1. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be:
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs
2. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:
a. Decrease anxiety and restlessness
b. Prevents shock and relieves pain
c. Dilates coronary blood vessels
d. Helps prevent fibrillation of the heart
3. Which of the following should the nurse teach the client about the signs of digitalis toxicity?
a. Increased appetite
b. Elevated blood pressure
c. Skin rash over the chest and back
d. Visual disturbances such as seeing yellow spots
4. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help…
a. Retard rapid drug absorption
b. Excrete excessive fluids accumulated at night
c. Prevents sleep disturbances during night
d. Prevention of electrolyte imbalance
5. What would be the primary goal of therapy for a client with pulmonary edema and heart failure?
a. Enhance comfort
b. Increase cardiac output
c. Improve respiratory status
d. Peripheral edema decreased
6. Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?
a. Upper extremity flexion with lower extremity flexion
b. Upper extremity flexion with lower extremity extension
c. Extension of the extremities after a stimulus
d. Flexion of the extremities after stimulus
7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:
a. GI bleeding
b. Peptic ulcer disease
c. Abdominal cramps
d. Partial bowel obstruction
8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?
a. Monitoring urine output frequently
b. Monitoring blood pressure every 4 hours
c. Obtaining serum potassium levels daily
d. Obtaining infusion pump for the medication
9. During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome?
a. Able to perform self-care activities without pain
b. Severe chest pain
c. Can recognize the risk factors of Myocardial Infarction
d. Can Participate in cardiac rehabilitation walking program
10. A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:
a. Application of elastic stockings to prevent flaccid by muscle
b. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
c. Use a bed cradle to prevent dorsiflexion of feet
d. Do passive range of motion exercise
11. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be…
a. Hourly urine output
b. Temperature
c. Able to turn side to side
d. Able to sips clear liquid
12. A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is…..
a. To determine the existence of CHD
b. To visualize the disease process in the coronary arteries
c. To obtain the heart chambers pressure
d. To measure oxygen content of different heart chambers
13. During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to…
a. Elevate clients bed at 45°
b. Instruct the client to cough and deep breathe every 2 hours
c. Frequently monitor client’s apical pulse and blood pressure
d. Monitor clients temperature every hour
14. Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?
a. Protamine Sulfate
b. Quinidine Sulfate
c. Vitamin C
d. Coumadin
15. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of…
a. Dental floss
b. Electric toothbrush
c. Manual toothbrush
d. Irrigation device
16. Among the following signs and symptoms, which would most likely be present in a client with mitral gurgitation?
a. Altered level of consciousness
b. Exceptional Dyspnea
c. Increase creatine phospholinase concentration
d. Chest pain
17. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the…
a. Urinary meatus
b. Pain in the Labium
c. Suprapubic area
d. Right or left costovertebral angle
18. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function.
a. Blood pressure
b. Consciousness
c. Distension of the bladder
d. Pulse rate
19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?
a. Tonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Clonic seizure
20. Smoking cessation is critical strategy for the client with Burgher’s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication?
a. Paracetamol
b. Ibuprofen
c. Nitroglycerin
d. Nicotine (Nicotrol)
21. Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by:
a. Episodic vasospastic disorder of capillaries
b. Episodic vasospastic disorder of small veins
c. Episodic vasospastic disorder of the aorta
d. Episodic vasospastic disorder of the small arteries
22. Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because…
a. More accurate
b. Can be done by the client
c. It is easy to perform
d. It is not influenced by drugs
23. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost…
a. 0.3 L
b. 1.5 L
c. 2.0 L
d. 3.5 L
24. Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of:
a. Osmosis
b. Diffusion
c. Active transport
d. Filtration
25. Myrna a 52 year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking?
a. Left leg discomfort
b. Weak biceps brachii
c. Triceps muscle spasm
d. Forearm weakness
26. Which of the following statements should the nurse teach the neutropenic client and his family to avoid?
a. Performing oral hygiene after every meal
b. Using suppositories or enemas
c. Performing perineal hygiene after each bowel movement
d. Using a filter mask
27. A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in
a. Sims position
b. Supine position
c. Semi-fowlers position
d. Dorsal recumbent position
28. Which nursing intervention ensures adequate ventilating exchange after surgery?
a. Remove the airway only when client is fully conscious
b. Assess for hypoventilation by auscultating the lungs
c. Position client laterally with the neck extended
d. Maintain humidified oxygen via nasal canula
29. George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should…
a. “Strip” the chest tube catheter
b. Check the system for air leaks
c. Recognize the system is functioning correctly
d. Decrease the amount of suction pressure
30. A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that…
a. I can eat celery sticks and carrots
b. I can eat broiled scallops
c. I can eat shredded wheat cereal
d. I can eat spaghetti on rye bread
31. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased…
a. Pressure in the portal vein
b. Production of serum albumin
c. Secretion of bile salts
d. Interstitial osmotic pressure
32. A newly admitted client is diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?
a. Vital signs
b. Incision site
c. Airway
d. Level of consciousness
33. A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?
a. Systolic blood pressure less than 90mm Hg
b. Pupils unequally dilated
c. Respiratory rate of 4 breath/min
d. Pulse rate less than 60bpm
34. Nurse Lucy is planning to give pre operative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?
a. Results of the surgery will be immediately noticeable postoperatively
b. Normal saline nose drops will need to be administered preoperatively
c. After surgery, nasal packing will be in place 8 to 10 days
d. Aspirin containing medications should not be taken 14 days before surgery
35. Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem?
a. Regular insulin
b. Potassium
c. Sodium bicarbonate
d. Calcium gluconate
36. Dr. Marquez tells a client that an increase intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:
a. Fish and fruit jam
b. Oranges
c. Carrots and potatoes
d. Spinach and mangoes
37. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client should…
a. Rest in sitting position
b. Take a short walk
c. Drink plenty of water
d. Lie down at least 30 minutes
38. After gastroscopy, an adaptation that indicates major complication would be:
a. Nausea and vomiting
b. Abdominal distention
c. Increased GI motility
d. Difficulty in swallowing
39. A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:
a. “Most people need to eat a high protein diet for 12 months after surgery”
b. “I should not eat those foods that upset me before the surgery”
c. “I should avoid fatty foods as long as I live”
d. “Most people can tolerate regular diet after this type of surgery”
40. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is:
a. Restlessness
b. Yellow urine
c. Nausea
d. Clay- colored stools
41. Which of the following antituberculosis drugs can damage the 8th cranial nerve?
a. Isoniazid (INH)
b. Paraoaminosalicylic acid (PAS)
c. Ethambutol hydrochloride (myambutol)
d. Streptomycin
42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following:
a. Genetic defect in gastric mucosa
b. Stress
c. Diet high in fat
d. Helicobacter pylori infection
43. Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
a. Bile green
b. Bright red
c. Cloudy white
d. Dark brown
44. Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the post operative period. Which of the following is best recommended for the client?
a. Watching circus
b. Bending over
c. Watching TV
d. Lifting objects
45. A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing:
a. Fracture
b. Strain
c. Sprain
d. Contusion
46. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part of the procedure
a. Pulling the auricle backward and upward
b. Warming the solution to room temperature
c. Pacing the tip of the dropper on the edge of ear canal
d. Placing client in side lying position
47. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom?
a. Absence of drainage from the ileostomy for 6 or more hours
b. Passage of liquid stool in the stoma
c. Occasional presence of undigested food
d. A temperature of 37.6 °C
48. Jerry has diagnosed with appendicitis. He develops a fever, hypotension and tachycardia. The nurse suspects which of the following complications?
a. Intestinal obstruction
b. Peritonitis
c. Bowel ischemia
d. Deficient fluid volume
49. Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis.
a. Myocardial Infarction
b. Cirrhosis
c. Peptic ulcer
d. Pneumonia
50. Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit?
a. Watery stool
b. Yellow sclera
c. Tarry stool
d. Shortness of breath
ANSWER:
- B. Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.
- B. Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.
- D. Seeing yellow spots and colored vision are common symptoms of digitalis toxicity
- C. When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.
- B. The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention.
- C. Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury.
- C. The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea.
- D. Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.
- A. By the 2nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain
- B. The left side of the body will be affected in a right-sided brain attack.
- A. After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early.
- B. The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries.
- C. Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. Apical pulse is taken to detect dysrhythmias related to cardiac irritability.
- A. Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery.
- C. The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.
- B. Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation.
- D. Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side.
- A. Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output.
- C. Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.
- D. Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome.
- D. Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.
- A. Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure.
- C. One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L.
- A. Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.
- D. Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.
- B. Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract.
- C. Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.
- C. Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur.
- B. Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.
- C. Wheat cereal has a low sodium content.
- A. Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites.
- C. Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange.
- A. Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
- D. Aspirin containing medications should not be taken 14 days before surgery to decrease the risk of bleeding.
- A. Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem.
- D. Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives, spinach, asparagus and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots, mangoes and tomatoes.
