Ms Exam 500 Items - Answers With Ratio

THE SULTAN REVIEW GROUPNURSING REVIEW
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Tel No.: (02) 7346432
MEDICAL-SURGICAL NURSING
July 2011 Nurse Licensure Examination
1. A two-year-old child who experienced a head

trauma and is receiving mechanical ventilation
suddenly develops increased intracranial
pressure. Which of the following actions would
a nurse take first?
a. Suction the endotracheal tube
b. Position the child in Trendelenburg position
c. Increase the oxygen concentration
d. Hyperventilate the child
Carbon Dioxide has a potent vasodilating effect
and will increase cerebral blood flow and
intracranial pressure. Cerebral hypoxia may result
if
intracranial
pressure
is
elevated.
Hyperventilation because it decreases carbon
dioxide levels, maybe induced to decrease the
intracranial pressure.
CGFNS Qualifying Exam, Official Study Guide,
page 240
2. A nurse places a patient in a four-pointrestraints following orders from a physician.
Which of the following measures should the
nurse include in the patients plan of care?
a. Socialize with other patients once a shift
b. Check circulation periodically
c. Provide stimulating diversional activities
d. Assess the rectal temperature frequently
Restraints encircle the limbs, placing the patient
at risk for circulation being restricted to the distal
areas of the extremities. Checking the patients
circulation every 15-30 minutes will allow the
nurse to adjust the restraints before injury from
decreased blood flow occurs. The nurse must
document the time of the check and the degree of
capillary refill
page 243
3. A patient has severe burns is receiving H2
receptor antagonist therapy. The nurse should
explain to the patient that the purpose of the
therapy is to:
a. Prevent stress ulcers
b. Enhance gas exchange
c. Facilitate protein absorption
d. Block prostaglandin synthesis
Curlings ulcer occurs in burn patients and is
caused by a generalized stress response. This
results in a decreased production of mucus and
increased gastric secretions. The best treatment
for this is prophylactic use of antacids and H2
receptor blocker
page 241
4. Which
of the
following
instructions
is
appropriate for the nurse to give to a patient
who has gastro esophageal reflux disease?
a. take prescribed antacids before eating
b. place blocks under the legs of the
head of the bed
SULTAN REVIEW GROUP NURSING REVIEW
c. eat high fat, low protein diet

d. lie down, one hour after eating
The nurse should ensure that the head of the bed
is elevated correctly(usually on four to six inch
blocks), and that the patient does not lie down
from two to three hours after eating
page 241
5. Which of the following statements would a
nurse include in discharge instructions to the
parent of an eight-year-old boy has been
diagnosed with concussion?
a. Call the physician if your child has
repeated episodes of vomiting
b. Dont give your child any non prescription
analgesics for 48 hours
c. Limit your child in a quiet and darkened
room while he is recovering
d. Limit your childs diet to clear liquids for 24
hours
A concussion is a transient and reversible
neuronal dysfunction with instantaneous loss of
awareness and responsiveness caused by trauma
of the head. The loss of awareness can persist for
minutes to hours. The child with a concussion can
be cared for and observed at home. The parents
are advised to check the child every two hours
and to monitor responsiveness or changes in the
level of consciousness. Vomiting may be a
symptom of increasing intracranial pressure and
should be reported immediately to the physician
page 241
6. A 15 year old child is suspected of having
Hodgkins disease. It is most important that a
nurse perform which of the following
assessments during the initial physical
examination?
a. Inspection of the mucous membranes
b. Percussion of the kidneys
c. Palpation of the lymph nodes
d. Auscultation of the bowel sounds
Hodgkins disease is a malignancy that originates
in the lymphoid system. It is characterized by the
painless enlargement of lymph nodes and occurs
in children 15-19 years old.
page 247
7. A patient who has sustained a head injury has a
urine output of 200 ml/ hr for three
consecutive hours. Which of the following
nursing measures is most appropriate in the
care of the patient?
a. Palpating the bladder
b. Offering additional fluid
c. Monitoring renal function tests
d. Measuring the urine specific gravity
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Instruction: Select the correct answer for each following questions. Mark only one answer for each item by
encircling the letter of your choice. STRICTLY NO ERASURES ALLOWED.

following behaviors would indicate that the

patient needs instruction in self care?
a. He wears sleeveless shirts
b. He keeps a dry dressing on his left arm
c. He wears a watch on his left wrist
d. He prefers to take a shower rather than tub
bath
Nothing should constrict the arm in which the
arteriovenous fistula is located. This includes
occlusion y blood pressure cuffs, jewelry or tight
fitting sleeves. A, B and D are acceptable actions
by the patient
page 261
13. A patient is scheduled for bronchoscopy. To
prepare the patient for the procedure, the
nurse should give which of the following
instructions?
a. A small needle will be inserted through the
skin into the lung tissue
b. Food and fluids will be withheld for
one to two hours following the
procedure
c. It will be uncomfortable to breathe deeply
following the procedure
d. You will cough some of the dye during few
days
Following a bronchoscopy, the patient should
remain NPO until gag reflex returns. A fiber optic
scope is inserted through the nose and once the
procedure is completed, the patient should not
have any problem with deep breathing. Dye is not
used during the procedure
page 262
14. Which of the following observations of a patient
who has pernicious anemia would indicate that the
goal of care has been achieved?
a. The patients skin has no petechiae
b. The patients tongue has lost its beefy
red color
c. The patient has no dependent edema
d. The patient has a good appetite
Pernicious Anemia is the absence of intrinsic
factor secreted by the gastric mucosa. It produces
a beefy red tongue. When treatment has been
effective, the tongue looses this appearance
page 205
15. A nurse is assessing a patient who is at risk of
development of compartment syndrome. To
which of the following assessment would the
nurse give the highest priority
a. Apical pulse
c.
Neurovascular
status
b. Papillary response
d.
Deep
tendon reflexes
Careful monitoring of the neurovascular status of
the extremities is crucial in the detection and the
prevention of compartment syndrome. This
syndrome is a complication of fractures and is
caused the progressive development of arterial
vessel compression and reduced blood supply in
the extremity. Fracture of the forearm or tibia
usually precedes the onset of muscle edema in the
fascia, which forms compartments for the muscles
of the forearm and lower leg. When there is severe
trauma, such as in fracture or compression of tight
cast, muscle ischemia occurs.
page 217
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An increase in urine output with low specific

gravity may herald the onset of diabetes insipidus.
The urine output should be 30 ml / hour
page 248
8. A nurse would expect a patient who has
Menieres disease to have which of the
following findings?
a. Distension of the abdomen
b. Swelling of the ankles
c. Shortness of breath
d. Loss of balance
Menieres
disease
represents
a
quadrad
symptoms; fluctuating, progressive sensorineural
hearing loss , tinnitus, a feeling of pressure or
fullness in the ear and episodic vertigo, which may
affect balance
page 249
9. A child who is receiving cancer chemotherapy
has a platelet count of 50,000 cu. Ml. Based on
this information, the childs parent should be
instructed to:
a. Maintain strict bed rest until the childs
blood levels return to normal
b. Use soft bristle toothbrush for the
childs oral hygiene
c. Anticipate the need for a red blood cell
transfusion for the child
d. Eliminate spicy foods from the childs diet
The patient with a platelet count of 50,000 cubic
ml is prone to bleeding. Using a soft bristle
toothbrush for the child s oral hygiene will
prevent irritation of the patients gums and will
decrease the likelihood of bleeding episodes
page 254
10. It is essential that a nurse take which of the
following measures when caring of the patient
who is in the acute phase of nephritic
syndrome?
a. Weigh the child every day
b. Obtain the childs hematocrit every 12
hours
c. Measure the child childs abdominal girth
every two hours
d. Dipstick the childs urine output every hour
As the child responds to treatment for nephritic
syndrome, fluid retention decreases. Daily weight
provides an assessment of fluid retention.
Additional methods of monitoring progress include
examination of urine for specific gravity and
albumin, measurement of abdominal girth,
assessment of edema and monitoring vital signs
page 255
11. Which of the following manifestation supports
the diagnosis of fluid volume excess in an
eight-year-old
child
who
has
acute
glumerulonephritis?
a. Polyuria
b. Periorbital edema
c. Nocturnal diaphoresis
d. Jugular vein distension
Initial manifestations of nephrotic reaction in
acute
glumerulonephritis
include
peiorbital
edema, anorexia and dark colored urine
page 256
12. A male patient has an arteriovenous fistula
created in his left forearm. Which of the

swallowing, and presents a danger of choking and

aspiration. Nursing diagnosis for the patient with
Myasthenia gravis are ineffective breathing,
impaired physical mobility and risk for aspiration
related to weakness in the muscles
page 222
21. A patient who is receiving a digitalis
preparation should be observed for symptoms
of toxicity, which include?
a. Hypertension
c. Tinnitus
b. Oliguria
d. Vomiting
A manifestation of Digoxin toxicity is vomiting.
Other gastrointestinal signs and symptoms of
digoxin toxicity are nausea, anorexia, abdominal
pain and diarrhea
page 222
22. A patient who had a laryngectomy is being
prepared for discharge. Which of the following
questions, if asked by the patient, would
indicate an understanding of the instructions?
a. What type of humidifier would you
recommend?
b. What are the best foods for a high fiber
diet?
c. How long would you suggest that I keep the
plug for the laryngectomy tube in a
disinfectant?
d. How long do I have to worry that I may
aspirate the food?
Since the nose normally humidifies the air,
supplemental humidifications is indicated for the
patient with laryngectomy. There are no dietary
restrictions in this patient. Laryngectomy tubes
are not plugged. There is no risk for aspiration
since there is no connection between esophagus
and respiratory tract
page 223
23. A patient has hyperthyroidism is taking
methimazole (Tapazole) and attends the clinic
regularly. To evaluate the effectiveness of
Tapazole therapy, the nurse should consider
which of the following questions?
a. Has the patients vision improved?
b. Has the patients appetite improved?
c. Has
the
patients
need
for
sleep
decreased?
d. Has
the
patients
pulse
rate
decreased?
Tapazole is used to decrease iodine use and
inhibit the synthesis of thyroid hormones.
Therefore, metabolic activity will be decreased if
the treatment is effective.
page 223
24. A few hours after a plaster of Paris hip spica is
applied, the patient tells the nurse that she
has tingling sensations in her leg and that her
foot is asleep. Which of the following actions
should the nurse take?
a. Explain to the patient that such feelings are
common while cast is drying
b. Make sure that the patients leg is elevated
so that her toes are higher than her heart
c. Tell the patient that moving her toes
frequently will increase the circulation in
her leg
d. Notify the patients physician
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16. A nurse is caring for a patient who underwent

a transurethral resection of the prostate
(TURP) several hours ago. The patient
experiences nausea, confusion, elevated blood
pressure and decreased pulse rate. The nurse
would most likely suspect which of the
following conditions to develop in the patient?
a. Bladder spasms
c. Dehydration
b. Hyponatremia
d. Sepsis
Hyponatremia post transurethral resection is due
to the absorption of irrigating fluid during and
after surgery. The patients blood pressure
increases, the pulse decreases and the patient
becomes confused and nauseated
page 219
17. To promote skin integrity of a patient who is in
Russels traction, which of the following
measures should be included in the plan of
care?
a. Having the patient lie on the right side for
20 minutes every 2 to 3 hours
b. Placing the pillow under the patients sacral
and scapular area
c. Massaging the patients back and
buttocks frequently
d. Applying an antiseptic solution to the
patients bony prominences after bathing
Massaging the patients back and buttocks
frequently promotes skin integrity and should be
included in the care plan of a patient in traction
page 220
18. Three hours after receiving an insulin injection
(Regular Insulin), a patient is diaphoretic.
Which of the following actions should the nurse
take first?
a. Help the patient to put on a dry night gown
b. Ask the patient for a urine specimen
c. Give the patient a glass of juice to
drink
d. Instruct the patient to stay in bed until seen
by the physician
Regular insulin peaks two to four hours. Since
diaphoresis is a symptom of hypoglycemia, a glass
of juice or skim milk should be given to the patient
to raise the blood sugar levels
page 221
19. The bowel retraining program for a patient
who has had a cerebrovascular accident should
include which of the following measures?
a. Checking for impaction daily
b. Increasing the intake of milk products
c. Utilizing incontinent pads until control is
achieved
d. Establishing a consistent time for
elimination
Bowel retraining is established by providing a
consistent time for evacuation each day
page 222
20. To which of the following nursing diagnoses
would the nurse give priority in caring for a
patient who has myasthenia gravis?
a. Ineffective individual coping
b. Situational low self esteem
c. Ineffective thermoregulation
d. Risk for aspiration
With Myastenia Gravis, weakness of the bulbar
muscle causes problems with chewing and

c. Prone, with his head turned to the left side.

d. Dorsal recumbent with a pillow at the back
of his head.
Fowlers position or sitting on side of the bed
with feet on stool provide easy access to
abdominal area and allows intestines to float to
prevent laceration.
Text Book of Medical Surgical Nursing by Brunner
and Suddarth 11 ed. Page 1295-1296
29. Marco returns to his room following a
transurethral resection of the prostate (TURP)
for benign prostatic hypertrophy (BPH). Which
of the following would cause the nurse incharge to suspect postoperative hemorrhage?
a. Decreased blood pressure, increased
pulse, increased respiration.
b. Fluctuating blood pressure, decreased pulse,
rapid respirations.
c. Increased blood pressure, bounding pulse,
irregular respirations.
d. Increased blood pressure, irregular pulse,
shallow respirations.
It is caused by decreased blood volume, as
intravascular volume decreases and BP falls, heart
rate increases in attempt to maintain cardiac
output, respiratory increase in attempt to increase
oxygenation.
30. David returns from his room following a cardiac
catheterization. Which of the following
assessments, if made by the nurse would
justify calling the physician?
a. Pain at the site of the catheter insertion.
b. Absence of a pulse distal to the
catheter insertion site.
c. Drainage on the dressing covering the
catheter insertion site.
d. Redness at the catheter insertion site.
Decrease in blood supply and a report of change
in sensation, color, pulses should be immediately
alert the physician.
and Suddarth 11 ed. Page 814
31. Marco who was diagnosed with brain tumor
was scheduled for craniotomy. In preventing
the development of cerebral edema after
surgery, the Nurse Anna should expect the use
of:
a. Muscle relaxant
c. Steroids
b. Antihypertensive
d. Anticonvuls
ants
Glucocorticoids (steroids) are used for their antiinflammatory action, which decreases the
development of edema.
Kaplan NCLEX RN Exam 2008 edition, Page 217
32. 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
These tests confirm the presence of HIV
antibodies that occur in response to the presence
of the human immunodeficiency virus (HIV).
33. Kenneth who has diagnosed with uremic
syndrome has the potential to develop
Page1
Paresthesias after a cast is applied indicate that

the cast is too tight. The physician should be
notified. Paresthesias should not occur while the
cast is drying. The symptoms indicate that the
arterial circulation is impaired. Elevating the leg
promotes venous return and is not indicated.
Moving
the
toes
is
an
assessment
of
neurovascular function. It does not increase
circulation to the leg
page 225
25. A patient who has a left frontal lobe tumor has
a craniotomy. Four hours after surgery, the
following data are obtained by the nurse.
Which of the following data would be most
indicatives of increasing intracranial pressure?
a. The patients blood pressure is 160/90; up
from 140/90
b. The patient is difficult to rouse
c. The patients Babinski response is negative
d. The patient is incontinent of urine 101
As the intracranial pressure increases, the
patient becomes less alert and more difficult to
rouse. This change in consciousness is one of the
earliest signs of increased intracranial pressure.
Pulse pressure widens with increased intracranial
pressure , causing a larger gap between the
systolic and diastolic pressures than is seen in this
patient
page 226
26. Mrs. Andres, a 78 year old client is admitted
with the diagnosis of mild chronic heart failure.
The nurse expects to hear when listening to
clients lungs indicative of chronic heart failure
would be:
a. Stridor
c. Wheezes
b. Crackles
d. Friction rubs
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.
27. Antonio is admitted for treatment of heart
failure. The physician orders an IV of 125 ml of
normal saline per hour and central venous
pressure (CVP) readings every 4 hours. Initial
reading was 6 cm/H20. Sixteen hours after
admission, the clients CVP reading is 3
cm/H2O. Which of the following evaluations of
the clients fluid status, if made by the nurse
would be most accurate?
a. The client has received enough fluid.
b. The clients fluid status remains unaltered.
c. The client has received too much fluid.
d. The client needs more fluid.
The client needs more fluid. The Normal CVP
reading is 4-10 cm/H2O. The reading is only 3
cm/H20 which indicates hypovolemia.
28. Nurse Olivia performs teaching with a client
undergoing a paracentesis for treatment of
cirrhosis. The client asks what position he will
be in for the procedure. Nurse Olivias reply
would be based on understanding that the
most appropriate position for the client is:
a. Sitting with his lower extremities well
supported.
b. Side-lying with a pillow between his knees.

d. A sensation of painful pressure in the

midsternal area
Duodenal ulcer is related to an increase in the
secretion of HCl. This can be buffered by food
intake thus the relief of the pain that is brought
about by food intake.
39. The client underwent Billroth surgery for
gastric ulcer. Post-operatively, the drainage
from his NGT is thick and the volume of
secretions has dramatically reduced in the last
2 hours and the client feels like vomiting. The
most appropriate nursing action is to:
a. Reposition the NGT by advancing it gently
NSS
b. Notify the MD of your findings
c. Irrigate the NGT with 50 cc of sterile
d. Discontinue the low-intermittent suction
The clients feeling of vomiting and the reduction
in the volume of NGT drainage that is thick are
signs of possible abdominal distention caused by
obstruction of the NGT. This should be reported
immediately to the MD to prevent tension and
rupture on the site of anastomosis caused by
gastric distention.
40. After Billroth II Surgery, the client developed
dumping syndrome. Which of the following
should the nurse exclude in the plan of care?
a. Sit upright for at least 30 minutes after
meals
b. Take only sips of H2O between bites of solid
food
c. Eat small meals every 2-3 hours
d. Reduce the amount of simple carbohydrate
in the diet
The dumping syndrome occurs within 30 mins
after a meal due to rapid gastric emptying,
causing distention of the duodenum or jejunum
produced by a bolus of food. To delay the
emptying, the client has to lie down after meals.
Sitting up after meals will promote the dumping
syndrome.
41. The laboratory of a male patient with Peptic
ulcer revealed an elevated titer of Helicobacter
pylori. Which of the following statements
indicate an understanding of this data?
a. Treatment will include Ranitidine and
Antibiotics
b. No treatment is necessary at this time
c. This result indicates gastric cancer caused
by the organism
d. Surgical treatment is necessary
One of the causes of peptic ulcer is H. Pylori
infection. It releases toxin that destroys the gastric
and duodenal mucosa which decreases the gastric
epitheliums resistance to acid digestion. Giving
antibiotics will control the infection and Ranitidine,
which is a histamine-2 blocker, will reduce acid
secretion that can lead to ulcer.
42. What would be the primary goal of therapy for
a client with pulmonary edema and heart
failure?
a. Enhance comfort
b. Increase cardiac output
Page1
complications. Which among the following

complications should the nurse anticipates:
a. Flapping hand tremors
b. An elevated hematocrit level
c. Hypotension
d. Hypokalemia
Elevation of uremic waste products causes
irritation of the nerves, resulting in flapping hand
tremors.
34. 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
Morphine is a central nervous system depressant
used to relieve the pain associated with
myocardial
infarction;
it
also
decreases
apprehension and prevents cardiogenic shock.
35. 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
Seeing yellow spots and colored vision are
common symptoms of digitalis toxicity
36. 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
When diuretics are taken in the morning, client
will void frequently during daytime and will not
need to void frequently at night.
37. Which of the following would be inappropriate
to include in a diabetic teaching plan?
a. Change position hourly to increase
circulation
b. Inspect feet and legs daily for any changes
c. Keep legs elevated on 2 pillows while
sleeping
d. Keep the insulin not in use in the refrigerator
The client with DM has decreased peripheral
circulation caused by microangiopathy. Keeping
the legs elevated during sleep will further cause
circulatory impairment.
38. Which description of pain would be most
characteristic of a duodenal ulcer?
a. Gnawing, dull, aching, hungerlike pain
in the epigastric area that is relieved
by food intake
b. RUQ pain that increases after meal
c. Sharp pain in the epigastric area that
radiates to the right shoulder


47. 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
c. Vitamin C
b. Quinidine Sulfate
d. Coumadin
Protamine Sulfate is used to prevent continuous
bleeding in client who has undergone open heart
surgery.
48. 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
c.
Manual
toothbrush
b. Electric toothbrush
d.
Irrigation
device
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.
49. Among the following signs and symptoms,
which would most likely be present in a client
with mitral gurgitation?
a. Altered level of consciousness
b. Exertional Dyspnea
c.
Increase
creatine
phospholinase
concentration
d. Chest pain
Weight gain due to retention of fluids and
worsening heart failure causes exertional dyspnea
in clients with mitral regurgitation. The other
options are least likely to be seen unless
complications set in.
50. 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
Discomfort or pain is a problem that originates in
the kidney. It is felt at the costovertebral angle on
the affected side.
51. 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
c.
Distension
of the bladder
b. Consciousness
d. Pulse rate
Perfusion can be best estimated by blood
pressure, which is an indirect reflection of the
adequacy of cardiac output.
Page1
c. Improve respiratory rate

d. Peripheral edema decreased
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.
43. 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
Decerebrate posturing is the extension of the
extremities after a stimulus which may occur with
upper brain stem injury.
44. Nurse Liza is assigned to care for a client who
has returned to the nursing unit after left
nephrectomy. Nurse Lizas highest priority
would be to:
a. Hourly urine outputc. Able to turn side to
side
b. Temperature
d. Able to sips clear
liquid
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.
45. 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
The lumen of the arteries can be assessed by
cardiac catheterization. Angina is usually caused
by narrowing of the coronary arteries.
46. 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 clients apical pulse
and blood pressure
d. Monitor clients temperature every hour
Blood
pressure
is
monitored
to
detect
hypotension which may indicate shock or
hemorrhage. Apical pulse is taken to detect
dysrhythmias related to cardiac irritability.

