TEST EXAMINATION: MS 1 OXY LANTING

Sit. 1: Aljay, 60 year old real estate broker, had been complaining of easy fatigue and cough for the past few
months. He was moderately overweight and lead a very stressful job. The doctor is suspecting of heart failure.

1. In history taking by the nurse, which of the following information data will confirm diagnosis of heart failure?
a. Swelling of ankles more in the morning than at night
b. Tingling sensation in the upper extremities
c. Feeling of being bloated after ingestion of food
d. Using two pillows when sleeping to reduce snoring

2. Edema due to heart failure will most likely tend to be

a. Dependent c. Pitting
b. Non pitting d. Painful

3. Digoxin, a cardiac glycoside, is given to Aljay for all of the following intended effects except
a. Increases cardiac output c. Reduced ventricular filling
b. Increases vascular resistance d. Decreased venous return

4. The doctor inserted a central venous pressure catheter as part of hemodynamic monitoring for Aljay. Which of the
following is not true regarding CVP?
a. The zero level of the manometer should be placed at level with right atrium
b. Aljay should be in supine position when taking the reading
c. The patency of the CVP is maintained by an infusion drip
d. Reading should be taken every morning prior to bedside care

5. The doctor prescribed Captopril for Aljay. Which instructions should the nurse include in her teaching?
a. Explain of taking food with the drug
b. Encourage him to eat banana to maitain potassium level
c. Instruct to gradually change his position
d. Advised to take cough suppressant if cough develops

Sit. 2:Chris was awakened from sleep by agonizing substernal chest pain and continued to have chest pain
throughout the next day. He was sent through an ambulance when his wife suspect of worsening heart condition.

6. Typically, the pain of coronary occlusion differs from that of angina pectoris in that the former is:
a. More apt to radiate c. More responsive to rest
b. Intermittent in nature d. Less often provoked by exertion

7. Blood exams were taken immediately after his admissions. An elevated WBC after admissions for acute MI should be
interpreted as
a. Evidence pneumonia has developed c. Requires antibiotic treatment
b. Serious complication d. Predictable response to injury

8. All of the following changes would be expected on the ECG of a recent MI patient except
a. Injury pattern c Evidence. of hypertrophy
b. Ischemic changes d. Evidence of necrosis

9. Morphine was given to Chris in order to:

a. reduce his pulse rate to a normal level
b. prevents reflex coronary spasm due to pain
c. increase the force of cardiac contraction
d. relax smooth muscle in blood vessel

10. In preparing Chris for sleep during his convalescence, the following measures should be done in which order?
1. Administer the ordered sedative 4. Change and tighten bed linen
2. Extinguish the room light 5. Offer the bedpan and urinal
3. Give an alcohol back rub

a. 5,3,4,1,2 b. 1,4,3,5,2 c. 1,5,4,2,3 d. 4,5,3,4,1

Sit. 3: Uma a portly businessman consulted his private doctor concerning episodes of sharp, knifelike chest pain.
Examination reveals a diagnosis of arteriosclerotic disease with angina pectoris.

11. The history revealed that Uma did not consult his doctor when he began to experience angina. Probably the delay
resulted from his
a. High threshold for physical pain and discomfort
b. Denial of the significance of the pain
c. Disinclination to react quickly to changed circumstances
d. Fear that the pain was psychosomatic in origin

12. The doctor prescribed Nitroglycerine tablets to be taken sublingually. To enhance the effect of the drug the nurse
emphasizes which of the following nursing actions?
a. Incorporate aerobic exercise with drug regimen
 b. Encourage chewing of the tablet
c. Take a glass of water prior to intake of drug
d. Monitor blood pressure during the treatment

13. UMa when taking nitrates should be taught by the nurse to avoid alcoholic beverages because
a. Shocklike syndrome may occur c. Chest pain is masked by alcohol
b. Nitrates enhance intoxication state d. Nitrates is rapidly metabolized

14. The nurse recommends regular mild exercise for Uma because it is thought to be beneficial to him by:
a. Increasing the thickness of cardiac muscle
b. Causing dilation of the lower cardiac muscles
c. Accelerate the development of collateral circulation
d. Decreases glycogen stores in myocardium

15. On assessment, the nurse finds the apical impulse below the fifth intercostals space. The nurse suspects
a. Left atrial enlargement c. Right atrial enlargement
b. Left ventricular enlargement d. Right ventricular enlargement

Sit. 4: Alana had been worried of frequent bouts of dizziness and brief fainting spells hence a cardiac workout was
scheduled for her. She was attached to a Holter monitoring device.

