b.

Glomerulus to withhold the proteins from the

urine
MASTERY TEST 2 ON MS 1
c. Nephron tubules to reabsorb glucose
Situation: Patients with Pituitary Disorders
d. Nephron tubules to reabsorb water
1. All of the following are secreted by the
anterior pituitary gland except: 5. A patient diagnosed with SIADH will
manifest the following manifestations, EXCEPT:
1 point
1 point
a. Somatotropin/growth hormone
a. Weight gain
b. Follicle stimulating hormone
b. Low urine specific gravity
c. Thyroid stimulating hormone
c. Hypertension
d. Gonadotropin hormone releasing hormone
d. Hypernatremia
2. The assessment that would be most
indicative of diabetes insipidus is: 6. Another patient was diagnosed with
acromegaly secondary to a pituitary tumor.
1 point
Which of the following nursing diagnosis is a
a. Decreased serum osmolarity priority for the said patient?

b. Elevation of blood pressure 1 point

c. Decreased urine concentration a. Disturbed body image

d. Increased blood glucose b. Ineffective individual coping

3. The nurse knows that the above client c. Self-care deficit

will receive which of the following medications:
d. Risk for injury
1 point
7. The client eventually underwent
a. Demeclocycline removal of pituitary tumor. Which of the
following are nursing considerations after the
b. Octreotide surgery?
c. Pitressin 1 point
d. Lithium carbonate a. Place the client in side-lying position to
4. Normally the antidiuretic hormone prevent aspiration
(ADH) influences kidney function by stimulating b. Restrain the patient if he becomes restless
the: after awakening
1 point c. Dim the lights on the patient’s room
a. Glomerulus to control the quantity of fluid d. Suction secretions as necessary to maintain
passing through it patent airway

Situation: Patients with Thyroid Disorders

8. A patient was admitted to the hospital 11. You are caring for Johnny who is
with hyperthyroidism. Prophylthiouracil (PTU) scheduled to undergo total thyroidectomy
was prescribed. What is the purpose of giving because of thyroid cancer. Prior to total
this drug at this time? thyroidectomy, you should instruct Johnny to:

1 point 1 point

a. To achieve euthyroid state a. Perform range of motion exercises on the

head and neck
b. To stimulate the production of thyroid
hormone b. Apply gentle pressure against the incision
when swallowing
c. To prevent over production of thyroxine
c. Cough and deep breathe every 2 hours
d. To replace thyroid hormone
d. Support head with the hands when changing
9. Pharmacological treatment was not
position
effective for the patient’s hyperthyroidism and
now, he is scheduled for thyroidectomy. Pre- 12. Which of the following nursing
operative teaching of patient for thyroidectomy, interventions is appropriate after a total
excludes: thyroidectomy?

1 point 1 point

a. Advising her to cough and expectorate a. Place pillows under your patient's shoulders
secretions freely
b. Raise the knee-gatch to 30 degrees
b. Showing her how to brace her head and neck
c. Keep your patient in a high-fowler's position
with her hands
d. Support the patient's head and neck with
c. Explaining that she has to remain in bed for
pillows and sandbags
the immediate anesthesia period
13. If there is an accidental injury to the
d. Emphasizing the importance and head
parathyroid gland during a thyroidectomy,
turning exercise
which ofthe following might the patient develop
10. Strong iodine solution was ordered for a postoperatively?
patient before thyroidectomy in order to:
1 point
1 point
a. Cardiac arrest
a. Increase the tone of myocardial and skeletal
b. Dyspnea
muscles
c. Respiratory failure
b. Interfere with transmission of nervous
impulses d. Tetany
c. Accelerate glycogen storage in the liver and 14. After surgery the patient develops
muscles peripheral numbness, tingling and muscle
twitching and spasm. What would you
d. Decrease the size and vascularity of the
anticipate to administer?
thyroid gland
1 point d. Levophed

