MS PREBOARDS

NP2 (71-80)

SITUATION: Patients with hematologic disorders. A registered nurse should be knowledgeable of the concepts involving
hematologic problems.

71. You are making a room assignment for a newly arrived patient whose laboratory test results indicate pancytopenia.
Which patient will be the best roommate for the new patient?
a. A patient with digoxin toxicity
b. A patient with viral pneumonia
c. A patient with shingles
d. A patient with cellulitis

RATIONALE:
A Patients with pancytopenia are at higher risk for infection. The patient with digoxin toxicity presents the least risk of
infecting the new patient. Viral pneumonia, shingles, and cellulitis are infectious processes.

72. A 67 y/o who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. Which
statement made by the patient when you are obtaining the admission history is of most concern?
a. Ive noticed that I bruise easily since the chemotherapy started
b. My bowel movements are soft and dark brown.
c. I take one aspirin every morning because of my history of angina.
d. My appetite has decreased since the chemotherapy started.
RATIONALE:
C Because aspirin will decrease platelet aggregation, patients with thrombocytopenia should not use aspirin routinely.
Patient teaching about this should be included in the care plan. Bruising is consistent with the patients admission problem
of thrombocytopenia. Soft, dark brown stool indicate that there is no frank blood in the bowel movements. Although the
patients decreased appetite requires further assessment by the nurse, this is a common complication of chemotherapy.

73. After a car accident, a patient with a medical alert bracelet indicating hemophilia A is admitted to the emergency
department (ED). Which physician order should you implement first?
a. Transport to the radiology department for cervical spine radiography
b. Transfuse factor VII concentrate
c. Type and cross-match for 4 units of red blood cells (RBCs)
d. Infuse normal saline at 250 mL/hr
RATIONALE:
B When a hemophiliac patient is at a high risk for bleeding, the priority intervention is to maximize the availability of
clotting factors. The other orders also should be implemented rapidly but do not have as high a priority as administration
of clotting factors

74. As a home health nurse, you are obtaining an admission history for a patient who has deep vein thrombosis and is
taking warfarin (Coumadin) 2 mg daily. Which statement by the patient is the best indicator that additional teaching
about warfarin may be needed?
a. I have started to eat more healthy foods like green salads and fruits
b. The doctor said that I is important to avoid becoming constipated
c. Coumadin makes me feel a little nauseated unless I take it with food.
d. I will need to have some blood testing done once or twice a week.
RATIONALE:
A Patients taking warfarin are advised to avoid making sudden dietary changes, because changing oral intake of food
high in vitamin K (such as green leafy vegetables and some fruits) will have an impact on the effectiveness of the
medication. The other statements suggest that further teaching may be indicated, but more assessment for teaching
needs is required first
75. A patient is admitted to the intensive care unit with disseminated intravascular coagulation associated with a gram-
negative infection. Which assessment information has the most immediate implication for the patients care?
a. There is no palpable radial or pedal pulse
b. The patient complains of chest pain
c. The patients oxygen saturation is 87%
d. There is mottling of the hands and feet
RATIONALE:
C Because the decrease in oxygen saturation will have the greatest immediate effect on al body systems, improvement
is oxygenation should be the priority goal of care. The other date also indicate the need for rapid intervention, but
improvement of oxygenation is the most urgent need
76. (Test 5) a 22 y/o with stage1 Hodgkin disease is admitted to the oncology u nit for radiation therapy. During the initial
assessment, the patient tells you, Sometimes Im afraid of dying. Which response is most appropriate at this time?
a. Many individuals with this diagnosis have some fears.
b. Perhaps you should ask the doctor about medication.
c. Tell me a little bit more about your fear of dying.
d. Most people with stage 1 Hodgkin disease survive.
RATIONALE:
C More assessment about the patient means is needed before any intervention can be planned or implemented. All the
other statements indicate an assumption that the patient is afraid of dying of Hodgkin disease, which may not be the case.
77. A transfusion of PRBCs has been infusing for 5 minute when the patient becomes flushed and tachypneic and says,
Im having chills. Please get me a blanket. Which actions should you take first?
a. Obtain a warm blanket for the patient
b. Check the patients oral temperature
c. Stop transfusion
d. Administer oxygen
RATIONALE:
C The patients symptoms indicate that a transfusion reaction may be occurring, so the first action should be to stop the
transfusion. Chills are indication of febrile reaction, so warming the patient may not be appropriate. Checking the patients
temperature and administering oxygen are also appropriate actions if a transfusion reaction is suspected; however,
stopping the transfusion is the priority.
78. You obtain the following data about a patient admitted with multiple myeloma. Which information has the most
immediate implications for the patients care?
a. The patient complains of chronic bone pain
b. The blood uric acid level is very elevated
c. The 24-hour urine test shows Bence Jones proteins
d. The patient complains of new-onset leg numbness
RATIONALE:
D The leg numbness may indicate spinal cord compression, which should be evaluated and treated immediately by the
physician to prevent further loss of function. Chronic bone pain, hyperuricemia, and the presence of Bence Jones proteins
in the urine all are typical of multiple myeloma ad do require assessment and/or treatment; the loss of motor or sensory
functions is an emergency
79. The nurse in the outpatient clinic is assessing a 22y/o with a history of recent splenectomy following a motor vehicle
accident. Which information obtained during the assessment will be of most immediate concern to the nurse?
a. The patient engages is unprotected sex
b. The oral temperature is 100 degree Fahrenheit (37.8 degree Celsius)
c. There is abnormal pain with light palpation
d. The patient admits to occasional marijuana use
RATIONALE:
B Because the spleen has an important role in the phagocytosis of microorganisms, the patient is at higher risk for
severe infection after a splenectomy. Medical therapy, such as antibiotic administration, is usually indicated for any
symptoms of infection. The other information also indicates the need for more treatment and intervention, but prevention
and treatment of infection are the highest priorities for this patient
80. After you receive the change-of-shift report, which patient will you assess first?
a. A 20 y/o with possible acute myelogenous leukemia who has just arrived on the medical unit
b. A 38 y/o with aplastic anemia who needs teaching about decreasing infection risk before discharge
c. A 40 y/o with lymphedema who request help in putting on compression stockings before getting out of bed
d. A 60 y/o with non-Hodgkin lymphoma who is refusing the ordered chemotherapy regimen
RATIONALE:
A the newly admitted patient should be assessed first, because the baseline assessment and plan of care need to be
completed. The other patients also need assessments or interventions but do not need immediate nursing care.
NP3 (11-21)

