1

Below are the nursing bullets for Medical-Surgical 11. Otosclerosis is characterized by replacement of
Nursing. normal bones by spongy and highly vascularized
1. Bone scan is done by injecting radioisotope per IV bones.Eyes and Ears
and then x-rays are taken.
2. To prevent edema on the site of sprain, apply cold 12. Use of high-pitched voice is inappropriate for the
compress on the area for the first 24 hours. client with hearing impairment.
3. To turn the client after lumbar Laminectomy, use
the logrolling technique. 13. Rinne’s test compares air conduction with bone
4. Carpal tunnel syndrome occurs due to the injury of conduction.
median nerve.
5. Massaging the back of the head is specifically 14. Vertigo is the most characteristic manifestation of
important for the client with Crutchfield tong. Meniere’s disease.
6. A one-year-old child has a fracture of the left
15. Low sodium is the diet for a client with Meniere’s
femur. He is placed in Bryant’s traction. The reason
disease.
for elevation of
his both legs at 90º angle is his weight isn’t adequate 16. A client who had cataract surgery should taught
to provide sufficient countertraction, so his entire to call his MD if he has eye pain.
body must
Below are the nursing bullets for Medical-Surgical 17. Risk for Injury takes priority for a client with
Nursing. Meniere’s disease.
1. Bone scan is done by injecting radioisotope per IV
and then x-rays are taken. 18. Irrigate the eye with sterile saline is the priority
2. To prevent edema on the site of sprain, apply cold nursing intervention when the client has a foreign
compress on the area for the first 24 hours. body protruding from the eye.
3. To turn the client after lumbar Laminectomy, use
the logrolling technique. 19. Snellen’s Test assesses visual acuity.
4. Carpal tunnel syndrome occurs due to the injury of
median nerve. 20. Presbyopia is an eye disorder characterized by
5. Massaging the back of the head is specifically lessening of the effective powers of accommodation.
important for the client with Crutchfield tong.
21. The primary problem in cataract is blurring of
6. A one-year-old child has a fracture of the left
femur. He is placed in Bryant’s traction. The reason vision.
for elevation of 22. The primary reason for performing iridectomy
his both legs at 90º angle is his weight isn’t adequate
after cataract extraction is to prevent secondary
to provide sufficient countertraction, so his entire
glaucoma.
body must
Below are the nursing bullets for Medical-Surgical 23. In acute glaucoma, the obstruction of the flow of
Nursing. aqueous humor is caused by displacement of the iris.
1. Bone scan is done by injecting radioisotope per IV 24. Glaucoma is characterized by irreversible
and then x-rays are taken. blindness.
2. To prevent edema on the site of sprain, apply cold 25. Hyperopia is corrected by convex lens.
compress on the area for the first 24 hours.
26. Pterygium is caused primarily by exposure to
3. To turn the client after lumbar Laminectomy, use dust.
the logrolling technique.
27. A sterile chronic granulomatous inflammation of
4. Carpal tunnel syndrome occurs due to the injury of the meibomian gland is chalazion.
median nerve.
28. The surgical procedure which involves removal
5. Massaging the back of the head is specifically of the eyeball is enucleation.
important for the client with Crutchfield tong.
29. Romberg’s test is a test for balance or gait.
6. A one-year-old child has a fracture of the left
femur. He is placed in Bryant’s traction. The reason 30. If the client with increased ICP demonstrates
for elevation of his both legs at 90º angle is his decorticate posturing, observe for flexion of elbows,
weight isn’t adequate to provide sufficient counter extension of the knees, plantar flexion of the feet.
traction, so his entire body must be used.
31. The nursing diagnosis that would have the highest
7. Swing-through crutch gait is done by advancing priority in the care of the client who has become
both crutches together and the client moves both legs comatose following cerebral hemorrhage is
past the level of the crutches. Ineffective Airway Clearance.

8. The appropriate nursing measure to prevent 32. The initial nursing action—for a client who is in
displacement of the prosthesis after a right total hip the clonic phase of a tonic-clonic seizure—is to
replacement for arthritis is to place the patient in the obtain equipment for orotracheal suctioning.
position of right leg abducted.
33. The first nursing intervention in a quadriplegic
9. Pain on non-use of joints, subcutaneous nodules client who is experiencing autonomic dysreflexia is
and elevated ESR are characteristic manifestations of to elevate his head as high as possible.
rheumatoid arthritis.
34. Following surgery for a brain tumor near the
10. Teaching program of a patient with SLE should hypothalamus, the nursing assessment should include
include emphasis on walking in shaded area. observing for inability to regulate body temp.
2

35.Post-myelography (using metrizamide 55. When assessing a patient’s eating habits, the
(Omnipaque) care includes keeping head elevated for nurse should ask, “What have you eaten in the last 24
at least 8 hours. hours?”

36. Homonymous hemianopsia is described by a 56. A vegan diet should include an abundant supply
client had CVA and can only see the nasal visual of fiber.
field on one side and the temporal portion on the
opposite side. 57. A hypotonic enema softens the feces, distends the
colon, and stimulates peristalsis.
37. Ticlopidine may be prescribed to prevent
thromboembolic CVA. 58. First-morning urine provides the best sample to
measure glucose, ketone, pH, and specific gravity
38. To maintain airway patency during a stroke in values.
evolution, have orotracheal suction available at all
times. 59. To induce sleep, the first step is to minimize
environmental stimuli.
39. For a client with CVA, the gag reflex must return
before the client is fed. 60. Before moving a patient, the nurse should assess
the patient’s physical abilities and ability to
40. Clear fluids draining from the nose of a client understand instructions as well as the amount of
who had a head trauma 3 hours ago may indicate strength required to move the patient.
basilar skull fracture.
61. To lose 1 lb (0.5 kg) in 1 week, the patient must
41. An adverse effect of gingival hyperplasia may decrease his weekly intake by 3,500 calories
occur during Phenytoin (DIlantin) therapy. (approximately500 calories daily). To lose 2 lb (1 kg)
in 1 week, the patient must decrease his weekly
42. Urine output increased: best shows that the caloric intake by 7,000calories (approximately 1,000
mannitol is effective in a client with increased ICP. calories daily).
43. A client with C6 spinal injury would most likely 62. To avoid shearing force injury, a patient who is
have the symptom of quadriplegia. completely immobile is lifted on a sheet.
44. Falls are the leading cause of injury in elderly 63. To insert a catheter from the nose through the
people. trachea for suction, the nurse should ask the patient to
45. The client is for EEG this morning. Prepare him swallow.
for the procedure by rendering hair shampoo, 64. Vitamin C is needed for collagen production.
excluding caffeine from his meal and instructing the
client to remain still during the procedure. 65. Bananas, citrus fruits, and potatoes are good
sources of potassium.
46. Primary prevention is true prevention. Examples
are immunizations, weight control, and smoking 66. Good sources of magnesium include fish, nuts,
cessation. and grains.

47. Secondary prevention is early detection. 67. Beef, oysters, shrimp, scallops, spinach, beets,
Examples include purified protein derivative (PPD), and greens are good sources of iron.
breast self-examination, testicular self-examination,
and chest X-ray. 68. The nitrogen balance estimates the difference
between the intake and use of protein.
48. Tertiary prevention is treatment to prevent long-
term complications.49. On noticing religious artifacts 69. A Hindu patient is likely to request a vegetarian
and literature on a patient’s night stand, a culturally diet.
aware nurse would ask the patient the meaning of the 70. No pork or pork products are allowed in a
items. Muslim diet.
50. A Mexican patient may request the intervention 71. In accordance with the “hot-cold” system used by
of a curandero, or faith healer, who involves the some Mexicans, Puerto Ricans, and other Hispanic
family inhealing the patient. and Latino groups, most foods, beverages, herbs, and
51. In an infant, the normal hemoglobin value is 12 drugs are described as “cold.”
g/dl. 72. Milk is high in sodium and low in iron.
52. A patient indicates that he’s coming to terms with 73. Discrimination is preferential treatment of
having a chronic disease when he says something individuals of a particular group. It’s usually
like: “I’m never going to get any better,” or when he discussed in a negativesense.
exhibits hopelessness.
74. Increased gastric motility interferes with the
Diet and Nutrition absorption of oral drugs.
53. Most of the absorption of water occurs in the 75. When feeding an elderly patient, the nurse should
large intestine. limit high-carbohydrate foods because of the risk of
54. Most nutrients are absorbed in the small intestine. glucose intolerance

76. When feeding an elderly patient, essential foods

should be given first.
3

78. For the patient who abides by Jewish custom, 1. Following surgery, Mario complains of mild
milk and meat shouldn’t be served at the same meal. incisional pain while performing deep- breathing and
coughing exercises. The nurse’s best response would
Pain Management be:
79. Only the patient can describe his pain accurately.
A. “Pain will become less each day.”
80. Cutaneous stimulation creates the release of B. “This is a normal reaction after surgery.”
endorphins that block the transmission of pain C. “With a pillow, apply pressure against the
stimuli. incision.”
D. “I will give you the pain medication the
81. Patient-controlled analgesia (PCA) is a safe physician ordered.”
method to relieve acute pain caused by surgical 2. The nurse needs to carefully assess the complaint
incision, traumatic injury, labor and delivery, or of pain of the elderly because older people
cancer.
A. are expected to experience chronic pain
82. An Asian-American or European-American B. have a decreased pain threshold
typically places distance between himself and others C. experience reduced sensory perception
when communicating. D. have altered mental function
3. Mary received AtropineSO4 as a pre-medication
83. Active euthanasia is actively helping a person to 30 minutes ago and is now complaining of dry mouth
die. and her PR is higher, than before the medication was
administered. The nurse’s best
84. Brain death is irreversible cessation of all brain
function.
A. The patient is having an allergic reaction to the
85. Passive euthanasia is stopping the therapy that’s drug.
sustaining life. B. The patient needs a higher dose of this drug
C. This is normal side-effect of AtSO4
86. Voluntary euthanasia is actively helping a patient D. The patient is anxious about upcoming surgery
to die at the patient’s request. 4. Ana’s postoperative vital signs are a blood
pressure of 80/50 mm Hg, a pulse of 140, and
87. A back rub is an example of the gate-control respirations of 32. Suspecting shock, which of the
theory of pain. following orders would the nurse question?
88. Pain threshold, or pain sensation, is the initial
point at which a patient feels pain. A. Put the client in modified Trendelenberg’s
position.
89. The difference between acute pain and chronic B. Administer oxygen at 100%.
pain is its duration C. Monitor urine output every hour.
D. Administer Demerol 50mg IM q4h
90. Referred pain is pain that’s felt at a site other than 5. Mr. Pablo, diagnosed with Bladder Cancer, is
its origin. scheduled for a cystectomy with the creation of an
ileal conduit in the morning. He is wringing his hands
91. Alleviating pain by performing a back massage is and pacing the floor when the nurse enters his room.
consistent with the gate control theory. What is the best approach?
92. Pain seems more intense at night because the
A. “Good evening, Mr. Pablo. Wasn’t it a pleasant
patient isn’t distracted by daily activities.
day, today?”
93. Older patients commonly don’t report pain B. “Mr, Pablo, you must be so worried, I’ll leave
because of fear of treatment, lifestyle changes, or you alone with your thoughts.
dependency. C. “Mr. Pablo, you’ll wear out the hospital floors
and yourself at this rate.”
94. Utilization review is performed to determine D. “Mr. Pablo, you appear anxious to me. How
whether the care provided to a patient was are you feeling about tomorrow’s surgery?”
appropriate and cost-effective. 6. After surgery, Gina returns from the Post-
anesthesia Care Unit (Recovery Room) with a
95. A value cohort is a group of people who nasogastric tube in place following a gall bladder
experienced an out-of-the-ordinary event that shaped surgery. She continues to complain of nausea. Which
their values. action would the nurse take?

96. A third-party payer is an insurance company. A. Call the physician immediately.

B. Administer the prescribed antiemetic.
97. Intrathecal injection is administering a drug
C. Check the patency of the nasogastric tube for
through the spine. any obstruction.
98. When a patient asks a question or makes a D. Change the patient’s position.
statement that’s emotionally charged, the nurse 7. Mr. Perez is in continuous pain from cancer that
has metastasized to the bone. Pain medication
should respond to the emotion behind the statement
provides little relief and he refuses to move. The
or question rather than to what’s being said or asked nurse should plan to:

A. Reassure him that the nurses will not hurt him

B. Let him perform his own activities of daily
living
Text Mode – Text version of the exam
4

C. Handle him gently when assisting with required C. “Continue your activity, and if the pain does not
care go away in 10 minutes, begin taking the nitro
D. Complete A.M. care quickly as possible when tablets one every 5 minutes for 15 minutes, then
necessary go lie down.”
8. A client returns from the recovery room at 9AM D. “Place one Nitroglycerine tablet under the
alert and oriented, with an IV infusing. His pulse is tongue every five minutes for three doses. Go to
82, blood pressure is 120/80, respirations are 20, and the hospital if the pain is unrelieved.
all are within normal range. At 10 am and at 11 am, 15. A client with chronic heart failure has been
his vital signs are stable. At noon, however, his pulse placed on a diet restricted to 2000mg. of sodium per
rate is 94, blood pressure is 116/74, and respirations day. The client demonstrates adequate knowledge if
are 24. What nursing action is most appropriate? behaviors are evident such as not salting food and
avoidance of which food?
A. Notify his physician.
B. Take his vital signs again in 15 minutes. A. Whole milk
C. Take his vital signs again in an hour. B. Canned sardines
D. Place the patient in shock position. C. Plain nuts
9. A 56 year old construction worker is brought to the D. Eggs
hospital unconscious after falling from a 2-story 16. A student nurse is assigned to a client who has a
building. When assessing the client, the nurse would diagnosis of thrombophlebitis. Which action by this
be most concerned if the assessment revealed: team member is most appropriate?

A. Reactive pupils A. Apply a heating pad to the involved site.

B. A depressed fontanel B. Elevate the client’s legs 90 degrees.
C. Bleeding from ears C. Instruct the client about the need for bed rest.
D. An elevated temperature D. Provide active range-of-motion exercises to
10. Which of the ff. statements by the client to the both legs at least twice every shift.
nurse indicates a risk factor for CAD? 17. A client receiving heparin sodium asks the nurse
how the drug works. Which of the following points
A. “I exercise every other day.” would the nurse include in the explanation to the
B. “My father died of Myasthenia Gravis.” client?
C. “My cholesterol is 180.”
D. “I smoke 1 1/2 packs of cigarettes per day.” A. It dissolves existing thrombi.
11. Mr. Braga was ordered Digoxin 0.25 mg. OD. B. It prevents conversion of factors that are needed
Which is poor knowledge regarding this drug? in the formation of clots.
C. It inactivates thrombin that forms and dissolves
A. It has positive inotropic and negative existing thrombi.
chronotropic effects D. It interferes with vitamin K absorption.
B. The positive inotropic effect will decrease urine 18. The nurse is conducting an education session for
output a group of smokers in a “stop smoking” class. Which
C. Toxixity can occur more easily in the presence finding would the nurse state as a common symptom
of hypokalemia, liver and renal problems of lung cancer? :
D. Do not give the drug if the apical rate is less
than 60 beats per minute. A. Dyspnea on exertion
12. Valsalva maneuver can result in bradycardia. B. Foamy, blood-tinged sputum
Which of the following activities will not stimulate C. Wheezing sound on inspiration
Valsalva’s maneuver? D. Cough or change in a chronic cough
19. Which is the most relevant knowledge about
A. Use of stool softeners. oxygen administration to a client with COPD?
B. Enema administration
C. Gagging while tooth brushing. A. Oxygen at 1-2L/min is given to maintain the
D. Lifting heavy objects hypoxic stimulus for breathing.
13. The nurse is teaching the patient regarding his B. Hypoxia stimulates the central chemoreceptors
permanent artificial pacemaker. Which information in the medulla that makes the client breath.
given by the nurse shows her knowledge deficit about C. Oxygen is administered best using a non-
the artificial cardiac pacemaker? rebreathing mask
D. Blood gases are monitored using a pulse
A. take the pulse rate once a day, in the morning oximeter.
upon awakening 20. When suctioning mucus from a client’s lungs,
B. may be allowed to use electrical appliances which nursing action would be least appropriate?
C. have regular follow up care
D. may engage in contact sports A. Lubricate the catheter tip with sterile saline
14. A patient with angina pectoris is being discharged before insertion.
home with nitroglycerine tablets. Which of the B. Use sterile technique with a two-gloved
following instructions does the nurse include in the approach
teaching? C. Suction until the client indicates to stop or no
longer than 20 second
A. “When your chest pain begins, lie down, and D. Hyperoxygenate the client before and after
place one tablet under your tongue. If the pain suctioning
continues, take another tablet in 5 minutes.” 21. Dr. Santos prescribes oral rifampin (Rimactane)
B. “Place one tablet under your tongue. If the pain and isoniazid (INH) for a client with a positive
is not relieved in 15 minutes, go to the Tuberculin skin test. When informing the client of
hospital.” this decision, the nurse knows that the purpose of this
choice of treatment is to
5

A. Cause less irritation to the gastrointestinal tract A. “I should limit my potassium intake because
B. Destroy resistant organisms and promote proper hyperkalemia is a side-effect of this drug.”
blood levels of the drugs B. “I must take this medicine exactly as my doctor
C. Gain a more rapid systemic effect ordered it. I shouldn’t skip doses.”
D. Delay resistance and increase the C. “This medicine will protect me from getting
tuberculostatic effect any colds or infection.”
22. Mario undergoes a left thoracotomy and a partial D. “My incision will heal much faster because of
pneumonectomy. Chest tubes are inserted, and one- this drug.”
bottle water-seal drainage is instituted in the 29. A client, who is suspected of having
operating room. In the postanesthesia care unit Mario Pheochromocytoma, complains of sweating,
is placed in Fowler’s position on either his right palpitation and headache. Which assessment is
side or on his back to essential for the nurse to make first?

A. Reduce incisional pain. A. Pupil reaction

B. Facilitate ventilation of the left lung. B. Hand grips
C. Equalize pressure in the pleural space. C. Blood pressure
D. Increase venous return D. Blood glucose
23. A client with COPD is being prepared for 30. The nurse is attending a bridal shower for a friend
discharge. The following are relevant instructions to when another guest, who happens to be a diabetic,
the client regarding the use of an oral inhaler starts to tremble and complains of dizziness. The next
EXCEPT best action for the nurse to take is to:

A. Breath in and out as fully as possible before A. Encourage the guest to eat some baked
placing the mouthpiece inside the mouth. macaroni
B. Inhale slowly through the mouth as the canister B. Call the guest’s personal physician
is pressed down C. Offer the guest a cup of coffee
C. Hold his breath for about 10 seconds before D. Give the guest a glass of orange juice
exhaling 31. An adult, who is newly diagnosed with Graves
D. Slowly breathe out through the mouth with disease, asks the nurse, “Why do I need to take
pursed lips after inhaling the drug. Propanolol (Inderal)?” Based on the nurse’s
24. A client is scheduled for a bronchoscopy. When understanding of the medication and Grave’s disease,
teaching the client what to expect afterward, the the best response would be:
nurse’s highest priority of information would be
A. “The medication will limit thyroid hormone
A. Food and fluids will be withheld for at least 2 secretion.”
hours. B. “The medication limit synthesis of the thyroid
B. Warm saline gargles will be done q 2h. hormones.”
C. Coughing and deep-breathing exercises will be C. “The medication will block the cardiovascular
done q2h. symptoms of Grave’s disease.”
D. Only ice chips and cold liquids will be allowed D. “The medication will increase the synthesis of
initially. thyroid hormones.”
25. The nurse enters the room of a client with chronic 32. During the first 24 hours after thyroid surgery, the
obstructive pulmonary disease. The client’s nasal nurse should include in her care:
cannula oxygen is running at a rate of 6 L per minute,
the skin color is pink, and the respirations are 9 per A. Checking the back and sides of the operative
minute and shallow. What is the nurse’s best initial dressing
action? B. Supporting the head during mild range of
motion exercise
A. Take heart rate and blood pressure. C. Encouraging the client to ventilate her feelings
B. Call the physician. about the surgery
C. Lower the oxygen rate. D. Advising the client that she can resume her
D. Position the client in a Fowler’s position. normal activities immediately
26. The nurse is preparing her plan of care for her 33. On discharge, the nurse teaches the patient to
patient diagnosed with pneumonia. Which is the most observe for signs of surgically induced
appropriate nursing diagnosis for this patient? hypothyroidism. The nurse would know that the
patient understands the teaching when she states she
A. Fluid volume deficit should notify the MD if she develops:
B. Decreased tissue perfusion.
C. Impaired gas exchange. A. Intolerance to heat
D. Risk for infection B. Dry skin and fatigue
27. A nurse at the weight loss clinic assesses a client C. Progressive weight gain
who has a large abdomen and a rounded face. Which D. Insomnia and excitability
additional assessment finding would lead the nurse to 34. What is the best reason for the nurse in
suspect that the client has Cushing’s syndrome rather instructing the client to rotate injection sites for
than obesity? insulin?

A. large thighs and upper arms A. Lipodystrophy can result and is extremely
B. pendulous abdomen and large hips painful
C. abdominal striae and ankle enlargement B. Poor rotation technique can cause superficial
D. posterior neck fat pad and thin extremities hemorrhaging
28. Which statement by the client indicates C. Lipodystrophic areas can result, causing erratic
understanding of the possible side effects of insulin absorption rates from these
Prednisone therapy? D. Injection sites can never be reused
6

35. Which of the following would be inappropriate to B. “The liver heals better with a high
include in a diabetic teaching plan? carbohydrates diet rather than protein.”
C. “Most people have too much protein in their
A. Change position hourly to increase circulation diets. The amount of this diet is better for liver
B. Inspect feet and legs daily for any changes healing.”
C. Keep legs elevated on 2 pillows while sleeping D. “Because of portal hyperemesis, the blood
D. Keep the insulin not in use in the refrigerator flows around the liver and ammonia made from
36. Included in the plan of care for the immediate protein collects in the brain causing
post-gastroscopy period will be: hallucinations.”
43. Which of the drug of choice for pain controls the
patient with acute pancreatitis?
A. Maintain NGT to intermittent suction
B. Assess gag reflex prior to administration of
fluids A. Morphine
C. Assess for pain and medicate as ordered B. NSAIDS
D. Measure abdominal girth every 4 hours C. Meperidine
37. Which description of pain would be most D. Codeine
characteristic of a duodenal ulcer? 44. Immediately after cholecystectomy, the nursing
action that should assume the highest priority is:
A. Gnawing, dull, aching, hungerlike pain in the
epigastric area that is relieved by food intake A. encouraging the client to take adequate deep
B. RUQ pain that increases after meal breaths by mouth
C. Sharp pain in the epigastric area that radiates to B. encouraging the client to cough and deep
the right shoulder breathe
D. A sensation of painful pressure in the C. changing the dressing at least BID
midsternal area D. irrigate the T-tube frequently
38. The client underwent Billroth surgery for gastric 45. A Sengstaken-Blakemore tube is inserted in the
ulcer. Post-operatively, the drainage from his NGT is effort to stop the bleeding esophageal varices in a
thick and the volume of secretions has dramatically patient with complicated liver cirrhosis. Upon
reduced in the last 2 hours and the client feels like insertion of the tube, the client complains of
vomiting. The most appropriate nursing action is to: difficulty of breathing. The first action of the nurse is
to:
A. Reposition the NGT by advancing it gently
NSS A. Deflate the esophageal balloon
B. Notify the MD of your findings B. Monitor VS
C. Irrigate the NGT with 50 cc of sterile C. Encourage him to take deep breaths
D. Discontinue the low-intermittent suction D. Notify the MD
39. After Billroth II Surgery, the client developed 46. The client presents with severe rectal bleeding, 16
dumping syndrome. Which of the following should diarrheal stools a day, severe abdominal pain,
the nurse exclude in the plan of care? tenesmus and dehydration. Because of these
symptoms the nurse should be alert for other
problems associated with what disease?
A. Sit upright for at least 30 minutes after meals
B. Take only sips of H2O between bites of solid
food A. Chrons disease
C. Eat small meals every 2-3 hours B. Ulcerative colitis
D. Reduce the amount of simple carbohydrate in C. Diverticulitis
the diet D. Peritonitis
40. The laboratory of a male patient with Peptic ulcer 47. A client is being evaluated for cancer of the
revealed an elevated titer of Helicobacter pylori. colon. In preparing the client for barium enema, the
Which of the following statements indicate an nurse should:
understanding of this data?
A. Give laxative the night before and a cleansing
A. Treatment will include Ranitidine and enema in the morning before the test
Antibiotics B. Render an oil retention enema and give laxative
B. No treatment is necessary at this time the night before
C. This result indicates gastric cancer caused by C. Instruct the client to swallow 6 radiopaque
the organism tablets the evening before the study
D. Surgical treatment is necessary D. Place the client on CBR a day before the study
41. What instructions should the client be given 48. The client has a good understanding of the means
before undergoing a paracentesis? to reduce the chances of colon cancer when he states:

A. NPO 12 hours before procedure A. “I will exercise daily.”

B. Empty bladder before procedure B. “I will include more red meat in my diet.”
C. Strict bed rest following procedure C. “I will have an annual chest x-ray.”
D. Empty bowel before procedure D. “I will include more fresh fruits and vegetables
42. The husband of a client asks the nurse about the in my diet.”
protein-restricted diet ordered because of advanced 49. Days after abdominal surgery, the client’s wound
liver disease. What statement by the nurse would best dehisces. The safest nursing intervention when this
explain the purpose of the diet? occurs is to

A. “The liver cannot rid the body of ammonia that A. Cover the wound with sterile, moist saline
is made by the breakdown of protein in the dressing
digestive system.” B. Approximate the wound edges with tapes
7

