C.

produces more distinct, crisp, speech

I D. eliminates garbled background sounds
1. A home care nurse is preparing to visit a client with a diagnosis of 11. Which nursing action is best for controlling the client’s
Meniere’s disease. The nurse review’s the physician’s orders and nosebleed?
expects to note that which of the following dietary measures will be A. have the client lay down slowly and swallow frequently
prescribed? B. have the client lay down and breathe through his mouth
A. low fiber diet with decreased fluids C. have the client lean forward and apply direct pressure
B. low sodium diet and fluid restriction D. have the client lean forward and clench his teeth
C. low carbohydrate diet and elimination of red meats Situation: Benjie 59 years old male was admitted to the hospital
D. low fat with restriction of citrus fruits complaining of nausea, vomiting,
2. A nurse is assigned to care for a client who has just undergone eye weight loss of 20 lbs, constipation and diarrhea. A diagnosis of
surgery. The nurse plans to instruct the client that which of the carcinoma of the colon was made.
following activities is permitted in the postoperative period? 12. A sigmoidoscopy was performed as a diagnostic measures. What
A. reading position Benjie should assume for hi examination?
B. watching television A. knee-chest
C. bending over B. Sim’s
D. lifting objects C. Fowler’s
3. A nurse is instilling an otic solution into an adult client’s left D. Trendelenburg
ear. The nurse avoids doing which of the following as part of this 13. As part of the preparation of the client for sigmoidoscopy the
procedure? nurse should:
A. warming the solution to room temperature A. explain to Benjie that he will swallow a chalk-like substance
B. placing the client in a side lying position with the ear facing up B. administer a cathartic the night before
C. pulling the auricle backward and upward C. withhold fluids and foods on the day of examination
D. placing the tip of the dropper on the edge of the ear canal D. administer cleansing enema in the morning of the
4. A client has undergone surgery for glaucoma. The nurse provides examination
which discharge instructions to the clients? 14. The doctor performed a colostomy, post operative nursing care
A. wound healing usually takes 12 weeks include:
B. expected the vision will be permanently impaired A. keeping the skin around the opening clean and dry
C. a shield or eye patch should be worn to protect the eye B. limiting visitors
D. the sutures are removed after 1 week C. withholding
5. Which assessment findings provide the best evidence that a client D. limiting fluid intake
with acute angle-closure glaucoma is responding to drug therapy? 15. During the irrigation of the colostomy, Benjie complains of
A. swelling of the eyelids decreases abdominal cramps, the nurse should:
B. redness of the sclera is reduced A. discontinue the irrigation
C. eye pain is reduced or eliminated B. clamp the catheter for a few minutes
D. peripheral vision is diminished C. advance the catheter about one inch
6. At the time of retinal detachment, a client most likely describes D. add color water
which symptoms? 16. If colostomy irrigation is done, the height of the irrigator can
A. a seeing flashes of light must be how many inches above the stoma?
B. being unable to see light A. 14-18 inches
C. feeling discomfort in light B. 18-20 inches
D. seeing poorly in daylight C. 20-24 inches
7. The most important health teaching the nurse can provide to the D. 10-14 inches
client with conjunctivitis is to: 17. Which of the following gastrointestinal condition is known to
A. eat a well balanced, nutritious diet predispose to Cancer of the colon?
B. wear sunglasses in bright light A. hemorrhoids
C. cease sharing towels and washcloths B. intussusception
D. avoid products containing aspirin C. islated colonic polyps
8. When the nurse prepares the client or the myringotomy, the best D. pyloric stenosis
explanation as to the purpose for the procedures is that it will: Situation: Mr. J was brought to the ER complaining of pain located in
A. prevent permanent hearing loss the upper abdomen
B. provide a pathway for drainage hematemesis and melena. Diagnosis is peptic ulcer.
C. aid in administering medications 18. A frequent discomfort experience by Mr. J due to his peptic ulcer
D. maintain motion of the ear bones is:
9. A nurse is reviewing the record of the client with a disorder A. diarrhea
involving the inner ear. Which of the following would the nurse B. vomiting
expect to see documented as an assessment finding in this client? C. eructation
A. severe hearing loss D. nausea
B. complaints of severe pain in the affected ear 19. Which of this diagnostic measure is not indicated for Mr. J?
C. complaints of burning in the ear A. x-ray of the abdomen
D. complaints of tinnitus B. patient’s history
10. A client with a conduction hearing loss asks the nurse how a C. gastrointestinal series
hearing aid improves hearing. The nurse most accurately informs the D. gastric analysis
client that a hearing aid: 20. The purpose of dietary treatment of Mr. J is to:
A. amplifies sound heard A. neutralize the free HCL in the stomach
B. makes sounds sharper and clearer B. delay gastric emptying
C. prevent constipation
 D. delay surgery
21. Antacids are administered to Mr. J to:
A. tranquilize the intestine
B. decrease gastric motility
C. lower the acidity of gastric secretion
D. aid in digestion
22. It is thought that emotional stress contribute to ulcer formation
through:
A. excessive stimulation of the parasympathetic nervous system
B. increased activity of the sympathetic nervous system
C. disturbance o cerebral cortex appetite control
D. decrease of pituitary function
23. The tissue change most characteristics of peptic ulcer is:
A. a soft mass of the necrotic tissue with bleeding
B. an erosion of the mucosa covered with thick exudates
C. a sharp excavation of tissue membrane with a clean base
D. an elevated fibrous tissue membrane with soft margins
24. The stool Guiac test was ordered to detect the presence of:
A. hydrochloric acid
B. occult blood
C. inflammatory cells
D. undigested food
25. In addition to its antacids effects, aluminum hydroxide gel is
locally:
A. analgesic
B. astringent
C. irritating
D. depressant
26. Intervention that would help control his bleeding:
A. gastric lavage using iced cold normal saline solution
B. gastric using warm normal saline solution
C. application of tourniquet
D. insertion of NGT
27. Since she has NGT the appropriate nursing action is:
A. render sponge bath
B. provide laxative at bedtime
C. administer enema once a day
D. provide oral hygiene 3x a day
28. He underwent total gastrectomy, dumping syndrome may occur
and the least symptoms he may experience would be:
A. feeling of soreness
B. weakness
C. feeling of fullness
D. diaphoresis
29. To prevent dumping syndrome the following includes your
nursing care except:
A. serve dry meals
B. allow him to walk for a while after eating
C. instruct him to lie down after eating
D. giving of fluids after meals must be avoided
30. Your operative nursing assessment after surgery:
A. note and report excessive bleeding only
B. assess for excessive secretions from the operative site
C. ensure that the NG tube is detached from suction apparatus
D. check the drainage from the NG tube everyday
31. What is the involvement of her total gastrectomy?
A. removal of the stomach only
B. removal of the stomach with anastomosis of the esophagus to
the jejunum
C. removal of the ovary and fallopian tube
D. removal of the stomach with anastomosis of the duodenal to
jejunum
32. A nurse is giving instructions to the client with peptic ulcer
disease about symptom management. The nurse tells the client to:
A. eat slowly and chew food thoroughly
B. eat large meals to absorb gastric acid
C. limit the intake of water
D. use acetylsalicylic acid (aspirin) to relieve gastric pain
33. A client has been given a prescription for Propantheline
(Probanthine) as adjunctive treatment for peptic ulcer disease. The
nurse tells the client to take this medication:
A. with antacids
B. 30 minutes before meals
C. with meals
D. just after meals
Situation: Kim was known to be alcoholic for 15 yrs. He was
admitted in the hospital after having vomited a large quantity of
bright red blood with some coffee ground appearance.
34. The most probable cause of Kim’s cirrhosis is:
A. malnutrition
B. bacterial inflammation of liver cells
C. alcoholism
D. obstruction of major bile ducts
35. Which of the following vitamins are stored by the normal liver?
A. vit. A, vit. B and vit. C
B. vit. A, vit. B, vit. C, and vit. D
C. vit A and vit B
D. vit. A and vit. C
36. The nurse should know how that pathophysiology predispose
him to:
A. varicose veins
B. splenic rupture
C. inguinal hernia
D. umbilical hernia
37. Kim’s portal hypertension is the result of:
A. contraction of vascular muscles response to psychological stress
B. compression of the liver substance due to emotional stress
C. acceleration of portal blood flow secondary to severe anemia
D. twisting and constriction of intralobular and interlobular
blood vessels
38. Kim is scheduled for a liver biopsy. What instructions regarding
respiration is essential for the nurse to give him prior to the biopsy:
A. exhale forcefully and to hold his breath for a few seconds
B. hold his breath when the needle has reached the liver site
C. take several deep breaths and to hold his breath while needle
is being introduced
D. flat with one pillow under his head
39. Which position in bed would be best for Kim immediately after
he has the needle biopsy of the liver?
A. on his right side, with a small pillow under the costal margin
B. anyway that he is comfortable
C. semi-Fowler’s with his knees flexed
D. flat with one pillow under his head
40. A Blakemore-Sengstaken tube is inserted to prevent bleeding
from esophageal varices. The nurse responsibility in this instance
would be to:
A. alternate inflate and deflate the esophageal balloon
B. make certain that the desired degree of pressure is constantly
maintained
C. deflate both balloons periodically
D. encourage Kim to swallow frequently while tube is I place
41. A physician orders the deflation of the esophageal balloon of a
Sengstaken-Balkemore tube in a client. The nurse prepares for the
procedure knowing that the deflation of the esophageal balloon
places. The client is at risk for:
A. increased ascites
B. esophageal necrosis
C. recurrent hemorrhage from the esophageal varices
D. gastritis
42. Foods usually omitted from diet of Kim with cirrhosis of liver
are:
A. whole grain cereals
B. milk products
C. cereal products
D. rich gravies and sauces
43. Clay colored stool are caused by:
A. improper utilization of vitamin K by the body
 B. the absence of bile salt in the feces
C. the absence of bile pigments in the urine
D. rich gravies and sauces
44. Kim develop ascites, this is caused by:
A. pulmonary failure
B. portal obstruction
C. capillary obstruction
D. arterial obstruction
45. Symptoms indicating progression into hepatic coma include:
1. flapping tremor
2. nystagmus
3. fruity odor breath
4. fetid breath
A. 2 and 4 C. 2 and 3
B. 1 and 4 D. 1 and 3
46. A client admitted to the hospital with a diagnosis of cirrhosis has
massive ascites and has difficulty breathing. A nurse performs which
intervention as a priority measure to assist the client with breathing?
A. auscultates the lung fields every 4 hours
B. repositions side to side every 2 hours
C. encourages deep breathing exercises every 2 hours
D. elevates the head of the bed 60 degrees
Situation: Karla is confine with a diagnosis of chronic cholecystitis.
47. After thorough examination your findings would be:
A. high red blood cell counts and fever
B. leukocyte count is low and high fever
C. leukocyte count high and pyrexia
D. leukocytosis and abdominal pain that radiates to the groin
48. The surgical intervention indicated for Karla is:
A. choledochostomy
B. cholecystostomy
C. cholecystotomy
D. cholecystectomy
49. Following exploration of the common duct is a T-tube
inserted. The rationale for this is to:
A. facilitate healing of the operative site
B. offer a route to post operative cholecystectomy
C. provide sufficient drainage to promote healing
D. ensure adequate bile drainage during duct healing
50. Upon admission her doctor ordered for cholecystoghram in
AM. The preparations of this procedure begins:
A. in early am
B. with evening meal
C. at bedtime
D. upon admission
51. The ingestion of fatty food usually precipitates rubies episodes of
the upper abdominal pain because;
A. fat in the stomach increases the rate of peristaltic movements
B. fat in the duodenal contents initiate the reaction that cause
gallbladder contraction
C. fatty foods are likely to generate gas
D. fatty foods contain higher amount of cholesterol than do proteins
52. Karla is having pruritus of the extremities. Which of the
following nursing measures might be most helpful in relieving her
discomfort.
A. rubbing the skin with potassium permanganate 10:1000 solution
B. bathing in weak sodium bicarbonate solution
C. dusting with liberal amount of talcum powder
D. rubbing the skin with alcohol
53. Karla is experiencing severe biliary colic. The drug of choice
during attack is:
A. ponstan
B. Demerol
C. atropine sulfate
D. morphine sulfate
54. A T-tube was inserted into the common bile duct. Her nursing
care of the T-tube is:
A. empty and measure the bile drainage every 4 hours
B. report STAT for any bile seen in the drainage system
C. secure it very well
D. irrigate the T-tube with sterile normal saline every 4 hours
55. A client with diverticulitis has just been advanced from a liquid
diet to solids. The nurse encourages the client to eat foods that are:
A. low residue
B. high residue
C. moderate in fat
D. high roughage
56. A client has just undergone an upper gastrointestinal (GI)
series. The nurse provides which of the following upon the client’s
return to the unit as an important part of routine post procedure care?
A. increased fluids
B. bland diet
C. NPO status
D. laxative
57. A nurse is administering continuous tube feedings to the
client. The nurse takes which of the following actions as party of
routine care for this client?
A. checks the residual every 4hours
B. changes the feeding bag and tubing every 12 hours
C. pours additional feeding into bag when 25 ml are left
D. holds the feeding if greater than 200 ml are aspirated
58. A nurse is monitoring drainage from a nasogastric (NG) tube in a
client who had a gastric resection. No drainage has been noted during
the past 4 hours and the client complains of severe nausea. The most
appropriate nursing action would be to:
A. reposition the tube
B. irrigate the tube
C. notify the physician
D. medicate for nausea
59. A nurse is performing a health history on a client with chronic
pancreatitis. The nurse expects to most likely note which of the
following when obtaining information regarding the client’s health
history?
A. abdominal pain relieved with food or antacids
B. exposure to occupational chemicals
C. weight gain
D. use of alcohol
60. A home care nurse visits a client with bowel cancer who recently
received a course of chemotherapy. The client has developed
stomatitis. The nurse avoids telling the client to:
A. drink foods and liquids that are cold
B. eat foods without spices
C. maintain a diet of soft foods
D. drink juices that are not citrus
61. A nurse is caring for a client with is receiving total parenteral
nutrition (TPN). The nurse plans which nursing intervention to
prevent infection?