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
Enlarged cirrhotic liver impinges the portal
system causing increased hydrostatic pressure
resulting to ascites.
58. A newly admitted client is diagnosed with
Hodgkins disease undergoes an excisional
cervical lymph node biopsy under local
anesthesia. What does the nurse assess first
after the procedure?
a. Vital signs
c. Airway
b. Incision site
d.
Level
of
consciousness
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.
59. 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
Typical signs and symptoms of hypovolemic
shock include systolic blood pressure of less than
90 mm Hg.
60. 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
c.
Sodium
bicarbonate
b. Potassium
d.
Calcium
gluconate
Metabolic acidosis is anaerobic metabolism
caused by lack of ability of the body to use
circulating glucose. Administration of insulin
corrects this problem.
61. Francis is admitted to the hospital for
treatment of hemolytic anemia. Which of the
following measures, if incorporated into
the nursing care plan, would best address the
clients needs.
a. Encourage activities with other clients in the
day room.
b. Isolate him from visitors and clients to avoid
infection.
c. Provide a diet high in vitamin C
d. Provide a quiet environment to
promote adequate rest.
In leukemia, the primary problem is activity
intolerance due to fatigue.
Page1

52. 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
c.
Myoclonic
seizure
b. Absence seizure
d.
Clonic
seizure
Myoclonic seizure is characterized by sudden
uncontrollable jerking movements of a single or
multiple muscle group.
53. Nurse Lilly has been assigned to a client with
Raynauds 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
Raynauds
disease
is
characterized
by
vasospasms of the small cutaneous arteries that
involve fingers and toes.
54. 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
c. 2.0 L
b. 1.5 L
d. 3.5 L
One liter of fluid approximately weighs 2.2
pounds. A 4.5 pound weight loss equals to
approximately 2L.
55. 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
c.
Triceps
muscle spasm
b. Weak biceps brachii d.
Forearm
weakness
Forearm muscle weakness is a probable sign of
radial nerve injury caused by crutch pressure on
the axillae
56. 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
Neutropenic client is at risk for infection
especially
bacterial
infection
of
the
gastrointestinal and respiratory tract.
57. A male client with a history of cirrhosis and
alcoholism is admitted with severe dyspnea
resulted to ascites. The nurse should be aware


68. 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
This indicates that the bladder is distended with
urine, therefore palpable.
69. 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
c. Hypertension
b. Myocardial damage d. Cancer
Detection of myoglobin is a diagnostic tool to
determine whether myocardial damage has
occurred.
70. Nurse Maureen would expect the a client with
mitral stenosis would demonstrate symptoms
associated with congestion in the:
a. Right atrium
c. Aorta
b. Superior vena cava
d. Pulmonary
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.
71. 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
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.
72. Nurse Hazel teaches the client with angina
about common expected side effects of
nitroglycerin including:
a. high blood pressure c. headache
b. stomach cramps
d. shortness of
breath
Because of its widespread vasodilating effects,
nitroglycerin often produces side effects such as
headache, hypotension and dizziness.
73. 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.
Page1
62. 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
c. Nausea
b. Yellow urine
d.
Claycolored
stools
Clay colored stools are indicative of hepatic
obstruction
63. 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
Streptomycin is an aminoglycoside and damage
on the 8th cranial nerve (ototoxicity) is a common
side effect of aminoglycosides.
64. 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
c. Watching
TV
b. Bending over
d. Lifting objects
Watching TV is permissible because the eye does
not need to move rapidly with this activity, and it
does not increase intraocular pressure.
65. 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
The dropper should not touch any object or any
part of the clients ear.
66. 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
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.
67. Jerry has diagnosed with appendicitis. He
develops a fever, hypotension and tachycardia.
The nurse suspects which of the following
complications?
a. Intestinal obstruction c. Bowel ischemia
b. Peritonitis
d.
Deficient
fluid volume
Complications
of
acute
appendicitis
are
peritonitis, perforation and abscess development.
76. After having several stroke attacks over 4

months, a client reluctantly agrees to
implantation of a permanent pacemaker.
Before discharge, the nurse Sheen reviews
pacemaker care and safety guidelines with the
client and spouse. Which safety precaution is
appropriate for a client with a pacemaker?
a. Stay at least 2 away from microwave ovens.
b. Never engage in activities that require
vigorous arm and shoulder movement.
c. Avoid going through airport metal detectors.
d. Avoid using a cellular phone.
A client with a pacemaker should avoid using
cellular phones because they may disrupt the
function of the pacemaker. This problem is less
likely to occur with newer microwave ovens;
nonetheless, the client should stay at least 5
away from microwaves, not 2. The client must
avoid vigorous arm and shoulder movement only
for the first 6 weeks after pacemaker implantation.
Airport metal detectors don't harm pacemakers;
however, the client should notify airport security
guards of the pacemaker because its metal casing
and programming magnet may trigger the metal

detector.
77. Which signs and symptoms are present with a
diagnosis of pericarditis?
a. Fever, chest discomfort, and elevated
erythrocyte sedimentation rate (ESR)
b. Low urine output secondary to left
ventricular dysfunction
c. Lethargy, anorexia, and heart failure
d. Pitting edema, chest discomfort, and
nonspecific ST-segment elevation
The classic signs and symptoms of pericarditis
include fever, positional chest discomfort,
nonspecific ST-segment elevation, elevated ESR,
and pericardial friction rub. All other symptoms
may result from acute renal failure.
78. A nurse is planning to assess the corneal reflex
on unconscious client. Which of the following is
the safest stimulus to touch the clients
cornea?
a. Cotton buds
c.
Sterile
tongue
depressor
b. Sterile glove
d. Wisp of cotton
A client who is unconscious is at greater risk for
corneal abrasion. For this reason, the safest way to
test the cornel reflex is by touching the cornea
lightly with a wisp of cotton.
79. A female client develops an infection at the
catheter insertion site. The nurse in charge
uses the term iatrogenic when describing the
infection because it resulted from:
a. Clients developmental level
b. Therapeutic procedure
c. Poor hygiene
d. Inadequate dietary patterns
Iatrogenic infection is caused by the heath care
provider or is induced inadvertently by medical
treatment or procedures.
80. A hospitalized client had a tonic-clonic seizure
while walking in the hall. During the seizure
the nurse priority should be:
a. Hold the clients arms and leg firmly
b. Place the client immediately to soft surface
c. Protects the clients head from injury
d. Attempt to insert a tongue depressor
between the clients teeth
Rhythmic contraction and relaxation associated
with tonic-clonic seizure can cause repeated
banging of head.
81. The nurse is performing her admission
assessment of a patient. When grading arterial
pulses, a 1+ pulse indicates:
a. Above normal perfusion.
b. Absent perfusion.
c. Normal perfusion.
d. Diminished perfusion
A 1+ pulse indicates weak pulses and is
associated with diminished perfusion. A 4+ is
bounding perfusion, a 3+ is increased perfusion, a
2+ is normal perfusion, and 0 is absent perfusion.
Page1
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.
74. 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
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.
75. Leo comes to the emergency department with
an
acute myocardial
infarction.
An
electrocardiogram shows a heart rate of 116
beats/minute
with
frequent
premature
ventricular
contractions.
The
client
experiences
ventricular
tachycardia
and
becomes unresponsive. After resuscitation, the
client moves to the intensive care unit. Which
nursing diagnosis is top priority?
a. Impaired physical mobility related to
complete bed rest
b. Deficient knowledge related to emergency
interventions
c. Social isolation related to restricted family
visits
d. Anxiety related to the threat of death
Anxiety related to the threat of death is an
appropriate nursing diagnosis. Anxiety can
adversely affect the client's heart rate and rhythm
by stimulating the autonomic nervous system. The
threat of death is an immediate and real concern
for the client. The other options are valid but their
priority is less urgent.

b. Stoma is oozes a small amount of blood

c. Stoma is lightly edematous
d. Stoma does not expel stool
Dark red to purple stoma indicates inadequate
blood supply.
87. Nurse KC should regularly assess the clients
ability to metabolize the total parenteral
nutrition
(TPN) solution
adequately
by
monitoring the client for which of the following
signs:
a. Hyperglycemia
b. Hypoglycemia
c. Hypertension
d. Elevate blood urea nitrogen concentration
During
Total
Parenteral
Nutrition
(TPN)
administration, the client should be monitored
regularly for hyperglycemia.
88. A female client has an acute pancreatitis.
Which of the following signs and symptoms the
nurse would expect to see?
a. Constipation
c. Ascites
b. Hypertension
d. Jaundice
Jaundice may be present in acute pancreatitis
owing to obstruction of the biliary duct.
89. What instructions should the client be given
before undergoing a paracentesis?
a.NPO 12 hours before procedure
b. Empty bladder before procedure
c. Strict bed rest following procedure
d. Empty bowel before procedure
Paracentesis involves the removal of ascitic fluid
from the peritoneal cavity through a puncture
made below the umbilicus. The client needs to
void before the procedure to prevent accidental
puncture of a distended bladder during the
procedure.
90. The husband of a client asks the nurse about
the protein-restricted diet ordered because of
advanced liver disease. What statement by the
nurse would best explain the purpose of the
diet?
a. The liver cannot rid the body of
ammonia that is made by the
breakdown of protein in the digestive
system.
b. The liver heals better with a high
carbohydrates diet rather than protein.
c. Most people have too much protein in their
diets. The amount of this diet is better for
liver healing.
d. Because of portal hyperemesis, the blood
flows around the liver and ammonia made
from protein collects in the brain causing
hallucinations.
The largest source of ammonia is the enzymatic
and bacterial digestion of dietary and blood
proteins in the GI tract. A protein-restricted diet
will therefore decrease ammonia production.
and Suddarth 11 ed. Page
91. Which of the drug of choice for pain controls
the patient with acute pancreatitis?
Page1

82. Murmurs that indicate heart disease are often
accompanied by other symptoms such as:
a. Dyspnea on exertion.
b. Subcutaneous emphysema.
c. Thoracic petechiae.
d. Periorbital edema.
A murmur that indicates heart disease is often
accompanied by dyspnea on exertion, which is a
hallmark of heart failure. Other indicators are
tachycardia,
syncope,
and
chest
pain.
Subcutaneous emphysema, thoracic petechiae,
and perior-bital edema arent associated with
murmurs and heart disease.
83. The priority nursing diagnosis for the patient
with cardiomyopathy is:
a. Anxiety related to risk of declining health
status.
b. Ineffective individual coping related to fear
of debilitating illness
c. Fluid volume excess related to altered
compensatory mechanisms.
d. Decreased cardiac output related to
reduced myocardial contractility.
Decreased cardiac output related to reduce
myocardial contractility is the greatest threat to
the survival of a patient with cardiomyopathy. The
other options can be addressed once cardiac
output and myocardial contractility have been
restored.
84. A patient with thrombophlebitis reached her
expected outcomes of care. Her affected leg
appears pink and warm. Her pedal pulse is
palpable and there is no edema present. Which
step in the nursing process is described above?
a. Planning
c. Analysis
b. Implementation
d. Evaluation
Evaluation assesses the effectiveness of the
treatment plan by determining if the patient has
met the expected treatment outcome. Planning
refers to designing a plan of action that will help
the
nurse
deliver
quality
patient
care.
Implementation refers to all of the nursing
interventions directed toward solving the patients
nursing problems. Analysis is the process of
identifying the patients nursing problems.
85. A client has undergone right pneumonectomy.
When turning the client, the nurse should plan
to position the client either:
a. Right side-lying position or supine
b. High Fowlers
c. Right or left side lying position
d. Low Fowlers position
Right side lying position or supine position
permits ventilation of the remaining lung and
prevent fluid from draining into sutured bronchial
stump.
86. During the initial postoperative period of the
clients stoma. The nurse evaluates which of
the following observations should be reported
immediately to the physician?
a. Stoma is dark red to purple

d. Place the client on CBR a day before the

study
Barium enema is the radiologic visualization of
the colon using a die. To obtain accurate results in
this procedure, the bowels must be emptied of
fecal material thus the need for laxative and
enema.
96. The client has a good understanding of the
means to reduce the chances of colon cancer
when he states:
a. I will exercise daily.
b. I will include more red meat in my diet.
c. I will have an annual chest x-ray.
d. I will include more fresh fruits and
vegetables in my diet.
Numerous aspects of diet and nutrition may
contribute to the development of cancer. A lowfiber diet, such as when fresh fruits and
vegetables are minimal or lacking in the diet,
slows transport of materials through the gut which
has been linked to colorectal cancer.
97. Days after abdominal surgery, the clients
wound
dehisces.
The
safest
nursing
intervention when this occurs is to
a. Cover the wound with sterile, moist
saline dressing
b. Approximate the wound edges with tapes
c. Irrigate the wound with sterile saline
d. Hold the abdominal contents in place with a
sterile gloved hand
Dehiscence is the partial or complete separation
of the surgical wound edges. When this occurs,
the client is placed in low Fowlers position and
instructed to lie quietly. The wound should be
covered to protect it from exposure and the
dressing must be sterile to protect it from infection
and moist to prevent the dressing from sticking to
the wound which can disturb the healing process.
98. An intravenous pyelogram reveals that Paulo,
age 35, has a renal calculus. He is believed to
have
a
small
stone
that
will
pass
spontaneously. To increase the chance of the
stone passing, the nurse would instruct the
client to force fluids and to
a. Strain all urine.
b. Ambulate.
c. Remain on bed rest.
d. Ask for medications to relax him.
Free unattached stones in the urinary tract can
be passed out with the urine by ambulation which
can mobilize the stone and by increased fluid
intake which will flush out the stone during
urination.
99. A 58 year old woman has newly diagnosed
with hypothyroidism. The nurse is aware that
the signs and symptoms of hypothyroidism
include:
a. Diarrhea
c. Tachycardia
b. Vomiting
d.
Weight
gain
Typical signs of hypothyroidism includes weight
gain, fatigue, decreased energy, apathy, brittle
Page1
a. Morphine
c.
Meperidine
b. NSAIDS
d. Codeine
Pain in acute pancreatitis is caused by irritation
and edema of the inflamed pancreas as well as
spasm due to obstruction of the pancreatic ducts.
Demerol is the drug of choice because it is less
likely to cause spasm of the Sphincter of Oddi
unlike Morphine which is spasmogenic.
92. Immediately
after
cholecystectomy,
the
nursing action that should assume the highest
priority is:
a. encouraging the client to take adequate
deep breaths by mouth
b. encouraging the client to cough and
deep breathe
c. changing the dressing at least BID
d. irrigate the T-tube frequently
Cholecystectomy requires a subcostal incision. To
minimize pain, clients have a tendency to take
shallow breaths which can lead to respiratory
complications like pneumonia and atelectasis.
Deep breathing and coughing exercises can help
prevent such complications.
93. A Sengstaken-Blakemore tube is inserted in the
effort to stop the bleeding esophageal varices
in a patient with complicated liver cirrhosis.
Upon insertion of the tube, the client
complains of difficulty of breathing. The first
action of the nurse is to:
a. Deflate the esophageal balloon
b. Monitor VS
c. Encourage him to take deep breaths
d. Notify the MD
When a client with a Sengstaken-Blakemore tube
develops difficulty of breathing, it means the tube
is displaced and the inflated balloon is in the
oropharynx causing airway obstruction.
94. The client presents with severe rectal bleeding,
16 diarrheal stools a day, severe abdominal
pain, tenesmus and dehydration. Because of
these symptoms the nurse should be alert for
other problems associated with what disease?
a.Crohns disease
c.
Diverticulitis
b. Ulcerative colitis
d. Peritonitis
Ulcerative colitis is a chronic inflammatory
condition producing edema and ulceration
affecting the entire colon. Ulcerations lead to
sloughing that causes stools as many as 10-20
times a day that is filled with blood, pus and
mucus.
The
other
symptoms
mentioned
accompany the problem.
95. A client is being evaluated for cancer of the
colon. In preparing the client for barium
enema, the nurse should:
a. Give laxative the night before and a
cleansing enema in the morning
before the test
b. Render an oil retention enema and give
laxative the night before
c. Instruct the client to swallow 6 radiopaque
tablets the evening before the study

The client shouldn't receive a complete bed bath

while the applicator is in place. In fact, she
shouldn't be bathed below the waist because of
the risk of radiation exposure to the nurse. During
this treatment, the client should remain on strict
bed rest, but the head of her bed may be raised to
a 30- to 45-degree angle. The nurse should check
the applicator's position every 4 hours to ensure
that it remains in the proper place.
105. Malou is receiving chemotherapy has a
nursing diagnosis of deficient diversional
activity related to decreased energy. Which
statement indicates an accurate understanding
of appropriate ways to deal with this deficit?
a. "I'll play card games with my friends."
b. "I'll take a long trip to visit my aunt."
c. "I'll bowl with my team after discharge."
d. "I'll eat lunch in a restaurant every day."
During chemotherapy, playing cards is an
appropriate diversional activity because it doesn't
require a great deal of energy. To conserve energy,
the client should avoid such activities as taking
long trips, bowling, and eating in restaurants
every day. However, the client may take
occasional short trips and can dine out on special
occasions.
106. Andrew is recovering from an ileostomy
that was performed to treat inflammatory
bowel disease. During discharge teaching, the
nurse should stress the importance of:
a. increasing fluid intake to prevent
dehydration.
b. wearing an appliance pouch only at
bedtime.
c. consuming a low-protein, high-fiber diet.
d. taking only enteric-coated medications.
Because stool forms in the large intestine, an
ileostomy typically drains liquid waste. To avoid
fluid loss through ileostomy drainage, the nurse
should instruct the client to increase fluid intake.
The nurse should teach the client to wear a
collection appliance at all times because ileostomy
drainage is incontinent, to avoid high-fiber foods
because they may irritate the intestines, and to
avoid enteric-coated medications because the
body can't absorb them after an ileostomy.
107. A male client with liver and renal failure
has severe ascites. On initial shift rounds, his
primary nurse finds his indwelling urinary
catheter collection bag too full to store more
urine. The nurse empties more than 2,000 ml
from the collection bag. One hour later, she
finds the collection bag full again. The nurse
notifies the physician, who suspects that a
bladder rupture is allowing the drainage of
peritoneal
fluid.
The
physician
orders
a urinalysis to be obtained immediately. If the
physician's suspicion is correct, the urine will
abnormally contain:
a. creatinine.
c. chloride.
b. urobilinogen.
d. albumin.
Albumin is an abnormal finding in a routine urine
specimen. Ascites present in liver failure contain
albumin; therefore, if the bladder ruptured, ascites
containing albumin would drain from the
indwelling urinary catheter because the catheter is
no longer contained in the bladder. Creatinine,
Page1
nails, dry skin, cold intolerance, constipation and

numbness.
100. A client has undergone for an ileal conduit,
the nurse in charge should closely monitor the
client for occurrence of which of the following
complications related to pelvic surgery?
a. Ascites
c. Inguinal hernia
b. Thrombophlebitis
d. Peritonitis
After a pelvic surgery, there is an increased
chance of thrombophlebitits owing to the pelvic
manipulation that can interfere with circulation
and promote venous stasis.
101. Dr. Marquez is about to defibrillate a client
in ventricular fibrillation and says in a loud
voice clear. What should be the action of the
nurse?
a. Places conductive gel pads for defibrillation
on the clients chest
b. Turn off the mechanical ventilator
c. Shuts off the clients IV infusion
d. Steps away from the bed and make
sure all others have done the same
For the safety of all personnel, if the defibrillator
paddles are being discharged, all personnel must
stand back and be clear of all the contact with the
client or the clients bed.
102. A client has been diagnosed with
glomerulonephritis complains of thirst. The
nurse should offer:
a. Juice
c. Milk shake
b. Ginger ale
d.
Hard
candy
Hard candy will relieve thirst and increase
carbohydrates but does not supply extra fluid.
103. Which nursing intervention is most
appropriate for a client with multiple
myeloma?
a. Monitoring respiratory status
b. Balancing rest and activity
c. Restricting fluid intake
d. Preventing bone injury
When caring for a client with multiple myeloma,
the nurse should focus on relieving pain,
preventing bone injury and infection, and
maintaining hydration. Monitoring respiratory
status and balancing rest and activity are
appropriate interventions for any client. To prevent
such complications as pyelonephritis and renal
calculi, the nurse should keep the client well
hydrated not restrict his fluid intake.
104. To treat cervical cancer, Norma has had an
applicator of radioactive material placed in the
vagina. Which observation by the nurse
indicates a radiation hazard?
a. The client is maintained on strict bed
rest.
b. The head of the bed is at a 30-degree angle.
c. The client receives a complete bed bath
each morning.
d. The nurse checks the applicator's position
every 4 hours.

c. "I'll gradually increase the amount of heavy

lifting I do."
d. "I'll eat frequent, small, bland meals
that are high in fiber."
In hiatal hernia, the upper portion of the stomach
protrudes into the chest when intra-abdominal
pressure increases. To minimize intra-abdominal
pressure and decrease gastric reflux, the client
should eat frequent, small, bland meals that can
pass easily through the esophagus. Meals should
be high in fiber to prevent constipation and
minimize straining on defecation (which may
increase intra-abdominal pressure from the
Valsalva maneuver). Eating three large meals daily
would increase intra-abdominal pressure, possibly
worsening the hiatal hernia. The client should
avoid spicy foods, alcohol, and tobacco because
they increase gastric acidity and promote gastric
reflux. To minimize intra-abdominal pressure, the
client shouldn't recline after meals, lift heavy
objects, or bend.
112. What is the primary nursing diagnosis for a
client with a bowel obstruction?
a. Deficient fluid volume
b. Deficient knowledge
c. Pain
d. Ineffective tissue perfusion
Feces, fluid, and gas accumulate above a bowel
obstruction. Then the absorption of fluids
decreases and gastric secretions increase. This
process leads to a loss of fluids and electrolytes in
circulation. Options B, C, and D are applicable but
not the primary nursing diagnosis.
113. Nurse Karen is caring for clients in the OR.
The nurse is aware that the last physiologic
function that the client loss during the
induction of anesthesia is:
a. Consciousness
c.
Respiratory
movement
b. Gag reflex
d.
Corneal
reflex
There is no respiratory movement in stage 4 of
anesthesia, prior to this stage, respiration is
depressed but present.
114. The nurse is assessing a client with pleural
effusion. The nurse expect to find:
a. Deviation of the trachea towards the
involved side
b. Reduced or absent of breath sounds at
the base of the lung
c. Moist crackles at the posterior of the lungs
d. Increased resonance with percussion of the
involved area
Compression of the lung by fluid that
accumulates at the base of the lungs reduces
expansion and air exchange.
115. A client admitted with newly diagnosed
with Hodgkins disease. Which of the following
would the nurse expect the client to report?
a. Lymph node pain
c.
Night
sweats
b. Weight gain
d. Headache
Page1
urobilinogen, and chloride are normally found in

urine.
108. As a client recovers from gastric resection,
nurse Zara monitors closely for complications.
When the client resumes oral feedings, the
nurse observes for early manifestations of
dumping
syndrome.
The
vasomotor
disturbances associated with this syndrome
usually occur how soon after eating?
a. Immediately
c. 1 to 2 hours
b. 5 to 30 minutes
d. 2 to 4 hours
Early manifestations of dumping syndrome occur
5 to 30 minutes after eating. Signs and symptoms
of this syndrome include vertigo, tachycardia,
syncope, sweating, pallor, palpitations, diarrhea,
nausea, and the desire to lie down. Manifestations
of dumping syndrome don't occur immediately
because food takes a few minutes to reach the
jejunum. Early manifestations of vasomotor
disturbances usually arise within 45 minutes.
109. Nurse
Lhyzette
must
provide
total
parenteral nutrition (TPN) to a client through a
triple-lumen
central
line.
To
prevent
complications of TPN, the nurse should:
a. Cover the catheter insertion site with
an occlusive dressing.
b. Use clean technique when changing the
dressing.
c. Insert an indwelling urinary catheter.
d. Keep the client on complete bed rest.
TPN increases the client's risk of infection
because the catheter insertion site creates a port
of entry for bacteria. To reduce the risk of
infection, the nurse should cover the insertion site
with an occlusive dressing, which is airtight.
Because the insertion site is an open wound, the
nurse should use sterile technique when changing
the dressing. TPN doesn't necessitate placement
of an indwelling urinary catheter or bed rest
110. A male client undergoes total gastrectomy.
Several hours after surgery, nurse Charina
notes that the client's nasogastric (NG) tube
has stopped draining. How should the nurse
respond?
a. Notify the physician
b. Reposition the tube
c. Irrigate the tube
d. Increase the suction level
An NG tube that fails to drain during the
postoperative period should be reported to the
physician immediately. It may be clogged, which
could increase pressure on the suture site because
fluid isn't draining adequately. Repositioning or
irrigating an NG tube in a client who has
undergone gastric surgery can disrupt the
anastomosis. Increasing the level of suction may
cause trauma to GI mucosa or the suture line.
111. Troy is diagnosed with a hiatal hernia.
Which statement indicates effective client
teaching about hiatal hernia and its treatment?
a. "I'll eat three large meals every day without
any food restrictions."
b. "I'll lie down immediately after a meal."


121. Lydia is scheduled for elective splenectomy.
Before the clients goes to surgery, the nurse in
charge final assessment would be:
a. signed consent
c. name band
b. vital signs
d. empty
bladder
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.
122. Marie with acute lymphocytic leukemia
suffers from nausea and headache. These
clinical manifestations may indicate all of the
following except
a. effects of radiation
c. meningeal
irritation
b. chemotherapy side effects
d. gastric
distension
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.
123. 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
Urine output provides the most sensitive
indication of the clients response to therapy for
hypovolemic shock. Urine output should be
consistently greater than 30 to 35 mL/hr.
124. Which of the following signs and symptoms
would Nurse Maureen include in teaching plan
as an early manifestation of laryngeal cancer?
a. Stomatitis
c. Hoarsenes
s
b. Airway obstruction
d. Dysphagia
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.
125. 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.
Page1
Assessment of a client with Hodgkins disease

most often reveals enlarged, painless lymph node,
fever, malaise and night sweats.
116. The Nurse is assessing the clients casted
extremity for signs of infection. Which of the
following findings is indicative of infection?
a. Edema
b. Weak distal pulse
c. Coolness of the skin
d. Presence of hot spot on the cast
Signs and symptoms of infection under a casted
area include odor or purulent drainage and the
presence of hot spot which are areas on the cast
that are warmer than the others.
117. Nurse Rhia is performing an otoscopic
examination on a female client with a
suspected diagnosis of mastoiditis. Nurse Rhia
would expect to note which of the following if
this disorder is present?
a. Transparent tympanic membrane
b.
Thick
and
immobile
tympanic
membrane
c. Pearly colored tympanic membrane
d. Mobile tympanic membrane
Otoscopic examnation in a client with mastoiditis
reveals a dull, red, thick and immobile tymphanic
membrane with or without perforation.
118. Nurse Jocelyn is caring for a client with
nasogastric tube that is attached to low
suction. Nurse Jocelyn assesses the client for
symptoms of which acid-base disorder?
a. Respiratory alkalosis c. Metabolic acidosis
b. Respiratory acidosis d.
Metabolic
alkalosis
Loss of gastric fluid via nasogastric suction or
vomiting causes metabolic alkalosis because of
the loss of hydrochloric acid which is a potent acid
in the body.
119. A client is suspected of developing
diabetes insipidus. Which of the following is
the most effective assessment?
a. Taking vital signs every 4 hours
b. Monitoring blood glucose
c. Assessing ABG values every other day
d. Measuring urine output hourly
Measuring the urine output to detect excess
amount and checking the specific gravity of urine
samples to determine urine concentration are
appropriate measures to determine the onset of
diabetes insipidus.
120. A 58 year old client is suffering from acute
phase of rheumatoid arthritis. Which of the
following would the nurse in charge identify as
the lowest priority of the plan of care?
a. Prevent joint deformity
b.
Maintaining
usual
ways
of
accomplishing task
c. Relieving pain
d. Preserving joint function
The nurse should focus more on developing less
stressful ways of accomplishing routine task.

