Medical – Surgical Nursing
Question the doctors order
Name:_____________________________
Situation 1: Mr. Rod Foz is admitted to the
cardiac care unit with myocardial infarction
1. The morning after admission, he and his
wife tell the nurse that he must be home
tonight to care for the children when his wife
goes to work. The problem identified at this
point would be:
a. Anxiety related to physical limitation
b. Alteration in cardiac output
c. Inability of client to understand disease
process
d. Safety needs related to inability to cope
2. During the second night in cardiac unit,
Mr. Rod develops heart failure. A pulmonary
artery is inserted to monitor the client for
left ventricular function because;
a. It provides information about the
pulmonary resistance
b. It measure myocardial oxygen
consumption
c. It controls renal blood flow
d. It controls afterload
3. The nurse who is caring fro Mr. Rod was
ordered to give oxygen administration.
Administering oxygen to this client is related
to which of the following client problems
a. Anxiety
b. Chest pains
c. Ineffective myocardial perfusion
d. Alteration in heart rate, rhythm or
conduction
4. The heart is manifesting myocardial
injury. The nurse will notice the following
changes in the ECG result
a. Elevated st segment
b. Inverted T wave
c. Elevated T wave
d. Pathological Q wave
5. After a month, Mr. Rod comes back to the
emergency room, complaining of chest pain
and difficulty in breathing. What would be
the best initial action of the nurse?
a. Administer Oxygen
b. Give Morphine sulfate
c. Give aspirin
d. ECG tracing
6. The doctor orders the nurse to give
digoxin. The Blood pressure of the patient is
100/70. What should the nurse do?
a.
b. Get the HR of the patient before giving
digoxin
c. Give the medication immediately
d. Test for allergy of the drug
7. The cardiac rhythm of the MI patient has
been normal sinus rhythm with occasional
PVC’s. The nurse notes a sudden change on
the cardiac monitor screen to a very
irregular, chaotic looking pattern. The client
appears to be sleeping. The most
appropriate action of the part of the nurse is
to:
a. Administer a precordial thump
b. Obtain defibrillator
c. Begin cardiopulmonary resuscitation
d. Check the client’s ECG electrodes
Situation: After several episodes of MI, the
patient condition further leads to Congestive
heart failure. Mrs. Edes is admitted to the
CCU for observation
8. The doctor orders to give digoxin to Mrs.
Edes. Which of the following physiological
responses indicates that the digoxin is
having the desired effect?
a. Increased heart rate
b. Decreased cardiac output
c. Increase urine output
d. Decreased myocardial contraction force
9. She manifested shortness of breath and
+3 peripheral edema. The care plan to
reduce the client’s edema should include
nursing strategies for
a. Establishing limits on activity
b. Fostering relaxed environment
c. Identifying goals for self care
d. Restricting IV fluids
10. Mrs. Edes is manifesting edema and
complains that she is always tired. Which of
the following would be the most appropriate
suggestion by the nurse while the client is
still on bed rest?
a. Continue to exercise your legs
b. Try not to think about the fatigue
c. Eat larger meals
d. Sleep as much as possible
11. Left sided CHF is diagnosed to the
patient. Which symptoms should the nurse
expects to find?
a. Ascites b. Jugular vein
distention
c. Hepatomegaly d. Rales
12. Digoxin 0.25mg is ordered daily. The
nurse should teach the patient that the signs
of digitalis toxicity include:
a. Auditory hallucinations and bradycardia
b. dry mucous membranes and diarrhea
c. heart block and brittle hair and nails
d. visual disturbances and premature
heartbeats
13. Which serum potassium level reported
for an adult adult requires no immediate
nursing intervention
a. 3.2 mEq/L
b. 4.0 mEq/L
c. 5.7 mEq/L
d. 6.0 mEq/L
14. A client with Buerger’s disease has
received instructions from the nurse about
how to limit the progression of the disease.
The nurse determines that the client needs
further instructions if which statement was
made by the client?
a) I need to eat balanced diet
b) a heating pad on my leg will help soothe
the leg pain
c) I need to take special care of my feet to
prevent injury
d) I should walk daily to increase the
circulation to my legs
15. A client seeks treatment in an
ambulatory care center for symptoms of
Raynaud's disease. The nurse instructs the
client to:
a) decrease cigarette smoking by one half
b) alternate exposures to both heat and cold
c) continue activity during vasospasm for
quicker relief of symptoms
d) wear protective items, such as gloves and
warm socks, as necessary
16. Nurse Fiona is caring a patient with
Raynaud’s disease. Which of the following
outcomes concerning medication regimen is
of highest priority?
a. Controlling the pain once vasospasm occur
b. Relaxing smooth muscle to avoid
vasospasms
c. Preventing major disabilities that may
occur
d. Avoiding lesions on the feet
17. When taking care of a patient with
Buerger’s disease, which of the following
early manifestation should the nurse
anticipate?
a. Gangrene of the foot
b. Leg cramps
c. Pain on the fingers when exposed to cold
d. Bleeding on the affected extremity
Situation 1: Mrs. Jane is diagnosed as
hypertensive client. She experienced
headaches, nausea and vomiting, and chest
pain
18. She is being treated with a thiazide
diuretic and dietary and lifestyle
modifications. The nurse knows that she
understands the treatment if she makes
which of the following statements?
a. I will use soy sauce or mustard instead of
salt on my food
b. I need to cut back to two, 4 ounce glasses
of wine a day
c. I will stop riding my bike because vigorous
exercise will raise my blood pressure
d. Smoking helped cause my hypertension,
but quitting won’t help
19. Captopril is prescribed by the doctor for
the patient. Which of the following statement
is true regarding the management
a. It decreases the blood pressure by
decreasing the cardiac contractility and
cardiac workload
b. It decreases the body fluids thus
decreasing the blood pressure
c. It prevent vasoconstriction on the vessels
d. It prevents calcium to be absorb in the
vessels of the heart leading to vasodilation
20. Which of the following statement if made
by the nurse needs correction?
a. The patient has a secondary hypertension
due to diabetes mellitus
b. The patient has essential hypertension
due to renal failure
c. The patient has non essential hypertension
due to hyperlipidemia
d. The patient has essential hypertension
and the cause is unknown
21. All of the following are risk factors for
hypertension, except;
a. Smoking
b. Age
c. Sex
d. Obesity
22. The patient is manifesting chest pain and
severe headache. Which of the following
should the nurse prepares to do first?
a. Take the patient BP and vital signs
b. Inform the physician
c. Give antihypertensive meds to relieve
increasing blood pressure
d. Place the patient in semifowlers position
Situation 2: Mrs. Nelly Ramirez is diagnosed
as having valvular defects. She is cyanotic
and complaining of difficulty in breathing and
lethargy.