A. using strict aseptic technique for intravenous site dressing
changes
B. monitoring serum blood urea nitrogen (BUN) daily
C. weighing the client daily
D. encouraging increased fluid intake
62. A nurse is caring for a client with possible cholelithiasis who is
being prepared for a cholangiogram. The nurse teaches the client
about the procedure. Which client statement indicates that the client
understands the purpose of this procedure?
A. “they are going to look at my gallbladder and ducts.”
B. “this procedure will drain my gallbladder”
C. “my gallbladder will be irritated”
D. “they will put medication in my gallbladder”
63. A client who has a history of chronic ulcerative colitis is
diagnosed with anemia. The nurse interprets that which of the
following factors is most likely responsible for the anemia?
A. decrease intake of dietary iron
B. intestinal malabsorption
C. blood loss
D. intestinal hookworm
64. A client’s nasogastric (NG) feeding tube has become
clogged. The nurse’s first action is to:
A. flush the tube with warm water
B. aspirate the tube
C. flush the carbonated liquids, such as cola
D. Replace the tube
65. When the client ask the nurse why he must take the neomycin
sulfate (Mycifradin), the most accurate explanation in this case is
that the drug is given to:
A. treat any current infection he may have
B. suppress the growth of intestinal bacteria
C. prevent the onset of postoperative diarrhea
D. reduce the number of bacteria near the incision
66. If the client is typical of others with appendicitis the nurse can
expect that when the client’s abdomen is palpated midway between
the umbilicus and right iliac crest, the client will:
A. experienced more pain when pressure is released
B. lack any sensation of pain or pressure on palpation
C. have extreme discomfort with the slightest pressure
D. will feel referred pain in the opposite quadrant
67. Which factor most probably contributed to the development of
the client’s hemorrhoids?
A. the client takes a daily stool softener
B. the client has a history of ulcerative colitis
C. the client is frequently constipated
D. the client works as a computer programmer
68. When the client describes her discomfort to the nurse she is most
likely to indicate that the pain she experiences becomes worse:
A. shortly after eating
B. especially on an empty stomach
C. following periods of activities
D. before rising in the morning
69. When the nurse empties the drainage in the Jackson Pratt bulb
reservoir. Which nursing action is essential for reestablishing the
negative pressure within this drainage device?
A. the nurse compresses the bulb reservoir and closes the
drainage valve
B. the nurse opens the drainage valve, allowing the bulb to fill with
air
C. the nurse fill the bulb reservoir with sterile normal saline
D. the nurse secures the bulb reservoir to the skin near the wound
70. When the client asks the nurse how she acquired hepatitis A, the
best answer is that a common route of hepatitis. A transmission is
from:
A. fecal contamination
B. insect carries
C. infected blood
D. wound drainage
71. It is essential that the nurse inform the client with hepatitis B that
for the remainder of his lifetime he must avoid:
A. sexual activity
B. donating blood
C. excessive caffeine
D. foreign travel
72. Which nursing action is appropriate prior to assisting with the
paracentesis?
A. the nurse asks the client to void
B. the nurse withholds food and water
C. the nurse cleanses the client’s abdomen with Betadine
D. the nurse obtains a suction machine from storage room
73. Which statements provides the best evidence that a client with
colostomy is adjusting to the change in body image?
A. the client wears loose-fitting garments
B. the client takes a shower each day
C. the client empties the appliance
D. the client avoids foods that form gas
74. A previously health client comes to the emergency department
complaining of severe nausea and vomiting hours after eating in a
restaurant. Which assessment question best determines if a food
borne pathogen is the cause of the client’s syndrome?
A. “what food did you eat?”
B. “did you take something for you nausea?”
C. “did your food look spoiled?”
D. “have you ever had food poisoning?”
75. A nurse is caring for a client with peptic ulcer. In assessing the
client for gastrointestinal perforation (GI), the nurse monitors for:
A. increase bowel sounds
B. sudden, severe abdominal pain
C. positive Guaiac test
D. slow, strong pulse
76. Which assessment is most important for the nurse to make before
advancing a client from liquid to solid food?
A. increase bowel sounds
B. appetite
C. presence of bowel sounds
D. chewing ability
77. What method would a nurse use to most accurately assess the
effectiveness of a weight loss diet for an obese client?
A. daily weights
B. serum protein levels
C. daily caloric counts
D. daily intake and output
78. A pregnant client has been diagnosed with a vaginal infection
from the organism Candida albicans. Which findings would the nurse
expect to note on assessment of the client?
A. absence of any and symptoms
B. pain, itching and vaginal discharge
C. proteinuria, hematuria, edema and hypertension
D. costovertebral angle pain
79. A nurse is caring for a client who is hospitalized with acute
systemic lupus erythematosus (SLE). The nurse monitors the client
knowing that which of the following clinical manifestation is not
associated with this disease?
A. fever
B. muscular aches and pains Associated with
SLE s/sx
C. butterfly rash on the face
D. bradycardia
80. A male being seen in the ambulatory care clinic has a history of
being treated for syphilis infection. The nurse interprets that the client
has been reinfected if which of the following characteristics is noted
in a penile lesion?
A. multiple vesicles, with some that have ruptured
B. popular areas and erythema
C. cauliflower-like appearance
D. induration and absence of pain
81. A nurse is preparing a poster for a booth at a health care to
promote primary prevention of cervical cancer. The nurse includes
which of the following recommendations on the poster?
A. perform monthly breast self-examination (BSE)
B. use oral contraceptives as a preferred method of birth control
C. use a commercial douches on a daily basis
D. seek treatment promptly for infections of the cervix
82. A nurse is caring for a client who has just had a mastectomy. The
nurse assists the client in doing which of the following exercises
during the first 24 hours following surgery?
A. elbow flexion and extension
B. shoulder abduction and external rotation
C. pendulum arm swing
D. hand wall climbing
83. Tretinoin (Retin-A) is prescribed for a client with acne. The client
calls the clinic nurse and says that the skin has become very red and
is beginning to pee. Which of the following nursing statements to the
client would be most appropriate?
A. “come to the clinic immediately”
B. “discontinue the medication”
C. “notify the physician”
 D. this is a normal occurrence with the use of medication” C. “I need to apply pressure to the irritated area to prevent
Situation: Luz 19 years old single is scheduled for mastectomy of the bleeding”
right breast D. “I need to eat a high-protein diet”
84. Based on the health history and other assessment data, Luz’s 95. A nurse is teaching a client about the modifiable risk factors that
nursing diagnosis includes the following except: can reduce the risk for colorectal cancer. The nurse places highest
A. potential sexual dysfunction priority on discussing which of the following risk factors with this
B. body image disturbance client?
C. pain related to anesthesia A. personal history of ulcerative colitis or gastrointestinal (GI)
D. self-care deficit related to immobility of arm on the operative side polyps
85. The following are her possible post operative complication B. distant relative with colorectal cancer
except: C. age over 30 years
A. hematoma D. high-fat, low fiber diet
B. lymphedema Situation: Fe, a 21-year-old fourth year physical therapy student has
C. neurovascular deficits been diagnosed with peptic ulcer. The personal and family history
D. infection shows that she has difficulty coping with the demands of the course
86. Luz complains of pain 2 hours after receiving her medication of and her mother is being treated for peptic ulcer to:
Meperidine HCL 50 mg IM ordered every 4 hours for the first 24 96. A relevant diagnosis the nurse identifies is one of the following:
hours only. You should: A. defensive coping
A. tell Luz to wait for 2 hours more B. self-esteem disturbance
B. give the medicine STAT C. sensory-perceptual alteration
C. give fractional dose of Meperidine HCL D. ineffective individual coping
D. use nursing measure to relieve pain 97. Typical personality traits of a person with peptic ulcer:
87. You informed her that the most common breast tumor occurring A. submissive and dependent
in young women is: B. competitive and aggressive
A. fibrocystic C. self-sacrificing and dependent
B. papilloma D. perfectionist and assertive
C. gynecomastia 98. One of the nursing intervention is to teach Fe:
D. fibroadenoma A. relaxation technique
88. Which of these work-up is not related to her surgery? B. behavior modification
A. CBC C. stress management technique
B. Urinalysis D. desensitization technique
C. B.T. 99. The following are psycho-physiological reactions except:
D. C.T. A. migraine
89. Rationale for moderately elevating post operative affected arm is B. constipation
to: C. bronchial asthma
A. prevent lymphedema D. peptic ulcer
B. reduce pain 100. The defense mechanism usually used by patient with peptic
C. B.T. ulcer is:
D. C.T. A. denial
90. Which of these maybe used to her post operatively? B. reaction formation
A. pleural drainage C. projection
B. hemovac D. sublimation
C. prevent infection
D. improve coping ability
91. Which of the following is not a post operative complication
A. bronchopneumonia
B. pneumonia II
C. atelectasis 1. The home health nurse is visiting the client who has had a
D. decubitus ulcer prosthetic valve replacement for severe mitral valve stenosis. Which
92. Allowing her to do deep breathing exercise every 2 hours would statement by the client reflects an understanding of specific
prevent: postoperative care for this surgery?
A. bronchopneumonia A. “I threw away my straight razor and brought an electric
B. atelectasis razor.”
C. bronchitis B. “I have to go to the bathroom several times at night”
D. pneumonia C. “I count my pulse everyday”
93. A client has a left mastectomy with axillary lymph node D. “I still do my deep breathing exercise”
dissection. The nurse determines that client understands post 2. A client has been diagnosed with thromboangitis obliterans. The
operative restrictions and arm care if the client states to: nurse is considering measures to help the client cope up with lifestyle
A. use a straight razor to shave under the arms changes needed to control the disease process. The nurse plans to
B. allow blood pressures to be taken only on the left arm refer the client to a:
C. carry a handbag and heavy objects on the left arm A. medical social worker
D. use gloves when working in the garden B. dietician
94. A nurse has provided instructions to a client who is receiving C. smoking cessation program
external radiation therapy. Which of the following if started by the D. pain management clinic
client would indicate a need for further instructions regarding self- 3. The nurse is implementing a plan of care for a client with deep
care related to the radiation therapy? pain thrombosis of the right leg. Which of the following interventions
A. “I need to avoid exposure to sunlight?” does the nurse avoid when delivering care to this client?
B. “I need to wash my skin with a mild soap and pat dry” A. elevation of the right leg
B. ambulation in the hall twice per shift
 C. application of moist heat to the right leg
D. administration of acetaminophen (Tylenol)
4. The client was hospitalized 5 days ago have developed left calf
tenderness and have a positive Homan’s sign. The nurse assigned to
this client, assesses the client for:
A. coolness and pallor of the affected limb
B. diminished distal peripheral pulses
C. increased calf circumference
D. bilateral edema
5. The nurse is monitoring a client with leukemia who is receiving
Doxorubicin (Adriamycin) by IV infusion. Which of the following
assessment findings indicate toxicity of the medication?
A. Elevated BUN
B. elevated creatinine
C. ECG changes
D. a red coloration of the urine * one of the adverse rxn, but
transient
6. A 45-year-old male returned to his room an hour ago following a
bronchoscopy. He is requesting for some water. The nurse must:
A. keep the client NPO until n order is written
B. check the vital signs first
C. check the gag and swallowing reflex
D. encourage coughing and deep breathing
7. A 45-year-old client is receiving heparin sodium for a pulmonary
embolus. The nurse evaluates which of the following laboratory
reports of partial thromboplastin time as indicative of effective
heparin therapy.
A. within normal range
B. one to 1.5 times the control value
C. two to 2.5 times the control value
D. three times the control value
8. A client is taking Wafarin (coumadin) following the placement of
an artificial mitral valve. The nurse instructs this client to avoid
taking the following commonly used drug:
A. Maalox plus
B. sudafed
C. Tylenol cold and flu medication
D. aspirin
9. A client with insulin dependent diabetes mellitus (IDDM) is being
discharged. The nurse knows that the client has understood essential
teaching when the following statement is heard:
A. “I need to cut my nails straight across”
B. “I can’t make any substitutions in my diet”
C. “my insulin should be given into my arms”
D. “I should eat less before exercising”
10. A client is on chemotherapy for acute myelogenous
leukemia. The nurse assesses the following laboratory test daily:
A. complete blood count
B. electrolyte studies
C. prothrombin time – for bleeding time
D. BUN and creatinine
11. A client has developed depression of the bone marrow from anti-
neoplastic drugs. The nurse states the nursing diagnosis of highest
priority as:
A. fluid volume deficit C. ineffective thermoregulation
B. High risk for aspiration D. high risk for infection
12. Radioactive iodine is being used to treat a client with cancer of
the thyroid gland. The nurse knows that the client has understood
teaching about the treatment when the following statement is heard:
A. “only my thyroid gland will be radioactive”
B. “I need not be concerned about radioactivity”
C. “my whole body will be radioactive”
D. “my body fluids will be radioactive for a short time”
13. A client’s TPN is 6 hours behind schedule. The nurse would:
A. run the fluid at rate to make up the lost time.
B. report the situation to the physician
C. run the IV at the prescribed site
D. check the blood glucose level
14. A 45-year-old client is in acute congestive heart failure. The
nurse and client establish a goal of highest priority as:
A. rest mentally as well as physically
B. learn stress management
C. train for a less demanding job
D. prevent complications of immobility
15. A client diagnosed with IDDM becomes irritable and
confused; the skin is cool and clammy and the pulse rate is 110. The
first action of the nurse would be to:
A. give a half-cup of orange juice
B. check the serum glucose
C. administer regular insulin
D. call the physician
16. A client with IDDM is recovering from DKA. Information of the
serum level of the following substance will be very important to the
nurse:
A. sodium C. potassium
B. calcium D. magnesium
17. A 17-year-old client’s mother has been recently diagnosed with
pulmonary tuberculosis. The nurse would expect the doctor to order
which of the following tests initially?