16. Which of the following instructions is most important for helping the doctor interpret the information being collected
by the Holter monitor?

a. Record the time and type of physical activities performed

b. Take the radial pulse every hour during the next days
c. Try to relax and limit exercise as much as possible
d. Eat lightly and avoid hot or spicy foods

17. To prevent electrical interference, it is most appropriate to recommend that Alana whose heart rhythm is being
assessed with Holter monitor avoid
a. Standing close to a microwave oven
b. Driving under overhead powerlines
c. Shaving with her electric razor
d. Using a cellular phone

18. If Alana understand’s the explanation, which structure will he identify as the site of natural pacemaker?
a. Purkinje fibers c. Carotid sinus
b. Sinoatrial nodes d. Atrioventricular nodes

19. Alana had developed a heart block. To assess the area where the permanent pacemaker battery has been implanted,
the nurse is most correct in examining the skin
a. Beneath the left nipple c. In the midsternum
b. Near the brachial artery d. Below the clavicle

20. As part of her discharge instruction, the nurse is most correct in telling Alana that a sign of pacemaker malfunction is
a. Tingling in the chest area c. Hiccups and epigastric pain
b. Dizzines during activity d. Tenderness beneath the skin

Sit. 5: Mario was awakened from sleep by agonizing substernal pain. He continued to have chest pain throughout
the next day which prompted him consult to the company doctor. A tentative diagnosis of acute coronary occlusion was
made prompting admission to the hospital. He was placed on constant telemetry monitoring.

21. As part of the cardiac assessment, the nurse palpates the apical pulse. To perform this assessment, the nurse places the
fingertips
a. To the right of the midclavicular line at the third intercostals space
b. At the medial aspect of the wrist on the left extremities
c. At the left midclavicular line at fifth intercostals space
d. At the left midclavucular line third intercostals space

22. The nurse on duty is applying ECG electrodes to a diaphoretic patient. The nurse does which of the following to keep
the electrodes from coming loose?
a. Cleanses the skin with alcohol before applying the electrodes
b. Secure the electrodes with adhesive tape
c. Place clear transparent dressing over the electrodes
d. Applies lanolin to the skin before applying the electrodes
 23. The nurse is monitoring Mario’s cardiac monitor. She is aware that the passage of electrical current from the AV
node to the Purkinje fibers represents which of the following?
a. P wave c. ST segment
b. QRS complex d. T wave

24. Mario develops a rapid atrial rate. He has a correct understanding of cardioversion if he tells the nurse that
involves
a. Evaluating blood flow to heart muscles
b. Scanning the heart after injecting a radioisotope
c. Administering electric current to the heart
d. Threading a thin plastic catheter in the heart

25. Before cardioversion is attempted, the nurse is most correct in withholding which of the following prescribed
medications?
a. Diazepam c. Nitroglycerine
b. Digoxin d. Glibenclamide

Mang Isko, a carpenter had been hypertensive for ten years, complains of on and off pain in the legs.
Sit. 6:
He had been taking his drugs irregularly with no medical check up. The doctor suspects of arterial occlusive
disorder of the legs.