Situation: Diabetes Mellitus ranks 3th as a national killer among the non-communicable diseases prevalent in the
Philippines affecting more than 5 million Filipinos. You are caring for Jacob, an 8 year old child diagnosed with DM type 1

11. Major treatment for DM type 1 is insulin therapy. The nurse knows that the shelf-life of intermediate insulin if not
refrigerated would last up to:
A. 1 week
B. 2 weeks
C. 3 weeks
D. 4 weeks

12. Jacob along with his mother is attending a dance in the school gym. He suddenly becomes flushed and complains of
hunger and dizziness. The school nurse, who is present at the dance, takes Jacob to the nurses office and performs
a blood glucose level test that shows 60 mg/dL. Which of the following is the appropriate initial nursing intervention?
A. Call the childs mother.
B. Call an ambulance to take the child to the hospital emergency department.
C. Assist the child with administering regular insulin.
D. Give the child 1/4 cup of a sugar-sweetened carbonated beverage.
Correct Answer: D
Rationale:
A blood glucose lower than 70 mg/dL indicates hypoglycemia. The child is attending an activity that is different from the
normal routine at school. Insulin requirements change with unfamiliar situations. When signs of hypoglycemia occur, the
child needs an immediate source of glucose. Regular insulin will lower the blood glucose level. Although the childs
mother will need to be notified of the occurrence, this is not the immediate action. There is no reason to take the child to
the emergency department.

13. Jacob with his mother comes to the health care clinic for a routine examination. The nurse evaluates the data
collected during this visit to determine if the child has been euglycemic since the last visit. Which information is the
most significant indicator of euglycemia?
A. Daily glucose monitor log
B. Fasting blood glucose performed on the day of the clinic visit
C. Glycosylated hemoglobin
D. Dietary history for the previous week
Correct Answer: C
Rationale:
The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and
remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by
human intervention. Daily glucose logs are useful if they are kept regularly and accurately. However, they reflect only the
blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time-
limited in its scope, as is the dietary history.

14. The nurse is teaching Jacobs mother on how to administer the childs insulin injection. The child will be receiving 2
units of regular insulin and 12 units of normal protamine Hagedorn (NPH) insulin every morning. The nurse teaches
his mother to:
A. Draw the insulin into separate syringes.
B. Draw the regular insulin first and then the NPH insulin into the same syringe.
C. Draw the NPH insulin first and then the regular insulin into the same syringe.
D. Check a blood glucose first, and if the result is between 80 and 120 mg/dL, withhold the insulin injection.
Correct Answer: B
Rationale:
When mixing types of insulin, always withdraw the clear, rapid-acting insulin into the syringe first and then the long- acting
insulin. This procedure avoids contaminating the short-acting insulin with the longer-acting insulin. Therefore, the regular
insulin would be drawn into the syringe first, followed by the NPH insulin. When a childs insulin dosage requires the
injection of both short- and intermediate-acting insulin at the same time, it is preferable to mix the two and use a single
injection. Blood glucose results between 80 and 120 mg/dL are considered to be euglycemic (normal), and the prescribed
dose would be administered to maintain euglycemia.