A. the mantoux C. a sputum culture
B. an X-ray D. gram stain of the sputum
18. The nurse injects 0.1 ml. of purified protein derivative (PPD)
intradermally into the inner aspect of the forearm of a client. This
nurse will interpret the reaction to this test as positive when the
following is seen:
A. redness greater than 5mm.
B. swelling greater than 7mm.
C. induration greater than 10mm.
D. exudates covering more than 12mm
19. A 29-year-old has been taking Prednisolone 60 mg. daily for an
inflammatory condition for the past 6 months. The physician just
wrote an order to discontinue the medication. The nurse should:
A. stop the medication as ordered
B. continue the medication until physician is available
C. call the physician and question the order
D. hold the medication until the physician is available
20. A 55 year old has a chest tube connected to a Pleur Evac system
to remove blood from the pleural cavity. While turning the client the
nurse remembers to:
A. keep the Pleur Evac below the level of the wound
B. Remove the suction from the Pleur vac
C. Clamp the tubing connected to the Pleur Evac
D. drain the sterile water from the Pleur Evac
21. A client on anti-neoplastic therapy has a platelet count of
20,000/cu.mm (N wbc 5,000 to 10,000). An appropriate intervention
for the nurse to use would be:
A. administering Vit. K IM
B. massaging injection sites to avoid absorption
C. encouraging the use of firm toothbrushes and vigorous flossing
D. avoiding rectal temperatures and other rectal procedures
22. A nurse assumes responsibility for the care of the client at 7
A.M. NPH insulin is ordered for 7:30 A.M. Before giving the insulin,
the nurse checks to see if the client will eat that day and for the:
A. signs and symptoms of hypoglycemia
B. previous sites of injection
C. serum glucagons level
D. serum glucose level
23. A nurse is teaching a client to observe for signs of hypoxia. The
nurse explains that cyanosis is not reliable indicator of the amount
that tissues are receiving because the blue color is caused by:
A. reduced hemoglobin
B. a low partial pressure of oxygen in the blood
C. inability of oxygen to enter the cell
D. increased pH of the blood
24. A client has ARDS. The lowest fraction of inspired oxygen
possible for optimizing gas exchange is used. The nurse explains to
the family that the reason for this precaution is to:
 A. avoid respiratory depression
B. prevent oxygen toxicity
C. increase lung compliance
D. promote production of surfactant
25. A client who is recovering from a myocardial infarction
demonstrates that touching has been effective with the statements:
A. “if my chest pain lasts for more than 5 minutes, I should get
myself to the emergency room”
B. “I just need to avoid salty foods and not add salt to my food”
C. “I need to avoid constipation and all activities that have
caused me chest pain in the past”
D. “I need to get to the drugstore to get some medicine for my cold”
26. A client is admitted to the hospital complaining of nervousness,
heat intolerance and muscle weakness. Her pulse rate is 118 and she
has exopthalmos. An essential part of her assessment will be:
A. palpation of the thyroid gland
B. evaluation of fluid and electrolyte balance
C. evaluation of deep tendon reflexes
D. use of the Glasgow Coma Scale
27. A client is scheduled for thyroidectomy. The nurse explains that
PTU or an iodine preparation is given prior to surgery in order to:
A. increase the size of the thyroid gland
B. render the parathyroid glands visible
C. induce a euthyroid state in the body
D. Separate the thyroid from the laryngeal nerve
28. A client is being evaluated for the possibility of Grave’s
disease. The nurse teaches that the best laboratory test for evaluating
whether a client has hypothyroidism or hyperthyroidism is the serum
level of:
A. thyroxine (T4) C. TSH
B. triiodothyroinine (T3) D. epinephrine
29. A client is taking Levothyroxine (synthroid) for
hypothyroidism. The nurse teaches the client to:
A. monitor the pulse regularly
B. restrict sodium in the diet
C. take the drug with meals
D. measure urinary output
30. A client with NIDDM is admitted to the hospital. The client is
confused and has dry mucus membranes and poor skin turgor. The
serum sodium is 149; the blood pressure 90/60 mmHg; the pulse is
118; and the serum glucose 465 mg/dl. The nurse anticipates that
insulin and the following will be needed:
A. a potassium drip C. intravenous fluids
B. sodium bicarbonate D. calcium gluconate
31. A nurse is teaching a diabetic client how to attain the optimal
level of health. When assessing for other risk factors stroke and heart
attack, this nurse looks for:
A. hypervolemia C. proteinuria
B. hypokalemia D. hypertension
32. A nurse stops at the sight of a motor vehicle accident to find a
young woman slumped over the wheel. She is breathing with a
regular rhythm at a rate of 22; ventilation efforts normal. Her
pulse rate is 110. The nurse’s next action would be:
A. check the level of consciousness
B. immobilize the spine
C. call the rescue squad
D. check for bleeding
33. A 57-year-old client is being prepared for discharge following a
myocardial infarction. The nurse knows that her teaching has been
understood when she hears:
A. “I guess my sex life is over”
B. “depression is bad for me. I must stay happy and optimistic”
C. “ the best way to know the amount of exercise I should take is
to watch my pulse”
D. “the injured area will be replaced with a new heart tissue”
34. A client with IDDM has just been admitted to the ER after hitting
a telephone pole with her car. Bystanders said she acted as if she has
been drinking. Her temperature is 37.4 degrees Celsius, pulse 80,
resp. 44 and deep. She complained of headache and acted
confused. A fruity odor was noted on her breath. Her ABG report
read= pH= 7.32, pCO2= 36, and bicarbonate= 18. The nurse prepared
for the treatment of:
A. metabolic acidosis C. respiratory acidosis
B. metabolic alkalosis D. respiratory alkalosis
35. A client with peptic ulcer is taking Maalox, Amoxicillin and
Famotidine. The nurse teaches the client to take the Maalox:
A. 1-2 hours before meals C. ½ hour before meals
B. with meals D. 1-2 hours after meals
36. A client with varicose veins tells the nurse, “I am afraid they will
burst while I am walking.” Which response by the nurse would be the
BEST?
A. “the only way to prevent rupture is to have surgery”
B. “you must find another job, one that requires less walking”
C. “if that happens, you could bleed to death”
D. “rupture of varicose veins rarely occur”
37. A client asks why is it important to check the pupils. The nurse
replies that changes in the pupils are a reflection of how well the
following area of the nervous system is functioning:
A. spinal cord C. midbrain
B. brain stem D. cerebellum
38. A 32-year-old client is being evaluated in the clinic today for
possible Addison’s disease. The nurse knows that the most common
cause of the disease is attributed to:
A. autoimmune response C. disseminated tuberculosis
B. blastomycosis D. diabetes mellitus
39. The nurse knows that the recommended diet for a client with
Addison’s disease includes:
A. 1 mg. Na C. low fat, low cholesterol
B. 3 gms. Na D. high potassium, high cholesterol
40. A 36-year-old client with a history of Cushing’s disease is being
seen in the ER for complaints of anorexia, vomiting, weakness and
muscle cramps for the past 24 hours. The nurse recognizes that these
clinical findings are a result of:
A. hypernatremia C. hyperglycemia
B. hypoglycemia D. hypokalemia
41. When teaching a patient about home care related to outpatient
corticosteroid therapy, the nurse emphasizes that side effects of
corticosteroid therapy include:
A. hyperglycemia and weight loss
B. hyponatremia and hypotension
C. hypoglycemia and gastric ulcers
D. hyperglycemia and weight gain
42. Additional teaming to a newly diagnosed diabetic client related to
the effects of regular insulin is necessary when the client asks, “if I
take my regular insulin at 8 A.M., when might I experience signs of
low blood sugar reaction?
A. 8:30 am
B. 11 am
C. 1:30 pm
D. 4 pm
43. The nurse recognizes which of the following as signs of early
hypoxia?
A. bradycardia, hypotension, facial flushing
B. confusion, bradycardia, headache
C. hypotension, tachypnea, lethargy
D. restlessness, yawning, tachycardia
44. A 68-year-old client has a new colostomy and is being treated
today at the clinic for diarrhea. When discussing diet with the client,
the nurse explains to him that the one food that caused this problem
was:
A. cabbage C. tapioca
B. eggs D. fried chicken
45. The nurse is caring for a client with folic acid deficiency. The
nurse recalls that one of the most frequent causes of folic acid
deficiency is:
A. poor nutritional intake due to alcoholism
B. lack of absorption of the intrinsic factor
C. a diet that consists of vegetables only and no meat
 D. a complicated pregnancy during the second trimester
46. When planning care for a patient who is pancytopenic, the major
goal should be:
A. prevent hemorrhage and infection
B. administering an oral iron preparation
C. preventing fatigue and fluid overload
D. encouraging consumption of a neutropenic diet
47. when explaining different effects of chemotherapy to students,
the nurse correctly identifies which group of chemotherapy drugs that
does not affect DNA synthesis to kill tumor cells?
A. hormones C. antimetabolites
B. vinca alkalosis D. alkylating agents
48. The nurse evaluates the client’s ability to self-monitor blood
glucose level at home. What information BEST indicates the average
degree of diabetes control during the past 2 to 4 months?
A. serum glycosylated hemoglobin
B. postprandial blood glucose level
C. a written record of daily blood glucose levels
D. a written record of daily double voided urine glucose levels
49. Which of the findings would the nurse most likely note during an
Addisonian crisis?
A. serum potassium of 3 mEq/L, BP=158/72 mmHg
B. serum potassium of 5.8 mEq/L, BP=62/48 mmHg
C. serum sodium of 150 mEq/L, BP= 158/72
D. serum sodium of 135 mEq/L, BP=62/48
50. Propanolol (Inderal) is commonly prescribed for clients with
hyperthyroidism to:
A. block formation of the thyroid hormone
B. decrease the vascularity of the thyroid gland
C. inhibit peripheral conversion of T4 and T3
D. decrease CNS stimulation
51. The client with cancer is receiving chemotherapy and develops
thrombocytopenia. Which goal should be given the highest priority in
the NCP?
A. ambulation tree times a day
B. monitoring temperature
C. monitoring hemoglobin and hematocrit
D. monitoring for pathologic fractures
52. The nurse assesses the oral cavity of a client with cancer and
notes white patches on the mucous membranes. The nurse determines
that this occurrence:
A. is common
B. is characteristic of thrush infection
C. indicates that oral hygiene need to be improved
D. suggests that the client is anemic
53. The nurse is monitoring the laboratory results of a client
preparing to receive chemotherapy. The nurse determines that the
WBC count is normal if which of the following results is present?
A. 3,000 to 8,000/cu.mm.
B. 4,000 to 9,000/cu.mm.
C. 7,000 to 15,000/cu.mm.
D. 2,000 to 5,000/cu. Mm.
54. The client suspected of having an abdominal tumor is scheduled
for a CT scan with dye injection. Which of the following is an
accurate description of the scan?
A. the test maybe painful
B. the dye injected may cause a warm, flushing, sensation
C. fluids will be restricted following the test
D. the test takes approximately 2 hours
55. The client is diagnosed as having a bowel tumor. Several
diagnostic test are prescribed. Which of the following test will
confirm the diagnosis of the malignancy?
A. MRI C. abdominal ultrasound
B. CT scan D. biopsy of the tumor
56. The oncology nurse is preparing to administer chemotherapy to
the client with Hodgkin’s disease. A multiagent medication regimen
known as MOPP is prescribed. The medications included in the
therapy are:
A. belomycin, oncovin, vincristine, prednisone
B. adrimycin, vincristine, oncovin, prednisone
C. adriamycin, cytoxan, prednisone, oncovin
D. procarbazine, mechlorethemine, oncovin, prednisone
57. The nurse is analyzing the laboratory results of a client with
leukemia who received a regimen of chemotherapy. Which of the
following laboratory values does the nurse note specifically as a
result of massive cell destruction that occurred from chemotherapy?
A. anemia C. decrease platelets
B. decreased WBC D. increased uric acid level
58. The client is receiving external radiation to the neck for cancer of
the larynx. The MOST likely side effect to be expected is:
A. constipation C. sore throat
B. dyspnea D. diarrhea
59. The nurse is providing instructions to the client receiving external
radiation therapy. Which of the following is NOT a component of the
instructions?
A. avoid exposure to sunlight
B. wash the skin with a mild soap and pat dry
C. apply pressure on the irritated area to prevent bleeding
D. eat a high protein diet
60. The nurse teaches skin care to the client receiving external
radiation therapy. Which of the following statements, if made by the
client indicates the need for further instruction?
A. “I will handle the area gently”
B. “I will avoid the use of deodorants”
C. “I will limit sun exposure to 1 hour daily”
D. “I will wear loose fitting clothing”
61. The nurse is reviewing the laboratory results of a client receiving
chemotherapy. The platelet count is 10,000/cu.mm. Based on this
laboratory value, the priority nursing assessment is which of the
following?
A. assess level of consciousness
B. assess temperature
C. assess bowel sounds
D. assess skin turgor
62. The client is admitted to the hospital with a diagnosis of
suspected Hodgkin’s disease. Which of the following assessment
signs would the nurse MOST likely to note in the client?
A. weakness C. weight gain
B. fatigue D. enlarged lymph nodes
63. The client with leukemia is receiving Busulfan
(myleran). Allopurinol (Zyloprim) is prescribed for the client. The
purpose of Allopurinol (Zyloprim) is to:
A. prevent gouty arthritis C. prevent hyperuricemia
B. prevent stomatitis D. prevent diarrhea
64. A gastrectomy is performed on a client with gastric cancer. In the
immediate postoperative period, the nurse notes bloody drainage
from the NGT. Which of the ff. is the MOST appropriate nursing
intervention?
A. notify the physician C. continue to monitor the drainage
B. measure abdominal girth D. irrigate the NGT
65. The nurse is reviewing the history of a client with bladder
cancer. The MOST common symptom of this type of cancer is which
of the following?
A. frequency of urination C. hematuria
B. urgency of urination D. dysuria
66. The nurse is assessing the stoma of a client following a
ureterostomy.
Which of the following does the nurse expect to note?
A. a pale stoma C. a red and moist stoma
B. a dry stoma D. a dark-colored stoma
67. The nurse is caring for a client following a radical
mastectomy. Which of the following nursing interventions would
assist in preventing lymphedema of the affected arm?
A. placing cool compress on the affected arm
B. elevating the affected arm on pillow below the heart level
C. maintaining an IV site below the antecubital area of the affected
side
D. avoiding arm exercises in the immediate post-operative period
68. The nurse is teaching BSE to a client who had a
hysterectomy. The MOST appropriate instruction regarding BSE
should be performed is:
A. 7 to 10 days after menstruation
B. just before menses begin
C. at ovulation time
D. at a specific day of the month and on the same day every month
thereafter
69. The nurse is instructing the client, Ben how to perform testicular
self-examination. Which instruction is correct?
