GORDON COLLEGE

College of Allied Health Studies

Tapinac Oval Sports Complex, Donor St., East Tapinac, Olongapo City

DIAGNOSTIC EXAMINATION 1-INP LEVEL IV

Name:__________________________________________
6. A client is admitted for hemodialysis. Which abnormal
Date: _______________ Score: __________________
lab value would the nurse anticipate not being improved
by hemodialysis?
Instructions: Read each question carefully and choose the
a. Low hemoglobin c. High serum creatinine
correct/best answer from the given options and circle the letter
b. Hypernatremia d. Hyperkalemia
of your choice. STRICTLY NO ERASURES ALLOWED.
7. The nurse is performing an assessment on a client with
1. The nurse is assessing a client with delayed wound
pneumococcal pneumonia. Which finding would the
healing. Which of the following risk factors is most
nurse anticipate?
important in this situation?
a. Bronchial breath sounds in outer lung fields
a. Glucose level of 120
b. Decreased tactile fremitus
b. History of myocardial infarction
c. Hacking, nonproductive cough
c. Long term steroid usage
d. Hyperresonance of areas of consolidation
d. Diet high in carbohydrates
8. A client complaining of severe shortness of breath is
2. A client with HIV infection has a secondary herpes
diagnosed with congestive heart failure. The nurse
simplex type 1 (HSV-1) infection. The nurse knows that
observes a falling pulse oximetry. The client's color
the most likely cause of the HSV-1 infection in this
changes to gray and she expectorates large amounts of
client is
pink frothy sputum. The first action of the nurse would
a. Immunosuppression c. Unprotected sexual activities
be which of the following?
b. Emotional stress d. Contact with saliva
a. Call the health care provider
b. Check vital signs
3. The nurse is caring for a client with a sigmoid
c. Position in high Fowler's
colostomy who requests assistance in removing the
d. Administer oxygen
flatus from a 1-piece drainable ostomy pouch. Which is
the correct intervention?
9. The nurse is caring for a client with benign prostatic
a. Piercing the plastic of the ostomy pouch with a pin to
hypertrophy. Which of the following assessments would
vent the flatus
the nurse anticipate finding?
b. Opening the bottom of the pouch, allowing the flatus
a. Large volume of urinary output with each voiding
to be expelled
b. Involuntary voiding with coughing and sneezing
c. Pulling the adhesive seal around the ostomy pouch
c. Frequent urination
to allow the flatus to escape
d. Urine is dark and concentrated
d. Assisting the client to ambulate to reduce the flatus in
the pouch
10. The nurse has been assigned to these clients in the
emergency room. Which client would the nurse go
4. When teaching a client with chronic obstructive
check first?
pulmonary disease about oxygen by cannula, the nurse
a. Viral pneumonia with atelectasis
should also instruct the client's family to:
b. Spontaneous pneumothorax with a respiratory rate of
a. Avoid smoking near the client
38
b. Turn off oxygen during meals
c. Tension pneumothorax with slight tracheal deviation
c. Adjust the liter flow to 10 as needed
to the right
d. Remind the client to keep mouth closed
d. Acute asthma with episodes of bronchospasm
5. A 7-year-old child is hospitalized following a major burn
11. The nurses on a unit are planning for stoma care for
to the lower extremities. A diet high in protein and
clients who have a stoma for fecal diversion. Which
carbohydrates is recommended. The nurse informs the
stomal diversion poses the highest risk for skin
child and family that the most important reason for this
breakdown
diet is to
a. Ileostomy c. Ileal conduit
a. Promote healing and strengthen the immune system
b. Transverse colostomy d. Sigmoid colostomy
b. Provide a well-balanced nutritional intake
c. Stimulate increased peristalsis absorption
12. When making a home visit to a client with chronic
d. Spare protein catabolism to meet metabolic needs
pyelonephritis, which nursing action has the highest
priority?