a. Magnesium sulfate 18. Your appropriate nursing diagnosis for

Zeny who is suffering from hypothyroidism
b. Calcium gluconate
would probably include which of the following.
c. Potassium iodide
1 point
d. Potassium chloride
a. Activity intolerance related tiredness
15. Another patient has undergone subtotal associated disorder
thyroidectomy. Which of the following
b. Risk to injury related to incomplete eyelid
indicatescomplication after surgery
closure
1 point
c. Imbalanced nutrition related to
a. Fasciculations. chest pain hypermetabolism

b. Intermittent claudication d. Deficient fluid volume related to diarrhea

c. Positive Scarf sign 19. Myxedema coma is a life threatening

complication of long standing and untreated
d. Irritability, tetany, spasms hypothyroidism with one of the following
16. You were on duty at the medical ward characteristics:
when Zeny came in for admission for tiredness, 1 point
cold intolerance, constipation, and weight gain.
Upon examination, the doctor's diagnosis was a. Hyperglycemia
hypothyroidism. Your independent nursing care
b. Hypothermia
for hypothyroidism include:
c. Hyperthermia
1 point
d. Hypoglycemia
a. Administer sedative round the clock
20. A client has a history of myxedema.
b. Administer thyroid hormone replacement
When performing a physical assessment the
c. Providing cool, quite, comfortable nurse would expect the client’s skin to be:
environment
1 point
d. Encourage to drink 6-8 glasses of water
a. Dry and flaky.
17. As the nurse, you should anticipate to
b. Warm and moist
administer which of the following medications
to Zeny who is diagnosed to be suffering from c. Flushed and dry.
hypothyroidism?
d. Smooth and silky
1 point
Situation: Patients with Adrenal Disorders
a. Levothyroxine
21. A client with hyperaldosteronism is
b. Lidocaine being discharged from the hospital. Dietary

c. Lipitor
discharge instructions by the nurse include d. Increased extracellular fluid volume
decreasing dietary:
25. The following are nursing
1 point responsibilities when administering steroids,
except:
a. Protein
1 point
b. Carbohydrates
a. Restrict sodium intake
c. Potassium
b. Administer the drug before meal
d. Sodium
c. Measure and record intake and output
22. A client is admitted with a diagnosis of
chronic adrenal insufficiency. Because of this d. Withdrawal of the drug should be done
condition, it would be unwise to place the client gradually
in a room:
26. A patient Cushing’s disease may
1 point manifest the following signs and symptoms,
except:
a. With an elderly client who has CVA
1 point
b. With middle-aged client who has pneumonia
a. Hypertension
c. Next to 17-year old with a fractures leg
b. Buffalo hump
d. That is private away from nurse’s station
c. Truncal obesity
23. The patient has been diagnosed to have
Addison’s disease. Which of the following is d. Hypoglycemia
least likely to be experienced by the patient?
27. When caring for a patient with
1 point Cushing’s syndrome, it’s important to monitor
the laboratory reports for hypokalemia,
a. Dehydration
hypocalcemia, and
b. Hypotension
1 point
c. Hypokalemia
a. Hypoglycemia
d. Bronze appearance of the skin
b. Hypernatremia
24. A client with adrenal insufficiency
c. Hyponatremia
complains of weakness and dizziness on arising
from bed in the morning. The nurse realizes d. Hypochloridemia
that this is most probably caused by:
28. When observing a client for cortisone
1 point overdose, the nurse should be particularly alert
for:
a. A lack of potassium
1 point
b. Postural hypertension
a. Hypoglycemia
c. A hypoglycemic reaction
b. Anaphylactic shock 32. A client with diabetes mellitus asks how
exercise will affect insulin and dietary needs.
c. Severe anorexia
The nurse should review how exercise:
d. Behavioral changes
1 point
Situation: Patients with Diabetes Mellitus
a. Increase the need for insulin and increase
29. If a patient has insulin reaction, the the need for carbohydrates
immediate reaction of the nurse is to give the
b. Decrease the need for insulin and decrease
patient the following except:
the need for carbohydrates
1 point
c. Increase the need for carbohydrates and
a. A glass of orange juice decrease the need for insulin