A. examine testicles when lying down
B. the best time for the examination is after a shower
C. gently feel the testicle with one finger to feel for a growth
D. testicular examination should be done at least every 6 months
70. The nurse is instructing a group of female about BSE. The nurse
instructs the clients to perform the examination:
A. at the onset of menstruation
B. one week after menstruation begins
C. every month during ovulation
D. weekly at the same time of the day
71. The client has undergone esophagogastroduodenoscopy (EGD).
The nurse places highest priority on which of the following items as
apart of the client’s care plan?
A. assessing for the return of the gag reflex
B. giving warm gargle for sore throat
C. monitoring temperature
D. monitoring complaints of heartburn
72. The client being seen in a physician’s office has just been
schedule for a barium swallow the next day. The nurse writes down
which of the following instructions for the client to follow before the
test?
A. removal all metal and jewelry before the test
B. eat regular supper and breakfast
C. continue to take all oral medication as scheduled
D. monitor own bowel movement pattern for constipation
73. The client is diagnosed with bleed and the bleeding has been
controlled antacid are prescribed to be administered every hour. The
nurse should plan on maintaining an approximately gastric pH of:
A. 3 B. 9 C. 6 D. 15
74. The nurse is caring for a client following a Billroth II
Procedure. On review of the post-operative orders, which of the
following, if prescribed, does the nurse question and verify?
A. irrigating the NG tube
B. coughing and deep breathing exercises
C. leg exercises
D. early ambulation
75. A client who has a peptic ulcer is schedule for a vagotomy. The
client asks about the purpose of this procedure. The BEST nursing
response is which of the following?
A. “decreases food absorption in the stomach”
B. “heal the gastric mucosa”
C. “halts stress reaction”
D. “reduces the stimulus to acid secretion”
76. The nurse ins monitoring a client for the early signs and
symptoms of dumping syndrome. Which of the following syndrome
indicate this occurrence?
A. abdominal cramping and pain
B. bradycardia and indigestion
C. sweating and pallor
D. double vision and chest pain
77. The nurse is caring for a hospitalized patient with a diagnosis of
ulcerative
colitis (inflammation). When assessing the client, which finding, if
noted, would the nurse report to the physician?
A. bloody diarrhea C. hemoglobin level of 12 mg/dl
B. hypotension D. rebound tenderness
78. The nurse is providing discharge instruction to a client following
gastrectomy, which of the following measures will the nurse instruct
the client to the following assist in preventing dumping syndrome?
A. eat high carbonated food
B. limit the fluid taking with food
C. ambulate following a meal
D. sit in a high-fowler’s position during meals
79. The nurse is caring for a client post-operatively following the
creation of a colostomy. Which of the ff. nursing diagnosis does the
nurse include in the plan of care?
A. altered nutrition; more than body requirements
B. body image disturbance
C. fear related to poor diagnosis
D. sexual dysnfunction
80. The nurse is reviewing the record of the client with Crohn’s
disease (inflammation). Which of the following stool characteristic
does the nurse expect to note in this client?
A. bloody stool
B. diarrhea
C. constipation alternating with diarrhea
D. stool constantly oozing from the rectum
81. The client with cirrhosis has ascites and a fluid volume
excess. Which measure will the nurse include in the plan of care for
this client?
A. increase the amount of sodium in diet
B. restrict the amount of fluids consumed
C. encourage ambulation frequently
D. administer magnesium antacids
82. The client with ascites is schedule for a paracentesis. The nurse is
assisting the physician in performing the procedure. Which of the
following positions will the nurse assist the client to assume for this
procedure?
A. supine C. right side lying
B. left side lying D. upright
83. An ultrasound of the gallbladder is schedule for the client with a
suspect diagnosis of cholecystitis. The nurse explain to the client that
this test:
A. requires the client to lie still for short intervals
B. requires that the client be NPO
C. requires the administration of oral tables
D. is uncomfortable
84. The nurse is providing preoperative teaching to a client scheduled
for a cholecystectomy. Which of the following interventions is of
highest priority in the preoperative teaching plan?
A. teaching coughing and deep breathing exercises
B. teaching leg exercises
C. instructions regarding fluid restrictions
D. frequent need to work overtime on short notice
85. A client with peptic ulcer states that stress frequently causes
exacerbation (aggrevate;increase) of the disease. The nurse interprets
that which of the following items mentioned by the client is most
likely responsible for the exacerbations?
A. sleeping 8 hours a night
B. eating 5 to 6 small meals per day
C. ability to work at home periodically
D. frequent need to work overtime on short notice
86. The client with peptic ulcer disease needs dietary modification to
reduce episode of epigastric pain. The nurse plans to teach the client
that which of the following items, which the client enjoys, does not
need to be limited or eliminated with this disease?
A. wine C. coffee
B. baked chicken D. fresh fruit
87. The medication history of a client with peptic ulcer disease
reveals intermittent use of the following medications. The nurse
teaches the client to avoid which of these medications altogether
because of the irritating effects on the lining of the GI tract?
A. (Prilosec)
B. ibuprofen (Motrin)
C. sucralfate (Carafate)
D. Nizatidine (Axid)
88. The nurse instructs the ileostomy client to do which of the
following as part of essential care of the stoma?
A. cleanse the peristomal skin meticulously
B. take in high-fiber foods such as nuts
C. massage the area below the stoma
D. limit fluid intake to prevent diarrhea
89. The client who has undergone creation of a colostomy has a
nursing diagnosis of Body Image disturbance. The nurse evaluates
that the client is making the most significant progress toward
identified goals if the client:
A. watches the nurse empty the ostomy bag
B. looks at the ostomy site
C. reads the ostomy product literature
D. practices cutting the ostomy appliance
90. The client with a new colostomy is concerned about odor from
stool in the ostomy drainage bag. The nurse should teach the client to
include which of the following foods in the diet to reduce odor?
A. yogurt C. cucumbers
B. broccoli D. eggs
91. The nurse is giving dietary instruction for the client who has a
new colostomy. The nurse encourages the client to eat foods
representing which of the following diets for the first 4 to 6 weeks
postoperatively?
A. high protein C. low calorie
B. high carbohydrates D. low residue
92. The nurse has given instructions to the client with an ileostomy
about foods to eat to thicken the stool. The nurse evaluates that the
client did not fully understand the instructions if the client stated that
eating which of the following foods makes the stool less watery?
A. pasta C. bran
B. boiled rice D. low-fat cheese
93. The client has just had surgery to create an ileostomy. The nurse
assesses the client in the immediate postoperatively period for which
of the following most frequent complications of this type of surgery?
A. intestinal obstruction
B. fluid and electrolyte imbalance
C. malabsorption of fat
D. folate deficiency
94. The client with acute pancreatitis is experiencing severe pain
from the disorder. The nurse teaches the client to avoid which of the
following positions that could aggravate the pain?
A. sitting up C. leaning forward
B. lying flat D. flexing the left leg
95. The nurse is evaluating the effect of dietary counseling on the
client with cholecystitis. The nurse evaluates that the client
understands the instructions given if the client stated that which of
the following food items is acceptable in the diet?
 A. baked scrod C. fried chicken 5. As the person grows older, the lens losses its elasticity, causing
B. sauces and gravies D. fresh whipped cream which kind of farsightedness?
96. The nurse assesses the client experiencing an acute episode of A. emmetropia
cholecystitis for pain that is located in the right: B. presbyopia
A. upper quadrant and radiates to the left scapula and shoulder C. diplopia (double vision)
B. upper quadrant and radiates to the right scapula and D. myopia
shoulder 6. If a person has a foreign object of unknown material that is not
C. lower quadrant and radiates to the umbilicus readily seen in one eye, what would the first action be?
D. lower quadrant and radiates to the back A. irrigate the eye with a boric acid solution
97. The client is beginning to show signs of hepatic B. examine the lower eyelid and then the upper eyelid
encephalopathy. The nurse plans a dietary consult to limit the amount C. irrigate the eye with opious amounts of water
of which of the following ingredients in the client’s diet? D. shield the eye from pressure, and seek medical help
A. fat 7. A sudden loss of an area of vision, as if a curtain were being
B. carbohydrates drawn, is a principal symptom of?
C. protein A. retinal detachment
D. minerals B. glaucoma
98. The client with Crohn’s disease has an order to begin taking C. cataracts
antispasmodic medication. The nurse should time the medication so D. keratitis (damage in cornea)
that each dose is taken: 8. Postoperative care following stapedectomy would not include
A. 30 minutes before meals which of the following
B. during meals A. out of bed as desired
C. 60 minutes after meals B. no moisture in the affected ear
D. upon arising and at bedtime C. avoid sneezing
99. The client with ulcerative colitis is diagnosed with mild case of D. no bending over or lifting
the disease. The nurse doing dietary teaching gives the client 9. Dimenhydrinate (Dramamine) is given after a stapedectomy
examples of foods to eat that represent which of the following A. to accelerate the auditory process
therapeutic diets? B. to dull the pain experienced with the semicircular canal is
A. high-fat with milk disturbed
B. high-protein without milk C. to minimize the sensations of equilibrium disturbances and
C. low-roughage without milk imbalance
D. low-roughage with milk D. to prevent an increase tendency toward nausea
100. It has been determined that the client with hepatitis has 10. A client with Meniere’s syndrome (idiopathicendolymphatic hydrops, is a
contracted the infection from contaminated food. What type of disorder of the inner ear. Although the cause is unknown, it probably results from an
hepatitis is this client most likely experiencing? abnormality in the fluids of the inner ear. ) is extremely uncomfortable
A. hepatitis A because of which of these?
B. hepatitis B A. severe earache
C. hepatitis C B. many perceptual difficulties
D. hepatitis D C. vertigo and resultant nausea
D. facial paralysis
11. What is the cataract of the eyes?
III A. opacity of the cornea
B. clouding of the aqueous humor
Situation: The head nurse of an eye and ear clinic is ordering nursing
C. opacity of the lens
students.
D. papilledema
1. Normal visual acuity as measured with a Snellen eye chart is
12. Treating a cataract primarily involves which of the following?
20/20. What does a visual acuity of 20/30 indicate?
A. instillation of miotics
A at 20 feet, an individual can only read letters large enough to
B. installation of mydriatics
be read at 30 feet
C. removal of the lens
B. at 30 feet, an individual can read letters large enough to be read
D. enucleation
at 20 feet
13. Preoperative instruction will not need to include
C. an individual can read 20 out of 30 total letters on the chart
A. type of surgery
D. an individual can read 30 out of 50 total letters on the chart at 20
B. how to use the call bell
feet
C. how to prevent paralytic illeus
2. Damage to the visual area of the occipital lobe of cerebrum, on the
D. how to prevent respiratory infetins
left side, would produce what type of visual loss?
14. In preparing to teach patient about adjustment to cataract lenses,
A. left eye only
the nurse needs to know that the lenses will.
B. right eye only
A. magnify objects by one-third- with central vision
C. medial half of the right eye and lateral half of the left eye
B. magnify objects by one-third with peripheral vision
D. medial half of the left eye and lateral half of the right eye
C. reduce objects by one-third with central vision
3. An anterior chamber of the eye refers to all the space in what area?
D. reduce objects by one-third with peripheral vision
A. anterior to the retina
15. In the immediate postoperative period the one action that is
B. between the iris and the cornea
contraindicated for patient compared with clients after most other
C. between the lens and the cornea
operations is which of the following?
D. between the lens and the iris
A. coughing
4. What condition results when rays of light are focused in front of
B. turning on the unoperative side
the retina?
C. measures to control nausea and vomiting
A. myopia (near sightedness)
D. eating after nausea passes
B. hyperopia (farsightedness)
16. Immediate nursing care following cataract extraction is directed
C. presbyopia (kind of farsightedness)
primarily toward preventing
D. emmetropia (normal)
 A. Atelectasis Situation: Roy, a 55-year-old man, is admitted to the hospital with
B. infection of the cornea wide-angle glaucoma
C. hemorrhage 26. What was the symptom that probably brought Roy to the
D. prolapse of the iris ophthalmologist initially?
17. The patient is confused during her first night after eye A. decreasing vision
surgery. What would the nurse do? B. extreme pain in eye
A. tell her to stay in bed C. redness and tearing of the eye
B. apply restraints to keep her in bed D. seeing colored flashes of light
C. explain why she cannot get out of bed, keep side rails up, and 27. The teaching plan for Roy would include which of the following?
check her frequently A. reduce fluid intake
D. sedate her B. add extra lighting in the home
18. Discharge teaching would probably not need to include C. wear dark glasses/during the day
A. staying in a darkened room as much as possible D. avoid exercise
B. avoiding alcoholic drinks,; limiting the use of tea and coffee 28. Miotics are used in the treatment of glaucoma. What is an
C. using no eye washes or drops unless they were prescribed by the example of a commonly used miotic (substance causes the constriction of the
physician pupil of the eye)?
D. avoiding being excessively sedentary A. atropine (mydriatic)
19. Patient also needs to be instructed to limit. B. pilocarpine
A. sewing C. acetazolamide (Diamox)
B. watching TV D. scopolamine
C. walking 29. What is the rationale for using miotics in the treatment of
D. weeding her garden (water) glaucoma?
Situation: Lea visit her ophthalmologist and receives a mydriatic drug A. they decrease the rate of aqueous humor production
in order to facilitate the examination. After returning home, she B. pupil constriction increases outflow of aqueous humor
experiences severe pain, nausea and vomiting, and blurred C. increased pupil size relaxes the ciliary muscles
vision. During a visit to the emergency room, a diagnosis of acute D. the blood flow to the conjunctiva is increased
glaucoma is made. 30. When instilling eye drops for a client with glaucoma, what
20. Lea’s glaucoma has been caused by the dilation of the pupil. procedure would the nurse follow?
A. blockage of the outflow of aqueous humor by the dilation of A. place the medication in the middle of the lower lid, and put
the pupil pressure on the lacrimal duct after instillation.