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.
131. Nurse
Ronald
plans
to
administer
dexamethasone cream to a client who has
dermatitis over the anterior chest How should
the nurse apply this topical agent?
a. With a circular motion, to enhance
absorption
b. With an upward motion, to increase blood
supply to the affected area
c. In long, even, outward, and downward
strokes in the direction of hair growth
d. In long, even, outward, and upward strokes
in the direction opposite hair growth
When applying a topical agent, the nurse should
begin at the midline and use long, even, outward,
and downward strokes in the direction of hair
growth. This application pattern reduces the risk of
follicle irritation and skin inflammation.
132. A male client with a severe staphylococcal
infection is receiving the aminoglycoside
gentamicin sulfate (Garamycin) by the I.V.
route. Nurse Marilyn should assess the client
for which adverse reaction to this drug?
a. Aplastic anemia
c.
Cardiac
arrhythmias
b. Ototoxicity
d. Seizures
The most significant adverse reactions to
gentamicin and other aminoglycosides are
ototoxicity (indicated by vertigo, tinnitus, and
hearing loss) and nephrotoxicity (indicated by
urinary cells or casts, oliguria, proteinuria, and
reduced creatinine clearance). These adverse
reactions are most common in elderly and
dehydrated clients, those with renal impairment,
and those receiving concomitant therapy with
another potentially ototoxic or nephrotoxic drug.
Gentamicin isn't associated with aplastic anemia,
cardiac arrhythmias, or seizures.
133. Trisha with a solar burn of the chest, back,
face, and arms is seen in urgent care. The
nurse's primary concern should be:
a. Fluid resuscitation.
c. Body image.
b. Infection.
d.
Pain
management.
With a superficial partial thickness burn such as a
solar burn (sunburn), the nurse's main concern is
pain management. Fluid resuscitation and
infection become concerns if the burn extends to
the dermal and subcutaneous skin layers. Body
image disturbance is a concern that has lower
priority than pain management.
134. A
female
client
with
acquired
immunodeficiency
syndrome (AIDS) is
admitted with Pneumocystis carinii pneumonia.
During a bath, the client begins to cry and says
that most friends and relatives have stopped
visiting and calling. What should Nurse Leng
do?
a. Continue with the bath and tell the client not
to worry.
Page1
Steroids decrease the bodys immune response

thus decreasing the production of antibodies that
attack the acetylcholine receptors at the
neuromuscular junction
126. A client has undergone bone biopsy. Which
nursing action should the nurse provide after
the procedure?
a. Administer analgesics via IM
b. Monitor vital signs
c. Monitor the site for bleeding, swelling
and hematoma formation
d. Keep area in neutral position
Nursing care after bone biopsy includes close
monitoring of the punctured site for bleeding,
swelling and hematoma formation.
127. 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.
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.
128. A male clients 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
Damage to blood vessels may decrease the
circulatory perfusion of the toes, this would
indicate the lack of blood supply to the extremity.
129. 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.
Elevation will help control the edema that usually
occurs.
130. 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
c. Face
b. Ears
d. Abdomen

active ROM exercises shouldn't be performed on

the affected leg during the postoperative period
because this could damage the operative site and
cause hip dislocation. Most clients should be
turned to the unaffected side, not from side to
side. After hip pinning, the client must avoid acute
flexion of the affected hip to prevent possible hip
dislocation; therefore, semi-Fowler's position
should be avoided.
138. Which
nursing
diagnosis
is
most
appropriate for lola Luisa an elderly client with
osteoarthritis?
a. Risk for injury related to altered
mobility
b. Impaired urinary elimination related to
effects of aging
c. Ineffective breathing pattern related to
immobility
d. Imbalanced nutrition: Less than body
requirements related to effects of aging
Typically, a client with osteoarthritis has stiffness
in large, weight-bearing joints, such as the hips.
This joint stiffness alters functional ability and
range of movement, placing the client at risk for
falling and injury. Therefore, Risk for injury is the
most appropriate nursing diagnosis. The other
options are incorrect because osteoporosis doesn't
affect urinary elimination, breathing, or nutrition.
139. A male client comes to the emergency
department complaining of pain in the right
leg. When obtaining the history, Nurse Ron
learns that the client was diagnosed
with diabetes mellitus at age 12. The nurse
knows that this disease predisposes the client
to which musculoskeletal disorder?
a. Degenerative joint disease
c.
Scoliosis
b. Muscular dystrophy
d. Paget's disease
Diabetes mellitus predisposes the client to
degenerative joint disease. It isn't a predisposing
factor for muscular dystrophy, scoliosis, or Paget's
disease.
140. A client who has just been diagnosed with
mixed muscular dystrophy asks the nurse
Cedric about the usual course of this disease.
How should the nurse respond?
a. "You should ask your physician about that."
b. "The strength of your arms and pelvic
muscles will decrease gradually, but
this
should
cause
only
slight
disability."
c. "You
may
experience
progressive
deterioration in all voluntary muscles."
d. "This form of muscular dystrophy is a
relatively benign disease that progresses
slowly."
Muscular
dystrophy
causes
progressive,
symmetrical wasting of skeletal muscles, without
neural or sensory defects. The mixed form of the
disease typically strikes between ages 30 and 50
and progresses rapidly, causing deterioration of all
voluntary muscles. Because the client asked the
nurse this question directly, the nurse should
answer and not simply refer the client to the
physician. Limb-girdle muscular dystrophy causes
Page1
b. Ask the physician to obtain a psychiatric

consultation.
c. Listen and show interest as the client
expresses feelings.
d. State that these friends' behavior shows
that they aren't true friends.
The
nurse
should
listen
actively
and
nonjudgmentally as the client expresses feelings.
Telling the client not to worry would provide false
reassurance. A psychiatric consultation would be
appropriate only after further assessment. Stating
that the client's friends aren't true friends would
discount the client's feelings.
135. Which nursing diagnosis should the nurse
Dianne expect to see in a plan of care for a
client in sickle cell crisis?
a. Imbalanced nutrition: Less than body
requirements related to poor intake
b. Disturbed sleep pattern related to external
stimuli
c. Impaired skin integrity related to pruritus
d. Pain related to sickle cell crisis
In sickle cell crisis, sickle-shaped red blood cells
clump together in a blood vessel, which causes
occlusion, ischemia, and extreme pain. Therefore,
option D is the appropriate choice. Although
nutrition is important, poor nutritional intake isn't
necessarily related to sickle cell crisis. During
sickle cell crisis, pain or another internal stimulus
is more likely to disturb the client's sleep than
external stimuli. Although clients with sickle cell
anemia can develop chronic leg ulcers caused by
small vessel blockage, they don't typically
experience pruritus.
136. Juan who agreed to become an organ donor
is pronounced dead. What is the most
important factor in selecting a transplant
recipient?
a. Blood relationship
b. Sex and size
c. Compatible blood and tissue types
d. Need
The donor and recipient must have compatible
blood and tissue types. They should be fairly close
in size and age. When a living donor is considered,
it's preferable to have a relative donate the organ.
Need is important but it can't be the critical factor
if a compatible donor isn't available.
137. Mrs. Roda undergoes hip-pinning surgery to
treat an intertrochanteric fracture of the right
hip. The nurse should include which
intervention in the postoperative plan of care?
a. Performing passive range-of-motion (ROM)
exercises on the client's legs once each
shift
b. Keeping a pillow between the client's
legs at all times
c. Turning the client from side to side every 2
hours
d. Maintaining the client in semi-Fowler's
position
After hip pinning, the client must keep the
affected leg abducted at all times; placing a pillow
between the legs reminds the client not to cross
the legs and to keep the leg abducted. Passive or

antidote that is specific to heparin. Which

agent fits this description?
a. phytonadione (vitamin K)
c. thrombin
b. protamine sulfate
d.
plasma
protein fraction
Protamine sulfate is the antidote specific to
heparin. Phytonadione (vitamin K) is the antidote
specific to oral anticoagulants such as warfarin.
(Heparin isn't given orally.) Thrombin is a
hemostatic agent used to control local bleeding.
Plasma protein fraction, a blood derivative,
supplies colloids to the blood and expands plasma
volume; it's used to treat clients in shock.
146. For a male client with cardiomyopathy, the
most important nursing diagnosis is:
a. Decreased cardiac output related to
reduced myocardial contractility.
b. Excessive fluid volume related to fluid
retention
and
altered
compensatory
mechanisms.
c. Ineffective individual coping related to fear
of debilitating illness.
d. Anxiety related to actual threat to health
status.
Decreased cardiac output related to reduced
myocardial contractility is the greatest threat to
the survival of a client with cardiomyopathy.
Although the other options are important nursing
diagnoses, they can be addressed when cardiac
output and myocardial contractility have been
restored.
147. Julius is admitted to the health care facility
for treatment of an abdominal aortic
aneurysm. When planning this client's care,
the nurse formulates interventions with which
goal in mind?
a. Decreasing blood pressure and increasing
mobility
b. Increasing blood pressure and reducing
mobility
c. Stabilizing the heart rate and blood
pressure and easing anxiety
d. Increasing blood pressure and monitoring
fluid intake and output
For a client with an aneurysm, nursing
interventions focus on stabilizing the heart rate
and blood pressure, to avoid aneurysm rupture.
Easing anxiety also is important because anxiety
and increased stimulation may speed the heart
rate and boost blood pressure, precipitating
aneurysm rupture. Typically, the client with an
abdominal aortic aneurysm is hypertensive, so the
nurse should take measures to lower the blood
pressure, such as administering antihypertensive
agents, as prescribed, to prevent aneurysm
rupture. To sustain major organ perfusion, a mean
arterial pressure of at least 60 mm Hg should be
maintained. Although mobility must be assessed
individually, most clients need bed rest initially
when attempting to gain stability.
148. An electrocardiogram (ECG) taken during a
routine checkup reveals that a male client has
had a silent myocardial infarction. On a 12-lead
ECG, which leads record electrical events in
the septal region of the left ventricle?
Page1
a gradual decrease in arm and pelvic muscle

strength,
resulting
in
slight
disability.
Facioscapulohumeral muscular dystrophy is a
slowly progressive, relatively benign form of
muscular dystrophy; it usually arises before age
10.
141. The Milwaukee brace is used often in the
treatment of scoliosis. Which the following
positions best describes the placement of the
pressure rods?
a. Laterally on the convex portion of the
curve.
b. Laterally on the concave portion of the
curve.
c. Posteriorly on the convex portion of the
curve.
d. Posteriorly along the spinal column at the
exact level of the curve.
Lateral pressure applied to the convex portion of
the curve will help best in reducing the curvature.
Pressure pads applied posteriorly will help
maintain erect pressure. Pressure applied to the
concave portion of the curve will increase the
kordosis.
Kaplan NCLEX Review Series 2008, Page 312
142. The nurse is aware that the following
defects involve the use of the Logan bow
postoperatively?
a. Cleft lip or palate
b. Esophageal atresia
c. Hiatal hernia
d. Tracheoesophageal fistula
Immediately after surgery for cleft lip or palate,
the Logan bow, a thin arched metal device, is used
to protect the suture line from tension.
143. Nurse Oliver is aware that the following
hormones is secreted by the anterior pituitary
gland?
a. Corticotropin
c. Cortisol
b. Antidiuretic hormone d. Oxytocin
Corticotropin is secreted by the anterior pituitary
gland. Antidiuretic hormone and oxytocin are
secreted by posterior pituitary gland. Cortisol is
secreted by the adrenal glands.
144. Which of the following condition is a
common cause of prerenal acute renal failure?
a. Atherosclerosis
b. Decreased cardiac output
c. Prostatic hypertrophy
d. Rhabdomyolysis
Prerenal refers to renal failure due to an
interference with renal perfusion. Decreased
cardiac output causes a decrease in renal
perfusion, which leads to a lower glomerular
filtration rate.
145. A postoperative female client is receiving
heparin (Heparin sodium injection) after
developing thrombophlebitis. Nurse Myrna
monitors the client carefully for adverse effects
of heparin, especially bleeding. If the client
starts to exhibit signs of excessive bleeding,
the nurse should expect to administer an

152. Rafael is admitted for treatment of a

gastric ulcer is being prepared for discharge on
antacid therapy. Discharge teaching should
include which instruction?
a. "Continue to take antacids even if your
symptoms subside."
b. "You may take antacids with other
medications."
c. "Avoid
taking
magnesium-containing
antacids if you develop a heart problem."
d. "Be sure to take antacids with meals."
Antacids decrease gastric acidity and should be
continued even if the client's symptoms subside.
Because other medications may interfere with
antacid action, the client should avoid taking
antacids concomitantly with other drugs. If cardiac
problems arise, the client should avoid antacids
containing sodium, not magnesium. For optimal
results, the client should take an antacid 1 hour
before or 2 hours after meals.
153. Nurse May is caring for a client with active
upper GI bleeding. What is the appropriate diet
for this client during the first 24 hours after
admission?
a. Regular diet
c.
Nothing
by
mouth
b. Skim milk
d. Clear liquids
Shock and bleeding must be controlled before
oral intake, so the client should receive nothing by
mouth. A regular diet is incorrect. When the
bleeding is controlled, the diet is gradually
increased, starting with ice chips and then clear
liquids. Skim milk shouldn't be given because it
increases gastric acid production, which could
prolong bleeding. A liquid diet is the first diet
offered after bleeding and shock are controlled.
154. Kristina is a 37-year old cook. She is
admitted for treatment of partial and fullthickness burns of her entire right lower
extremity and the anterior portion of her right
upper extremity. Her respiratory status is
compromised, and she is in pain and anxious.
Performing an immediate appraisal, using the
rule of nines, the nurse estimates the percent
of Claras body surface that is burned is:
a. 4.5%
c. 18 %
b. 9%
d. 22.5%
The entire right lower extremity is 18% the
anterior portion of the right upper extremity is
4.5% giving a total of 22.5%.
155. Nurse Marianne applies mafenide acetate
(Sulfamylon cream) to Clara, who has second
and third degree burns on the right upper and
lower extremities, as ordered by the physician.
This medication will:
a. Inhibit bacterial growth
b. Relieve pain from the burn
c. Prevent scar tissue formation
d. Provide chemical debridement
Sulfamylon is effective against a wide variety of
gram positive and gram negative organisms
including anaerobes.
Page1
a. Leads I, aVL, V5, and V6

c. Leads V1
and V2
b. Leads II, III, and aVF d. Leads V3 and V4
Leads V3 and V4 record electrical events in the
septal region of the left ventricle. Leads I, aVL, V5,
and V6 record electrical events on the lateral
surface of the left ventricle. Leads II, III, and aVF
record electrical events on the inferior surface of
the left ventricle. Leads V1 and V2 record
electrical events on the anterior surface of the
right ventricle and the anterior surface of the left
ventricle.
149. Mrs. Cruz has a routine Papanicolaou (Pap)
test during a yearly gynecologic examination.
The result reveals a class V finding. What
should the nurse tell the client about this
finding?
a. It's normal and requires no action.
b. It calls for a repeat Pap test in 3 months.
c. It calls for a repeat Pap test in 6 weeks.
d. It calls for a biopsy as soon as
possible.
A class V finding in a Pap test suggests probable
cervical cancer; the client should have a biopsy as
soon as possible. Only a class I finding, which is
normal, requires no action. A class II finding, which
indicates inflammation, calls for a repeat Pap test
in 3 months. A class III finding, which indicates
mild to moderate dysplasia, calls for a repeat Pap
test in 6 weeks to 3 months. A class IV finding
indicates possible cervical cancer; like a class V
finding, it warrants a biopsy as soon as possible.
150. Nurse Blessy is teaching a male client to
perform monthly testicular self-examinations.
Which of the following points would be
appropriate to make?
a. Testicular cancer is a highly curable
type of cancer.
b. Testicular cancer is very difficult to
diagnose.
c. Testicular cancer is the number one cause of
cancer deaths in males.
d. Testicular cancer is more common in older
men.
Testicular cancer is highly curable, particularly
when it's treated in its early stage. Selfexamination allows early detection and facilitates
the early initiation of treatment. The highest
mortality rates from cancer among men are in
men with lung cancer. Testicular cancer is found
more commonly in younger men.
151. What laboratory finding is the primary
diagnostic indicator for pancreatitis?
a. Elevated blood urea nitrogen (BUN)
b. Elevated serum lipase
c. Elevated aspartate aminotransferase (AST)
d. Increased lactate dehydrogenase (LD)
Elevation of serum lipase is the most reliable
indicator of pancreatitis because this enzyme is
produced solely by the pancreas. A client's BUN is
typically elevated in relation to renal dysfunction;
the AST, in relation to liver dysfunction; and LD, in
relation to damaged cardiac muscle.

Systolic phase is the period when the heart

contracts. term. Lub-dub phase is not an accepted
medical term. Resting phase is seen between
electrical activities of the heat.
161. The nurse is caring for a child who has just
returned
from
surgery
following
a
tonsillectomy and adenoidectomy. Which
action by the nurse is appropriate?
a. Offer ice cream every 2 hours
b. Place the child in a supine position
c. Allow the child to drink through a straw
d. Observe swallowing patterns
D - Swallowing patterns will enable the nurse to
know if there is active bleeding, the more the child
swallows the more bleeding happens. A. Offering
an ice cream every 2 hours is not appropriate at
this time. B - Placing the child in a supine position
will increase the risk of aspiration of blood from
the surgical site. C - Allowing the child to drink
through a straw is impossible since initially the
child is placed on NPO.
162. An elderly client is on an anticholinergic
metered dose inhaler (MDI) for chronic
obstructive pulmonary disease. Why should
the nurse suggest a spacer?
a. Decrease administration time of the
medication
b. Increase client compliance
c. Improve aerosol delivery in clients who are
not able to coordinate the MDI
d. Prevent exacerbation of COPD
D - Prevent exacerbation of COPD, increased
delivery of oxygen may also trigger exacerbations,
spacers are used to regulate the entering air to
the client. A - Decrease administration time of the
medication is not the purpose of the spacer. B Increase client compliance is not the primary
purpose of the spacer, it may only be secondary. C
- Improve aerosol delivery in clients who are not
able to coordinate the MDI spacers wont help
clients with MDI.
163. A client is 2 days post operative. The vital
signs are: BP-120/70, HR-110, RR-26, and
temperature100.4
degrees
Fahrenheit
(38degrees Celsius). The client suddenly
becomes profoundly short of breath, skin color
is gray. Which assessment would have alerted
the nurse first to the clients change in
condition?
a. Heart rate
c.
Blood
pressure
b. Respiratory rate
d. Temperature
Airway and breathing first
164. The nurse must know that the most
accurate oxygen delivery system available is
a. The venturi mask
b. Nasal cannula
c. Partial non-re breather mask
d. Simple face mask
Partial non-re breather mask delivers the highest
oxygen concentration from 95% to 100% by
means of other mechanical ventilation. The
venturi mask delivers oxygen concentrations
Page1
156. Forty-eight hours after a burn injury, the

physician orders for the client 2 liters of IV fluid
to be administered q12 h. The drop factor of
the tubing is 10 gtt/ml. Nurse Jasmine should
set the flow to provide:
a. 18 gtt/min
c. 32 gtt/min
b. 28 gtt/min
d. 36 gtt/min
This is the correct flow rate; multiply the amount
to be infused (2000 ml) by the drop factor (10)
and divide the result by the amount of time in
minutes (12 hours x 60 minutes)
157. A client asks what the coronary arteries
have to do with angina. When determining the
answer,
the
nurses
should
take
into
consideration that the coronary arteries:
a. Supply blood to the endocardium
b. Carry blood from the aorta to the
myocardium
c. Carry reduced oxygen-content blood to the
lungs
d. Carry high-oxygen content blood from the
lungs towards the heart.
Supply blood to the endocardium this is the
function of the coronary arteries. Right ventricle
carry reduced oxygen-content blood to the lungs.
Pulmonary veins carry high-oxygen content blood
from the lungs towards the heart.
158. Tricuspid and mitral valves is also known
as:
a. Semilunar valves
c.
Atrioventricular valves
b. Pulmonic valves
d.
Aortic
Valves
Atrioventricular valves are Tricuspid and mitral
valves. Semilunar valves either of two valves, one
located at the opening of the aorta and the other
at the opening of the pulmonary artery, each
consisting of three crescent-shaped cusps and
serving to prevent blood from flowing back into
the ventricles. Pulmonic valve A fold in the
pulmonary artery that directs blood to the lungs. It
may be transferred to replace a severely diseased
aortic valve during heart valve replacement
surgery for aortic stenosis. Aortic valve is the
guarding the entrance to the aorta from the left
ventricle.
159. The nurse observes a clients cardiac
monitor
and
identifies
asystole.
This
dysrhythmia
requires
nursing
attention
because the heart is:
a. Not beating
c. Beating regularly
b. Beating slowly
d. Beating rapidly
The heart is not beating during asystole.
Bradycardia happens when the heart beats slowly.
Tachycardia happens when the heart is beating
rapidly.
160. Ventricular contraction is a phase in cardiac
cycle called:
a. Diastolic phase
c.
Lub-dub
phase
b. Systolic phase
d. Resting Phase
Diastolic phase is the period of time when the
heart fills with blood after systole (contraction).