15. Jacob was suddenly admitted to the emergency department for treatment of diabetic ketoacidosis after missing his
dose of insulin. Which assessment findings should the nurse expect to note?
A. Sweating and tremors
B. Hunger and hypertension
 C. Cold, clammy skin and irritability
D. Fruity breath odor and decreasing level of consciousness
Correct Answer: D
Rationale:
Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs.
Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level
of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic
ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs
during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

16. Jacobs mother states that the child has been complaining of abdominal pain. Diabetic ketoacidosis is diagnosed.
Anticipating the plan of care, the nurse prepares to administer:
A. Potassium IV infusion
B. NPH insulin IV infusion
C. 5% dextrose IV infusion
D. Normal saline IV infusion
Correct Answer: D
Rationale:
Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs.
Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal
saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to
the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may
be required, depending on the potassium level, but would not be part of the initial treatment.

17. In the emergent phase of burn, Insulin is given because it facilitates

A. Potassium reuptake by the cells to prevent hypokalemia
B. Potassium reuptake by the cells to prevent hyperkalemia
C. Potassium excretion by the kidneys to prevent hypokalemia
D. Potassium excretion by the kidneys to prevent hyperkalemia

RATIONALE: Insulin promotes the reuptake of potassium by the cells thus preventing hyperkalemia in burn patients

18. A nurse in the health care clinic is reviewing the record of a client with diabetes mellitus who was just seen by the
physician. The nurse notes that the physician has prescribed metformin (Glucophage). Which of the following
preexisting disorders, if noted in the clients record, would indicate a need to collaborate with the physician before
instructing the client to take the medication?
A. Hypertension
B. Foot ulcers
C. Renal Insufficiency
D. Hypothyroidism
Correct Answer: C
Rationale:
Metforrnin should be used with caution in clients with kidney disease because of the side effect of lactic acidosis and ARF.
Options 1, 2, and 4 are not cautions or contraindications associated with use of this medication.

19. The clients serum blood glucose level is 389 mg/dL. The nurse would expect to find which of the following as an
additional finding when assessing this client?
A. Unsteady gait
B. Slurred speech
C. Increased thirst
D. Cold, clammy skin
Correct Answer: C
Rationale:
A clinical manifestation of hyperglycemia is increased thirst secondary to frequent urination. Options 1, 2, and 4 would
most likely be noted in hypoglycemia.

20. A nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The priority nursing
diagnosis would be:
A. Deficient knowledge
B. Deficient fluid volume
C. Fluid Volume Excess
D. Imbalenced nutrition, less than body requirements
Correct Answer: B
Rationale:
An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied
by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it
becomes severe. Options 1, 3, and 4 are not related specifically to the subject of the question.

21. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic
hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following
anticipated physicians prescriptions?
A. Endotracheal intubation
B. 100 units of NPH insulin
C. Intravenous infusion of normal saline
D. Intravenous infusion of sodium bicarbonate
Correct Answer: C
Rationale:
The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to
restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in
diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be
administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in
serum potassium levels. Intubation and mechanical ventilation are not required to treat HHNS.

NP4 (16-29)

SITUATION: Peripheral Vascular Disorders are another concept that the nurse should be knowledgeable about. Nurses
caring for patients with PVDs should learn proper assessments and intervention for each type of PVD.

16. A client is discovered to have a popliteal aneurysm.

Because of the aneurysm, a nurse should closely
monitor the client for:
A. thoracic outlet syndrome.
B. ischemia in the lower limb.
C. pulmonary embolism.
D. Raynauds phenomenon.

ANSWER: B
A popliteal aneurysm (located in the space behind the knee) may cause
ischemia in the leg distal to the aneurysm due to thrombus forming inside
the aneurysm and potential emboli. Thoracic outlet syndrome is compression
of the subclavian artery due to anatomic structures leading to pain
and ischemia in the arm. Pulmonary embolism develops from deep venous
thromboses in the leg or pelvic veins. Raynauds phenomenon consists of vasospasms
in small arteries of the extremities causing intermittent ischemia.

17. A client with Raynauds disease is seen in a vascular clinic 6 weeks after nifedipine (Procardia) has been
prescribed. A nurse evaluates that the medication has been effective when which findings are noted?
A. The clients blood pressure is 110/68 mm Hg.
B. The client states experiencing less pain and numbness.
C. The client states that tolerance to heat is improved.
D. The client walks without claudication.
ANSWER: B
Raynauds disease is a disease in which cutaneous arteries in the
extremities have recurrent episodes of vasospasm with blanching and
then redness. The episodes are brought on by cold and result in pain
and numbness. Nifedipine, a calcium channel blocker, causes vasodilation,
which reduces pain and numbness. Nifedipine is used as an antihypertensive
agent but that is not the purpose here. The client is at risk to
develop hypotension as an adverse effect. Tolerance to cold, not heat,
should improve. Claudication is not associated with Raynauds disease
but is associated with arteriosclerotic changes in the larger arteries.
18. A 31-year-old male client seeks care at a vascular clinic because of painful fingers and toes. He is diagnosed with
Buergers disease (thromboangiitis obliterans). A nurse is teaching the client ways to prevent progression of the
disease. Which prevention measure should be the nurses initial focus when teaching the client?
A. Avoiding exposure to cold
B. Maintaining meticulous hygiene practices
C. Abstaining from all tobacco products in all forms
D. Following a low-fat diet
ANSWER: C
Buergers disease is an uncommon vascular occlusive disease that affects
the medial and small arteries and veins, initially in the distal limbs. It is
strongly associated with tobacco smoking, which causes vasoconstriction.
The most important action to communicate to the client is that he
must abstain from tobacco in all forms to prevent progression of the disease.
The other interventions are correct but not as important as abstaining
from tobacco. Avoiding exposure to cold will reduce the pain. Meticulous
hygiene and a low-fat diet are also positive actions to follow.