23. As a nurse taking care of the patient,
which of the following statement indicates a
thorough understanding of mitral valve
stenosis?
a. The right valve the separates the atrium
and ventricles is unable to close during
systole
b. One of the factors that contribute to mitral
stenosis is having SLE
c. This disorder will manifest the same as
right sided heart failure
d. The patient preload will increase and
afterload will decrease
24. Mrs. Nelly asked the nurse what will
happen if the valve will not close during
systole. Which of the following response of
the nurse needs correction?
a. There will be accumulation of blood in the
chamber leading to backflow
b. Cardiac output will decrease and there will
be an increase afterload
c. There will be an increase preload and
increase afterload
d. The blood will accumulate in the lungs and
the patient will manifest respiratory
symptoms
25. The patient is going to undergo
valvuloplasty. Which of the following
statement if made by the nurse is correct?
a. The patient mitral valve will be replaced
by a new valve
b. The patient condition will not be treated
by the manifestation will decrease
c. After the operation, the immediate
concern of the nurse would be infection
d. The patient’s valve will be repaired and
reconstructed
26. Which of the following is not included in
the management of valvular disorders?
a. Oxygen supplement
b. Giving thiazide diuretics
c. Let the patient rest to decrease oxygen
demand of the heart
27. The patient has aortic regurgitation,
which of the following statement is not true
regarding to the disease?
a. Lung involvement would not be possible
b. There will be incomplete emptying of the
left ventricles
c. The will be left ventricular hypertrophy
d. The left atrium will be affected
Situation 3: Mrs. Maniego, 26 yrs old,
female, is manifesting Rheumatic heart
disease
28. Which of the following conditions would
least contribute to the condition?
a. Rheumatic fever
b. GABHS infection
c. Staphylococcal infection
d. Atheroscelerosis
29. The nurse is taking care of Mrs. Maniego,
which of the following should the nurse the
highest priority in the care of the patient?
a. Oxygenation
b. Chest pain
c. Infection
d. Valve damage prevention
30. Due to untreated RHD, The patient
manifested pericarditis. Which of the
following findings is not included in the
laboratory studies?
a. There will be dysrhythmias
b. The patient will have fever and chills
c. WBC will increase
d. Chest pain will be concentrated on the
anterior portion of the chest
31. Which of the following would be the drug
of choice for RHD?
a. Penicillin
b. Digoxin
c. Pericardiocentesis
d. Corticosteroids
32. In conjunction with corticosteroid
therapy for inflammation of pericarditis, what
should the nurse anticipate as partner
management for corticosteroids?
a. Give oxygen supplement
b. Give digoxin to increase cardiac
contractility
c. Give antibiotics to fight off infection
d. Give diuretics to decrease fluid
accumulation
Situation 4: Patient Diane, age 30, has a
history of angina pectoris and now often
complaining of chest pain

33. Mrs. Diane has a history of coronary
artery disease and angina pectoris. After
walking to the bathroom, she complains of
aching substernal pain that radiates to her
left shoulder. The nurse should
a. Assist her to lie down and elevate her legs
b. Administer a prn dose of nitroglycerin
sublingually
c. Use pillows to support and immobilize the
left shoulder
d. Administer prn dose of aspirin or
acetaminophen
34. A nitroglycerin patch was prescribed 6
weeks ago for Diane to treat angina pectoris.
The nurse knows that the patch has been
effective if:
a. the client’s serum cholesterol level has
decreased
b. the client’s BP is within normal limits
c. the client reports no episodes of chest
pain
d. Pulse oximetry shows the client’s oxygen
saturation is improved
35. Diane still complains of chest pain after
taking three nitroglycerin tablets. Her skin is
cool and pale and she is diaphoretic and
mildly short of breath. The best initial action
of the nurse is to:
a. Auscultate heart and lung sounds
b. Administer another nitroglycerin tablet
c. Inform the physician and prepare to give
morphine sulfate
d. Elevate the legs and position the patient
with head slightly elevated
36. The nurse who is caring for diane knows
that nitroglycerine is given because it:
a. Slows and strengthen the heart rate
b. Assists smooth muscles to contract
c. Increase venous return to the heart
d. Reduces both preload and afterload
37. A man who received nitroglycerin for
chest pain says that the nitroglycerin had no
taste or sensation. What is the most
appropriate response by the nurse?
a. “That is good, it can be unpleasant”
b. “I will get a fresh supply of tablets”
c. “Maybe we should switch to another
brand”
d. “Many improvements have been made in
nitroglycerin”
38. Discharge teaching for Diane includes a
complete review of nitroglycerine usage. The
nurse tells the client that sublingual
nitroglycerin can be used after the vial has
been opened for up to:
a. 1 week
b. 1 month
c. 4 months
d. 6 months
39. What advice should the nurse give a
client who takes a sublingual nitroglycerin
tablet without relief of pain
a. go to the emergency department
b. take another tablet sublingually
c. take two more tablets orally
d. double the strength of the next dose
40. What special precautions are necessary
for a client with angina who is planning to go
jogging?
a. Take a warm bath first
b. Drink plenty of water
c. Bring nitroglycerin tablets and have period
of rest
d. When chest pain occurs, go to the nearest
hospital
41. The client, an 18-year-old female, 5_4
tall, weighing 113 kg, comes to the clinic for
a wound on her lower leg that has not healed
for the last two (2) weeks. Which disease
process would the nurse suspect that the
client has developed?
a. Type 1 diabetes c.
Gestational diabetes.
b. Type 2 diabetes d.
Acanthosis nigricans.
42. The client diagnosed with Type 1
diabetes has a glycosylated
hemoglobin (A1c) of 8.1%. Which
interpretation should the nurse make
based on this result?
a. This result is below normal
levels.
b. This result is within acceptable
levels.
c. This result is above
recommended levels.
d. This result is dangerously
high.
43. The nurse is developing a care plan
for the client diagnosed with Type 1
diabetes. The nurse identifies the
problem “high risk for hyperglycemia
related to noncompliance with the
medication regimen.” Which
statement would be an appropriate
short-term goal for the client?
 a. The client will have a blood d. Tell the assistant that the
glucose level between 90 and client cannot have anything
140 mg/dL. else.
b. The client will demonstrate 48. The client diagnosed with Type 2
appropriate insulin injection diabetes comes to the emergency
technique. department. The client’s blood
c. The nurse will monitor the glucose is 680 mg/dL and the client is
client’s blood glucose levels diagnosed with HHS. Which question
four times a day. should the nurse ask the client to
d. The client will maintain normal determine the cause of this acute
kidney function with 30 mL/hr complication?
urine output. a. When is the last time you took
44. The elderly client is admitted to the your insulin?
intensive care department diagnosed b. When did you have your last
with severe HHS. Which collaborative meal?
intervention should the nurse include c. Have you had some type of
in the plan of care? infection lately?
a. Infuse 0.9% normal saline d. How long have you had
intravenously. diabetes?
b. Administer intermediate-acting 49. Which arterial blood gas would the
insulin. nurse expect in the client diagnosed
c. Perform blood glucometer with diabetic ketoacidosis?
checks daily. a. pH 7.34, PaO2 99, PaCO2 48,
d. Monitor arterial blood gas HCO3 24.
results. b. pH 7.38, PaO2 95, PaCO2 40,
45. Which electrolyte replacement should HCO3 22.
the nurse anticipate being ordered by c. pH 7.46, PaO2 85, PaCO2 30,
the health-care provider in the client HCO3 26.
diagnosed with DKA who has just d. pH 7.30, PaO2 90, PaCO2 30,
been admitted to the ICD? HCO3 18.
a. Glucose b. Potassium c. 1. Endcrine
Calcium d. Sodium 50. The client is admitted to the hospital
46. The client diagnosed with HHS was diagnosed with DKA. Which
admitted yesterday with a blood interventions should the nurse
glucose level of 780 mg/dL. The implement? Select all that apply.
client’s blood glucose level is now 300 1. Maintain adequate ventilation.
mg/dL. Which intervention should the 2. Assess fluid volume status.
nurse implement? 3. Administer intravenous potassium.
a. Increase the regular insulin IV 4. Check for urinary ketones.
drip. 5. Monitor intake and output.
b. Check the client’s urine for
urinary ketones. a. all of these b. 1,2,3,
c. Provide the client with a c. 2,3,4,5 d. 2,3,5
therapeutic diabetic meal.
d. Notify the physician to obtain 51. The nurse is admitting a client
an order to decrease insulin diagnosed with primary adrenal
therapy. cortex insufficiency (Addison’s
47. The nursing assistant on the medical disease). When assessing the client,
floor tells the primary nurse that the which clinical manifestations would
client diagnosed with DKA wants the nurse expect to find?
something else to eat for lunch. What a. Moon face, buffalo hump, and
action should the nurse implement? hyperglycemia.
a. Instruct the assistant to get b. Hirsutism, fever, and
the client additional food. irritability.
b. Notify the dietician about the c. Bronze pigmentation,
client’s request. hypotension, and anorexia.
c. Ask the assistant to obtain a d. Tachycardia, bulging eyes, and
glucometer reading. goiter.