168. The nurse is caring for a client with a

tracheostomy.
An
appropriate
nursing
diagnosis for this client is
a. Impaired verbal communication related to
absence of speaking ability
b. Ineffective airway clearance related to
increased tracheobronchial secretions
c. Risk for impaired skin integrity related to
tracheostomy incision
d. Alteration in comfort: pain related to
tracheostomy
Ineffective airway clearance related to increased
tracheobronchial secretions is the appropriate
nursing diagnosis since the tracheostomy is
indicated to make a passageway for an open
airway. Impaired verbal communication related to
absence of speaking ability is expected since a
tracheostomy is inserted. Risk for impaired skin
integrity related to tracheostomy incision could be
second priority. Alteration in comfort: pain related
to tracheostomy can least priority.
169. When obtaining a specimen from a client
for sputum culture and sensitivity (C and S),
the nurse knows that which of the following
instructions is BEST?
a. After pursed-lip breathing, cough into a
container
b. Upon awakening, cough deeply and
expectorate into a container
c. Save all the sputum for three days in a
covered container
d. After respiratory treatment, expectorate into
a container
Upon awakening, cough deeply and expectorate
into a container is the appropriate instruction
since it confines the specimen without too much
exposure. The other options are vague when it
comes to understanding.
170. A home care nurse is planning activities for
the day. Which of the following clients should
the nurse see first?
a. A new mother is breastfeeding her two day
old infant who was born five days early.
b. A man discharged yesterday following
treatment with IV heparin for a deep vein
thrombosis.
c. An elderly woman discharged from the
hospital
three
days
ago
with
pneumonia.
d. An elderly man who used all his diuretic
medication and is expectorating pink
tinged mucus
An elderly woman discharged from the hospital
three days ago with pneumonia is the priority
since the case was infectious and the case may
have recurred. A man discharged yesterday
following treatment with IV heparin for a deep vein
thrombosis could be the next patient to check. An
elderly man who used all his diuretic medication
and is expectorating pink tinged mucus. A new
mother is breastfeeding her two day old infant
who was born five days could be the least to
attend to.
Kaplan Nursing Review Series 2006, 217
171. The nurse is caring for a client 2 hours after
a right lower lobectomy. During the evaluation
of the water seal chest drainage system, it is
Page1
varying from 24% to 40% or 4 to 6 liters per

minute.
Nasal
cannula
delivers
oxygen
concentrations varying from 2 to 6 liters per
minute. Simple face mask delivers oxygen
concentration from 5 to 8 liters per minute.
165. When teaching a client with chronic
obstructive pulmonary disease about oxygen
by cannula, the nurse should also instruct the
clients family to
a. Avoid smoking near the client
b. Turn off oxygen during meals
c. Adjust the liter flow to 10 as needed
d. Remind the client to keep mouth closed
Avoid smoking near the client since oxygen is
combustible
and
it
may
catch
fire
immediately.Turn off oxygen during meals will not
help the patient, continuous air flow is needed for
this client.Adjust the liter flow to 10 as needed,
the limit of COPD patients is 2-3 liters per minute,
a higher air flow may hinder the patient to have a
drive in breathing.Remind the client to keep
mouth closed wont help the him having an
adequate ventilation.
166. The nurse walks into a clients room and
found the client lying still and silent on the
floor. The nurse should first
a. Assess the clients airway
b. Call for help
c.
Establish
that
the
client
is
unresponsive
d. See if anyone saw the client fall
Establish that the client is unresponsive is done
by calling the patients name and if he responds in
some degree then there is a conscious part
remaining. Assess the clients airway is the second
priority after establishing the responsiveness of
the patient.Call for help is the third appropriate
thing to do in this scenario.See if anyone saw the
client fall is a part of a background check of the
factors that may contribute to the clients current
state.
167. A client with emphysema visits the clinic.
While teaching about proper nutrition, the
nurse should emphasize that the client.
a. Eat foods high in sodium increases sputum
liquefaction
b. Use oxygen during meals improves gas
exchange
c. Perform exercise after respiratory therapy
enhances appetite
d. Cleanse the mouth of dried secretions
reduces the risk of infection
Use oxygen during meals improves gas exchange
helps in preventing undue fatigue during eating.
Eating foods high in sodium does not increase
sputum liquefaction. Perform exercise after
respiratory therapy enhances appetite, is not
recorded to have been increasing the appetite of
patients. Cleanse the mouth of dried secretions
reduces the risk of infection, does not answer the
question being asked about the nutritional needs
of the patient with COPD.

174. A client is diagnosed with lung cancer and

undergoes
a
pneumonectomy.
In
the
immediate postoperative period, which of the
following nursing assessments is MOST
important?
a. Presence of breath sounds bilaterally.
b. Position of the trachea in the sternal
notch
c. Amount and consistency of sputum
d. Increase in the pulse pressure
Position of the trachea in the sternal notch
denotes the proper access of the airway for proper
respiration. Presence of breath sounds bilaterally
is impossible to hear since the surgical procedure
done was done as a removal of the lung. Amount
and consistency of sputum is not necessary for the
time of procedure. Increase in pulse pressure is
not relevant in the nature of the case.
175.
A client is admitted to the emergency
room following an acute asthma attack. Which
of the following actions would the nurse do
first?
a. Check the carotid pulse
b. Deliver 5 abdominal thrusts
c. Give 2 rescue breaths
d. Open the clients airway
Open the clients airway is the priority nursing
action since the problem is in the respiratory
system. Checking the carotid pulse is the second
step, then giving two rescue breaths and the last
thing is delivering 5 abdominal thrusts.
176. A client is admitted to the emergency room
following an acute asthma attack. Which of the
following assessments would be expected by
the nurse?
a. Diffuse expiratory wheezing
b. Loose, productive cough
c. No relief from inhalant
d. Fever and chills
Diffuse expiratory wheezing is caused by the
constriction of the bronchial tree. Loose productive
cough is a result of an active secretion of mucus in
the lungs. No relied from inhalant is irrelevant.
Fever and chills are general symptoms.
177. A nurse admits a premature infant who has
respiratory distress syndrome. In planning
care, nursing actions are based on the fact that
the most likely cause of this problem stems
from the infants inability to
a. Stabilize thermoregulation
b. Maintain alveolar surface tension
c. Begin normal pulmonary blood flow
d. Regulate intracardiac pressure
Maintaining alveolar surface tension is the
primary problem of a premature infant with
respiratory distress syndrome since the baby lacks
surfactant which helps the lungs inflate with air
and keeps the air sacs from collapsing. Stabilizing
the thermoregulation is the next priority nursing
care since babies like this has trouble in regulating
their own temperature as they depend more on
brown fat. The next would be beginning the
normal pulmonary blood flow and regulating the
intracardiac pressure
Page1
noted that the fluid level bubbles constantly in

the water seal chamber. On inspection of the
chest dressing and tubing, the nurse does not
find any air leaks in the system. The next best
action for the nurse is to:
a. Check for subcutaneous emphysema in the
upper torso
b. Reposition the client to a position of comfort
c. Call the health care provider as soon as
possible
d. Check for any increase in the amount of
thoracic drainage
Call the health care provider as soon as possible
since this is a surgical emergency. The major goal
is to prevent pneumothorax. Checking for
subcutaneous emphysema in the upper torso
wont solve the problem. Reposition the client to a
position of comfort is impossible since the client at
that time might be gasping for air. Check for any
increase in the amount of thoracic drainage is also
impossible.
172. The nurse is caring for a child receiving
chest physiotherapy (CPT). Which of the
following actions by the nurse would be
appropriate?
a. Schedule the therapy thirty minutes after
meals
b. Teach the child not to cough during the
treatment
c. Confine the percussion to the rib cage
area
d. Place the child in a prone position for
therapy
Confining the percussion to the rib cage area will
enable the secretions to loosen properly.
Scheduling the therapy 30 minutes after meals will
induce vomiting. Teaching the child not to cough
during the treatment will make the treatment not
effective. Placing the child in a prone position for
therapy will not help the secretion to loosen.
173. A 48-year-old man with an endocrinal tube
needs suctioning. Which of the following
statements is an accurate description of how
the nurse should perform the procedure?
a. Insert the suction catheter four inches into
the tube. Apply suction for 30 seconds,
using a twirling motion as the catheter is
withdrawn.
b. Hyperoxygenate the client and then insert
the suction catheter into the tube. Suction
while you remove the catheter using a
back and forth motion
c. Explain the procedure to the patient. Insert
the catheter while gently applying suction,
and withdraw using a twisting motion
d. Insert the suction catheter until
resistance is met, then withdraw it
slightly, apply suction intermittently
as the catheter is withdrawn.
Inserting the suction catheter until resistance is
met, then withdraw it slightly, apply suction
intermittently as the catheter is withdrawn is the
correct way of suctioning avoiding injury to the
area. The rest of the options does not pertain to
the correct procedure.

like effect that causes them to constrict thereby

preventing bleeding.
183. The transurethral resection of the prostate is
performed on a client with BPH. Following
surgery, nursing care should include:
a. Changing the abdominal dressing
b. Maintaining patency of the cystotomy tube
c. Maintaining patency of a three-way
Foley catheter for cystoclysis
d. Observing for hemorrhage and wound
infection
Patency of the catheter promotes bladder
decompression, which prevents distention and
bleeding. Continuous flow of fluid through the
bladder limits clot formation and promotes
hemostasis
184. Nurse Jon performs full range of motion on a
bedridden clients extremities. When putting
his ankle through range of motion, the nurse
must perform:
a. Flexion, extension and left and right rotation
b. Abduction, flexion, adduction and
extension
c. Pronation,
supination,
rotation,
and
extension
d. Dorsiflexion, plantar flexion, eversion and
inversion
These movements include all possible range of
motion for the ankle joint
185. The nurse is aware that the routine
postoperative IV fluids are designed to supply
hydration and electrolyte and only limited
energy. Because 1 L of a 5% dextrose solution
contains 50 g of sugar, 3 L per day would apply
approximately:
a. 400 Kilocalories
c.
800
Kilocalories
b. 600 Kilocalories
d.
1000
Kilocalories
Carbohydrates provide 4 kcal/ gram; therefore 3L
x 50 g/L x 4 kcal/g = 600 kcal; only about a third
of the basal energy need.
186. Mr. Sy, a client with CHF, has been receiving
a cardiac glycoside, a diuretic, and a
vasodilator drug. His apical pulse rate is 44
and he is on bed rest. Nurse Angela concludes
that his pulse rate is most likely the result of
the:
a. Diuretic
c. Bed-rest regimen
b. Vasodilator
d.
Cardiac
glycoside
A cardiac glycoside such as digitalis increases
force of cardiac contraction, decreases the
conduction speed of impulses within the
myocardium and slows the heart rate.
187. You are preparing the patients medication
with an active G.I. bleed, which of the following
is a Proton-pump inhibitor?
a. Mylanta
c. Ranitidine (Zantac)
b. Lansoprazole (Prevacid) d.
Sucralfate
(Carafate)
Lansoprazole s a proton-pump inhibitor (PPI)
which prevents the stomach from producing
Page1

178. Which of the following is best likely to be
included in the nursing interventions for client
with COPD?
a.Placing the client in the high fowlers
position,
leaning
forward,
arms
supported on an over bed table
b.Providing high protein and low carbohydrate
diet
c.Administering oxygen at 6 L/min
d.Administer bronchodilator
Orthopneic position promotes optimal lung
expansion. B, C and D are dependent nursing
interventions
179. On a post-thyroidectomy clients discharge,
Nurse Sandy teaches her to observe for signs
of surgically induced hypothyroidism. Nurse
Sandy would know that the client understands
the teaching when she states she should notify
the physician if she develops:
a. Intolerance to heat
c. Progressive
weight loss
b. Dry skin and fatigue
d.
Insomnia
and excitability
Dry skin is most likely caused by decreased
glandular function and fatigue caused by
decreased metabolic rate. Body functions and
metabolism are decreased in hypothyroidism.
180. When a post-thyroidectomy client returns
from surgery, Nurse Eve assesses her for
unilateral injury of the laryngeal nerve every
30 to 60 minutes by:
a. Observing for signs of tetany
b. Checking her throat for swelling
c. Asking her to state her name out loud
d. Palpating the side of her neck for blood
seepage
If the recurrent laryngeal nerve is damaged
during surgery, the client will be hoarse and have
difficulty speaking.
181. Twenty-four hours after TURP surgery, the
client tells the nurse he has lower abdominal
discomfort. Nurse Julia notes that the catheter
drainage has stopped. The nurses initial action
should be to:
a. Irrigate the catheter with saline
b. Milk the catheter tubing
c. Remove the catheter
d. Notify the physician
Milking the tubing will usually dislodge the plug
and will not harm the client. A physicians order is
not necessary for a nurse to check catheter
patency.
182. Following prostate surgery, the retention
catheter is secured to the clients leg causing
slight traction of the inflatable balloon against
the prostatic fossa. This is done to:
a. Limit discomfort
b. Provide hemostasis
c. Reduce bladder spasms
d. Promote urinary drainage
The pressure of the balloon against the small
blood vessels of the prostate creates a tampon-

that indicates adequate tissue perfusion to

vital organs is:
a. Urinary output is 30 ml in an hour
b. Central venous pressure reading of 2 cm
H2O
c. Pulse rates of 120 and 110 in a 15 minute
period
d. Blood pressure readings of 50/30 and 70/40
within 30 minutes
A rate of 30 ml/hr is considered adequate for
perfusion of kidney, heart and brain.
193. Nurse Oliver would know that dietary
teaching had been effective for a client with
colostomy when he states that he will eat:
a. Food low in fiber so that there is less stool
b. Everything he ate before the operation
but will avoid those foods that cause
gas
c. Bland foods so that his intestines do not
become irritated
d. Soft foods that are more easily digested and
absorbed by the large intestines
There is no special diet for clients with
colostomy. These clients can eat a regular diet.
Only gas-forming foods that cause distention and
discomfort should be avoided.
194. When observing an ostomate do a return
demonstration of the colostomy irrigation,
Nurse Henry notes that he needs more
teaching if he:
a. Stops the flow of fluid when he feels
uncomfortable
b. Lubricates the tip of the catheter before
inserting it into the stoma
c. Hangs the bag on a clothes hook on the
bathroom door during fluid insertion
d. Discontinues the insertion of fluid after only
500 ml of fluid has been instilled
The irrigation bag should be hung 12-18 inches
above the level of the stoma; a clothes hook is too
high which can create increase pressure and
sudden intestinal distention and cause abdominal
discomfort to the patient.
195. Health teachings to be given to a female
client with Pernicious Anemia regarding her
therapeutic regimen concerning Vit. B12 will
include:
a. Oral tablets of Vitamin B12 will control her
symptoms
b. IM injections are required for daily control
c. IM injections once a month will
maintain control
d. Weekly Z-track injections provide needed
control
Deep IM injections bypass B12 absorption defect
in the stomach due to lack of intrinsic factor, the
transport carrier component of gastric juices. A
monthly dose is usually sufficient since it is stored
in active body tissues such as the liver, kidney,
heart, muscles, blood and bone marrow
196. Which of the following activities is not
encouraged in a female patient after an eye
surgery?
Page1
gastric acid. Mylanta an antacid is any substance,

generally an acid or acidic salt, which neutralizes
stomach acidity. Ranitidine is a histamine H2receptor antagonist that inhibits stomach acid
production. Sucralfate is an oral gastrointestinal
medication primarily indicated for the treatment of
active duodenal ulcers.
188. The physician stated that approximately a
patient lost 1,000 to 1,500 cc of blood. This
patient may show the following signs EXCEPT:
a. Weakness and anxiety
b. Minimal urine output
c. Heart rate of 100 120 bpm
d. Capillary refill time (CRT) >3 seconds
Class II Hemorrhage involves 15-30% of total
blood volume. A patient is often tachycardic (rapid
heart beat) with a narrowing of the difference
between the systolic and diastolic blood pressures.
The body attempts to compensate with peripheral
vasoconstriction. Skin may start to look pale and
be cool to the touch. The patient may exhibit
slight changes in behavior.
189. You are in the emergency room department,
a patient suffering from a massive bleeding
with 40% or 2,000 cc blood loss was under
your care for that shift. These are all present
during the time you have taken responsibility,
EXCEPT:
a. Cold, clammy skin
b. Minimal urine output
c.
Respiratory
rate
>24
with
hypoventilation
d. BP <90 systolic
Respiratory rate >24 with hypoventilation Class
III Hemorrhage involves loss of 30-40% of
circulating blood volume. The patient's blood
pressure drops, the heart rate increases,
peripheral hypoperfusion (shock), such as capillary
refill worsens, and the mental status worsens.
Fluid resuscitation with crystalloid and blood
transfusion are usually necessary.
190. During and 8 hour shift, Ryan drinks two 6 oz.
cups of tea and vomits 125 ml of fluid. During
this 8 hour period, his fluid balance would be:
a. +55 ml
c. +235 ml
b. +137 ml
d. +485 ml
The clients intake was (6oz x 30 ml) X 2 = 360
ml and loss was 125 ml of fluid; loss is subtracted
from intake
191. Mr. Foo, jokes about his leukemia even
though he is becoming sicker and weaker. The
nurses most therapeutic response would be:
a. Your laugher is a cover for your fear.
b. He who laughs on the outside, cries on the
inside.
c. Why are you always laughing?
d. Does it help you to joke about your
illness?
This non-judgmentally on the part of the nurse
points out the clients behavior.
192. In the evaluation of a male clients response
to fluid replacement therapy, the observation

b. Alleviate pain
c. Maintain darkened room
d. Promote low-sodium diet
After surgery to correct a detached retina,
prevention of increased intraocular pressure is the
priority goal.
202. When suctioning an unconscious client, which
nursing intervention should the nurse prioritize
in maintaining cerebral perfusion?
a. Administer diuretics
b. Administer analgesics
c. Provide hygiene
d. Hyperoxygenate before and after
suctioning
It is a priority to hyperoxygenate the client
before and after suctioning to prevent hypoxia and
to maintain cerebral perfusion.
203. When discussing breathing exercises with a
postoperative client, Nurse Hazel should
include which of the following teaching?
a. Short frequent breaths
b. Exhale with mouth open
c. Exercise twice a day
d. Place hand on the abdomen and feel it
rise
Abdominal breathing improves lungs expansion
204. 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
c. Glucose
b. Specific gravity
d. Microorganism
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
mucus or CSF. A CSF normally contains glucose.
205. 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
It is crucial to monitor the pupil size and papillary
response to indicate changes around the cranial
nerves.
and
Suddarth 11 ed. Page 2134
206. 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.
The nurse most positive approach is to
encourage the client with multiple sclerosis to stay
Page1
a. sneezing, coughing and blowing the nose

b. straining to have a bowel movement
c. wearing tight shirt collars
d. sexual intercourse
To reduce increases in IOP, teach the client and
family
about
activity
restrictions.
Sexual
intercourse can cause a sudden rise in IOP.
197. Nurse Melody is performing CPR on an adult
patient. When performing chest compressions,
the nurse understands the correct hand
placement is located over the:
a. upper half of the sternum
b. upper third of the sternum
c. lower half of the sternum
d. lower third of the sternum
The exact and safe location to do cardiac
compression is the lower half of the sternum.
Doing it at the lower third of the sternum may
cause gastric compression which can lead to a
possible aspiration.
198. Which of the following interventions would be
included in the care of plan in a female client
with cervical implant?
a. Frequent ambulation
b. Unlimited visitors
c. Low residue diet
d. Vaginal irrigation every shift
It is important for the nurse to remember that
the implant be kept intact in the cervix during
therapy. Mobility and vaginal irrigations are not
done. A low residue diet will prevent bowel
movement that could lead to dislodgement of the
implant. Patient is also strictly isolated to protect
other people from the radiation emissions.
199. 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
The palms should bear the clients weight to
avoid damage to the nerves in the axilla.
200. 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
Active exercises, alternating extension, flexion,
abduction, and adduction, mobilize exudates in
the joints relieves stiffness and pain.
201. A client has undergone surgery for retinal
detachment. Which of the following goal
should be prioritized?
a. Prevent
an
increase
intraocular
pressure

212. 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
In burn, the capillaries and small vessels dilate,
and cell damage cause the release of a histaminelike substance. The substance causes the capillary
walls to become more permeable and significant
quantities of fluid are lost.
213. Tony has diagnosed with hepatitis A. The
information from the health history that is
most likely linked to hepatitis A is:
a. Exposed with arsenic compounds at work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants
Hepatitis A is primarily spread via fecal-oral
route. Sewage polluted water may harbor the
virus.
214. Dr. Marquez orders serum electrolytes. To
determine the effect of persistent vomiting,
Nurse Trish should be most concerned with
monitoring the:
a. Chloride and sodium levels
b. Phosphate and calcium levels
c. Protein and magnesium levels
d. Sulfate and bicarbonate levels
Sodium, which is concerned with the regulation
of extracellular fluid volume, it is lost with
vomiting. Chloride, which balances cations in the
extracellular compartments, is also lost with
vomiting, because sodium and chloride are
parallel
electrolytes,
hyponatremia
will
accompany.
215. A male client with tuberculosis asks Nurse
Brian how long the chemotherapy must be
continued. Nurse Brians accurate reply would
be:
a. 1 to 3 weeks
c. 3 to 5 months
b. 6 to 12 months
d. 3 years and
more
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
216. Minerva refuses to acknowledge that her
breast was removed. She believes that her
breast is intact under the dressing. The nurse
should
a. call the MD to change the dressing so
Minerva can see the incision
b. recognize that Minerva is experiencing
denial, a normal stage of the grieving
process
c. reinforce Minervas belief for several days
until her body can adjust to stress of
surgery.
Page1
active, use stress reduction techniques and avoid

fatigue because it is important to support the
immune system while remaining active.
207. Nurse Trish is aware that temporary
heterograft (pig skin) is used to treat burns
because this graft will:
a. Relieve pain and promote rapid
epithelialization
b. Be sutured in place for better adherence
c. Debride necrotic epithelium
d.
Concurrently
used
with
topical
antimicrobials
The graft covers the nerve endings, which
reduces pain and provides framework for
granulation
208. Tony returns from surgery with permanent
colostomy. During the first 24 hours the
colostomy does not drain. The nurse should be
aware that:
a. Proper functioning of nasogastric suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery
This is primarily caused by the trauma of
intestinal manipulation and the depressive effects
anesthetics and analgesics.
209. When teaching a client about the signs of
colorectal cancer, Nurse Trish stresses that the
most common complaint of persons with
colorectal cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits
Constipation, diarrhea, and/or constipation
alternating with diarrhea are the most common
symptoms of colorectal cancer.
210. Immediately after liver biopsy, the client is
placed on the right side, the nurse is aware
that that this position should be maintained
because it will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary ducts
c. Position with greatest comfort
d. Promote circulating blood volume
Pressure applied in the puncture site indicates
that a biliary vessel was puncture which is a
common complication after liver biopsy.
211. Nurse Jon assesses vital signs on a client
undergone epidural anesthesia. Which of the
following would the nurse assess next?
a. Headache
c. Dizziness
b. Bladder distension
d. Ability
to
move legs
The last area to return sensation is in the
perineal area, and the nurse in charge should
monitor the client for distended bladder.

The nurse must maintain skeletal traction

continuously to ensure its effectiveness. The client
should be repositioned every 2 hours to prevent
skin breakdown. Traction weights must hang freely
to be effective; they should never be supported.
The nurse should increase, not restrict, the client's
fluid and fiber intake (unless contraindicated by a
concurrent illness) to prevent constipation
associated with complete bed rest.
220. On admission, the blood work of a young
male client with leukemia indicates an
elevated blood urea nitrogen (BUN) and uric
acid. Nurse Bea is aware that these laboratory
results may be related to:
a. Lymphadenopathy
c.
Hypermetabolic state
b. Thrombocytopenia
d.
Hepatic
encephalopathy
The hypermetabolic state associated with
leukemia causes more urea and uric acid (end
products of metabolism) to be produced and to
accumulate in the blood.
221. Mang Jose a retired farmer has been
admitted
with
a
diagnosis
of
acute
lymphoblastic leukemia. When he is receiving
chemotherapy, nurse Leng should assess for
the
development
of
life-threatening
thrombocytopenia by monitoring the client for:
a. Fever
c. Headache
b. Diarrhea
d. Hematuria
Thrombocytes are involved in the clotting
mechanism; thrombocytopenia is a reduced
number of thrombocytes in the blood; hematuria is
blood in the urine.
222. Mr. Y, who has had bone pains of insidious
onset for 4 months is suspected of having
multiple myeloma. Nurse Anna understands
that one of the diagnostic findings specific for
multiple myeloma would be:
a. Low serum calcium levels.
b. Bence-Jones protein in urine.
c. Occult and frank blood in the stool.
d. Positive bacterial culture of sputum.
This protein (globulin) results from tumor cell
metabolites; it is present in clients with multiple
myeloma.
223. Nurse Tina understands that the most
definitive test to confirm a diagnosis of
multiple myeloma is:
a. Bone marrow biopsy.
b. Serum test for hypercalcemia.
c. Urine test for Bence-Jones protein.
d. X-ray films of the ribs, spine, and skull.
A definite confirmation of multiple myeloma can
only be made through a bone marrow biopsy; this
is a plasma cell malignancy with widespread bone
destruction.
224. The nurse discusses to the nursing students
on duty about colostomy. If sigmoid colostomy
is done, what type of feces would the students
expect to be expelled?
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d. remind Minerva that she needs to accept

her diagnosis so that she can begin
rehabilitation exercises.
A person grieves to a loss of a significant object.
The initial stage in the grieving process is denial,
then anger, followed by bargaining, depression
and last acceptance. The nurse should show
acceptance of the patients feelings and
encourage verbalization.
217. Delia, with osteoarthritis tells the nurse she is
concerned that the disease will prevent her
from doing her chores. Which suggestion
should the nurse offer?
a. "Do all your chores in the morning, when
pain and stiffness are least pronounced."
b. "Do all your chores after performing morning
exercises to loosen up."
c. "Pace yourself and rest frequently,
especially after activities."
d. "Do all your chores in the evening, when
pain and stiffness are least pronounced."
A client with osteoarthritis must adapt to this
chronic and disabling disease, which causes
deterioration of the joint cartilage. The most
common symptom of the disease is deep, aching
joint pain, particularly in the morning and after
exercise and weight-bearing activities. Because
rest usually relieves the pain, the nurse should
instruct the client to rest frequently, especially
after activities, and to pace herself during daily
activities. Option A is incorrect because the pain
and
stiffness
of
osteoarthritis
are
most
pronounced in the morning. Options B and D are
incorrect because the client should pace herself
and take frequent rests rather than doing all
chores at once.
218. Which of the following is a priority nursing
diagnosis for a male client with an amputated
extremity?
a. Impaired skin integrity related to effects of
the injury
b. Anticipatory grieving related to the loss of a
limb
c. Disturbed body image related to changes in
the structure of a body part
d. Ineffective peripheral tissue perfusion
related to injury and amputation
The priority diagnosis is Ineffective peripheral
tissue perfusion resulting from the loss of
circulation secondary to amputation. All the
nursing diagnoses listed are appropriate for a
client presenting with a traumatic amputation of
an extremity.
219. After a traumatic back injury, a male client
requires skeletal traction. When caring for this
client, Nurse Jen must:
a. change the client's position only if ordered
by the physician.
b. maintain
traction
continuously
to
ensure its effectiveness.
c. support the traction weights with a chair or
table to prevent accidental slippage.
d. restrict the client's fluid and fiber intake to
reduce the movement required for bedpan
use.