C. Irrigate the wound with sterile saline interventions to prevent complications from
D. Hold the abdominal contents in place with a occurring.
sterile gloved hand 9. Answer: (C) Bleeding from ears . The nurse
50. An intravenous pyelogram reveals that Paulo, age needs to perform a thorough assessment that
35, has a renal calculus. He is believed to have a could indicate alterations in cerebral function,
small stone that will pass spontaneously. To increase increased intracranial pressures, fractures and
the chance of the stone passing, the nurse would bleeding. Bleeding from the ears occurs only
instruct the client to force fluids and to with basal skull fractures that can easily
contribute to increased intracranial pressure and
A. Strain all urine. brain herniation.
B. Ambulate. 10. Answer: (D) “I smoke 1 1/2 packs of cigarettes
C. Remain on bed rest. per day.” Smoking has been considered as one
D. Ask for medications to relax him. of the major modifiable risk factors for
Answers and Rationales coronary artery disease. Exercise and
maintaining normal serum cholesterol levels
1. Answer: (C) “With a pillow, apply pressure help in its prevention.
against the incision.” Applying pressure against 11. Answer: (B) The positive inotropic effect will
the incision with a pillow will help lessen the decrease urine output . Inotropic effect of drugs
intra-abdominal pressure created by coughing on the heart causes increase force of its
which causes tension on the incision that leads contraction. This increases cardiac output that
to pain. improves renal perfusion resulting in an
2. Answer: (C) experience reduced sensory improved urine output.
perception . Degenerative changes occur in the 12. Answer: (A) Use of stool softeners. Straining or
elderly. The response to pain in the elderly bearing down activities can cause vagal
maybe lessened because of reduced acuity of stimulation that leads to bradycardia. Use of
touch, alterations in neural pathways and stool softeners promote easy bowel evacuation
diminished processing of sensory data. that prevents straining or the valsalva
3. Answer: (C) This is normal side-effect of maneuver.
AtSO4. Atropine sulfate is a vagolytic drug that 13. Answer: (D) may engage in contact sports . The
decreases oropharyngeal secretions and client should be advised by the nurse to avoid
increases the heart rate. contact sports. This will prevent trauma to the
4. Answer: (D) Administer Demerol 50mg IM area of the pacemaker generator.
q4h. Administering Demerol, which is a 14. Answer: (D) “Place one Nitroglycerine tablet
narcotic analgesic, can depress respiratory and under the tongue every five minutes for three
cardiac function and thus not given to a patient doses. Go to the hospital if the pain is
in shock. What is needed is promotion for unrelieved. Angina pectoris is caused by
adequate oxygenation and perfusion. All the myocardial ischemia related to decreased
other interventions can be expected to be done coronary blood supply. Giving nitroglycerine
by the nurse. will produce coronary vasodilation that
5. Answer: (D) “Mr. Pablo, you appear anxious to improves the coronary blood flow in 3 – 5
me. How are you feeling about tomorrow’s mins. If the chest pain is unrelieved, after three
surgery?”. The client is showing signs of tablets, there is a possibility of acute coronary
anxiety reaction to a stressful event. occlusion that requires immediate medical
Recognizing the client’s anxiety conveys attention.
acceptance of his behavior and will allow for 15. Answer: (B) Canned sardines . Canned foods
verbalization of feelings and concerns. are generally rich in sodium content as salt is
6. Answer: (C) Check the patency of the used as the main preservative.
nasogastric tube for any obstruction. Nausea is 16. Answer: (C) Instruct the client about the need
one of the common complaints of a patient after for bed rest. In a client with thrombophlebitis,
receiving general anesthesia. But this complaint bedrest will prevent the dislodgment of the clot
could be aggravated by gastric distention in the extremity which can lead to pulmonary
especially in a patient who has undergone embolism.
abdominal surgery. Insertion of the NGT helps 17. Answer: (B) It prevents conversion of factors
relieve the problem. Checking on the patency of that are needed in the formation of
the NGT for any obstruction will help the nurse clots. Heparin is an anticoagulant. It prevents
determine the cause of the problem and institute the conversion of prothrombin to thrombin. It
the necessary intervention. does not dissolve a clot.
7. Answer: (C) Handle him gently when assisting 18. Answer: (D) Cough or change in a chronic
with required care . Patients with cancer and cough .Cigarette smoke is a carcinogen that
bone metastasis experience severe pain irritates and damages the respiratory
especially when moving. Bone tumors weaken epithelium. The irritation causes the cough
the bone to appoint at which normal activities which initially maybe dry, persistent and
and even position changes can lead to fracture. unproductive. As the tumor enlarges,
During nursing care, the patient needs to be obstruction of the airways occurs and the cough
supported and handled gently. may become productive due to infection.
8. Answer: (B) Take his vital signs again in 15 19. Answer: (A) Oxygen at 1-2L/min is given to
minutes. Monitoring the client’s vital signs maintain the hypoxic stimulus for
following surgery gives the nurse a sound breathing. COPD causes a chronic CO2
information about the client’s condition. retention that renders the medulla insensitive to
Complications can occur during this period as a the CO2 stimulation for breathing. The hypoxic
result of the surgery or the anesthesia or both. state of the client then becomes the stimulus for
Keeping close track of changes in the VS and breathing. Giving the clientoxygen in low
validating them will help the nurse initiate concentrations will maintain the client’s
hypoxic drive.
8

20. Answer: (C) Suction until the client indicates to secretion of catecholamines that can elevate the
stop or no longer than 20 second .One hazard blood pressure.
encountered when suctioning a client is the 30. Answer: (D) Give the guest a glass of orange
development of hypoxia. Suctioning sucks not juice . In diabetic patients, the nurse should
only the secretions but also the gases found in watch out for signs of hypoglycemia manifested
the airways. This can be prevented by by dizziness, tremors, weakness, pallor
suctioning the client for an average time of 5-10 diaphoresis and tachycardia. When this occurs
seconds and not more than 15 seconds and in a conscious client, he should be given
hyperoxygenating the client before and after immediately carbohydrates in the form of fruit
suctioning. juice, hard candy, honey or, if unconscious,
21. Answer: (D) Delay resistance and increase the glucagons or dextrose per IV.
tuberculostatic effect . Pulmonary TB is treated 31. Answer: (C) “The medication will block the
primarily with chemotherapeutic agents for 6- cardiovascular symptoms of Grave’s
12 mons. A prolonged treatment duration is disease.” Propranolol (Inderal) is a beta-
necessary to ensure eradication of the adrenergic blocker that controls the
organisms and to prevent relapse. The cardiovascular manifestations brought about by
increasing prevalence of drug resistance points increased secretion of the thyroid hormone in
to the need to begin the treatment with drugs in Grave’s disease.
combination. Using drugs in combination can 32. Answer: (A) Checking the back and sides of the
delay the drug resistance. operative dressing . Following surgery of the
22. Answer: (B) Facilitate ventilation of the left thyroid gland, bleeding is a potential
lung. Since only a partial pneumonectomy is complication. This can best be assessed by
done, there is a need to promote expansion of checking the back and the sides of the operative
this remaining Left lung by positioning the dressing as the blood may flow towards the side
client on the opposite unoperated side. and back leaving the front dry and clear of
23. Answer: (D) Slowly breath out through the drainage.
mouth with pursed lips after inhaling the 33. Answer: (C) Progressive weight
drug. If the client breathes out through the gain . Hypothyroidism, a decrease in thyroid
mouth with pursed lips, this can easily force the hormone production, is characterized by
just inhaled drug out of the respiratory tract that hypometabolism that manifests itself with
will lessen its effectiveness. weight gain.
24. Answer: (A) Food and fluids will be withheld 34. Answer: (C) Lipodystrophic areas can result,
for at least 2 hours. Prior to bronchoscopy, the causing erratic insulin absorption rates from
doctors sprays the back of the throat with these . Lipodystrophy is the development of
anesthetic to minimize the gag reflex and thus fibrofatty masses at the injection site caused by
facilitate the insertion of the bronchoscope. repeated use of an injection site. Injecting
Giving the client food and drink after the insulin into these scarred areas can cause the
procedure without checking on the return of the insulin to be poorly absorbed and lead to erratic
gag reflex can cause the client to aspirate. The reactions.
gag reflex usually returns after two hours. 35. Answer: (C) Keep legs elevated on 2 pillows
25. Answer: (C) Lower the oxygen rate. The client while sleeping . The client with DM has
with COPD is suffering from chronic CO2 decreased peripheral circulation caused by
retention. The hypoxic drive is his chief microangiopathy. Keeping the legs elevated
stimulus for breathing. Giving O2 inhalation at during sleep will further cause circulatory
a rate that is more than 2-3L/min can make the impairment.
client lose his hypoxic drive which can be 36. Answer: (B) Assess gag reflex prior to
assessed as decreasing RR. administration of fluids . The client, after
26. Answer: (C) Impaired gas exchange. gastroscopy, has temporary impairment of the
Pneumonia, which is an infection, causes lobar gag reflex due to the anesthetic that has been
consolidation thus impairing gas exchange sprayed into his throat prior to the procedure.
between the alveoli and the blood. Because the Giving fluids and food at this time can lead to
patient would require adequate hydration, this aspiration.
makes him prone to fluid volume excess. 37. Answer: (A) Gnawing, dull, aching, hungerlike
27. Answer: (D) posterior neck fat pad and thin pain in the epigastric area that is relieved by
extremities .“ Buffalo hump” is the food intake . Duodenal ulcer is related to an
accumulation of fat pads over the upper back increase in the secretion of HCl. This can be
and neck. Fat may also accumulate on the face. buffered by food intake thus the relief of the
There is truncal obesity but the extremities are pain that is brought about by food intake.
thin. All these are noted in a client with 38. Answer: (B) Notify the MD of your
Cushing’s syndrome. findings . The client’s feeling of vomiting and
28. Answer: (B) “I must take this medicine exactly the reduction in the volume of NGT drainage
as my doctor ordered it. I shouldn’t skip doses.” that is thick are signs of possible abdominal
The possible side effects of steroid distention caused by obstruction of the NGT.
administration are hypokalemia, increase This should be reported immediately to the MD
tendency to infection and poor wound healing. to prevent tension and rupture on the site of
Clients on the drug must follow strictly the anastomosis caused by gastric distention.
doctor’s order since skipping the drug can 39. Answer: (A) Sit upright for at least 30 minutes
lower the drug level in the blood that can after meals . The dumping syndrome occurs
trigger acute adrenal insufficiency or within 30 mins after a meal due to rapid gastric
Addisonian Crisis emptying, causing distention of the duodenum
29. Answer: (C) Blood or jejunum produced by a bolus of food. To
pressure . Pheochromocytoma is a tumor of the delay the emptying, the client has to lie down
adrenal medulla that causes an increase after meals. Sitting up after meals will promote
the dumping syndrome.
9

40. Answer: (A) Treatment will include Ranitidine to prevent the dressing from sticking to the
and Antibiotics . One of the causes of peptic wound which can disturb the healing process.
ulcer is H. Pylori infection. It releases toxin that 50. Answer: (B) Ambulate. Free unattached stones
destroys the gastric and duodenal mucosa in the urinary tract can be passed out with the
which decreases the gastric epithelium’s urine by ambulation which can mobilize the
resistance to acid digestion. Giving antibiotics stone and by increased fluid intake which will
will control the infection and Ranitidine, which flush out the stone during urination.
is a histamine-2 blocker, will reduce acid
secretion that can lead to ulcer.
41. Answer: (B) Empty bladder before Text Mode – Text version of the exam
procedure . Paracentesis involves the removal 1. A female client is admitted with a diagnosis of
of ascitic fluid from the peritoneal cavity acute renal failure. She is awake, alert, oriented, and
through a puncture made below the umbilicus. complaining of severe back pain, nausea and
The client needs to void before the procedure to vomiting and abdominal cramps. Her vital signs are
prevent accidental puncture of a distended blood pressure 100/70 mm Hg, pulse 110,
bladder during the procedure. respirations 30, and oral temperature 100.4°F (38°C).
42. Answer: (A) “The liver cannot rid the body of Her electrolytes are sodium 120 mEq/L, potassium
ammonia that is made by the breakdown of 5.2 mEq/L; her urinary output for the first 8 hours is
protein in the digestive system.” The largest 50 ml. The client is displaying signs of which
source of ammonia is the enzymatic and electrolyte imbalance?
bacterial digestion of dietary and blood proteins
in the GI tract. A protein-restricted diet will A. Hyponatremia
therefore decrease ammonia production. B. Hyperkalemia
43. Answer: (C) Meperidine . Pain in acute C. Hyperphosphatemia
pancreatitis is caused by irritation and edema of D. Hypercalcemia
the inflamed pancreas as well as spasm due to 2. Assessing the laboratory findings, which result
obstruction of the pancreatic ducts. Demerol is would the nurse most likely expect to find in a client
the drug of choice because it is less likely to with chronic renal failure?
cause spasm of the Sphincter of Oddi unlike
Morphine which is spasmogenic. A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L,
44. Answer: (B) encouraging the client to cough creatinine 0.5 to 1.5 mg/dl
and deep breathe . Cholecystectomy requires a B. Decreased serum calcium, blood pH 7.2,
subcostal incision. To minimize pain, clients potassium 6.5 mEq/L
have a tendency to take shallow breaths which C. BUN 15 mg/dl, increased serum calcium,
can lead to respiratory complications like creatinine l.0 mg/dl
pneumonia and atelectasis. Deep breathing and D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH
coughing exercises can help prevent such 7.35, decreased serum calcium
complications. 3. Treatment with hemodialysis is ordered for a client
45. Answer: (A) Deflate the esophageal and an external shunt is created. Which nursing
balloon . When a client with a Sengstaken- action would be of highest priority with regard to the
Blakemore tube develops difficulty of external shunt?
breathing, it means the tube is displaced and the
inflated balloon is in the oropharynx causing
airway obstruction A. Heparinize it daily.
46. Answer: (B) Ulcerative colitis . Ulcerative B. Avoid taking blood pressure measurements or
colitis is a chronic inflammatory condition blood samples from the affected arm.
producing edema and ulceration affecting the C. Change the Silastic tube daily.
entire colon. Ulcerations lead to sloughing that D. Instruct the client not to use the affected arm.
causes stools as many as 10-20 times a day that 4. Romeo Diaz, age 78, is admitted to the hospital
is filled with blood, pus and mucus. The other with the diagnosis of benign prostatic hyperplasia
symptoms mentioned accompany the problem. (BPH). He is scheduled for a transurethral resection
47. Answer: (A) Give laxative the night before and of the prostate (TURP). It would be inappropriate to
a cleansing enema in the morning before the include which of the following points in the
test .Barium enema is the radiologic preoperative teaching?
visualization of the colon using a die. To obtain
accurate results in this procedure, the bowels A. TURP is the most common operation for BPH.
must be emptied of fecal material thus the need B. Explain the purpose and function of a two-way
for laxative and enema. irrigation system.
48. Answer: (D) “I will include more fresh fruits C. Expect bloody urine, which will clear as
and vegetables in my diet.” Numerous aspects healing takes place.
of diet and nutrition may contribute to the D. He will be pain free.
development of cancer. A low-fiber diet, such 5. Roxy is admitted to the hospital with a possible
as when fresh fruits and vegetables are minimal diagnosis of appendicitis. On physical examination,
or lacking in the diet, slows transport of the nurse should be looking for tenderness on
materials through the gut which has been linked palpation at McBurney’s point, which is located in
to colorectal cancer. the
49. Answer: (A) Cover the wound with sterile,
moist saline dressing . Dehiscence is the partial A. left lower quadrant
or complete separation of the surgical wound B. left upper quadrant
edges. When this occurs, the client is placed in C. right lower quadrant
low Fowler’s position and instructed to lie D. right upper quadrant
quietly. The wound should be covered to 6. Mr. Valdez has undergone surgical repair of his
protect it from exposure and the dressing must inguinal hernia. Discharge teaching should include
be sterile to protect it from infection and moist
10

A. telling him to avoid heavy lifting for 4 to 6 D. D5NSS

weeks 14. A patient is hemorrhaging from multiple trauma
B. instructing him to have a soft bland diet for sites. The nurse expects that compensatory
two weeks mechanisms associated with hypovolemia would
C. telling him to resume his previous daily cause all of the following symptoms EXCEPT
activities without limitations
D. recommending him to drink eight glasses of A. hypertension
water daily B. oliguria
7. A 30-year-old homemaker fell asleep while C. tachycardia
smoking a cigarette. She sustained severe burns of D. tachypnea
the face,neck, anterior chest, and both arms and 15. Maria Sison, 40 years old, single, was admitted to
hands. Using the rule of nines, which is the best the hospital with a diagnosis of Breast Cancer. She
estimate of total body-surface area burned? was scheduled for radical mastectomy. Nursing care
during the preoperative period should consist of
A. 18%
B. 22% A. assuring Maria that she will be cured of cancer
C. 31% B. assessing Maria’s expectations and doubts
D. 40% C. maintaining a cheerful and optimistic
8. Nursing care planning is based on the knowledge environment
that the first 24-48 hours post-burn are characterized D. keeping Maria’s visitors to a minimum so she
by: can have time for herself
16. Maria refuses to acknowledge that her breast was
A. An increase in the total volume of intracranial removed. She believes that her breast is intact under
plasma the dressing. The nurse should
B. Excessive renal perfusion with diuresis
C. Fluid shift from interstitial space A. call the MD to change the dressing so Kathy
D. Fluid shift from intravascular space to the can see the incision
interstitial space B. recognize that Kathy is experiencing denial, a
9. If a client has severe bums on the upper torso, normal stage of the grieving process
which item would be a primary concern? C. reinforce Kathy’s belief for several days until
her body can adjust to stress of surgery.
A. Debriding and covering the wounds D. remind Kathy that she needs to accept her
B. Administering antibiotics diagnosis so that she can begin rehabilitation
C. Frequently observing for hoarseness, stridor, exercises.
and dyspnea 17. A chemotherapeutic agent 5FU is ordered as an
D. Establishing a patent IV line for fluid adjunct measure to surgery. Which of the ff.
replacement statements about chemotherapy is true?
10. Contractures are among the most serious long-
term complications of severe burns. If a burn is A. it is a local treatment affecting only tumor cells
located on the upper torso, which nursing measure B. it affects both normal and tumor cells
would be least effective to help prevent contractures? C. it has been proven as a complete cure for cancer
D. it is often used as a palliative measure.
A. Changing the location of the bed or the TV set, 18. Which is an incorrect statement pertaining to the
or both, daily following procedures for cancer diagnostics?
B. Encouraging the client to chew gum and blow
up balloons A. Biopsy is the removal of suspicious tissue and
C. Avoiding the use of a pillow for sleep, or the only definitive method to diagnose cancer
placing the head in a position of hyperextension B. Ultrasonography detects tissue density changes
D. Helping the client to rest in the position of difficult to observe by X-ray via sound waves.
maximal comfort C. CT scanning uses magnetic fields and radio
11. An adult is receiving Total Parenteral Nutrition frequencies to provide cross-sectional view of
(TPN). Which of the following assessment is tumor
essential? D. Endoscopy provides direct view of a body
cavity to detect abnormality.
A. evaluation of the peripheral IV site 19. A post-operative complication of mastectomy is
B. confirmation that the tube is in the stomach lymphedema. This can be prevented by
C. assess the bowel sound
D. fluid and electrolyte monitoring A. ensuring patency of wound drainage tube
12. Which drug would be least effective in lowering a B. placing the arm on the affected side in a
client’s serum potassium level? dependent position
C. restricting movement of the affected arm
A. Glucose and insulin D. frequently elevating the arm of the affected side
B. Polystyrene sulfonate (Kayexalate) above the level of the heart.
C. Calcium glucomite 20. Which statement by the client indicates to the
D. Aluminum hydroxide nurse that the patient understands precautions
13. A nurse is directed to administer a hypotonic necessary during internal radiation therapy for cancer
intravenous solution. Looking at the following of the cervix?
labeled solutions, she should choose
A. “I should get out of bed and walk around in my
A. 0.45% NaCl room.”
B. 0.9% NaCl B. “My 7 year old twins should not come to visit
C. D5W me while I’m receiving treatment.”
11

C. “I will try not to cough, because the force might A. Elevated hematocrit levels.
make me expel the application.” B. Urine output of 30 to 50 ml/hr.
D. “I know that my primary nurse has to wear one C. Change in level of consciousness.
of those badges like the people in the x-ray D. Estimate of fluid loss through the burn eschar.
department, but they are not necessary for 28. A thoracentesis is performed on a chest-injured
anyone else who comes in here.” client, and no fluid or air is found. Blood and fluids is
21. High uric acid levels may develop in clients who administered intravenously (IV), but the client’s vital
are receiving chemotherapy. This is caused by: signs do not improve. A central venous pressure line
is inserted, and the initial reading is 20 cm H^O. The
A. The inability of the kidneys to excrete the drug most likely cause of these findings is which of the
metabolites following?
B. Rapid cell catabolism
C. Toxic effect of the antibiotic that are given A. Spontaneous pneumothorax
concurrently B. Ruptured diaphragm
D. The altered blood ph from the acid medium of C. Hemothorax
the drugs D. Pericardial tamponade
22. Which of the following interventions would be 29. Intervention for a pt. who has swallowed a
included in the care of plan in a client with cervical Muriatic Acid includes all of the following except;
implant?
A. administering an irritant that will stimulate
A. Frequent ambulation vomiting
B. Unlimited visitors B. aspirating secretions from the pharynx if
C. Low residue diet respirations are affected
D. Vaginal irrigation every shift C. neutralizing the chemical
23. Which nursing measure would avoid constriction D. washing the esophagus with large volumes of
on the affected arm immediately after mastectomy? water via gastric lavage
30. Which initial nursing assessment finding would
A. Avoid BP measurement and constricting best indicate that a client has been successfully
clothing on the affected arm resuscitated after a cardio-respiratory arrest?
B. Active range of motion exercises of the arms
once a day. A. Skin warm and dry
C. Discourage feeding, washing or combing with B. Pupils equal and react to light
the affected arm C. Palpable carotid pulse
D. Place the affected arm in a dependent position, D. Positive Babinski’s reflex
below the level of the heart 31. Chemical burn of the eye are treated with
24. A client suffering from acute renal failure has an
unexpected increase in urinary output to 150ml/hr. A. local anesthetics and antibacterial drops for 24
The nurse assesses that the client has entered the – 36 hrs.
second phase of acute renal failure. Nursing actions B. hot compresses applied at 15-minute intervals
throughout this phase include observation for signs C. Flushing of the lids, conjunctiva and cornea
and symptoms of with tap or preferably sterile water
D. cleansing the conjunctiva with a small cotton-
A. Hypervolemia, hypokalemia, and tipped applicator
hypernatremia. 32. The Heimlich maneuver (abdominal thrust), for
B. Hypervolemia, hyperkalemia, and acute airway obstruction, attempts to:
hypernatremia.
C. Hypovolemia, wide fluctuations in serum A. Force air out of the lungs
sodium and potassium levels. B. Increase systemic circulation
D. Hypovolemia, no fluctuation in serum sodium C. Induce emptying of the stomach
and potassium levels. D. Put pressure on the apex of the heart
25. An adult has just been brought in by ambulance 33. John, 16 years old, is brought to the ER after a
after a motor vehicle accident. When assessing the vehicular accident. He is pronounced dead on arrival.
client, the nurse would expect which of the following When his parents arrive at the hospital, the nurse
manifestations could have resulted from sympathetic should:
nervous system stimulation?
A. ask them to stay in the waiting area until she
A. A rapid pulse and increased RR can spend time alone with them
B. Decreased physiologic functioning B. speak to both parents together and encourage
C. Rigid posture and altered perceptual focus them to support each other and express their
D. Increased awareness and attention emotions freely
26. Ms. Sy undergoes surgery and the abdominal C. Speak to one parent at a time so that each can
aortic aneurysm is resected and replaced with a graft. ventilate feelings of loss without upsetting the
When she arrives in the RR she is still in shock. The other
nurse’s priority should be : D. ask the MD to medicate the parents so they can
stay calm to deal with their son’s death.
A. placing her in a trendeleburg position 34. An emergency treatment for an acute asthmatic
B. putting several warm blankets on her attack is Adrenaline 1:1000 given hypodermically.
C. monitoring her hourly urine output This is given to:
D. assessing her VS especially her RR
27. A major goal for the client during the first 48 A. increase BP
hours after a severe bum is to prevent hypovolemic B. decrease mucosal swelling
shock. The best indicator of adequate fluid balance C. relax the bronchial smooth muscle
during this period is
12

D. decrease bronchial secretions A. Osmotic diuretics and corticosteroids are given

35. A nurse is performing CPR on an adult patient. to decrease cerebral edema
When performing chest compressions, the nurse B. Anticonvulsants are given to prevent seizures
understands the correct hand placement is located C. Thrombolytics are most useful within three
over the hours of an occlusive CVA
D. Aspirin is used in the acute management of a
A. upper half of the sternum completed stroke.
B. upper third of the sternum 43. What would be the MOST therapeutic nursing
C. lower half of the sternum action when a client’s expressive aphasia is severe?
D. lower third of the sternum
36. The nurse is performing an eye examination on A. Anticipate the client wishes so she will not need
an elderly client. The client states ‘My vision is to talk
blurred, and I don’t easily see clearly when I get into B. Communicate by means of questions that can
a dark room.” The nurse best response is: be answered by the client shaking the head
C. Keep us a steady flow rank to minimize silence
A. “You should be grateful you are not blind.” D. Encourage the client to speak at every possible
B. “As one ages, visual changes are noted as part opportunity.
of degenerative changes. This is normal.” 44. A client with head injury is confused, drowsy and
C. “You should rest your eyes frequently.” has unequal pupils. Which of the following nursing
D. “You maybe able to improve you vision if you diagnosis is most important at this time?
move slowly.”
37. Which of the following activities is not A. altered level of cognitive function
encouraged in a patient after an eye surgery? B. high risk for injury
C. altered cerebral tissue perfusion
A. sneezing, coughing and blowing the nose D. sensory perceptual alteration
B. straining to have a bowel movement 45. Which nursing diagnosis is of the highest priority
C. wearing tight shirt collars when caring for a client with myasthenia gravis?
D. sexual intercourse
38. Which of the following indicates poor practice in A. Pain
communicating with a hearing-impaired client? B. High risk for injury related to muscle weakness
C. Ineffective coping related to illness
A. Use appropriate hand motions D. Ineffective airway clearance related to muscle
B. Keep hands and other objects away from your weakness
mouth when talking to the client 46. The client has clear drainage from the nose and
C. Speak clearly in a loud voice or shout to be ears after a head injury. How can the nurse determine
heard if the drainage is CSF?
D. Converse in a quiet room with minimal
distractions A. Measure the ph of the fluid
39. A client is to undergo lumbar puncture. Which is B. Measure the specific gravity of the fluid
least important information about LP? C. Test for glucose
D. Test for chlorides
A. Specimens obtained should be labeled in their 47. The nurse includes the important measures for
proper sequence. stump care in the teaching plan for a client with an
B. It may be used to inject air, dye or drugs into amputation. Which measure would be excluded from
the spinal canal. the teaching plan?
C. Assess movements and sensation in the lower
extremities after the A. Wash, dry, and inspect the stump daily.
D. Force fluids before and after the procedure. B. Treat superficial abrasions and blisters
40. A client diagnosed with cerebral thrombosis is promptly.
scheduled for cerebral angiography. Nursing care of C. Apply a “shrinker” bandage with tighter arms
the client includes the following EXCEPT around the proximal end of the affected limb.
D. Toughen the stump by pushing it against a
A. Inform the client that a warm, flushed feeling progressively harder substance (e.g., pillow on
and a salty taste may be a foot-stool).
B. Maintain pressure dressing over the site of 48. A 70-year-old female comes to the clinic for a
puncture and check for routine checkup. She is 5 feet 4 inches tall and
C. Check pulse, color and temperature of the weighs 180 pounds. Her major complaint is pain in
extremity distal to the site of her joints. She is retired and has had to give up her
D. Kept the extremity used as puncture site flexed volunteer work because of her discomfort. She was
to prevent bleeding. told her diagnosis was osteoarthritis about 5 years
41. Which is considered as the earliest sign of ago. Which would be excluded from the clinical
increased ICP that the nurse should closely observed pathway for this client?
for?
A. Decrease the calorie count of her daily diet.
A. abnormal respiratory pattern B. Take warm baths when arising.
B. rising systolic and widening pulse pressure C. Slide items across the floor rather than lift
C. contralateral hemiparesis and ipsilateral dilation them.
of the pupils D. Place items so that it is necessary to bend or
D. progression from restlessness to confusion and stretch to reach them.
disorientation to lethargy 49. A client is admitted from the emergency
42. Which is irrelevant in the pharmacologic department with severe-pain and edema in the right
management of a client with CVA? foot. His diagnosis is gouty arthritis. When
13