52. The nurse is developing a plan of care
for the client diagnosed with acquired
 immunodeficiency syndrome (AIDS) b. Assess for nausea and
who has developed an infection in the vomiting and weigh daily.
adrenal gland. Which problem would c. Monitor potassium levels and
have the highest priority? encourage fluid intake.
a. Altered body image c. d. Administer vasopressin IV and
Impaired coping. conduct a fluid deprivation
b. Activity intolerance d. test.
Fluid volume deficit 57. The nurse is planning the care of a
53. The nurse is planning the care of a client diagnosed with syndrome of
client diagnosed with Addison’s inappropriate antidiuretic hormone
disease. Which interventions should (SIADH). Which interventions should
be included? be implemented? Select all that
a. Administer steroid apply.
medications. 1. Restrict fluids per health-care
b. Place the client on fluid provider order.
restriction. 2. Assess level of consciousness
c. Provide frequent stimulation. every two (2) hours.
d. Consult physical therapy for 3. Provide atmosphere of
gait training. stimulation.
54. The client is admitted to rule out 4. Monitor urine and serum
Cushing’s syndrome. Which osmolality.
laboratory tests would the nurse 5. Weigh the client every three (3)
anticipate being ordered? days.
a. Plasma drug levels of
quinidine, digoxin, and a. 1,2,4, b. 2,3,5 c.
hydralazine. 2,4,5 d. All of the above
b. Plasma levels of ACTH and
cortisol.
c. 24-hour urine for 58. The nurse is caring for a client
metanephrine and diagnosed with diabetes insipidus
catecholamine. (DI). Which nursing intervention
d. Spot urine for creatinine and should be implemented?
white blood cells. a. Monitor blood glucoses before
55. The client has developed iatrogenic meals and at bedtime.
Cushing’s disease. Which is a b. Restrict caffeinated beverages.
scientific rationale for the c. Check urine ketones if blood
development of this problem? glucose is > 250.
a. The client has an autoimmune d. Assess tissue turgor every four
problem that causes the (4) hours.
destruction of the adrenal 59. The client is diagnosed with
cortex. hypothyroidism. Which
b. The client has been taking signs/symptoms would the nurse
steroid medications for an expect the client to exhibit?
extended period for another a. Complaints of extreme fatigue
disease process. and hair loss.
c. The client has a pituitary gland b. Exophthalmos and complaints
tumor that causes the adrenal of nervousness.
glands to produce too much c. Complaints of profuse
cortisol. sweating and flushed skin.
d. The client has developed an d. Tetany and complaints of
adrenal gland problem for stiffness of the hands.
which the health-care provider 2. Endocrine
does not have an explanation. 60. The nurse identifies the client
56. The client diagnosed with a pituitary problem “risk for imbalanced body
tumor has developed syndrome of temperature” for the client diagnosed
inappropriate antidiuretic hormone with hypothyroidism. Which
(SIADH). Which interventions would intervention would be included in the
the nurse implement? client problem?
a. Assess for dehydration and a. Encourage the use of an
monitor blood glucose levels. electric blanket.
 b. Protect from exposure to cold c. “My skin is really becoming dry
and drafts. and coarse.”
c. Keep the room temperature d. “I have noticed that all my
cool. collars are getting tighter.”
d. Space activities to promote 66. The nurse is teaching the client
rest. diagnosed with hyperthyroidism.
61. The client diagnosed with Which information should be taught
hypothyroidism is prescribed the to the client? Select all that apply.
thyroid hormone levothyroxine 1. Notify the physician if a three
(Synthroid). Which assessment data (3)-pound weight loss occurs in
indicate the medication has been two (2) days.
effective? 2. Discuss ways to cope with the
a. The client has a three (3)- emotional lability.
pound weight gain. 3. Notify the physician if taking
b. The client has a decreased over-the-counter medication.
pulse rate. 4. Carry a medical identification card
c. The client’s temperature is or bracelet.
WNL. 5. Teach how to take antithyroid
d. The client denies any medications correctly.
diaphoresis.
62. Which nursing intervention should be a. 1,2,4 b. 2,3,4,5 c.
included in the plan of care for the 1,2,3,4,5 d. 3,4,5
client diagnosed with 67. Which signs/symptoms would make
hyperthyroidism? the nurse suspect that the client is
a. Increase the amount of fiber in experiencing a thyroid storm?
the diet. a. Obstipation and hypoactive
b. Encourage a low-calorie, low- bowel sounds.
protein diet. b. Hyperpyrexia and extreme
c. Decrease the client’s fluid tachycardia.
intake to 1000 mL day. c. Hypotension and bradycardia.
d. Provide six (6) small, well- d. Decreased respirations and
balanced meals a day. hypoxia.
63. The client with hypothyroidism is 68. Which sign/symptom would indicate
admitted to the intensive care to the nurse that the client is
department diagnosed with experiencing hyperparathyroidism?
myxedema coma. Which assessment a. A negative Trousseau’s sign.
data would warrant immediate b. A positive Chvostek’s sign.
intervention by the nurse? c. Nocturnal muscle cramps.
a. Serum blood glucose level of d. Tented skin turgor.
74 mg/dL. 69. Which laboratory data would make
b. Pulse oximeter reading of the nurse suspect that the client with
90%. primary hyperparathyroidism is
c. Telemetry reading showing experiencing a complication?
sinus bradycardia. a. A serum creatinine level of 2.8
d. The client is lethargic and mg/dL.
sleeps all the time. b. A calcium level of 9.2 mg/dL.
64. Which medication order would the c. A serum triglyceride level of
nurse question in the client diagnosed 130 mg/dL.
with untreated hypothyroidism? d. A sodium level of 135 mEq/L.
a. Thyroid hormones b. Oxygen 70. Which information is a risk factor for
c. Sedatives d. Laxatives developing pheochromocytoma?
65. Which statement made by the client a. A history of skin cancer.
would make the nurse suspect that b. A history of high blood
the client is experiencing pressure.
hyperthyroidism? c. A family history of adrenal
a. “I just don’t seem to have any tumors.
appetite anymore.” d. A family history of migraine
b. “I have a bowel movement headaches.
about every 3 to 4 days.”
Situation 1: Nurse Jean in the coronary care d. Participate in an exercise program
unit is taking care of a client post myocardial that includes overhead lifting and
infarction. reaching
71. Nurse Jean should observe for one or
more common complications of MI, 76. When listening to heart sounds, the
which is: nurse can best hear the first heart
a. Hypokalemia sound (S1) at the:
b. Anaphylactic shock a. Base of the heart
c. Cardiac dysrhythmia b. Apex of the heart
d. Cardiac enlargement c. Mitral valve area of the heart
d. Tricuspid area of the heart
72. Nurse Jean observes ventricular
irritability of the cardiac monitor. The 77. During an admission nursing
nurse should prepare to administer: assessment, a client with diabetes
a. Digoxin (Lanoxin) describes his leg pain as “dull,
b. Furosemide (Lasix) burning sensation.” The nurse
c. Lidocaine (Xylocaine) recognizes this description to be
d. Levarterenol bitartrate (Levophed) characteristic of which type of pain?
a. Physiological c. Visceral
73. Nurse Jean enters the room of a client b. Somatic d. Neuropathic
with MI and finds the client quietly Situation 9: Meng, 40 years old, is exhibiting
crying. After determining that there is fatigue and failure to carry out ADLs. Further
no physiological reason for the client’s examination reveals Hashimoto’s Thyroiditis.
distress, the nurse replies:
78. Hashimoto’s thyroiditis is the most
a. “Do you want me to call your
common form of hypothyroidism in
daughter?”
adults. This occurs when:
b. “Can you tell me a little what causes
a. The thyroid gland is hypoactive
you so upset?’
b. The pituitary is not secreting enough
c. “I understand how you feel. I’d cry
TSH
too if I had a major heart attack.”
c. The thyroid gland is inflamed due to
d. “Try not to be so upset. Psychological
severe infection and bacterial
stress is bad for your heart.”
infiltration that leads to the decrease
production of thyroid hormone
74. The client is recovering from an acute
79. For some unknown reason, the body
MI. Which client action on the evening
is producing an antibody against its
before discharge suggests that the
own thyroid gland Which of the
client is in the denial phase?
following is NOT a sign of
a. Requests a sedative for sleep at
hypothyroidism?