19. An experienced nurse tells a new nurse that lymphedema is a complication that commonly occurs
after women have received surgery for breast cancer. Which statement to the new nurse regarding lymphedema is
correct?
A. Lymphedema is characterized by severe swelling in the arm and hand on the affected side.
B. Lymphedema usually resolves after the cancer treatment is completed when collateral lymph circulation develops.
C. Lymphedema is mainly controlled by encouraging women to keep their arm elevated.
D. Lymphedema frequently signifies that there is a recurrence of the malignancy.
ANSWER: A
Lymphedema is a chronic condition characterized by extreme edema in the involved extremity. The lymph
circulation is disrupted by the lymph node dissection (even 20% of persons with sentinel node biopsy develop
lymphedema) that is part of the treatment of breast cancer. Collateral lymph circulation does not develop. Lymphedema is
best controlled by wearing compression sleeves and/or gloves. Lymphedema occurs from the lymph node dissection and
is not associated with recurrence of the malignancy.

20. A nurse is assessing a client who is taking atorvastatin (Lipitor). For which manifestations should the nurse specifically
assess?
A. Constipation and hemorrhoids
B. Muscle pain and weakness
C. Fatigue and dysrhythmias
D. Flushing and postural hypotension
ANSWER: B
Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA)
reductase inhibitor (statin) used to lower lipid levels. Statins can
cause muscle tissue injury manifested by muscle ache or weakness.
Muscle injury can progress to myositis (muscle inflammation) or
rhabdomyolysis (muscle disintegration). Bile acid sequestrants may
cause constipation and hemorrhoids because they are not absorbed from
the small intestine. Diarrhea, not constipation, is a side effect of statin
medications. Side effects of niacin, a lipid-lowering agent, include
flushing, dysrhythmias, and postural hypotension.

SITUATION: A lot of Filipino have one or more types of cardiovascular disease (CVD), including hypertension, coronary
artery disease (CAD), heart failure (HF), stroke, and congenital cardiovascular defects. Because of the prevalence of
CVD, nurses practicing in any setting across the continuum of care, whether in the home, office, hospital, nursing home,
or rehabilitation facility, must be capable of assessing the cardiovascular system.

21. After an inferior-septal wall myocardial infarction. Which complication should a nurse suspect when noting jugular
venous distention (JVD) and ascites?
A. Left-sided heart failure
B. Pulmonic valve malfunction
C. Right-sided heart failure
D. Ruptured septum
ANSWER: C
Right-sided heart failure produces venous congestion in the systemic
circulation resulting in JVD and ascites (from vascular congestion in
the gastrointestinal tract). Additional signs include hepatomegaly,
splenomegaly, and peripheral edema. Left-sided heart failure produces
signs of pulmonary congestion, including crackles, S3 and S4 heart sounds,
and pleural effusion. A characteristic finding of pulmonic valve malfunction
would be a murmur. A murmur would also be auscultated with a ruptured
septum, and the client would experience signs of cardiogenic shock.

22. A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as
daily prescribed medications. The nurse tells the client to report which of the following as an indication that the
medications are not having the intended effect?
A. Cough accompanied by other signs of respiratory infection
B. Sudden increase in appetite
C. Weight gain of 2 to 3 lb in a few days
D. Increased urine output during the day
Correct Answer: C
Rationale:
Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema,
persistent cough, and nocturia. An increase in urine output during the day is expected with diuretic therapy (Lasix). A
cough due to respiratory infection does not necessarily indicate that heart failure is worsening.

23. During assessment of a client newly diagnosed with hypertension, the nurse recognizes that it is common for the
client to do which of the following?
A. Have frequent nosebleeds
B. Be asymptomatic
C. Have visual disturbances
D. Be short of breath
Correct Answer: B
Rationale:
Hypertensive clients often have no symptoms until target organ involvement, which happens with very high blood
pressure. Options 1, 3, and 4 are incorrect because those dinical manifestations occur with severely high hypertension.

24. A nurse is teaching adult cardiopulmonary resuscitation (CPR) guidelines to a group of laypeople. The nurse tells the
group that how many chest compressions should be delivered with every two rescue breaths?
A. 25
B. 15
C. 20
D. 30
Correct Answer: D
Rationale:
When performing CPR on adults, the ratio of chest compressions to breaths should be 30:2. Therefore, options A, B and
C are incorrect.