26. The careful inspection of nurse on Mang Isko’s leg would most likely reveal which of the following findings
that would confirm arterial occlusive disorder of the leg?
a. Edema and blistering c. Redness on lowering the extremities
b. Ulcer at the lateral side d. Brown discoloration of the foot

27. As the nurse suspects arterial insufficiency of both lower extremities,an essential intervention would be to
teach Mang Isko to:
a. Massage the legs when painful
b. Maintain elevation of both legs
c. Apply hot water bottle to the legs
d. Check arterial pulses regularly

28. When supporting vasodilation by the use of warmth for a patient with arterial insufficiency, the nurse should
caution Mang Isko to avoid:
a. Maintaining a cool room temperature
b. Applying hot water bottle to the abdomen
c. Drinking a cup of coffee when feeling chilly
d. Use of heating pad to wrap the extremities

29. A nurse gives the dose of IV Hydralazine. To evaluate the effectiveness of the medication by monitoring which
of the following patient’s parameter
a. Blood pressure c. urine output
b. cardiac rhythm d. blood glucose level

30. Base on the findings of the doctor, the nurse would expect Mang Isko to experience which of the following
symptoms?
a. Muscle pain caused by exercise c. Muscle pain not relieved by rest
b. Muscle pain relieved by exercise d. Muscle pain that worsens at night

Sit. 7: Mr. Cruz had been hypertensive for the past ten years and significantly does not feel anything until lately he
started to experience easy fatigue and mild dyspnea. On physical examination his blood pressure was elevated.

31. In his history, the nurse expects Mr. Cruz to report experiencing the most common symptom associated with
hypertension which is
a. Fatigue c. Headache
b. Nose bleeds d. Flushed face

32. In examination the nurse is aware that the basic cause of Mr. Cruz’s increasing blood pressure was:
a. Generalized spasm of the peripheral arterioles
b. Increased force of myocardial infarction
c. Increase in circulating blood volume
d. Increased viscosity of circulating blood

33. The doctor prescribed Enalapril. Which information indicates that you need to contact the doctor about the change in
therapy?
a. Patient coughs often c. Complains of occasional dizziness
b. Reports of frequent urination d. Increase in appetite

34. Which of the following nursing diagnosis would warrant the highest priority nursing problem for Mr. Cruz ?
a. Impaired gas exchange c. Alteration in tissue perfusion
b. Ineffective health maintenance d. Alteration in comfort
35. While teaching Mr. Cruz in blood pressure monitoring, the nurse should emphasize that the diastolic BP is recorded
when
a. the first sound is heard during cuff deflation
b. the muffled sound is heard during cuff deflation
c. the muffled sound is heard during cuff inflation
d. the last sound is heard during cuff deflation

Sit. 8: Imelda, a known diabetic had been admitted in the ward because of a non healing wound on her right
extremities. She had been following her medical regimen as reported and is scheduled for possible surgical intervention.

36. An extremity with impaired arterial blood flow may be expected to demonstrate which of the following symptoms?
a. Dependent edema c. Trophic changes
b. Crampy pain d. Reduced temperature

37. In anticipating her postoperative situation Imelda was probably most concerned about her
a. Physical disfiguration c. Phantom sensations
b. Wound pain d. Dependence on others

38. Encasing Imelda’s leg in cracked ice for some time before amputation would produced all except one of the following?
a. Inhibition of pain sensation c. Increased arterial blood supply
b. Curtailment of infection d. Retardation of gangrene

39. The best means of reducing edema of Imelda’s stump on the second day following her leg amputation would be to
a. Elevate the stump on rubber covered pillows
b. Crank up the foot gatch of the bed frame
c. Suspend the stump from a Balkan frame
d. Raise the foot of the bed frame on blocks

40. After Imelda’s surgical wound healed completely, which type of dressing would probably be ordered for her stump?
a. Warm moist compress c. Elastic pressure bandage
b. Vaseline gauze strips d. Dry fluff gauze

Sit. 10: Shellane had been so concerned with her varicose veins and had been experiencing leg cramps on
prolonged standing and small ulcer on the medial aspects of her foot.