10:00 pm
a. Intolerance to perfume
b. Expresses hesitancy to leave the
b. Intolerance to noise
hospital
c. Intolerance to heat
c. Walks up and down three flights of
d. Intolerance to cold
stairs unsupervised
d. Consumes 25% of foods and fluids for
80. Which of the following drugs should
supper
be used with extreme caution in
clients with hypothyroidism?
a. Fentanyl c.
Trimethobenzamide
75. Nurse Jean is providing home care
b. Isoptin d. Colchicine
instructions to a client recovering
from an acute MI with recurrent
81. A drug used to treat hypothyroidism
angina. The nurse teaches the client
by artificially replacing the lost
to:
thyroid hormone is:
a. Avoid sexual intercourse for at least 4
a. PTU c. Vasopressin
months
b. SSKI d. Synthroid
b. Replace sublingual nitroglycerin
tablets yearly
c. Recognize the adverse effects of ASA
(aspirin), which include tinnitus and
hearing loss
 82. The priority monitoring that a nurse
should do when Meng starts to take
thyroid drug is:
a. Check the blood pressure level
b. Check for the respiratory rate
c. Check for the occurrence of chest
pain
d. Check for the clients temperature
Situation 13: Effective health education lays
a solid foundation for health wellness.
Teaching is an integral tool that all nurses
use to assist patients in developing effective
health behaviors and promoting positive
health outcomes.
83. The nurse teaches the patient which
of the following guidelines regarding
lifestyle modifications for
hypertension?
a. Reduce smoking to no more than four
cigarettes per day
b. Maintain adequate dietary intake of
potassium
c. Limit aerobic physical activity to 15
minutes, three times per week
d. Stop alcohol intake
84. Instructions for the patient with low
back pain include which of the
following?
a. When lifting, place the load away
from the body
b. When lifting, use a narrow base of
support
c. When lifting, bend the knees and
loosen the abdominal muscles
d. When lifting, avoid overreaching
85. A client with diabetes mellitus has
expressed frustration in learning the
diabetic regimen and insulin
administration. The home care nurse
would initially:
a. Identify the cause of the
frustration
b. Continue with diabetic
teaching knowing that the
client will overcome any
frustrations
c. Call the physician to discuss
termination from home care
services
d. Offer to administer the insulin
on a daily basis until the client
is ready to learn
86. A need for cognitive learning becomes
apparent when an adolescent,
recently diagnosed as having diabetes
mellitus, asks:
a. “What is diabetes?”
b. “What will my friends think?”
c. “How do I give myself an
injection?”
d. “Can you show me how the
glucose monitor works?”
87. When promoting affective learning in
a client with a newly diagnosed
disease, the nurse must first consider
the influence of the:
a. Client’s past experience
b. Total stress of the situation
c. Client’s personal resources
d. Type of onset of the disease
Situation 18: Nursing care involves
counseling the client regarding the
management of his/her condition.
88. The nurse teaches a client with
acromegaly that pharmacologic
treatment might include:
a. Radioactive iodine c.
Somatomedin C
b. Somatostatin d.
Vasopressin
89. A client with acromegaly is scheduled
for surgery to remove a pituitary
adenoma that is causing her
acromegaly. Preoperative teaching
should include telling her that:
a. She’ll have an IV insulin
infusion when she returns
from surgery
b. She’ll be able to brush her
teeth right after the surgery
c. Her bed will be kept flat after
surgery
d. She should avoid bending,
overstraining, and blowing her
nose after surgery
Situation 19: The primary objective of
antihypertensive therapy is to control
essential hypertension, and maintain BP with
minimal adverse effects. As a nurse, you
should know the accompanying
responsibilities in giving these medications.
90. A client is started on Prazosin
(Minipress) 1 mg PO daily. Which
client teaching instructions should the
nurse stress?
a. Rise slowly from a lying or sitting
position
b. Take the drug on an empty stomach
c. Force fluids to 2 liters/day
d. Take the medication in the morning
91. Which of the following should the a. Fat face, big legs and thin
nurse specifically assess for prior to arms
clients starting on captopril (Capoten) b. Big chest, thin extremities
therapy? c. Big legs and arms, big trunk
a. Depression c. Liver disease d. Small trunk, big extremities
b. Renal dysfunction d. 99. Patient is manifesting arrhythmias
Hyperglycemia due to hyperkalemia. Which of the
92. Which antihypertensive drug may following is expected to be ordered?
block the production of angiotensin a. Lidocaine
II? b. Beta blockers
a. Guanethidine (Ismelin) c. Amiodarone
b. Hydralazine (Apresoline) d. Nifedipine
c. Reserpine 100. Patient with MI is about to
d. Captopril receive Morphine sulfate. Which is the
nursing priority before giving the
93. Which of the following actions should meds?
the nurse take when administering a. Assess the respiratory rate
nitroglycerine tablet? b. Assess the level of pain
a. Mix the solution in normal saline c. Assess when the pain started
b. Administer the drug by oral route d. Assess the capacity of the
c. Monitor neuro checks and VS every patient
hour SITUATION: Nurse Karen is caring for
d. Give via sublingual AlingToyang, a 67-year-old female client
admitted due to myocardial infarction. She is
94. Which side effect should the client be hooked in a cardiac monitor and CVP and is
aware of when taking clonidine under cardiac drug therapy including
(Catapress)? heparin.
a. Frequent urination c. Dry mouth 101. AlingToyang is evaluated to
b. Diarrhea d. Irritability more likely experiencing
95. Which of the following is the drug of hypervolemia if her CVP reading is:
choice for SIADH? a. 10 cm of H2O. c. 6 cm of H2O.
a. Desmopressin b. 8 cm of H2O. d. 14 cm of H2O.
b. Vasopressin 102. Which of the following nursing
c. Diuretics interventions is not included in the
d. Diabenes prevention of vasovagal stimulation in
96. The nurse is taking care of a patient AlingToyang who has MI?
with hyperparathyroidism. Which of a. Avoid giving very hot or very cold
the following manifestation is drinks
expected? b. Obtaining rectal temperature
a. Chvostek sign c. Administer Colace as ordered
b. Tetany d. Advise client to avoid holding his
c. Bone pain breath when turning to side
d. Hirsutism 103. AlingToyang who is on heparin
97. A patient with cushing’s disease is therapy has APTT result of 80 seconds.
complaining of tachycardia and This indicates that:
hypertension. Which of the following a. She is prone to bleeding.
best describe this manifestation? b. It is the therapeutic effect of the drug.
a. There is an underproduction of c. She may develop thromboembolism.
ACTH d. She is not receiving adequate dose of
b. There is Increase water and the drug.
sodium retention 104. Nurse Karen is correct when she
c. There is increase states which of the following statements
glucocorticoids production as true regarding cardioversion?
d. D. there is insufficient a. “It is done to revert cardiac arrest.”
aldosterone production b. “The electric shock is applied during
98. Patient lea is complaining about his the R wave.”
appearance due to cushing’s disease. c. “It involves unsynchronized application
Which of the following best describes of electric shock to the heart.”
truncal obesity? d. “It is done on the T wave.”