 a. Follow-up on lab values before the visit
b. Observe client findings for the effectiveness of
antibiotics
c. Ask for a log of urinary output
d. As for the log of the oral intake
13. The nurse is teaching a client with dysrhythmia about
the electrical pathway of an impulse as it travels
through the heart. Which of these demonstrates the
normal pathway?
a. AV node, SA node, Bundle of His, Purkinje fibers
b. Purkinje fibers, SA node, AV node, Bundle of His
c. Bundle of His, Purkinje fibers, SA node, AV node
d. SA node, AV node, Bundle of His, Purkinje fibers
14. Clients with mitral stenosis would likely manifest
findings associated with congestion in the?
a. Pulmonary circulation c. Superior vena cava
b. Descending aorta d. Bundle of His
15. The nurse is caring for a client with end stage renal
disease. What action should the nurse take to assess
for patency in a fistula used for hemodialysis?
a. Observe for edema proximal to the site
b. Irrigate with 5 mL of 0.9% Normal Saline
c. Palpate for a thrill over the fistula
d. Check color and warmth in the extremity
16. When assessing a client who has just undergone a
cardioversion, the nurse finds the respirations are 12.
Which action should the nurse take first?
a. Try to vigorously stimulate normal breathing
b. Ask the nurse to assess the vital signs
c. Measure the pulse oximetry
d. Continue to monitor respirations
17. In order to enhance a client's response to medication
for chest pain from acute angina, the nurse should
emphasize what?
a. Learning relaxation techniques
b. Limiting alcohol use
c. Eating smaller meals
d. Avoiding passive smoke
18. The primary nursing diagnosis for a client with
congestive heart failure with pulmonary edema is
a. Pain c. Cardiac output altered: decreased
b. Impaired gas exchange d. Fluid volume excess
19. The nurse is caring for a post myocardial infarction
client in an intensive care unit. It is noted that urinary
output has dropped from 60 -70 ml per hour to 30 ml
per hour. This change is most likely due to
a. Dehydration
b. Diminished blood volume
c. Decreased cardiac output
d. Renal failure
20. Which complication of cardiac catheterization should
the nurse monitor for in the initial 24 hours after the
procedure?
a. angina at rest
b. thrombus formation
c. dizziness
d. falling blood pressure
21. A client is admitted to the emergency room with renal
calculi and is complaining of moderate to severe flank
pain and nausea. The client’s temperature is 100.8
degrees Fahrenheit. The priority nursing goal for this
client is
a. Maintain fluid and electrolyte balance
b. Control nausea
c. Manage pain
d. Prevent urinary tract infection
22. A client comes to the clinic for treatment of recurrent
pelvic inflammatory disease. The nurse recognizes that
this condition most frequently follows which type of
infection?
a. Trichomoniasis
b. Chlamydia
c. Staphylococcus
d. Streptococcus
23. The nurse is performing a neurological assessment on
a client post right CVA. Which finding, if observed by
the nurse, would warrant immediate attention?
a. Decrease in level of consciousness
b. Loss of bladder control
c. Altered sensation to stimuli
d. Emotional lability
24. The nurse is preparing to administer an enteral feeding
to a client via a nasogastric feeding tube. The most
important action of the nurse is
a. Verify correct placement of the tube
b. Check that the feeding solution matches the dietary
order
c. Aspirate abdominal contents to determine the
amount of last feeding remaining in stomach
d. Ensure that feeding solution is at room temperature
25. The nurse is caring for a client with a serum potassium
level of 3.5 mEq/L. The client is placed on a cardiac
monitor and receives 40 mEq KCL in 1000 ml of 5%
dextrose in water IV. Which of the following EKG
patterns indicates to the nurse that the infusions should
be discontinued?