25. A female client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure
having a bowel movement. The nurses response incorporates the information that bearing down or straining would
trigger:
A. Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility
B. Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility
C. Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility
D. Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility
Correct Answer: A
Rationale:
Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve
causes a decrease in heart rate and cardiac contractility. Stimulation of the sympathetic nervous system has the opposite
effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis.
26. A nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is receiving
oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse accurately explains
that:
A. Oxygen has a calming effect.
B. Oxygen will prevent the development of any thrombus.
C. Oxygen dilates the blood vessels so they can supply more nutrients to the heart muscle.
D. The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.
Correct Answer: D
Rationale:
The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that
places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart
muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.

27. A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit
after the procedure, and the nurse provides instructions to the client regarding home care measures. Which of the
following statements, if made by the client, indicates an understanding of the instructions?
A. I am so relieved that I can eat anything that I want to now.
B. I need to cut down on cigarette smoking.
C. I am so relieved that my heart is repaired.
D. I need to adhere to my dietary restrictions.
Correct Answer: D
Rationale:
After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must be followed. Making
the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the
artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An
angioplasty does not repair the heart.

28. A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of
stairs or after walking four blocks. The nurse determines that the client is experiencing which of the following types of
angina?
A. Stable
B. Unstable
C. Variant
D. Intractable
Correct Answer: A
Rationale:
Stable angina is triggered by a predictable amount of effort or emotion. Unstable angina is triggered by an unpredictable
amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time.
Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to
occur early in the day and at rest. Intractable angina is chronic and incapacitating and is refractory to medical therapy.

29. A client is admitted to the hospital for an acute episode of angina pectoris. Which of the following parameters is the
priority for the nurse to monitor?
A. Temperature and chest pain
B. Right upper quadrant pain and fatigue
C. Food tolerance and urinary output
D. Pulse and blood pressure
Correct Answer: D
Rationale:
Angina pectoris is transient chest pain or discomfort that is caused by an imbalance between myo7cardial oxygen supply
and demand. The discomfort typically occurs in the retrostemal area; may or may not radiate; and is described as a
tight, heavy, squeezing, burning, or choking sensation. The two major types of angina pectoris are stable (classic
exertional) angina and unstable angina. Stable angina, the most common type, is usually precipitated by physical
exertion or emotional stress, lasts 3 to 5 minutes, and is relieved by rest and nitroglycerin. Acute intervention for the client
who has an anginal attack includes vital signs first, followed by continuous electrocardiographic monitoring and pain relief.

NP4 (56-60)

SITUATION: Mr. Sta. Rita, a post acute myocardial infarction (AMI) on his 2nd day post attack is assigned to you, the
physician said his recovery is uneventful. The following questions apply.

56. Morphine sulfate intravenous (I.V.) was prescribed for pain. The nurse understands that morphine sulfate I.V. was
preferred because of two reasons. These are:
1. Bypasses the variable rates of absorption 3. Elevates enzyme levels
2. Increases cardiac output 4. Rapid onset of action
A. 2 and 3 B. 2 and 1 C. 3 and 4 D. 1 and 4

ANSWER: D

RATIONALE:

Morphine sulfate is used in relief of moderate to severe acute and chronic pain; relief of pain of myocardial infarction;
relief of dyspnea of acute left ventricular failure and pulmonary edema; preanesthetic medication.

Morphine sulfate actions is that it binds to opiate receptors in the CNS, causing inhibiting of ascending pain pathways,
altering the perception of and response to pain; produces generalized CNS depression. In myocardial infarction
morphine sulfate IV is given primary to decreases pain. In addition to that, this medication also decreases the
circulating cathecolamines thereby decreasing the preload, and afterload and subsequently the heart rate and blood
pressure which has a direct effect in the oxygen demand of the heart. IV morphine sulfate was the drug of choice
simply because of two reasons, since this medication is given through Iv it bypasses the variable rate of
absorption and the onset of action upon administration is usually 5 10 minutes

OPTIONS A, B and C are INCORRECT. Statements on No. 2 and 3 are inaccurate reagarding the information related
to the use of IV morphine sulfate.

As stated earlier, this medication decreases the circulating catecolamine, thereby decreasing the preload and the
after. If these components are decrease, cardiac output also decreases. These conditions occur to balance the
myocardial oxygen demand.

Morphine sulfate does not elevate enzymes evel, not decreases the enzymes levels that are related to myocardial
infarction.

57. Mr. Sta. Rita is taking Aspirin, a platelet inhibitor. The client understood the nurses instruction on how to take the drug
if he:
A. Swallowed medicine in small amount of water C. Chewed and allowed the drug to dissolve with saliva
B. Took the medicine two hours before meals D. Took the medicine with meals

ANSWER: D

RATIONALE:

Aspirin is an antiplatelet medication that is used in clients with myocardial infarction. This medication prevents platelet
aggregation. The major side effects that can occur during the intake of this medication is gastrointestinal
upset/ulceration. This can lead to bleeding since this medication inhibits platelet aggregation. Therefore, it is
necessary to instruct the client to take the medication with food.
 OPTION A is INCORRECT. This intervention would not prevent the occurrence of gastrointestinal upset. Besides, the
medication should be taken with a FULL glass of water.