41.The nurse is aware that venous valve may be said to be incompetent when
a. Obstruct the flow of blood returning from the extremities to the heart
b. Fail to prevent blood from flowing caudally under the influence of gravity
c. Prevent the flow of blood between superficial and deep leg vein
d. Fail to filter bacteria from the blood as it flows toward the heart

42. In her treatment to Shellane’s leg ulcer, which of the following may be applied to the ulcer site to stimulate the
formation of granulation tissues?

a. Silver nitrate c. Gold leaf

b. Copper sulfate d. Aluminum hydroxide

43.In the cleaning of Shellane’s ulcer which of the following would be most helpful to flush the necrotic material from the
base of the ulcer?
a. Distilled water c. Normal saline
b. Hydrogen peroxide d. Penicillin solution

44. To facilitate healing, doctor also included Unna paste boot to be applied for Shellane for which of the following
purpose?
a. Decrease likelihood of vasomotor collapse
b. Prevent orthopedic deformities during bedrest
c. Provide support for superficial veins
d. Protect the ulcer from sunlight to reduce discharges

45. In her preparation for application of Unna’s paste boot, the nurse should include
a. Covering ulcer with dry sterile gauze
b. Legs flat on bed for half an hour
c. Wrapping the leg in a sheet wadding
d. Encasing the leg in a stockinette

Sit. 10: At the PGH medical male ward, Manong Oscar, 55 years old was admitted due to anemia with the
usual accompanying symptoms.

46. The nurse is aware that the tachycardia in anemia is probably the result of
 a. Chronic low grade bacterial infection c. Reflex response to anoxia
b. Atheromatous narrowing of arteries d. Anxiety due to physical exam

47. Which of the following blood findings would be characteristic of iron deficiency anemia?
a. Microcytic, hypochromic c. Microcytic, normochromic
b. Macrocytic, hypochromic d. Macrocytic, hyperchromic

48. Which of the following is an important nursing intervention to provide warmth for Manong Oscar an anemic client who
complains of being cold?
a. hot water bottle c. heating pad
b. hyperthermic banket d. socks and blanket

49. To which of the following circulatory disorders would Manong Oscar be particularly susceptible before
antianemic therapy begins to take effect?
a. Thrombophlebitis c. Cerebrovascular accident
b. Congestive heart failure d. Pulmonary embolism

50. In preparing Mang Oscar for sleep each evening the nurse should
a. Massage his hand and feet briskly c. Raise the side rails of the bed
b. Offer warm tea and toast d. Immobilize legs with sandbags

Sit. 11: Manuel, a known asthmatic, was mild URTI for the past few days. Upon waking up he experienced
severe dyspnea and immediately went to the hospital for treatment. At the ER, the nurse observes Manuel to be
diaphoretic, restless , and was gasping for air.

51. The hyperresonance of Manuel’s chest detected on admission to the hospital was a manifestation of:
a. Constriction of bronchi c. Overdistention of alveoli
b. Consolidation of air sacs d. Distention of pleural sac

52. The flaring of Manuel’s alae nasi was probably a manifestation of

a. Acute anxiety c. Physical exhaustion
b. Inspiratory difficulty d. Respiratory acidosis

53. When teaching Manuel’s on how to reduce exposure to allergens, the nurse best tell him
a. Maintain indoor humidity c. Work outdoors early in the morning
b. Damp dusting of furnitures d. Frequent washing of sheets and pillow

54. Since Manuel had been taking Zileuton the nurse anticipates the doctor to monitor which of the following?
a. Liver enzymes c. Reflexes
b. Arterial blood gases d. Triglyceride levels

55. The ER nurse should make which of the following available for possible use in caring for Manuel on admission?
a. Emesis basis c. Endotracheal tube
b. Nasogastric tube d. Tracheostomy set

Sit. 12: Anton ,a heavy smoker, complained to his doctor of frequent episode of shortness of breath and dyspnea
on exertion. The doctor made a diagnosis of emphysema with cor pulmonale

56. Which of the following result of emphysema is primarily responsible for Manny’s cardiomegaly?
a. Secretion of excessive amount of pericardial fluid
b. Decreased number of circulating RBC
c. Hypertrophy of muscles encircling the bronchi
d. Increased pressure in the pulmonary circulation