a. Narrowed QRS complex
b. Shortened "PR" interval
c. Tall peaked T waves
d. Prominent "U" waves
 26. During an assessment of a client with cardiomyopathy, b. hypokalemia and hyponatremia
the nurse finds that the systolic blood pressure has c. hyperkalemia and hyponatremia
decreased from 145 to 110 mm Hg and the heart rate d. hyperkalemia and hypernatremia
has risen from 72 to 96 beats per minute and the client
complains of periodic dizzy spells. The nurse instructs 33. Teddy, who sustained deep partial thickness and full
the client to thickness burns of the face, whole anterior chest and
a. Increase fluids that are high in protein both upper extremities two days ago, begins to exhibit
b. Restrict fluids extreme restlessness. You recognize that this most
c. Force fluids and reassess blood pressure likely indicates that Teddy is developing:
d. Limit fluids to non-caffeine beverages a. Cerebral hypoxia
b. Hypervolemia
27. A client has a Swan-Ganz catheter in place. The nurse c. Metabolic acidosis
understands that this is intended to measure d. Renal failure.
a. Right heart function
Situation– Colorectal cancer can affect old and younger people.
b. Left heart function
Surgical procedures and other modes of treatment are done to
c. Renal tubule function
ensure quality of life. You are assigned in the Cancer institute to
d. Carotid artery function
care of patients with this type of cancer.
28. A nurse enters a client's room to discover that the client 34. Larry, 55 years old, who is suspected of having
has no pulse or respirations. After calling for help, the colorectal cancer, is admitted to the CI. After taking the
first action the nurse should take is history and vital signs the physician does which test as
a. Start a peripheral IV a screening test for colorectal cancer.
b. Initiate closed-chest massage a. Barium enema
c. Establish an airway b. Carcinoembryonic antigen
d. Obtain the crash cart c. Annual digital rectal examination
d. Proctosigmoidoscopy
Situation– Because of the serious consequences of severe
burns management requires a multidisciplinary approach. You
35. To confirm his impression of colorectal cancer, Larry
have important responsibilities as a nurse.
will require which diagnostic study?
29. While Sergio was lighting a barbecue grill with a lighter a. carcinoembryonic antigen
fluid, his shirt burst into flames. The most effective way b. Proctosigmoidoscopy
to extinguish the flames with as little further damage as c. stool hematologic test
possible is to: d. abdominal computed tomography (CT) test
a. log rolls on the grass/ground
b. slaps the flames with his hands 36. The following are risk factors for colorectal cancer,
c. removes the burning clothes EXCEPT:
d. pours cold liquid over the flames a. inflammatory bowels
b. high fat, high fiber diet
30. Once the flames are extinguished, it is most important c. smoking
to: d. genetic factors-familial adenomatous polyposis
a. cover Sergio with a warm blanket
b. give him sips of water 37. Symptoms associated with cancer of the colon include:
c. calculate the extent of his burns a. constipation, ascites and mucus in the stool
d. assess the Sergio’s breathing b. diarrhea, heartburn and eructation
c. blood in the stools, anemia, and pencil-shaped,
31. Sergio is brought to the Emergency Room after the stools
barbecue grill accident. Based on the assessment of d. anorexia, hematemesis, and increased peristalsis
the physician, Sergio sustained superficial partial
thickness bums on his trunk, right upper extremities ad 38. Several days prior to bowel surgery, Larry may be given
right lower extremities. His wife asks what that means. sulfasuxidine and neomycin primarily to:
Your most accurate response would be: a. promotes rest of the bowel by minimizing peristalsis
a. Structures beneath the skin are damaged b. reduces the bacterial content of the colon
b. Dermis is partially damaged c. empties the bowel of solid waste
c. Epidermis and dermis are both damaged d. softens the stool by retaining water in the colon
d. Epidermis is damaged
Situation– Ensuring safety is one of your most important
responsibilities. You will need to provide instructions and
32. During the first 24 hours after thermal injury, you should
information to your clients to prevent complications.