b. 5 ml of honey d. Decrease the need for carbohydrates but

does not affect the need for insulin
c. A chocolate
33. Emergency management for
d. 3 oz of soft drink hyperinsulinism is the administration of:
30. The client with diabetes mellitus 1 point
developed diabetes ketoacidosis. Which of the
following results of laboratory tests should the a. Glucose intravenously
nurse not expect?
b. Regular insulin SC
1 point
c. Adrenalin IM
a. Elevated serum glucose
d. Resume O2 inhalation
b. Increased acidity
34. Instructions for foot care to a patient
c. Low carbon dioxide with diabetes mellitus should include the
following, except:
d. High carbon dioxide
1 point
31. At 4:30 PM a client who has been
receiving Humulin N insulin every morning state a. Wear properly fitting shoes
“I feel very nervous.” The nurse observes that
b. Massage feet
the client’s skin is moist and cool. The most
accurate interpretation of these finding would c. Wash feet daily, dry thoroughly and gently
be.
d. Remove ingrown and file nails
1 point
35. The best parameter to monitor long-
a. Polydipsia term adherence to the diabetic regimen is:

b. Ketoacidosis 1 point

c. Glycogenesis a. Hemaglucotest

d. Hypoglycemia b. Glucose tolerance test

c. Glycosylated hemoglobin determination
d. Clinitest
36. A patient with non-insulin dependent
diabetes mellitus is receiving an oral
hypoglycemic agent. The mother asks the nurse
why it is given. The nurse is correct when she
says:
1 point
a. It stimulates the pancreas to produce insulin
b. It prevents occurrence of hyperglycemia
c. It decreases dependence on insulin
d. It is an oral insulin preparation
37. Oral hypoglycemic agents are
prescribed for patients with DM. Metformin
acts bydecreasing production of glucose in the
liver. Which of the following signs is indicative
ofMetformin toxicity?
1 point
a. Hyperthermia
b. Decreasing LOC or unusual somnolence
c. Tachycardia
d. Increased urine specific gravity
38. A client with IDDM is being considered
for the tight-control program. In determining if
the client is a candidate for this program, the
nurse and health care team evaluate the:
1 point
a. Client's daily dietary requirements
b. Client's family support system
c. Client's previous compliance history
d. Length of time the client has had DM
39. The nurse is performing health
education activities for Natalia Segovia, a 30
year old dentist with insulin dependent diabetes
mellitus.
1 point
a. Lantus
b. NPH
c. HR
d. HN
40. Natalia is preparing a mixed dose of
insulin The nurse is satisfied with her
performance when she:
1 point
a. Draw insulin from the vial of clear insulin first
b. Draw insulin from the vial of the intermediate
acting insulin first
c. Fill both syringes with the prescribed insulin
dosage then shake the bottle vigorously
d. Withdraw the intermediate acting insulin
before withdrawing the short acting insulin
41. Natalia complains of nausea vomiting,
diaphoresis and headache which of the
following nursing intervention are you going to
carry out first?
1 point
a. Withhold the client's next insulin injection
b. Test the client's blood glucose level
c. Administer Tylenol as ordered
d. Offer fruit juice, gelatin and chicken bouillon
42. Natalia administered regular insulin at 7
am and the nurse should instruct Natalia to
avoid exercising at around:
1 point
a. 9 to 11 am
b. After 8 hours
c. Between 8 to 9 am
d. In the afternoon after taking lunch
43. Natalia was brought at the emergency
room after four months because she fainted in
her clinic. The nurse should monitor of the
following test to evaluate the overall
therapeutic compliance of a diabetic patient?
1 point
a. Glycosylated hemoglobin
b. Fasting blood glucose
c. Ketone bodies
d. Urine glucose level
44. Upon the assessment of the HbA1c of
Mrs. Segovia the nurse has been informed of a
9% result In this case, she will teach the patient
to:
1 point
a. Avoid infection
b. Take adequate food and nutrition
c. Prevent and recognize hyperglycemia
d. Prevent and recognize hypoglycemia
45. The nurse is teaching plan of care for
Natalia with regards to proper foot care.
Which of the following should be included in
the plan?
1 point
a. Soak feet in hot water
b. Avoid using mild soap on the feet
c. Apply a moisturizing lotion to dry feet but not
between the toes
d. Always have podiatrist to cut your toe nails
and never cut them yourself
46. Another patient was brought to the
emergency room in an unresponsive state and a
diagnosis of hyperglycemic hyperosmolar non-
ketonic syndrome is made The nurse
immediately prepares to initiate which of the
following anticipated treatments?
1 point
a. dilated urethra
b. 100 units of NPH insulin
c. Intravenous infusion of normal saline
d. Intravenous infusion of sodium bicarbonate
47. The nurse teaches Natalia to know the
difference between hypoglycemia and
ketoacidosis Natalia demonstrates
understanding of the teaching by stating that
glucose will be taken if which of the following
symptoms develops?
1 point
a. Polyuria
b. Shakiness
c. Blurred vision
d. Bad breath odor
48. Nursing intervention for a patient on
low dose IV insulin therapy includes the
following except:
1 point
a. Elevation of serum ketones to monitor