57. . In cor pulmonale which of the following symptoms tends to appear first?
a. Pedal edema c. Watery sputum
b. Substernal pain d. Severe albuminuria

58.. The primary purpose of the breathing improvement exercise ordered for Manny would be to
a. Increased the depth of respiration c. Restore normal chest dimensions
b. Improve gaseous exchange d. Increase the force of exhalation

59. On examination, Manny’s reduced vital capacity is primarily the result of

a. reduction in lung air space c. Fixed elevation of diaphragm
b. Increased in residual air volume d. Flaccid paralysis of intercostals muscles

60. While waiting for the doctor to arrive, Manny would have been most comfortable in which of the following positions?
a. Sitting on edge of bed c. Reclining on his left side
b. Supine with head lowered d. Lying flat on bed
 Sit. 13: Raphael is admitted to SICU with stab wound to his right chest. While he was in the ER, a chest tube was
inserted because of hemothorax.

61. Upon admission of Raphael in the SICU, the nurse will expect to have which of the following examination findings?
a. Increased in tactile fremitus c. Paradoxical chest movement
b. Unequal chest expansion d. Flat sound on percussion

62. The nurse is assessing him for tracheal deviation after the x-ray revealed presence of pneumothorax and hemothorax.
She will expect to observe the trachea to deviate to
a. Contralateral side in simple pneumothorax
b. Affected side in hemothorax
c. Affected side in tension pneumothorax
d. Contralateral side in hemothorax

63. The nurse is assisting the doctor with the insertion of chest tube. The nurse monitors the patient and observes
fluctuations of the fluid at the water seal chamber. On the basis of this, which of the following actions would be most
appropriate?
a. Reinforce the bandage dressing
b. Continue to monitor
c. Inform the physician
d. Encourage the client to deep breathe

64. As you assess Raphael physically , you know that a sign of tension pneumothorax is:
a. Increased BP c. Unequal chest expansion
b. Neck vein distention d. Inspiratory stridor

65. Raphael underwent right lobectomy. While caring for him at the PACU, the nurse most likely place him in which of the
following positions?
a. Right side lying or semi Fowler’s c. Left side lying or supine
b. Orthopneic position d. Left side lying or Fowler’s

Sit. 14: Ms. Simang had been experiencing slight slurring of speech and mild ptosis for the past few days.
Disturbed by her condition she sought consult with a neurologist and a diagnosis of myasthenia gravis was made.

66. The nurse anticipates which of the following manifestations is seen early in a client with myasthenia gravis:
a. Failure to close the eyes c. Pupillary dilation
b. Sagging of the face d. Dyspnea

67. Which intervention is important to include in your plan for Ms Simang with myasthenia gravis
a. Helping her to cope with mood swing c. Warm baths prior to exercise
b. Schedule care with periods of rest d. Encourage independence in ADL

68. The nurse in making the care plan includes observing for the most common problem arising from the use of
Pyridostigmine that include:
a. Gastric distress- nausea, diarrhea
b. Elimination problem- urinary retention
c. CNS excitation-flushing, irritanility
d. cardiac arrythmias- palpitations

69. In her care with Ms. Simang the nurse will anticipate which of the following instrument be place on her bedside?
a. Tracheostomy set c. Emesis basin
b. Endotracheal tube d. Oxygen tank

70. While giving Neostigmine to Ms Simang, which intervention is a key to correctly administer this drug?
a. Monitor renal and hepatic reactions c. Monitor physical activities

b. Regulate doses base on needs d. Give the drug at the right time

Sit. 15: Sheryn was admitted in the hospital because of a breast mass for biopsy and possible surgery. She has
history of hysterectomy three years ago for myoma. She was a bit anxious

71. The admitting nurse is asking Sheryn about breast self examination. The nurse that Sheryn is correct when she reports
she do it:
a. at the onset of menstruation c. one week after menstruation
b. every month during ovulation d. monthly at same date

72. She was scheduled for surgery. The nurse knows that a modified radical mastectomy involves the removal of:
a. breast only
b. breast and axillary nodes
 c. breast, pectoralis major muscle and axillary lymph nodes
d. breast, underlying chest muscle, axillary and internal mammary nodes