developing a plan of care, which action would have Tissue injury causes vasodilation that results in
the highest priority? increase capillary permeability making fluids
shift from the intravascular to the interstitial
A. Apply hot compresses to the affected joints. space. This can lead to a decrease in circulating
B. Stress the importance of maintaining good blood volume or hypovolemia which decreases
posture to prevent deformities. renal perfusion and urine output.
C. Administer salicylates to minimize the 9. Answer: (C) Frequently observing for
inflammatory reaction. hoarseness, stridor, and dyspnea . Burns located
D. Ensure an intake of at least 3000 ml of fluid per in the upper torso, especially resulting from
day. thermal injury related to fires can lead to
50. A client had a laminectomy and spinal fusion inhalation burns. This causes swelling of the
yesterday. Which statement is to be excluded from respiratory mucosa and blistering which can
your plan of care? lead to airway obstruction manifested by
hoarseness, noisy and difficult breathing.
Maintaining a patent airway is a primary
A. Before log rolling, place a pillow under the concern.
client’s head and a pillow between the client’s 10. Answer: (D) Helping the client to rest in the
legs. position of maximal comfort . Mobility and
B. Before log rolling, remove the pillow from placing the burned areas in their functional
under the client’s head and use no pillows position can help prevent contracture
between the client’s legs. deformities related to burns. Pain can
C. Keep the knees slightly flexed while the client immobilize a client as he seeks the position
is lying in a semi-Fowler’s position in bed. where he finds less pain and provides maximal
D. Keep a pillow under the client’s head as needed comfort. But this approach can lead to
for comfort. contracture deformities and other
Answers and Rationales complications.
1. Answer: (A) Hyponatremia . The normal serum 11. Answer: (D) fluid and electrolyte
sodium level is 135 – 145 mEq/L. The client’s monitoring . Total parenteral nutrition is a
serum sodium is below normal. Hyponatremia method of providing nutrients to the body by an
also manifests itself with abdominal cramps and IV route. The admixture is made up of proteins,
nausea and vomiting carbohydrates, fats, electrolytes, vitamins, trace
2. Answer: (B) Decreased serum calcium, blood minerals and sterile water based on individual
pH 7.2, potassium 6.5 mEq/L. Chronic renal client needs. It is intended to improve the
failure is usually the end result of gradual tissue clients nutritional status. Because of its
destruction and loss of renal function. With the composition, it is important to monitor the
loss of renal function, the kidneys ability to clients fluid intake and output including
regulate fluid and electrolyte and acid base electrolytes, blood glucose and weight.
balance results. The serum Ca decreases as the 12. Answer: (D) Aluminum hydroxide . Aluminum
kidneys fail to excrete phosphate, potassium hydroxide binds dietary phosphorus in the GI
and hydrogen ions are retained. tract and helps treat hyperphosphatemia. All the
3. Answer: (B) Avoid taking blood pressure other medications mentioned help treat
measurements or blood samples from the hyperkalemia and its effects.
affected arm. In the client with an external 13. Answer: (A) 0.45% NaCl . Hypotonic solutions
shunt, don’t use the arm with the vascular like 0.45% NaCl has a lower tonicity that the
access site to take blood pressure readings, blood; 0.9% NaCl and D5W are isotonic
draw blood, insert IV lines, or give injections solutions with same tonicity as the blood; and
because these procedures may rupture the shunt D5NSS is hypertonic with a higher tonicity thab
or occlude blood flow causing damage and the blood.
obstructions in the shunt. 14. Answer: (A) hypertension . In hypovolemia,
4. Answer: (D) He will be pain free. Surgical one of the compenasatory mechanisms is
interventions involve an experience of pain for activation of the sympathetic nervous system
the client which can come in varying degrees. that increases the RR & PR and helps restore
Telling the pain that he will be pain free is the BP to maintain tissue perfusion but not
giving him false reassurance. cause a hypertension. The SNS stimulation
5. Answer: (C) right lower quadrant . To be exact, constricts renal arterioles that increases release
the appendix is anatomically located at the Mc of aldosterone, decreases glomerular filtration
Burney’s point at the right iliac area of the right and increases sodium & water reabsorption that
lower quadrant. leads to oliguria.
6. Answer: (A) telling him to avoid heavy lifting 15. Answer: (B) assessing Maria’s expectations and
for 4 to 6 weeks . The client should avoid lifting doubts . Assessing the client’s expectations and
heavy objects and any strenuous activity for 4-6 doubts will help lessen her fears and anxieties.
weeks after surgery to prevent stress on the The nurse needs to encourage the client to
inguinal area. There is no special diet required. verbalize and to listen and correctly provide
The fluid intake of eight glasses a day is good explanations when needed.
advice but is not a priority in this case. 16. Answer: (B) recognize that Kathy is
7. Answer: (C) 31% . Using the Rule of Nine in experiencing denial, a normal stage of the
the estimation of total body surface burned, we grieving process . A person grieves to a loss of
allot the following: 9% – head; 9% – each a significant object. The initial stage in the
upper extremity; 18%- front chest and grieving process is denial, then anger, followed
abdomen; 18% – entire back; 18% – each lower by bargaining, depression and last acceptance.
extremity and 1% – perineum. The nurse should show acceptance of the
8. Answer: (D) Fluid shift from intravascular patient’s feelings and encourage verbalization.
space to the interstitial space . This period is the 17. Answer: (B) it affects both normal and tumor
burn shock stage or the hypovolemic phase. cells . Chemotherapeutic agents are given to
14

destroy the actively proliferating cancer cells. 27. Answer: (B) Urine output of 30 to 50
But these agents cannot differentiate the ml/hr. Hypovolemia is a decreased in
abnormal actively proliferating cancer cells circulatory volume. This causes a decrease in
from those that are actively proliferating normal tissue perfusion to the different organs of the
cells like the cells of the bone marrow, thus the body. Measuring the hourly urine output is the
effect of bone marrow depression. most quantifiable way of measuring tissue
18. Answer: (C) CTscanning uses magnetic fields perfusion to the organs. Normal renal perfusion
and radio frequencies to provide cross-sectional should produce 1ml/kg of BW/min. An output
view of tumor . CT scan uses narrow beam x- of 30-50 ml/hr is considered adequate and
ray to provide cross-sectional view. MRI uses indicates good fluid balance.
magnetic fields and radio frequencies to detect 28. Answer: (D) Pericardial
tumors. tamponade . Pericardial tamponade occurs
19. Answer: (D) frequently elevating the arm of the when there is presence of fluid accumulation in
affected side above the level of the the pericardial space that compresses on the
heart. . Elevating the arm above the level of the ventricles causing a decrease in ventricular
heart promotes good venous return to the heart filling and stretching during diastole with a
and good lymphatic drainage thus preventing decrease in cardiac output. . This leads to right
swelling. atrial and venous congestion manifested by a
20. Answer: (B) “My 7 year old twins should not CVP reading above normal.
come to visit me while I’m receiving 29. Answer: (A) administering an irritant that will
treatment.” . Children have cells that are stimulate vomiting . Swallowing of corrosive
normally actively dividing in the process of substances causes severe irritation and tissue
growth. Radiation acts not only against the destruction of the mucous membrane of the GI
abnormally actively dividing cells of cancer but tract. Measures are taken to immediately
also on the normally dividing cells thus remove the toxin or reduce its absorption. For
affecting the growth and development of the corrosive poison ingestion, such as in muriatic
child and even causing cancer itself. acid where burn or perforation of the mucosa
21. Answer: (B) Rapid cell catabolism . One of the may occur, gastric emptying procedure is
oncologic emergencies, the tumor lysis immediately instituted, This includes gastric
syndrome, is caused by the rapid destruction of lavage and the administration of activated
large number of tumor cells. . Intracellular charcoal to absorb the poison. Administering an
contents are released, including potassium and irritant with the concomitant vomiting to
purines, into the bloodstream faster than the remove the swallowed poison will further cause
body can eliminate them. The purines are irritation and damage to the mucosal lining of
converted in the liver to uric acid and released the digestive tract. Vomiting is only indicated
into the blood causing hyperuricemia. They can when non-corrosive poison is swallowed.
precipitate in the kidneys and block the tubules 30. Answer: (C) Palpable carotid pulse . Presence
causing acute renal failure. of a palpable carotid pulse indicates the return
22. Answer: (C) Low residue diet . It is important of cardiac function which, together with the
for the nurse to remember that the implant be return of breathing, is the primary goal of CPR.
kept intact in the cervix during therapy. Pulsations in arteries indicates blood flowing in
Mobility and vaginal irrigations are not done. A the blood vessels with each cardiac contraction.
low residue diet will prevent bowel movement Signs of effective tissue perfusion will be noted
that could lead to dislodgement of the implant. after.
Patient is also strictly isolated to protect other 31. Answer: (C) Flushing of the lids, conjunctiva
people from the radiation emissions and cornea with tap or preferably sterile
23. Answer: (A) Avoid BP measurement and water . Prompt treatment of ocular chemical
constricting clothing on the affected arm . A BP burns is important to prevent further damage.
cuff constricts the blood vessels where it is Immediate tap-water eye irrigation should be
applied. BP measurements should be done on started on site even before transporting the
the unaffected arm to ensure adequate patient to the nearest hospital facility. In the
circulation and venous and lymph drainage in hospital, copious irrigation with normal saline,
the affected arm instillation of local anesthetic and antibiotic is
24. Answer: (C) Hypovolemia, wide fluctuations in done.
serum sodium and potassium levels. . The 32. Answer: (A) Force air out of the lungs . The
second phase of ARF is the diuretic phase or Heimlich maneuver is used to assist a person
high output phase. The diuresis can result in an choking on a foreign object. The pressure from
output of up to 10L/day of dilute urine. Loss of the thrusts lifts the diaphragm, forces air out of
fluids and electrolytes occur. the lungs and creates an artificial cough that
25. Answer: (A) A rapid pulse and increased expels the aspirated material.
RR . The fight or flight reaction of the 33. Answer: (B) speak to both parents together and
sympathetic nervous system occurs during encourage them to support each other and
stress like in a motor vehicular accident. This is express their emotions freely . Sudden death of
manifested by increased in cardiovascular a family member creates a state of shock on the
function and RR to provide the immediate family. They go into a stage of denial and anger
needs of the body for survival. in their grieving. Assisting them with
26. Answer: (D) assessing her VS especially her information they need to know, answering their
RR . Shock is characterized by reduced tissue questions and listening to them will provide the
and organ perfusion and eventual organ needed support for them to move on and be of
dysfunction and failure. Checking on the VS support to one another.
especially the RR, which detects need for 34. Answer: (C) relax the bronchial smooth
oxygenation, is a priority to help detect its muscle . Acute asthmatic attack is characterized
progress and provide for prompt management by severe bronchospasm which can be relieved
before the occurrence of complications. by the immediate administration of
15

bronchodilators. Adrenaline or Epinephrine is clearly indicate a problem of decrease cerebral

an adrenergic agent that causes bronchial perfusion. Restoring cerebral perfusion is most
dilation by relaxing the bronchial smooth important to maintain cerebral functioning and
muscles. prevent further brain damage.
35. Answer: (C) lower half of the sternum . The 45. Answer: (D) Ineffective airway clearance
exact and safe location to do cardiac related to muscle weakness . Myasthenia gravis
compression is the lower half of the sternum. causes a failure in the transmission of nerve
Doing it at the lower third of the sternum may impulses at the neuromuscular junction which
cause gastric compression which can lead to a may be due to a weakening or decrease in
possible aspiration. acetylcholine receptor sites. This leads to
36. Answer: (B) “As one ages, visual changes are sporadic, progressive weakness or abnormal
noted as part of degenerative changes. This is fatigability of striated muscles that eventually
normal.” . Aging causes less elasticity of the causes loss of function. The respiratory muscles
lens affecting accommodation leading to can become weak with decreased tidal volume
blurred vision. The muscles of the iris increase and vital capacity making breathing and
in stiffness and the pupils dilate slowly and less clearing the airway through coughing difficult.
completely so that it takes the older person to The respiratory muscle weakness may be severe
adjust when going to and from light and dark enough to require and emergency airway and
environment and needs brighter light for close mechanical ventilation.
vision. 46. Answer: (C) Test for glucose . The CSF
37. Answer: (D) sexual intercourse . To reduce contains a large amount of glucose which can
increases in IOP, teach the client and family be detected by using glucostix. A positive result
about activity restrictions. Sexual intercourse with the drainage indicate CSF leakage.
can cause a sudden rise in IOP. 47. Answer: (C) Apply a “shrinker” bandage with
38. Answer: (C) Speak clearly in a loud voice or tighter arms around the proximal end of the
shout to be heard . Shouting raises the affected limb. The “shrinker” bandage is
frequency of the sound and often makes applied to prevent swelling of the stump. It
understanding the spoken words difficult. It is should be applied with the distal end with the
enough for the nurse to speak clearly and tighter arms. Applying the tighter arms at the
slowly. proximal end will impair circulation and cause
39. Answer: (D) Force fluids before and after the swelling by reducing venous flow.
procedure. LP involves the removal of some 48. Answer: (D) Place items so that it is necessary
amount of spinal fluid. To facilitate CSF to bend or stretch to reach them. Patients with
production, the client is instructed to increase osteoarthritis have decreased mobility caused
fluid intake to 3L, unless contraindicated, for 24 by joint pain. Over-reaching and stretching to
to 48 hrs after the procedure. get an object are to be avoided as this can cause
40. Answer: (D) Kept the extremity used as more pain and can even lead to falls. The nurse
puncture site flexed to prevent should see to it therefore that objects are within
bleeding. Angiography involves the threading easy reach of the patient.
of a catheter through an artery which can cause 49. Answer: (D) Ensure an intake of at least 3000
trauma to the endothelial lining of the blood ml of fluid per day. Gouty arthritis is a
vessel. The platelets are attracted to the area metabolic disease marked by urate deposits that
causing thrombi formation. This is further cause painful arthritic joints. The patient should
enhanced by the slowing of blood flow caused be urged to increase his fluid intake to prevent
by flexion of the affected extremity. The the development of urinary uric acid stones.
affected extremity must be kept straight and 50. Answer: (B) Before log rolling, remove the
immobilized during the duration of the bedrest pillow from under the client’s head and use no
after the procedure. Ice bag can be applied pillows between the client’s legs. Following a
intermittently to the puncture site. laminectomy and spinal fusion, it is important
41. Answer: (D) progression from restlessness to that the back of the patient be maintained in
confusion and disorientation to lethargy . The straight alignment and to support the entire
first major effect of increasing ICP is a decrease vertebral column to promote complete healing.
in cerebral perfusion causing hypoxia that Text Mode – Text version of the exam
produces a progressive alteration in the LOC. 1. The nurse is assisting in planning care for a client
This is initially manifested by restlessness. with a diagnosis of immune deficiency. The nurse
42. Answer: (D) Aspirin is used in the acute would incorporate which of the ff. as a priority in the
management of a completed stroke. . The plan of care?
primary goal in the management of CVA is to
improve cerebral tissue perfusion. Aspirin is a A. providing emotional support to decrease fear
platelet deaggregator used in the prevention of B. protecting the client from infection
recurrent or embolic stroke but is not used in C. encouraging discussion about lifestyle changes
the acute management of a completed stroke as D. .identifying factors that decreased the immune
it may lead to bleeding. function
43. Answer: (D) Encourage the client to speak at 2. Joy, an obese 32 year old, is admitted to the
every possible opportunity. Expressive or motor hospital after an automobile accident. She has a
aphasia is a result of damage in the Broca’s area fractured hip and is brought to the OR for surgery.
of the frontal lobe. It is amotor speech problem After surgery Joy is to receive a piggy-back of
in which the client generally understands what Clindamycin phosphate (Cleocin) 300 mg in 50 ml of
is said but is unable to communicate verbally. D5W. The piggyback is to infuse in 20 minutes. The
The patient can best he helped therefore by drop factor of the IV set is 10 gtt/ml. The nurse
encouraging him to communicate and reinforce should set the piggyback to flow at:
this behavior positively.
44. Answer: (C) altered cerebral tissue
perfusion . The observations made by the nurse A. 25 gtt/min
B. 30 gtt/min
16

C. 5 gtt/min test that is the most reliable early indicator of

D. 45 gtt/min myocardial insult is:
3. The day after her surgery Joy asks the nurse how
she might lose weight. Before answering her A. SGPT
question, the nurse should bear in mind that long- B. LDH
term weight loss best occurs when: C. CK-MB
D. AST
A. Fats are controlled in the diet 11. An early finding in the EKG of a client with an
B. Eating habits are altered infarcted mycardium would be:
C. Carbohydrates are regulated
D. Exercise is part of the program A. Disappearance of Q waves
4. The nurse teaches Joy, an obese client, the value of B. Elevated ST segments
aerobic exercises in her weight reduction program. C. Absence of P wave
The nurse would know that this teaching was D. Flattened T waves
effective when Joy says that exercise will: 12. Jose, who had a myocardial infarction 2 days
earlier, has been complaining to the nurse about
A. Increase her lean body mass issues related to his hospital stay. The best initial
B. Lower her metabolic rate nursing response would be to:
C. Decrease her appetite
D. Raise her heart rate A. Allow him to release his feelings and then leave
5. The physician orders non-weight bearing with him alone to allow him to regain his composure
crutches for Joy, who had surgery for a fractured hip. B. Refocus the conversation on his fears,
The most important activity to facilitate walking with frustrations and anger about his condition
crutches before ambulation begun is: C. Explain how his being upset dangerously
disturbs his need for rest
A. Exercising the triceps, finger flexors, and elbow D. Attempt to explain the purpose of different
extensors hospital routines
B. Sitting up at the edge of the bed to help 13. Twenty four hours after admission for an Acute
strengthen back muscles MI, Jose’s temperature is noted at 39.3 C. The nurse
C. Doing isometric exercises on the unaffected leg monitors him for other adaptations related to the
D. Using the trapeze frequently for pull-ups to pyrexia, including:
strengthen the biceps muscles
6. The nurse recognizes that a client understood the A. Shortness of breath
demonstration of crutch walking when she places her B. Chest pain
weight on: C. Elevated blood pressure
D. Increased pulse rate
A. The palms and axillary regions 14. Jose, who is admitted to the hospital for chest
B. Both feet placed wide apart pain, asks the nurse, “Is it still possible for me to
C. The palms of her hands have another heart attack if I watch my diet
D. Her axillary regions religiously and avoid stress?” The most appropriate
7. Joey is a 46 year-old radio technician who is initial response would be for the nurse to:
admitted because of mild chest pain. He is 5 feet, 8
inches tall and weighs 190 pounds. He is diagnosed A. Suggest he discuss his feelings of vulnerability
with a myocardial infarct. Morphine sulfate, with his physician.
Diazepam (Valium) and Lidocaine are prescribed. B. Tell him that he certainly needs to be especially
The physician orders 8 mg of Morphine Sulfate to be careful about his diet and lifestyle.
given IV. The vial on hand is labeled 1 ml/ 10 mg. C. Avoid giving him direct information and help
The nurse should administer: him explore his feelings
D. Recognize that he is frightened and suggest he
A. 8 minims talk with the psychiatrist or counselor.
B. 10 minims 15. Ana, 55 years old, is admitted to the hospital to
C. 12 minims rule out pernicious anemia. A Schilling test is ordered
D. 15 minims for Ana. The nurse recognizes that the primary
8. Joey asks the nurse why he is receiving the purpose of the Schilling test is to determine the
injection of Morphine after he was hospitalized for client’s ability to:
severe anginal pain. The nurse replies that it:
A. Store vitamin B12
A. Will help prevent erratic heart beats B. Digest vitamin B12
B. Relieves pain and decreases level of anxiety C. Absorb vitamin B12
C. Decreases anxiety D. Produce vitamin B12
D. Dilates coronary blood vessels 16. Ana is diagnosed to have Pernicious anemia. The
9. Oxygen 3L/min by nasal cannula is prescribed for physician orders 0.2 mg of Cyanocobalamin (Vitamin
Joey who is admitted to the hospital for chest pain. B12) IM. Available is a vial of the drug labeled 1
The nurse institutes safety precautions in the room ml= 100 mcg. The nurse should administer:
because oxygen:
A. 0.5 ml
A. Converts to an alternate form of matter B. 1.0 ml
B. Has unstable properties C. 1.5 ml
C. Supports combustion D. 2.0 ml
D. Is flammable 17. Health teachings to be given to a client with
10. Myra is ordered laboratory tests after she is Pernicious Anemia regarding her therapeutic regimen
admitted to the hospital for angina. The isoenzyme concerning Vit. B12 will include:
17

A. Oral tablets of Vitamin B12 will control her 24. The nurse would know that dietary teaching had
symptoms been effective for a client with colostomy when he
B. IM injections are required for daily control states that he will eat:
C. IM injections once a month will maintain
control A. Food low in fiber so that there is less stool
D. Weekly Z-track injections provide needed B. Everything he ate before the operation but will
control avoid those foods that cause gas
18. The nurse knows that a client with Pernicious C. Bland foods so that his intestines do not
Anemia understands the teaching regarding the become irritated
vitamin B12 injections when she states that she must D. Soft foods that are more easily digested and
take it: absorbed by the large intestines
25. Eddie, 40 years old, is brought to the emergency
A. When she feels fatigued room after the crash of his private plane. He has
B. During exacerbations of anemia suffered multiple crushing wounds of the chest,
C. Until her symptoms subside abdomen and legs. It is feared his leg may have to be
D. For the rest of her life amputated. When Eddie arrives in the emergency
19. Arthur Cruz, a 45 year old artist, has recently had room, the assessment that assume the greatest priority
an abdominoperineal resection and colostomy. Mr. are:
Cruz accuses the nurse of being uncomfortable
during a dressing change, because his “wound looks A. Level of consciousness and pupil size
terrible.” The nurse recognizes that the client is using B. Abdominal contusions and other wounds
the defense mechanism known as: C. Pain, Respiratory rate and blood pressure
D. Quality of respirations and presence of
A. Reaction Formation pulsesQuality of respirations and presence of
B. Sublimation pulses
C. Intellectualization 26. Eddie, a plane crash victim, undergoes
D. Projection endotracheal intubation and positive pressure
20. When preparing to teach a client with colostomy ventilation. The most immediate nursing intervention
how to irrigate his colostomy, the nurse should plan for him at this time would be to:
to perform the procedure:
A. Facilitate his verbal communication
A. When the client would have normally had a B. Maintain sterility of the ventilation system
bowel movement C. Assess his response to the equipment
B. After the client accepts he had a bowel D. Prepare him for emergency surgery
movement 27. A chest tube with water seal drainage is inserted
C. Before breakfast and morning care to a client following a multiple chest injury. A few
D. At least 2 hours before visitors arrive hours later, the client’s chest tube seems to be
21. When observing an ostomate do a return obstructed. The most appropriate nursing action
demonstration of the colostomy irrigation, the nurse would be to
notes that he needs more teaching if he:
A. Prepare for chest tube removal
A. Stops the flow of fluid when he feels B. Milk the tube toward the collection container as
uncomfortable ordered
B. Lubricates the tip of the catheter before C. Arrange for a stat Chest x-ray film.
inserting it into the stoma D. Clam the tube immediately
C. Hangs the bag on a clothes hook on the 28. The observation that indicates a desired response
bathroom door during fluid insertion to thoracostomy drainage of a client with chest injury
D. Discontinues the insertion of fluid after only is:
500 ml of fluid has been instilled
22. When doing colostomy irrigation at home, a A. Increased breath sounds
client with colostomy should be instructed to report B. Constant bubbling in the drainage chamber
to his physician : C. Crepitus detected on palpation of chest
D. Increased respiratory rate
A. Abdominal cramps during fluid inflow 29. In the evaluation of a client’s response to fluid
B. Difficulty in inserting the irrigating tube replacement therapy, the observation that indicates
C. Passage of flatus during expulsion of feces adequate tissue perfusion to vital organs is:
D. Inability to complete the procedure in half an
hour A. Urinary output is 30 ml in an hour
23. A client with colostomy refuses to allow his wife B. Central venous pressure reading of 2 cm H2O
to see the incision or stoma and ignores most of his C. Pulse rates of 120 and 110 in a 15 minute
dietary instructions. The nurse on assessing this data, period
can assume that the client is experiencing: D. Blood pressure readings of 50/30 and 70/40
within 30 minutes
A. A reaction formation to his recent altered body 30. A client with multiple injury following a
image. vehicular accident is transferred to the critical care
B. A difficult time accepting reality and is in a unit. He begins to complain of increased abdominal
state of denial. pain in the left upper quadrant. A ruptured spleen is
C. Impotency due to the surgery and needs sexual diagnosed and he is scheduled for emergency
counseling splenectomy. In preparing the client for surgery, the
D. Suicide thoughts and should be seen by nurse should emphasize in his teaching plan the:
psychiatrist
A. Complete safety of the procedure
18

B. Expectation of postoperative bleeding B. “He who laughs on the outside, cries on the
C. Risk of the procedure with his other injuries inside.”
D. Presence of abdominal drains for several days C. “Why are you always laughing?”
after surgery D. “Does it help you to joke about your illness?”
31. To promote continued improvement in the 38. In dealing with a dying client who is in the denial
respiratory status of a client following chest tube stage of grief, the best nursing approach is to:
removal after a chest surgery for multiple rib fracture,
the nurse should: A. Agree with and encourage the client’s denial
B. Reassure the client that everything will be okay
A. Encourage bed rest with active and passive C. Allow the denial but be available to discuss
range of motion exercises death
B. Encourage frequent coughing and deep D. Leave the client alone to discuss the loss
breathing 39. During and 8 hour shift, Mario drinks two 6 oz.
C. Turn him from side to side at least every 2 cups of tea and vomits 125 ml of fluid. During this 8
hours hour period, his fluid balance would be:
D. Continue observing for dyspnea and crepitus
32. A client undergoes below the knee amputation A. +55 ml
following a vehicular accident. Three days B. +137 ml
postoperatively, the client is refusing to eat, talk or C. +235 ml
perform any rehabilitative activities. The best initial D. +485 ml
nursing approach would be to: 40. Mr. Ong is admitted to the hospital with a
diagnosis of Left-sided CHF. In the assessment, the
A. Give him explanations of why there is a need to nurse should expect to find:
quickly increase his activity
B. Emphasize repeatedly that with as prosthesis, A. Crushing chest pain
he will be able to return to his normal lifestyle B. Dyspnea on exertion
C. Appear cheerful and non-critical regardless of C. Extensive peripheral edema
his response to attempts at intervention D. Jugular vein distention
D. Accept and acknowledge that his withdrawal is 41. The physician orders on a client with CHF a
an initially normal and necessary part of cardiac glycoside, a vasodilator, and furosemide
grieving (Lasix). The nurse understands Lasix exerts is effects
33. The key factor in accurately assessing how body in the:
image changes will be dealt with by the client is the:
A. Distal tubule
A. Extent of body change present B. Collecting duct
B. Suddenness of the change C. Glomerulus of the nephron
C. Obviousness of the change D. Ascending limb of the loop of Henle
D. Client’s perception of the change 42. Mr. Ong weighs 210 lbs on admission to the
34. Larry is diagnosed as having myelocytic hospital. After 2 days of diuretic therapy he weighs
leukemia and is admitted to the hospital for 205.5 lbs. The nurse could estimate that the amount
chemotherapy. Larry discusses his recent diagnosis of of fluid he has lost is:
leukemia by referring to statistical facts and figures.
The nurse recognizes that Larry is using the defense
mechanism known as: A. 0.5 L
B. 1.0 L
C. 2.0 L
A. Reaction formation D. 3.5 L
B. Sublimation 43. Mr. Ong, a client with CHF, has been receiving a
C. Intellectualization cardiac glycoside, a diuretic, and a vasodilator drug.
D. Projection His apical pulse rate is 44 and he is on bed rest. The
35. The laboratory results of the client with leukemia nurse concludes that his pulse rate is most likely the
indicate bone marrow depression. The nurse should result of the:
encourage the client to:
A. Diuretic
A. Increase his activity level and ambulate B. Vasodilator
frequently C. Bed-rest regimen
B. Sleep with the head of his bed slightly elevated D. Cardiac glycoside
C. Drink citrus juices frequently for nourishment 44. The diet ordered for a client with CHF permits
D. Use a soft toothbrush and electric razor him to have a 190 g of carbohydrates, 90 g of fat and
36. Dennis receives a blood transfusion and develops 100 g of protein. The nurse understands that this diet
flank pain, chills, fever and hematuria. The nurse contains approximately:
recognizes that Dennis is probably experiencing:
A. 2200 calories
A. An anaphylactic transfusion reaction B. 2000 calories
B. An allergic transfusion reaction C. 2800 calories
C. A hemolytic transfusion reaction D. 1600 calories
D. A pyrogenic transfusion reaction 45. After the acute phase of congestive heart failure,
37. A client jokes about his leukemia even though he the nurse should expect the dietary management of
is becoming sicker and weaker. The nurse’s most the client to include the restriction of:
therapeutic response would be:
A. Magnesium
A. “Your laugher is a cover for your fear.” B. Sodium
C. Potassium
19