A suction bottle should have a continuous

bubbling therefore B is wrong. Electrical
fluctuation causes an intermittent bubbling on the
tube, thus A is incorrect. Having more water on
the suction bottle would not affect its function. So,
C should be eliminated. No bubbling on the
suction bottle is caused by the overexpansion of
the lungs (D).
229. Mr. B is scheduled for chest tube removal.
During the tube withdrawal, which is vital to
prevent the entrance of air in the tube?
a. Observe patient for signs of distress.
b. Clamp the tubes.
c. Instruct the patient to exhale forcefully
with a closed mouth or pinching the
nose.
d. Encourage the client to perform arm
exercises.
The client should perform a valsalva maneuver
(forceful exhalation against a close glottis) as the
tube is withdrawn by the physician. Therefore, the
correct answer is letter C. Never clamp the tubes
(B) as this may result to tension pneumothorax.
230. Cancer surgery is an example of what
operation type basing on the time it is required
to be performed?
a. Optional surgery
c. Emergency
surgery
b. Imperative surgery
d.
Elective
surgery
Cancer surgery should be performed within 2448 hours, thus it is an imperative/urgent surgery.
(A) Optional surgery like liposuction is not needed
and at the patients preference. (C) Emergency
surgery like intestinal obstruction should be done
immediately without delay to maintain life. (D)
Elective surgery is done at the patience
convenience as failure of not having it is not lifethreatening such as excision of a superficial cyst.
231. Hysterectomy is the removal of the uterus. It
is what type of surgery based on its purpose?
a. Ablative
c. Constructive
b. Diagnostic
d. Exploratory
Ablative is the removal of a diseased organ. BDiagnostic is used to confirm a diagnosis. CConstructive
is
used
to
repair
defects
(cheiloplasty) D- Exploratory surgery estimates the
degree of the disease and confirm the diagnosis
(Exploratory Laparotomy)
232. Preoperative teaching least likely includes:
a. Deep breathing exercises
c. Nutritional
status
b. Extremity exercises
d.
Purse-lip
breathing
This is a pre-op assessment not teaching. A, B
and D are pre-op teachings that must be taught to
the patient.
233. At what stage of anesthesia administration
does a client is observed to be unconscious?
a. First stage
c.
Third
stage
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a. Mushy
c. Formed
b. Fluid
d. Semi-mushy
A-For transverse colon colostomy B- For
ascending colon colostomy C- As sigmoid colon
is near the rectum, you expect the stools to be
formed and solid. D- For descending colon
colostomy
225. Upon assessment the nurse notes that the
client has a deep vein thrombosis (DVT). The
client asked what might have caused it. The
nurse enumerated the causes of the thrombus
formation by saying that a Virchows triad are
the following except:
a. Venous stasis
b. Homans sign
c. Vessel wall injury
d. Too much blood coagulating ability
Homans sign is a calf pain that is a
manifestation of DVT. Virchows triad is the one
that causes DVT and is seen in A, C and D.
226. A nurse is conducting a health teaching on
thrombophlebitis. The most effective action to
prevent thrombophlebitis after a vein surgery
is done is to do which of the following:
a. Elevating the leg when lying or sitting
b. Compression with elastic bandage
c. Applying pressure on the site
d. Early ambulation
All the option given are the interventions done
after a vein surgery is done. However, the most
effective way of thrombophlebitis prevention is
mobilization.
227. Mr. B is on chest tube. A three way bottle
system is used. The patient is asking what
should be observed on the bottle at the middle
(water seal). The nurses best response is:
a. The bottle at the middle should have
an intermittent bubbling.
b. The bottle at the middle should have a
continuous bubbling.
c. No bubbling should be seen on that bottle.
Please call me immediately if you observe
bubbling in it.
d. Just be sure all the bottles are not
bubbling.
A water seal bottle should have an intermittent
bubbling because it rises during inhalation and
falls on exhalation. B If continuous bubbling is
observed an air leak would be suspected. CBlockage or obstruction on the tubes can cause
the water seal chamber not to bubble. D - The
suction bottle should be bubbling continuously.
Thus, this is incorrect.
228. As the nurse is administering medications to
Mr. B, he again inquired about his chest tube.
He was asking what possible reason would
cause no bubbling on the suction bottle. The
nurses best response is:
a. It is caused by an electrical fluctuation.
b. It is just a normal observation for a suction
bottle.
c. It is caused by too much water on the
suction bottle.
d. It is caused by the overexpansion of
the lungs.
237. A client has a diagnosis of right-sided heart

failure.
You
expect
to
note
which
manifestations during assessment and workup:
a. Coughing
c. Hemoptysis
b. Ascites
d. Dyspnea
Systemic signs and symptoms will be noted in a
client with a right sided heart failure such as
distended neck veins, hepatomegaly, ascites (B)
and edema. Respiratory-related signs and
symptoms are seen in left-sided heart failure (A,C
and D).
238. A hypertensive client has been prescribed
with Apresoline. What drug classification does
this drug belong?
a. Diuretics
c.
Vasodilator
b. Beta blockers
d. Calcium channel
blocker
Hydralazine (Apresoline) is a vasodilator which

causes dilation of the arterioles thereby,
decreasing BP. In the pharmacologic interventions
for hypertension all this drug types are given.
239. An elderly patient may have sustained a
basilar skull fracture after slipping and falling
on an wet sidewalk. The nurse knows that
basilar skull fractures:
a. Are the least significant type of skull
fracture.
b. May have cause cerebrospinal fluid
(CSF) leaks from the nose or ears.
c. Have no characteristic findings.
d. Are always surgically repaired
A basilar skull fracture carries the risk of
complications of dural tear, causing CSF leakage
and damage to cranial nerves I, II, VII, and VIII.
Classic findings in this type of fracture may
include otorrhea, rhinorrhea, Battles signs, and
raccoon eyes. Surgical treatment isnt always
required.
240. Which of the following types of drugs might
be given to control increased intracranial pressure
(ICP)?
a. Barbiturates
b. Carbonic anhydrase inhibitors
c. Anticholinergics
d. Histamine receptor blockers
Barbiturates may be used to induce a coma in a
patient with increased ICP. This decreases cortical
activity and cerebral metabolism, reduces cerebral
blood volume, decreases cerebral edema, and
reduces the brains need for glucose and oxygen.
Carbonic anhydrase inhibitors are used to
decrease ocular pressure or to decrease the serum
pH in a patient with metabolic alkalosis.
Anticholinergics have many uses including
reducing GI spasms. Histamine receptor blockers
are used to decrease stomach acidity.
241. The nurse is teaching family members of a
patient with a concussion about the early signs
of increased intracranial pressure (ICP). Which
of the following would she cite as an early sign
of increased ICP?
a. Decreased systolic blood pressure
b. Headache and vomiting
c. Inability to wake the patient with noxious
stimuli
d. Dilated pupils that dont react to light
Headache and projectile vomiting are early signs
of increased ICP. Decreased systolic blood
pressure, unconsciousness, and dilated pupils that
dont reac to light are considered late signs.
242. Jessie James is diagnosed with retinal
detachment. Which intervention is the most
important for this patient?
a. Admitting him to the hospital on strict
bed rest
b. Patching both of his eyes
c. Referring him to an ophthalmologist
d. Preparing him for surgery
Immediate bed rest is necessary to prevent
further injury. Both eyes should be patched to
avoid consensual eye movement and the patient
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b. Second stage
d. Fourth stage
First stage: client is drowsy B- Second stage:
increased autonomic activity noted. C- Third stage
: client is unconcious D- Fourth stage : client not
be breathing (resuscitation needed)
234. The main goal after a surgery is:
a. Promotion of wound healing
b. Promotion of adequate respiratory
function
c. Promotion of adequate cardiac function
d. Promotion of adequate fluid and electrolyte
balance
Follow the principle of prioritization A-B-C! Airway
first, then breathing and circulation. Thus,
respiratory first then cardiac function (C) followed
by electrolyte balance (D)and wound healing (A).
235. Open
wound
healing
that
requires
regeneration of much more tissue that at times
may require grafting is healing by:
a. Primary intention
c.
Tertiary
intention
b. Dehiscence
d.
Secondary
intention
Primary intention fills wound with new tissue
leaving a thin and flat scar. B- Dehiscence
separation of wound edges. C- Tertiary intention
wounds that are closed later because of infection
due to contamination leaving a wide scar and
delayed closure D- Secondary intention healing
of open wounds that require regeneration of of
much more tissue and at times require grafting.
236. The following are risk predictors of decubitus
ulcers except:
a. Friction
c. Moisture
b. Activity
d.
Thrombophlebitis
Thrombophlebitis is an inflammation of the vein
that occurs 7-14 days post operatively if the
patient will not promote early ambulation. A, B
and C are risk factors of D.Ulcer.

a. Diuretics
c. Vasodilator
b. Beta blockers
d. Calcium channel
blocker
Verapamil (Calan) is a Calcium channel blocker
that blocks entry of calcium into the smooth
muscle thus, lowering BP.
247. A 33 year old male client enters the clinic
with complaints of pain at the calf muscle. He
said that pain aggravates when he ambulates
or walks. You expect this disorder to be an:
a. Arterial disorder
b. Hypertension
c. Venous disorder
d. Raynauds disease
In arterial disorder the pain is aggravated by
walking and exercise thus, A is the best choice. (C)
Venous D/O is caused by prolonged standing and
management involves elevating the legs.
248. Buergers
disease
or
thromboangitis
Obliterans commonly affects:
a. Medical professionals c. Adolescents
b. Smokers
d. A and B
Buergers disease causes thrombotic and
inflammatory occlusions of the small arterioles
among smokers.
249. A client was admitted in the ER with profuse
bleeding due to a vehicular accident. You
expect what type of shock will occur in this
client if prompt treatment is not implemented?
a. Cardiogenic
c. Anaphylactic
b. Neurogenic
d. Hypovolemic
Hypovolemic shock is caused by a decrease in
circulating volume such as bleeding or plasma loss
in burns. A cardiogenic shock is caused by a loss
of cardiac pumping action (M.I.). Anaphylactic
shock is caused by an allergy. Neurogenic shock is
most likely caused by a spinal injury or shock
250. Pancreatitis would most likely cause:
a. Increased insulin secretion
b. Vasoconstriction
c. Bronchodilation
d. Tachycardia
Increased insulin secretion Pancreatitis is
inflammation of the pancreas. The pancreas is a
gland located behind the stomach. It releases the
hormones insulin and glucagon, as well as
digestive enzymes that help you digest and
absorb food.
251. Which symptom is associated with peritoneal
irritation?
a. Cullens sign
c.
Rebound
tenderness
b. Ascites
d. Grey Turners sign
Rebound tenderness is a clinical sign that a
doctor may detect in physical examination of a
patient's abdomen. Cullen's sign is superficial
edema and bruising in the subcutaneous fatty
tissue around the umbilicus. Ascites is a
gastroenterological term for an accumulation of
fluid in the peritoneal cavity. Grey Turner's sign
refers to bruising of the flanks.
Page1
should receive early referral to an ophthalmologist

should treat the condition immediately. Retinal
reattachment can be accomplished by surgery
only. If the macula is detached or threatened,
surgery is urgent; prolonged detachment of the
macula results in permanent loss of central vision.
243. Dr. Baldez, a chemist, sustained a chemical
burn to one eye. Which intervention takes
priority for a patient with a chemical burn of
the eye?
a. Patch the affected eye and call the
ophthalmologist.
b. Administer a cycloplegic agent to reduce
ciliary spasm.
c. Immediately
instill
a
tropical
anesthetic, then irrigate the eye with
saline solution.
d. Administer antibiotics to reduce the risk of
infection
A chemical burn to the eye requires immediate
instillation of a topical anesthetic followed by
irrigation with copious amounts of saline solution.
Irrigation should be done for 5 to 10 minutes, and
then the pH of the eye should be checked.
Irrigation should be continued until the pH of the
eye is restored to neutral (pH 7.0): Double
eversion of the eyelids should be performed to
look for and remove ciliary spasm, and an
antibiotic ointment can be administered to reduce
the risk of infection. Then the eye should be
patched. Parenteral narcotic analgesia is often
required for pain relief. An ophthalmologist should
also be consulted.
244. The nurse is assessing a patient and notes a
Brudzinskis sign and Kernigs sign. These are
two classic signs of which of the following
disorders?
a. Cerebrovascular accident (CVA)
b. Meningitis
c. Seizure disorder
d. Parkinsons disease
A positive response to one or both tests indicates
meningeal irritation that is present with
meningitis. Brudzinskis and Kernigs signs
dont occur in CVA, seizure disorder, or
Parkinsons disease.
245. The nurse should instruct the patient with
Parkinsons disease to avoid which of the
following?
a. Walking in an indoor shopping mall
b. Sitting on the deck on a cool summer
evening
c. Walking to the car on a cold winter day
d. Sitting on the beach in the sun on a
summer day
The patient with Parkinsons disease may be
hypersensitive to heat, which increases the risk of
hyperthermia, and he should be instructed to
avoid sun exposure during hot weather.
246. Upon reading the clients chart, Verapamil
(Calan) is also prescribed for the client. This
drug is an antihypertive that specifically is
classified as:

a. Alcohol
c. Cirrhosis
b. Aspirin
d. NSAIDS
Cirrhosis is most commonly caused by
alcoholism, hepatitis B and C, and fatty liver
disease, but has many other possible causes.
Some cases are idiopathic, i.e., of unknown cause.
257. As a post-procedure nursing care after
endoscopic therapy of upper GI bleeding,
observe the following EXCEPT:
a. Fever
c. Heartburn
b. Pain
d. Increased bowel
sounds
Monitor the patient for possible complications
such as adverse effects from sedation, cardiac
arrhythmias, respiratory depression and bleeding.
It is impossible for the patient to have increased
bowel sounds since the patient lies supine for
hours.
258. Among the tests being done to evaluate a
case of acute pancreatitis, which of the
following is the imaging gold standard for it?
a. CT scan
c. Ultrasound
b. Plain radiograph
d. Arteriogram
A reasonable indication for a CT scan at
admission (but not necessarily a CT with IV
contrast) is to distinguish acute pancreatitis from
another serious intra-abdominal condition, such as
a perforated ulcer.
259. In acute pancreatitis, an early nutrition is
ordered. This is via:
a. Mouth
c. Jejunostomy tube
b. Nasogastric tube
d.
Intravenous line
Intravenous line - The patient is inhibited to eat
or under NPO in order to prevent undue damage
to
the
gastrointestinal
disorders.
Likewise
intravenous line makes it easier for medications to
be absorbed.
260. The results of the blood examination was
handed in to the station. For a patient with
pancreatitis which of the values is mostly
under monitoring?
a. Iron
c. Potassium
b. Cholesterol
d. Glucose
Glucose Glucose is the primary source of energy
for the body's cells, and blood lipids (in the form of
fats and oils) are primarily a compact energy
store. Glucose is transported from the intestines or
liver to body cells via the bloodstream, and is
made available for cell absorption via the hormone
insulin, produced by the body primarily in the
pancreas.
261. Which of the following interventions will be
most effective in improving Transcultural
communications with oncology clients and
their families?
a. Use touch to show concern and caring for
the client
b. Focus attention on verbal communication
skills only
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252. A client was diagnosed to have suffered from
pancreatitis. One risk factor for acute
pancreatitis is
a. Hyperlipidemia
c. Smoking
b. Bacterial Pneumonia d. Hemophilia
Hyperlipidemia Elevated serum amylase and
lipase levels, in combination with severe
abdominal pain, often trigger the initial diagnosis
of acute pancreatitis.
253. The client want to know which diagnostic test
is most specific for acute pancreatitis. What
will the nurse reply?
a. CBC count
c. Amylase
b. Liver function test
d. Lipase
Lipase is a protein (enzyme) released by the
pancreas into the small intestines. It triggers the
breakdown of fat into fatty acids. Amylase is an
enzyme that helps digest carbohydrates. It is
produced mainly in the pancreas and the glands
that make saliva. When the pancreas is diseased
or inflamed, amylase releases into the blood.
254. A patient after having an endoscopy was
found out to have localized erosions of the
innermost layer of the digestive tract, which is
the term used for it?
a. Peptic ulcers
b. Hemorrhagic cystitis
c. Mallory-Weiss syndrome
d. Gastroesophageal varices
Peptic ulcers A peptic ulcer, also known as, PUD
or peptic ulcer disease,is an ulcer (defined as
mucosal erosions equal to or greater than 0.5 cm)
of an area of the gastrointestinal tract that is
usually acidic and thus extremely painful.
Hemorrhagic cystitis or Haemorrhagic cystitis is
diffuse inflammation of the bladder leading to
dysuria, hematuria, and hemorrhage. MalloryWeiss syndrome or gastro-esophageal laceration
syndrome refers to bleeding from tears (a MalloryWeiss tear) in the mucosa at the junction of the
stomach and esophagus, usually caused by severe
retching, coughing, or vomiting. Gastroesophageal
varices are extremely dilated sub-mucosal veins in
the lower esophagus.
255. A patient is to be taken for TIPS (transjugular
intrahepatic portosystemic shunt). As a nurse
you know that this procedure is used to
prevent recurrent bleeding from:
a. Peptic ulcers
b. Hemorrhagic gastritis
c. Mallory-Weiss syndrome
d. Gastroesophageal varices
TIPS (transjugular intrahepatic portosystemic
shunt) it is used to treat portal hypertension
(which is often due to scarring of the liver (liver
cirrhosis)) which frequently leads to intestinal
bleeding (esophageal varices) or the buildup of
fluid within the abdomen (ascites).
256. A patient asks what substances promote
peptic ulcer formation. You have enumerated
the following EXCEPT:

Conservative management of the nausea and

vomiting may be achieved with the use of.
a. A nasogastric suction tube
c.
Osmotic
laxatives
b. Intravenous antiemetics
d. A clear
liquid diet
A clear liquid diet for this patient is appropriate
in order to lessen the episodes of nausea and
vomiting. The three other options denote invasive
approaches.
267. Which of the following represents the most
appropriate nursing intervention for a client
with pruritus caused by cancer or the
treatments?
a. Administration of antihistamines
b. Steroids
c. Cool baths
d. Silk sheets
Cool baths denotes an independent nursing
interventions which targets comfort of the patient.
Administering antihistamines and steroids needs
the order of physicians which means it is a
dependent role of the nurse. Silk sheets do not
provide relief from the pruritus.
268. The nurse caring for a client who is receiving
external radiation therapy for treatment of
lung cancer should anticipate that the client
will have which of the following?
a. Diarrhea
b. Improved energy level
c. Dysphagia
d. Normal white blood cell count
External radiation therapy is a treatment which
uses radiation (x-ray energy) to kill cancer cells. It
can be used to treat or prevent the spread of one
or more cancer tumors. Side effects when external
radiation therapy is applied include problems in
breathing, or have swelling and infections if a
tumor is inside the lungs and difficulty in
swallowing. Diarrhea, improved energy level and
normal white blood cell count are not part of the
side effects of it.
269. Cancer prevalence is defined as:
a. The number of new cancers in a year
b. All cancer cases more than 5 years
c. The like hood cancer will occur in a lifetime
d. The number of persons with cancer at
a given point in time
Cancer prevalence is the number of person with
cancer at a given point in time. Crude rate is the
number of new cancers in a year. Lifetime risk is
the like hood cancer will occur at a given point in
time. Cancer incidence is the number of persons
with cancer at a given point in time.
270. A nurse is providing education in community
setting about general measures to avoid
excessive sun exposure. Which of the following
recommendations is appropriate?
a. Apply sunscreen only after going to the
water
b. Avoid peek exposure from 9am to 1pm
c. Wear a loosely woven clothing for added
ventilation
Page1
c. Establish a rapport and listen to their

concerns
d. Maintain eye contact at all times
Establishing a rapport and listening to their
concerns builds a universal trusting relationship
necessary for the nursing care. Use of touch,
verbal communication skills and eye contact
varies from culture to culture and norms.
262. The nurse is assisting the physician with a
thoracentesis for a client with suspected lung
cancer. If the client has malignant effusion, the
nurse would expect the fluid to be
a. Milky white
c. Turbid
b. Straw colored
d. Bloody
An exudative pleural effusion which is bloody
suggests malignant effusion. Parapneumonic
effusion has the following characteristic from
turbid to milky white. Straw colored is seen mostly
at the first hours of post-thoracentesis.
263. Which of the following has been associated
with fatigue from cancer chemotherapy?
a. Decreased quality of life
b. Increase risk of infection
c. Improved disease prognosis
d. Pericardial effusion
Cancer fatigue is manifested by weakness and
verbalizations of decreased energy in performing
the daily activities of living. Increased risk for
infection, improved disease prognosis and
pericardial effusion has no direct relationship with
fatigue.
264. Which of the following would be considered
an iatrogenic cause of cancer?
a. Ionizing radiation from radon
b. Ionizing radiation from uranium one
c. X-rays used to treat a tumor
d. Ultraviolet radiation from sun
X-rays used to treat a tumor is considered
iatrogenic cause of cancer since iatrogenic means
doctor or hospital related cause of cancer. The
other options pertain to environmental cause of
cancer.
265. In addition to acetaminophen, which drugs
are recommended from Step 1 of the World
Health Organiztion (WHO) analgesic ladder for
the treatment of mild to moderate cancerrelated pain?
a. Oxycodone
c. Codeine
b. NSAIDs
d.
Propoxyphene
NSAIDs (non-steriodal anti-inflammatory drugs)
are included in the Step 1 of the World Health
organization analgesic ladder. Oxycodone belongs
to the step 3, codeine is an example of opoids on
step 2. Propoxyphene is in a group of drugs called
narcotic pain relievers. It is used to relieve mild to
moderate pain.
266. A terminally ill 82 year old client in hospice
care is experiencing nausea and vomiting
because of a partial bowel obstruction.