73. The nurse caring for a Shereyn with breast cancer is receiving high dose of Methotrexate and Folic acid. The nurse is
aware that the purpose of Folic acid is
a. Promote DNA synthesis
b. Preserve normal cells
c. Promote medication excretion
d. Promote synthesis of nucleic acid

74. The nurse should frequently check both the operation of the suction apparatus attached to the flap catheter and the
quantity of fluid aspirated in order to prevent
a. Displacement of mediastinum c. Collapse of the lung on affected side
b. Destruction of skin graft d. Distention of pleural sac

75. Which of the following devices would be most helpful in positioning Sheryn’s left arm as to minimize discomfort when
she first sits up in a chair?
a. Overbed table c. Overhead trapeze
b. Squeeze ball d. Muslin sling

Sit. 16: Mario was admitted with chief complaints of chronic productive cough with dyspnea on exertion. The
attending doctor diagnosed him with chronic bronchitis on mild exacerbation.

76. In planning care for Mario, the nurse should know that his paroxysms of coughing would most often be
precipitated by

a. Decreasing temperature c. Ingesting foods

b. Changing position d. Increasing humidity

77. When assessing Mario with COPD, which health promotion information would be most important for the nurse
to obtain?
a. Possibility for lifestyle changes c. Risk factors for complications
b. Number of years he has smoked d. Ability to administer inhaled drugs

78. The doctor ordered the use of postural drainage for Mario. The nurse knows that the most common hazards of
postural drainage are
a. Nausea and vomiting c. Dizziness and falling
b. Aspiration and asphyxia d. Headache and tinnitus

79. In order to increase the benefits of postural drainage, the nurse should tell Mario that while he is in postural
drainage position he should
a. Take short shallow breaths to reduce the danger of coughing
b. Swallow forcefully and frequently to prevent regurgitation of food
c. Compress one nostril at a time and exhale to open his sinuses
d. Breathe deeply and cough in order to stimulate removal of sputum

80. While Mario is in postural drainage, the nurse should provide him with
1. Glass of water 3. Sputum cup 5. Call bell

2. Tissue wipes 4. Small pillow

a. 2,3,5 b. 1,2,3 c. 2,3,4 d. 1,3,4

Sit. 17: Maria was coughing, anxious and perspiring freely. On examination, chest auscultation
revealed hyperesonance, expiratory wheezing and rhonchi. The nurse is aware that Maria has an acute attack of asthma.

81. During the attack, Maria’s bronchial secretions would differ from those of a well person that they would be
a. Thinner and more copious c. Frothy and blood streaked
b. Thicker and tenacious d. Yellow green and sticky

82. While in the emergency room, which diagnostic test will be ordered to determine the status of Maria’s
condition?
a. Complete blood count c. Allergy skin testing
b. Drug cortisol level d. Pulmonary function test

83. Which intervention should the ER nurse implement first for the Maria admitted with asthma?
 a. Assess the breath sounds c. Administer glucocorticoid as ordered
b. Encourage to cough forcefully d. Establish a patent IV line

84. The admitting doctor prescribed Fluticasone inhaler for Maria to control her symptoms. Which of the following
information should the nurse teach?
a. Do not abruptly stop taking this medication, taper it slowly
b. Hold the medication in the mouth for 15 seconds before swallowing
c. Rinse the mouth following drug administration
d. Take the medication immediately when an attack starts

85. The doctor gave Maria a metered dose inhaler. Which of the following indicates understanding of the health
teachings given to her regarding its use?

a. I will flex my head forward and breathe out forcefully

b. As I press down the canister,I will inhale slowly over 10 seconds
c. I will hold my breath for 5 seconds to allow the drug to reach my lungs
d. I will wait 1 minute between puffs

Sit. 18: Lola Ising had become progressively more weak and confused with complains of numbness and tingling in
her legs. A diagnosis of pernicious anemia was made.