ketosis
b. Vital signs including BP
c. Estimate serum potassium
d. Elevation of blood glucose
49. Multiple-vial-dose insulin when in use
should be:
1 point
a. Kept at room temperature
b. Kept in the refrigerator
c. Kept in narcotic cabinet
d. Store in the freezer
50. Mr. Tomas, a type I diabetic client is on
insulin therapy. To avoid lipodystrophy, the
nurse should teach the client to do which of the
following?
1 point
1. Exercise regularly.
2. Massage the injection site.
3. Inject insulin at room temperature.
4. Rotate injection sites.
a. 1, 2 only
b. 3, 4 only
c. 1, 3, 4
d. 2, 3, 4
51. Management of dumping syndrome is
best accomplished by planning to maintain the
client on a:
1 point
a. Low-residue, bland diet.
b. Fluid intake below 500 ml.
c. Small frequent feedings schedule.
d. Low protein, high carbohydrate diet.
52. The physician orders cimetidine
(Tagamet) for a client with dyspepsia. The nurse
should teach that this drug acts by:
1 point
a. Lowering the stress level.
b. Neutralizing gastric acidity.
c. Decreasing gastric motor activity.
d. Diminishing gastric secretion in the stomach.
53. A client with severe gastritis vomits a
large amount of blood and a lavage is
performed. A room temperature irrigating
solution is used to produce:
1 point
a. Coagulation of blood
b. Constriction of blood vessels
c. Neutralization of acids
d. Stimulation of vagus nerve
54. Following the surgery for a colostomy, the
most effective way of helping a client accept the
colostomy would be to:
1 point
a. Begin to teach self-care of the colostomy
immediately.
b. Provide literature containing factual data
about colostomies.
c. Contact a member of a support group to
come and speak with the client.
d. Point out the number of important people
who have had colostomies.
55. Which of the following statements
indicates that the client understands the dietary
modifications he will need to follow at home to
avoid exacerbation of his ulcer condition?
1 point
a. “ I should eat a bland, soft diet”
b. “It is important to eat six small meals a day.”
c. “I should drink several glasses of milk a day.”
d. “I should avoid alcohol and caffeine.
SITUATION: Mrs. Goons, 58years-old, was
admitted with the chief complaint of change in
bowel habit. Proctosigmoidoscopy was done
and revealed the absence of a rectal mass.
56. The following are nursing responsibilities
prior to proctosigmoidoscopy,
1 point
1. Place the client on NPO from midnight
2. Administer castor oil 40cc if not
contraindicated
3. Do cleansing enema in early morning
4. Note for any history of allergy to seafoods
since a dye will be installed through scope
A. 1, 2, 3
B. 1, 2, 4
C. 1, 3, 4
D. All of the above
SITUATION: Several days after, the client was
scheduled for an abdominal-perineal resection
(APR)
57. Which of the following statements will best
described the above surgery?
1 point
1. The sigmoid colon is removed through as
abdominal incision and the rectum is removed
through a perineal
Incision.
2. A permanent, single-barreled colostomy is
created to provide an outlet for fecal waste.
3. A segment of the bowel is brought to the
abdomen and sutured, to serve as a temporary
colostomy
4. A loop colostomy is performed to divert fecal
flow away from operative area
A. 1, 3
B. 2, 3
C. 2,4
D. 1,2
58. Which of the following nursing interventions
is least likely to be included in the care of the
client with appendicitis?
1 point
A. Keep on NPO untill further order
B. Administer laxative to promote defecation
C. Maintain bed rest to reduce peristalsis
D. Monitor Laboratory result
59. After appendectomy under spinal
anesthesia, the following are appropriate
nursing interventions, EXCEPT:
1 point
A. Place in semi- fowler’s position during
immediate post to facilitate lung expansion
B. Keep on NPO until peristalsis return
C. Note for the time of return of sensation in
the lower extremities
D. Ambulate after 24 hours
Situation : A 55 year-old male client sought
admission to Medical Center for pain and
discomfort. The admitting physician noted "a
typical peptic ulcer case."
60. The nurse took the history and initial
assessment. Which pain description best
describes that of a client suffering from peptic
ulcer?
1 point
A. The pain tends to recur at intervals of hours
to days
B. Pain is felt near the midline in the B. Nausea and vomiting
epigastrium radiating to the back
C. Blood in the stool
C. The pain is periumbilical and felt in-between
D. Numbness in the legs
meals
64. The client is ordered Ranitidine (Zantax)
D. The pain is gnawing, burning ussually
300 mg once daily. For greatest protection of
rhythmic the stomach is empty
the gastric mucosa, the nurse gives the drug at
61. The client claims that he has been very which time schedule?
careful not to miss a meal and avoiding highly
1 point
seasoned foods. He inquires which could have
been the cause of his disease. The nurse cites A. Before dinner
the two most common cause of peptic ulcer.
Identify these causes. 1) H. pylori infection 2) B. After lunch
Playing mahjong 3) Genetic predisposition 4) C. At bedtime
Non Steroidal Anti-Inflammatory Drugs intake 5)
Dietary indiscretions. D. Before breakfast