274. A client returns from the recovery room at
9am alert and oriented, with an IV infusing. His
pulse is 82, blood pressure is 120/80,
respirations are 20, and all are within normal
range. At 10 am and at 11 am, his vital signs
are stable. At noon, however, his pulse rate is
94, blood pressure is 110/70, and respirations
are 24. What nursing action is most
appropriate?
a. Notify his physician.
b. Take his vital signs again in 15 minutes
c. Take his vital signs again in an hour.
d. Place the patient in shock position.
Monitoring the clients vital signs following
surgery gives the nurse sound information about
the clients condition. Complications can occur
during this period as a result of the surgery or the
anesthesia or both. Keeping close track of changes
in the VS and validating them will help the nurse
initiate interventions to prevent complications
from occurring.
275. Which of the ff. statements by the client to
the nurse indicates a risk factor for CAD?
a. I exercise every other day.
b. My father died of Myasthenia Gravis.
c. My cholesterol is 180.
d. I smoke 1 1/2 packs of cigarettes per
day.
Smoking has been considered as one of the
major modifiable risk factors for coronary artery
disease. Exercise and maintaining normal serum
cholesterol levels help in its prevention.
276. Mr. Braga was ordered Digoxin 0.25 mg. OD.
Which is poor knowledge regarding this drug?
a. It has positive inotropic and negative
chronotropic effects
b. The positive inotropic effect will
decrease urine output
c. Toxicity can occur more easily in the
presence of hypokalemia, liver and renal
problems
d. Do not give the drug if the apical rate is less
than 60 beats per minute.
Inotropic effect of drugs on the heart causes
increase force of its contraction. This increases
cardiac output that improves renal perfusion
resulting in an improved urine output.
277. Valsalva maneuver can result in bradycardia.
Which of the following activities will further
prevent doing Valsalvas maneuver?
a. Use of stool softeners.
b. Enema administration
c. Gagging while toothbrushing.
d. Lifting heavy objects
Straining or bearing down activities can cause
vagal stimulation that leads to bradycardia. Use of
stool softeners promotes easy bowel evacuation
that prevents straining or the valsalva maneuver.
278. The nurse is teaching the patient regarding
his permanent artificial pacemaker. Which
information given by the nurse shows her
Page1
d. Apply sunscreen with a sun protection factor

of 15 or more before sun exposure
This is the best recommendation that a nurse
could say. Applying sunscreen only after going to
the water makes the sunscreen ineffective.
Wearing loosely woven clothing for added
ventilation is not appropriate. Applying sunscreen
with a sun protection factor of 15 or more before
sun exposure is correct however it does not
answer the question on how to avoid it.
271. Which of the following nursing interventions
would be most helpful in making the
respiratory effort of a client with metastatic
lung cancer more efficient?
a. Teaching the client diaphragmatic breathing
techniques
b. Administering cough suppressants as
ordered
c. Teaching an encouraging pursed-lip
breathing
d. Placing the client in a low semi-fowlers
position
Pursed-lip breathing is one of the simplest ways
to control shortness of breath. Diaphragmatic
breathing is only effective for pain management.
Administering
cough
suppressants
is
not
therapeutic at this stage. While placing the client
in a low semi-fowlers position makes it harder for
the patient to breathe due to the incorrect angle.
272. A
58-year
old
client
is
receiving
chemotherapy for lung cancer. He asks the
nurse how the chemotherapeutic drugs will
work. The most accurate explanation the nurse
can give is which of the following?
a. Chemotherapy affects all rapidly
dividing cells
b. The molecular structure of the DNA is
altered
c. Cancer cell are susceptible to drug toxins
d. Chemotherapy encourages cancer cells to
divide
Chemotherapy affects all rapidly dividing cells is
the appropriate answer. It does not only destroy
the molecular structure of the DNA, not
susceptible to toxins and it does not encourage
cells to divide.
273. Mr. Perez is in continuous pain from cancer
that has metastasized to the bone. Pain
medication provides little relief and he refuses
to move. The nurse should plan to:
a. Reassure him that the nurses will not hurt
him
b. Let him perform his own activities of
daily
living
c. Handle him gently when assisting
with
required
care
d. Complete A.M. care quickly as possible
when necessary
Patients with cancer and bone metastasis
experience severe pain especially when moving.
Bone tumors weaken the bone to appoint at which
normal activities and even position changes can
lead to fracture. During nursing care, the patient
needs to be supported and handled gently.

c. Suction until the client indicates to

stop or no longer than 20 second
d. Hyperoxygenate the client before and after
suctioning
One hazard encountered when suctioning a client
is the development of hypoxia. Suctioning sucks
not only the secretions but also the gases found in
the airways. This can be prevented by suctioning
the client for an average time of 5-10 seconds and
not more than 15 seconds and hyperoxygenating
the client before and after suctioning.
283. A patient with angina pectoris is being
discharged home with nitroglycerine tablets.
Which of the following instructions does the
nurse include in the teaching?
a. When your chest pain begins, lie down, and
place one tablet under your tongue. If the
pain continues, take another tablet in 5
minutes.
b. Place one tablet under your tongue. If the
pain is not relieved in 15 minutes, go to the
hospital.
c. Continue your activity, and if the pain does
not go away in 10 minutes, begin taking
the nitro tablets one every 5 minutes for 15
minutes, then go lie down.
d. Place one Nitroglycerine tablet under
the tongue every five minutes for
three doses. Go to the hospital if the
pain is unrelieved.
Angina pectoris is caused by myocardial
ischemia related to decreased coronary blood
supply. Giving nitroglycerine will produce coronary
vasodilation that improves the coronary blood flow
in 3 5 mins. If the chest pain is unrelieved, after
three tablets, there is a possibility of acute
coronary occlusion that requires immediate
medical attention.
284. Which of the following variables is most
important to asses when determining the
impact of the cancer diagnosis and treatment
modalities on a long term survivors quality of
life:
a. Occupation and employability
b. Functional status
c. Evidence of disease
d. Individual values and beliefs
The patients will to survive matters a lot. Hope
during the darkest part of cancer may have the
key to successful treatment since the patient has
the energy to cooperate and compliant with the
regimen. Occupation and employability and
functional status are similar in idea could be
classified as factors that maybe affected by the
diagnosis but not with the treatment of cancer.
Evidence of the disease has varied impact to the
patient.
285. A 57-year old woman has difficulty with
mobility after her cancer treatment therapies
and states, Why should I bother trying to get
better? It doesnt seem to make any difference
that I do the nurse response by helping the
client establish reasonable activity goals,
choose her own foods from the menu, and
make choices about her daily activities. These
Page1
knowledge deficit about the artificial cardiac

pacemaker?
a. take the pulse rate once a day, in the
morning upon awakening
b. may be allowed to use electrical appliances
c. have regular follow up care
d. may engage in contact sports
The client should be advised by the nurse to
avoid contact sports. This will prevent trauma to
the area of the pacemaker generator.
279. A client receiving heparin sodium asks the
nurse how the drug works. Which of the
following points would the nurse include in the
explanation to the client?
a. It dissolves existing thrombi.
b. It prevents conversion of factors that
are needed in the formation of clots.
c. It inactivates thrombin that forms and
dissolves existing thrombi.
d. It interferes with vitamin K absorption.
Heparin is an anticoagulant. It prevents the
conversion of prothrombin to thrombin. It does not
dissolve a clot.
280. The nurse is conducting an education session
for a group of smokers in a stop smoking
class. Which finding would the nurse state as a
common symptom of lung cancer? :
a. Dyspnea on exertion
b. Foamy, blood-tinged sputum
c. Wheezing sound on inspiration
d. Cough or change in a chronic cough
Cigarette smoke is a carcinogen that irritates and
damages the respiratory epithelium. The irritation
causes the cough which initially maybe dry,
persistent and unproductive. As the tumor
enlarges, obstruction of the airways occurs and
the cough may become productive due to
infection.
281. Which is the most relevant knowledge about
oxygen administration to a client with COPD?
a. Oxygen at 1-2L/min is given to
maintain the hypoxic stimulus for
breathing.
b.
Hypoxia
stimulates
the
central
chemoreceptors in the medulla that makes
the client breath.
c. Oxygen is administered best using a nonrebreathing mask
d. Blood gases are monitored using a pulse
oximeter.
COPD causes a chronic CO2 retention that
renders the medulla insensitive to the CO2
stimulation for breathing. The hypoxic state of the
client then becomes the stimulus for breathing.
Giving the client oxygen in low concentrations will
maintain the clients hypoxic drive.
282. When suctioning mucus from a clients lungs,
which nursing action would be least
appropriate?
a. Lubricate the catheter tip with sterile saline
before insertion.
b. Use sterile technique with a two-gloved
approach

a. Manifested by night sweats

b. Asymptomatic
c. Manifested by productive cough
d. Manifested by pain on the lower lobe
A Night sweats is one of the signs that is
apparent during the severe stage of the disease. B
Patients are initially asymptomatic which means,
the patient has an active tubercle bacilli but does
not show signs of the disease. C Productive
cough is manifested as a defences from foreign
bodies or microbes that enters the respiratory
tract. D Pain on the lower lobe belongs to signs
of pneumonia not tuberculosis.
289. A
10-year
boy
who
is
undergoing
chemotherapy can be placed in a room with:
a. A 13-year-old boy with chicken pox
b. A 9-year-old girl post appendectomy
c. A 10-year-old boy with CHF
d. An 8-year-old boy with salmonellosis
A A 13-year-old boy with chicken pox means
that he is contagious enough to compromise the
child
who
was
recently
undergone
a
chemotherapy.
B
9-year-old
girl
post
appendectomy has a non-infectious case, however
the gender of the child is not appropriate. C A
10-year-old boy with CHF is appropriate to be his
roommate since they are of the same age and
gender. This lowers the anxiety as well as it
promotes a familiarity for both kids. D- An 8-yearold-boy with salmonellosis is not also appropriate
to be place with the child since it is an infectious
type of case.
Kaplan NCLEX Review Series 2008 page 451
290. A patient was diagnosed to be suffering from
phenylketonuria. Interventions by the nurse
should be aimed in monitoring the patients
growth and development due to which of the
following complications:
a. Hydrocephalus
c. Malnutrition
b. Paralysis
d.
Mental
retardation
Mental retardation is the complication of
phenylketonuria since the baby has an inborn
abnormality of lacking the ability to break down
phenylalanine. A - Hydrocephalus is a complication
for meningitis. B - Paralysis is a complication for
cases like tetanus or nerve damage. C Malnutrition is a case when a vitamin or mineral is
depleted in the body.
291. Gary Jordan suffered a cerebrovascular
accident that left her unable to comprehend
speech and unable to speak. This type of
aphasia is known as:
a. Receptive aphasia
c.
Global
aphasia
b. Expressive aphasia
Conduction
aphasia
Global aphasia occurs when all language
functions are affected. Receptive aphasia, also
known as Wernickes aphasia, affects the ability to
comprehend written or spoken words. Expressive
aphasia, also known as Brocas aphasia, affected
the patients ability to form language and express
thoughts.
Conduction
aphasia
refers
to
abnormalities in speech repetition.
Page1
interventions represent the nurses attempt to

address which of the following nursing
diagnoses?
a. Ineffective coping
c.
Impaired
adjustment
b. Powerlessness
d.
Dysfunctional grieving
Powerlessness according to NANDA is perception
that ones own actions will not significantly affect
an outcome; a perceived lack of control over a
current situation or immediate happening.
Ineffective coping is Inability to form a valid
appraisal of the stressors, inadequate choices of
practiced responses, and/or inability to use
available resources. Impaired adjustment is
inability to modify lifestyle or behavior in a
manner consistent with a change in health status.
Dysfunctional
grieving
is
intellectual
and
emotional responses and behaviors by which
individuals, families, communities work through
the process of modifying self-concept based on the
perception of potential loss.
286. Which of the following activities indicates
that the client with cancer is adapting well to
body image changes?
a. The client names his brother as the person
to call if he is experiencing suicidal
intention
b. The client discusses changes in body
structure and function
c. The client discusses the date he has to
return work
d. The client serves as a volunteer in a
client-to-client visitation program
Client to client visitation program allows each
patient with similar cancer to interact and publicly
denounce stigma due to alterations in the body.
Suicidal intention denotes depression and
desperation. If the client discusses changes in
body structure and function, he is trying to
rationalize which is a defense mechanism.
287. When a 62-year old client and his family
receive the initial diagnosis of colon cancer,
the nurse can act as an advocate:
a. Helping them maintain a sense of optimism
and hopefulness
b. Determining their understanding of the
results of the diagnostic testing
c. Listening carefully to their perceptions
of what their needs are
d. Providing them with written materials about
the cancer site and its treatment
Listening carefully to their perception of what
their needs are is acting in behalf of the patient
and looking on the interest of the patient. Helping
them maintains a sense of optimism and
hopefulness means that the nurse functions as a
counselor. Determining their understanding of the
results of the diagnostic testing and giving them
with written materials about the cancer site and
its treatment are ways when a nurse functions as
a teacher.
288. A patient is suspected to be suffering from
tuberculosis. The nurse knows that the disease
is initially:

the husband indicates that he understands the

drugs use?
a. Nimodipine replaces calcium.
b. Nimodipine promotes growth of blood
vessels in the brain.
c. Nimodipine reduces the brains demand for
oxygen.
d. Nimodipine reduces vasospasm in the
brain.
Nimodipine is a calcium channel blocker that acts
on cerebral blood vessels to reduce vasospasm.
The drug doesnt increase the amount of calcium,
affect cerebral vasculature growth, or reduce
cerebral oxygen demand.
297. Many men who suffer spinal injuries continue
to be sexually active. The teaching plan for a
man with a spinal cord injury should include
sexually concerns. Which of the following
injuries would most likely prevent erection and
ejaculation?
a. C5
c. T4
b. C7
d. S4
Men with spinal cord injury should be taught that
the higher the level of the lesion, the better their
sexual function will be. The sacral region is the
lowest area on the spinal column and injury to this
area will cause more erectile dysfunction.
298. An
early
symptom
associated
with
amyotrophic lateral sclerosis (ALS) includes:
a. Fatigue while talking
b. Change in mental status
c. Numbness of the hands and feet
d. Spontaneous fractures
Early symptoms of ALS include fatigue while
talking, dysphagia, and weakness of the hands
and arms. ALS doesnt cause a change in mental
status, paresthesia, or fractures.
299. When caring for a patient with esophageal
varices, the nurse knows that bleeding in this
disorder usually stems from:
a. Esophageal perforation
c.
Portal
hypertension
b. Pulmonary hypertension
d. Peptic ulcers
Increased pressure within the portal veins causes
them to bulge, leading to rupture and bleeding
into the lower esophagus. Bleeding associated
with esophageal varices doesnt stem from
esophageal perforation, pulmonary hypertension,
or peptic ulcers.
300. Tiffany is diagnosed with type A hepatitis.
What special precautions should the nurse take
when caring for this patient?
a. Put on a mask and gown before entering the
patients room.
b. Wear gloves and a gown when
removing the patients bedpan.
c. Prevent the droplet spread of the organism.
d. Use caution when bringing food to the
patient.
The nurse should wear gloves and a gown when
removing the patients bedpan because the type A
hepatitis virus occurs in stools. It may also occur
in blood, nasotracheal secretions, and urine. Type
Page1
292. Immediately following cerebral aneurysm

rupture, the patient usually complains of:
a. Photophobia
c. Seizures
b. Explosive headache d. Hemiparesis
An explosive headache or the worst headache
Ive ever had is typically the first presenting
symptom of a bleeding cerebral aneurysm.
Photophobia, seizures, and hemiparesis may occur
later.
293. Which of the following is a cause of embolic
brain injury?
a. Persistent hypertension
c.
Atrial
fibrillation
b. Subarachnoid hemorrhage
d.
Skull
fracture
An embolic injury, caused by a traveling clot,
may result from atrial fibrillation. Blood may pool
in the fibrillating atrium and be released to travel
up the cerebral artery to the brain. Persistent
hypertension may place the patient at risk for a
thrombotic injury to the brain. Subarachnoid
hemorrhage and skull fractures arent associated
with emboli.
294. Although Ms. Santos has a spinal cord injury,
she can still have sexual intercourse.
Discharge teaching should make her aware
that:
a. She must remove indwelling urinary
catheter prior to intercourse.
b. She can no longer achieve orgasm.
c. Positioning may be awkward.
d. She can still get pregnant.
Women with spinal cord injuries who were
sexually active may continue having sexual
intercourse and must be reminded that they can
still become pregnant. She may be fully capable of
achieving orgasm. An indwelling urinary catheter
may be left in place during sexual intercourse.
Positioning will need to be adjusted to fit the
patients needs.
295. Ivy, age 25, suffered a cervical fracture
requiring immobilization with halo traction.
When caring for the patient in halo traction,
the nurse must:
a. Keep a wrench taped to the halo vest
for quick removal if cardiopulmonary
resuscitation is necessary.
b. Remove the brace once a day to allow the
patient to rest.
c. Encourage the patient to use a pillow under
the ring.
d. Remove the brace so that the patient can
shower.
The nurse must have a wrench taped on the vest
at all times for quick halo removal in emergent
situations. The brace isnt to be removed for any
other reason until the cervical fracture is healed.
Placing a pillow under the patients head may alter
the stability of the brace.
296. The nurse asks a patients husband if he
understands why his wife is receiving
nimodipine (Nimotop), since she suffered a
cerebral aneurysm rupture. Which response by

shift into the cells, possibly resulting in rupture. An

isotonic solution, which has the same osmotic
pressure as the cells, wouldnt cause any shift. A
solutions alkalinity is related to the hydrogen ion
concentration, not its osmotic effect.
305. Particles move from an area of greater
osmolarity to one of lesser osmolarity through:
a. Active transport
c. Diffusion
b. Osmosis
d. Filtration
Particles move from an area of greater
osmolarity to one of lesser osmolarity through
diffusion. Active transport is the movement of
particles though energy expenditure from other
sources such as enzymes. Osmosis is the
movement of a pure solvent through a
semipermeable membrane from an area of greater
osmolarity to one of lesser osmolarity until
equalization
occurs.
The
membrane
is
impermeable to the solute but permeable to the
solvent. Filtration is the process by which fluid is
forced through a membrane by a difference in
pressure; small molecules pass through, but large
ones dont.
306. Which
assessment
finding
indicates
dehydration?
a. Tenting of chest skin when pinched
b. Rapid filling of hand veins
c. A pulse that isnt easily obliterated
d. Neck vein distention
Tenting of chest skin when pinched indicates
decreased skin elasticity due to dehydration. Hand
veins fill slowly with dehydration, not rapidly. A
pulse that isnt easily obliterated and neck vein
distention indicate fluid overload, not dehydration.
307. Which nursing intervention would most likely
lead to a hypo-osmolar state?
a. Performing nasogastric tube irrigation with
normal saline solution
b. Weighing the patient daily
c. Administering tap water enema until
the return is clear
d. Encouraging the patient with excessive
perspiration to dink broth
Administering a tap water enema until return is
clear would most likely contribute to a hypoosmolar state. Because tap water is hypotonic, it
would be absorbed by the body, diluting the body
fluid concentration and lowering osmolarity.
Weighing the patient is the easiest, most accurate
method to determine fluid changes. Therefore, it
helps identify rather than contribute to fluid
imbalance. Nasogastric tube irrigation with normal
saline solution wouldnt cause a shift in fluid
balance. Drinking broth wouldnt contribute to a
hypo-osmolar state because it doesnt replace
sodium and water lost through excessive
perspiration.
308. Which assessment finding would indicate an
extracellular fluid volume deficit?
a. Bradycardia
b. A central venous pressure of 6 mm Hg
c. Pitting edema
d. An orthostatic blood pressure change
Page1
A hepatitis isnt transmitted through the air by

way of droplets. Special precautions arent needed
when feeding the patient, but disposable utensils
should be used.
301. The nurse explains to the patient who has an
abdominal
perineal
resection
that
an
indwelling urinary catheter must be kept in
place for several days afterward because:
a. It prevents urinary tract infection following
surgery
b. It
prevents
urine
retention
and
resulting pressure on the perineal
wound
c. It minimizes the risk of wound contamination
by the urine
d. It determines whether the surgery caused
bladder trauma
An indwelling urinary catheter is kept in place
several days after this surgery to prevent urine
retention that could place pressure on the perineal
wound. An indwelling urinary catheter may be a
source of postoperative urinary tract infection.
Urine wont contaminate the wound. An indwelling
urinary catheter wont necessarily show bladder
trauma.
302. The first day after, surgery the nurse finds no
measurable fecal drainage from a patients
colostomy
stoma.
What
is
the
most
appropriate nursing intervention?
a. Call the doctor immediately.
b. Obtain an order to irrigate the stoma.
c. Place the patient on bed rest and call the
doctor.
d. Continue the current plan of care.
The colostomy may not function for 2 days or
more (48 to 72 hours) after surgery. Therefore, the
normal plan of care can be followed. Since no fecal
drainage is expected for 48 to 72 hours after a
colostomy (only mucous and serosanguineous),
the doctor doesnt have to be notified and the
stoma shouldnt be irrigated at this time.
303. If a patients GI tract is functioning but hes
unable to take foods by mouth, the preferred
method of feeding is:
a. Total parenteral nutrition
b. Peripheral parenteral nutrition
c. Enteral nutrition
d. Oral liquid supplements
If the patients GI tract is functioning, enteral
nutrition via a feeding tube is the preferred
method. Peripheral and total parenteral nutrition
places the patient at risk for infection. If the
patient is unable to consume foods by mouth, oral
liquid supplements are contraindicated.
304. Which type of solution causes water to shift
from the cells into the plasma?
a. Hypertonic
c. Isotonic
b. Hypotonic
d. Alkaline
A hypertonic solution causes water to shift from
the cells into the plasma because the hypertonic
solution has a greater osmotic pressure than the
cells. A hypotonic solution has a lower osmotic
pressure than that of the cells. It causes fluid to

c. Assess the irrigation catheter for

patency and drainage
d. Administer
meperidine
(Demerol)
as
prescribed
Although postoperative pain is expected, the
nurse should ensure that other factors, such as an
obstructed irrigation catheter, arent the cause of
the pain. After assessing catheter patency, the
nurse should administer an analgesic such as
meperidine as prescribed. Increasing the I.V. flow
rate may worse the pain. Notifying the doctor isnt
necessary unless the pain is severe or unrelieved
by the prescribed medication.
313. A 50-year-old patient who has been admitted
in the hospital with an abdominal aneurysm
would most likely have which of these
symptoms?
a. Pulsating abdominal mass
b. Distended abdomen
c. Decreased bowel sounds
d. Blood in stools
A - Pulsating abdominal mass denotes that the
buildup clot is located at the abdominal area. B Distended abdomen may mean that there is
accumulation of air or liquid or substances. C Decreased bowel sounds may mean indigestion or
for post operated patients; it is common that there
are decreased bowel sounds. D - Blood in stools or
melena may mean colorectal cancer or just
damage on the veins near the rectal area.
314. Which of these questions is appropriate for
the nurse to ask a patient who is suspected of
having acromegaly?
a. Do you urinate often at night?
b. Are you buying larger shoe sizes?
c. Is your mouth frequently dry after meals?
d. Have you had alopecia lately?
A - Do you urinate often at night? This is only
appropriate for patients with enuresis or urinary
tract infection. B - Are you buying larger shoe
sizes? This denotes growth in the bone
structure of the feet. C - Is your mouth frequently
dry after meals?. D - Have you had alopecia
lately? This type of question is for patients who
have undergone chemotherapy or some kind of
integumentary dysfunction.
315. In a 10 year old patient who lost large
amount of fluid due to profuse diarrhea, which
of these symptoms would the nurse observe?
a. Increased blood pressure
c.
Distended
neck veins
b. Flushed dry skin
d.
Bilateral
basal rales
A - Increased blood pressure may mean cardiac
demand only. B - Flushed dry skin is a sign of
dehydration. C - Distended neck veins is present
for Congestive Heart Failure or right-sided heart
failure.. D - Bilateral basal rales may denote fluid
overload on the lungs.
316. Pernicious anemia in an elderly patient most
likely is the result of:
a. Atrophy of the stomach lining
b. Reduced function of the bone marrow
Page1
An orthostatic blood pressure indicates an

extracellular
fluid
volume
deficit.
(The
extracellular compartment consists of both the
intravascular compartment and interstitial space.)
A fluid volume deficit within the intravascular
compartment would cause tachycardia, not
bradycardia or orthostatic blood pressure change.
A central venous pressure of 6 mm Hg is in the
high normal range, indicating adequate hydration.
Pitting edema indicates fluid volume overload.
309. A patient with metabolic acidosis has a
preexisting problem with the kidneys. Which
other organ helps regulate blood pH?
a. Liver
c. Lungs
b. Pancreas
d. Heart
The respiratory and renal systems act as
compensatory mechanisms to counteract-base
imbalances. The lungs alter the carbon dioxide
levels in the blood by increasing or decreasing the
rate and depth of respirations, thereby increasing
or decreasing carbon dioxide elimination. The
liver, pancreas, and heart play no part in
compensating for acid-base imbalances.
310. The nurse considers the patient anuric if the
patient;
a. Voids during the nighttime hours
b. Has a urine output of less than 100 ml
in 24 hours
c. Has a urine output of at least 100 ml in 2
hours
d. Has pain and burning on urination
Anuria refers to a urine output of less than 100
ml in 24 hours. The baseline for urine output and
renal function is 30 ml of urine per hour. A urine
output of at least 100 ml in 2 hours is within
normal limits. Voiding at night is called nocturia.
Pain and burning on urination is called dysuria.
311. Which nursing action is appropriate to
prevent infection when obtaining a sterile urine
specimen from an indwelling urinary catheter?
a. Aspirate urine from the tubing port
using a sterile syringe and needle
b. Disconnect the catheter from the tubing and
obtain urine
c. Open the drainage bag and pour out some
urine
d. Wear sterile gloves when obtaining urine
To obtain urine properly, the nurse should
aspirate it from a port, using a sterile syringe after
cleaning the port. Opening a closed urine drainage
system increases the risk of urinary tract infection.
Standard precautions specify the use of gloves
during contract with body fluids; however, sterile
gloves arent necessary.
312. After undergoing a transurethral resection of the
prostate to treat benign prostatic hypertrophy, a
patient is returned to the room with continuous
bladder irrigation in place. One day later, the
patient reports bladder pain. What should the
nurse do first?
a. Increase the I.V. flow rate
b. Notify the doctor immediately