SITUATION: Nurse Kate Singleton is the
Nurse On-Duty in the Medical Ward. The
following are the drug administration
responsibilities commonly encountered in the
ward.
105. If a client has an order to
begin an IV nitroglycerin (Nitrostat)
drip, Nurse Kate will prepare this
medication by mixing the medication:
a. In a solution that is covered by a
plastic bag
b. In a solution that is in a glass bottle
c. Every 2 hours because it is unstable
d. Under a laminar flow hood
106. Nurse Kate is giving nitroglycerin
tablets sublingually for chest pain for a
client with angina pectoris. The client
states that she dislikes the medication
because it causes headache. Which of the
following interpretations about the
client’s statement is the appropriate
response?
a. This is a common but unhealthy
response to the medication.
b. This is a common response that will
diminish as tolerance to the
medication develops.
c. This is a response caused by cerebral
hypoxia induced by the medication.
d. This is an adverse reaction that must
be reported to the physician
immediately.
107. Nurse Kate would be most concerned
that a client is developing digoxin toxicity
after noting which of the following?
a. Palpitations, elevated blood pressure,
and shortness of breath
b. Anorexia, nausea, and reports of
yellow vision
c. Chest pain, fatigue, and decreased
blood pressure
d. Taste alterations, dry mouth, and
constipation
108. A client has an order to receive 5,000
units of heparin subcutaneously.
Available is a vial labeled Heparin 10,000
units per mL. How many mLs of heparin
should Nurse Kate administer?
a. 0.50 mLb.1 mL c.1.50 mL d.
2 mL
SITUATION: Nurse Cres is teaching her
students about peripheral vascular disorders.
109. Which of the following patients
is at greatest risk for developing deep
vein thrombosis (DVT)?
a. 45-year-old obese woman on birth
control pills.
b. 65-year-old woman with in-situ
cervical cancer.
c. 35-year-old malnourished man.
d. 25-year-old man with fractured tibia.
110. Nurse Cres is discussing about
Raynaud’s disease. The following are
characteristics of Raynaud’s disease
except:
a. Characterized by vasospasm of
arteries in the digits.
b. Triggered by exposure to cold and
emotional stress.
c. More common among cigarette-
smoking males.
d. May be characterized by ulcerations on
the fingertips and toes.
111. Nurse Cres’ student is correct when
she states that all of the following are
characteristics of venous insufficiency
except:
a. Brown pigments around ankle.
b. Peripheral pulses are present.
c. Ulcers develop in the toes.
d. Edema is present, diminished by
elevation.
112. Nurse Cres teaches her students
regarding appropriate client teachings in
arterial insufficiency. All of the following
are correct except:
a. Place legs in slight dependency to
promote arterial flow.
b. Rub the legs from ankle to knee for 10
minutes.
c. Use several layers of clothing during
cold weather.
d. Avoid crossing the legs.
113. The nurse teaches a client about
elastic stockings. Which of the following
statements, if made by the client,
indicates to the nurse that teaching was
successful?
a. “I should put on the stockings before
getting out of bed in the morning.”
b. “Every four hours I should remove the
stockings for a half hour.”
c. “I will wear the stockings until the
physician tells me to remove them.”
d. “I should wear the stockings even
when I am asleep”.
SITUATION: Nurse Kathy is assigned in
caring for MangPedring, a 72-year-old client
who was diagnosed with emphysema.
114. Nurse Kathy enters the room
of MangPedring and his oxygen is
running at 8L/min. Which of the
following is best initial nursing action:
a. Check the doctor’s order
b. Lower oxygen rate at 2L/min
c. Take his vital signs
d. Put the client in Fowler’s position
115. MangPedring is observed to have
labored breathing and exhibits slow,
shallow respirations. This endangers him
to develop:
a. Respiratory alkalosis c. Respiratory
acidosis
b. Metabolic acidosis d. Metabolic
alkalosis
116. The most comfortable position for
MangPedring is:
a. Semi-Fowler’s position
b. Sitting upright, leaning forward
c. Lateral position
d. High-Fowler’s position
117. Which of the following breathing
techniques will assist MangPedring’s
during exhalation?
a. Push on abdomen during exhalation
b. Sit in high-Fowler’s position with legs
extended
c. Lean forward 30 to 40 degrees with
each exhalation
d. Sit up, with shoulders back
118. MangPedring is wheezing and his
oxygen saturation is 85% but it has been
noted that 4 hours ago, it was 88%. It is
MOST important for the nurse to take
which of the following actions?
a. Listen to breath sounds
b. Administer bronchodilator by nebulizer
c. Increase oxygen at 6L/min
d. Administer beclomethasone via
nebulizer
SITUATION: Nurse Eunice and her colleagues
are providing health teachings regarding
various medications used by clients with
problems in oxygenation as part of their
client education program.
119. Nurse Eunice is teaching a
client with chronic obstructive
pulmonary disease (COPD) how to
administer multiple medications by
inhalation. Which statement by the
client indicates an understanding of
the instruction?
a. “If my symptoms get worse I can
double my dosage.”
b. “I will wait at least 1 minute between
use of my different inhalers.”
c. “I can take any of the over-the-counter
medications I need for my
symptoms.”
d. “I cannot rinse my inhaler equipment
because it is not supposed to get
wet.”
120. The client asks Nurse Eunice why the
physician ordered beclomethasone
(Beclovent) for his chronic obstructive
pulmonary disease (COPD). Which
statement by Nurse Eunice is most
appropriate?
a. “Beclovent prevents airway dilation.”
b. “Beclovent decreases inflammation and
makes it easier to breathe.”
c. “Beclovent suppresses the immune
response.”
d. “Beclovent decreases responsiveness
to medications that dilate the airway.”
121. Nurse Eunice is teaching a client
about Aminophylline. Which of the
following statements should she make
about the mechanism of action of this
medication?
a. “Aminophylline relaxes bronchial
smooth muscle to assist with
bronchodilation.”
b. “Aminophylline limits inflammation and
therefore bronchoconstriction with an
exposure to allergen.”
c. “Aminophylline helps to liquefy
secretions to promote expectoration.”
d. “Aminophylline promotes
bronchoconstriction of overly dilated
airways.”
122. Nurse Eunice is teaching the client
proper technique for administration of
nasal sprays. Which explanations should
she use in order to provide accurate
information?
a. “Lie down and instill the nasal spray,
squeezing the bottle twice for each
application.”
b. “Sit and squeeze the nasal spray once
as you inhale while holding your
finger over the other nostril.”
c. “Be careful not to rinse the tip of the
spray bottle after use, or you will
contaminate the medication.”
d. “Lean your head back and administer
two applications to each nostril for
each dose to be sure some of the
medication is instilled.”
123. A client with asthma has started to
take a beta-adrenergic agent. Nurse
Eunice should inform the client for which
of the following complications?
a. Hypotension c. Tachycardia
b. Hypertension d. Bradycardia
SITUATION: Compliance to the standards of
safe intravenous therapy is essential to the
nursing practice. The following questions
pertain to these.
124. Nurse Ken is to insert a
peripheral intravenous (IV) line. He
determines the following steps in
order to perform this procedure
correctly.
1. Apply tourniquet.
 2. Insert catheter at 5 to 15 degree angle
through skin.
3. Select vein.
4. Attach tubing primed with IV solution.
5. Gather equipment.
a. 3, 5, 2, 1, and 4 c. 5, 1,
3, 2, and 4
b. 5, 3, 1, 2, and 4 d. 3, 5,
1, 2, and 4
125. Which of the following if noted during
IV insertion would indicate to refrain from
advancing the catheter?
a. Blood backflow into the IV catheter
b. Mild resistance with advancement
c. No reports of client discomfort
d. IV catheter inserted bevel side up
126. While on duty, the nurse assessed a
client’s intravenous line and notes that
the area is swollen, cool, pale, and
causes client’s discomfort. Nurse Ken
should document this as to which of the
following complications of IV therapy?
a. Infiltration c.Infection
b. Phlebitis d. Air
embolism
127. The client is receiving 5% dextrose
and 0.45% sodium chloride intravenously
and is complaining of pain at the IV site.