D. Calcium A. 30 degrees
46. Jude develops GI bleeding and is admitted to the B. 45 degrees
hospital. An important etiologic clue for the nurse to C. 60 degrees
explore while taking his history would be: D. 90 degrees
54. Rene, age 62, is scheduled for a TURP after being
A. The medications he has been taking diagnosed with a Benign Prostatic Hyperplasia
B. Any recent foreign travel (BPH). As part of the preoperative teaching, the
C. His usual dietary pattern nurse should tell the client that after surgery:
D. His working patterns
47. The meal pattern that would probably be most A. Urinary control may be permanently lost to
appropriate for a client recovering from GI bleeding some degree
is: B. Urinary drainage will be dependent on a
urethral catheter for 24 hours
A. Three large meals large enough to supply C. Frequency and burning on urination will last
adequate energy. while the cystotomy tube is in place
B. Regular meals and snacks to limit gastric D. His ability to perform sexually will be
discomfort permanently impaired
C. Limited food and fluid intake when he has pain 55. The transurethral resection of the prostate is
D. A flexible plan according to his appetite performed on a client with BPH. Following surgery,
48. A client with a history of recurrent GI bleeding is nursing care should include:
admitted to the hospital for a gastrectomy. Following
surgery, the client has a nasogastric tube to low A. Changing the abdominal dressing
continuous suction. He begins to hyperventilate. The B. Maintaining patency of the cystotomy tube
nurse should be aware that this pattern will alter his C. Maintaining patency of a three-way Foley
arterial blood gases by: catheter for cystoclysis
D. Observing for hemorrhage and wound infection
A. Increasing HCO3 56. In the early postoperative period following a
B. Decreasing PCO2 transurethral surgery, the most common complication
C. Decreasing pH the nurse should observe for is:
D. Decreasing PO2
49. Routine postoperative IV fluids are designed to A. Sepsis
supply hydration and electrolyte and only limited B. Hemorrhage
energy. Because 1 L of a 5% dextrose solution C. Leakage around the catheter
contains 50 g of sugar, 3 L per day would apply D. Urinary retention with overflow
approximately: 57. Following prostate surgery, the retention catheter
is secured to the client’s leg causing slight traction of
A. 400 Kilocalories the inflatable balloon against the prostatic fossa. This
B. 600 Kilocalories is done to:
C. 800 Kilocalories
D. 1000 Kilocalories A. Limit discomfort
50. Thrombus formation is a danger for all B. Provide hemostasis
postoperative clients. The nurse should act C. Reduce bladder spasms
independently to prevent this complication by: D. Promote urinary drainage
58. Twenty-four hours after TURP surgery, the client
A. Encouraging adequate fluids tells the nurse he has lower abdominal discomfort.
B. Applying elastic stockings The nurse notes that the catheter drainage has
C. Massaging gently the legs with lotion stopped. The nurse’s initial action should be to:
D. Performing active-assistive leg exercises
51. An unconscious client is admitted to the ICU, IV A. Irrigate the catheter with saline
fluids are started and a Foley catheter is inserted. B. Milk the catheter tubing
With an indwelling catheter, urinary infection is a C. Remove the catheter
potential danger. The nurse can best plan to avoid D. Notify the physician
this problem by: 59. The nurse would know that a post-TURP client
understood his discharge teaching when he says “I
A. Emptying the drainage bag frequently should:”
B. Collecting a weekly urine specimen
C. Maintaining the ordered hydration A. Get out of bed into a chair for several hours
D. Assessing urine specific gravity daily
52. The nurse performs full range of motion on a B. Call the physician if my urinary stream
bedridden client’s extremities. When putting his decreases
ankle through range of motion, the nurse must C. Attempt to void every 3 hours when I’m awake
perform: D. Avoid vigorous exercise for 6 months after
surgery
A. Flexion, extension and left and right rotation 60. Lucy is admitted to the surgical unit for a subtotal
B. Abduction, flexion, adduction and extension thyroidectomy. She is diagnosed with Grave’s
C. Pronation, supination, rotation, and extension Disease. When assessing Lucy, the nurse would
D. Dorsiflexion, plantar flexion, eversion and expect to find:
inversion
53. A client has been in a coma for 2 months. The A. Lethargy, weight gain, and forgetfulness
nurse understands that to prevent the effects of B. Weight loss, protruding eyeballs, and lethargy
shearing force on the skin, the head of the bed should C. Weight loss, exopthalmos and restlessness
be at an angle of: D. Constipation, dry skin, and weight gain
20

61. Lucy undergoes Subtotal Thyroidectomy for be administered q12 h. The drop factor of the tubing
Grave’s Disease. In planning for the client’s return is 10 gtt/ml. The nurse should set the flow to provide:
from the OR, the nurse would consider that in a
subtotal thyroidectomy: A. 18 gtt/min
B. 28 gtt/min
A. The entire thyroid gland is removed C. 32 gtt/min
B. A small part of the gland is left intact D. 36 gtt/min
C. One parathyroid gland is also removed 69. Clara, a burn client, receives a temporary
D. A portion of the thyroid and four parathyroids heterograft (pig skin) on some of her burns. These
are removed grafts will:
62. Before a post- thyroidectomy client returns to her
room from the OR, the nurse plans to set up A. Debride necrotic epithelium
emergency equipment, which should include: B. Be sutured in place for better adherence
C. Relieve pain and promote rapid epithelialization
A. A crash cart with bed board D. Frequently be used concurrently with topical
B. A tracheostomy set and oxygen antimicrobials.
C. An airway and rebreathing mask 70. A client with burns on the chest has periodic
D. Two ampules of sodium bicarbonate episodes of dyspnea. The position that would provide
63. When a post-thyroidectomy client returns from for the greatest respiratory capacity would be the:
surgery the nurse assesses her for unilateral injury of
the laryngeal nerve every 30 to 60 minutes by: A. Semi-fowler’s position
B. Sims’ position
A. Observing for signs of tetany C. Orthopneic position
B. Checking her throat for swelling D. Supine position
C. Asking her to state her name out loud 71. Jane, a 20- year old college student is admiited to
D. Palpating the side of her neck for blood seepage the hospital with a tentative diagnosis of myasthenia
64. On a post-thyroidectomy client’s discharge, the gravis. She is scheduled to have a series of diagnostic
nurse teaches her to observe for signs of surgically studies for myasthenia gravis, including a Tensilon
induced hypothyroidism. The nurse would know that test. In preparing her for this procedure, the nurse
the client understands the teaching when she states explains that her response to the medication will
she should notify the physician if she develops: confirm the diagnosis if Tensilon produces:

A. Intolerance to heat A. Brief exaggeration of symptoms

B. Dry skin and fatigue B. Prolonged symptomatic improvement
C. Progressive weight loss C. Rapid but brief symptomatic improvement
D. Insomnia and excitability D. Symptomatic improvement of just the ptosis
65. A client’s exopthalmos continues inspite of 72. The initial nursing goal for a client with
thyroidectomy for Grave’s Disease. The nurse myasthenia gravis during the diagnostic phase of her
teaches her how to reduce discomfort and prevent hospitalization would be to:
corneal ulceration. The nurse recognizes that the
client understands the teaching when she says: “I A. Develop a teaching plan
should: B. Facilitate psychologic adjustment
C. Maintain the present muscle strength
A. Elevate the head of my bed at night D. Prepare for the appearance of myasthenic crisis
B. Avoid moving my extra-ocular muscles 73. The most significant initial nursing observations
C. Avoid using a sleeping mask at night that need to be made about a client with myasthenia
D. Avoid excessive blinking include:
66. Clara is a 37-year old cook. She is admitted for
treatment of partial and full-thickness burns of her A. Ability to chew and speak distinctly
entire right lower extremity and the anterior portion B. Degree of anxiety about her diagnosis
of her right upper extremity. Her respiratory status is C. Ability to smile an to close her eyelids
compromised, and she is in pain and anxious. D. Respiratory exchange and ability to swallow
Performing an immediate appraisal, using the rule of 74. Helen is diagnosed with myasthenia gravis and
nines, the nurse estimates the percent of Clara’s body pyridostigmine bromide (Mestinon) therapy is
surface that is burned is: started. The Mestinon dosage is frequently changed
during the first week. While the dosage is being
A. 4.5% adjusted, the nurse’s priority intervention is to:
B. 9%
C. 18 % A. Administer the medication exactly on time
D. 22.5% B. Administer the medication with food or mild
67. The nurse applies mafenide acetate (Sulfamylon C. Evaluate the client’s muscle strength hourly
cream) to Clara, who has second and third degree after medication
burns on the right upper and lower extremities, as D. Evaluate the client’s emotional side effects
ordered by the physician. This medication will: between doses
75. Helen, a client with myasthenia gravis, begins to
A. Inhibit bacterial growth experience increased difficulty in swallowing. To
B. Relieve pain from the burn prevent aspiration of food, the nursing action that
C. Prevent scar tissue formation would be most effective would be to:
D. Provide chemical debridement
68. Forty-eight hours after a burn injury, the A. Change her diet order from soft foods to clear
physician orders for the client 2 liters of IV fluid to liquids
21

B. Place an emergency tracheostomy set in her results in an increase in oxygen consumption

room and demand. This need for oxygen increases the
C. Assess her respiratory status before and after heart rate, which is reflected in the increased
meals pulse rate. Increased BP, chest pain and
D. Coordinate her meal schedule with the peak shortness of breath are not typically noted in
effect of her medication, Mestinon fever.
Answers and Rationales 14. Answer: (C) Avoid giving him direct
information and help him explore his
1. Answer: (B) protecting the client from feelings . To help the patient verbalize and
infection. Immunodeficiency is an absent or explore his feelings, the nurse must reflect and
depressed immune response that increases analyze the feelings that are implied in the
susceptibility to infection. So it is the nurse’s client’s question. The focus should be on
primary responsibility to protect the patient collecting data to minister to the client’s
from infection. psychosocial needs.
2. Answer: (A) 25 gtt/min . To get the correct 15. Answer: (C) Absorb vitamin B12 . Pernicious
flow rate: multiply the amount to be infused (50 anemia is caused by the inability to absorb
ml) by the drop factor (10) and divide the result vitamin B12 in the stomach due to a lack of
by the amount of time in minutes (20) intrinsic factor in the gastric juices. In the
3. Answer: (B) Eating habits are altered . For Schilling test, radioactive vitamin B12 is
weight reduction to occur and be maintained, a administered and its absorption and excretion
new dietary program, with a balance of foods can be ascertained through the urine.
from the basic four food groups, must be 16. Answer: (D) 2.0 ml . First convert milligrams to
established and continued micrograms and then use ratio and proportion
4. Answer: (A) Increase her lean body (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml :
mass . Increased exercise builds skeletal muscle ml 100 X= 200 X = 2 ml. Inject 2 ml. to give
mass and reduces excess fatty tissue. 0.2 mg of Cyanocobalamin.
5. Answer: (A) Exercising the triceps, finger 17. Answer: (C) IM injections once a month will
flexors, and elbow extensors . These sets of maintain control . Deep IM injections bypass
muscles are used when walking with crutches B12 absorption defect in the stomach due to
and therefore need strengthening prior to lack of intrinsic factor, the transport carrier
ambulation. component of gastric juices. A monthly dose is
6. Answer: (C) The palms of her hands .The palms usually sufficient since it is stored in active
should bear the client’s weight to avoid damage body tissues such as the liver, kidney, heart,
to the nerves in the axilla (brachial plexus) muscles, blood and bone marrow
7. Answer: (C) 12 minims . Using ratio and 18. Answer: (D) For the rest of her life . Since the
proportion 8 mg/10 mg = X minims/15 minims intrinsic factor does not return to gastric
10 X= 120 X = 12 minims The nurse will secretions even with therapy, B12 injections
administer 12 minims intravenously equivalent will be required for the remainder of the client’s
to 8mg Morphine Sulfate life.
8. Answer: (B) Relieves pain and decreases level 19. Answer: (D) Projection. Projection is the
of anxiety. Morphine is a specific central attribution of unacceptable feelings and
nervous system depressant used to relieve the emotions to others which may indicate the
pain associated with myocardial infarction. It patients nonacceptance of his condition.
also decreases anxiety and apprehension and 20. Answer: (A) When the client would have
prevents cardiogenic shock by decreasing normally had a bowel movement . Irrigation
myocardial oxygen demand. should be performed at the time the client
9. Answer: (C) Supports combustion. The nurse normally defecated before the colostomy to
should know that Oxygen is necessary to maintain continuity in lifestyle and usual bowel
produce fire, thus precautionary measures are function/habit.
important regarding its use. 21. Answer: (C) Hangs the bag on a clothes hook
10. Answer: (C) CK-MB. The cardiac marker, on the bathroom door during fluid
Creatinine phosphokinase (CPK) isoenzyme insertion . The irrigation bag should be hung
levels, especially the MB sub-unit which is 12-18 inches above the level of the stoma; a
cardio-specific, begin to rise in 3-6 hours, peak clothes hook is too high which can create
in 12-18 hours and are elevated 48 hours after increase pressure and sudden intestinal
the occurrence of the infarct. They are therefore distention and cause abdominal discomfort to
most reliable in assisting with early diagnosis. the patient.
The cardiac markers elevate as a result of 22. Answer: (B) Difficulty in inserting the
myocardial tissue damage. irrigating tube . Difficulty of inserting the
11. Answer: (B) Elevated STsegments . This is a irrigating tube indicates stenosis of the stoma
typical early finding after a myocardial infarct and should be reported to the physician.
because of the altered contractility of the heart. Abdominal cramps and passage of flatus can be
The other choices are not typical of MI. expected during colostomy irrigations. The
12. Answer: (B) Refocus the conversation on his procedure may take longer than half an hour.
fears, frustrations and anger about his condition 23. Answer: (B) A difficult time accepting reality
. This provides the opportunity for the client to and is in a state of denial. As long as no one
verbalize feelings underlying behavior and else confirms the presence of the stoma and the
helpful in relieving anxiety. Anxiety can be a client does not need to adhere to a prescribed
stressor which can activate the sympathoadrenal regimen, the client’s denial is supported
response causing the release of catecholamines 24. Answer: (B) Everything he ate before the
that can increase cardiac contractility and operation but will avoid those foods that cause
workload that can further increase myocardial gas . There is no special diets for clients with
oxygen demand. colostomy. These clients can eat a regular diet.
13. Answer: (D) Increased pulse rate . Fever causes
an increase in the body’s metabolism, which
22

Only gas-forming foods that cause distention client’s only way of coping, and it permits
and discomfort should be avoided. future movement through the grieving process
25. Answer: (D) Quality of respirations and when the client is ready. Dying clients move
presence of pulsesQuality of respirations and through the different stages of grieving and the
presence of pulses . Respiratory and nurse must be ready to intervene in all these
cardiovascular functions are essential for stages.
oxygenation. These are top priorities to trauma 39. Answer: (C) +235 ml . The client’s intake was
management. Basic life functions must be 360 ml (6oz x 30 ml) and loss was 125 ml of
maintained or reestablished fluid; loss is subtracted from intake
26. Answer: (C) Assess his response to the 40. Answer: (B) Dyspnea on exertion . Pulmonary
equipment . It is a primary nursing congestion and edema occur because of fluid
responsibility to evaluate effect of interventions extravasation from the pulmonary capillary bed,
done to the client. Nothing is achieved if the resulting in difficult breathing. Left-sided heart
equipment is working and the client is not failure creates a backward effect on the
responding pulmonary system that leads to pulmonary
27. Answer: (B) Milk the tube toward the collection congestion.
container as ordered . This assists in moving 41. Answer: (D) Ascending limb of the loop of
blood, fluid or air, which may be obstructing Henle . This is the site of action of Lasix being
drainage, toward the collection chamber a potent loop diuretic.
28. Answer: (A) Increased breath sounds . The 42. Answer: (C) 2.0 L . One liter of fluid weighs
chest tube normalizes intrathoracic pressure and approximately 2.2 lbs. Therefore a 4.5 lbs
restores negative intra-pleural pressure, drains weight loss equals approximately 2 Liters.
fluid and air from the pleural space, and 43. Answer: (D) Cardiac glycoside . A cardiac
improves pulmonary function glycoside such as digitalis increases force of
29. Answer: (A) Urinary output is 30 ml in an cardiac contraction, decreases the conduction
hour . A rate of 30 ml/hr is considered adequate speed of impulses within the myocardium and
for perfusion of kidney, heart and brain. slows the heart rate.
30. Answer: (D) Presence of abdominal drains for 44. Answer: (B) 2000 calories . There are 9 calories
several days after surgery . Drains are usually in each gram of fat and 4 calories in each gram
inserted into the splenic bed to facilitate of carbohydrate and protein
removal of fluid in the area that could lead to 45. Answer: (B) Sodium . Restriction of sodium
abscess formation. reduces the amount of water retention that
31. Answer: (B) Encourage frequent coughing and reduces the cardiac workload
deep breathing . This nursing action prevents 46. Answer: (A) The medications he has been
atelectasis and collection of respiratory taking . Some medications, such as aspirin and
secretions and promotes adequate ventilation prednisone, irritate the stomach lining and may
and gas exchange. cause bleeding with prolonged use
32. Answer: (D) Accept and acknowledge that his 47. Answer: (B) Regular meals and snacks to limit
withdrawal is an initially normal and necessary gastric discomfort . Presence of food in the
part of grieving . The withdrawal provides time stomach at regular intervals interacts with HCl
for the client to assimilate what has occurred limiting acid mucosal irritation. Mucosal
and integrate the change in the body image. irritation can lead to bleeding.
Acceptance of the client’s behavior is an 48. Answer: (B) Decreasing
important factor in the nurse’s intervention. PCO2 . Hyperventilation results in the
33. Answer: (D) Client’s perception of the increased elimination of carbon dioxide from
change . It is not reality, but the client’s feeling the blood that can lead to respiratory alkalosis.
about the change that is the most important 49. Answer: (B) 600 Kilocalories . Carbohydrates
determinant of the ability to cope. The client provide 4 kcal/ gram; therefore 3L x 50 g/L x 4
should be encouraged to his feelings. kcal/g = 600 kcal; only about a third of the
34. Answer: (C) Intellectualization . People use basal energy need.
defense mechanisms to cope with stressful 50. Answer: (D) Performing active-assistive leg
events. Intellectualization is the use of exercises . Inactivity causes venous stasis,
reasoning and thought processes to avoid the hypercoagulability, and external pressure
emotional upsets. against the veins, all of which lead to thrombus
35. Answer: (D) Use a soft toothbrush and electric formation. Early ambulation or exercise of the
razor . Suppression of red bone marrow lower extremities reduces the occurrence of this
increases bleeding susceptibility associated phenomenon
with thrombocytopenia, decreased platelets. 51. Answer: (C) Maintaining the ordered
Anemia and leucopenia are the two other hydration . Promoting hydration, maintains
problems noted with bone marrow depression. urine production at a higher rate, which flushes
36. Answer: (C) A hemolytic transfusion the bladder and prevents urinary stasis and
reaction . This results from a recipient’s possible infection
antibodies that are incompatible with transfused 52. Answer: (D) Dorsiflexion, plantar flexion,
RBC’s; also called type II hypersensitivity; eversion and inversion . These movements
these signs result from RBC hemolysis, include all possible range of motion for the
agglutination, and capillary plugging that can ankle joint
damage renal function, thus the flank pain and 53. Answer: (A) 30 degrees . Shearing force occurs
hematuria and the other manifestations. when 2 surfaces move against each other; when
37. Answer: (D) “Does it help you to joke about the bed is at an angle greater than 30 degrees,
your illness?” . This non-judgmentally on the the torso tends to slide and causes this
part of the nurse points out the client’s phenomenon. Shearing forces are good
behavior. contributory factors of pressure sores.
38. Answer: (C) Allow the denial but be available 54. Answer: (B) Urinary drainage will be
to discuss death . This does not take away the dependent on a urethral catheter for 24
23

hours . An indwelling urethral catheter is used, framework for granulation that promotes
because surgical trauma can cause urinary effective healing.
retention leading to further complications such 70. Answer: (C) Orthopneic position . The
as bleeding. orthopneic position lowers the diaphragm and
55. Answer: (C) Maintaining patency of a three- provides for maximal thoracic expansion
way Foley catheter for cystoclysis . Patency of 71. Answer: (C) Rapid but brief symptomatic
the catheter promotes bladder decompression, improvement . Tensilon acts systemically to
which prevents distention and bleeding. increase muscle strength; with a peak effect in
Continuous flow of fluid through the bladder 30 seconds, It lasts several minutes.
limits clot formation and promotes hemostasis 72. Answer: (C) Maintain the present muscle
56. Answer: (B) Hemorrhage . After transurethral strength . Until diagnosis is confirmed, primary
surgery, hemorrhage is common because of goal should be to maintain adequate activity
venous oozing and bleeding from many small and prevent muscle atrophy
arteries in the prostatic bed. 73. Answer: (D) Respiratory exchange and ability
57. Answer: (B) Provide hemostasis . The pressure to swallow . Muscle weakness can lead to
of the balloon against the small blood vessels of respiratory failure that will require emergency
the prostate creates a tampon-like effect that intervention and inability to swallow may lead
causes them to constrict thereby preventing to aspiration
bleeding. 74. Answer: (C) Evaluate the client’s muscle
58. Answer: (B) Milk the catheter tubing . Milking strength hourly after medication Peak response
the tubing will usually dislodge the plug and occurs 1 hour after administration and lasts up
will not harm the client. A physician’s order is to 8 hours; the response will influence dosage
not necessary for a nurse to check catheter levels.
patency. 75. Answer: (D) Coordinate her meal schedule with
59. Answer: (B) Call the physician if my urinary the peak effect of her medication,
stream decreases . Urethral mucosa in the Mestinon . Dysphagia should be minimized
prostatic area is destroyed during surgery and during peak effect of Mestinon, thereby
strictures my form with healing that causes decreasing the probability of aspiration.
partial or even complete ueinary obstruction. Mestinon can increase her muscle strength
60. Answer: (C) Weight loss, exopthalmos and including her ability to swallow.
restlessness . Classic signs associated with
hyperthyroidism are weight loss and Text Mode – Text version of the exam
restlessness because of increased basal 1. The nurse is performing her admission assessment
metabolic rate. Exopthalmos is due to of a patient. When grading arterial pulses, a 1+ pulse
peribulbar edema. indicates:
61. Answer: (B) A small part of the gland is left
intact . Remaining thyroid tissue may provide A. Above normal perfusion.
enough hormone for normal function. Total B. Absent perfusion.
thyroidectomy is generally done in clients with C. Normal perfusion.
Thyroid Ca. D. Diminished perfusion.
62. Answer: (B) A tracheostomy set and 2. Murmurs that indicate heart disease are often
oxygen . Acute respiratory obstruction in the accompanied by other symptoms such as:
post-operative period can result from edema,
subcutaneous bleeding that presses on the
trachea, nerve damage, or tetany. A. Dyspnea on exertion.
63. Answer: (C) Asking her to state her name out B. Subcutaneous emphysema.
loud . If the recurrent laryngeal nerve is C. Thoracic petechiae.
damaged during surgery, the client will be D. Periorbital edema.
hoarse and have difficult speaking. 3. Which pregnancy-related physiologic change
64. Answer: (B) Dry skin and fatigue . Dry skin is would place the patient with a history of cardiac
most likely caused by decreased glandular disease at the greatest risk of developing severe
function and fatigue caused by decreased cardiac problems?
metabolic rate. Body functions and metabolism
are decreased in hypothyroidism. A. Decrease heart rate
65. Answer: (C) Avoid using a sleeping mask at B. Decreased cardiac output
night . The mask may irritate or scratch the eye C. Increased plasma volume
if the client turns and lies on it during the night. D. Increased blood pressure
66. Answer: (D) 22.5% . The entire right lower 4. The priority nursing diagnosis for the patient with
extremity is 18% the anterior portion of the cardiomyopathy is:
right upper extremity is 4.5% giving a total of
22.5% A. Anxiety related to risk of declining health
67. Answer: (A) Inhibit bacterial status.
growth . Sulfamylon is effective against a wide B. Ineffective individual coping related to fear of
variety of gram positive and gram negative debilitating illness
organisms including anaerobes C. Fluid volume excess related to altered
68. Answer: (B) 28 gtt/min . This is the correct compensatory mechanisms.
flow rate; multiply the amount to be infused D. Decreased cardiac output related to reduced
(2000 ml) by the drop factor (10) and divide the myocardial contractility.
result by the amount of time in minutes (12 5. A patient with thrombophlebitis reached her
hours x 60 minutes) expected outcomes of care. Her affected leg appears
69. Answer: (C) Relieve pain and promote rapid pink and warm. Her pedal pulse is palpable and there
epithelialization . The graft covers nerve is no edema present. Which step in the nursing
endings, which reduces pain and provides a process is described above?
24

A. Planning C. Walking to the car on a cold winter day

B. Implementation D. Sitting on the beach in the sun on a summer day
C. Analysis 14. Gary Jordan suffered a cerebrovascular accident
D. Evaluation that left her unable to comprehend speech and unable
6. An elderly patient may have sustained a basilar to speak. This type of aphasia is known as:
skull fracture after slipping and falling on an icy
sidewalk. The nurse knows that basilar skull factures: A. Receptive aphasia
B. Expressive aphasia
A. Are the least significant type of skull fracture. C. Global aphasia
B. May have cause cerebrospinal fluid (CSF) leaks D. Conduction aphasia
from the nose or ears. 15. Kelly Smith complains that her headaches are
C. Have no characteristic findings. occurring more frequently despite medications.
D. Are always surgically repaired. Patients with a history of headaches should be taught
7. Which of the following types of drugs might be to avoid:
given to control increased intracranial pressure
(ICP)? A. Freshly prepared meats.
B. Citrus fruits.
A. Barbiturates C. Skim milk
B. Carbonic anhydrase inhibitors D. Chocolate
C. Anticholinergics 16. Immediately following cerebral aneurysm
D. Histamine receptor blockers rupture, the patient usually complains of:
8. The nurse is teaching family members of a patient
with a concussion about the early signs of increased A. Photophobia
intracranial pressure (ICP). Which of the following B. Explosive headache
would she cite as an early sign of increased ICP? C. Seizures
D. Hemiparesis
A. Decreased systolic blood pressure 17. Which of the following is a cause of embolic
B. Headache and vomiting brain injury?
C. Inability to wake the patient with noxious
stimuli A. Persistent hypertension
D. Dilated pupils that don’t react to light B. Subarachnoid hemorrhage
9. Jessie James is diagnosed with retinal detachment. C. Atrial fibrillation
Which intervention is the most important for this D. Skull fracture
patient? 18. Although Ms. Priestly has a spinal cord injury,
she can still have sexual intercourse. Discharge
A. Admitting him to the hospital on strict bed rest teaching should make her aware that:
B. Patching both of his eyes
C. Referring him to an ophthalmologist A. She must remove indwelling urinary catheter
D. Preparing him for surgery prior to intercourse.
10. Dr. Bruce Owen, a chemist, sustained a chemical B. She can no longer achieve orgasm.
burn to one eye. Which intervention takes priority for C. Positioning may be awkward.
a patient with a chemical burn of the eye? D. She can still get pregnant.
19.Ivy Hopkins, age 25, suffered a cervical fracture
A. Patch the affected eye and call the requiring immobilization with halo traction. When
ophthalmologist. caring for the patient in halo traction, the nurse must:
B. Administer a cycloplegic agent to reduce ciliary
spasm. A. Keep a wrench taped to the halo vest for quick
C. Immediately instill a tropical anesthetic, then removal if cardiopulmonary resuscitation is
irrigate the eye with saline solution. necessary.
D. Administer antibiotics to reduce the risk of B. Remove the brace once a day to allow the
infection patient to rest.
11. The nurse is assessing a patient and notes a C. Encourage the patient to use a pillow under the
Brudzinski’s sign and Kernig’s sign. These are two ring.
classic signs of which of the following disorders? D. Remove the brace so that the patient can
shower.
A. Cerebrovascular accident (CVA) 20. The nurse asks a patient’s husband if he
B. Meningitis understands why his wife is receiving nimodipine
C. Seizure disorder (Nimotop), since she suffered a cerebral aneurysm
D. Parkinson’s disease rupture. Which response by the husband indicates
12. A patient is admitted to the hospital for a brain that he understands the drug’s use?
biopsy. The nurse knows that the most common type
of primary brain tumor is: A. “Nimodipine replaces calcium.”
B. “Nimodipine promotes growth of blood vessels
A. Meningioma. in the brain.”
B. Angioma. C. “Nimodipine reduces the brain’s demand for
C. Hemangioblastoma. oxygen.”
D. Glioma. D. “Nimodipine reduces vasospasm in the brain.”
13. The nurse should instruct the patient with 21. Many men who suffer spinal injuries continue to
Parkinson’s disease to avoid which of the following? be sexually active. The teaching plan for a man with
a spinal cord injury should include sexually concerns.
A. Walking in an indoor shopping mall Which of the following injuries would most likely
B. Sitting on the deck on a cool summer evening prevent erection and ejaculation?
25

A. C5 A. It prevents urinary tract infection following

B. C7 surgery
C. T4 B. It prevents urine retention and resulting
D. S4 pressure on the perineal wound
22. Cathy Bates, age 36, is a homemaker who C. It minimizes the risk of wound contamination
frequently forgets to take her carbamazepine by the urine
(Tegretol). As a result, she has been experiencing D. It determines whether the surgery caused
seizures. How can the nurse best help the patient bladder trauma
remember to take her medication? 29. The first day after, surgery the nurse finds no
measurable fecal drainage from a patient’s colostomy
A. Tell her take her medication at bedtime. stoma. What is the most appropriate nursing
B. Instruct her to take her medication after one of intervention?
her favorite television shows.
C. Explain that she should take her medication A. Call the doctor immediately.
with breakfast. B. Obtain an order to irrigate the stoma.
D. Tell her to buy an alarm watch to remind her. C. Place the patient on bed rest and call the doctor.
23. Richard Barnes was diagnosed with D. Continue the current plan of care.
pneumococcal meningitis. What response by the 30. If a patient’s GI tract is functioning but he’s
patient indicates that he understands the precautions unable to take foods by mouth, the preferred method
necessary with this diagnosis? of feeding is:

A. “I’m so depressed because I can’t have any A. Total parenteral nutrition

visitors for a week.” B. Peripheral parenteral nutrition
B. “Thank goodness, I’ll only be in isolation for 24 C. Enteral nutrition
hours.” D. Oral liquid supplements
C. “The nurse told me that my urine and stool are 31. Which type of solution causes water to shift from
also sources of meningitis bacteria.” the cells into the plasma?
D. “The doctor is a good friend of mine and won’t
keep me in isolation.” A. Hypertonic
24. An early symptom associated with amyotrophic B. Hypotonic
lateral sclerosis (ALS) includes: C. Isotonic
D. Alkaline
A. Fatigue while talking 32. Particles move from an area of greater osmelarity
B. Change in mental status to one of lesser osmolarity through:
C. Numbness of the hands and feet
D. Spontaneous fractures A. Active transport
25. When caring for a patient with esophageal B. Osmosis
varices, the nurse knows that bleeding in this disorder C. Diffusion
usually stems from: D. Filtration
33. Which assessment finding indicates dehydration?
A. Esophageal perforation
B. Pulmonary hypertension A. Tenting of chest skin when pinched
C. Portal hypertension B. Rapid filling of hand veins
D. Peptic ulcers C. A pulse that isn’t easily obliterated
26. Tiffany Black is diagnosed with type A hepatitis. D. Neck vein distention
What special precautions should the nurse take when 34. Which nursing intervention would most likely
caring for this patient? lead to a hypo-osmolar state?