assess Sergio for
a. hypokalemia and hypernatremia
 39. Randy has chest tubes attached to a pleural drainage
system. When caring for him you should:
a. empties the drainage system at the end of the shift
b. clamps the chest tube when auctioning
c. palpates the surrounding areas for crepitus
d. changes the dressing daily using aseptic techniques
40. Fanny came in from PACU after pelvic surgery. As
Fanny’s nurse you know that the sign that would be
indicative of a developing thrombophlebitis would be:
a. a tender, painful area on the leg
b. a pitting edema of the ankle
c. a reddened area at the ankle
d. pruritus on the calf and ankle
41. To prevent recurrent attacks on Terry who has acute
glomerulonephritis, you should instruct her to:
a. seeks early treatment for respiratory infections
b. takes showers instead of tub bath
c. continues to take the same restrictions on fluid intake
d. avoids situations that involve physical activity
42. Herbert has a laryngectomy and he is now for
discharge. Re verbalized his concern regarding his
laryngectomy tube being dislodged. What should you
teach him first?
a. Recognize that prompt closure of the tracheal
opening may occur
b. Keep calm because there is no immediate
emergency
Situation– With the improvement in life expectancies and the
c. Reinsert another tubing immediately
emphasis in the quality of life it is important to provide quality
d. Notify the physician at once
care to our older patients. There are frequently encountered
situations and issues relevant to the older, patients.
43. When caring for Larry after an exploratory chest
surgery and pneumonectomy, your priority would be to
maintain:
a. supplementary oxygen
b. ventilation exchange
c. chest tube drainage
d. blood replacement
Situation– As a nurse you need to anticipate the occurrence of
complications of stroke so that life threatening situations can be
prevented.
44. Wendy is admitted to the hospital with signs and
symptoms of stroke. Her Glasgow Coma Scale is 6 on
admission. A central venous catheter was inserted and
an I.V. infusion was started. As a nurse assigned to
Wendy what will he your priority goal?
a. Prevent skin breakdown
b. Preserve muscle function
c. Promote urinary elimination
d. Maintain a patent airway
45. Knowing that for a comatose patient hearing is the best
last sense to be lost, as Judy’s nurse, what should you
do?
a. Tell her family that probably she can’t hear them
b. Talk loudly so that Wendy can hear you
c. Tell her family who are in the room not to talk
d. Speak softly then hold her hands gently
46. Which among the following interventions should you
consider as the highest priority when caring for June
who has hemiparesis secondary to stroke?
a. Place June on an upright lateral position
b. Perform range of motion exercises
c. Apply antiembolic stocking
d. Use hand rolls or pillows for support
47. Ivy, age 40, was admitted to the hospital with a severe
headache, stiff neck and photophobia. She was
diagnosed with a subarachnoid hemorrhage secondary
to ruptured aneurysm. While waiting for surgery, you
can provide a therapeutic by doing which of the
following?
a. honoring her request for a television
b. placing her bed near the window
c. dimming the light in her room
d. allowing the family unrestricted visiting privileges
48. When performing a neurological assessment on Walter,
you find that his pupils are fixed and dilated. This
indicated that he:
a. probably has meningitis
b. is going to be blind because of trauma
c. is permanently paralyzed
d. has received a significant brain injury
49. Hypoxia may occur in the older patients because of
which of the following physiologic changer associated
with aging.
a. Ineffective airway clearance
b. Decreased alveolar surface area
c. Decreased anterior-posterior chest diameter
d. Hyperventilation
50. The older patient is at higher risk for in inconvenience
because of:
a. dilated urethra
b. increased glomerular filtration rate
c. diuretic use
d. decreased bladder capacity
Prepared by:
MICHAEL P. TUYAY, RN, LPT, MASE
Instructor III
GOOD, BETTER, BEST. NEVER LET IT REST. 'TIL YOUR
GOOD IS BETTER AND YOUR BETTER IS BEST.
(ST. JEROME)
IT DOES NOT MATTER HOW SLOWLY YOU GO AS LONG
AS YOU DO NOT STOP.
(CONFUCIUS)
"DON'T BE AFRAID TO GIVE UP THE GOOD TO GO FOR
THE GREAT."
(JOHN D. ROCKEFELLER)