1 point 65. A client has a diagnosis of acute

cholecystitis with biliary colic. In addition to
A. 1 and 5 pain in the right upper quadrant, the nurse
B. 2 and 3 should expect the client to have:

C. 3 and 4 1 point

D. 1 and 4 a. Melena and diarrhea

62. The medication history of the client b. Vomiting of coffee–ground emesis

reveals intermittent use of several medications. c. An intolerance to foods high in lipids
The nurse would teach the client to avoid which
of the following medications? d. Gnawing pain when the stomach is empty

1 point 66. Following a cholecystectomy, Mrs.

Santillan should be assessed for signs of
A. Sucrafate (Carafate) bleeding or hemorrhage. These observations
B. Omepazole (Pilosec) are made because:

C. Ibuprofen (Motrin) 1 point

D. Nizatidine (Axid) a. Prostaglandins are released at the surgical

site
63. The doctor's order reads "Monitor for
signs of perforation". Which assessment b. The inflammatory process interferes with
findings of the nurse would indicate perforation platelet formation
of the ulcer? c. Diaphragmatic excursion places pressure on
1 point the suture line

A. A rigid broadlike abdomen

d. Blood clotting may be hindered by lack of
vitamin K absorption
67. A client has a T-tube in place following a
cholecystectomy and a choledochostomy. A T-
tube is inserted primarily to:
1 point
a. Drain bile from the cystic duct
b. Keep the common bile duct patent
c. Prevent abscess formation at the surgical site
d. Provide a port for contrast dye in a
Cholangiogram
68. When caring for a client 8 hours
following the surgical creation of a colostomy,
the observation that would be considered
normal is:
1 point
a. The presence of hyperactive bowel sounds.
b. The absence of drainage from the colostomy.
c. A dusky-colored edematous appearance
d. Bright bloody drainage from the colostomy
Situation: Mr. Serrano, 50 years old, has had a
significant problem with alcohol abuse for 15
years. He is brought to the ER because he is
increasingly confused and is vomiting. His
diagnosis is cirrhosis of the liver. He has ascites
and esophageal varices.
69. The doctor has orders for Sengstaken
Blakemore tube to be inserted. The purpose of
this procedure is to:
1 point
a. apply direct pressure to bleeding ulcers
b. apply indirect pressure to bleeding ulcers via
the esophagus
c. decrease the blood supply to the cardiac
sphincter of the stomach
d. apply direct pressure to the esophagus and
cardiac sphincter
CHRONIC OBSTRUCTIVE PULMONARY DISEASES
70. COPD is characterized by all of the
following except:
1 point
a. affects mostly males above 45 years old
b. chronic inflammation is one of the underlying
pathologic mechanism
c. cigarette smoking is the only risk factor
d. bronchodilators is the mainstay of treatment
71. Auscultating the lungs of an asthmatic
client, the nurse notes no inspiratory wheezing,
which would suggest:
1 point
a. airway constriction requiring intensive
interventions.
b. an appropriate reaction to the medications
used in the client’s management.
c. the need to assess further for manifestations
of a pleural effusion.
d. overuse of the intercostal muscles resulting
in poor air exchange.
72. The nurse is caring for a client who is
experiencing an acute asthmatic attack. He is
dyspneic and experiencing orthopnea; his PR is
120beats/min. In what order will the nurse
provide care to this client?
1 point
1. administer humidified oxygen
2. place in semi-upright position
3. provide nebulizer treatment with
bronchodilator
4. discuss factors that precipitate attack.
a. 1,2,3,4
b. 2,4,1,3
c. 2,1,3,4
d. 3,2,1,4
73. You are the ER nurse assigned to a
COPD patient in exacerbation. The medical
resident ordered bronchodilator nebulization
every 15min. for 3 doses then every hour
thereafter. You expect the following while on
inhalation therapy except:
1 point
a. less wheezing on auscultation
b. alteration in sensorium
c. loosening of secretions
d. tachycardia