A. Put on a mask and gown before entering the A. Performing nasogastric tube irrigation with
patient’s room. normal saline solution
B. Wear gloves and a gown when removing the B. Weighing the patient daily
patient’s bedpan. C. Administering tap water enema until the return
C. Prevent the droplet spread of the organism. is clear
D. Use caution when bringing food to the patient. D. Encouraging the patient with excessive
27. Discharge instructions for a patient who has been perspiration to dink broth
operated on for colorectal cancer include irrigating 35. Which assessment finding would indicate an
the colostomy. The nurse knows her teaching is extracellular fluid volume deficit?
effective when the patient states he’ll contact the
doctor if:
A. Bradycardia
B. A central venous pressure of 6 mm Hg
A. He experiences abdominal cramping while the C. Pitting edema
irrigant is infusing D. An orthostatic blood pressure change
B. He has difficulty inserting the irrigation tube 36. A patient with metabolic acidosis has a
into the stoma preexisting problem with the kidneys. Which other
C. He expels flatus while the return is running out organ helps regulate blood pH?
D. He’s unable to complete the procedure in 1
hour
28. The nurse explains to the patient who has an A. Liver
abdominal perineal resection that an indwelling B. Pancreas
urinary catheter must be kept in place for several C. Lungs
days afterward because: D. heart
37. The nurse considers the patient anuric if the
patient;
26

A. Voids during the nighttime hours A. Decreased urine output, increased reabsorption
B. Has a urine output of less than 100 ml in 24 of sodium and water
hours B. Decreased urine output, decreased reabsorption
C. Has a urine output of at least 100 ml in 2 hours of sodium and water
D. Has pain and burning on urination C. Increased urine output, increased reabsorption
38. Which nursing action is appropriate to prevent of sodium and water
infection when obtaining a sterile urine specimen D. Increased urine output, decreased reabsorption
from an indwelling urinary catheter? of sodium and water
45. While assessing a patient who complained of
A. Aspirate urine from the tubing port using a lower abdominal pressure, the nurse notes a firm
sterile syringe and needle mass extending above the symphysis pubis. The
B. Disconnect the catheter from the tubing and nurse suspects:
obtain urine
C. Open the drainage bag and pour out some urine A. A urinary tract infection
D. Wear sterile gloves when obtaining urine B. Renal calculi
39. After undergoing a transurethral resection of the C. An enlarged kidney
prostate to treat benign prostatic hypertrophy, a D. A distended bladder
patient is retuned to the room with continuous 46. Gregg Lohan, age 75, is admitted to the medical-
bladder irrigation in place. One day later, the patient surgical floor with weakness and left-sided chest
reports bladder pain. What should the nurse do first? pain. The symptoms have been present for several
weeks after a viral illness. Which assessment finding
A. Increase the I.V. flow rate is most symptomatic of pericarditis?
B. Notify the doctor immediately
C. Assess the irrigation catheter for patency and A. Pericardial friction rub
drainage B. Bilateral crackles auscultated at the lung bases
D. Administer meperidine (Demerol) as prescribed C. Pain unrelieved by a change in position
40. A patient comes to the hospital complaining of D. Third heart sound (S3)
sudden onset of sharp, severe pain originating in the 47. James King is admitted to the hospital with right-
lumbar region and radiating around the side and side-heart failure. When assessing him for jugular
toward the bladder. The patient also reports nausea vein distention, the nurse should position him:
and vomiting and appears pale, diaphoretic, and
anxious. The doctor tentatively diagnoses renal A. Lying on his side with the head of the bed flat.
calculi and orders flat-plate abdominal X-rays. Renal B. Sitting upright.
calculi can form anywhere in the urinary tract. What C. Flat on his back.
is their most common formation site? D. Lying on his back with the head of the bed
elevated 30 to 45 degrees.
A. Kidney 48. The nurse is interviewing a slightly overweight
B. Ureter 43-year-old man with mild emphysema and
C. Bladder borderline hypertension. He admits to smoking a
D. Urethra pack of cigarettes per day. When developing a
41. A patient comes to the hospital complaining of teaching plan, which of the following should receive
severe pain in the right flank, nausea, and vomiting. highest priority to help decrease respiratory
The doctor tentatively diagnoses right ureter- complications?
olithiasis (renal calculi). When planning this patient’s
care, the nurse should assign highest priority to which A. Weight reduction
nursing diagnosis? B. Decreasing salt intake
C. Smoking cessation
A. Pain D. Decreasing caffeine intake
B. Risk of infection 49. What is the ratio of chest compressions to
C. Altered urinary elimination ventilations when one rescuer performs
D. Altered nutrition: less than body requirements cardiopulmonary resuscitation (CPR) on an adult?
42. The nurse is reviewing the report of a patient’s
routine urinalysis. Which of the following values A. 15:1
should the nurse consider abnormal? B. 15:2
C. 12:1
A. Specific gravity of 1.002 D. 12:2
B. Urine pH of 3 50. When assessing a patient for fluid and electrolyte
C. Absence of protein balance, the nurse is aware that the organs most
D. Absence of glucose important in maintaining this balance are the:
43. A patient with suspected renal insufficiency is
scheduled for a comprehensive diagnostic work-up. A. Pituitary gland and pancreas
After the nurse explains the diagnostic tests, the B. Liver and gallbladder.
patient asks which part of the kidney “does the C. Brain stem and heart.
work.” Which answer is correct? D. Lungs and kidneys.
Answers and Rationales
A. The glomerulus
B. Bowman’s capsule 1. Answer: D. A 1+ pulse indicates weak pulses
C. The nephron and is associated with diminished perfusion. A
D. The tubular system 4+ is bounding perfusion, a 3+ is increased
44. During a shock state, the renin-angiotensin- perfusion, a 2+ is normal perfusion, and 0 is
aldosterone system exerts which of the following absent perfusion.
effects on renal function? 2. Answer: A.A murmur that indicates heart
disease is often accompanied by dyspnea on
27

exertion, which is a hallmark of heart failure. narcotic analgesia is often required for pain
Other indicators are tachycardia, syncope, and relief. An ophthalmologist should also be
chest pain. Subcutaneous emphysema, thoracic consulted.
petechiae, and perior-bital edema aren’t 11. Answer: B. A positive response to one or both
associated with murmurs and heart disease. tests indicates meningeal irritation that is
3. Answer: C.Pregnancy increase plasma volume present with meningitis. Brudzinski’s and
and expands the uterine vascular bed, possibly Kernig’s signs don’t occur in CVA, seizure
increasing both the heart rate and cardiac disorder, or Parkinson’s disease.
output. These changes may cause cardiac stress, 12. Answer: D. Gliomas account for approximately
especially during the second trimester. Blood 45% of all brain tumors. Meningiomas are the
pressure during early pregnancy may decrease, second most common, with 15%. Angiomas
but it gradually returns to prepregnancy levels. and hemangioblastomas are types of cerebral
4. Answer: D.Decreased cardiac output related to vascular tumors that account for 3% of brain
reduced myocardial contractility is the greatest tumors.
threat to the survival of a patient with 13. Answer: D. The patient with Parkinson’s
cardiomyopathy. The other options can be disease may be hypersensitive to heat, which
addressed once cardiac output and myocardial increases the risk of hyperthermia, and he
contractility have been restored. should be instructed to avoid sun exposure
5. Answer: D.Evaluation assesses the during hot weather.
effectiveness of the treatment plan by 14. Answer: C. Global aphasia occurs when all
determining if the patient has met the expected language functions are affected. Receptive
treatment outcome. Planning refers to designing aphasia, also known as Wernicke’s aphasia,
a plan of action that will help the nurse deliver affects the ability to comprehend written or
quality patient care. Implementation refers to all spoken words. Expressive aphasia, also known
of the nursing interventions directed toward as Broca’s aphasia, affected the patient’s ability
solving the patient’s nursing problems. to form language and express thoughts.
Analysis is the process of identifying the Conduction aphasia refers to abnormalities in
patient’s nursing problems. speech repetition.
6. Answer: B.A basilar skull fracture carries the 15. Answer: D. Patients with a history of
risk of complications of dural tear, causing CSF headaches, especially migraines, should be
leakage and damage to cranial nerves I, II, VII, taught to keep a food diary to identify potential
and VIII. Classic findings in this type of food triggers. Typical headache triggers include
fracture may include otorrhea, rhinorrhea, alcohol, aged cheeses, processed meats, and
Battle’s signs, and raccoon eyes. Surgical chocolate and caffeine-containing products.
treatment isn’t always required. 16. Answer: B. An explosive headache or “the
7. Answer: A. Barbiturates may be used to induce worst headache I’ve ever had” is typically the
a coma in a patient with increased ICP. This first presenting symptom of a bleeding cerebral
decreases cortical activity and cerebral aneurysm. Photophobia, seizures, and
metabolism, reduces cerebral blood volume, hemiparesis may occur later.
decreases cerebral edema, and reduces the 17. Answer: C. An embolic injury, caused by a
brain’s need for glucose and oxygen. Carbonic traveling clot, may result from atrial fibrillation.
anhydrase inhibitors are used to decrease ocular Blood may pool in the fibrillating atrium and be
pressure or to decrease the serum pH in a released to travel up the cerebral artery to the
patient with metabolic alkalosis. brain. Persistent hypertension may place the
Anticholinergics have many uses including patient at risk for a thrombotic injury to the
reducing GI spasms. Histamine receptor brain. Subarachnoid hemorrhage and skull
blockers are used to decrease stomach acidity. fractures aren’t associated with emboli.
8. Answer: B. Headache and projectile vomiting 18. Answer: D. Women with spinal cord injuries
are early signs of increased ICP. Decreased who were sexually active may continue having
systolic blood pressure, unconsciousness, and sexual intercourse and must be reminded that
dilated pupils that don’t reac to light are they can still become pregnant. She may be
considered late signs. fully capable of achieving orgasm. An
9. Answer: A. Immediate bed rest is necessary to indwelling urinary catheter may be left in place
prevent further injury. Both eyes should be during sexual intercourse. Positioning will need
patched to avoid consensual eye movement and to be adjusted to fit the patient’s needs.
the patient should receive early referral to an 19. Answer: A. The nurse must have a wrench
ophthalmologist should treat the condition taped on the vest at all times for quick halo
immediately. Retinal reattachment can be removal in emergent situations. The brace isn’t
accomplished by surgery only. If the macula is to be removed for any other reason until the
detached or threatened, surgery is urgent; cervical fracture is healed. Placing a pillow
prolonged detachment of the macula results in under the patient’s head may alter the stability
permanent loss of central vision. of the brace.
10. Answer: C. A chemical burn to the eye requires 20. Answer: D. Nimodipine is a calcium channel
immediate instillation of a topical anesthetic blocker that acts on cerebral blood vessels to
followed by irrigation with copious amounts of reduce vasospasm. The drug doesn’t increase
saline solution. Irrigation should be done for 5 the amount of calcium, affect cerebral
to 10 minutes, and then the pH of the eye vasculature growth, or reduce cerebral oxygen
should be checked. Irrigation should be demand.
continued until the pH of the eye is restored to 21. Answer: D. Men with spinal cord injury should
neutral (pH 7.0): Double eversion of the eyelids be taught that the higher the level of the lesion,
should be performed to look for and remove the better their sexual function will be. The
ciliary spasm, and an antibiotic ointment can be sacral region is the lowest area on the spinal
administered to reduce the risk of infection. column and injury to this area will cause more
Then the eye should be patched. Parenteral erectile dysfunction.
28

22. Answer: C. Tegretol should be taken with food solvent through a semipermeable membrane
to minimize GI distress. Taking it at meals will from an area of greater osmolarity to one of
also establish a regular routine, which should lesser osmolarity until equalization occurs. The
help compliance. membrane is impermeable to the solute but
23. Answer: B. Patient with pneumococcal permeable to the solvent. Filtration is the
meningitis require respiratory isolation for the process by which fluid is forced through a
first 24 hours after treatment is initiated. membrane by a difference in pressure; small
24. Answer: A. Early symptoms of ALS include molecules pass through, but large ones don’t.
fatigue while talking, dysphagia, and weakness 33. Answer: A. Tenting of chest skin when pinched
of the hands and arms. ALS doesn’t cause a indicates decreased skin elasticity due to
change in mental status, paresthesia, or dehydration. Hand veins fill slowly with
fractures. dehydration, not rapidly. A pulse that isn’t
25. Answer: C. Increased pressure within the portal easily obliterated and neck vein distention
veins causes them to bulge, leading to rupture indicate fluid overload, not dehydration.
and bleeding into the lower esophagus. 34. Answer: C. Administering a tap water enema
Bleeding associated with esophageal varices until return is clear would most likely
doesn’t stem from esophageal perforation, contribute to a hypo-osmolar state. Because tap
pulmonary hypertension, or peptic ulcers. water is hypotonic, it would be absorbed by the
26. Answer: B. The nurse should wear gloves and a body, diluting the body fluid concentration and
gown when removing the patient’s bedpan lowering osmolarity. Weighing the patient is
because the type A hepatitis virus occurs in the easiest, most accurate method to determine
stools. It may also occur in blood, nasotracheal fluid changes. Therefore, it helps identify rather
secretions, and urine. Type A hepatitis isn’t than contribute to fluid imbalance. Nasogastric
transmitted through the air by way of droplets. tube irrigation with normal saline solution
Special precautions aren’t needed when feeding wouldn’t cause a shift in fluid balance.
the patient, but disposable utensils should be Drinking broth wouldn’t contribute to a hypo-
used. osmolar state because it doesn’t replace sodium
27. Answer: B. The patient should notify the doctor and water lost through excessive perspiration.
if he has difficulty inserting the irrigation tube 35. Answer: D. An orthostatic blood pressure
into the stoma. Difficulty with insertion may indicates an extracellular fluid volume deficit.
indicate stenosis of the bowel. Abdominal (The extracellular compartment consists of both
cramping and expulsion of flatus may normally the intravascular compartment and interstitial
occur with irrigation. The procedure will often space.) A fluid volume deficit within the
take an hour to complete. intravascular compartment would cause
28. Answer: B. An indwelling urinary catheter is tachycardia, not bradycardia or orthostatic
kept in place several days after this surgery to blood pressure change. A central venous
prevent urine retention that could place pressure pressure of 6 mm Hg is in the high normal
on the perineal wound. An indwelling urinary range, indicating adequate hydration. Pitting
catheter may be a source of postoperative edema indicates fluid volume overload.
urinary tract infection. Urine won’t contaminate 36. Answer: C. The respiratory and renal systems
the wound. An indwelling urinary catheter act as compensatory mechanisms to counteract-
won’t necessarily show bladder trauma. base imbalances. The lungs alter the carbon
29. Answer: D. The colostomy may not function dioxide levels in the blood by increasing or
for 2 days or more (48 to 72 hours) after decreasing the rate and depth of respirations,
surgery. Therefore, the normal plan of care can thereby increasing or decreasing carbon dioxide
be followed. Since no fecal drainage is elimination. The liver, pancreas, and heart play
expected for 48 to 72 hours after a colostomy no part in compensating for acid-base
(only mucous and serosanguineous), the doctor imbalances.
doesn’t have to be notified and the stoma 37. Answer: B. Anuria refers to a urine output of
shouldn’t be irrigated at this time. less than 100 ml in 24 hours. The baseline for
30. Answer: C. If the patient’s GI tract is urine output and renal function is 30 ml of urine
functioning, enteral nutrition via a feeding tube per hour. A urine output of at least 100 ml in 2
is the preferred method. Peripheral and total hours is within normal limits. Voiding at night
parenteral nutrition places the patient at risk for is called nocturia. Pain and burning on urination
infection. If the patient is unable to consume is called dysuria.
foods by mouth, oral liquid supplements are 38. Answer: A. To obtain urine properly, the nurse
contraindicated. should aspirate it from a port, using a sterile
31. Answer: A. A hypertonic solution causes water syringe after cleaning the port. Opening a
to shift from the cells into the plasma because closed urine drainage system increases the risk
the hypertonic solution has a greater osmotic of urinary tract infection. Standard precautions
pressure than the cells. A hypotonic solution specify the use of gloves during contract with
has a lower osmotic pressure than that of the body fluids; however, sterile gloves aren’t
cells. It causes fluid to shift into the cells, necessary.
possibly resulting in rupture. An isotonic 39. Answer: C. Although postoperative pain is
solution, which has the same osmotic pressure expected, the nurse should ensure that other
as the cells, wouldn’t cause any shift. A factors, such as an obstructed irrigation
solution’s alkalinity is related to the hydrogen catheter, aren’t the cause of the pain. After
ion concentration, not its osmotic effect. assessing catheter patency, the nurse should
32. Answer: C. Particles move from an area of administer an analgesic such as meperidine as
greater osmolarity to one of lesser osmolarity prescribed. Increasing the I.V. flow rate may
through diffusion. Active transport is the worse the pain. Notifying the doctor isn’t
movement of particles though energy necessary unless the pain is severe or
expenditure from other sources such as unrelieved by the prescribed medication.
enzymes. Osmosis is the movement of a pure
29

40. Answer: A. Renal calculi most commonly from expects to hear when listening to client’s lungs
in the kidney. They may remain there or indicative of chronic heart failure would be:
become lodged anywhere along the urinary
tract. The ureter, bladder, and urethra are less A. Stridor
common sites of renal calculi formation. B. Crackles
41. Answer: A. Ureterolithiasis typically causes C. Wheezes
such acute, severe pain that the patient can’t D. Friction rubs
rest and becomes increasingly anxious. 2. Patrick who is hospitalized following a myocardial
Therefore, the nursing diagnosis of pain takes infarction asks the nurse why he is taking morphine.
highest priority. Risk for infection and altered The nurse explains that morphine:
urinary elimination are appropriate once the
patient’s pain is controlled. Altered nutrition:
less than body requirements isn’t appropriate at A. Decrease anxiety and restlessness
this time. B. Prevents shock and relieves pain
42. Answer: B. Normal urine pH is 4.5 to 8; C. Dilates coronary blood vessels
therefore, a urine pH of 3 is abnormal and may D. Helps prevent fibrillation of the heart
indicate such conditions as renal tuberculosis, 3. Which of the following should the nurse teach the
pyrexia, phenylketonuria, alkaptonuria, and client about the signs of digitalis toxicity?
acidosis. Urine specific gravity normally ranges
from 1.002 to 1.032, making the patient’s value A. Increased appetite
normal. Normally, urine contains no protein, B. Elevated blood pressure
glucose, ketones, bilirubin, bacteria, casts, or C. Skin rash over the chest and back
crystals. D. Visual disturbances such as seeing yellow spots
43. Answer: C. The nephron is the kidney’s 4. Nurse Trisha teaches a client with heart failure to
functioning unit. The glomerulus, Bowman’s take oral Furosemide in the morning. The reason for
capsule, and tubular system are components of this is to help…
the nephron.
44. Answer: A. As a response to shock, the renin- A. Retard rapid drug absorption
angiotensin-aldosterone system alters renal B. Excrete excessive fluids accumulated at night
function by decreasing urine output and C. Prevents sleep disturbances during night
increasing reabsorption of sodium and water. D. Prevention of electrolyte imbalance
Reduced renal perfusion stimulates the renin- 5. What would be the primary goal of therapy for a
angiotensin-aldosterone system in an effort to client with pulmonary edema and heart failure?
conserve circulating volume.
45. Answer: D. The bladder isn’t usually palpable
A. Enhance comfort
unless it is distended. The feeling of pressure is
B. Increase cardiac output
usually relieved with urination. Reduced
C. Improve respiratory status
bladder tone due to general anesthesia is a
D. Peripheral edema decreased
common postoperative complication that causes
6. Nurse Linda is caring for a client with head injury
difficulty in voiding. A urinary tract infection
and monitoring the client with decerebrate posturing.
and renal calculi aren’t palpable. The kidneys
Which of the following is a characteristic of this type
aren’t palpable above the symphysis pubis.
of posturing?
46. Answer: A. A pericardial friction rub may be
present with the pericardial effusion of
pericarditis. The lungs are typically clear when A. Upper extremity flexion with lower extremity
auscultated. Sitting up and leaning forward flexion
often relieves pericarditis pain. An S3 indicates B. Upper extremity flexion with lower extremity
left-sided heart failure and isn’t usually present extension
with pericarditis. C. Extension of the extremities after a stimulus
47. Answer: D. Assessing jugular vein distention D. Flexion of the extremities after stimulus
should be done when the patient is in semi- 7. A female client is taking Cascara Sagrada. Nurse
Fowler’s position (head of the bed elevated 30 Betty informs the client that the following maybe
to 45 degrees). If the patient lies flat, the veins experienced as side effects of this medication:
will be more distended; if he sits upright, the
veins will be flat. A. GI bleeding
48. Answer: C. Smoking should receive highest B. Peptic ulcer disease
priority when trying to reduce risk factors for C. Abdominal cramps
with respiratory complications. Losing weight D. Partial bowel obstruction
and decreasing salt and caffeine intake can help 8. Dr. Marquez orders a continuous intravenous
to decrease risk factors for hypertension. nitroglycerin infusion for the client suffering from
49. Answer: B. The correct ratio of compressions to myocardial infarction. Which of the following is the
ventilations when one rescuer performs CPR is most essential nursing action?
15:2
50. Answer: D. The lungs and kidneys are the A. Monitoring urine output frequently
body’s regulators of homeostasis. The lungs are B. Monitoring blood pressure every 4 hours
responsible for removing fluid and carbon C. Obtaining serum potassium levels daily
dioxide; the kidneys maintain a balance of fluid D. Obtaining infusion pump for the medication
and electrolytes. The other organs play 9. During the second day of hospitalization of the
secondary roles in maintaining homeostasis. client after a Myocardial Infarction. Which of the
following is an expected outcome?
Text Mode – Text version of the exam. View
Answers A. Able to perform self-care activities without pain
1. Mrs. Chua a 78 year old client is admitted with the B. Severe chest pain
diagnosis of mild chronic heart failure. The nurse
30

C. Can recognize the risk factors of Myocardial C. Increase creatine phospholinase concentration
Infarction D. Chest pain
D. Can Participate in cardiac rehabilitation 17. Kris with a history of chronic infection of the
walking program urinary system complains of urinary frequency and
10. A 68 year old client is diagnosed with a right- burning sensation. To figure out whether the current
sided brain attack and is admitted to the hospital. In problem is in renal origin, the nurse should assess
caring for this client, the nurse should plan to: whether the client has discomfort or pain in the…

A. Application of elastic stockings to prevent A. Urinary meatus

flaccid by muscle B. Pain in the Labium
B. Use hand roll and extend the left upper C. Suprapubic area
extremity on a pillow to prevent contractions D. Right or left costovertebral angle
C. Use a bed cradle to prevent dorsiflexion of feet 18. Nurse Perry is evaluating the renal function of a
D. Do passive range of motion exercise male client. After documenting urine volume and
11. Nurse Liza is assigned to care for a client who characteristics, Nurse Perry assesses which signs as
has returned to the nursing unit after left the best indicator of renal function.
nephrectomy. Nurse Liza’s highest priority would
be… A. Blood pressure
B. Consciousness
A. Hourly urine output C. Distension of the bladder
B. Temperature D. Pulse rate
C. Able to turn side to side 19. John suddenly experiences a seizure, and Nurse
D. Able to sips clear liquid Gina notice that John exhibits uncontrollable jerking
12. A 64 year old male client with a long history of movements. Nurse Gina documents that John
cardiovascular problem including hypertension and experienced which type of seizure?
angina is to be scheduled for cardiac catheterization.
During pre cardiac catheterization teaching, Nurse A. Tonic seizure
Cherry should inform the client that the primary B. Absence seizure
purpose of the procedure is….. C. Myoclonic seizure
D. Clonic seizure
A. To determine the existence of CHD 20. Smoking cessation is critical strategy for the
B. To visualize the disease process in the coronary client with Burgher’s disease, Nurse Jasmin
arteries anticipates that the male client will go home with a
C. To obtain the heart chambers pressure prescription for which medication?
D. To measure oxygen content of different heart
chambers A. Paracetamol
13. During the first several hours after a cardiac B. Ibuprofen
catheterization, it would be most essential for nurse C. Nitroglycerin
Cherry to… D. Nicotine (Nicotrol)
21. Nurse Lilly has been assigned to a client with
A. Elevate clients bed at 45° Raynaud’s disease. Nurse Lilly realizes that the
B. Instruct the client to cough and deep breathe etiology of the disease is unknown but it is
every 2 hours characterized by:
C. Frequently monitor client’s apical pulse and
blood pressure A. Episodic vasospastic disorder of capillaries
D. Monitor clients temperature every hour B. Episodic vasospastic disorder of small veins
14. Kate who has undergone mitral valve C. Episodic vasospastic disorder of the aorta
replacement suddenly experiences continuous D. Episodic vasospastic disorder of the small
bleeding from the surgical incision during arteries
postoperative period. Which of the following 22. Nurse Jamie should explain to male client with
pharmaceutical agents should Nurse Aiza prepare to diabetes that self-monitoring of blood glucose is
administer to Kate? preferred to urine glucose testing because…

A. Protamine Sulfate A. More accurate

B. Quinidine Sulfate B. Can be done by the client
C. Vitamin C C. It is easy to perform
D. Coumadin D. It is not influenced by drugs
15. In reducing the risk of endocarditis, good dental 23. Jessie weighed 210 pounds on admission to the
care is an important measure. To promote good hospital. After 2 days of diuretic therapy, Jessie
dental care in client with mitral stenosis in teaching weighs 205.5 pounds. The nurse could estimate the
plan should include proper use of… amount of fluid Jessie has lost…

A. Dental floss A. 0.3 L

B. Electric toothbrush B. 1.5 L
C. Manual toothbrush C. 2.0 L
D. Irrigation device D. 3.5 L
16. Among the following signs and symptoms, which 24. Nurse Donna is aware that the shift of body fluids
would most likely be present in a client with mitral associated with Intravenous administration of
gurgitation? albumin occurs in the process of:

A. Altered level of consciousness A. Osmosis

B. Exceptional Dyspnea B. Diffusion
31

C. Active transport A. Vital signs

D. Filtration B. Incision site
25. Myrna a 52 year old client with a fractured left C. Airway
tibia has a long leg cast and she is using crutches to D. Level of consciousness
ambulate. Nurse Joy assesses for which sign and 33. A client has 15% blood loss. Which of the
symptom that indicates complication associated with following nursing assessment findings indicates
crutch walking? hypovolemic shock?