B. blockage of the outflow of aqueous humor by the constriction of B. Instill the drug to the outer angle of the eye, have client tilt head
the pupil back
C. increase intraocular pressure resulting from the increased C. instill the drug at the innermost angle; wipe with cotton away
production of aqueous humor from inner aspect
D. decrease intraocular pressure resulting from decrease production D. instill medication in middle eye, have client blink for better
of aqueous humor absorption
21. Intraocular pressure is measured clinically by tonometer. What 31. Carbonic anhydrase inhibitors are sometimes used in the
tonometer reading would be indicative of glaucoma? treatment of glaucoma because they:
A. pressure of 10 mmHg A. depress secretion of a aqueous humor
B. pressure of 15 mmHg B. dilate the pupil
C. pressure of 20 mmHg C. paralyze the power of accommodation
D. pressure of 25 mmHg D. increase the power of accommodation
22. Which cranial nerve transmits visual impulses? 32. Teaching a client with glaucoma will not include which of the
A. I (olfactory) following?
B. II (optic) A. vision can be restored only if the client remains under a
C. III (oculomotor) physician’s care
D. IV (abducens) B. avoid stimulant (eg., caffeine)
23. Untreated or uncontrolled glaucoma damages the optic C. take all medications conscientiously
nerve. Three of the following signs and symptoms result from optic D. prevent constipation and avid heavy lifting and emotional
nerve atrophy; which one does not? excitement
A. colored halos around lights 33. Glaucoma is a progressive disease that can lead to blindness. It
B. severe pain in the eye can be managed if diagnosed early. Preventive health teaching would
C. dilated and fixed pupils best include which of the points?
D. opacity of the lens A. early surgical action may be necessary
24. Glaucoma is conservatively managed with miotic eye B. all clients over 40 years of age should have an annual
drops. Mydriatic eye drops are contraindicated for glaucoma. Which tonometry exam
of the following drugs is a mydriatic (it dilates the pupil)? C. the use of contract lances in older clients is not advisable
A. neostigmine D. clients should seek early treatment for eye infections
B. pilocarpine 34. A client with progressive glaucoma may be experiencing sensory
C. physostigmatine deprivation. Which of the following actions would best minimize this
D. atropine problem?
25. Glaucoma may require surgical treatment. Preoperatively, the A. speak in a louder voice
client would be taught to expect which of the following B. ensure that a sedative is ordered
postoperatively? C. orient the client to time, place, and person
A. cough and deep-breathing qh. D. use touch frequently when providing care
B. turn only to the unaffected side Situation: 5-Gary is seen in the emergency room with the diagnosis
C. medication for severe eye pain of epitaxis.
D. restriction of fluids for the first 24 hours 35. It is unlikely that Gary’s history will include
A. minor trauma to the nose
 B. a deviated septum
C. acute sinusitis
D. hypotension
36. Which of the following medications would be used with in order
to promote vasoconstriction and control bleeding?
A. epinephrine
B. lidocaine
C. pilovarpine
D. cylospentolate
37. Which of the following positions would be most desirable for
Gary?
A. trendelenburg’s to control shock
B. a sitting position, unless he is hypotensive
C. side-lying, to prevent aspiration
D. prone, to prevent aspiration
38. The physician decides to insert nasal packing. Of the following
nursing actions, which would have the highest priority?
A. encourage Gary to breath through his mouth, because he may feel
panicky after the insertion.
B. advice Gary to expectorate the blood in the nasopharynx gently
and not to swallow it
C. periodically check the position of the nasal packing, because
airway obstruction can occur if the packing accidentally slip
out of place
D. take rectal temperature, because he must rely on mouth breathing
and would be unable to keep his mouth closed on the thermometer.
39. After bleeding has been controlled, Gary taken to surgery to
correct a deviated nasal septum. Which of the following is likely
complication of this surgery?
A. loss of the ability to smell
B. inability to breath through the nose
C. infection
D. hemorrhage
40. Upon his discharge, the nurse instructs Gary on the use of
vasoconstrictive nose drops and cautions him to avoid too frequent,
and excessive use to these drugs, which of the following provides the
best rationale for this caution
A. A rebound effect occurs in which stuffness worsens after each
successive dose
B. cocaine, a frequent ingredient in nose drops, may lead to
psychological addiction
C. these medications may be absorbed systematically, causing severe
hypotension
D. persistent vasoconstriction of the nasal mucosa can lead
to alterations in the olfactory nerve
Situation: Brix had redial and neck surgery for cancer of the larynx.
41. Brix has tracheostomy. When suctioning through laryngectomy
tube . When doing these two
procedures at the same time, the nurse would not do which of the ff:
A. Use sterile technique
B. turn head to right to suction left bronchus
C. suction for no longer then 10 to 15 seconds
D. observe for tachycardia
42. Brix requires both nasopharyngeal suctioning and suctioning
through laryngectomy tube. When doing these two procedures at the
same time, the nurse would not do which of the ff:
A. use a sterile suction setup
B. suction the nose first, then the laryngectomy tube
C. suction the laryngectomy tube first, then the nose
D. lubricate the catheter with saline
43. A nasogastric tube is used to provide Brix with fluids and
nutrient for approximately 10 days, for which of the following
reasons?
A. to prevent pain while swallowing
B. to prevent contamination of the suture line
C. to decrease need for swallowing
D. to prevent need for holding head up to ear
44. Brix’s children are concerned about their own risk of developing
cancer. All but one of the following are facts that describe malignant
neoplasia and must be considered by the nurse in her
responses. Which one is correct?
A. family factors may influence an individual’s susceptibility to
neoplasia
B. long-term use of corticosteroids enhances the body’s defense
C. Sexual differences influence an individuals susceptibility to
specific neoplasm
D. living in industrialized areas increase an individual’s
susceptibility to a malignant neoplasm
45. When would Brix best begin speech rehabilitation?
A. when he leaves the hospital
B. when the esophageal suture line is healed
C. three months after surgery
D. when he regains all his strength
46. The nurse is complaining the initial morning assessment on the
client. Which physical examination technique would be used first
when assessing the abdomen?
A. inspection
B. light palpation
C. auscultation
D. percussion
47. The client has orders for a nasogastric (NG) tube
insertion. During the procedure, instruction that will assist in
insertion would be:
A. instruct the client to tilt his head back for insertion into the
nostril, then flex his neck for final insertion
B. after insertion into the nostril, instruct the client to extend his
neck
C. introduce the tube with the client’s head tilted back, then instruct
him to keep his head upright for final insertion
D. instruct the client to hold his chin down, then back for insertion of
the tube
48. The most important pathophysiologic factor contributing to the
formation of esophageal varices is:
A. decreased prothrombin formation
B. decreased albumin formation by the liver
C. portal hypertension
D. increased central venous pressure
49. The nurse analyzes the results of the blood chemistry tests done
on a client with acute pancreatitis. Which of the following results
would the nurse expect to find?
A. low glucose
B. low alkaline phosphatase
C. elevated amylase
D. elevated creatinine
50. A client being treated for esophageal varices has a Sengstaken-
Blakemore tube inserted to control the bleeding. The most important
assessment is for the nurse to:
A. check that a hemostat is at the bedside
B. monitor IV fluids for the shift
C. regularly assess respiratory status
D. check that the balloon is deflated on a regular basis
51. A female client complains of gnawing (bite/chew) midepigastric D. 1 inch
pain for a few hours after meals. At times, when the pain is severe, 61. Following a liver biopsy, the highest priority assessment of the
vomiting occurs. Specific tests are indicated to rule out: client’s condition is to check for:
A. cancer of the stomach A. pulmonary edema
B. peptic ulcer disease B. uneven respiratory pattern
C. chronic gastritis C. hemorrhage
D. pylorospasm D. pain
52. When a client has peptic ulcer disease, the nurse would expect a 62. A client has a bile duct obstruction and is jaundiced. Which
priority intervention to be: intervention will be most effective in controlling the itching
A. assisting in inserting a Miller-Abbott tube associated with his jaundice?
B. assisting in inserting an atrial pressure line A. keep the client’s nails clean and short
C. inserting a nasogastric tube B. maintain the client’s room temperature at 72 to 75 deg. F
D. inserting an IV C. provide tepid water for bathing
53. A 40-year-old male client has been hospitalized with peptic ulcer D. use alcohol for back rubs
disease. He is being treated with a histamine receptor antagonists 63. When a client is in liver failure, which of the following
(cimetidine), antacids, and diet. The nurse doing discharge planning behavioral changes is the most important assessment to report?
will teach him that the action of cimetidine is to: A. shortness of breath
A. reduce gastric acid output B. lethargy
B. protect the ulcer surface C. fatigue
C. inhibit the production of hydrochloric acid (HCl) D. nausea
D. inhibit vagal nerve stimulation 64. A client with a history of cholecystitis is now being admitted to
54. The nurse is admitting a client with Crohn’s disease who is the hospital for possible surgical intervention. The orders include
scheduled for intestinal surgery. Which surgical procedure would the NPO, IV therapy, and bed rest. In addition to assessing for nausea,
nurse anticipate for the treatment of this condition: vomiting and anorexia, the nurse should observe for pain:
A. ileostomy with total colectomy A. in the right lower quadrant
B. sigmoid colostomy with mucous fistula B. after ingesting food
C. intestinal resection with end-to-end anastomosis C. radiating to the left shoulder
D. colonoscopy with biopsy and polypectomy D. in the upper quadrant
55. A client who has just returned home following ileostomy surgery 65. The nurse taking a nursing history from a newly admitted client
will need a diet that is supplemented: learns that he has a Denver shunt. This suggest that he has a history
A. potassium of:
B. vitamin B12 A. hydrocephalus
C. sodium B. renal failure
D. fiber C. peripheral occlusive disease
56. A client scheduled for colostomy surgery. An appropriate D. cirrhosis
preoperative diet will include: 66. A female client had a laparoscopic cholecystectomy this
A. broiled chicken, baked potato, and wheat bread morning. She is now complaining of right shoulder pain. The nurse
B. ground hamburger, rice, and salad would explain to the client this symptom is:
C. broiled fish, rice, squash, and tea (deodorant) A. common following this operation
D. steak, mashed potatoes, raw carrots, and celery B. expected after general anesthesia
57. As the nurse is completing evening care for a client, he observes C. unusual and will be reported to the surgeon
that the client is upset, quiet, and withdrawn. The nurse knows that D. indicative of a need to use the incentive spirometer
the client is scheduled for diagnostic tests the following day. An 67. For a client with the diagnosis of acute pancreatitis, the nurse
important assessment question to ask the client is: would plan for which critical component of his care?
A. “would you like to go to the dayroom to watch TV?” A. testing for Homan’s sign
B. “are you prepared for the test tomorrow?” B. measuring the abdominal girth
C. “have you talked with anyone about the test tomorrow?” C. performing a glucometer test
D. “have you asked your physician to give you a sleeping pill D. straining the urine
tonight?” 68. After removing a fecal impaction, the client complains of feeling
58. Following abdominal surgery, a client complaining of “gas pains” lightheaded and the pulse rate is 44. The priority intervention is:
will have a rectal tube inserted. The client should be positioned on A. monitoring vital signs
his: B. place in shock position
A. left side, recumbent C. call the physician
B. left side, sims D. begin CPR
C. right side, semi-fowler’s 69. Peritoneal reaction to acute pancreatitis results in a shift of fluid
D. left side, semi-Fowler’s from the vascular space into the peritoneal cavity. If this occurs, the
59. Which of the following statements is most correct regarding nurse would evaluate for:
colostomy irrigations? A. decreased serum albumin
A. the solution temperature should be 100 deg. F B. abdominal pain
B. 1000 ml/1L is the usual amount of solution for the irrigation C. oliguria
C. the solution container should be placed 10 inches above the stoma D. peritonitis
D. the irrigation cone is inserted in an upward direction in relation to 70. The assessment finding should be reported immediately if it
the stoma develop in the client with acute pancreatitis which is:
60. The nurse is teaching a client with a new colostomy how to apply A. nausea and vomiting
an appliance to a colostomy. How much skin should remain exposed B. abdominal pain
between the stoma and the ring of the appliance? C. decreased bowel sounds
A. 1/8 inch D. shortness of breath
B. ½ inch 71. Following brain surgery, the client suddenly exhibits polyuria and
C. ¾ inch begins voiding 15 to 20 L/day. Specific gravity of the urine is
1.006. The nurse will recognize these symptoms as the possible
development of:
A. diabetes insipidus
B. diabetes, type 1
C. diabetes, type 2
D. Addison’s disease
72. A person with a diagnosis of adult Diabetes, type 2, should
understand the symptoms of a hyperglycemic reaction. The nurse will
know this client understands if she says these symptoms are:
A. thirst, polyuria and decreased appetite
B. flushed cheeks, acetone breath, and increased thirst
C. nausea, vomiting and diarrhea
D. weight gain, normal breath and thirst
73. The non-insulin dependent diabetic who is obese is best
controlled by weight loss because obesity:
A. reduces the number of insulin receptors
B. causes pancreatic islet cell exhaustion
C. reduces insulin binding T receptor sites
D. reduces pancreatic insulin production
74. A nursing assessment for initial signs of hypoglycemia will
include:
A. Pallor, blurred vision, weakness, behavioral changes
B. frequent urination, flushed face, pleural friction rub
C. abdominal pain, diminished deep tendon reflexes, double vision
D. weakness, lassitude, irregular pulse, dilated pupils
75. Which of the following nursing diagnosis would be most
appropriate for the client with decreased thyroid function:
A. alteration in growth and development related to increased growth
hormone production
B. alteration in thought processes related to decreased neurologic
function
C. fluid volume deficit related to polyuria
D. hypothermia related to decreased metabolic rate
76. The RN should assess for which of the following clinical
manifestations in the client with Cushing’s syndrome?
A. hypertension, diaphoresis, nausea and vomiting
B. tetany, irritability, dry skin and seizures
C. unexplained weight gain, energy loss, and cold intolerance
D. water retention, moon face, hirsutism and purple striae
77. The client hyperparathyroidism should have extremities handled
gently because:
A. decreased calcium bone deposits can lead to pathologic
fractures
B. edema causes stretched tissue to tear easily
C. hypertension can lead to stroke with residual paralysis
D. polyuria leads to dry skin and mucous membrane that can
breakdown
78. Which of the following priority nursing implementation for a
client with a tumor of the posterior lobe of the pituitary gland who
has had a urine output of 3 L in the last hour with a specific gravity of
1.002?