74. A client receiving prednisone for
treatment of asthma should be monitored for
which of the following adverse effects:
1 point
a. hyperkalemia, hypotension and edema
b. moon facies, hirsutism and weight loss
c. weight gain, elevated sodium levels and
edema
d. gastric irritation, congestion and hypotension
75. The nurse would coach the asthmatic
client in pursed-lip breathing because this
technique provides which of the following?
1 point
a. increases pressure in the airway.
b. decreases drying of the mucous membranes.
c. increases oxygenation.
d. decreases anxiety by distraction.
76. A client arrives at the emergency room
with complains of severe dyspnea after cleaning
her apartment. PE revealed nasal flaring,
subcostal retractions, wheezes, and O2
saturation of 80%. What action should the
nurse take to initiate care to the patient?
1 point
a. Provide oxygen therapy and reassess client in
10min.
b. Draw blood samples for arterial blood gas
c. Encourage the client to relax and breathe
slowly through the mouth
d. Administer bronchodilator therapy as
ordered
You are the ER nurse on duty when Agatha, 38-
year-old, 10 pack-year smoker, came in because
of dyspnea. History started 5 days prior when
she started to experience cough mostly
occurring at night and wheezing. She self-
medicated with antibiotics and continued to
report to work as a bank teller. However,
symptoms persisted until 1 day prior to
admission she experienced dyspnea on exertion
and severe wheezing. PE revealed: conscious,
speaks in phrases, with alar flaring, intercostal
and subcostal retractions. VS are as follows: BP
130/98, HR 110 and RR 32.
77. Based on your assessment, your nursing
care plan is for a patient with:
1 point
a. COPD
b. Community-Acquired Pneumonia
c. Bronchial asthma
d. Acute bronchitis
78. The most important nursing diagnosis
for this patient that need immediate
intervention is:
1 point
a. risk for activity intolerance
b. impaired ventilation related to airway
inflammation
c. pain related to inflammation of the lung
tissue
d. altered nutrition related to excessive
secretions
79. Based on the above findings, what
action should you take to initiate care of your
patient:
1 point
A. Provide oxygen therapy and reassess client in
10min.
B. draw blood samples for arterial blood gas
C. encourage the client to relax and breathe
slowly through the mouth
D. administer bronchodilator therapy as
ordered
80. Which of the following arterial blood
gases might reflect an individual with
uncompensated respiratory acidosis due to
emphysema?
1 point
a. pH 7.50 PaCO2 40 HCO3 32
b. pH 7.20 PaCO2 60 HCO3 24
c. pH 7.38 PaCO2 40 HCO3 24
d. pH 7.35 PaCO2 50 HCO3 28
81. On discharge from the hospital to
home, outcome criteria for the client with COPD
would include that he
1 point
a. Promise to do pursed lip breathing at home.
b. States action to9 reduced pain caused by the
disease process.
c. Exhibits temperature not exceeding 100o F.
d. Agrees to call the physician if dyspnea on
exertion increases.
CLUSTER: PLEURAL DISORDERS
82. Nurse Jane of the ER department is
assessing a client who sustained a blunt injury
to the chest wall. Which of the following
indicates presence of pneumothorax?
1 point
a. Sucking wound on the site of injury
b. Diminished breath sounds
c. Low respiratory rate
d. Barrel chest deformity
83. In a client with pleural effusion, the
nurse is instructing appropriate breathing
technique. Which of the following is included in
teaching?
1 point
a. Inhale slowly and hold breath for 3 to 5
seconds after each inhalation
b. Practice abdominal breathing
c. Breath normally
d. Hold the breath after each inspiration for 1
full minute
84. A client is about to have a chest tube
inserted in the left upper chest. When the tube
is inserted. It begins to drain a large amount of
serosanguineous fluid. Which of the following
explanations best describes what caused this?
1 point
a. The chest tube was inserted improperly 1 point

