtts, QU, Q.I.D.,
should be installed according to which of
the following procedures?
a. 2 drops of the drug in both eyes four
times daily
b. 2 drops on the sclera of the left eye four
times daily
c. 2 drops over the lacrimal duct of the right
eye four times daily
d. 2 drops of the drug toward the nasal side
of each conjunctival sac four times daily
80. A client is diagnosed with Meniere’s
disease. Which of the following nursing
diagnosis take priority following nursing
diagnosis?
a. Ineffective tissue perfusion
b. Imbalance nutrition: more than body
requirements
c. Impaired social interaction
d. Risk for injury
81. When using the Snellen alphabet
chart, the nurse records the client’s
vision as 20/40. Which of the following
statements best describes 20/40 vision?
a. The client has alterations in near vision
and is legally blind
b. The client can see at 20 feet what the
person with normal vision sees at 40 ft
c. The client can see at 40 feet what the
person with normal vision sees at 20 ft
d. A client has a 20% decrease in acuity in
one eye, and 40% decrease in the other eye
82. Which of the following instruments is
used to record intraocular pressure?
a. Goniometer
b. Ophtalmoscope
c. Slit lamp
d. Tonometer
83. Cataract surgery results in aphakia.
Which of the following statements best
describes this term?
a. Absence of the crystalline lens
b. A “keyhole” pupil
c. Loss of accomodation
d. retinal detachment
84. The client has a double-barrel,
transverse colostomy. The nurse has
formulated nursing diagnosis, risk for
impaired skin integrity related to irritation
of the peristoma. The most appropriate
nursing action for this nursing diagnosis:
a. Strict measurement of I and O
b. Assess for bowel sounds when changing
ostomy appliance
c. Wash peristoma, skin with astringent
solution to reduce bacterial contamination
d. Apply skin barrier before applying
colostomy pouch
85. Cirrhosis is known sequela of
hepatitis. Which type of cirrhosis follows
hepatitis?
a. Primary biliary
b. Secondary biliary
c. Laennec’s
d. Post necrotic
86. Functions of the liver that are altered
in the liver cirrhosis are the following,
EXCEPT:
a. CHO, CHON metabolism
b. Storage and contraction of bile
c. Storage of vitamin ADEK and B12
d. Formation of prothrombin, fibrinogen and
other clotting factors
87. A client is admitted to the post
anesthesia care unit after an abdominal
hysterectomy. The observation that
should be reported to the physician
immediately is:
a. An apical of 90
b. Increased drainage from NGT
c. A decreased urinary output
d. Serosanguinous drainage on the
peritoneal pad.
88. After administering the atropine SO4
pre-operatively, the nurse should be
particularly observant for the occurrence
of:
a. Polyuria
b. Diarrhea
c. Murmurs
d. Tachycardia
89. Before cholecystectomy, the MD
ordered to modify the diet. The nurse
understands that the cholecystitis:
a. Soft-textured food are used to reduce the
digestive burden
b. Low cholesterol foods are used to avoid
further formation of gallstones
c. Fat is decreased to avoid stimulation of
the cholecystokinin mechanism
d. Increase CHON and calories are needed
to promote tissue healing and provide
energy
90. Immediately after cholecystectomy,
the nursing action that should assume
the highest priority is:
a. Encouraging the client to take adequate
fluids by mount
b. Encouraging the client to cough and deep
breathe
c. Changing the dressing at least BID
d. Irrigating the T-tube frequently
91. Clients with osteoarthritis may be on
bed rest for prolonged periods. Which of
the following nursing interventions would
be appropriate for these clients?
a. Encourage coughing and deep breathing
and limit fluid intake
b. Provide only passive range of motion
(ROM), and decreased stimulation
c. Have a client lie as still as possible, and
give adequate pain medicine
d. Turn the client every 2 hours, and
encourage coughing and deep breathing
92. Which of the following symptoms is
an early sign of compartment
syndrome?
a. Heat
b. Paresthesia
c. skin pallor
d. Swelling
93. Which of the following areas could
be included in a neurovascular
assessment?
a. Orientation, movement, pulses, warmth
b. Capillary refill, movement, pulses, warmth
c. Orientation, papillary response,
temperature, pulses
d. Respiratory pattern, orientation, pulses,
temperature
94. A client describes a foul odor from
his cast. Which of the following
responses or interventions would be
most appropriate?
a. Assess further because this may be a
sign of infection
b. Teach him proper cast care, including
hygienic measures
c. He is normal, especially when a cast is in
place for a few weeks
d. Assess further because this may be a
sign of neurovascular compromise
95. A client asks why a cast can’t get
wet. Which of the following responses
would be most appropriate?
a. A wet cast can cause a foul odor
b. A wet cast will weaken or be destroyed
c. A wet cast is heavy and difficult to
maneuver
d. It’s all right to get the cast wet, just use a
hair dryer to dry it off
96. Which of the following signs and
symptoms can occur with fat emboli?
a. Tachypnea, tachycardia, shortness of
breath, paresthesia
b. Paresthesia, bradypnea, bradycardia,
petechial rash on chest and neck
c. Bradypnea, bradycardia, shortness of
breath, petechial rash on chest and neck
d. Tachypnea, tachycardia, shortness of
breath, petechial rash on chest and neck
97. Vitamin D intake is important in the
healing of fracture for which of the
following reason?
a. It reduces the excretion of calcium and
phosphorus
b. It increases the excretion of calcium and
phosphorus
c. It reduces the absorption and use of
calcium and phosphorus
d. It increases the absorption and use of
calcium and phosphorus
98. A nurse receives endorsement in the
morning. She prioritizes which of the
following clients first?
a. 58 years old requesting pain medication
for abdominal incision pain rated at 6 on a
pain scale of 10
b. 44 year old asking about draining a
Jackson-Pratt drain
c. 35 year old client for intersection of NGT
and connect to bedside bottle
d. 76 year old client with thrombocytopenia
with episodes of confusion
99. A nurse in the triage area of an
emergency department should assign
the highest priority to:
a. A 4 year old with asthma who has
diminished wheezing is pale and very
irritable
b. A 1 year old who has had vomiting and
diarrhea for 2 days and has slightly
depressed anterior fontanel
c. A 6 year old who fell off her bike and has
several lower extremity lacerations that
require suturing
d. A 7 month old rolled off a chair onto a
carpeted floor hitting his head but not losing
consciousness

100. The nurse is teaching a group of

women to perform breast self-
examination. The nurse should explain
that the main purpose of performing this
examination is to discover:
a. Changes from previous self-examinations
b. Fibrocystic masses
c. Areas of thickness or fullness
d. Cancerous lumps