A. measure and record vital signs each shift
B. turn client every 2 hours to prevent skin breakdown
C. administer Pitressin Tannate as ordered
D. maintain a dark and quiet room
79. A client has a diagnosis of diabetes. His physician has ordered
short and long acting insulin. When administering two type of
insulin, the nurse would:
A. withdraw the long acting insulin into the syringe before the short
acting insulin
B. withdraw the short acting insulin into the syringe before the
long acting insulin
C. draw up in two separate syringes, then combine in one syringe
D. withdraw long acting insulin, inject air into regular insulin, and
withdraw insulin
80. Certain physiological changes will result from the treatment for
myxedem. The symptoms that may indicate adverse changes in the
body that the nurse should observe for are:
A. increased respiratory excursion
B. increased the frequency of rest periods
C. initiate postural drainage
D. continue with routine nursing care
81. A client with myxedema has been in the hospital for 3 days. The
nursing assessment reveals the following clinical
manifestations: respiratory rate 8/min, diminished breath sounds in
the right lower lobe, crackles in the left lower lobe. The most
appropriate nursing intervention is to:
A. increased the use of ROM, turning, deep breathing exercises
B. increased the frequency of rest periods
C. initiate postural drainage
D. continue with routine nursing care
82. In an individual with the diagnosis of hyperparathyroidism, the
nurse will assess for which primary symptom:
A. fatigue, muscular weakness
B. cardiac arrhytmias
C. tetany
D. constipation
83. The nurse explains to a client who has just received the diagnosis
of type 2 non-insulin dependent diabetes mellitus (NIDDM) that
sulfonylureas, one group of oral hypoglycemic agents, as act by:
A. stimulating the pancreas to produce or release insulin
B. making the insulin that is produce more available for use
C. lowering the blood sugar by facilitating the uptake and utilization
of glucose
D. altering both fat and protein metabolism
84. A client has been admitted to the hospital with a tentative
diagnosis of adrenocortical hyperfucntion. In assessing the client, an
observable sign the nurse would chart is:
A. butterfly rash on the face
B. moon face
C. positive Chvostek’s sign
D. bloated extremities
85. The nurse is teaching a diabetic client to monitor glucose using a
glucometer. The nurse will know the client is competent in
performing her finger-stick to obtain blood when she:
A. uses a ball of a finger as the puncture site
B. uses the side of fingertip as the puncture site
C. avoid using the fingers of her dominant hand as puncture sites
D. avoid using the thumbs as puncture sites
86. A client is scheduled for a voiding cystogram. Which nursing
intervention would be essential to carry put several hours before the
test?
A. maintain NPO status
B. medicating with urinary antiseptics
C. administering bowel preparations
D. forcing fluids
87. A retention catheter for a male client is correctly taped if it is:
A. on the lower abdomen
B. on the umbilicus
C. under the thigh
D. on the inner thigh
88. A client with a diagnosis of gout will betaking colchicines and
allopurinol BID to prevent recurrence. The most common early sign
of colchicines toxicity that the nurse assess for is:
A. blurred vision
B. anorexia
C. diarrhea
D. fever
89. A client’s laboratory results have been returned and the creatinine
level is 7 mg/dl. This finding would lead the nurse to place the
highest priority on assessing:
A. temperature
B. intake andoutput
C. capillary refill
D. pupillary reflex
90. After the lungs, the kidneys work to maintain body pH. The best
explanation of how the kidneys accomplish regulation of pH is that
they:
 A. secrete hydrogen ions and sodium
B. secrete ammonia
C. exchange hydrogen and sodium in the kidney tubules
D. decrease sodium ions, hold on to the hydrogen ions, and then
secrete sodium bicarbonate
91. Conditions known to predispose to renal calculi formation
include:
A. Polyuria
B. dehydration, immobility
C. glycosuria
D. presence of an indwelling Foley catheter
92. the most appropriate nursing intervention, based on physician’s
orders, for treating metabolic acidosis is to:
A. replace potassium ions immediately to prevent hypokalemia
B. administer oral sodium bicarbonate to act as a buffer
C. administer IV cathecholamines (Levophed) to prevent
hypertension
D. administer fluids to prevent dehydration
93. IV is attached to a controller to maintain the flow rate. If the
alarm sounds on the controller:
A. ensure that drip chamber is full
B. assess that height of IV container is at least 30 inches above
venipuncture site
C. ensure that the drop sensor is properly placed on the drip chamber
D. evaluate the needle and IV tubing to determine if they are patent
and positioned appropriately
94. A 76-year-old woman who has been in good health develops
urinary incontinence over a period of several days and is admitted to
the hospital for a diagnostic workup. The nurse would assess the
client for other indicators of:
A. renal failure
B. urinary tract infection
C. fluid volume excess
D. dementia
95. A 60-year-old male client’s physician schedules a prostatectomy
and orders a straight urinary drainage system to be inserted
preoperatively. For the system to be effective, the nurse would:
A. coil the tubing above the level of the bladder
B. position the collection bag above the level of the bladder
C. check that the collection bag is vented and distensible
D. determine that the tubing is less that 3 feet in length
96. During a retention catheter insertion or bladder irrigation, the
nurse must use:
A. sterile equipment and wear sterile gloves
B. clean equipment and maintain surgical asepsis
C. sterile equipment and maintain medical asepsis
D. clean equipment and technique
97. The physician has ordered a 24 hours urine specimen. After
explaining the procedure to the client, the nurse collects the first
specimen. This specimen. This specimen is the:
A. discarded, then collection begins
B. saved as part of the 24 hours collection
C. tested, then discarded
D. placed in a separate container and later added to collection
98. The most common cause of bladder infection in the client with a
retention catheter is contamination:
A. due to insertion technique
B. at the time of the catheter removal
C. of the urethral/ catheter interface
D. of the internal lumen of the catheter
99. A client in acute renal failure receive an IV infusion of 10 percent
dextrose in water with 20 units of regular insulin. The nurse
understands that the rational for this therapy is to:
A. correct the hyperglycemia that occurs with acute renal failure
B. facilitate the intracellular movement of potassium
C. provide calories to prevent tissue catabolism and azotemia
D. force potassium into cells to prevent arrhythmias
100. A client with chronic renal failure is on continuous ambulatory
peritoneal dialysis (CAPD). Which nursing diagnosis should have the
highest priority?
A. powerlessness
B. high risk for infection
C. altered nutrition: less than body requirements
D. high risk for fluid volume deficit\
IV
AM-CARE Review Academy for Nurses
Room 301 3rd Floor P & J Lim Bldg.
Tiano Brothers Kalambaguhan Sts., Cagayan de Oro City
Tel. No. (08822) 721-805
NLE DECEMBER 2005
MEDICAL SURGICAL NURSING IV
Situation: John Lee is an 18-year old high school student who
suffered an injury to his cervical spine in a football game.
1. In directing emergency care until the ambulance arrives, it is most
important that the school nurse
A. place a small makeshift pillow under his head
B. check to see if he can move all of his extremities
C. keep him flat and immobilized in a natural position
D. cover him with a blanket
2. A primary goal of nursing care when John is brought into the
emergency room will be
A. prevention of spinal shock
B. maintenance of respiration
C. maintenance of orientation
D provision for pain relief
Situation: Crutchfield tongs are used to apply traction to realign the
spinal cord.
3. A nursing measure for john while he is in cervical traction should
be to
A. massage the back of his head
B. position him from side to side
C. remove the weights at least once a shift
D. encourage involvement in his own care
Situation: John is found to have a temperature of 36ºC (96.8ºF).
4. The most appropriate initial nursing measure for John in response
to his hypothermia would be to
A. cover him with additional blankets
B. place a hot-water bottle at his feet
C. check for signs of shock
D. notify his physician
Situation: John has a tracheostomy performed and is on assisted
ventilation.
5. The alarm on the ventilator sounds. The initial response by the
nurse should be to quickly
A. notify the respiratory therapist
B. check all connections from the respirator
C. notify the respiratory therapist to come immediately
D. use a self-inflating bag to ventilate John
6. When suctioning John, the nurse should
A. ensure that he is able to take a breath between insertions of
the catheter
B. suction him for at least 30 seconds with each catheter insertion
C. apply suction and gently rotate the catheter while inserting it
into the bronchial bifurcation
D. use clean technique during the suction procedure
7. John suddenly becomes diaphoretic, his blood pressure rises to
190/110, and he complains of a headache. The nurse should assess
the patient for signs of
A. increased intracranial pressure
 B. spinal meningitis
C. pulmonary congestion
D. fecal impaction
8. Upon admission John had a complete loss of motor ability. Within
48 hours he is noted to be having muscle spasms. His family
becomes very excited when they notice these movements. Which of
the following choices would be the most appropriate response by the
nurse?
A. at this stage, muscle spasms are expected, but it is too soon to
evaluate the extent of the injury or its permanent effects
B. I can understand your excitement. These movements are a
good sign that he is making progress
C. these movements are an indication that he is trying to move
and that his will is very strong
D. these movements are reflex activities that indicate that his
spinal cord is intact
Situation: Mark Richards has a compound fracture of the temporal
bone.
9. The nurse notices bleeding from the orifice of the ear. Which of
the following actions by the nurse can be safely used to determine if
the drainage contains cerebrospinal fluid (CSF)? The nurse should
A. swab the orifice of the ear with sterile applicator and send the
specimen to the laboratory
B. blot the drainage with a sterile gauze pad and look for a
clear halo or ring around the spot of blood
C. gently suction the ear an send the specimen to the laboratory
D. test the CSF with a Tes-Tape and get a negative reading for
sugar
10. The nursing care plans states “Observe for early signs of
increased intracranial pressure (IIP).” Early symptoms of IIP include
A. widening pulse pressure and dilated pupils
B. rising blood pressure and bradycardia
C. elevated temperature and decerebrate posturing
D. nausea, vomiting, and restlessness
11. During the initial period after a head injury, nursing intervention
for Mr. Richards should include
A. packing the ear with cotton balls to stop bleeding
B. awakening the patient every 2 hours to determine his level
of consciousness
C. placing the patient in Trendelenburg’s position
D. forcing fluids to restore hydration
12. Before discharge, a computerized axial tomogram will be
performed to rule out any intracranial or extracranial bleeding. Mr.
Richards should be told that
A. the procedure is noninvasive and he will not feel any pain
B. he will experience a burning sensation as the dye is being
injected
C. the procedure is done in the operating room under anesthesia
D. local anesthetic is used before injecting air into the ventricles
of the brain via the spinal canal
Situation: Tonnie Miccio is a 43-year old divorced man who has been
rushed to the emergency room with an acute gouty arthritis.
13. While admitting Mr. Miccio to the hospital, the nurse should
recognize those factors that can precipitate an acute attack. They
include
A. excessive smoking
B. large alcohol intake
C. emotional stress
D. improper rest
14. A serum uric acid level is performed by the hospital laboratory. In
acute gout, the uric acid level is approximately
A. 1.0 mg/100 ml
B. 2.1 mg/100 ml
C. 6.5 mg/100 ml
D. 10 mg/100 ml
15. Colchicine is the standard drug used to treat acute gout: The
physician orders colchicines, 1.0 mg every 2 hours. After receiving
the third dose, the patient complains of nausea, vomiting, and
diarrhea. The nurse should recognize that this is
A. a transient side effect and give the next dose
B. a sign of toxicity and withhold the medication
C. an allergic response to the drug and notify the physician
D. a psychogenic response to the severe pain
16. The expected outcome for colchicine is to
A. reduce uric acid levels
B. relieve joint pain and inflammation
C. increase blood flow to the kidney
D. detoxify purines in the liver
17. During the night, Mr. Miccio complains of severe pain in his toe
and asks the nurse for 2 aspirin tablets. The nurse should
A. give the patient the 2 aspirin tablets
B. elevate the foot on a pillow
C. notify the physician
D. offer the patient a cup of tea
18. Some physicians prescribe an alkali-ash diet to enhance the effect
of the medications. Which of the following foods are allowed?
A. liver, shellfish, and fats
B. cranberries, cheese, and whole grain cereals
C. milk, vegetables, and most fruits
D. eggs, milk, prunes, and plums
19. After the acute attack subsides, the physician orders allopurinol
(Zyloprim), 300 mg/day. The expected outcome for this drug is to
A. lower the plasma and urinary uric acid level
B. reduce inflammation of the affected joints
C. produce diuresis
D. relieve pain
20. A teaching program for Mr. Miccio should include
A. emphasizing that aspirin is contraindicated in patient’s taking
allopurinol
B. restricting fluid intake to 1,000 ml/day
C. explaining that acute gouty attacks often occur during
initiation of allopurinol therapy
D. stating that a low-purine diet should be followed while taking
allopurinol
21. About 2 months after taking the allopurinol, Mr. Miccio develops
a skin rash. The nurse should
A. recognize this as a minor side effect that will subside
B. ask the patient if he has been taking any aspirin while taking
the allopurinol
C. recognize this is an indication to discontinue the drug
D. be aware that concomitant use of colchicines with allopurinol
causes this reaction
22. One day, Jennifer asks her roommate, Erin, how her scoliosis was
first recognized. Erin replies, “The school health nurse told me that
there may be a problem after all the girls in my class were asked to
stand erect while she examined our backs.” The nurse suspected
scoliosis when she observed that Erin’s shoulder on one side was
elevated and her
A. head appeared aligned to the opposite side
B. leg on the same side appeared shorter
C. hip on the opposite side appeared prominent
D. arm on the same side appeared longer
23. When Erin’s scoliosis was diagnosed after x-ray examination of
her spine, she was fitted with a Milwaukee brace. Erin asks the nurse
when it could be removed each day. Which of the following would
be the best response?
A. only when you are lying flat, either resting or sleeping
B. for 1 hour a day when you bathe, shower, or go swimming
C. only for special occasions, such as a party
D. for 3 hours a day: one in the morning, one in the afternoon,
and one in the evening
Situation: Erin’s admission to the hospital for spinal fusion was
necessary because hr scoliosis did not respond to the Milwaukee
brace.
24. Preoperative preparation for Erin includes explaining that for 2
weeks after surgery she will be positioned
A. on either side or prone
B. sitting upright
 C. flat and will be logrolled
D. on her back
25. When Erin is told that after surgery she will wear a body cast for
about 1 year, she begins to sob. She tells the nurse she will look like
a football player, not a girl. Which of the following is the best
response the nurse can make?
A. the people who really care about you won’t even notice your
cast
B. it only will be for a year. You’re mature enough to wait
C. just ignore any comments that people make
D. a pretty hairstyle and some loose peasant blouses will keep
you looking feminine
26. After surgery, the nurse applies slight pressure to Erin’s toes and
asks Erin is he can feel her foot being touched. Erin replies, “No, I
don’t feel anything.” The nurse should then
A. wait 1 hour and supply pressure again
B. record Erin’s expected response
C. ask Erin if her toes feel cold
D. report Erin’s response to the surgeon
Situation: Virginia K is a 25- year old woman who works as a
lifeguard at the local beach. On her way to work she is in an
automobile accident and is rushed to the hospital by
ambulance. A diagnosis of complete transaction of the spinal cord at
the third lumbar (L3) level is made.