b. This always happens when a chest tube is a. Bronchial sounds heard at both bases
inserted
b. Vesicular sounds heard over upper lung fields
c. An artery was nicked when the chest tube
c. Bronchovesicular sounds heard over both
was placed
lung fields
d. The client had hemothorax instead of a
d. Crackles head on the affected side
pneumothorax
88. The above client with chest tubes is
85. A hospitalized client needs a central IV
now transferred to the unit. The first nursing
catherer inserted. The physician places the
measure concerning the closed chest drainage
catheter in the subclavian vein. Shortly
system is:
afterward, the client develops shortness of
breath and appears restless. Which of the 1 point
following actions would the nurse do first?
a. Milking the tubing to prevent accumulation of
1 point fibrin and clots
a. Administer a sedative b. Raising the bottle to bed height to accurately
assess the meniscus level
b. Advise the client to calm down
c. Attaching the chest tubes to the bed linen to
c. Auscultate breath sounds
ensure that airflow and drainage are
d. Check to see if the client can have medication unhindered by kinks

86. Following the diagnosis of Left d. Marking the time and the amount of drainage
Pneumothorax, the physician ordered for a 3 - in the collection bottle
bottle chest drainage system. On his rounds,
89. The nurse auscultates scattered crackles
Nurse Ulysses noted that the bottle had cracks.
bilaterally on a client with CTT. Which of the
In this situation, it would be appropriate to do
following interventions would be most
which of the following nursing actions?
appropriate?
1 point
1 point
a. Remove the tube from the patient’s chest
a. Check the water-seal system
and cover with vaselinized gauze
b. Encourage deep breathing and ambulation as
b. Clamp the chest tube near the patient’s
soon as the client is able
thorax
c. Perform suctioning once per shift and ask the
c. Provide another suction machine and
physician to order an expectorant
attached the tube
d. Reduce the frequency of pain medication and
d. Place the end of the connecting tube into
increase the suction in the water-seal bottle
container of sterile water
90. Dr. Jimenez asked you to assist him with
87. Which of the following results shows
the removal of Mocha’s chest tube. You would
that a chest tube insertion was done correctly?
instruct the client to:
1 point
a. Continuously breathe normally during the
removal of the chest tube
b. Take a deep breath, exhale and bear down
c. Exhale upon actual removal of the tube
d. Hold until the chest tube is pulled out
91. Peter, a 60-year old male patient
diagnosed with lung cancer, underwent
pneumonectomy. On which of the following
positions should you place the patient post-
operatively?
1 point
a. On his abdomen or on the side opposite the
surgery
b. On his back or on the side of surgery
c. Any position is acceptable
d. Prone position
92. Following a thoracentesis procedure, it
would be appropriate to position the client
considering all of the following except?
1 point
a. Lying on the unaffected side with head of bed
at 30-40 angle
b. Lying prone with head elevated at 15-30
angle
c. Sitting on the edge of the bed with feet
supported and arms and head rested on a
padded overbed table.
d. Sitting on chair with head resting on back of
the chair.