OPTION B is INCORRECT. This intervention should be avoided as this may lead to gastrointestinal upset.

OPTION C is INCORRECT. The nurse should instruct the client to dont chew the medication.

58. The clients wife observes the facial expression of Mr. Sta. Rita and interprets that her husband is in pain. She asks
the nurse, What is causing the pain? The nurse responded that:
A. Release of tissue substances during inflammatory process can stimulate pain receptors.
B. Pain is felt when the myocardial muscles contract rapidly
C. Pain is triggered by the high blood pressure
D. Chest pain occurs when the oxygen demand of the heart is not met

ANSWER: D

RATIONALE:

The main problem in myocardial infarction is the imbalance between the oxygen demand and supply of the heart. This
imbalance will result to the shifting of metabolism from aerobic to anaerobic metabolism and can lead to the
production of LACTIC ACID. The nerve endings in the heart is sensitive with lactic acid, and this can cause chest
pain.

OPTION A is INCORRECT. This statement is somewhat correct, but it does not answer the concern of the wife
directly

OPTION B is INCORRECT. Ventricular tachycardia may occur in clients with myocardial infarction but it does not
cause the pain.

OPTION C is INCORRECT. Increase blood pressure happens with pain, but it does not directly cause the pain.

REFERENCE: Smeltzer, Suzanne C. Brunner and Suddarths Medical-Surgical Nursing 12th Edition, (2010), Volume
2, p. 774.

59. One of the priority nursing diagnosis is Ineffective Tissue Perfusion. Which of the following would you watch for as
the first indication of altered perfusion?
A. Adventitious lung sounds C. Change in the level of consciousness
B. Presence of dysrhythmias D. Abnormal heart sounds

ANSWER: B

RATIONALE:

Ineffective Tissue Perfusion pertains to altered blood flow to myocardial tissue. In MI. decrease myocardial
contractility and ventricular compliance caused by necorsis may lead to dysrhythmias. If dysrhythmia occurs, cardiac
output and blood pressure may be decreased and can lead to ineffective tissue perfusion to various organ in the
body.

OPTIONS A and D are INCORRECT. Adventitious lung sounds and abnormal heart sounds may indicate left
ventricular failure.

OPTION C is INCORRECT. Change in the level of consciousness may also occur but in the later stage.
 REFERENCES: Ignatavicius and Workmans Medical-Surgical Nursing: Critical Thinking for Collaborative Care 5th
Edition, (2006), Volume 1, p. 853.

Smeltzer, Suzanne C. Brunner and Suddarths Medical-Surgical Nursing 12th Edition, (2010), Volume 2, pp. 775-776.

60. During episodes of chest pain, which of the following procedures would the nurse expect to be prescribed to provide
assessment for myocardial infarction?
A. Electrocardiography B. Echocardiography C. Radionuclide imaging D. Angiography

ANSWER: A

RATIONALE:

Electrocardiography provides information that assists in ulling out or diagnosis and evaluating an acute MI. IT should
be obtained within 10 minutes from the time a client reports pain or arrives in the emergency department. The
ECG changes that occurs with an MI are seen in the leads that view the involved surface of the heart. The classic
ECG changes are T-WAVE INVERSION (ZONE ISCHEMIA), ST-SEGMENT ELEVATION (ZONE OF INJRUY), and
ABNORMAL Q WAVE (ZONE OF INFARCTION)

OPTION B is INCORRECT. Echocardiography is a noninvasive ultrasound test that is used to measure the ejection
fraction and examine the size, shape, and motion of cardiac structures. It is particularly useful for diagnosisng
pericardial effusions; determining chamber size and the etiology of heart murmurs; evaluating the function of heart
valves, including prosthetic heart valves; and evaluation ventricular wall motion

OPTION C is INCORRECT. Radionuclide scanning, also called nuclear medicine scanning, is a test that produces
pictures (scans) of internal body parts using mall amount of radioactive material. This test is used to provide images of
organs and areas of the body that cannot be seen well with manual standard X-rays. This test is very useful in
detecting tissue growths such as tumors. In addition, this diagnostic technique can also be used to evaluate
myocardial ischemia and infarction. However, between ECG and this diagnostic technique, ECG provides the quickest
and convenient way to assess myocardial infarction

OPTION D is INCORRECT. Angiography is useful in evaluating CAD. This diagnostic technique used contrast agent
is injected into the vascular system to outline the heart and blood vessels.

REFERENCE: Smeltzer, Suzanne C. Brunner and Suddarths Medical-Surgical Nursing 12th Edition, (2010), Volume
1, p. 713

NP5 (1-10)

SITUATION: Lace is an Emergency Department nurse working during the morning shift. A newly hired nurse was
assigned to work with her as part of the orientation program.