A. Left leg discomfort A. Systolic blood pressure less than 90mm Hg

B. Weak biceps brachii B. Pupils unequally dilated
C. Triceps muscle spasm C. Respiratory rate of 4 breath/min
D. Forearm weakness D. Pulse rate less than 60bpm
26. Which of the following statements should the 34. Nurse Lucy is planning to give pre operative
nurse teach the neutropenic client and his family to teaching to a client who will be undergoing
avoid? rhinoplasty. Which of the following should be
included?
A. Performing oral hygiene after every meal
B. Using suppositories or enemas A. Results of the surgery will be immediately
C. Performing perineal hygiene after each bowel noticeable postoperatively
movement B. Normal saline nose drops will need to be
D. Using a filter mask administered preoperatively
27. A female client is experiencing painful and rigid C. After surgery, nasal packing will be in place 8
abdomen and is diagnosed with perforated peptic to 10 days
ulcer. A surgery has been scheduled and a nasogastric D. Aspirin containing medications should not be
tube is inserted. The nurse should place the client taken 14 days before surgery
before surgery in 35. Paul is admitted to the hospital due to metabolic
acidosis caused by Diabetic ketoacidosis (DKA). The
A. Sims position nurse prepares which of the following medications as
B. Supine position an initial treatment for this problem?
C. Semi-fowlers position
D. Dorsal recumbent position A. Regular insulin
28. Which nursing intervention ensures adequate B. Potassium
ventilating exchange after surgery? C. Sodium bicarbonate
D. Calcium gluconate
A. Remove the airway only when client is fully 36. Dr. Marquez tells a client that an increase intake
conscious of foods that are rich in Vitamin E and beta-carotene
B. Assess for hypoventilation by auscultating the are important for healthier skin. The nurse teaches the
lungs client that excellent food sources of both of these
C. Position client laterally with the neck extended substances are:
D. Maintain humidified oxygen via nasal canula
29. George who has undergone thoracic surgery has A. Fish and fruit jam
chest tube connected to a water-seal drainage system B. Oranges and grapefruit
attached to suction. Presence of excessive bubbling is C. Carrots and potatoes
identified in water-seal chamber, the nurse should… D. Spinach and mangoes
37. A client has Gastroesophageal Reflux Disease
A. “Strip” the chest tube catheter (GERD). The nurse should teach the client that after
B. Check the system for air leaks every meals, the client should…
C. Recognize the system is functioning correctly
D. Decrease the amount of suction pressure A. Rest in sitting position
30. A client who has been diagnosed of hypertension B. Take a short walk
is being taught to restrict intake of sodium. The nurse C. Drink plenty of water
would know that the teachings are effective if the D. Lie down at least 30 minutes
client states that… 38. After gastroscopy, an adaptation that indicates
major complication would be:
A. I can eat celery sticks and carrots
B. I can eat broiled scallops A. Nausea and vomiting
C. I can eat shredded wheat cereal B. Abdominal distention
D. I can eat spaghetti on rye bread C. Increased GI motility
31. A male client with a history of cirrhosis and D. Difficulty in swallowing
alcoholism is admitted with severe dyspnea resulted 39. A client who has undergone a cholecystectomy
to ascites. The nurse should be aware that the ascites asks the nurse whether there are any dietary
is most likely the result of increased… restrictions that must be followed. Nurse Hilary
would recognize that the dietary teaching was well
A. Pressure in the portal vein understood when the client tells a family member
B. Production of serum albumin that:
C. Secretion of bile salts
D. Interstitial osmotic pressure A. “Most people need to eat a high protein diet for
32. A newly admitted client is diagnosed with 12 months after surgery”
Hodgkin’s disease undergoes an excisional cervical B. “I should not eat those foods that upset me
lymph node biopsy under local anesthesia. What does before the surgery”
the nurse assess first after the procedure? C. “I should avoid fatty foods as long as I live”
32

D. “Most people can tolerate regular diet after this A. Absence of drainage from the ileostomy for 6
type of surgery” or more hours
40. Nurse Rachel teaches a client who has been B. Passage of liquid stool in the stoma
recently diagnosed with hepatitis A about untoward C. Occasional presence of undigested food
signs and symptoms related to Hepatitis that may D. A temperature of 37.6 °C
develop. The one that should be reported 48. Jerry has diagnosed with appendicitis. He
immediately to the physician is: develops a fever, hypotension and tachycardia. The
nurse suspects which of the following complications?
A. Restlessness
B. Yellow urine A. Intestinal obstruction
C. Nausea B. Peritonitis
D. Clay- colored stools C. Bowel ischemia
41. Which of the following antituberculosis drugs can D. Deficient fluid volume
damage the 8th cranial nerve? 49. Which of the following compilations should the
nurse carefully monitors a client with acute
A. Isoniazid (INH) pancreatitis.
B. Paraoaminosalicylic acid (PAS)
C. Ethambutol hydrochloride (myambutol) A. Myocardial Infarction
D. Streptomycin B. Cirrhosis
42. The client asks Nurse Annie the causes of peptic C. Peptic ulcer
ulcer. Nurse Annie responds that recent research D. Pneumonia
indicates that peptic ulcers are the result of which of 50. Which of the following symptoms during the
the following: icteric phase of viral hepatitis should the nurse expect
the client to inhibit?
A. Genetic defect in gastric mucosa
B. Stress A. Watery stool
C. Diet high in fat B. Yellow sclera
D. Helicobacter pylori infection C. Tarry stool
43. Ryan has undergone subtotal gastrectomy. The D. Shortness of breath
nurse should expect that nasogastric tube drainage Answers and Rationales
will be what color for about 12 to 24 hours after
surgery? 1. B. Left sided heart failure causes fluid
accumulation in the capillary network of the
lung. Fluid eventually enters alveolar spaces
A. Bile green
and causes crackling sounds at the end of
B. Bright red
inspiration.
C. Cloudy white
2. B. Morphine is a central nervous system
D. Dark brown
depressant used to relieve the pain associated
44. Nurse Joan is assigned to come for client who has
with myocardial infarction, it also decreases
just undergone eye surgery. Nurse Joan plans to teach
apprehension and prevents cardiogenic shock.
the client activities that are permitted during the post
3. D. Seeing yellow spots and colored vision are
operative period. Which of the following is best
common symptoms of digitalis toxicity
recommended for the client?
4. C. When diuretics are taken in the morning,
client will void frequently during daytime and
A. Watching circus will not need to void frequently at night.
B. Bending over 5. B. The primary goal of therapy for the client
C. Watching TV with pulmonary edema or heart failure is
D. Lifting objects increasing cardiac output. Pulmonary edema is
45. A client suffered from a lower leg injury and an acute medical emergency requiring
seeks treatment in the emergency room. There is a immediate intervention.
prominent deformity to the lower aspect of the leg, 6. C. Decerebrate posturing is the extension of the
and the injured leg appears shorter that the other leg. extremities after a stimulus which may occur
The affected leg is painful, swollen and beginning to with upper brain stem injury.
become ecchymotic. The nurse interprets that the 7. C. The most frequent side effects of Cascara
client is experiencing: Sagrada (Laxative) is abdominal cramps and
nausea.
A. Fracture 8. D. Administration of Intravenous Nitroglycerin
B. Strain infusion requires pump for accurate control of
C. Sprain medication.
D. Contusion 9. A. By the 2nd day of hospitalization after
46. Nurse Jenny is instilling an otic solution into an suffering a Myocardial Infarction, Clients are
adult male client left ear. Nurse Jenny avoids doing able to perform care without chest pain
which of the following as part of the procedure 10. B. The left side of the body will be affected in a
right-sided brain attack.
A. Pulling the auricle backward and upward 11. A. After nephrectomy, it is necessary to
B. Warming the solution to room temperature measure urine output hourly. This is done to
C. Pacing the tip of the dropper on the edge of ear assess the effectiveness of the remaining kidney
canal also to detect renal failure early.
D. Placing client in side lying position 12. B. The lumen of the arteries can be assessed by
47. Nurse Bea should instruct the male client with an cardiac catheterization. Angina is usually
ileostomy to report immediately which of the caused by narrowing of the coronary arteries.
following symptom? 13. C. Blood pressure is monitored to detect
hypotension which may indicate shock or
33

hemorrhage. Apical pulse is taken to detect Vitamin E is found in the following foods:
dysrhythmias related to cardiac irritability. wheat germ, corn, nuts, seeds, olives, spinach,
14. A. Protamine Sulfate is used to prevent asparagus and other green leafy vegetables.
continuous bleeding in client who has Food sources of beta-carotene include dark
undergone open heart surgery. green vegetables, carrots,mangoes and
15. C. The use of electronic toothbrush, irrigation tomatoes.
device or dental floss may cause bleeding of 37. A. Gravity speeds up digestion and prevents
gums, allowing bacteria to enter and increasing reflux of stomach contents into the esophagus.
the risk of endocarditis. 38. B. Abdominal distension may be associated
16. B. Weight gain due to retention of fluids and with pain, may indicate perforation, a
worsening heart failure causes exertional complication that could lead to peritonitis.
dyspnea in clients with mitral regurgitation. 39. D. It may take 4 to 6 months to eat anything,
17. D. Discomfort or pain is a problem that but most people can eat anything they want.
originates in the kidney. It is felt at the 40. D. Clay colored stools are indicative of hepatic
costovertebral angle on the affected side. obstruction
18. A. Perfusion can be best estimated by blood 41. D. Streptomycin is an aminoglycoside and
pressure, which is an indirect reflection of the damage on the 8th cranial nerve (ototoxicity) is
adequacy of cardiac output. a common side effect of aminoglycosides.
19. C. Myoclonic seizure is characterized by 42. D. Most peptic ulcer is caused by Helicopter
sudden uncontrollable jerking movements of a pylori which is a gram negative bacterium.
single or multiple muscle group. 43. D. 12 to 24 hours after subtotal gastrectomy
20. D. Nicotine (Nicotrol) is given in controlled gastric drainage is normally brown, which
and decreasing doses for the management of indicates digested food.
nicotine withdrawal syndrome. 44. C. Watching TV is permissible because the eye
21. D. Raynaud’s disease is characterized by does not need to move rapidly with this activity,
vasospasms of the small cutaneous arteries that and it does not increase intraocular pressure.
involves fingers and toes. 45. A. Common signs and symptoms of fracture
22. A. Urine testing provides an indirect measure include pain, deformity, shortening of the
that maybe influenced by kidney function while extremity, crepitus and swelling.
blood glucose testing is a more direct and 46. C. The dropper should not touch any object or
accurate measure. any part of the client’s ear.
23. C. One liter of fluid approximately weighs 2.2 47. A. Sudden decrease in drainage or onset of
pounds. A 4.5 pound weight loss equals to severe abdominal pain should be reported
approximately 2L. immediately to the physician because it could
24. A. Osmosis is the movement of fluid from an mean that obstruction has been developed.
area of lesser solute concentration to an area of 48. B. Complications of acute appendicitis are
greater solute concentration. peritonitis, perforation and abscess
25. D. Forearm muscle weakness is a probable sign development.
of radial nerve injury caused by crutch pressure 49. D. A client with acute pancreatitis is prone to
on the axillae. complications associated with respiratory
26. B. Neutropenic client is at risk for infection system.
especially bacterial infection of the 50. B. Liver inflammation and obstruction block
gastrointestinal and respiratory tract. the normal flow of bile. Excess bilirubin turns
27. C. Semi-fowlers position will localize the the skin and sclera yellow and the urine dark
spilled stomach contents in the lower part of the and frothy.
abdominal cavity. Text Mode – Text version of the exam
28. C. Positioning the client laterally with the neck 1. Marco who was diagnosed with brain tumor was
extended does not obstruct the airway so that scheduled for craniotomy. In preventing the
drainage of secretions and oxygen and carbon development of cerebral edema after surgery, the
dioxide exchange can occur. nurse should expect the use of:
29. B. Excessive bubbling indicates an air leak
which must be eliminated to permit lung A. Diuretics
expansion. B. Antihypertensive
30. C. Wheat cereal has a low sodium content. C. Steroids
31. A. Enlarged cirrhotic liver impinges the portal D. Anticonvulsants
system causing increased hydrostatic pressure 2. Halfway through the administration of blood, the
resulting to ascites. female client complains of lumbar pain. After
32. C. Assessing for an open airway is the priority. stopping the infusion Nurse Hazel should:
The procedure involves the neck, the anesthesia
may have affected the swallowing reflex or the
inflammation may have closed in on the airway A. Increase the flow of normal saline
leading to ineffective air exchange. B. Assess the pain further
33. A. Typical signs and symptoms of hypovolemic C. Notify the blood bank
shock includes systolic blood pressure of less D. Obtain vital signs.
than 90 mm Hg. 3. Nurse Maureen knows that the positive diagnosis
34. D. Aspirin containing medications should not for HIV infection is made based on which of the
be taken 14 days before surgery to decrease the following:
risk of bleeding.
35. A. Metabolic acidosis is anaerobic metabolism A. A history of high risk sexual behaviors.
caused by lack of ability of the body to use B. Positive ELISA and western blot tests
circulating glucose. Administration of insulin C. Identification of an associated opportunistic
corrects this problem. infection
36. D. Beta-carotene and Vitamin E are D. Evidence of extreme weight loss and high fever
antioxidants which help to inhibit oxidation.
34

4. Nurse Maureen is aware that a client who has been B. High levels of high density lipid (HDL)
diagnosed with chronic renal failure recognizes an cholesterol
adequate amount of high-biologic-value protein when C. Low concentration triglycerides
the food the client selected from the menu was: D. Low levels of LDL cholesterol.
13. Which of the following represents a significant
A. Raw carrots risk immediately after surgery for repair of aortic
B. Apple juice aneurysm?
C. Whole wheat bread
D. Cottage cheese A. Potential wound infection
5. Kenneth who has diagnosed with uremic syndrome B. Potential ineffective coping
has the potential to develop complications. Which C. Potential electrolyte balance
among the following complications should the nurse D. Potential alteration in renal perfusion
anticipates: 14. Nurse Josie should instruct the client to eat which
of the following foods to obtain the best supply of
A. Flapping hand tremors Vitamin B12?
B. An elevated hematocrit level
C. Hypotension A. dairy products
D. Hypokalemia B. vegetables
6. A client is admitted to the hospital with benign C. Grains
prostatic hyperplasia, the nurse most relevant D. Broccoli
assessment would be: 15. Karen has been diagnosed with aplastic anemia.
The nurse monitors for changes in which of the
A. Flank pain radiating in the groin following physiologic functions?
B. Distention of the lower abdomen
C. Perineal edema A. Bowel function
D. Urethral discharge B. Peripheral sensation
7. A client has undergone with penile implant. After C. Bleeding tendencies
24 hrs of surgery, the client’s scrotum was edematous D. Intake and out put
and painful. The nurse should: 16. Lydia is scheduled for elective splenectomy.
Before the clients goes to surgery, the nurse in charge
A. Assist the client with sitz bath final assessment would be:
B. Apply war soaks in the scrotum
C. Elevate the scrotum using a soft support A. signed consent
D. Prepare for a possible incision and drainage. B. vital signs
8. Nurse hazel receives emergency laboratory results C. name band
for a client with chest pain and immediately informs D. empty bladder
the physician. An increased myoglobin level suggests 17. What is the peak age range in acquiring acute
which of the following? lymphocytic leukemia (ALL)?

A. Liver disease A. 4 to 12 years.

B. Myocardial damage B. 20 to 30 years
C. Hypertension C. 40 to 50 years
D. Cancer D. 60 60 70 years
9. Nurse Maureen would expect the a client with 18. Marie with acute lymphocytic leukemia suffers
mitral stenosis would demonstrate symptoms from nausea and headache. These clinical
associated with congestion in the: manifestations may indicate all of the following
except
A. Right atrium
B. Superior vena cava A. effects of radiation
C. Aorta B. chemotherapy side effects
D. Pulmonary C. meningeal irritation
10. A client has been diagnosed with hypertension. D. gastric distension
The nurse priority nursing diagnosis would be: 19. A client has been diagnosed with Disseminated
Intravascular Coagulation (DIC). Which of the
A. Ineffective health maintenance following is contraindicated with the client?
B. Impaired skin integrity
C. Deficient fluid volume A. Administering Heparin
D. Pain B. Administering Coumadin
11. Nurse Hazel teaches the client with angina about C. Treating the underlying cause
common expected side effects of nitroglycerin D. Replacing depleted blood products
including: 20. Which of the following findings is the best
indication that fluid replacement for the client with
A. high blood pressure hypovolemic shock is adequate?
B. stomach cramps
C. headache A. Urine output greater than 30ml/hr
D. shortness of breath B. Respiratory rate of 21 breaths/minute
12. The following are lipid abnormalities. Which of C. Diastolic blood pressure greater than 90 mmhg
the following is a risk factor for the development of D. Systolic blood pressure greater than 110 mmhg
atherosclerosis and PVD? 21. Which of the following signs and symptoms
would Nurse Maureen include in teaching plan as an
A. High levels of low density lipid (LDL) early manifestation of laryngeal cancer?
cholesterol
35

A. Stomatitis 29. Mang Jose with rheumatoid arthritis states, “the

B. Airway obstruction only time I am without pain is when I lie in bed
C. Hoarseness perfectly still”. During the convalescent stage, the
D. Dysphagia nurse in charge with Mang Jose should encourage:
22. Karina a client with myasthenia gravis is to
receive immunosuppressive therapy. The nurse A. Active joint flexion and extension
understands that this therapy is effective because it: B. Continued immobility until pain subsides
C. Range of motion exercises twice daily
A. Promotes the removal of antibodies that impair D. Flexion exercises three times daily
the transmission of impulses 30. A male client has undergone spinal surgery, the
B. Stimulates the production of acetylcholine at nurse should:
the neuromuscular junction.
C. Decreases the production of autoantibodies that A. Observe the client’s bowel movement and
attack the acetylcholine receptors. voiding patterns
D. Inhibits the breakdown of acetylcholine at the B. Log-roll the client to prone position
neuromuscular junction. C. Assess the client’s feet for sensation and
23. A female client is receiving IV Mannitol. An circulation
assessment specific to safe administration of the said D. Encourage client to drink plenty of fluids
drug is: 31. Marina with acute renal failure moves into the
diuretic phase after one week of therapy. During this
A. Vital signs q4h phase the client must be assessed for signs
B. Weighing daily ofdeveloping:
C. Urine output hourly
D. Level of consciousness q4h A. Hypovolemia
24. Patricia a 20 year old college student with B. renal failure
diabetes mellitus requests additional information C. metabolic acidosis
about the advantages of using a pen like insulin D. hyperkalemia
deliverydevices. The nurse explains that the 32. Nurse Judith obtains a specimen of clear nasal
advantages of these devices over syringes includes: drainage from a client with a head injury. Which of
the following tests differentiates mucus from
A. Accurate dose delivery cerebrospinal fluid (CSF)?
B. Shorter injection time
C. Lower cost with reusable insulin cartridges A. Protein
D. Use of smaller gauge needle. B. Specific gravity
25. A male client’s left tibia was fractured in an C. Glucose
automobile accident, and a cast is applied. To assess D. Microorganism
for damage to major blood vessels from the fracture 33. A 22 year old client suffered from his first tonic-
tibia, the nurse in charge should monitor the client clonic seizure. Upon awakening the client asks the
for: nurse, “What caused me to have a seizure? Which of
the following would the nurse include in the primary
A. Swelling of the left thigh cause of tonic clonic seizures in adults more the 20
B. Increased skin temperature of the foot years?
C. Prolonged reperfusion of the toes after
blanching A. Electrolyte imbalance
D. Increased blood pressure B. Head trauma
26. After a long leg cast is removed, the male client C. Epilepsy
should: D. Congenital defect
34. What is the priority nursing assessment in the
A. Cleanse the leg by scrubbing with a brisk first 24 hours after admission of the client with
motion thrombotic CVA?
B. Put leg through full range of motion twice daily
C. Report any discomfort or stiffness to the A. Pupil size and papillary response
physician B. cholesterol level
D. Elevate the leg when sitting for long periods of C. Echocardiogram
time. D. Bowel sounds
27. While performing a physical assessment of a 35. Nurse Linda is preparing a client with multiple
male client with gout of the great toe, Nurse Vivian sclerosis for discharge from the hospital to home.
should assess for additional tophi (urate deposits) on Which of the following instruction is most
the: appropriate?

A. Buttocks A. “Practice using the mechanical aids that you

B. Ears will need when future disabilities arise”.
C. Face B. “Follow good health habits to change the course
D. Abdomen of the disease”.
28. Nurse Katrina would recognize that the C. “Keep active, use stress reduction strategies,
demonstration of crutch walking with tripod gait was and avoid fatigue.
understood when the client places weight on the: D. “You will need to accept the necessity for a
quiet and inactive lifestyle”.
A. Palms of the hands and axillary regions 36. The nurse is aware the early indicator of hypoxia
B. Palms of the hand in the unconscious client is:
C. Axillary regions
D. Feet, which are set apart A. Cyanosis
36

B. Increased respirations 46. Nurse Faith should recognize that fluid shift in an
C. Hypertension client with burn injury results from increase in the:
D. Restlessness
37. A client is experiencing spinal shock. Nurse A. Total volume of circulating whole blood
Myrna should expect the function of the bladder to be B. Total volume of intravascular plasma
which of the following? C. Permeability of capillary walls
D. Permeability of kidney tubules
A. Normal 47. An 83-year-old woman has several ecchymotic
B. Atonic areas on her right arm. The bruises are probably
C. Spastic caused by:
D. Uncontrolled
38. Which of the following stage the carcinogen is A. increased capillary fragility and permeability
irreversible? B. increased blood supply to the skin
C. self inflicted injury
A. Progression stage D. elder abuse
B. Initiation stage 48. Nurse Anna is aware that early adaptation of
C. Regression stage client with renal carcinoma is:
D. Promotion stage
39. Among the following components thorough pain A. Nausea and vomiting
assessment, which is the most significant? B. flank pain
C. weight gain
A. Effect D. intermittent hematuria
B. Cause 49. A male client with tuberculosis asks Nurse Brian
C. Causing factors how long the chemotherapy must be continued.
D. Intensity Nurse Brian’s accurate reply would be:
40. A 65 year old female is experiencing flare up of
pruritus. Which of the client’s action could aggravate A. 1 to 3 weeks
the cause of flare ups? B. 6 to 12 months
C. 3 to 5 months
A. Sleeping in cool and humidified environment D. 3 years and more
B. Daily baths with fragrant soap 50. A client has undergone laryngectomy. The
C. Using clothes made from 100% cotton immediate nursing priority would be:
D. Increasing fluid intake
41. Atropine sulfate (Atropine) is contraindicated in A. Keep trachea free of secretions
all but one of the following client? B. Monitor for signs of infection
C. Provide emotional support
A. A client with high blood D. Promote means of communication
B. A client with bowel obstruction Answers and Rationales
C. A client with glaucoma
D. A client with U.T.I 1. C. Glucocorticoids (steroids) are used for their
42. Among the following clients, which among them anti-inflammatory action, which decreases the
is high risk for potential hazards from the surgical development of edema.
experience? 2. A. The blood must be stopped at once, and then
normal saline should be infused to keep the line
patent and maintain blood volume.
A. 67-year-old client
3. B. These tests confirm the presence of HIV
B. 49-year-old client
antibodies that occur in response to the
C. 33-year-old client
presence of the human immunodeficiency virus
D. 15-year-old client
(HIV).
43. Nurse Jon assesses vital signs on a client
4. D. One cup of cottage cheese contains
undergone epidural anesthesia. Which of the
approximately 225 calories, 27 g of protein, 9 g
following would the nurse assess next?
of fat, 30 mg cholesterol, and 6 g of
carbohydrate. Proteins of high biologic value
A. Headache (HBV) contain optimal levels of amino acids
B. Bladder distension essential for life.
C. Dizziness 5. A. Elevation of uremic waste products causes
D. Ability to move legs irritation of the nerves, resulting in flapping
44. Nurse Katrina should anticipate that all of the hand tremors.
following drugs may be used in the attempt to control 6. B. This indicates that the bladder is distended
the symptoms of Meniere’s disease except: with urine, therefore palpable.
7. C. Elevation increases lymphatic drainage,
A. Antiemetics reducing edema and pain.
B. Diuretics 8. B. Detection of myoglobin is a diagnostic tool
C. Antihistamines to determine whether myocardial damage has
D. Glucocorticoids occurred.
45. Which of the following complications associated 9. D. When mitral stenosis is present, the left
with tracheostomy tube? atrium has difficulty emptying its contents into
the left ventricle because there is no valve to
A. Increased cardiac output prevent back ward flow into the pulmonary
B. Acute respiratory distress syndrome (ARDS) vein, the pulmonary circulation is under
C. Increased blood pressure pressure.
D. Damage to laryngeal nerves 10. A. Managing hypertension is the priority for the
client with hypertension. Clients with
37

hypertension frequently do not experience pain, 28. B. The palms should bear the client’s weight to
deficient volume, or impaired skin integrity. It avoid damage to the nerves in the axilla.
is the asymptomatic nature of hypertension that 29. A. Active exercises, alternating extension,
makes it so difficult to treat. flexion, abduction, and adduction, mobilize
11. C. Because of its widespread vasodilating exudates in the joints relieves stiffness and
effects, nitroglycerin often produces side effects pain.
such as headache, hypotension and dizziness. 30. C. Alteration in sensation and circulation
12. A. An increased in LDL cholesterol indicates damage to the spinal cord, if these
concentration has been documented at risk occurs notify physician immediately.
factor for the development of atherosclerosis. 31. A. In the diuretic phase fluid retained during the
LDL cholesterol is not broken down into the oliguric phase is excreted and may reach 3 to 5
liver but is deposited into the wall of the blood liters daily, hypovolemia may occur and fluids
vessels. should be replaced.
13. D. There is a potential alteration in renal 32. C. The constituents of CSF are similar to those
perfusion manifested by decreased urine output. of blood plasma. An examination for glucose
The altered renal perfusion may be related to content is done to determine whether a body
renal arteryembolism, prolonged hypotension, fluid is a mucus or a CSF. A CSF normally
or prolonged aortic cross-clamping during the contains glucose.
surgery. 33. B. Trauma is one of the primary cause of brain
14. A. Good source of vitamin B12 are dairy damage and seizure activity in adults. Other
products and meats. common causes of seizure activity in adults
15. C. Aplastic anemia decreases the bone marrow include neoplasms, withdrawal from drugs and
production of RBC’s, white blood cells, and alcohol, and vascular disease.
platelets. The client is at risk for bruising and 34. A. It is crucial to monitor the pupil size and
bleeding tendencies. papillary response to indicate changes around
16. B. An elective procedure is scheduled in the cranial nerves.
advance so that all preparations can be 35. C. The nurse most positive approach is to
completed ahead of time. The vital signs are the encourage the client with multiple sclerosis to
final check that must be completed before the stay active, use stress reduction techniques and
client leaves the room so that continuity of care avoid fatigue because it is important to support
and assessment is provided for. the immune system while remaining active.
17. A. The peak incidence of Acute Lymphocytic 36. D. Restlessness is an early indicator of hypoxia.
Leukemia (ALL) is 4 years of age. It is The nurse should suspect hypoxia in
uncommon after 15 years of age. unconscious client who suddenly becomes
18. D. Acute Lymphocytic Leukemia (ALL) does restless.
not cause gastric distention. It does invade the 37. B. In spinal shock, the bladder becomes
central nervous system, and clients experience completely atonic and will continue to fill
headaches and vomiting from meningeal unless the client is catheterized.
irritation. 38. A. Progression stage is the change of tumor
19. B. Disseminated Intravascular Coagulation from the preneoplastic state or low degree of
(DIC) has not been found to respond to oral malignancy to a fast growing tumor that cannot
anticoagulants such as Coumadin. be reversed.
20. A. Urine output provides the most sensitive 39. D. Intensity is the major indicative of severity
indication of the client’s response to therapy for of pain and it is important for the evaluation of
hypovolemic shock. Urine output should be the treatment.
consistently greater than 30 to 35 mL/hr. 40. B. The use of fragrant soap is very drying to
21. C. Early warning signs of laryngeal cancer can skin hence causing the pruritus.
vary depending on tumor location. Hoarseness 41. C. Atropine sulfate is contraindicated with
lasting 2 weeks should be evaluated because it glaucoma patients because it increases
is one of the most common warning signs. intraocular pressure.
22. C. Steroids decrease the body’s immune 42. A. A 67 year old client is greater risk because
response thus decreasing the production of the older adult client is more likely to have a
antibodies that attack the acetylcholine less-effective immune system.
receptors at the neuromuscular junction 43. B. The last area to return sensation is in the
23. C. The osmotic diuretic mannitol is perineal area, and the nurse in charge should
contraindicated in the presence of inadequate monitor the client for distended bladder.
renal function or heart failure because it 44. D. Glucocorticoids play no significant role in
increases the intravascular volume that must be disease treatment.
filtered and excreted by the kidney. 45. D. Tracheostomy tube has several potential
24. A. These devices are more accurate because complications including bleeding, infection and
they are easily to used and have improved laryngeal nerve damage.
adherence in insulin regimens by young people 46. C. In burn, the capillaries and small vessels
because the medication can be administered dilate, and cell damage cause the release of a
discreetly. histamine-like substance. The substance causes
25. C. Damage to blood vessels may decrease the the capillary walls to become more permeable
circulatory perfusion of the toes, this would and significant quantities of fluid are lost.
indicate the lack of blood supply to the 47. A. Aging process involves increased capillary
extremity. fragility and permeability. Older adults have a
26. D. Elevation will help control the edema that decreased amount of subcutaneous fat and
usually occurs. cause an increased incidence of bruise like
27. B. Uric acid has a low solubility, it tends to lesions caused by collection of extravascular
precipitate and form deposits at various sites blood in loosely structured dermis.
where blood flow is least active, including
cartilaginous tissue such as the ears.
38