Nurse Ken assessed the site and noted
erythema and edema. Which of the
following would be his appropriate
nursing action?
a. Slow the infusion rate.
b. Discontinue the IV and apply a warm
compress to the IV site.
c. Apply antibiotic ointment to the IV site.
d. Gently pull back the IV access device
to reposition within the vein.
128. Nurse Ken is starting a new
peripheral intravenous (IV) line in a
client. The client reports a latex allergy.
Nurse Kenneth has a typical IV start kit.
Because of the latex allergy, Nurse
Kenneth should take which of the
following actions?
a. Obtain a new tourniquet
b. Utilize a blood pressure cuff.
c. Avoid putting povidone iodine on the
skin.
d. Suggest an alternative therapy to a
peripheral intravenous line.
SITUATION:Nurse Jon is caring for Dexter,
25 year old , who is scheduled for
appendectomy. Part of his responsibility is to
provide preoperative care.
129. Which of the following is the
best way for the nurse to begin the
preoperative interview?
a. Walk in and ask, “Are you Mr. Dexter?”
b. Walk in, sit down and take the client’s
blood pressure
c.Walk in, sit down, maintain eye
contact, and introduce yourself
d. Walk in and ask the client his name
130. During the preoperative interview,
the nurse obtains information about the
client’s medication history. Which of the
following is not necessary to record about
the client?
a. Current use of medications and
vitamins
b. Over-the-counter medication use in
the last 6 weeks
c. Steroids use in the last year
d. Use of all drugs taken in the last 18
months
131. While witnessing a preoperative
consent, Nurse Jon learns that the client
does not understand the risks of the
surgery. The nurse’s best action is to:
a. Notify the surgeon c. Notify the
anesthetist
b. Notify the surgical unit d. Notify
the client’s family
132. Prior to surgery, a client receives a
preoperative anticholinergic medication.
This medication is used to:
a. Reduce anxiety
b. Provide sedation
c. Reduce oral and pulmonary secretions
d. Reduce gastric fluid volume and acidity
SITUATION: Maggy, 35 years old, was
brought to the ER with acute asthmatic
attack. RR is 46/min and she appears to be
in acute respiratory distress.
133. Upon assessment, Maggy
stops wheezing and breath sounds
aren’t audible. The nurse should be
alert since the reason for this change
is:
a. The attack is over
b. The airways are so swollen that no air
cannot get through
c. The swelling has decreased
d. Crackles have replaced wheezes
134. Based on this situation, which of the
following nursing actions should be
initiated first?
a. Promote emotional support
b. Administer oxygen at 6L/min
c. Suction the client every 30 minutes
d. Administer bronchodilator by nebulizer
135. Aminophylline was ordered for acute
asthmatic attack. The mother asked the
nurse, what its indication is. The nurse
knows that it is given to:
a. Relax smooth muscles of the bronchial
airway
 b. Promote expectoration
c. Prevent thickening of secretions
d. Suppress cough
136. Which of the following should not be
included to Maggy’s health instructions?
a. Avoid emotional stress and extreme
temperature
b. Avoid pollution like smoking
c. Avoid pollens, dust, seafood
d. Practice respiratory isolation
137. The asthmatic client asked you what
breathing technique he can best practice
when asthmatic attack starts. What will
be the best position?
a. Sit in high Fowler’s position with
extended legs
b. Sit up with shoulders back
c. Push on abdomen during exhalation
d. Lean forward 30-40 degrees with each
exhalation
SITUATION:Marlon was diagnosed with
chronic open-angle glaucoma which is a
disorder characterized by increased
intraocular pressure (IOP) that can lead to
blindness. He is about to receive the
following interventions from the primary
health care provider.
138. Marlon is to receive 3 drops of
Acetazolamide (Diamox) in the left eye.
What should the nurse do?
a. Ask the client to close his right eye
while administering the drug in the
left eye
b. Have the client look up while the nurse
administers the eye drops
c. Have the client lift his eyebrows while
the nurse positions the hand with the
dropper on the client’s forehead
d. Wipe the eyes with a tissue following
administration of the drops
139. Which of the following signs or
symptoms is most commonly
experienced by clients with chronic open-
angle glaucoma?
a. Eye pain
b. Colored light flashes
c. Excessive lacrimation
d. Decreasing peripheral vision
140. Miotics are frequently used in the
treatment of glaucoma. The nurse
should be aware that the action of
miotics is by:
a. Paralyzing ciliary muscles
b. Constricting the pupil
c. Constricting intraocular vessels
d. Relaxing ciliary muscle
141. Tonometry measures intraocular
pressure. Which of the following
information should the nurse provide to
the client regarding the procedure?
a. Oral pain medication will be given
before the procedure
b. It is a painless procedure with no
adverse effects
c. Blurred or double vision may occur
after the procedure
d. Medication will be given to dilate the
pupils before the procedure
142. The nurse observes the client while he
instills his eyedrops. The client says, “I
just try to hit the middle of my eyeball so
the drops don’t run out of my eye.” The
nurse explains to the client that the
method he is now using may cause:
a. Scleral staining
b. Corneal injury
c. Excessive lacrimation
d. Systemic drug absorption
143. A client with glaucoma asks the nurse if
complete vision will return. The most
appropriate response is:
a. “Although some vision has been lost
and cannot be restored, further loss
may be prevented by adhering to the
treatment plan.”
b. “Your vision will return as soon as the
medication begins to work.”
c. “Your vision will return to normal.”
“Your vision loss is temporary and will return
in about 3 – 4 weeks.”
SITUATION:Iglot, a 43 year-old client,
complained that he has gained weight and
that his face and body are rounder. An initial
diagnosis of Cushing’s disease is made.
144. When examining the patient, which of
the following the nurse would expect to
find?
a. Orthostatic hypotension
b. Bruised areas on the skin
c. large extremities
d. Decreased body hair
145. Cushing’s disease is manifested by
excessive secretion of corticosteroids.
The hormones involved are:
a. Glucocorticoids and aldosterone
b. Adrenocorticotrophic hormone (ACTH)
c. Glucocorticoids, aldosterone and
androgens
d. Catecholamines
146. Which of the following test results
would be considered consistent with
Iglot’s diagnosis of Cushing’s disease?
 a. Hypoglycemia c. Metabolic alkalosis, partially
b. Hypokalemia compensated
c. Hyponatremia d. Normal ABG result
d. Decreased urine calcium level 152. You review the arterial blood gas of a
147. All of the following are management of client. The results indicate respiratory
Cushing’s Disease, except: acidosis. Which of the following values
would indicate that this acid-bas
a. Increase the amount of potassium in imbalance exists?
the diet a. pH of 7.30 c. PaCO2 of 32
b. Steroid therapy mmHg
c. Adrenalectomy b. pH of 7.48 d.HCO3 of 20
d. Radiation therapy mEq/L
SITUATION: Miss Eleonor is a 25-year old SITUATION: Nurse Fely is in charge of a
woman who is being treated in the endocrine client who was admitted for management of
clinic from adult-onset myxedema. acute episode of cholecystitis.