1. A 41 year old victim of gunshot wound is being assessed closely for signs of hypovolemic shock. Which of the following
instructions of Lace to the newly hired nurse is least intended to obtain data regarding hypovolemic shock?
B. Talk to the patient. C. Report to me changes in vital signs
C. Note skin color of the patient D. Maintain pressure on the wound

ANSWER: D

RATIONALE:

The question is asking for an action that will obtain data regarding hypovolmic shock. Maintaining pressure on the
wound will not help in obtaining relevant information regarding the clients condition.
 OPTIONS A, B and C are INCORRECT. These statements are all important to use to obtain data regarding the
clients condition

2. The newly hired nurse observed Lace perform assessment on a 50 year old female who sustained partial and full
thickness burns on both lower extremities due to fire. Which of the following questions asked by Lace will the newly
hired nurse consider as an attempt to determine full thickness burns?
A. Can you move both extremities?
B. How long were your extremities exposed to the flames?
C. Did you cover extremities with any material like a blanket?
D. Do you experience pain?

ANSWER: D

RATIONALE:

A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying
tissue, muscle, and bone. Wound color ranges widely from pale white to red, brown, or charred black. One of the
unique characteristic of full-thickness burn is that pain is not usually present as compare to superficial partial-
thickness burn and deep partial-thickness burn. Therefore, in an attempt to distinguish the burn depths, the nurse may
ask the client if she is experiencing pain.

OPTION A is INCORRECT. This statement is irrelevant and would not help in distinguishing depths of burn.

OPTION C is INCORRECT. This statement can be used. However, assessment of pain which is one of the most
common complaints would be most helpful.

OPTION C is INCORRECT. This statement is irrelevant and would not help in distinguishing burn depths.

REFERENCE: Smeltzer, Suzanne C. Brunner and Suddarths Medical-Surgical Nursing 12th Edition, (2010), Volume
2, p. 1720.

3. Lace administered as prescribed, antivenom and tetanus toxoid to a client admitted with history of snake bite. If you
were the newly hired nurse, which of the following will you consider incorrect?
A. Tetanus toxoid enhances effect of antivenom
B. Amount of antivenom is dependent on the severity of reaction than weight of the client
C. Complications induced may be prevented by the tetanus toxoid
D. Antivenom is an antidote for snake bite

ANSWER: C

RATIONALE:

This statement is too general. Not all complications related to snake bite will be prevent by the administration of
tetanus toxoid. Only INFECTION does tetanus toxoid can prevent.

OPTION A is INCORRECT. This statement is accurate. However, it is considered incorrect ebcuase the question is
looking for a statement that is not accurate regarding tetanus toxoid and antivenom. Tetanus is given to prevent
infection from snakebite, at the same time it also enhances the effect of antivenom.

OPTIONS B and D are INCORRECT. Antivennom is required as the ANTIDOTE for snakebite. However, not all
snakebite victims need antivenom administration. The decision whether or not to give antivenom is based upon the
severity of the envenomation. Therefore, statement on option B is accurate. As the amount of antivenom is dependent
on the severity of reaction than weight of the client. NOTE: If indicated, antivenom should be administered within 4
hours of bite to be effective. If administered after 2 hours from the time of the bite, it is considered ineffective.
 REFERENCES: Delmars Critical Care Nursing Care Plans Chapter 9.3 p. 350.

Ignatavicius and Workmans Medical-Surgical Nursing: Critical Thinking for Collaborative Care 5th Edition, (2006),
Volume 1, p. 177.

4. Lace instructed the newly hired nurse to inform the client with congestive heart failure to avoid Valsalva-type
maneuvers. The newly hired nurse understands that these include the following, except:
A. Walking to and from the bathroom C. Coughing and straining
B. Moving from supine to lateral position D. Getting out of bed to a wheelchair

ANSWER: A

RATIONALE:

Valsalva-type maneuver is forced exhalation against closed glottis which increases intra thoracic pressure thus,
interfere with the return of venous blood to the heart. It occurs when one strains during defecation and urination, uses
the arms and the upper trunk muscles to move up in bed or strains during coughing,gagging or vomiting. Walking
does not causes Valsalva maneuver

OPTIONS B, C and D are INCORRECT. Please refer to the explanation above.

5. When appraising the performance of the newly hired nurse during the shift, which of the following behaviors will Lace
consider as reflective of a responsibility to improve evaluation ability?
A. Seeks clarifications regarding deviations from standard procedures
B. Organizes reference materials on medication prescriptions
C. Questions appropriately data obtained from the client
D. Asks for supervision on performance of a new procedure

ANSWER: A

RATIONALE:

To evaluate is to judge or to appraise. Components of evaluation process are:

1. Collecting data related to desired outcome

2. Comparing data with desired outcome
3. Relating nursing activities to outcome
NOTE: Performance evaluation must always be based on established standards

OPTIONS B, C and D are INCORRECT.

SITUATION: Hero, 8 years old, has two chest tubes connected to a disposable water sealed drainage system because of
chest injuries from a vehicular accident.