93. Thoracentesis is performed to the client
with effusion. The nurse knows that the
removal of fluid should be slow. Rapid removal
of fluid in thoracentesis might cause:
1 point
a. Hypertension
b. Cardiovascular collapse
c. Pneumothorax
d. Pleurisy or pleuritis
94. Which of the following measures to
prevent pulmonary embolism after lower
extremity surgery is best?
1 point
a. Early ambulation
b. Frequent chest x-rays to find an embolism
c. Frequent lower extremity scans
d. Intubation of the client
95. A client has experienced pulmonary
embolism. A nurse assesses for which symptom,
which is most commonly reported?
1 point
a. Dyspnea when deep breaths are taken
b. Hot flushed feeling
c. Sudden chills and fever
d. Chest Pain that occurs suddenly
96. A client with a pulmonary embolus has
been medicated for pain but appears anxious
and restless. The additional nursing measure
that most likely would assist the client in
dealing with fear is
1 point
a. reassuring the client that the pain medication
will be effective in 30 minutes.
b. asking the client not to focus on the pain.
c. explaining the monitoring devices to the
client.
d. remaining at the bedside with the client.
97. A 50-year old patient was admitted due
to bacterial pneumonia. An order to collect
sputum specimen for culture and gram stain
was endorsed. What critical instruction would
you give to the client before collection of the
specimen?
1 point
a. Obtain the specimen in the morning after first
meal
100. A Nurse performs an assessment on a
client with acute pulmonary edema and notes
the following: severe dyspnea; tachypnea;
hyperpnea; expectoration of large amounts of
frothy, blood-tinged sputum; wheezing; diffuse
crackles bilaterally on lung auscultation;
extreme restlessness; and confusion. Arterial
blood gas measurements are prescribed. The
Nurse would expect that the arterial blood gas
values indicate:
1 point

b. Normal salt solution gargle A. Respiratory acidosis

c. Warm water gargle B. Respiratory alkalosis

d. Antiseptic mouthwash C. Metabolic acidosis

98. Based on the initial assessment, the D. Metabolic alkalosis

priority nursing diagnosis is "Ineffective
ANSWERS:
breathing related to chest pain." Relevant
nursing intervention would all the following 1. B
EXCEPT: 2. C
3. C
1 point
4. D
a. Suctioning prn 5. C
6. A
b. Frequent changes in position 7. A
c. Increase fluid intake 8. A
9. B
d. Use of cough suppressant round the clock 10. D
99. During the surgery the FS results 11. D
revealed squamous cell carcinoma and 12. D
lobectomy was then performed. The Physician 13. D
placed a chest tube on the left side to : 14. B
15. D
1 point 16. C
17. A
a. Prevent pneumothorax on the affected lung
18. A
b. Prevent hemothorax on the affected lung 19. B
20. A
c. Prevent accumulation of air and blood or pus
21. D
on the affected side
22. B
d. Prevent accumulation of air and blood on the 23. C
unaffected side 24. B
25. B 69. D
26. D 70. C
27. B 71. D
28. A 72. A
29. A 73. D
30. A 74. B
31. D 75. C
32. C 76. D
33. A 77. A
34. D 78. B
35. C 79. D
36. A 80. B
37. C 81. D
38. C 82. A
39. D 83. B
40. A 84. B
41. B 85. D
42. A 86. D
43. A 87. C
44. D 88. D
45. D 89. A
46. B 90. B
47. A 91. A
48. D 92. B
49. A 93. C
50. B 94. A
51. C 95. D
52. D 96. D
53. C 97. C
54. A 98. A
55. D 99. C
56. D 100. A
57. D
58. B
59. B
60. D
61. D
62. C
63. A
64. D
65. C
66. C
67. A
68. C