148. The physician has ordered 156. Nurse Fely did her
serum thyoxine (T4) admission. She understands
concentration and serum that the pain is characterized
cholesterol tests. Which finding as
should the nurse expect? a. Tenderness that is generalized in the
a. Decreased serum T4 and decreased upper epigastric area
serum cholesterol b. Pain in the left upper quadrant
b. Decreased serum T4 and increased radiating to the left shoulder
serum cholesterol c. Tenderness and rigidity at the left
c. Increased serum T4 and increased epigastric area radiating to the back
serum cholesterol d. Tenderness and rigidity at the upper
d. Increased serum T4 and decreased right abdomen radiating to the right
serum cholesterol shoulder
149. While taking nursing history, 157. To confirm the
the nurse should expect Miss diagnosis of cholecystitis, the
Eleonor to complain about: attending physician ordered a
a. Facial puffiness c. procedure that can detect
Exopthalmos gallstones as small as 1-2 cm
b. Intolerance to heat d.Heart and inflammation. The nurse
palpitation would prepare the client for
SITUATION: You are assigned in the Medical- which specific diagnostic
Surgical Ward and frequently encounter procedure?
client’s charts with ABG results attached. a. Cholangiography c. Gall
Knowledge of acid-base imbalances and their bladder series
interpretation is essential in order to provide b. Ultrasonography d. Oral
competent and effective nursing care to cholecystogram
these clients. 158. The diagnosis was
150. The following ABG results are confirmed as cholecystitis with
on the client’s chart: pH 7.40, gallstones. The doctor
PaCO2 39, HCO3- 24. Which of the prepared the client for the
following correctly reflects the removal of the gallbladder. The
above result? client asks the nurse how the
a. Metabolic alkalosis, partially procedure will affect digestion.
compensated The nurse’s most correct
b. Respiratory alkalosis, compensated response would be
c. Metabolic alkalosis, uncompensated a. Removal of the gallbladder would
d. Normal ABG result significantly interfere only with the
151. A client is admitted to the hospital. digestion of fatty foods.
ABG results are pH 7.37, PaCO2 43, b. Removal of the gallbladder does not
HCO3- 23. You will interpret this result usually interfere with digestion
as: c. The body will adjust in due time
a. Respiratory acidosis, uncompensated d. Removal of the gallbladder usually
b. Metabolic acidosis, partially interferes with digestion but can be
compensated remedied by dietary modifications
159. Reviewing the laboratory findings of c. Assess for signs of diabetes insipidus
the client, the nurse would found which as temporary postoperative
findings are elevated? complication.
1. White blood cell count d. Keep oral mucous membranes dry.
2. Total serum bilirubin 164. Johnny who is 80 hours post-
3. Alkaline phosphate transphenoidalhypophysectomy reports
4. Red blood cell count numbness on the upper lip and gum, a
5. Cholesterol headache when reclining, and has a
6. Serum amylase tendency to kick around small rugs in the
a. 1, 2, and 3 c. 3, 5, and 6 room when walking. Nurse JR should do
b. 2, 3, and 4 d. 1, 2, and 5 which of the following?
160. A T-tube was inserted and the a. Inform Johnny that these are normal
physician ordered, “Monitor the amount, responses and will disappear over 2
color, consistency and odor of drainage.” to 3 weeks.
Which of the following procedures can b. Assess neuromuscular function and
the nurse perform without the doctor’s incisional area and then report all
order? findings to the surgeon.
a. Clamping c. c. Immediately arrange Johnny to be
Irrigating transported to the hospital for
b. Aspirating treatment of increased intracranial
pressure.
d. Emptying the drainage d. Assess vital signs, fluid volume status,
SITUATION: Johnny was diagnosed with bowel function and nutrition status
hyperpituitarism. He was admitted at St. 165. Johnny underwent post-
Luke’s Medical Center where he underwent transphenoidalhypophysectomy. He
transsphenoidalhypophysectomy. Nurse JR demonstrates understanding of education
was assigned to care for this client. when he states, “I know I need to be
161. Nurse JR is assessing careful not to increase pressure in my
for signs of hyperpituitarism. head by:
What assessment findings a. sitting in a soft chair and leaning over
should Nurse JR observe for in slowly to tie my shoes.”
this client? b. holding my breath when I reach down
1. Short stature if onset is in childhood to pick up something from the floor.”
2. Large hands and feet with prominent c. bending my knees first before
jawbone squatting down to reach something
3. Joint changes consistent with arthritis on the floor.”
4. Soft, high-pitched voice d. holding my breath while I use
5. Hypertension mouthwash, then leaning my head
a. 1, 2, and 3 c. 1, 4, and 5 down toward the sink to spit it out.”
b. 2, 3, and 5 d. 2, 4, and 5 SITUATION: You admitted Englebert, 70
162. Nurse JR knows that excessive years old, because of pulmonary edema. He
secretion of growth hormone in children has a history of congestive heart failure,
before long bone epiphyseal closure type 2 diabetes mellitus and hypertension.
results in: 166. Based on the history,
a. Gigantism you specifically noted that
b. Acromegaly Englebert regularly took
c. Syndrome of Inappropriate Antidiuretic Lanoxin (Digoxin). Which of
Hormone (SIADH) the following is the specific
d. Cushing’s Syndrome action of this drug on the
163. Which of the following postoperative patient?
care by Nurse JR is considered incorrect a. Improves myocardial contractility,
when caring for Johnny who is post- decreases the heart rate, and reduces
hypophysectomy? oxygen consumption
a. Monitor vital signs (VS), level of b. Causes vasoconstriction, increased
consciousness (LOC), and elements of resistance preload and dilation of the
neurological status. ventricles
b. Keep head of bed elevated to c. Reduces peripheral vascular resistance
approximately 30 degrees. and afterload, reducing myocardial
workload
 d. Interfered with the production of
angiotensin II resulting in improved 172. Based on an understanding of
cardiac output and reducing Heparin therapy, the nurse administers it
pulmonary congestion to Timothy who has undergone repair of
167. Which of the following specific aneurysm for which of the following
positions would be most helpful for reasons?
Englebert to facilitate and trap excess a. To prevent recurrence of aneurysm
fluids in the lower extremities? b. To control hemorrhage
a. Head bent forward on an overbed table c. To maintain arterial pressure
supported with pillows d. To prevent clot formation
b. Upright sitting position with the legs 173. To counteract reactions to overdosage
dangling of intravenous infusion of Heparin, which
c. Lateral position with the upper leg of the following drugs will the nurse
flexed and lower leg extended expect the physician to prescribe?
d. Fowler’s position with the patient lying a. Protamine sulfate c. Vitamin K
on the left side b. Epinephrine d. Atropine
168. Furosemide (Lasix) 20 mg was Sulfate
administered by IV push at 10 am with c. To determine level of
urinary output from indwelling catheter consciousness, the Glasgow Coma
at the level of 120 cc. At 10:15 AM, the Scale (GCS) is used. Which of the
nurse observed that the urinary output following is a correct
did not change. Which of the following interpretation of the nurse of the
will you check first? GCS score of Kevin?
a. Foley catheter connecting tube for a. The higher the score, the
kinks higher is the probability of
b. Patient’s hypogastrium for urinary permanent damage
retention b. The lower the score is, the
c. Intravenous site for swelling lower is the probability of
d. Foley catheter for leakage delayed recovery
169. While preparing the medication, you c. The higher the score, the
checked the medication which was greater is the impairment in
dispensed by the pharmacist with the the brain
written order of the physician. Which of d. The lower the score, the more
the following actions will you do first if serious is the brain injury
you found out that instead of Regular Situation 7. A 45 years old client is
insulin, the pharmacist dispensed NPH admitted to the medical-surgical unit
insulin? with complaints of fatigue, loss of
a. Validate the order with the physician
appetite, nausea, vomiting, and
b. Document the error
c. Ask the pharmacist to change the drug increased bronze pigmentation of the
d. Report the error to the unit manager skin. A diagnosis of Addison's disease is