6. The nurse observed that the drainage from the chest tubes have not increased from the previous shift report. Which of
the following is the priority action of the nurse?
A. Change position of the patient C. Check the chest tube for kinks
B. Document observation in the chart D. Assess for breath sounds

ANSWER: C

RATIONALE:
 The priority nursing action in this situation is to assess for the patency of the tube. However, make sure to avoid
milking or stripping the tube because these techniques do not improve chest tube patency. Squeezing hand over
hand along the tubing and releasing the tubing between squeezes may help improve patency.

OPTION A is INCORRECT. Reposition promotes drainage, however before doing this intervention the nurse should
first assess for any obstruction that is present.

OPTION B is INCORRECT. This is not a normal finding specially in this kind of situation, in which blood accumulation
happens inside the pleural space because of chest injuries. The drainage should be increase over time. However,
make sure that the fluid in bottle one must NEVER come into contact with either the draining from the client o the tube
connecting this bottle to the water seal chamber because if the fluids come incontat with the tube, drainage will stop.

OPTION D is INCORRECT. Assessment of breath sound is indicated to a client with chest tube but not particularly I
this kind of situation where in tube patency is the problem.

REFERENCES: Koziers Fundamentals of Nursing 8th Edition, (2008), Volume 2, p. 1394.

Ignatavicius and Workmans Medical-Surgical Nursing: Critical Thinking for Collaborative Care 5th Edition, (2006),
Volume 1, pp. 623 & 624.

7. Frequent assessment of the closed drainage system is important to ensure appropriate functioning. The nurse
observes that water level fluctuates with respiratory effort. The nurse considers this as a sign of:
A. Trapped air B. An inefficient system C. Patent tubes D. Air leaks

ANSWER: C

RATIONALE:

Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and he drainage
chamber and indicates that the drainange system is PATENT.

OPTION B is INCORRECT. This observation by the nurse isnt indicative of inefficient drainage system

OPTION D is INCORRECT. Air leaks should be suspected if the continuous bubbling is observed in the water seal
chamber.

REFERENCES: Koziers Fundamentals of Nursing 8th Edition, (2008), Volume 2, p. 1394.

Ignatavicius and Workmans Medical-Surgical Nursing: Critical Thinking for Collaborative Care 5th Edition, (2006),
Volume 1, pp. 623 & 624.

Smeltzer, Suzanne C. Brunner and Suddarths Medical-Surgical Nursing 12th Edition, (2010), Volume 1, pp. 668-670.

8. The nurse works with a nursing aide. Which of the following is a correct action of the nurse? The nurse directed the
nursing aide to:
A. Always check that clamp is available at the bedside
B. Observe regularly the amount and color of drainage from chest tubes
C. Report signs of patients discomforts at the site of the chest tubes
D. Turn the patient regularly and maintain connections of the tubes

ANSWER: A
 RATIONALE:

Checking of equipment could be delegated to nursing aide.

OPTIONS B, C and D are INCORRECT. Assessment, nursing intervention and care of invasive lines is the sole
responsibility of the nurse and should not be delegated to nursing aide.

REFERENCE: Hogan, Marry Ann,. et. al. Fundamentals of Nursing 2 nd Edition, p. 461.

9. While the nurse was turning the patient during bed bath, one of the chest tubes was pulled out from its site. Which of
the following will the nurse do first?
A. Cover wound site with sterile gauze C. Reinsert the chest tube
B. Disconnect chest tube from drainage system D. Clamp the chest tube

ANSWER: A

RATIONALE:

If the tube is inadvertently pulled out, the wound should be immediately covered with a dry sterile dressing. If you can
hear air leaking out of the site, ensure that the dressing is NOT OCCLUSIVE. If the air canot escape, this would lead
to a TENSION PNEUMOTHORAX.

OPTION B is INCORRECT. Disconnecting chest tube to the drainage sysem would not help the situation.

OPTION C is INCORRECT. Reinserting the tube would be the responsibility of the physician.

OPTION D is INCORRECT. Clamping he tube would not help the problem. Moreover, clamping should be avoided
unless specifically ordered by the clients attending physician.

REFERENCE: Koziers Fundamentals of Nursing 8th Edition, (2008), Volume 2, p. 1394.

10. To determine if chest tubes are in place and pneumothorax is corrected, which of the following will the nurse expect
physician to order?
A. Arterial blood gas analysis C. Tidal volume measurement
B. Thoracentesis D. Chest radiograph

ANSWER: D

RATIONALE:

Chest radiograph is the definitive test to determine if the chest tubes are in place or if the pneumothorax has been
corrected.

OPTION A is INCORRECT. Arterial blood gas analysis helps provide information regarding acid-base imbalance that
occurring in the body in response to a specific health problem.

OPTION B is INCORRECT. Thoracentesis is defined as aspiration of fluid in the pleural space. This procedure is
used as diagnostic and curative specially to clients with pleural effusion.

OPTION C is INCORRECT. Tidal volume measurement does not indicate if the chest tube is in place or if the
pneumothorax has been corrected. Instead this test is useful in clients with constrictive lung disease especially those
with COPD.
REFERENCE: Silvestri, Linda Anne. Saunders Comprehesive Review for the NCLEX-RN EXAMINATION 4TH Edition,
Chapter 21, p. 38