321. An arterial blood gases test (ABG) is ordered
for a confused client. The respiratory therapist
draws the blood and then asks the nurse to
apply pressure to the area so the therapist can
take the specimen to the laboratory. How long
should the nurse apply pressure to the area?
a. 3 minutes
c. 8 minutes
b. 5 minutes
d. 10 minutes
5 minutes The ample time for the clot to form
and the bleeding will stop. A is too short for clot
formation. C & D is too long and the clot has
already formed.
322. A nurse notices that the client has painted
finger nails on admission to the ambulatory
surgey unit. The nurse reviews the preoperative orders, a pulse oximetry is clearly
ordered. Which statement by the nurse is
appropriate?
a. So that we can assure your oxygen level,
please remove the polish from at least 2
nails.
b. If you do not remove all your polish, I will
request a needlestick to test oxygen
levels.
c. I am sorry. All your nail polish must
be removed
d. I will ask your provider if we must ruin
those beautiful nails.
I am sorry. All your nail polish must be
removed is a firm and concise information for
the patient. A this is not a hospital protocol. B &
D are not therapeutic for the patient and may
cause anxiety.
323. The following are the precursors of the major
formed elements of blood EXCEPT:
a. Megakaryocytes
c.
Reticulocytes
b. Granulocytes
d. Erythrocytes
Erythrocytes It is the result of the reticulocytes,
it is another name of Red blood cells.
Megakaryocytes are bone marrow cell responsible
for the production of blood thrombocytes
(platelets). Granulocytes re a category of white
blood cells characterized by the presence of
granules in their cytoplasm. Reticulocytes are the
precursors of the major formed elements of blood.
324. When assessing a wound that exhibits signs
of blood coagulation and healing, the nurse
understands that the soluble substance
becomes an insoluble gel is:
a. Fibrin
c. Fibrinogen
b. Thrombin
d. Prothrombin
Fibrin - soluble substance becomes an insoluble
gel. Thrombin is also known as coagulation factor
II. Fibrinogen is a soluble plasma glycoprotein,
synthesized by the liver. Prothrombin is a
glycoprotein formed by and stored in the liver and
present in the blood plasma that is converted to
thrombin in the presence of thromboplastin and
calcium ion during blood clotting.
and Suddarth 11 ed. Page 1041.
Page1
c. Diminished liver metabolism

d. Erosion of the intestinal rugae
A - Atrophy of the stomach lining happens since
during Vit B12 deficiency, there is also lack of
intrinsic factor B - Reduced function of the bone
marrow happens when chemotherapy is rendered
since it kills not only the cancer cells but also
affects the source of cells such as the bone
marrow C - Diminished liver metabolism is
apparent for cases like liver cancer or
encephalopathy D - Erosion of intestinal rugae is
present for ulcer.
Kaplan NCLEX Review Series 2008, Page 456
317. Which of the following nursing diagnosis is a
priority for a patient with gout
a. Pain
b. Fatigue
c. Risk for infection
d.
Risk
for
peripheral
neurovascular
dysfunction
Pain is the priority nursing diagnosis since gout is
a metabolic disease marked by the urate crystal
deposits in joints throughout the body which
causes inflammatory responses. Choices B to D
are secondary only to pain.
318. Which of the following statements reflect a
common symptom associated with aspirin
toxicity?
a. Im having frequent urination
b. I hear buzzing sounds
c. I feel nauseated and sick
d. My neck is aching.
I hear buzzing sounds is associated with aspirin
toxicity a sign of tinnitus which is a nonspecific
nonsensitive clinical effect of salicylism. Choice A
is a sign of UTI, Choices C & D are general
symptoms and signals a wide array of diseases.
319. The nurse is assessing a client with COPD
receiving oxygen for low levels of PaO2 levels.
Which assessment is a nursing priority?
a. Evaluating SaO2 levels
b. Observing for skin color changes
c. Assessing for club fingers
d. Identifying tactile fremitus
Evaluating SaO2 levels is a concrete measure of
the oxygen levels and the drive to take in more
oxygen. Choices B to D serve as a supportive
assessment finding only.
320. The nurse enters the room of a client
diagnosed with COPD. The clients skin is pink,
and respirations are 8 per minute. The clients
oxygen is running at 6 liters per minute. What
should be the nurses first action?
a. Call the health care provider
b. Put the client in Fowlers position
c. Lower the oxygen rate
d. Take the vital signs
Lower the oxygen rate this enables the patient
breathe in and cope up with the normal breathing,
the prescribed oxygen level for COPD should not
exceed 4 liters per minute. A it is important to
give an intervention first before calling the doctor.
B Positioning could be done after lowering the
oxygen. D This could be done after positioning
the patient properly.


329. James King is admitted to the hospital with
right-side-heart failure. When assessing him
for jugular vein distention, the nurse should
position him:
a. Lying on his side with the head of the bed
flat.
b. Sitting upright.
c. Flat on his back.
d. Lying on his back with the head of the
bed elevated 30 to 45 degrees.
Assessing jugular vein distention should be done
when the patient is in semi-Fowlers position (head
of the bed elevated 30 to 45 degrees). If the
patient lies flat, the veins will be more distended;
if he sits upright, the veins will be flat.
330. The nurse is interviewing a slightly
overweight
43-year-old
man
with
mild
emphysema and borderline hypertension. He
admits to smoking a pack of cigarettes per day.
When developing a teaching plan, which of the
following should receive highest priority to
help decrease respiratory complications?
a. Weight reduction
b. Decreasing salt intake
c. Smoking cessation
d. Decreasing caffeine intake
Smoking should receive highest priority when
trying to reduce risk factors for with respiratory
complications. Losing weight and decreasing salt
and caffeine intake can help to decrease risk
factors for hypertension.
331. What is the ratio of chest compressions to
ventilations when one rescuer performs
cardiopulmonary resuscitation (CPR) on an
adult?
a. 15:1
c. 12:1
b. 15:2
d. 12:2
The correct ratio of compressions to ventilations
when one rescuer performs CPR is 15:2
332. When assessing a patient for fluid and
electrolyte balance, the nurse is aware that the
organs most important in maintaining this
balance are the:
a. Pituitary gland and pancreas
b. Liver and gallbladder.
c. Brain stem and heart.
d. Lungs and kidneys.
The lungs and kidneys are the bodys regulators
of homeostasis. The lungs are responsible for
removing fluid and carbon dioxide; the kidneys
maintain a balance of fluid and electrolytes. The
other organs play secondary roles in maintaining
homeostasis.
333. Mario undergoes a left thoracotomy and a
partial pneumonectomy. Chest tubes are
inserted, and one-bottle water-seal drainage
is instituted in the operating room. In the
postanesthesia care unit Mario is placed in
Fowlers position on either his right
side or on his back to
a. Reduce incisional pain.
Page1
325. The nurse is reviewing the report of a

patients routine urinalysis. Which of the
following values should the nurse consider
abnormal?
a. Specific gravity of 1.002
c. Absence of
protein
b. Urine pH of 3
d. Absence of glucose
Normal urine pH is 4.5 to 8; therefore, a urine pH
of 3 is abnormal and may indicate such conditions
as renal tuberculosis, pyrexia, phenylketonuria,
alkaptonuria, and acidosis. Urine specific gravity
normally ranges from 1.002 to 1.032, making the
patients value normal. Normally, urine contains
no protein, glucose, ketones, bilirubin, bacteria,
casts, or crystals.
326. During a shock state, the renin-angiotensinaldosterone system exerts which of the
following effects on renal function?
a. Decreased urine output, increased
reabsorption of sodium and water
b. Decreased
urine
output,
decreased
c. Increased
urine
output,
increased
d. Increased
urine
output,
decreased
As a response to shock, the renin-angiotensinaldosterone system alters renal function by
decreasing
urine
output
and
increasing
reabsorption of sodium and water. Reduced renal
perfusion
stimulates
the
renin-angiotensinaldosterone system in an effort to conserve
circulating volume.
327. While assessing a patient who complained of
lower abdominal pressure, the nurse notes a
firm mass extending above the symphysis
pubis. The nurse suspects:
a. A urinary tract infection
c. An enlarged
kidney
b. Renal calculi
d.
A
distended
bladder
The bladder isnt usually palpable unless it is
distended. The feeling of pressure is usually
relieved with urination. Reduced bladder tone due
to general anesthesia is a common postoperative
complication that causes difficulty in voiding. A
urinary tract infection and renal calculi arent
palpable. The kidneys arent palpable above the
symphysis pubis.
328. Greg, age 75, is admitted to the medicalsurgical floor with weakness and left-sided
chest pain. The symptoms have been present
for several weeks after a viral illness. Which
assessment finding is most symptomatic of
pericarditis?
a. Pericardial friction rub
b. Bilateral crackles auscultated at the lung
bases
c. Pain unrelieved by a change in position
d. Third heart sound (S3)
A pericardial friction rub may be present with the
pericardial effusion of pericarditis. The lungs are
typically clear when auscultated. Sitting up and
leaning forward often relieves pericarditis pain. An
S3 indicates left-sided heart failure and isnt
usually present with pericarditis.

b. Hand grips
d. Blood glucose
Pheochromocytoma is a tumor of the adrenal
medulla that causes an increase secretion of
catecholamines that can elevate the blood
pressure.
338. The nurse is attending a bridal shower for a
friend when another guest, who happens to be
a diabetic, starts to tremble and complains of
dizziness. The next best action for the nurse to
take is to:
a. Encourage the guest to eat some baked
macaroni
b. Call the guests personal physician
c. Offer the guest a cup of coffee
d. Give the guest a glass of orange juice
In diabetic patients, the nurse should watch out
for signs of hypoglycemia manifested by dizziness,
tremors, weakness, pallor diaphoresis and
tachycardia. When this occurs in a conscious
client,
he
should
be
given
immediately
carbohydrates in the form of fruit juice, hard
candy, honey or, if unconscious, glucagons or
dextrose per IV.
339. An
adult,
who
is
newly
diagnosed
with Graves disease, asks the nurse, Why do I
need to take Propanolol (Inderal)? Based on
the nurses understanding of the medication
and Graves disease, the best response would
be:
a. The medication will limit thyroid hormone
secretion.
b. The medication limit synthesis of the
thyroid hormones.
c. The medication will block the
cardiovascular symptoms of Graves
disease.
d. The medication will increase the synthesis
of thyroid hormones.
Propranolol (Inderal) is a beta-adrenergic blocker
that controls the cardiovascular manifestations
brought about by increased secretion of the
thyroid hormone in Graves disease.
340. During the first 24 hours after thyroid
surgery, the nurse should include in her care:
a. Checking the back and sides of the
operative
dressing
b. Supporting the head during mild range
of
motion
exercise
c. Encouraging the client to ventilate her
feelings
about
the
surgery
d. Advising the client that she can resume
her normal activities immediately
Following surgery of the thyroid gland, bleeding
is a potential complication. This can best be
assessed by checking the back and the sides of
the operative dressing as the blood may flow
towards the side and back leaving the front dry
and clear of drainage.
341. On discharge, the nurse teaches the patient
to observe for signs of surgically induced
hypothyroidism. The nurse would know that
the patient understands the teaching when she
Page1
b. Facilitate ventilation of the left lung.

c. Equalize pressure in the pleural space.
d. Increase venous return
Since only a partial pneumonectomy is done,
there is a need to promote expansion of this
remaining Left lung by positioning the client on
the opposite unoperated side.
334. A client with COPD is being prepared for
discharge.
The
following
are
relevant
instructions to the client regarding the use of
an oral inhaler EXCEPT
a. Breath in and out as fully as possible before
placing the mouthpiece inside the mouth.
b. Inhale slowly through the mouth as the
canister is pressed down
c. Hold his breath for about 10 seconds before
exhaling
d. Slowly breath out through the mouth
with pursed lips after inhaling the
drug.
If the client breathes out through the mouth with
pursed lips, this can easily force the just inhaled
drug out of the respiratory tract that will lessen its
effectiveness.
335. A nurse at the weight loss clinic assesses a
client who has a large abdomen and a rounded
face. Which additional assessment finding
would lead the nurse to suspect that the client
has Cushings syndrome rather than obesity?
a. large thighs and upper arms
b. pendulous abdomen and large hips
c. abdominal striae and ankle enlargement
d. posterior neck fat pad and thin
extremities
Buffalo hump is the accumulation of fat pads
over the upper back and neck. Fat may also
accumulate on the face. There is truncal obesity
but the extremities are thin. All these are noted in
a client with Cushings syndrome.
336. Which statement by the client indicates
understanding of the possible side effects of
Prednisone therapy?
a. I should limit my potassium intake because
hyperkalemia is a side-effect of this drug.
b. I must take this medicine exactly as
my doctor ordered it. I shouldnt skip
doses.
c. This medicine will protect me from getting
any colds or infection.
d. My incision will heal much faster because
of this drug.
The
possible
side
effects
of
steroid
administration
are
hypokalemia,
increase
tendency to infection and poor wound healing.
Clients on the drug must follow strictly the
doctors order since skipping the drug can lower
the drug level in the blood that can trigger acute
adrenal insufficiency or Addisonian Crisis
337. A client, who is suspected of having
Pheochromocytoma, complains of sweating,
palpitation and headache. Which assessment
is essential for the nurse to make first?
a. Pupil reaction
c. Blood pressure

Atropine sulfate is a vagolytic drug that

decreases oropharyngeal secretions and increases
the heart rate.
346. Mr. Pablo, diagnosed with Bladder Cancer, is
scheduled for a cystectomy with the creation
of an ileal conduit in the morning. He is
wringing his hands and pacing the floor when
the nurse enters his room. What is the best
approach?
a. "Good evening, Mr. Pablo. Wasnt it a
pleasant day, today?"
b. "Mr. Pablo, you must be so worried, Ill leave
you alone with your thoughts.
c. Mr. Pablo, youll wear out the hospital floors
and yourself at this rate."
d. "Mr. Pablo, you appear anxious to me.
How are you feeling about tomorrows
surgery?"
The client is showing signs of anxiety reaction to
a stressful event. Recognizing the clients anxiety
conveys acceptance of his behavior and will allow
for verbalization of feelings and concerns.
347. A 32-year-old client with a history of sickle
cell anemia is admitted to the hospital during a
sickle cell crisis. The physician orders all of
these interventions. Which order will you
implement first?
a. Give morphine sulfate 4-8 mg IV every hour
as needed.
b. Start a large-gauge IV line and infuse normal
saline at 200 mL/hour.
c. Immunize with Pneumovax and Haemophilus
influenzae vaccines.
d. Administer oxygen at an F102 of 100%
per non-rebreather mask.
Hypoxia and deoxygenation of the red blood cells
are the most common cause of sickling, so
administration
of
oxygen
is
the
priority
intervention here. Pain control and hydration are
also important interventions for this client and
should be accomplished rapidly. Vaccination may
help prevent future sickling episodes by
decreasing the risk of infection, but it will not help
with the current sickling crisis.
348. You are making a room assignment for a
newly arrived client whose laboratory testing
indicates pancytopenia. All of these clients are
already on the nursing unit. Which one will be
the best roommate for the new client?
a. client with digoxin toxicity
b. The client with viral pneumonia
c. The client with shingles
d. The client with cellulitis
Clients with pancytopenia are at higher risk for
infection. The client with digoxin toxicity presents
the least risk of infecting the new client. Viral
pneumonia, shingles, and cellulites are infectious
processes.
349. A 67-year-old client who is receiving
chemotherapy for lung cancer is admitted to
the hospital with thrombocytopenia. While you
are taking the admission history, the client
makes these statements. Which statement is
of most concern?
Page1
states she should notify the MD if she

develops:
a. Intolerance to heat
b. Dry skin and fatigue
c. Progressive weight gain
d. Insomnia and excitability
Hypothyroidism, a decrease in thyroid hormone
production, is characterized by hypometabolism
that manifests itself with weight gain.
342. What is the best reason for the nurse in
instructing the client to rotate injection sites
for insulin?
a. Lipodystrophy can result and is extremely
painful
b. Poor rotation technique can cause
superficial hemorrhaging
c. Lipodystrophic areas can result,
causing erratic insulin absorption
rates from these
d. Injection sites can never be reused
Lipodystrophy is the development of fibrofatty
masses at the injection site caused by repeated
use of an injection site. Injecting insulin into these
scarred areas can cause the insulin to be poorly
absorbed and lead to erratic reactions.
343. Following surgery, Mario complains of mild
incisional pain
while performing
deepbreathing and coughing exercises. The nurses
best response would be:
a. Pain will become less each day.
b. This is a normal reaction after surgery.
c. With a pillow, apply pressure against
the incision.
d. I will give you the pain medication the
physician ordered.
Applying pressure against the incision with a
pillow will help lessen the intra-abdominal
pressure created by coughing which causes
tension on the incision that leads to pain.
344. The nurse needs to carefully assess the
complaint of pain of the elderly because older
people
a. are expected to experience chronic pain
b. have a decreased pain threshold
c. experience
reduced
sensory
perception
d. have altered mental function
Degenerative changes occur in the elderly. The
response to pain in the elderly maybe lessened
because of reduced acuity of touch, alterations in
neural pathways and diminished processing of
sensory data.
345. Mary received AtropineSO4 as a premedication 30 minutes ago and is now
complaining of dry mouth and her PR is higher,
than before the medication was administered.
The nurses best
a. The patient is having an allergic reaction to
the drug.
b. The patient needs a higher dose of this
drug
c. This is normal side-effect of AtSO4
d. The patient is anxious about upcoming
surgery

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 I Hodgkins disease
survive.
Most assessment about what the client means is
needed before any interventions can be planned
or implemented. All of the other statements
indicate a conclusion that the client is afraid of
dying of Hodgkins disease.
353. After receiving change-of-shift report about
all of these clients, which one will you assess
first?
a. A 26-year-old with thalassemia major who
has a short-stay admission for a blood
transfusion
b. A 44-year-old who was admitted 3 days
previously with a sickle cell crisis and has
orders for a CT scan
c. A 50-year-old with newly diagnosed stage IV
non-Hodgskins lymphoma who is crying
and stating Im not ready to die.
d. A 69-year-old with chemotherapyinduced neutropenia who has an
elevated oral temperature
Any temperature elevation in a neutropenic
client may indicate the presence of a lifethreatening infection, so actions such as blood
cultures and antibiotic administration should be
initiated quickly. The other clients need to e
assessed as soon as possible, but are not critically
ill.
354. A
long-term-care
client
with
chronic
lymphocytic leukemia has a nursing diagnosis
of Activity Intolerance related to weakness and
anemia. Which of these nursing activities is
most appropriate for you, as the charge nurse,
to delegate to a nursing assistant?
a. Evaluate the clients response to normal
activities of daily living.
b. Check the clients blood pressure and
pulse rate after ambulation.
c. Determine which self-care activities the
client can do independently.
d. Assist the client in choosing a diet that will
improve strength.
Nursing assistant education include routine
nursing skills such as assessment of vital signs.
Evaluation, baseline assessment of client abilities,
and nutrition planning are roles appropriate to RN
practice.
Kaplan NCLEX RN Review Series 2008 Page, 212
355. A transfusion of PRBCs has been infusing for
5 minutes when the client becomes flushed
and tachypneic and says, I am having chills.
Please get me a blanket. Which action should
you take first?
a. Obtain a warm blanket for the client.
b. Check the clients oral temperature.
c. Stop the medication.
d. Administer oxygen.
The clients symptoms indicate that a transfusion
reaction may be occurring so the first action
should be to stop the transfusion. Chills are an
indication of a febrile reaction, so warming the
client is not appropriate. Checking the clients
Page1
a. Ive noticed that I bruise more easily since

the chemotherapy started.
b. My bowel movements are soft and dark
brown in color.
c. I take one aspirin every morning
because of my history of angina.
d. My appetite has decreased since the
chemotherapy started.
Because
aspiring
will
decrease
platelet
aggregation, clients with thrombocytopenia should
not use aspirin routinely. Client teaching about his
should be included in the care plan. Bruising is
consistent with the clients admission problem of
thrombocytopenia. Soft, dark brown stools indicate
that there is no frank blood in the bowel
movements. A decrease in appetite is common
with chemotherapy, and more assessment is
indicated.
350. As home health nurse, you are taking an
admission history for a client who has a deep
vein thrombosis and is taking warfarin
(Coumadin) 2 mg daily. Which statement by
the client is the best indicator that additional
teaching about warfarin may be needed?
a. I have started to eat more healthy
foods like green vegetables and
fruit.
b. The doctor said that it 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.
Clients taking warfarin are advised to avoid
making sudden diet changes, because changing
the oral intake of foods 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 indicated first.
351. A client is admitted to the intensive care unit
(ICU)
with
disseminated
intravascular
coagulation (DIC) associated with a gramnegative
infection.
Which
assessment
information
has
the
most
immediate
implications for the clients care?
a. There is no palpable radial or pedal pulse.
b. The client complains of chest pain.
c. The clients oxygen saturation is 87%
d. There is mottling of the hands and feet.
Because the decrease in oxygen saturation will
have the greatest immediate effect on all body
systems, improvement in oxygenation should be
the priority goal of care. The other data also
indicate the need for rapid intervention, but
improvement of oxygenation is the most urgent
need.
352. A 22-year-old with stage I Hodgkins disease
is admitted to the oncology unit for radiation
therapy. During the initial assessment, the
client tells you, Sometimes I am afraid of
dying. Which response is most appropriate at
this time?

d. Numbness and tingling of the feet

A non-tender swelling in this area (or near any
lymph node) may indicate that he client has
developed lymphoma, a possible adverse effect of
immunosuppressive therapy. The client should
receive further evaluation immediately. The other
symptoms may also indicate side effects of
cyclosporine
(gingival
hyperplasia,
nausea,
paresthesia) but do not indicate the need for
immediate action.
360. You have developed the nursing diagnosis
Risk for Impaired Tissue Integrity related to
effects of radiation for a client with Hodgkins
lymphoma who is receiving radiation to the
groin area. Which nursing activity is best
delegated to a nursing assistant caring for the
client?
a. Check the skin for signs of redness or
peeling.
b. Apply alcohol-free lotion to the area after
cleaning.
c. Explain good skin care to the client and
family.
d. Clean the skin over daily with a mild
soap.
Skin care is included in nursing assistant
education and job description. Assessment and
client teaching are more complex tasks that
should be delegated to registered nurses. Use of
lotions to the irradiated area is usually avoided
during radiation therapy.
361. Which of the following is a characteristic of a
patient with advanced Parkinsons disease?
a. Disturbed vision
b. Forgetfulness
c. Mask like facial expression
d. Muscle atrophy
Parkinson's disease does not affect the cognitive
ability of a person. It is a disorder due to the
depletion of the neurotransmitter dopamine which
is needed for inhibitory control of muscular
contractions. Client will exhibit mask like facial
expression, Cog wheel rigidity, bradykinesia,
Shuffling gait etc. Muscle atrophy does not occur
in Parkinson's disease nor visual disturbances.
362. The onset of Parkinsons disease is between
50-60 years old. This disorder is caused by:
a. Injurious chemical substances
b. Hereditary factors
c. Death of brain cells due to old age
d. Impairment of dopamine producing
cells in the brain
Dopamine producing cells in the basal ganglia
mysteriously deteriorates due to unknown cause.
363. The patient was prescribed with levodopa.
What is the action of this drug?
a. Increase dopamine availability
b. Activates dopaminergic receptors in the
basal ganglia
c. Decrease acetylcholine availability
d. Release dopamine and other catecholamine
from neurological storage sites
Page1
temperature and administration of oxygen are also

appropriate actions if a transfusion reaction is
suspected; however, stopping the transfusion is
the priority.
356. You obtain the following data about a client
admitted with multiple myeloma. Which
information
has
the
most
immediate
implications for the clients care?
a. The client complains of chronic bone pain.
b. The blood uric acid level is very elevated.
c. The 240hour urine shows Bence-Jones
protein.
d. The client is unable to plantar flex the
feet.
The lack of plantar flexion may indicate spinal
cord compression, which should be evaluated and
treated immediately by the physician to prevent
further loss of function. While chronic bone pain,
hyperuricemia, and the presence of Bence-Jones
protein in the urine all are typical.
357. The nurse in the outpatient clinic is assessing
a 22-year-old with a history of a recent
splenectomy after a motor vehicle accident.
Which information obtained during the
assessment will be of most immediate concern
to the nurse?
a. The client engages in unprotected sex.
b. The client has an oral temperature of
39 C
c. The client has abdominal pain with light
palpation.
d. The client admits to occasional marijuana
use.
Because the spleen has an important role in the
phagocytosis of microorganisms, the client 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 assessment and
intervention, but prevention and treatment of
infection are the highest priorities for this client.
358. A client with acute myelogenous leukemia is
receiving induction phase chemotherapy.
Which assessment information is of most
concern?
a. Serum potassium level of 7.8 mEq/L
b. Urine output less than intake by 400 mL
c. Inflammation and redness of oral mucosa
d. Ecchymoses present on anterior trunk
Fatal hyperkalemia may be caused by tumor lysis
syndrome, a potentially serious consequence of
chemotherapy in acute leukemia. The other
symptoms also indicate a need for further
assessment or intervention, but are not as critical
as the elevated potassium level.
359. A client who has been receiving cyclosporine
following an organ transplant is experiencing
these symptoms. Which one is of most
concern?
a. Bleeding of the gums while brushing the
teeth
b. Non-tender swelling in the right groin
c. Occasional nausea after taking the
medication