48. D. Intermittent pain is the classic sign of renal D. Attempt to insert a tongue depressor between
carcinoma. It is primarily due to capillary the client’s teeth
erosion by the cancerous growth. 8. A client has undergone right pneumonectomy.
49. B. Tubercle bacillus is a drug resistant When turning the client, the nurse should plan to
organism and takes a long time to be eradicated. position the client either:
Usually a combination of three drugs is used for
minimum of 6 months and at least six months A. Right side-lying position or supine
beyond culture conversion. B. High fowlers
50. A. Patent airway is the most priority; therefore C. Right or left side lying position
removal of secretions is necessary. D. Low fowler’s position
9. Nurse Jenny should caution a female client who is
sexually active in taking Isoniazid (INH) because the
Text Mode – Text version of the exam
drug has which of the following side effects?
1. A client is scheduled for insertion of an inferior
vena cava (IVC) filter. Nurse Patricia consults the
physician about withholding which regularly A. Prevents ovulation
scheduled medication on the day before the surgery? B. Has a mutagenic effect on ova
C. Decreases the effectiveness of oral
contraceptives
A. Potassium Chloride
D. Increases the risk of vaginal infection
B. Warfarin Sodium
10. A client has undergone gastrectomy. Nurse Jovy
C. Furosemide
is aware that the best position for the client is:
D. Docusate
2. A nurse is planning to assess the corneal reflex on
unconscious client. Which of the following is the A. Left side lying
safest stimulus to touch the client’s cornea? B. Low fowler’s
C. Prone
D. Supine
A. Cotton buds
11. During the initial postoperative period of the
B. Sterile glove
client’s stoma. The nurse evaluates which of the
C. Sterile tongue depressor
following observations should be reported
D. Wisp of cotton
immediately to thephysician?
3. A female client develops an infection at the
catheter insertion site. The nurse in charge uses the
term “iatrogenic” when describing the infection A. Stoma is dark red to purple
because it resulted from: B. Stoma is oozes a small amount of blood
C. Stoma is lightly edematous
D. Stoma does not expel stool
A. Client’s developmental level
12. Kate which has diagnosed with ulcerative colitis
B. Therapeutic procedure
is following physician’s order for bed rest with
C. Poor hygiene
bathroom privileges. What is the rationale for this
D. Inadequate dietary patterns
activity restriction?
4. Nurse Carol is assessing a client with Parkinson’s
disease. The nurse recognize bradykinesia when the
client exhibits: A. Prevent injury
B. Promote rest and comfort
C. Reduce intestinal peristalsis
A. Intentional tremor
D. Conserve energy
B. Paralysis of limbs
13. Nurse KC should regularly assess the client’s
C. Muscle spasm
ability to metabolize the total parenteral nutrition
D. Lack of spontaneous movement
(TPN) solution adequately by monitoring the client
5. A client who suffered from automobile accident
for which of the following signs:
complains of seeing frequent flashes of light. The
nurse should expect:
A. Hyperglycemia
B. Hypoglycemia
A. Myopia
C. Hypertension
B. Detached retina
D. Elevate blood urea nitrogen concentration
C. Glaucoma
14. A female client has an acute pancreatitis. Which
D. Scleroderma
of the following signs and symptoms the nurse would
6. Kate with severe head injury is being monitored by
expect to see?
the nurse for increasing intracranial pressure (ICP).
Which finding should be most indicative sign of
increasing intracranial pressure? A. Constipation
B. Hypertension
C. Ascites
A. Intermittent tachycardia
D. Jaundice
B. Polydipsia
15. A client is suspected to develop tetany after a
C. Tachypnea
subtotal thyroidectomy. Which of the following
D. Increased restlessness
symptoms might indicate tetany?
7. A hospitalized client had a tonic-clonic seizure
while walking in the hall. During the seizure the
nurse priority should be: A. Tingling in the fingers
B. Pain in hands and feet
C. Tension on the suture lines
A. Hold the clients arms and leg firmly
D. Bleeding on the back of the dressing
B. Place the client immediately to soft surface
16. A 58 year old woman has newly diagnosed with
C. Protects the client’s head from injury
hypothyroidism. The nurse is aware that the signs and
symptoms of hypothyroidism include:
39

A. Diarrhea D. “Does the pain feel like the muscle was

B. Vomiting stretched?”
C. Tachycardia 25. The Nurse is assessing the client’s casted
D. Weight gain extremity for signs of infection. Which of the
17. A client has undergone for an ileal conduit, the following findings is indicative of infection?
nurse in charge should closely monitor the client for
occurrence of which of the following complications A. Edema
related to pelvic surgery? B. Weak distal pulse
C. Coolness of the skin
A. Ascites D. Presence of “hot spot” on the cast
B. Thrombophlebitis 26. Nurse Rhia is performing an otoscopic
C. Inguinal hernia examination on a female client with a suspected
D. Peritonitis diagnosis of mastoiditis. Nurse Rhia would expect to
18. Dr. Marquez is about to defibrillate a client in note which of the following if this disorder is
ventricular fibrillation and says in a loud voice present?
“clear”. What should be the action of the nurse?
A. Transparent tympanic membrane
A. Places conductive gel pads for defibrillation on B. Thick and immobile tympanic membrane
the client’s chest C. Pearly colored tympanic membrane
B. Turn off the mechanical ventilator D. Mobile tympanic membrane
C. Shuts off the client’s IV infusion 27. Nurse Jocelyn is caring for a client with
D. Steps away from the bed and make sure all nasogastric tube that is attached to low suction. Nurse
others have done the same Jocelyn assesses the client for symptoms of which
19. A client has been diagnosed with acid-base disorder?
glomerulonephritis complains of thirst. The nurse
should offer: A. Respiratory alkalosis
B. Respiratory acidosis
A. Juice C. Metabolic acidosis
B. Ginger ale D. Metabolic alkalosis
C. Milk shake 28. A male adult client has undergone a lumbar
D. Hard candy puncture to obtain cerebrospinal fluid (CSF) for
20. A client with acute renal failure is aware that the analysis. Which of the following values should be
most serious complication of this condition is: negative if the CSF is normal?

A. Constipation A. Red blood cells

B. Anemia B. White blood cells
C. Infection C. Insulin
D. Platelet dysfunction D. Protein
21. Nurse Karen is caring for clients in the OR. The 29. A client is suspected of developing diabetes
nurse is aware that the last physiologic function that insipidus. Which of the following is the most
the client loss during the induction of anesthesia is: effective assessment?

A. Consciousness A. Taking vital signs every 4 hours

B. Gag reflex B. Monitoring blood glucose
C. Respiratory movement C. Assessing ABG values every other day
D. Corneal reflex D. Measuring urine output hourly
22. The nurse is assessing a client with pleural 30. A 58 year old client is suffering from acute phase
effusion. The nurse expect to find: of rheumatoid arthritis. Which of the following
would the nurse in charge identify as the lowest
A. Deviation of the trachea towards the involved priority of the plan of care?
side
B. Reduced or absent of breath sounds at the base A. Prevent joint deformity
of the lung B. Maintaining usual ways of accomplishing task
C. Moist crackles at the posterior of the lungs C. Relieving pain
D. Increased resonance with percussion of the D. Preserving joint function
involved area 31. Among the following, which client is
23. A client admitted with newly diagnosed with autotransfusion possible?
Hodgkin’s disease. Which of the following would the
nurse expect the client to report? A. Client with AIDS
B. Client with ruptured bowel
A. Lymph node pain C. Client who is in danger of cardiac arrest
B. Weight gain D. Client with wound infection
C. Night sweats 32. Which of the following is not a sign of
D. Headache thromboembolism?
24. A client has suffered from fall and sustained a leg
injury. Which appropriate question would the nurse A. Edema
ask the client to help determine if the injury caused B. Swelling
fracture? C. Redness
D. Coolness
A. “Is the pain sharp and continuous?” 33. Nurse Becky is caring for client who begins to
B. “Is the pain dull ache?” experience seizure while in bed. Which action should
C. “Does the discomfort feel like a cramp?” the nurse implement to prevent aspiration?
40

A. Position the client on the side with head flexed A. Relieve pain and promote rapid epithelialization
forward B. Be sutured in place for better adherence
B. Elevate the head C. Debride necrotic epithelium
C. Use tongue depressor between teeth D. Concurrently used with topical antimicrobials
D. Loosen restrictive clothing 43. Mark has multiple abrasions and a laceration to
34. A client has undergone bone biopsy. Which the trunk and all four extremities says, “I can’t eat all
nursing action should the nurse provide after the this food”. The food that the nurse should suggest to
procedure? be eaten first should be:

A. Administer analgesics via IM A. Meat loaf and coffee

B. Monitor vital signs B. Meat loaf and strawberries
C. Monitor the site for bleeding, swelling and C. Tomato soup and apple pie
hematoma formation D. Tomato soup and buttered bread
D. Keep area in neutral position 44. Tony returns form surgery with permanent
35. A client is suffering from low back pain. Which colostomy. During the first 24 hours the colostomy
of the following exercises will strengthen the lower does not drain. The nurse should be aware that:
back muscle of the client?
A. Proper functioning of nasogastric suction
A. Tennis B. Presurgical decrease in fluid intake
B. Basketball C. Absence of gastrointestinal motility
C. Diving D. Intestinal edema following surgery
D. Swimming 45. When teaching a client about the signs of
36. A client with peptic ulcer is being assessed by the colorectal cancer, Nurse Trish stresses that the most
nurse for gastrointestinal perforation. The nurse common complaint of persons with colorectal cancer
should monitor for: is:

A. (+) guaiac stool test A. Abdominal pain

B. Slow, strong pulse B. Hemorrhoids
C. Sudden, severe abdominal pain C. Change in caliber of stools
D. Increased bowel sounds D. Change in bowel habits
37. A client has undergone surgery for retinal 46. Louis develops peritonitis and sepsis after
detachment. Which of the following goal should be surgical repair of ruptures diverticulum. The nurse in
prioritized? charge should expect an assessment of the client to
reveal:
A. Prevent an increase intraocular pressure
B. Alleviate pain A. Tachycardia
C. Maintain darkened room B. Abdominal rigidity
D. Promote low-sodium diet C. Bradycardia
38. A Client with glaucoma has been prescribed with D. Increased bowel sounds
miotics. The nurse is aware that miotics is for: 47. Immediately after liver biopsy, the client is
placed on the right side, the nurse is aware that that
A. Constricting pupil this position should be maintained because it will:
B. Relaxing ciliary muscle
C. Constricting intraocular vessel A. Help stop bleeding if any occurs
D. Paralyzing ciliary muscle B. Reduce the fluid trapped in the biliary ducts
39. When suctioning an unconscious client, which C. Position with greatest comfort
nursing intervention should the nurse prioritize in D. Promote circulating blood volume
maintaining cerebral perfusion? 48. Tony has diagnosed with hepatitis A. The
information from the health history that is most likely
A. Administer diuretics linked to hepatitis A is:
B. Administer analgesics
C. Provide hygiene A. Exposed with arsenic compounds at work
D. Hyperoxygenate before and after suctioning B. Working as local plumber
40. When discussing breathing exercises with a C. Working at hemodialysis clinic
postoperative client, Nurse Hazel should include D. Dish washer in restaurants
which of the following teaching? 49. Nurse Trish is aware that the laboratory test result
that most likely would indicate acute pancreatitis is
A. Short frequent breaths an elevated:
B. Exhale with mouth open
C. Exercise twice a day A. Serum bilirubin level
D. Place hand on the abdomen and feel it rise B. Serum amylase level
41. Louie, with burns over 35% of the body, C. Potassium level
complains of chilling. In promoting the client’s D. Sodium level
comfort, the nurse should: 50. Dr. Marquez orders serum electrolytes. To
determine the effect of persistent vomiting, Nurse
A. Maintain room humidity below 40% Trish should be most concerned with monitoring the:
B. Place top sheet on the client
C. Limit the occurrence of drafts A. Chloride and sodium levels
D. Keep room temperature at 80 degrees B. Phosphate and calcium levels
42. Nurse Trish is aware that temporary heterograft C. Protein and magnesium levels
(pig skin) is used to treat burns because this graft D. Sulfate and bicarbonate levels
will: Answers and Rationales
41

1. B. In preoperative period, the nurse should 24. A. Fractured pain is generally described as
consult with the physician about withholding sharp, continuous, and increasing in frequency.
Warfarin Sodium to avoid occurrence of 25. D. Signs and symptoms of infection under a
hemorrhage. casted area include odor or purulent drainage
2. D. A client who is unconscious is at greater risk and the presence of “hot spot” which are areas
for corneal abrasion. For this reason, the safest on the cast that are warmer than the others.
way to test the cornel reflex is by touching the 26. B. Otoscopic examnation in a client with
cornea lightly with a wisp of cotton. mastoiditis reveals a dull, red, thick and
3. B. Iatrogenic infection is caused by the heath immobile tymphanic membrane with or without
care provider or is induced inadvertently by perforation.
medical treatment or procedures. 27. D. Loss of gastric fluid via nasogastric suction
4. D. Bradykinesia is slowing down from the or vomiting causes metabolic alkalosis because
initiation and execution of movement. of the loss of hydrochloric acid which is a
5. B. This symptom is caused by stimulation of potent acid in the body.
retinal cells by ocular movement. 28. A. The adult with normal cerebrospinal fluid
6. D. Restlessness indicates a lack of oxygen to has no red blood cells.
the brain stem which impairs the reticular 29. D. Measuring the urine output to detect excess
activating system. amount and checking the specific gravity of
7. C. Rhythmic contraction and relaxation urine samples to determine urine concentration
associated with tonic-clonic seizure can cause are appropriate measures to determine the onset
repeated banging of head. of diabetes insipidus.
8. A. Right side lying position or supine position 30. B. The nurse should focus more on developing
permits ventilation of the remaining lung and less stressful ways of accomplishing routine
prevent fluid from draining into sutured task.
bronchial stump. 31. C. Autotransfusion is acceptable for the client
9. C. Isoniazid (INH) interferes in the who is in danger of cardiac arrest.
effectiveness of oral contraceptives and clients 32. D. The client with thromboembolism does not
of childbearing age should be counseled to use have coolness.
an alternative form of birth control while taking 33. A. Positioning the client on one side with head
this drug. flexed forward allows the tongue to fall forward
10. B. A client who has had abdominal surgery is and facilitates drainage secretions therefore
best placed in a low fowler’s position. This prevents aspiration.
relaxes abdominal muscles and provides 34. C. Nursing care after bone biopsy includes
maximum respiratory and cardiovascular close monitoring of the punctured site for
function. bleeding, swelling and hematoma formation.
11. A. Dark red to purple stoma indicates 35. D. Walking and swimming are very helpful in
inadequate blood supply. strengthening back muscles for the client
12. C. The rationale for activity restriction is to suffering from lower back pain.
help reduce the hypermotility of the colon. 36. C. Sudden, severe abdominal pain is the most
13. A. During Total Parenteral Nutrition (TPN) indicative sign of perforation. When perforation
administration, the client should be monitored of an ulcer occurs, the nurse maybe unable to
regularly for hyperglycemia. hear bowel sounds at all.
14. D. Jaundice may be present in acute pancreatitis 37. A. After surgery to correct a detached retina,
owing to obstruction of the biliary duct. prevention of increased intraocular pressure is
15. A. Tetany may occur after thyroidectomy if the the priority goal.
parathyroid glands are accidentally injured or 38. A. Miotic agent constricts the pupil and
removed. contracts ciliary muscle. These effects widen
16. D. Typical signs of hypothyroidism includes the filtration angle and permit increased out
weight gain, fatigue, decreased energy, apathy, flow of aqueous humor.
brittle nails, dry skin, cold intolerance, 39. D. It is a priority to hyperoxygenate the client
constipation and numbness. before and after suctioning to prevent hypoxia
17. B. After a pelvic surgery, there is an increased and to maintain cerebral perfusion.
chance of thrombophlebitits owing to the pelvic 40. D. Abdominal breathing improves lungs
manipulation that can interfere with circulation expansion
and promote venous stasis. 41. C. A Client with burns is very sensitive to
18. D. For the safety of all personnel, if the temperature changes because heat is loss in the
defibrillator paddles are being discharged, all burn areas.
personnel must stand back and be clear of all 42. A. The graft covers the nerve endings, which
the contact with the client or the client’s bed. reduces pain and provides framework for
19. D. Hard candy will relieve thirst and increase granulation
carbohydrates but does not supply extra fluid. 43. B. Meat provides proteins and the fruit proteins
20. C. Infection is responsible for one third of the vitamin C that both promote wound healing.
traumatic or surgically induced death of clients 44. C. This is primarily caused by the trauma of
with renal failure as well as medical induced intestinal manipulation and the depressive
acute renal failure (ARF) effects anesthetics and analgesics.
21. C. There is no respiratory movement in stage 4 45. D. Constipation, diarrhea, and/or constipation
of anesthesia, prior to this stage, respiration is alternating with diarrhea are the most common
depressed but present. symptoms of colorectal cancer.
22. B. Compression of the lung by fluid that 46. B. With increased intraabdominal pressure, the
accumulates at the base of the lungs reduces abdominal wall will become tender and rigid.
expansion and air exchange. 47. A. Pressure applied in the puncture site
23. C. Assessment of a client with Hodgkin’s indicates that a biliary vessel was puncture
disease most often reveals enlarged, painless which is a common complication after liver
lymph node, fever, malaise and night sweats. biopsy.
42

48. B. Hepatitis A is primarily spread via fecal-oral A. During exercise the body will use
route. Sewage polluted water may harbor the carbohydrates for energy production, which in
virus. turn will decrease the need for insulin
49. B. Amylase concentration is high in the B. With an increase in activity the body will utilize
pancreas and is elevated in the serum when the more carbohydrates; therefore more insulin will
pancreas becomes acutely inflamed and also it be required.
distinguishes pancreatitis from other acute C. The increase in activity results in an increase in
abdominal problems. the utilization of insulin; therefore the client
50. A. Sodium, which is concerned with the should decrease his/her carbohydrate intake
regulation of extracellular fluid volume, it is D. Exercise will improve pancreatic circulation
lost with vomiting. Chloride, which balances and stimulate the islet of Langerhans to increase
cations in the extracellular compartments, is the production of intrinsic insulin
also lost with vomiting, because sodium and 8.) The nurse is caring for a client who has
chloride are parallel electrolytes, hyponatremia exophthalmos associated with her thyroid disease.
will accompany. What is the cause of exophthalmos?

Text Mode – Text version of the exam A. Fluid edema in the retro-orbital tissues which
1.) A client is receiving NPH insulin 20 units subq at force the eyes to protrude
7:00 AM daily, at 3 PM how would the nurse finds if B. Impaired vision, which causes the client to
the client were having a hypoglycemic reaction? squint in order to see
C. Increased eye lubrication, which makes the
A. Feel the client and bed for dampness client blink less
B. Observe client kussmaul respirations D. Decrease in extraocular eye movements, which
C. Smell client’s breathe for acetone odor results in the “thyroid stare.”
D. Check client’s pupils for dilation 9.) What is characteristic symptom of hypoglycemia
2.) Postoperative thyroidectomy nursing care that should alert nurse to an early insulin reaction?
includes which measures?
A. Diaphoresis
A. Have the client speak every 5-10 mins if B. Drowsiness
hoarseness is present C. Severe thirst
B. Provide a low calcium diet to prevent D. Coma
hypercalcemia 10.) A client is scheduled for routine glycosylated
C. Check the dressing all the back of the neck for hemoglobin (HbA1c) test. What is important for the
bleeding nurse to tell the client before this test?
D. Apply a soft cervical collar to restrict neck
movement A. Drink only water after midnight and come to
3.) What would the nurse note as typical findings on the clinic early in the morning
the assessment of a client with acute pancreatitis? B. Eat a normal breakfast and be at the clinic 2
hours because of the multiple blood draws
A. Steatorrhea, abd. Pain, fever C. Expect to be at the clinic for several hours
B. Fever, hypoglycemia, DHN because of the multiple blood draws
C. Melena, persistent vomiting, hyperactive bowel D. Come to the clinic at the earliest convenience to
sounds have blood drawn
D. Hypoactive bowel sounds, decreased amylase 11.) A client has been inhalation vasopressin therapy.
and lipase levels What will the nurse evaluate to determine the
4.) A client is found to be comatose and therapeutic response to this medication?
hypoglycemic with a blood suger level 50 mg/dl.
What nursing action is implemented first? A. Urine specific gravity
B. Blood glucose
A. Infuse 1000 ml of D5W over a 12-hour period C. Vital signs
B. Administer 50% glucose IV D. Oxygen saturation levels
C. Check the client’s urine for the presence of 12.) A client with diagnosis of type 2 diabetes has
sugar and acetone been ordered a course of prednisone for her severe
D. Encourage the client to drink orange juice with arthritic pain. An expected change that requires close
added sugar monitoring by the nurse is;
5.) Which medication will the nurse have available
for the emergency treatment of tetany in the client A. Increased blood glucose level
who has had a thyroidectomy? B. Increased platelet aggregation
C. Increased ceatinine clearance
A. Calcium chloride D. Increased ketone level in urine
B. Potassium chloride 13.) The nurse performing an assessment on a client
C. Magnesium sulfate who has been receiving long-term steroid therapy
D. Sodium bicarbonate would expect to find:
6.) What is the primary action of insulin in the body?
A. Jaundice
A. Enhances the transport of glucose across cell B. Flank pain
walls C. Bulging eyes
B. Aids in the process of gluconeogenesis D. Central obesity
C. Stimulates the pancreatic beta cells 14.) A diabetic client receives a combination of
D. Decreases the intestinal absorption of glucose regular and NPH insulin at 0700 hours. The nurse
7.) What will the nurse teach the diabetic client teaches the client to be alert for signs of
regarding exercise in his /her treatment program? hypoglycemia at
43

A. 1200 and 1300 hours B. “Screening for glaucoma should be included in

B. 1100 and 1700 hours an annual eye exam for everyones over 50.”
C. 1000 and 2200 hours C. “There may be a genetic factor with glaucoma
D. 0800 and 1100 hours and your children over 30 y/o should be
15.) It is important for the nurse to teach the client screened yearly.”
that metformin (Glcucophage): D. “Are your grandchildren complaining of any
eye problems? Glaucoma generally skips a
A. May cause nocturia generation.”
B. Should be taken at night 23.) What will be important to include in the nursing
C. Should be taken with meals care for the client with angle-closure glaucoma?
D. May increase the effects of aspirin
16.) A nurse assessing a client with SIADH would A. Evaluation of medications to determine if any
expect to find laboratory values of: of them cause an increase in IOP is a side
effect.
A. Serum Na= 150 mEq/L and low urine B. Observation for an increase in loss of vision; it
osmolality can be reversed if promptly identified.
B. Serum K= 5 mEq/L and low serum osmolality C. Control BP to decrease the client’s potential
C. Serum Na=120 mEq/L and low serum loss of peripheral vision.
osmolality D. Assessment for a level of discomfort; the client
D. Serum K= 3 mEq/L and high serum osmolality may experience considerable pain until the
17.) A priority nursing diagnostic for a client optic nerve atrophies
admitted to the hospital with a diagnosis of diabetes 24.) A child is scheduled for a myringotomy. What
insipidus is: goal of this procedure will the nurse discuss with the
parents?
A. Sleep pattern deprivation related nocturia
B. Activity intolerance r/t muscle weakness A. Promote drainage from the ear
C. Fluid volume excess r/t intake greater that B. Irrigate the Eustachian tube
output C. Correct a malformation in the inner ear
D. Risk for impaired skin integrity r/t generalized D. Equalize pressure on the tympanic membrane
edema 25.) After a client’s eye has been anesthetized, what
18.) A client admitted with a pheochrocytoma returns instructions will be important for the nurse to give the
from the operating room after adrenalectomy. The client?
nurse should carefully assess this client for:
A. Do not watch TV for at least one day
A. Hypokalemia B. Do not rub the eye for 15-20 minutes
B. Hyperglycemia C. Irrigate the eye every hour to prevent dryness
C. Marked Na and water intake D. Wear sunglasses when in direct sunlight for the
D. Marked fluctuations in BP next 6 hours
19.) When caring for client in thyroid crisis, the nurse 26.) A child diagnosed with conjunctivitis. Which
would question an order for: statement reflects that the child understood the
nurse’s teaching?
A. IV fluid
B. Propanolol (Inderal) A. “It’s okay for me to let my friends use my
C. Prophylthiouracil sunglasses while we are playing together.”
D. A hyperthermia blanket B. “It’s okay for me to softly rub my eye, as long
20.) A client is prescribed levothyroxine (Synthroid) as I use the back of my hand.”
daily. The most important instruction to give the C. “I can pick the crustly stuff out of my eyelashes
client for administration of this drug is: with my fingers when I wake up in the
morning.”
D. “I will use my own washrag and towel while
A. Taper dose and discontinue if mental and my eyes are sick.”
emotional statuses stabilize 27.) What medication would the nurse anticipate
B. Take it at bedtime to avoid the side effects of giving a client with Meniere’s dse?
nausea and flatus
C. Call the M.D. immediately at the onset of
palpitations or nervousness A. Nifedipine
D. Decrease intake of juices and fruits with high B. Amoxicillin
potassium and calcium contents C. Propanolol
21.) The nurse would question which medication D. Hydrochloride (Hydro DIURIL)
order for a client with acute-angled glaucoma? 28.) When teaching a family and a client about the
use of a hearing aid, the nurse will base the teaching
on what information regarding the hearing aid?
A. Atropine (Atrposil) 1-2 drops in each eye now
B. Hydrochloride (Diuril) 25 mg PO daily
C. Propanolol (Inderal) 20 mg PO 2 times a day A. Provides mechanical transmission for damaged
D. Carbanyl choline (Isopto carbachol) eye drops; part of the ear
1 drop 2 times a day B. Stimulates the neural network of the inner ear
22.) A client tells you she has heard that glaucoma to amplify sound
may be a hereditary problem and she is concerned C. Amplifies sound but does not improve the
about her adult children. What is the best response? ability to hear
D. Tunes out extraneous noise in the lower-
frequency sound spectrum
A. “There is no need for concern; glaucoma is not 29.) What statement by the client recovering from
hereditary order.” cataract surgery would indicate to the nurse need for
additional teaching?
44

A. “I’ll call if I have a significant amount of pain.” A. Provide a diet low in protein and high in
B. “I’ll continue to take my Metamucil for another carbohydrates
week.” B. Avoid fresh vegetables that are not cooked or
C. “I’ll just do some laundry this afternoon instead peeled
of going to work.” C. Notify the M.D. if the child’s temperature
D. “I’ll take my acetazolamide (Diamox) drops exceeds 101F (39C)
with my other morning medications D. Increase the use of humidifiers throughout the
30.) A client is walking down the hall and begins to house
experience vertigo. What is the most important 38.) Which client is most likely to have iron
nursing action when this occurs? deficiency anemia?