86. As the nurse assist Lola Ising from the wheelchair, she noted that Lola Ising seemed short of breath. Her dyspnea was
probably the result of
a. Anoxia c. Heart failure
b. Anxiety d. Pneumonia

87. Which of the following emotional states is Lola Ising most apt to display during the early period of her hospitalization?
a. Apathy c. Euphoria
b. Hysteria d. Irritability

88. Which of the following is thought to be a probable cause of pernicious anemia?

a. Insufficient intake of meat and eggs c. Toxic depression of marrow
b. Inflammation in the ileum d. Lack of extrinsic factor

89. Lola Ising’s friend is planning to give her a gift and she confided it to the nurse. The nurse might best propose to suggest
which of the following suitable for the patient?
a. Cotton flannel jacket c. Pair of Havaianas slipper
b. Box of chocolate candy d. Tablecloth to embroider

90. The nurse must be particularly alert to protect Lola Ising which of the following when she is first given with ambulatory
privileges?
a. Falling c. Chilling
b. Fainting d. Infection

Sit. 19: Marie a nursing student had been having on and off fever for the past few days. She complains of
painful cough. She decided to seek consult at the school’s dispensary hospital.

91. Which of the following findings on nursing assessment would most likely be associated with the diagnosis of
pneumonia?
a. Dry hacking cough at night c. Diminished breath sounds
b. Accessory use of muscles d. Hematemesis in the morning

92. Marie has anorexia because of the effort required for eating while dyspneic and decreased taste sensation.
Which of the following will be most helpful in increasing her appetite?
a. Push fluids to 2-3 l/day c. Provide three large meals
b. Keep water at the bedside d. Provide mouth care before meals

93. The nurse is auscultating the chest of a Marie and suspects with new onset pleurisy. She does not have pleural
friction rub, which was noted the other day. The nurse understands that this is likely due to:
a. the deep breaths the patient is taking
b. decreased inflammatory reaction at the site
c. accumulation of pleural fluid in the inflamed area
d. effectiveness of medication given.

94. Marie has a suspected pleural effusion secondary to her pneumonia. The nurse assesses her for which typical
manifestation of this respiratory problem?
a. dyspnea on exertion and moist productive cough
b. dyspnea on exertion and dry non productive cough
c. dyspnea at rest with moist productive cough
d. dyspnea at rest with non productive cough
95. The doctor just finished doing a thoracentesis for Marie for her pleural effusion and was able to remove 1,600
ml of fluid. Which of the following will be of most concern to the nurse?
a. Marie cries and states that she cannot go on with the treatment longer
b. Her BP is 100/50 and her pulse rate is 108/minute
c. The dressing site has a 1.5 cm bloody discharge
d. She reports of sharp stabbing pain every time she takes a deep breath

Sit. 20: : Samuel had been diagnosed to have endocarditis for the past two years and have developed valvular heart
defect as a consequence of his condition. He had been complaining of on and off joint pains with occasional palpitations.

96. Samuel’s therapeutic intervention will be directed primarily toward the prevention in which of the possible
complication of his illness?
a. Progressive joint ankylosis c. Congestive heart failure
b. Skeletal muscle contraction d. Cerebrovascular hemorrhage

97. The auscultatory area in the left midclavicular line at the level of the fifth ICS is the
a. tricuspid area c. aortic area
b. mitral area d. pulmonic area

98. The nurse is aware that Samuel developed tricuspid regurgitation. The nurse will most likely expect which of the
following physical findings?
a. Bipedal edema c. Cyanosis
b. Shortness of breath d. Chest pain

99. The doctor immediately ordered Benzathine penicillin in order to:

a. Sterilize joint effusion and facilitate healing
b. Prevent streptococcal infection and rheumatic activation
c. Destroy bacteria inhabiting the myocardium
d. Reverse the tissue changes causing joint symptoms

100. What would be the home care goal for Samuel who has bacterial endocarditis?
a. To begin an exercise regimen as soon as possible
b. To decrease activity until pulse stabilize
c. To monitor urinary output
d. To decrease activity until pulse stabilizes