27. While assess Ms. K for neurologic function, the nurse can expect
she will be unable to
A. shrug her shoulders
B. tighten her abdominal muscles
C. bend her elbow
D. straighten her legs
28. Long-term goals for Ms. K include developing skills in
A. performing wheelchair ambulation
B. activating an electric wheelchair
C. walking with leg braces and crutches
D. walking without aids
29. observing for symptoms of which of the following is the priority
of care for Ms. K in the acute stages of complete transaction of the
lumbar cord?
A. spinal shock
B. respiratory insufficiency
C. autonomic hyperreflexia
D. hypertensive crisis
30. To prevent the complication of urinary tract infections, which of
the following measures should be included in the nursing care plan?
A. encouraging extra fluid intake
B. offering at least two servings of citrus fruit juice per day
C. telling the patient to avoid fruit juices such as plum, prune, and
cranberry
D. notifying the dietician to include a container of milk at all
meals
Situation: Jim, a 17-year old senior in high school, has sustained a
simple fracture of the mandible after falling from his motorbike.
31. Upon admission to the emergency room, which of the following
choices should the nurse expect to observe?
A. bleeding in the external auditory canal
B. dropped prominence of the cheek on the affected side
C. edema of the eyes and cheeks
D. teeth unevenly lined up
Situation: An open reduction with wiring of the lower jaw to the
upper jaw has been done by the surgeon.
32. In anticipating the postoperative needs o the patient, which of the
following actions has the priority for Jim?
A. placing paper and pencil at the bedside
B. providing a tracheostomy set for tracheostomy care
C. taping a wire cutter to the head of the bed
D. inserting a gauze wick in the inside of the cheek
33. While teaching Jim mouth care the nurse should
A. show him how to use moistened gauze sponges to clean his
mouth and tongue
B. demonstrate how an oral irrigation can be performed by
inserting the catheter along the inside of the mouth between the
teeth and the cheek
C. explain to him that mouth care should not be done until the
wires are removed
D. tell him to use an astringent mouthwash to remove all the
debris
Mrs. Marian H is a 50-year old woman who has a spinal cord lesion
at the fourth thoracic (T4) vertebra.
34. When there are lesions above T4 and T6, the patient may
experience autonomic hyperreflexia. This condition can be prevented
by
A. avoiding bladder distention
B. changing the patient’s position hourly
C. wearing supportive elastic hose
D. doing a neurologic check
35. Mrs. H complains of severe headache and is extremely
anxious. The nurse checks her blood pressure and finds it is
210/110. The nurse should then
A. check the patency of the urinary catheter
B. apply ice packs to her head
C. place the patient in a flat position
D. sit with the patient until the symptoms subside
Situation: Dorothy C, RN, age 35, is at work. After moving a
particularly heavy patient, she suddenly develops severe pain in the
lumbosacral area that radiates down her right leg. The preliminary
diagnosis is rupture of an intervertebral disk.
36. Proper body mechanics may have prevented this injury to Ms.
C. If she had adhered to the correct method of turning a patient from
the supine position to the left side, she would have crossed the
patient’s right arm over chest, and crossed the right leg over the left
leg. Then, while standing with her feet
A. together at the patient’s right side, she would gently turn the
patient by pushing at the shoulder and sacral areas
B. apart at the right side of the bed, she would turn the patient by
gently pushing at the shoulder and center of the back
C. apart at the left side of the bed, she would gently roll the
patient toward her while keeping her legs straight
D. apart at the left side of the bed, she would gently roll the
patient toward her while flexing her knees
37. Instructions for Ms. C’s recuperation at home should include the
use of a bed board, firm mattress, and rest in which of the following
positions?
A. completely flat in bed
B. head elevated on a pillow, and knees and feet elevated with
pillows
C. head elevated with several pillows, and her legs flat
D. Head elevated with several pillows, and several pillows under
her knees
38. Ms. C should be reminded that if she is turning on her side, it is
best if she
A. grasps a chair leg by the side of the bed, and slowly pulls
herself over, flexing the uppermost knee
B. keeps her legs extended while crossing them to the side to
which she is turning, and then uses her
arms to help turn the upper portion of her body
C. crosses her arms, flexes the uppermost knee toward the side
to which she is turning, and then rolls over
D. crosses her arms, crosses her legs while they are extended to
the side toward which she is turning,
and then rolls over
39. The physician gives Ms. C a prescription for methocarbamol
(Robaxin). Because of her nursing background, Ms. C will know that
the mediation is having the desired effects if which of the following
occurs?
A. She feels drowsy, and is sleeping more
B. she has a feeling of euphoria
C. there is a decrease in muscle spasms
 D. there is an increase in the knee-jerk reflex
Situation: After a week of bed rest at home, Ms. C’s condition
remains about the same. She is admitted to the hospital for further
treatment and diagnostic tests.
40. Phenylbutazone (Butazolidin) is ordered for Ms. C. Planning for
the administration of this medication should include directions to
A. administer it immediately before or after eating
B. avoid administering it with dairy products
C. administer it at least 2 hours after eating
D. administer it at specific time intervals, without regard to meals
41. In addition to the order for phenylbutazone, Ms. C is placed on
bed rest and in pelvic traction. To diminish adverse responses to this
treatment, the nurse should request an order for
A. acetylsalicylic acid (aspirin)
B. diphenoxylate hydrochloride (Lomotil)
C. prochlorpeazine (Compazine)
D. dioctyl sodium sulosuccinate (Colace)
42. A myelogram is performed on Mrs. C with a water-soluble
contrast medium. Care after this procedure should include
A. limiting fluid intake and elevating the head of the bed to 15 to
30 degrees
B. not allowing anything by mouth and keeping the bed flat
C. encouraging fluid intake and keeping the bed flat
D. encouraging fluid intake and raising the head of the bed to
15 to 30 degrees
43. Ms. C has a laminectomy. Postoperatively, she complains that the
pain is no different now than it was before surgery. The nurse should
A. administer analgesics as ordered, and explain that the pain
is to be expected because of the edema that results from the
surgery
B. administer the analgesics as ordered, but request that the
physician check the patient immediately
C. withhold the analgesic and notify the physician
D. administer the analgesics as ordered, and tell Ms. C it will give
her relief shortly
44. Rehabilitation will be facilitated if Ms. C is encouraged to do
which of the following?
A. sleep in prone position
B. sit up for at least part of he day
C. perform abdominal-strengthening exercise
D. perform full trunk range-of-motion exercises
Situation: Martha S is a 27-year old patient who has experienced
increasing generalized stiffness, especially in the morning, fatigue,
general malaise, and swelling and pain in the finger joints. She has a
tentative diagnosis of rheumatoid arthritis.
45. Upon admission, Mrs. S is noted to have a rectal temperature of
37.7ºC (100ºF). A white blood count is ordered, and the report
comes back at 8,500/mm³. The nurse should recognize this as being
consistent with rheumatoid arthritis because it is
A. within normal limits
B. evidence of leukopenia
C. only slightly elevated
D. indicative of a generalized infectious process
46. Which of the following blood-analysis tests would be consistent
with diagnosis of rheumatoid arthritis?
A. an elevated erythrocyte sedimentation rate and negative C-
reactive protein
B. an elevated erythrocyte sedimentation rate and positive C-
reactive protein
C. a low erythrocyte sedimentation rate and negative C-reactive
protein
D. a low erythrocyte sedimentation rate and positive C-reactive
protein
47. The primary goal of nursing care for Mrs. S during this initial
acute phase of rheumatoid arthritis should be to
A. prevent deformity and reduce inflammation
B. prevent the spread of the inflammation to other joints
C. provide for comfort and relief of pain
D. assist her to accept the fact that rheumatoid arthritis is a log-
term illness
48. During hospitalization, the nurse should explain to Mrs. Samuel
that analgesics of choice would be
A. codeine
B. acetylsalicylic acid (aspirin)
C. acetaminophen (Tylenol)
D. proppoxyphene hydrochloride (Darvon)
49. During the acute phase of Mrs. S’s illness, which of the following
measures would be the most appropriate?
A. frequent periods of active exercises
B. frequent periods of bed rest
C. rest for he affected joints only
D. encouragement to perform activities of daily living
independently
50. The nurse understands that the main nursing goal in helping Mrs.
S adapt to her chronic illness and plan is to
A. provide the care she is unable to give herself
B. provide guidance so that she will not repress her illness
C. plan for social contacts so that she will not feel alone
D. arrange for her after-care with the home health aide
51. Mrs. S is given instructions for using paraffin for her hands. The
nurse should include the fact that the dips will be most effective if
they are performed
A. before exercising her hands
B. after exercising her hands
C. instead of exercising her fingers
D. while exercising her fingers
52. Whenever Mrs. S feels pain from her arthritis, she tells the nurse
she feels not only the pain but that her “whole body feels
threatened.” Which response by the nurse is the most therapeutic?
A. I will have someone stay with you so you won’t harm yourself
B. I will teach you some relaxing exercises so you won’t be so
tense
C. you must have some medication to help you gain control
D. arthritic pain will lessen if you try to grin and bear it
53. When Mrs. S is discharged, she is instructed to take aspirin at
home. It is important that she be told to take the drug
A. on a regular basis throughout the day
B. only when other measures are not effective
C. upon arising and again at bedtime
D. between meals to promote its absorption
54. When Mrs. S is discharged, the nursing staff refers her to a nurse
therapist who will assist her in dealing with the anxiety over her
arthritis and the changes it has made in her life. The nursing team
recognizes that the role of the nurse therapist is to
A. work in conjunction with a psychiatrist
B. provide individual nursing psychotherapy
C. lead groups in therapy for those with similar problems
D. give family nursing psychotherapy
Situation: Twenty years after Mrs. S was first diagnosed with
rheumatoid arthritis, she is admitted for a right total hip
replacement. She has experienced severe right hip pain that has not
responded to treatment for several years, and has had increasing
difficulty moving about because of damage to the right hip joint.
55. Preoperative teaching for Mrs. S should include
A. isometric exercises of the quadriceps and gluteal muscles
B. instructions on the necessity for keeping the right leg perfectly
straight after surgery
C. the need to flex the involved hip postoperatively to maintain
mobility
D. the avoidance of aspirin for 4 days prior to surgery
56. Which of the following should the nurse consider to be most
significant if noted when checking Mrs. S 3 days postoperatively?
A. pain in the operative site
B. swelling of the operative sites
C. pain and tenderness in the calf
D. orthostatic hypotension
57. The physical therapist orders exercises of Mrs. S’s right hip,
knee, and foot to gradually increase range of motion to the right
hip. The nurse can best assist Mrs. S by
A. administering an analgesic before the exercises
B. stopping the exercises if Mrs. S experiences pain
C. performing the exercises for Mrs. S
D. observing Mrs. S’s ability to perform the exercises
58. Mrs. S should be instructed to avoid
A. adduction of her right leg
B. abduction of hr right leg
C. bearing any weight on her right leg
D. the prone position in bed
59. The nurse and Mrs. S plan for her rehabilitation. Mrs. S asks the
nurse, “What do I have to do in therapy?” Which reply by the nurse
most accurately describes the task of the patient in rehabilitation? To
A. follow the instructions of the rehabilitation team
B. regain some function that was lost
C. prevent further loss of your ability to function
D. learn to deal realistically with your disability
60. When the rehabilitation therapist tells Mrs. S that the outcome of
her therapy depends on “the ability of the nursing staff” as well as on
her motivation, Mrs. S questions the nurse on the meaning of this
phrase. The nurse should reply that “the nurse’s role in
rehabilitation is to
A. make the patient as comfortable as possible
B. follow the directions of the rehabilitation therapist
C. supervise the patient’s therapy appointments and exercise
program
D. assist the patient in establishing therapy priorities and
goals
61. Mrs. S asks the nurse if her new joint will function normally. The
nurse can best answer this by saying that
A. the new joint will be stronger than the old one
B. the new joint won’t function as well as a normal joint, but it
will be better than the arthritic joint
C. the new joint will function almost as well as a normal joint,
particularly if you perform your exercise faithfully
D. the doctor will be able to assess your limitations in 6 weeks and
then explain them to you
Situation: Mr. Lee is a 20-year-old patient who sustains a compound
fracture of the right shaft of the femur and a simple fracture of the
ulna in a motorcycle accident.
62. While serving as a member of a first aid squad, Mary V, RN,
reaches the scene of the motorcycle accident and administers
emergency treatment, which includes the application of a splint. It is
important that the splint
A. be applied while the limb is in good alignment
B. be applied to the limb in the position in which it is found
C. extend from the fracture site downward
D. extend from the fracture site upward
63. While Mr. Lee is being transported in the ambulance to the
hospital, he should be positioned with the affected limbs
A. elevated
B. in a flat position
C. lower than his heart
D. slightly abducted
64. While taking a history from the patient, the nurse determines that
his last booster injection for tetanus immunization was 5 years
ago. The nurse should recognize that this information is important
because it
means that he should receive
A. a full tetanus immunization program
B. nothing, because he is sufficiently immunized against tetanus
C. an additional booster injection
D. human tetanus immune globulin
Situation: Mr. Lee is taken to the operating room and the wound
caused by the fracture of the femur is cleansed and debrided. The
fracture is then reduced, and a Steinmann pin for skeletal traction is
inserted. A closed reduction of the ulna is performed, and a cast is
applied.