- A. Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.
- B. Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis.
- D. It may take 4 to 6 months to eat anything, but most people can eat anything they want.
- D. Clay colored stools are indicative of hepatic obstruction
- D. Streptomycin is an aminoglycoside and damage on the 8th cranial nerve (ototoxicity) is a common side effect of aminoglycosides.
- D. Most peptic ulcer is caused by Helicopter pylori which is a gram negative bacterium.
- D. 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food.
- C. Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure.
- A. Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling.
- C. The dropper should not touch any object or any part of the client’s ear.
- A. Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed.
- B. Complications of acute appendicitis are peritonitis, perforation and abscess development.
- D. A client with acute pancreatitis is prone to complications associated with respiratory system.
- B. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.
Medical Surgical Nursing Practice Test Part 2
1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
a. Diuretics
b. Antihypertensive
c. Steroids
d. Anticonvulsants
2. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
a. Increase the flow of normal saline
b. Assess the pain further
c. Notify the blood bank
d. Obtain vital signs.
3. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:
a. A history of high risk sexual behaviors.
b. Positive ELISA and western blot tests
c. Identification of an associated opportunistic infection
d. Evidence of extreme weight loss and high fever
4. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
a. Raw carrots
b. Apple juice
c. Whole wheat bread
d. Cottage cheese
5. Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:
a. Flapping hand tremors
b. An elevated hematocrit level
c. Hypotension
d. Hypokalemia
6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
a. Flank pain radiating in the groin
b. Distention of the lower abdomen
c. Perineal edema
d. Urethral discharge
7. A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:
a. Assist the client with sitz bath
b. Apply war soaks in the scrotum
c. Elevate the scrotum using a soft support
d. Prepare for a possible incision and drainage.
8. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
a. Liver disease
b. Myocardial damage
c. Hypertension
d. Cancer
9. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
a. Right atrium
b. Superior vena cava
c. Aorta
d. Pulmonary
10. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
a. Ineffective health maintenance
b. Impaired skin integrity
c. Deficient fluid volume
d. Pain
11. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
a. high blood pressure
b. stomach cramps
c. headache
d. shortness of breath
12. The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
a. High levels of low density lipid (LDL) cholesterol
b. High levels of high density lipid (HDL) cholesterol
c. Low concentration triglycerides
d. Low levels of LDL cholesterol.
13. Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
a. Potential wound infection
b. Potential ineffective coping
c. Potential electrolyte balance
d. Potential alteration in renal perfusion
14. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
a. dairy products
b. vegetables
c. Grains
d. Broccoli
15. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
d. Intake and out put
16. Lydia
a. signed consent
b. vital signs
c. name band
d. empty bladder
17. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
a. 4 to 12 years.
b. 20 to 30 years
c. 40 to 50 years
d. 60 60 70 years
18. Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except
a. effects of radiation
b. chemotherapy side effects
c. meningeal irritation
d. gastric distension
19. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?
a. Administering Heparin
b. Administering Coumadin
c. Treating the underlying cause
d. Replacing depleted blood products
20. Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
a. Urine output greater than 30ml/hr
b. Respiratory rate of 21 breaths/minute
c. Diastolic blood pressure greater than 90 mmhg
d. Systolic blood pressure greater than 110 mmhg
21. Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
a. Stomatitis
b. Airway obstruction
c. Hoarseness
d. Dysphagia
22. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
a. Promotes the removal of antibodies that impair the transmission of impulses
b. Stimulates the production of acetylcholine at the neuromuscular junction.
c. Decreases the production of autoantibodies that attack the acetylcholine receptors.
d. Inhibits the breakdown of acetylcholine at the neuromuscular junction.
23. A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
a. Vital signs q4h
b. Weighing daily
c. Urine output hourly
d. Level of consciousness q4h
24. Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen like insulin delivery devices. The nurse explains that the advantages of these devices over syringes includes:
a. Accurate dose delivery
b. Shorter injection time
c. Lower cost with reusable insulin cartridges
d. Use of smaller gauge needle.
25. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
a. Swelling of the left thigh
b. Increased skin temperature of the foot
c. Prolonged reperfusion of the toes after blanching
d. Increased blood pressure
26. After a long leg cast is removed, the male client should:
a. Cleanse the leg by scrubbing with a brisk motion
b. Put leg through full range of motion twice daily
c. Report any discomfort or stiffness to the physician
d. Elevate the leg when sitting for long periods of time.