170. You administered morphine sulfate 1 made.
mg intravenously as ordered. The
following are the intended actions of this 174. The nurse should
drug except observe the client closely for
a. Improved efficacy of breathing signs of infectious
b. Reduce preload complications because there is
c. Decrease anxiety a disturbance in:
171. The physician initially a. Respiratory function
treated Timothy with b. Stress response
Propranolol (Inderal). The c. Electrolyte balances
nurse noted in her nursing d. Metabolic processes
care plan that this drug will 175. An important nursing intervention
a. Increase contractility of the heart specific for the client is:
a. Encouraging exercise
b. Enhance electrical conduction of the b. Protecting from exertion
heart c. Restricting fluid intake
c. Decrease release of epinephrine d. Monitoring for hypokalemia

d. Reduce heart rate

 176. An important nursing radioactive isotope is injected
intervention specific for the intravenously
client is: 181. After the client has had the
e. Encouraging exercise esophagogastroduodenoscopy procedure,
f. Protecting from exertion the most important nursing action would
g. Restricting fluid intake be to:
h. Monitoring for hypokalemia a. Assess the client's vital signs
frequently
b. Assess the client's neck for cervical
177. Therapy for the client is aimed chiefly crepitus
at: c. Place the client in a side-lying
a. Restoring electrolyte balance position to prevent aspiration
b. Decreasing eosinophils d. Give the client an anesthetic lozenge
c. Increasing lymphoid tissue for his sore throat
d. Improving carbohydrate metabolism 182. The client has a sliding esophageal
178. Before the discharge of the client, the hernia. The physician prescribes an H 2-
physician prescribes hydrocortisone and receptor antagonist. The nurse explains
fludrocortisone. The nurse expects that H2-receptor antagonists work by:
hydrocortisone to: a. Coating the mucous membrane of the
a. Decrease cardiac dysrhythmias and esophagus and stomach
dyspnea b. Decreasing the pressure in the lower
b. Control excessive loss of potassium esophageal sphincter (LES)
salts c. Inhibiting secretion of gastric acid by
c. Prevent hypoglycemia and permit the the parietal cells
client to respond to stress d. Neutralizing gastric acid
d. Increase amounts of angiotensin II to 183. The nurse prepares to administer an
raise the client's blood pressure H2-receptor antagonist to the client.
179. The client is receiving cortisone Which of the following drugs is an H2-
therapy. In the event that the client receptor antagonist?
neglects to continue the cortisone a. Metoclopramide
therapy, an acute adrenocortical b. Sucralfate
insufficiency may occur. The predominant c. Omeprazole
sign the client should be advised to d. Cimetidine
report is: 184. Discharge teaching for the client
a. Dysphagia should include:
b. Decreased blood pressure a. Explaining that he should elevate the
c. Diplopia head of his bed with 6 to 8 inches (15
d. Decreased heart rate to 20 cm) blocks
b. Telling the client to recline for 1 hour
after eating
Situation 13. A client, age 50, is c. Instructing the client to increase fluid
admitted to the medical-surgical unit of intake with meals
a tertiary hospital with complaints of d. Telling the client to eat three regular
gastroesophageal reflux, regurgitation, meals every day
Situation 14. A client, age 43, is
dysphagia, and belching. The physician
admitted to the medical unit with
suspects a hiatal hernia.
complaints of dyspepsia, heartburn,
180. The client is scheduled eructation and frequent regurgitation.
for an The physician suspects a
esophagogastroduodenoscopy gastroesophageal reflux disease
(EGD) procedure. The nurse (GERD).
explains that EGD:
a. Examines gastric fluid that is 185. To limit symptoms of
aspirated with a flexible tube gastroesophageal reflux
b. Directly visualizes the esophagus with disease (GERD), the nurse
a flexible fiber-optic endoscope should advise the client to:
c. Is an esophageal X-ray that is taken a. Lie down after eating
while the client swallows a barium b. Avoid heavy lifting
solution c. Increase fluid intake with meals
d. Visualizes the esophagus after a d. Wear an abdominal binder or girdle
186. The client complains about having
difficulty sleeping at night. Appropriate 191. From an ECG reading, a
intervention would be: QRS complex represents
a. Eliminating carbohydrates from the a. ventricular depolarization
diet b. ventricular repolarization
b. Suggesting a large glass of milk c. end of ventricular depolarization
before retiring d. atrial depolarization
c. Sleeping on two or three pillows
d. Administering antacids such as 192. Which of the following
sodium bicarbonate represents ventricular
187. The client is prescribed famotidine repolarization?
(Pepcid). In order to provide effective a. T wave c. QRS complex
teaching, the nurse must have which of b. ST segments d. PR interval
these understandings about the action of 193. It is important that the
the drug? nurse measures intervals of
a. The drug increases lower esophageal QRS complex. Which of the
sphincter (LES) tone following represents the
b. The drug improves gastric motility normal interval of the QRS
c. The drug coats the distal portion of complex?
the esophagus a. greater than 20 sec. c. 10 sec
d. The drug decreases the secretion of b. 20 sec d. 12 sec.tov20 sec
gastric acid 194. Later in the acute
188. The client should make diet and phase of myocardial infraction,
lifestyle changes. What instructions which of the following typically
should the nurse include in the client's appears as the first sign of
discharge teaching? tissue death?
1. Avoid alcohol a. ST segment suppression
2. Add milk to coffee or tea b. Short wave
3. Eat slowly and chew thoroughly c. Prolonged PR interval
4. Elevate the foot of the bed 6 inches d. Pathologic Q wave
5. Eat three evenly spaced meals daily SITUATION 7- Mang FELIX, a 79 year
6. Restrict the diet to small, frequent old man is brought to the Surgical Unit
meals from PACU after a transurethral
a. 1, 2 and 6 c. 3, 4 and 5 resection. You are assigned to receive
b. 1, 3 and 6 d. 2, 3 and 4 him. You noted that he has a 3-way
indwelling urinary catheter for
continuous fast drip bladder irrigation
189. When developing a teaching plan for which is connected to a straight
the client, the nurse should include which drainage.
discharge instruction? 195. Immediately after
a. “Elevate the foot of the bed by 6 to 8 surgery, what would you
inches.” expect his urine to be?
b. “Lie down immediately after a meal.” a. Light yellow c. Bright red
c. “Take antidiarrheal medication after b. Amber d. Pinkish red
each loose stool.”
d. “Avoid caffeine, tobacco, and 196. The purpose f the
peppermint.” continuous bladder irrigation is
SITUATION 1- P. Cruz,65 years old, was to:
admitted in the Telemetry because of a. allow continuous monitoring of the
signs and symptoms of acute myocardial fluid output status
infraction. You are expected to b. provide continuous flushing of
recognize electro cardio graphic clots and debris from the bladder
readings on the cardiac monitor. c. allow for proper exchange of
190. Which of the following electrolytes and fluid
appear abnormal on an EKG d. ensure accurate monitoring of intake
when ischemia and injury and output
occur in the myocardium?
a. QRS interval 197. Mang Felix informs you
b. ST segment and T wave that he feels some discomfort
c. P wave on the hypogastric area and
d. PR interval
 he has to void. What will be
your most appropriate action?
a. Remove his catheter then allow him
to void on his own
b. Irrigate the catheter
c. Tell him to “ Go ahead and void.” You
have a catheter
d. Assess color and rate of outflow, if
there is a change refer to urologist for
possible irrigation

198. You decided to check n

Mang Felix’s fluid infusion. You
noted a change in flow rate,
pallor and coldness around the
insertion site. What is your
assessment finding?
a. phlebitis
b. infiltration to subcutaneous tissue
c. pyrogenic reaction
d. air embolism

199. Knowing that proper

documentation of assessment
findings and interventions are
important responsibilities of
the nurse during the first
operative day, which of the
following is the LEAST relevant
to document in the case of
Mang Felix?
a. chest pain and vital signs
b. intravenous infusion rate
c. amount, color, and consistency of
bladder irrigation drainage
d. activities of daily living started

100. Your priorities when caring for the

older person who sustained traumatic
injuries include:
a. circulation, airway, breathing
b. airway, breathing, disability (
neurologic)
c. airways, breathing , circulation
d. disability ( neurologic), airway,
breathing