65. The most important nursing measure in the immediate
postoperative period will be
A. encouragement of isometric exercises
B. cleansing of the area around the Steinmann pin
C. careful observation of vital signs
D. massage of pressure areas
66. After Mr. Lee returns to his room, he complains of pain in his
right arm. The initial action of the nurse should be to
A. administer analgesics as ordered
B. check his fingers
C. notify his physician immediately
D. pad the edges of the cast
67. To maintain proper alignment and immobilization of the femur,
the physician has ordered skeletal traction with a Thomas
splint. While caring for Mr. Lee, the nurse should explain to him that
he
A. cannot turn or sit up
B. cannot turn but can sit up
C. can turn but cannot sit up
D. can turn and can sit up
68. In dealing with the weights that are applying the traction, the
nurse should
A. allow them to hang freely in place
B. hold them up if the patient is shifting position in bed
C. remove them if the patient is being moved up in bed
D. lighten them for short periods if the patient complains of pain
69. Mr. Lee has a Thomas knee splint in place. In addition to the
usual measures for a patient in traction, it will be important that the
nurse observe
A. the groin area for pressure
B. for constipation
C. his skin for sings of decubiti
D. for signs of hypostatic pneumonia
70. If Mr. Lee should show an increase in blood pressure and signs of
confusion and increased restlessness, the nurse should suspect
A. a concussion
B. impending shock
C. fat emboli
D. anxiety
71. Because of the nature of Mr. Lee’s wound and the insertion of a
Steinmann pin, it is especially important that the nurse observe for
A. a foul odor
B. foot drop
C. pulmonary congestion
D. fecal impaction
72. Mr. Lee develops an acute localized osteomyelitis. He is placed
on intravenous antibiotic therapy. The wound is incised and drained,
and neomycin irrigations are ordered four times a day. It is important
that these irrigations be performed
A. with strict aseptic techniques
B. with a warm solution
C. for at least 5 minutes
D. at equal time intervals
Situation: Maria Alfredo is a 30-year old married woman who has
systemic lupus erythematosus (SLE).
73. While doing as nursing history on Mrs. Alfredo, the nurse should
recognize that the most common initial symptoms of SLE are
A. petechiae in the skin, nosebleeds, and pallor
B. hematuria, increased blood pressure, and edema
C. tachycardia, tremors, and loss of weight
D. painful muscles and joints, stiffness, and inflammation of
joints
74. Mrs. Afredo is instituted on long-term prednisone therapy. Her
daily maintenance dose is 5 mg/day. In the instructions to Mrs.
Alfredo, the nurse should emphasize that
A. once the symptoms of SLE subside, the medication will be
discontinued gradually
 B. a weight gain 2 pounds per week should be reported to the
physician
C. the maintenance dose will be the lowest dose that controls
symptoms
D. if adrenal atrophy occurs, adrenocorticotropic hormone
(ACTH) will have to be prescribed
75. Mrs. Alfredo questions the nurse about family planning and birth
control. Which of the following choices should the nurse include in
her answer?
A. oral contraceptives can precipitate an acute exacerbation
of your condition
B. Intrauterine devices are the recommended brithcontrol
measures
C. there are no contraindications for pregnancy, as long as the
disease is being treated
D. studies indicate that the corticosteroids produce fetal damage
76. The nursing care plan states, “Observe for signs of Raynaud’s
phenomenon.” The nurse should recognize that this phenomenon
A. occurs as a side effect of prednisone
B. is aggravated by smoking
C. is relieved by application of cold compresses to the hands
D. is the priority care
77. Although many abnormal laboratory findings are found in SLE,
there is no one specific diagnostic test. The test that is positive in
over 95 percent of all patients with SLE is the blood test for
A. the lupus erythematosus (LE) factor
B. the rheumatoid factor
C. antinuclear antibodies (ANA)
D. C-reactive protein (CRP)
78. The teaching program for Mrs. Alfredo planned by the nurse
should include emphasis on which of the following?
A. once the symptoms are controlled, the corticosteroids will be
discontinued
B. if hair loss occurs, it is irreversible
C. overexposure to the sun can produce an exacerbation of
symptoms
D. a low-potassium, low-protein diet is recommended
79. Mrs. Alfredo tells the nurse that she has had black, tarry
stools. The nurse should
A. reassure the patient that this is a minor side effect of
prednisone
B. tell the patient that if she takes the prednisone with milk,
black, tarry stools will be avoided
C. tell the patient that she will ask the physician to prescribe
aluminum hydroxide
D. notify the physician because black, tarry stools can be an
indication of bleeding peptic ulcer
80. Mrs. Alfredo calls the physician’s office and complains that she
has chills, a fever, and a cough. The nurse should
A. advise that she remain in bed, drink extra fluids, and take
aspirin every 4 hours
B. recommended that she increase her dose of prednisone until
her temperature is normal
C. recommended that she come to the office to be examined
by the physician
D. tell Mrs. Alfredo to call for an appointment when she is feeling
better
Situation: Irene P is being treated in the emergency room for an
acute attack of Meniere’s syndrome
81. The nurse should recognize that the triad of symptoms associated
with Meniere’s syndrome is
A. nystagmus, arthralgia, and vertigo
B. nausea, vomiting, and arthralgia
C. syncope, headache, and hearing loss
D. hearing loss, vertigo, and tinnitus
82. Patient teaching for Mrs. P includes helping her to recognize that
A. Meniere’s syndrome is psychogenic and is brought on by
stress
B. most patients can be successfully treated with a low-salt
diet and diuretics
C. acute infection can precipitate an attack
D. a labyrinthectomy is the preferred treatment for relieving
symptoms and restoring hearing
83. Nursing intervention during an acute attack includes
A. encouraging the patient to walk
B. placing the patient in a semi-Fowler’s position
C. Having the patient lie flat
D. placing the patient in Trendelenburg’s position
Situation: Mrs. C, 30 years old, has symptoms of diplopia, fatigue,
slight vertigo, and a lack of coordination. After a neurological work-
up she is diagnosed as having multiple sclerosis.
84. The main goal of nursing care for Mrs. C during the acute phase
of the disease should be to
A. promotes rest
B. prevent constipation
C. maintain normal functioning
D. encourage activities of daily living
85. Mrs. C is note d to be having mood swings. In deciding what
approach to use with her, the nursing staff should recognize that this
A. is probably the result of an underlying mental disorder
B. indicates that Mrs. C is having difficulty accepting her
diagnosis
C. may be a result of pathology and involvement of the limbic
system in the disease
D. indicates that Mrs. C’s intellectual capacity has been
compromised
86. Mrs. C questions the nurse concerning the usual course of
multiple sclerosis. Which would be the best reply by the nurse?
A. each individual is very different; we cannot tell what will
happen
B. I know you are worried, but it is too soon to predict what will
happen
C. usually, acute episodes like this are followed by remissions,
which may last a long time
D. the future will take care of itself; let’s concentrate on the
present
87. As Mrs. C’s condition improves, it is most important that she be
given guidance in
A. developing a program of exercise
B. learning to handle stressful situations
C. seeking vocational rehabilitation
D. limiting her activities to those that are absolutely necessary
Situation: Barbara is a 23-year-old woman who lives with her
mother, sister, and brother in a private residence. She is attending the
neurological out-patient clinic for the first time. Her health history
includes two grand mal seizures./ A diagnosis of idiopathic epilepsy
has been made. The physician has ordered an electroencephalogram
(EEG) and phenytoin sodium (Dilantin), 300 mg/day
88. While doing a nursing history on Barbara, the nurse should
recognize that
A. persons with idiopathic epilepsy have a lower intelligence
level
B. grand mal seizures do not cause mental deterioration
C. a common characteristic of idiopathic epilepsy is committing
acts of violence
D. idiopathic epilepsy is a form of mental illness
89. To prepare Barbara for EEG, the nurse should explain that
A. during the test she will experience small electric shocks that
feels like pin pricks
B. the test measures mental status as well as electrical brain
waves
C. during the hyperventilation portion of the test, she may
experience dizziness
D. she will be unconscious during the test
90. Health teaching for Barbara includes ensuring that she
understands that
 A. proper prophylactic medication can control the incidence
of seizures
B. moderate use of alcohol is permitted
C. forcing fluids helps to reduce the incidence of seizures
D. the incidence of seizures is related to hyperglycemia
91. During a follow-up clinic visit, Barbara tells the nurse that her
urine has had a reddish-brown color. The nurse should
A. reassure Barabara that this is a harmless side effect of
phenytoin sodium (Dilantin)
B. tell Barbara that this is a sign of hepatic toxicity
C. recommend that Barbara go to the laboratory for a serum
Dilantin concentration test
D. notify the physician that Barbara has hematuria
92. A long-term goal for Barbara is to minimize the gingival
hyperplasia associated with Dilantin therapy. The nurse should
recognize that
A. another anticonvulsant will be prescribed if it occurs
B. the physician will reduce the dosage at the first sign of
hyperplasia
C. a regular plan of good oral hygiene is essential
D. vitamin C should be taken daily with the Dilantin
93. Barbara’s serum concentration level Dilantin is 15 µg/ml. The
nurse should recognize this as
A. a desired therapeutic serum level
B. below the desired therapeutic level
C. above the recommended serum level
D. a toxic serum level
94. Family members should be instructed about caring Barbara
during a grand mal seizure. Immediate care during a seizure should
include
A. restraining Barbara’s arms and legs
B. forcing the mouth open to insert an airway
C. giving orange juice before the clonic stage begins
D. turning Barbara’s head to the side
95. The nurse explains to Barbara that safety precautions can be taken
by those who have warning symptoms before the seizure. (These
symptoms are not part of the seizure, as the aura is.) What warning
symptoms should the nurse tell Barbara to be aware of?
A. Hot and cold sensations, gastrointestinal problems,
anxiety, and mood changes
B. Muscle twitching, lapse of consciousness, anxiety, and
gastrointestinal problems
C. tingling in a local region, anxiety, and lapse of consciousness
D. increased tonicity of muscles and autonomic behavior
96. The nurse should tell Barbara’s family that after a seizure she will
be in a confused state and will need some supervision. It is most
important for the caring one to be calm because the confused state of
the epileptic is considered to be
A. One mood swings and a feeling of general inadequacy and
fatigue that result in a decrease of interest
B. an adaptive period, when one slowly learns to cope with the
devastating insults to one’s psychological and physical integrity
C. a gross impairment in social and intellectual functioning with
crude, tactless, and impulsive
behavior
D. a helpless state, with intellectual deterioration, difficulty in
communication, and regression to the
infantile state
97. Barbara asks the nurse if it is true that there is an “epileptic
personality.” Which of the following choices would be the nurse’s
best response/
A. the person must be aware that anxiety over anticipation of a
seizure may cause personality problems
B. No, deviation in personality is caused by restrictions imposed
by society
C. Yes, one may learn to induce seizures as a way of getting
attention from others
D. the person may take on a sick role if mismanaged at home
or in the community
Situation: Ms. R, a 35-year old woman, has myasthenia gravis. She
has been referred to the neurology clinic by her physician.
98. While doing a nursing history on Ms. R, the nurse should expect
her to complain of which of the following symptoms?
A. passive tremors, cogwheel rigidity, and drooling
B. spastic weakness of the limbs, intention tremors, and
incontinence
C. diplopia, ptosis, and fatigue
D. nystagmus, ataxia, and tinnitus
99. In preparing a teaching plan for Ms. R, the nurse should
emphasize that
A. the anticholinesterase medications cause fewer side effects
when taken on an empty stomach
B. physical activity should be planned for the late afternoon early
evening
C. a member of the family should be taught how to use
suction for emergency use
D. edrophonium chloride (Tensilon) is the drug of choice in the
treatment of myasthenia gravis
100. Respiratory distress is common in people with myasthenic
crisis? Marked improvement of respirations occurs after the
administration of intravenous
A. diazepam (Valium)
B. hydrocortisone
C. atropine sulfate
D. edrophonium chloride (Tensilon)
101. The medication used to treat cholinergic crisis
A. atropine sulfate
B. neostigmine (Prostigmin)
C. aminophylline
D. hydrocortisone
102. The physician has prescribed pyridostigmine (Mestinon), 180
mg/day. Ms. R tells the nurse that each time she takes the medication
she feels nauseated. The nurse should tell Ms. R to
A. crush the tablet before taking it
B. take the tablet with food or milk
C. take the tablet on an empty stomach
D. not to take the medication until she notifies the physician
Mr. Go, who has had Parkinsosn’s disease for 4 years, visits his wife
daily during her hospital stay. His illness is being treated with
levodopa (L-dopa).
103. When Mr. Go visits his wife, he is observed to be walking rather
slowly. The nurse should recognize that Mr. Go is
A. exhibiting a long-range side effect of L-dopa
B. exhibiting a symptom that is characteristic of stage II
Parkinson’s disease
C. beginning to experience atrophy of the cerebral cortex and
cellular changes
D. probably doing this on purpose as a way of
104. The nurse can help him to be more comfortable by
A. discussing this problem and how he handles it, and
discussing hygiene measures with him
B. opening the windows and providing as much ventilation as
possible while he is visiting
C. suggesting that he is probably dressing too warmly for the
hospital environment
D. explaining that this is a side effect of his medication, and
encouraging increased intake of fluids
Situation: Mr. go has a sudden exacerbation of symptoms. He
develops tachycardia, a respiratory rate of 40, and appears extremely
anxious. He is hospitalized with a diagnosis of parkinsonian crisis.
105. Planning for Mr. Go’s care should include measures to
A. provide a quiet, restful environment
B. maintain joint range of motion
C. decrease social isolation
D. improve his nutritional status
106. Mr. Go responds to treatment, and his condition gradually
improves. However, he complains that he feels dizzy whenever he
tries to stand up from a lying position. The nurse should
 A. explain that this is just part of his illness
B. tell him that his doctor will be notified of this symptom
C. encourage him to change his position slowly
D. discuss his feelings about his wife’s hospitalization
107. Mr. Go has problems in dressing himself as a result of tremors,
but he refuses all assistance. Which of the following is the best initial
action by the nurse in response to this complaint?
A. tell him he needs assistance, and gradually help him
B. give him more time and encouragement to dress himself
C. suggest that for the present he wear only the hospital gown
D. listen to his refusal, but give him assistance as needed
108. Mr. Go discusses his work as an accountant with the nurse. He
states that he his glad that he will be able to continue working. An
appropriate initial response would be based on the nurse’s
recognition that he
A. should be encouraged to be active
B. should be cautioned against overfatigue
C. is being unrealistic about his future
D. needs to recognize that his situation is unique
109. Mr. Go tells the nurse that someone told him that people with
Parkinson’s disease develop early senility. In response, the nurse
should explain that
A. Parkinson’s disease progresses very slowly over a period of
years, and it is only in the late stages that any mental changes
might take place
B. his information is false, because Parkinson’s disease does not
cause any changes in the individual’s
intellectual capacities
C. he does not have to worry about senility because he is
responding so well to treatment
D. although Parkinson’s disease does cause mental confusion, this
condition is clinically different from senility