A. Have the client sit in a chair and lower his head A. A client with cancer receiving radiation therapy
B. Administer meclizine (Antivert) PO twice a week
C. Assist the client to sit or lie down B. A toddler whose primary nutritional intake is
D. Assess if the occurrence is vertigo or dizziness milk
31.) Which client is at highest risk for retinal C. A client with peptic ulcer who had surgery 6
detachment? weeks ago
D. A 15-year old client in sickle cell crisis
A. 4-year old with amblyopia 39.) A client has an order for one unit of whole
B. 17 y/o who plays physical contact blood. What is a correct nursing action?
C. 33 y/o with severe ptosis and diplopia
D. 72 y/o with nystagmus and Bell’s palsy A. Initiate an IV with 5% dextrose in water (D5W)
32.) To promote and maintain safety for a client after to maintain a patent access site
a stapedectomy. What would be included in the B. Initiate the transfusion within 30 minutes of
nursing care plan? receiving the blood
C. Monitor the client’s vital signs for the first 5
A. Implement fall precautions minutes
B. Prevent aspirations D. Monitor V/S every 2 hours during the
C. Begin oxygen 2-4L/min via nasal cannula transfusion
D. Change inner ear dressing when saturated 40.) The nurse is caring for a client who is receiving
33.) The nurse would question the administration of a blood transfusion. The transfusion was started 30
which eye drop in a patient with increased ICP? mins ago at a rate of 100 ml/hr. The client begins to
complain of low back pain and headache and is
increasing restless, what is the first nursing action?
A. Artificial tears
B. Betaxolol (Betoptic)
C. Acetazolamide (Diamox) A. Slow the infusion and evaluate the V/S and
D. Epinephrine HCL (Epirate) client’s history of transfusion reaction
34.) A client is being admitted for problems with B. Stop the transfusion, disconnect the blood
Meniere’s disease. What is most important to the tubing and begin a primary infusion of normal
nurse to assess? saline solution
C. Stop the infusion of blood and begin infusion of
NSS from the Y connector
A. Diet history D. Recheck the unit of blood for correct
B. Screening hearing test identification numbers and cross-match
C. Effect on client’s activities of daily living information
(ADLs) 41.) The nurse is preparing to start an IV infusion
D. Frequency and severity before the administration of a unit of packed red
35.) A client calls the nurse regarding an accident blood cells, what fluid will the nurse select to
that just occurred during which an unknown chemical maintain the infusion before hanging the unit of
was splashed in his eyes. What is the most important blood?
for the nurse to tell the client to do immediately?
A. D5W
A. Rinse the eye with large amount of water or B. D5W/.45NaCl
saline solution C. LR solution
B. Put a pad soaked in the sterile saline solution D. .9% Na Cl
over the eye 42.) A client in sickle cell crisis is admitted to the
C. Go to the closest emergency room emergency department what are the priorities of care?
D. Have a co-worker visually checks the eye for a
foreign body
36.) A 25- year old woman comes to the clinic A. Nutrition, hydration, electrolyte balance
complaining of dizziness, weakness and palpitations. B. Hydration, pain management, electrolyte
What will be important for the nurse to initially balance
evaluate when obtaining the health history? C. Hydration, oxygenation, apin management
D. Hydration, oxygenation, electrolyte balance
43.) A client in the ICU has been diagnosed with
A. Activity and exercise patterns DIC. The nurse will anticipate administering which
B. Nutritional patterns of the following fluids?
C. Family health status
D. Coping and stress tolerance
37.) A child with leukemia is being discharged after A. Packed RBC
beginning chemotherapy. What instructions will the B. Fresh Frozen plasma (FFP)
nurse include in the teaching plan for the parents of C. Volume expanders, such as D10W
this child? D. Whole blood
44.) The nurse is assessing a client who has been
given a diagnosis of polycythemia vera. What
45

characteristics will the nurse anticipate finding when inserted into the endotracheal tube to suction
assessing this client? the lower airway
C. With suction applied, the catheter is inserted
A. Increased fatigue and bleeding tendencies into the endotracheal tube; when resistance is
B. Hemoglobin below 13 mg/dl met, the catheter is slowly withdrawn
C. Headaches, dyspnea, claudication D. The catheter is inserted into the endotracheal
D. Back pain, ecchymosis, and joint tenderness tube to a point of resistance, and intermittent
45.) A client has been diagnosed with pernicious suction is applied during withdrawal.
anemia what will the nurse teach this client regarding Answers and Rationales
medication he will need to take after he goes home?
1. A. Feel the client and bed for dampness
2. C. Check the dressing all the back of the neck
A. Monthly Vit. B12 injections will be necessary for bleeding
B. Ferrous sulfate PO daily will be prescribed 3. A. Steatorrhea, abd. Pain, fever
C. Coagulation studies are important to evaluate 4. B. Administer 50% glucose IV
medications 5. A. Calcium chloride
D. Decrease intake of leafy green vegetables 6. A. Enhances the transport of glucose across cell
because of increased Vit. K walls
46.) First postop day after a right lower lobe (RLL) 7. A. During exercise the body will use
lobectomy, the client breathes and coughs but has carbohydrates for energy production, which in
difficulty raising mucus. What indicates that the turn will decrease the need for insulin
client is not adequately clearing secretions? 8. A. Fluid edema in the retro-orbital tissues
which force the eyes to protrude
A. Chest x-ray film shows right sided pleural fluid 9. A. Diaphoresis
B. A few scattered crackles on RLL on 10. D. Come to the clinic at the earliest
auscultation convenience to have blood drawn
C. PCO2 increases from 35-45 mm Hg 11. A. Urine specific gravity
D. Decrease in forced vital capacity 12. A. Increased blood glucose level
47.) What nursing observations indicate that the cuff 13. D. Central obesity
on an endotracheal tube is leaking? 14. B. 1100 and 1700 hours
15. C. Should be taken with meals
A. An increase in peak pressure on the ventilator 16. C. Serum Na=120 mEq/L and low serum
B. Client is able to speak osmolality
C. Increased swallowing efforts by client 17. B. Activity intolerance r/t muscle weakness
D. Increased crackles (rales) over left lung field 18. D. Marked fluctuations in BP
48.) The client with COPD is to be discharged home 19. D. A hyperthermia blanket
while receiving continuous oxygen at a rate of 2 20. C. Call the M.D. immediately at the onset of
L/min via cannula. What information does the nurse palpitations or nervousness
provide to the client and his wife regarding the use of 21. A. Atropine (Atrposil) 1-2 drops in each eye
oxygen at home? now
22. C. “There may be a genetic factor with
glaucoma and your children over 30 y/o should
A. Because of his need for oxygen, the client will be screened yearly.”
have to limit activity at home 23. A. Evaluation of medications to determine if
B. The use of oxygen will eliminate the client’s any of them cause an increase in IOP is a side
shortness of breath effect.
C. Precautions are necessary because oxygen can 24. A. Promote drainage from the ear
spontaneously ignite and explode 25. B. Do not rub the eye for 15-20 minutes
D. Use oxygen during activity to relieve the strain 26. D. “I will use my own washrag and towel while
on the client’s heart my eyes are sick.”
49.) The wife of a client with COPD is worried about 27. D. Hydrochloride (Hydro DIURIL)
caring for her husband at home. Which statement by 28. C. Amplifies sound but does not improve the
the nurse provides the most valid information? ability to hear
29. C. “I’ll just do some laundry this afternoon
A. “You should avoid emotional situations that instead of going to work.”
increase his shortness of breathe.” 30. C. Assist the client to sit or lie down
B. “Help your husband arrange activities so that he 31. B. 17 y/o who plays physical contact
does as little walking as possible.” 32. A. Implement fall precautions
C. “Arrange a schedule so your husband does all 33. D. Epinephrine HCL (Epirate)
necessary activities before noon; then he can 34. D. Frequency and severity
rest during the afternoon and evening.” 35. A. Rinse the eye with large amount of water or
D. “Your husband will be no more short of breath saline solution
when he walks but that will not hurt him.” 36. B. Nutritional patterns
50.) Which statement correctly describes suctioning 37. B. Avoid fresh vegetables that are not cooked
through an endotracheal tube or peeled
38. B. A toddler whose primary nutritional intake is
A. The catheter is inserted into the endotracheal milk
tube; intermittent suction is applied until no 39. B. Initiate the transfusion within 30 minutes of
further secretions are retrieved; the catheter is receiving the blood
then withdrawn. 40. B. Stop the transfusion, disconnect the blood
B. The catheter is inserted through the nose, and tubing and begin a primary infusion of normal
the upper airway is suctioned; the catheter is saline solution
then removed from the upper airway and 41. D. .9% Na Cl
42. C. Hydration, oxygenation, apin management
43. B. Fresh Frozen plasma (FFP)
46

44. C. Headaches, dyspnea, claudication Situation . Hearing, impairment appears to be

45. A. Monthly Vit. B12 injections will be common among elderly patients. But also occurs
necessary among children.
46. C. PCO2 increases from 35-45 mm Hg 6. To assess the degree of hearing impairment of a
47. B. Client is able to speak 70-year-old client. Which communication approach
48. A. Because of his need for oxygen, the client would you initiate?
will have to limit activity at home
49. C. “Arrange a schedule so your husband does A. Use verbal communication and observe the
all necessary activities before noon; then he can response
rest during the afternoon and evening.” B. Give message to client in writing
50. D. The catheter is inserted into the endotracheal C. Asks a family member about the client’s
tube to a point of resistance, and intermittent D. Post a sign “Patient deaf”
suction is applied during withdrawal. 7. While you are mating your routine rounds you
were told that there is a client in the 1CU who is in
respirator and who lip- reads. To establish
Text Mode – Text version of the exam
relationship with him, communication is best
1. A 42-year-old client admitted with an acute
accomplished by:
myocardial infarction asks to see his chart. What
should the nurse do first?
A. Speaking slowly but aloud
B. Writing messages
A. Allow the client to view his chart
C. Gesturing while speaking
B. Contact the supervisor and physician for
D. Using simple “charade” approach or strategy
approval
8. One of your client’s has just undergone an ear
C. Ask the client if he has concerns about his care
surgery. Which of the following would be
D. Tell the client that he isn’t permitted to view his
inappropriate in planning for his care?
chart.
2. A registered nurse who works in the preoperative
area of the operating room notices that a client is A. Administration of anti-emetics and analgesics
scheduled for a partial mastectomy and axillary as ordered
lymph node removal the following week. The nurse B. Daily irrigation of the ear canal
should make sure, that the client is well educated C. Walking with assistance at least 24 hours after
about her surgery by: operation
D. Teaching the patient to avoid sneezing,
coughing and nose blowing
A. taking with the nursing staff at the physician’s
9. Which of the following conditions would an
office to find out what the client has been
irrigation of the ear canal be appropriate
taught and her level of understanding
intervention?
B. making sure that the post-anesthesia recovery
unit nurses know what to teach the patient
before discharge A. Foreign body in the ear canal
C. providing all of the preoperative teaching B. Serious otitis
before surgery C. Impacted cerumen
D. having the post-operative nurses teach the D. Tympanic membrane perforation
patient because she’ll be too anxious before 10. Children who have undetected hearing loss are
surgery likely to exhibit which of the following:
3. A male client brings a list of his prescribed
medications to the clinic. During the initial A. Indifference and lack of interest in the
assessment, he tells the nurse that environment
he has been experiencing delayed ejaculation. Which B. Hyperactivity
drug class is associated with this problem? C. An increased interest in reading
D. Hand gestures while speaking
A. Anticoagulants Situation . One of the main fools of the nursing
B. Antibiotics profession is the use of therapeutic communication.
C. Antihypertens ive The following situation would require you of your
D. Steroids communication skills.
Situation: Larry was admitted at Manila Doctor’s 11. A patient who is diagnosed to have terminal
Hospital because of a second-degree burn wound. illness tells you. “I’m really scared. Am I dying?”
4. Before debriding a second-degree burn wound in What could be your most appropriate response?
the left lower leg, the nurse should do which of the
following? A. “Tell me about what you think.”
B. “I’m sure you are scared; other clients in your
A. Apply Lindane (Kwell) to the affected area situation feel the same way.”
B. Medicate the client with narcotic analgesic C. “You should be careful not to let your family
C. Administer acylovir (Zovirax) IV know you’re scared”
D. Apply a topical antimicrobial ointment D. “Why are you scared?”
5. Larry’s anterior trunk, both front upper 12. The nurse assessing a male client who has been
extremities, both lower extremities sustained second admitted for treatment of alcoholism. Which
and third degree burn. Estimate the total percentage question by the nurse is least appropriate?
of body surface area burned using the Rule of Nines.
A. “How much do you think?”
A. 60% B. “What other drugs do you use?” .
B. 63% C. “How is your general health?”
C. 62% D. “Why do you drink so much?”
D. 61%
47

13. A 58-year-old male client tells the office nurse D. facial rubor
that his wife does not let him change his colostomy 19. ASA (aspirin) is being administered to a client.
bag himself. Which response by the nurse indicates The nurse understands that the most common
as understanding of the situation? mechanism of action for nonnarcotic analgesic is
their ability to:
A. “Your wife’s need to help you is a reality you
should accept” A. Inhibit prostaglandin systhesis
B. “Do you think your wife might benefit from B. After pain perception in the cerebellum
counseling?” C. Directly affect the central nervous system
C. “You feel you need privacy when changing D. Target the pain-producing effect of kinins
your colostomy?” 20. The nurse caring for an adult client who is
D. “Have you discussed the situation with your receiving TPN will need to be monitored for which of
doctor?” the following metabolic complications?
14. An 87 year old widow was hospitalized for
treatment of chronic renal disease. She lives with her A. Hypoglycemia and Hypercalcemia
daughter and son-in- law and their family, who are B. Hyperglycemia and Hypokalemia
very supportive. She is now ready for discharge. The C. Hyperglycemia and Kyperkalemia
doctor has ordered high carbohydrates, low-protein, D. Hyperkalemia and Hypercalcemia
low sodium diet for her and the family has asked for 21. Total parenteral nutrition is ordered for an adult.
assistance in planning low-sodium diet meals. Which Which nutrient is not likely to be in the solution?
of the following choices best reflects the pre-
discharge information the nurse should provide for
the client’s family regarding low-sodium diet? A. Dextrose 10%
B. Trace minerals
C. Amino acids
A. Avoid canned and processed foods, do not use D. Non of the above
salt replacements substitute herbs and replaces 22. A man has sprained his ankle. The physician
for salt in cooking and when seasoning foods, would order cold applied to the injured area to.
call a dietitian for help.
B. Use potassium salts in place of table salt when
coking and seasoning foods, read the labels on A. Reduce the body’s temperature
packaged foods to determine sodium content, B. Increase circulation to the area
and avoid snacks food C. Aid in absorbing the edema
C. Limit milk and dairy products, cook separate D. Relieve pain and control bleeding.
meals that are low in sodium and encourage 23. An adult is to have a tepid sponge bath to lower
increased fluid intake his fever. What temperature should the nurse make
D. Avoid eating in a restaurant, soak vegetables the water?
well before cooking to remove sodium, omit all
canned foods, and remove salt shakes from A. 65 F
table. B. 90 F
15. You are encouraging your patient for major C. 110 F
cancer operation to verbalize her fears. She D. 105 F
remarked,” I am afraid to do”. Your appropriate 24. An adult has chronic lower back pain and
response is receives hot pack three times a week. The nurse
knows that the treatment is given for which of the
A. “I know how you feel about your condition”. following reasons?
B. “Don’t worry, you are in good hands.”
C. “Let me call a chaplain to see you.” A. To help remove debris from the wound
D. “Let us asks your doctor about your operation.” B. To keep the client warm and raise his
16. The nurse is caring for a client whose arterial temperature
blood gases indicate metabolic acidosis. The nurse C. To improve the client’s general circulation
knows that of the following, the least likely to cause D. To relieve muscle spasm and promote muscle
metabolic acidosis is: relaxation
25. A patient classification system where patients
A. cardiac arrest minimal therapy and less frequent observation
B. Diabetic ketoacidosis
C. decreased serum potassium level A. minimal care (category 1)
D. renal failure B. moderate care (category 2)
17. The nurse is caring for a client who is receiving C. maximum care (category 3)
IV fluids, Which observation the nurse makes best D. intensive care (category 4)
indicates that the IV has infiltrated? 26. The nurse is to apply a dressing to a stage II
pressure ulcer. Which of the following dressing is
A. Pain at the site best?
B. A change in flow rate
C. Coldness around the insertion site A. Dry gauze dressing
D. Redness around the insertion site B. wet gauze dressing
18 A 27 y.o adult is admitted for treatment of C. wet to dry dressing
Crohn’s disease. Which information is most D. moisture vapor permeable dressing
significant when the nurse assesses nurtritional 27. The client has been placed in the trendelenburg
health? position. The nurse knows the effects of this position
to the client include which of the following.
A. Anthropometric measurements
B. bleeding gums A. increase blood flow to the feet
C. dry skin B. decrease blood pressure
48

C. increase pressure on the diaphragm D. over the temporal area

D. decrease intracranial pressure 36. A client who receives general anesthesia returns
28. A man who has been in an MVA is going into from surgery. Postoperatively, which nursing
shock. Before placing the client in a modified diagnosis takes highest priority for this client?
trendelenburg position, the nurse should assess the
client for: A. Pain related to the surgery
B. Fluid volume deficit related to fluid and blood
A. long bone fracture loss from surgery
B. air embolus C. Impared physical mobility related to surgery
C. head injury D. Risk for aspiration related to anesthesia
D. thrombophlebitis 37. After a client receives an IM injection, he
29. The nurse enter a room and finds a fire. Which is complains of a burning pain in the injection site.
the best initial action? Which nursing action whould be best to take at this
time?
A. Evacuate any people in the room, beginning
with the most ambultory and ending with the A. apply a cold compress to decrease swelling
least mobile B. apply a warm compress to dilate the blood
B. activating the fire alarm or call the operator, vessels
depending on the institutions system C. Massage the area to promote absorption of the
C. get a fire extinguisher and put out the fire drug
D. close all the windows and doors and turn off D. Instruct the client to tighten his gluteal muscles
any oxygen or electricity appliance. to enhance absorption of the drug
30. The nurse is to open a sterile package from 38. A patient classification system where patients
central supply. Which is the correct direction to open need close attention and complete care in most
the first lap? activities and requires frequent and complex
treatments and medications:
A. Toward the nurse
B. Away from the nurse A. Minimal Care (category 1)
C. To the nurse’s left or right hand B. Moderate Care (category 2)
D. It does not matter as long as the nurse touches C. Maximum Care (category 3)
only the outside edge D. Intensive Care (category 4)
31. The nurse knows which of the following is the 39. An observation consistent with complete-airway
proper technique for medical asepsis? obstruction is:

A. gloving for all the client contact A. Loud crowing when attempting to speak
B. changing hospital linens weekly B. Inability to cough
C. using your hands to turn off the faucet after C. Wheezes on auscultation
handwashing D. Gradual
D. gowning to care for a 1 year old child w/ 40. The nurse assesses the client’s home environment
infections diarrhea for the safe use crutches. Which one of the following
32. An adult ha a left, above the knee amputation two would pose the greatest hazard to the client’s safe use
weeks ago. The nurse places him in a prone position of crutches at home?
tree times a day because:
A. A 4-year old cocker spaniel
A. Prevents pressure ulcer on the sacrum B. Scatter rugs
B. helps the prosthesis to fit correctly C. Snack tables
C. prevents flexion constractures D. Diet high in fat
D. allow better blood flow to the heart 41. A patient who has kaposis sarcoma has all of the
33. A woman is to have a pelvic exam. Which of the following nursing diagnoses. To which one should
following should the nurse have the client do first? the nurse give priority?

A. Remove all her clothes and her socks and shoes A. Altered thought processes related to lesions
B. go to the bahtroom and void saving a sample B. Altered with maintenance related to non
C. assume a lithotomy position on the exam table compliance
D. assemble all the equipments needed for the C. Defensive coping related to loss of boundaries
examination D. Hopelessness, related to inability to control
34. An adult is supine. Which of the ff. can the nurse disease process
to to prevent external rotation of the legs? 42. Which of the following statements, if made by a
patient who has had a basal cell carcinoma removed,
A. put a pillow under the clients lower legs would indicate to the nurse the need for further
B. place a pillow directly under the client knee instruction?
C. use a trochanter rool alongside the client’s
upper thighs A. “I will use sunscreen with at least a sun
D. lower the client’s legs so that they ae below protection factor (SPF) of 15.”
hips. B. “I will use tanning booths rather than
35. The nurse prepares to palpate a clients maxillary sunbathing from now on.”
sinues. For this procedure, where should the nurse C. “I will stay out of the sun between 10:00 AM
place the hands? and 2:00 PM”
D. “I will wear a broad – brimmed heat when I am
A. On the bridge of the nose in the sun”
B. below the eyebrows 43. A patient who has a diagnosis is metastatic cancer
C. below the cheekbones of the kidney is told by the physician that the kidney
49

needs to be removed. The patient asks the nurse. 2. A. taking with the nursing staff at the
“What should I do?”Which of the following physician’s office to find out what the client has
responses by the nurse would be most therapeutic? been taught and her level of understanding
3. C. Antihypertensive
A. “Let’s talk about your options.” 4. B. Medicate the client with narcotic analgesic
B. “You need to follow the doctor’s advice.” 5. B. 63%
C. “What does your family want you to do.” 6. A. Use verbal communication and observe the
D. “I wouldn’t have the surgery done without a response
second opinion. 7. A. Speaking slowly but aloud
44. Which of the following conditions, reported to a 8. D. Teaching the patient to avoid sneezing,
nurse by a 20 year old male patient, would indicate a coughing and nose blowing
risk for development of testicular cancer? 9. C. Impacted cerumen
10. A. Indifference and lack of interest in the
environment
A. Genital Herpes 11. A. “Tell me about what you think.”
B. Undescended testicle 12. D. “Why do you drink so much?”
C. Measles 13. C. “You feel you need privacy when changing
D. Hydrocele your colostomy?”
45. A client has been diagnosed as having bladder 14. A. Avoid canned and processed foods, do not
cancer, and a cystectomy and an ileal conduit are use salt replacements substitute herbs and
scheduled. Preoperatively, the nurse plans to: replaces for salt in cooking and when seasoning
foods, call a dietitian for help.
A. Limit fluid intake for 24 hours 15. A. “I know how you feel about your condition”.
B. Teach muscle tightening exercises 16. C. decreased serum potassium level
C. Teach the procedure for irrigation of the stoma 17. C. Coldness around the insertion site
D. Provide cleansing enemas and laxatives as 18. A. Anthropometric measurements
ordered 19. A. Inhibit prostaglandin systhesis
46. To gain access to a vein and an artery, an external 20. B. Hyperglycemia and Hypokalemia
shunt may be used for clients who require 21. D. Non of the above
hemodialysis. The most serious problem with an 22. D. Relieve pain and control bleeding.
external shunt is. 23. B. 90 F
24. D. To relieve muscle spasm and promote
A. Septicemia muscle relaxation
B. Clot-formation 25. A. minimal care (category 1)
C. Exsanguination 26. D. moisture vapor permeable dressing
D. Sclerosis of vessels 27. C. increase pressure on the diaphragm
47. A client has been diagnosed as having bladder 28. C. head injury
cancer, and a cystectomy and an ileal conduit are 29. A. Evacuate any people in the room, beginning
scheduled. Preoperatively, the nurse plans to: with the most ambultory and ending with the
least mobile
30. B. Away from the nurse
A. Limit fluid intake for 24 hours
31. D. gowning to care for a 1 year old child w/
B. Teach the procedure for irrigation of the stoma
infections diarrhea
C. Teach muscle-tightening exercises
32. C. prevents flexion constractures
D. Provide cleansing enemas and laxatives as
33. B. go to the bahtroom and void saving a sample
ordered
34. C. use a trochanter rool alongside the client’s
48. Intramedullary nailing is used in the treatment of:
upper thighs
35. C. below the cheekbones
A. Slipped epiphysis of the femur 36. D. Risk for aspiration related to anesthesia
B. Fracture of shaft of the femur 37. B. apply a warm compress to dilate the blood
C. Fracture of the neck of the femur vessels
D. Intertrochanteric fracture of the femur 38. D. Intensive Care (category 4)
49. The nurse should know that, following a fracture 39. B. Inability to cough
of the neck of the femur, the desirable position for the 40. B. Scatter rugs
41. D. Hopelessness, related to inability to control
A. Internal rotation with extension of the knee disease process
B. Internal rotation with flexion of the knee and 42. B. “I will use tanning booths rather than
hip sunbathing from now on.”
C. External rotation with flexion of the knee and 43. A. “Let’s talk about your options.”
hip 44. B. Undescended testicle
D. External rotation with extension of the knee and 45. D. Provide cleansing enemas and laxatives as
hip ordered
50. A client with myasthenia gravis has been 46. C. Exsanguination
receiving Neostigmine (Prostigmin). This drug acts 47. D. Provide cleansing enemas and laxatives as
by: ordered
48. B. Fracture of shaft of the femur
A. Stimulating the cerebral cortex 49. A. Internal rotation with extension of the knee
B. Blocking the action of cholinesterase 50. B. Blocking the action of cholinesterase
C. Replacing deficient neurotransmitters
D. Accelerating transmission along neural swaths
Answers and Rationales

1. C. Ask the client if he has concerns about his

care