27. While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:
a. Buttocks
b. Ears
c. Face
d. Abdomen
28. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:
a. Palms of the hands and axillary regions
b. Palms of the hand
c. Axillary regions
d. Feet, which are set apart
29. Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
a. Active joint flexion and extension
b. Continued immobility until pain subsides
c. Range of motion exercises twice daily
d. Flexion exercises three times daily
30. A male client has undergone spinal surgery, the nurse should:
a. Observe the client’s bowel movement and voiding patterns
b. Log-roll the client to prone position
c. Assess the client’s feet for sensation and circulation
d. Encourage client to drink plenty of fluids
31. Marina
a. Hypovolemia
b. renal failure
c. metabolic acidosis
d. hyperkalemia
32. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
a. Protein
b. Specific gravity
c. Glucose
d. Microorganism
33. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?
a. Electrolyte imbalance
b. Head trauma
c. Epilepsy
d. Congenital defect
34. What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
a. Pupil size and papillary response
b. cholesterol level
c. Echocardiogram
d. Bowel sounds
35. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
a. “Practice using the mechanical aids that you will need when future disabilities arise”.
b. “Follow good health habits to change the course of the disease”.
c. “Keep active, use stress reduction strategies, and avoid fatigue.
d. “You will need to accept the necessity for a quiet and inactive lifestyle”.
36. The nurse is aware the early indicator of hypoxia in the unconscious client is:
a. Cyanosis
b. Increased respirations
c. Hypertension
d. Restlessness
37. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
a. Normal
b. Atonic
c. Spastic
d. Uncontrolled
38. Which of the following stage the carcinogen is irreversible?
a. Progression stage
b. Initiation stage
c. Regression stage
d. Promotion stage
39. Among the following components thorough pain assessment, which is the most significant?
a. Effect
b. Cause
c. Causing factors
d. Intensity
40. A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?
a. Sleeping in cool and humidified environment
b. Daily baths with fragrant soap
c. Using clothes made from 100% cotton
d. Increasing fluid intake
41. Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
a. A client with high blood
b. A client with bowel obstruction
c. A client with glaucoma
d. A client with U.T.I
42. Among the following clients, which among them is high risk for potential hazards from the surgical experience?
a. 67-year-old client
b. 49-year-old client
c. 33-year-old client
d. 15-year-old client
43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?
a. Headache
b. Bladder distension
c. Dizziness
d. Ability to move legs
44. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s disease except:
a. Antiemetics
b. Diuretics
c. Antihistamines
d. Glucocorticoids
45. Which of the following complications associated with tracheostomy tube?
a. Increased cardiac output
b. Acute respiratory distress syndrome (ARDS)
c. Increased blood pressure
d. Damage to laryngeal nerves
46. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules
47. An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:
a. increased capillary fragility and permeability
b. increased blood supply to the skin
c. self inflicted injury
d. elder abuse
48. Nurse Anna is aware that early adaptation of client with renal carcinoma is:
a. Nausea and vomiting
b. flank pain
c. weight gain
d. intermittent hematuria
49. A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be:
a. 1 to 3 weeks
b. 6 to 12 months
c. 3 to 5 months
d. 3 years and more
50. A client has undergone laryngectomy. The immediate nursing priority would be:
a. Keep trachea free of secretions
b. Monitor for signs of infection
c. Provide emotional support
d. Promote means of communication
ANSWER
1. C. Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
2. A. The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
3. B. These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
4. D. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
5. A. Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
6. B. This indicates that the bladder is distended with urine, therefore palpable.
7. C. Elevation increases lymphatic drainage, reducing edema and pain.
8. B. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
9. D. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent back ward flow into the pulmonary vein, the pulmonary circulation is under pressure.
10. A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
11. C. Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.
12. A. An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
13. D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
14. A. Good source of vitamin B12 are dairy products and meats.
15. C. Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
16. B. An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.
17. A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
18. D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
19. B. Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
20. A. Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
21. C. Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.
22. C. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
23. C. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
24. A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.
25. C. Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
26. D. Elevation will help control the edema that usually occurs.
27. B. Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
28. B. The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
29. A. Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
30. C. Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.
31. A. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.
32. C. The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
33. B. Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
34. A. It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
35. C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
36. D. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
37. B. In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
38. A. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
39. D. Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
40. B. The use of fragrant soap is very drying to skin hence causing the pruritus.
41. C. Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
42. A. A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
43. B. The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.
44. D. Glucocorticoids play no significant role in disease treatment.
45. D. Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
46. C. In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
47. A. Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis.
48. D. Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.
49. B. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.
50. A. Patent airway is the most priority; therefore removal of secretions is necessary