369. The patient wants to know more about her

condition. You would start by telling her that
the main cause of idiopathic thrombocytopenic
purpura (ITP) is that:
a. Your body makes antibodies that
destroy your platelets which causes
you to bleed.
b. ITP is caused by recent bacterial infection.
c. Your excessive intake of aspirin has caused
this problem.
d. This form of anemia will improve with iron
supplements.
In the acute form usually follows a viral infection,
such as rubella or chicken pox and can result from
immunization with live vaccines. The chronic form
seldom follows infection and is commonly linked
with other immunologic disorders.
370. Which of the following assessment cues
would indicate that blood transfusion has been
effective?
a. A decreased urine output
b. A normal heart beat
c. A negative Guiac test result
d. A normal temperature
Symptoms of anemia include fatigue, weakness,
pallor, tachycardia and dyspnea. The heart rate
returns to normal when enough blood has been
transfused to restore oxygen carrying capacity.
371. Nona is diagnosed with Disseminated
Intravascular Coagulopathy (DIC). Which of the
following products would you anticipate to be
administered to her as part of her treatment?
a. Albumin
b. Fresh frozen plasma
c. Packed red blood cells
d. Tissue plasminogen activator (tPA)
The nurse should expect to administer fresh
frozen plasma. It supplies patient clotting factors
absent in DIC.
372. Nona suddenly becomes restless and
anxious. Her heart rate increases to 125
beats/min and her blood pressure drops to
80/60 mmHg. The nurse notifies the doctor
because she suspects that the patient may be
having:
a. an internal hemorrhage
c. stroke.
b. oliguria.
d.
heart
attack.
A change in mental status, tachycardia, and cool
clammy skin is a sign of hypovolemic shock. The
nurse should suspect an internal hemorrhage.
373. A knowledgeable nurse knows that for a
client with cardiogenic shock, the mechanical
device which can be used to increase coronary
perfusion and cardiac output and decrease
myocardial workload and oxygen consumption
is:
a. cardiac pacemaker.
b. defibrillator.
c. hypothermia/hyperthermia machine.
d. intra-aortic balloon pump.
Page1
Levodopa is an altered form of dopamine. It is

metabolized by the body and then converted into
dopamine for brain's use thus increasing
dopamine availability. Dopamine is not given
directly because of its inability to cross the BBB.
364. You are discussing with the dietician what
food to avoid with patients taking levodopa?
a. Vitamin C rich food
c.
Thiamine
rich food
b. Vitamin E rich food
d. Vitamin B6
rich food
Vitamin B6 or pyridoxine is avoided in patients
taking levodopa because levodopa increases
vitamin b6 availability leading to toxicity.
365. Nurse Jet wants to measure Mr. Batumbakals
CN II Function. What test would Nurse Jet
implement to measure CN IIs Acuity?
a. Slit lamp
c. Woods light
b. Snellens Chart
d. Gonioscopy
CN II is the optic nerve. To assess its acuity,
Snellen's chart is used. Slit lamp is the one you
see in the usual Eye glasses shop where in, you
need to look into its binocular-like holes and the
optometrist is on the other side to magnify the
structures of the eye to assess gross damage and
structure. Woods light is a BLUE LIGHT used in
dermatology. It is use to mark lesions usually
caused skin infection. Gonioscopy is the angle
measurement of the eye.
366. A patient states that he has smoked a half
pack of cigarettes per day for 40 years. The
nurse documents this as:
a. 10 pack years.
c. 30 pack years.
b. 20 pack years.
d.
40
pack
years.
The formula for determining pack years is the
number of years the patient smoked multiplied by
the number of packs of cigarettes smoked per day.
Thus 40 years times one half pack per day equals
20 pack years.
367.
A client with emphysema is having labored
breathing with slow and shallow respirations. This
may predispose him to develop:
a. respiratory alkalosis. c. metabolic alkalosis
b. respiratory acidosis.
d.
Metabolic
acidosis
Shallow breathing can decrease the release of
carbon dioxide in the lungs and accumulation of
CO2 causes increase in carbonic acid which is
acidic in nature.
368. The client becomes acutely anxious and
feels shortness of breath. Which of the
following nursing interventions is most likely to
reduce dyspnea?
a. Lower the head of the bed.
b. Instruct him to breathe through a paper bag.
c. Increase the oxygen flow rate to 8L/min.
d. Encourage him to breathe deeply and
rhythmically.
This would help client attain a more comfortable,
relaxed breathing.

b. A fractured femur
c. Ventricular fibrillation
d. A penetrating abdominal wound
VF could alter the circulation since the heart is
the main pumping organ of the body, an
emergency
situation,
emboli
formed
from
fibrillation might lead to infarction on the major
organs of the body.
378. Which of the following statements, if made
by a patient who is suspected of having
congested heart disease, would support the
diagnosis?
a. I sleep using two pillows.
b. My ears have a ringing sensation.
c. My weight has gone down.
d. I am not able to tolerate it.
When the client lies supine, the feeling of
congestion is felt and cannot tolerate it longer
than the normal person.
379. Which of this statement, if made by a
patient who has a prescription for sublingual
nitroglycerine tablets, would indicate a correct
understanding of the medication instruction?
a. I should take the pills with a full glass of
water.
b. I should protect these pills from
sunlight.
c. I should wait 30 minutes before taking the
second pill.
d. I should chew the pill for faster effect.
These drugs are photosensitive and are placed in
an amber colored bottle
380. A
client
has
undergone
a
left
hemicolectomy for bowel cancer. Which of
these activities should the nurse include post
operatively
to
prevent
pulmonary
complications such as pneumonia?
a. Administering oxygen, coughing, breathing
deeply, and maintaining bed rest
b. Coughing, breathing deeply, maintaining
bed rest, and using an incentive spirometer
c. Coughing, breathing deeply, frequent
repositioning, and using an incentive
spirometer
d. Administering pain medications, frequent
repositioning, and limiting fluid intake
Activities that help to prevent the occurrence of
postoperative pneumonia are: coughing, breathing
deeply, frequent repositioning, medicating the
client for pain, and using an incentive spirometer.
Limiting fluids and lying still will increase the risk
of pneumonia.
381. What should Mang Gibo, 49 years old, do to
ensure early identification of prostate cancer?.
a. Have a digital rectal examination and
prostate-specific antigen (PSA) test
done yearly.
b. Have a transrectal ultrasound every 5 years.
c. Have a complete blood count (CBC) yearly
(including blood urea nitrogen [BUN] and
creatinine assessment).
d. Perform
monthly
testicular
selfexaminations, especially after age 50.
The incidence of prostate cancer increases after
age 50. The digital rectal examination, which
Page1
Counterpulsation with an intra-aortic balloon

pump may be indicated for temporary circulatory
assistance in clients with cardiogenic shock.
374. A patient with heart failure taking daily
doses of Furosemide and Digoxin complains of
weakness and palpitation after several days.
She was recently discharged from the hospital
after having an episode of heart failure. What
action should the nurse do?
a. Tell the client to stop taking the digoxin, and
call the physician.
b. Tell the client to avoid foods that contain
caffeine.
c. Call
the
physician,
report
the
symptoms, and request to draw a
blood sample to determine the client's
potassium level.
d. Tell the client to rest more often.
Furosemide is a potassium-wasting diuretic. A
low potassium level may cause weakness and
palpitations.
375. A patient with right-sided heart failure
presents signs such as hepatomegaly, ascites,
edema and distended neck veins. Which of the
following can also be seen as a sign of rightsided heart failure?
a. A physiologic second heart sound (S2) split
b. P wave pulmonale
c. Pericardial friction rub
d. Expiratory wheezing
The elevated pulmonary pressures present with
pulmonary embolus can lead to right-sided heart
failure, leading to an increase in right atrial
volume. This increased atrial volume will appear
as an altered P wave (known as P pulmonale) on
the electrocardiogram. The P wave will be taller
and more peaked than a normal P wave.
376. Bong who had a fight with his wife arrives
in the emergency department complaining of
squeezing substernal pain that radiates to the
left shoulder and jaw. He also complains of
nausea, diaphoresis, and shortness of breath.
What should the nurse do?
a. Gain
I.V.
access,
give
sublingual
nitroglycerin,
and alert the cardiac
catheterization team.
b. Complete
the
client's
registration
information, perform an electrocardiogram,
gain I.V. access, and take vital signs..
c. Alert the cardiac catheterization team,
administer oxygen, attach a cardiac
monitor, and notify the physician.
d. Administer oxygen, attach a cardiac
monitor,
take
vital
signs,
and
administer sublingual nitroglycerin
Cardiac chest pain is caused by myocardial
ischemia. Administering supplemental oxygen will
increase the myocardial oxygen supply. Cardiac
monitoring will help detect life-threatening
arrhythmias. Ensure that the client isn't
hypotensive before giving sublingual nitroglycerin
for chest pain.
377. The nurse would prioritize care and provide
treatment first for client with:
a. Head injuries

The nurse best to assists the client on

maintaining restriction by:
a. prohibiting
beverages with sugar
to
maximize thirst
b. asking the client to calculate the IV fluids
into the total daily allotment.
c. using mouthwash with alcohol for mouth
care.
d. removing the water pitcher from the
bedside.
Since oral intake is the greatest source of fluid
intake, this may assist client to restrict his oral
fluid intake.
387. Mary is hospitalized with an exacerbation
of chronic gastritis due to chronic alcoholism.
When assessing her nutritional status, Nurse
Berto should expect a deficiency in:
a. vitamin A.
c.
vitamin
B12.
b. vitamin B6.
D. vitamin C.
Injury to the gastric mucosa causes gastric
atrophy and impaired function of the parietal cells.
This results in reduced production of intrinsic
factor, which is necessary for the absorption of
vitamin B12.
388. Nurse Berto administered NPH insulin to
Sheera with Type 1 Diabetes Mellitus at 7 a.m.
At what time would the nurse expect Sheera to
be most at risk for a hypoglycemic reaction?
a. 10 a.m.
c. 4 p.m.
b. Noon
d. 10 p.m
NPH is an intermediate-acting insulin that peaks
8 to 12 hours after administration. Because the
nurse administered NPH insulin at 7 a.m., the
client is at greatest risk for hypoglycemia from 3
p.m. to 7 p.m.
Kaplan NURSING REVIEW Series 2008, Page 476
389. Loren tells Nurse Berto that she has been
working hard for the past 3 months to control
her Type 2 Diabetes Mellitus with diet and
exercise and proper medication. To determine
the effectiveness of the client's efforts, the
nurse should check:
a. urine glucose level
b. fasting blood glucose level.
c. serum fructosamine level
d. glycosylated hemoglobin level.
Because some of the glucose in the bloodstream
attaches to some of the hemoglobin and stays
attached during the 120-day life span of red blood
cells, glycosylated hemoglobin levels provide
information about blood glucose levels during the
previous 3 months.
390. Nurse Berto is assessing Helayne with
possible Cushing's syndrome. In a client with
Cushing's syndrome, the nurse would expect
Helayne to manifest:
a. decrease blood pressure
b. thick, coarse skin.
c. deposits of adipose tissue in the trunk
and dorsocervical area.
d. weight gain in arms and legs
Because of changes in fat distribution, adipose
tissue accumulates in the trunk, face (moon face),
and dorsocervical areas (buffalo hump).
Page1
identifies enlargement or irregularity of the

prostate, and the PSA test, a tumor marker for
prostate cancer, are effective diagnostic measures
that should be done yearly.
382. After thoracentesis for pleural effusion, a
client returns to the physicians office for a
follow up visit. Nurse Bob would suspect a
recurrence of pleural effusion when the client
says:
a. Lately I can only breathe well when I sit
up. b. During the night I sometimes have fever
and chills.
c. I get a sharp stabbing pain when I
take deep breath.
d. I am coughing up larger amounts of thicker
mucus for the last two days
Fluid accumulation exerts pressure on the pleural
tissues irritating the nerve endings
383. Nurse Pia is caring for 65-year-old female
client who is diagnosed with cystitis. Which
assessment finding, if obtained by the nurse,
would not be consistent with the typical clinical
picture seen in this disorder?
a. Urinary retention
c. Hematuria
b. Burning on urination d. Low back pain
There is no blockage in the urinary tract in
cystitis.
384. Nurse Anna is assessing a client who
underwent renal transplants. The nurse
assesses for signs of acute graft rejection,
which includes:
a. hypotension, graft tenderness, and anemia
b. hypertension
oliguria
thirst
and
hypothermia.
c. fever, monitoring hypertension and copious
amounts of dilute urine.
d. fever, hypertension, graft tenderness,
and malaise.
Fever is the bodys response to any infection or
rejection. Hypertension is due to malfunctioning
kidney that has been transplanted. Graft
tenderness is due to inflammatory response of the
body to the site of rejection and malaise is due to
accumulation of body toxins and inadequate blood
and oxygen circulation in the body.
385. After a car crash, a client with bladder
injury has had a surgical repair of the injured
area and placement of a suprapubic catheter.
The nurse plans to do which of the following to
prevent complications of this procedure?
a. Monitor urine output every shift.
b. Encourage a high intake of oral fluids.
c. Prevent kinking of the catheter tubing.
d. Measure specific gravity once every shift.
Kink in the catheter can prevent free outflowing
of the urine, and could cause urine from leaking in
the insertion site of the catheter leading to
infection or worse, peritonitis.
386. A fluid restriction of 1500ml per day is
ordered for a client with chronic kidney disease
secondary to Diabetes Mellitus Nephropathy.

d. Say the client's name loudly before starting

to talk.
Standing directly in front of a hearing-impaired
client allows him to lip-read and see facial
expressions that offer cues to what's being said
396. Nurse Berto is caring for a client who
requires intracranial pressure (ICP) monitoring.
As a nurse, you should be alert for what major
complication of ICP monitoring?
a. Coma
c. High blood pressure
b. Infection
d. Apnea
The catheter for measuring ICP is inserted
through a burr hole into a lateral ventricle of the
cerebrum, thereby creating a risk of infection
397. Ambrosio, who was injured during a car
accident in SCTEX is brought to the emergency
department of Jose B. Lingad Hospital by
Ambulance. Which clinical finding indicates
that Ambrosio sustained head injury?
a. Tachycardia
c. Hypotension
b. Widening pulse pressure d.
Rapid
respiratory rate
As intracranial pressure increases following a
head injury, the systolic blood pressure rises.
Widening of pulse pressure occurs as the
difference between systolic and diastolic blood
pressure increases.
398. Tado, an elderly client, may have sustained
skull fracture after slipping and falling on a
sidewalk on his way home. Nurse Berto knows
that basilar skull fractures:
a. Are the least significant type of fracture
b. May cause cerebrospinal fluid (CSF)
leaks from the nose or ears
c. Have no characteristic findings
d. repair isnt always required
A basilar fracture carries the risk of complications
of dural tear, causing CSF leakage and damage to
cranial nerves I, II, VI and VIII. Classic findings in
this type may include otorrhea, rhinorrhea,
Battles sign and raccoon eyes.
399. Beatrice a patient with arterial insufficiency
underwent below-knee amputation of the right
leg. Which action should Nurse Berto include in
the postoperative plan of care?
a. Elevating the stump for the first 24 hours
b. Maintaining the client on complete bed rest
c. Applying heat to the stump as the client
desires
d. Removing the pressure dressing after the first
8 hours
Stump elevation for the first 24 hours after
surgery helps reduce edema and pain by
increasing venous return and decreasing venous
pooling at the distal portion of the extremity.
400. Jusper a six-year-old child who sustained a
fracture has a long leg cast applied on the left
leg. Which of the following statements, if made
by Jusper's mother, would indicate a need for
further teaching?
Page1
391. Every morning, Lea with Type 1 Diabetes,

receives 15 units of Humulin 70/30. What does
this type of insulin contain?
a. 70 units of NPH insulin and 30 units of
regular insulin
b. 70 units of regular insulin and 30 units of
NPH insulin
c. 70% NPH insulin and 30% regular
insulin
d. 70% regular insulin and 30% NPH insulin
Humulin 70/30 insulin is a combination of 70%
NPH insulin and 30% regular insulin.
392. Nurse Berto is caring for Joan with
cholecystitis receiving 1,000 ml of I.V. fluids
infused over 12 hours. The administration set
the drop factor to 15 gtts/ml. What should the
drip rate be?
a. 15 gtts/minute
c. 67 gtts/minute
b. 21 gtts/minute
d.
84
gtts/minute
When administering I.V. fluids, the nurse should
use the following formula to calculate flow rate:
(total volume)/(infusion time in minutes)(drop
factor). In this example, the equation would be:
(1,000 ml)/(720 minutes) (15 gtts/ml) = 1.39
ml/minute 15 gtts/ml = 20.8 gtts/minute, which is
rounded to 21 gtts/minute.
393. Antonio who recently had cerebrovascular
accident requires a cane to ambulate. When
providing teaching about cane use, the
rationale for holding a cane on the uninvolved
side is to:
a. prevent leaning.
b. distribute weight away from the
involved side.
c. maintain stride length.
d. prevent edema.
Holding a cane on the uninvolved side distributes
weight away from the involved side.
394. Nurse Berto is preparing Romeo a client
with systemic lupus erythematosus (SLE) for
discharge. Which of the following instructions
should Nurse Berto include in the teaching
plan?
a. Exposure to sunlight will help control skin
rashes.
b. There are no activity limitations between
flare-ups.
c. Monitor body temperature.
d. Corticosteroids may be stopped when
symptoms are relieved.
Fever can signal an exacerbation and should be
reported to the physician.Fatigue can cause a
flare-up of SLE
395. Mandy has conductive hearing loss caused
by otosclerosis and has repeatedly refused to
have surgery. To facilitate communication with
Mandy, Nurse Berto should utilize the
technique of:
a. Sit or stand in front of the client when
speaking.
b. Use exaggerated lip and mouth movements
when talking.
c. Stand in front of a light or window when
speaking.

405. A female client is admitted with a diagnosis

of acute renal failure. She is awake, alert,
oriented, and complaining of severe back pain,
nausea and vomiting and abdominal cramps.
Her vital signs are blood pressure 100/70 mm
Hg, pulse 110, respirations 30, and oral
temperature 100.4F (38C). Her electrolytes
are sodium 120 mEq/L, potassium 5.2 mEq/L;
her urinary output for the first 8 hours is 50 ml.
The client is displaying signs of which
electrolyte imbalance?
a. Hyponatremia
c.
Hyperphosphatemia
b. Hyperkalemia
d. Hypercalcemia
The normal serum sodium level is 135 145
mEq/L. The clients serum sodium is below normal.
Hyponatremia also manifests itself with abdominal
cramps and nausea and vomiting
406. Assessing the laboratory findings, which
result would the nurse most likely expect to
find in a client with chronic renal failure?
a. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L,
creatinine 0.5 to 1.5 mg/dl
b. Decreased serum calcium, blood pH
7.2, potassium 6.5 mEq/L
c. BUN 15 mg/dl, increased serum calcium,
creatinine l.0 mg/dl
d. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L,
pH 7.35, decreased serum calcium
Chronic renal failure is usually the end result of
gradual tissue destruction and loss of renal
function. With the loss of renal function, the
kidneys ability to regulate fluid and electrolyte and
acid base balance results. The serum Ca
decreases as the kidneys fail to excrete
phosphate, potassium and hydrogen ions are
retained.
407. Treatment with hemodialysis is ordered for
a client and an external shunt is created.
Which nursing action would be of highest
priority with regard to the external shunt?
a. Heparinize it daily
b.
Avoid
taking blood
pressure
measurements or blood samples from
the affected arm
c. Change the Silastic tube daily
d. Instruct the client not to use the affected
arm
In the client with an external shunt, dont use the
arm with the vascular access site to take blood
pressure readings, draw blood, insert IV lines, or
give injections because these procedures may
rupture the shunt or occlude blood flow causing
damage and obstructions in the shunt.
408. Mark, age 78, is admitted to the hospital
with the diagnosis of benign prostatic
hyperplasia (BPH). He is scheduled for
a transurethral
resection
of
the
prostate (TURP). It would be inappropriate to
include which of the following points in the
preoperative teaching?
a. TURP is the most common operation for BPH
b. Explain the purpose and function of a twoway irrigation system
Page1
a. "I will call the clinic if my child complains of

sudden pain in his foot."
b. "I will check the skin temperature of my
child's toes at least once each day."
c. "I should not let my child put anything inside
the cast to relieve itching."
d. "I should not expect my child to have
sensation in the toes while the cast is
on"
It should have a sensation otherwise there could
be a problem with nerve pathways in the affected
extremity
401. In the OR, there are safety protocols that
should be followed. Nurse Berto should be well
versed with all these to safeguard the safety
and quality of patient delivery outcome. Which
of the following should be given highest
priority when receiving patient in the OR?
a. Asses level of consciousness
b. Verify
patient
identification
and
informed consent
c. Assess vital signs
d. Inform the physician of the presence of the
patient
To ensure that correct patient is brought to the
OR
402. It is the responsibility of the pre-op nurse to
do skin prep for patients undergoing surgery. If
hair at the operative site is not shaved, what
should be done to make suturing easy and
lessen chance of incision infection?
a. Draped
c. Clipped
b. Pulled
d. Shampooed
Clipping is cutting the hair length but is not up to
the base. Would help prevent infection from
contamination from hair and makes suturing
easier, exposes the part better.
403. Team effort is best demonstrated in the OR.
If you are the nurse in charge for scheduling
surgical cases, what important information do
you need to ask the surgeon?
a. Who is your internist?
b. Who
is
your
assistant
and
anaesthesiologist, and what is your
preferred time and type of surgery?
c. Who are your anaesthesiologist, internist,
and assistant?
d. Who is your anaesthesiologist?
Knowing who are you working with enhances
team effort, knowing the preferred time and type
allow you to prepare prior to surgery
404. Rosie, 57, who is diabetic, is for
debridement if incision wound. When the
circulating nurse checked the present IV fluid,
she found out that there is no insulin
incorporated as ordered. What should the
circulating nurse do?
a. Double check the doctors order and
call the attending MD
b. Communicate with the ward nurse to verify
if insulin was incorporated
c. Communicate with the client to verify if
insulin was incorporated
d. Incorporate insulin as ordered
The best way to confirm or checked your doubts
prior to doing any action.

lead to airway obstruction manifested by

hoarseness,
noisy
and
difficult
breathing.
Maintaining a patent airway is a primary concern.
413. Contractures are among the most serious
long-term complications of severe burns. If a
burn is located on the upper torso, which
nursing measure would be least effective to
help prevent contractures?
a. Changing the location of the bed or the TV
set, or both, daily
b. Encouraging the client to chew gum and
blow up balloons
c. Avoiding the use of a pillow for sleep, or
placing the head in a position of
hyperextension
d. Helping the client to rest in the
position of maximal comfort
Mobility and placing the burned areas in their
functional position can help prevent contracture
deformities related to burns. Pain can immobilize a
client as he seeks the position where he finds less
pain and provides maximal comfort. But this
approach can lead to contracture deformities and
other complications.
414. An adult is receiving Total Parenteral
Nutrition (TPN). Which of the following
assessment is essential?
a. evaluation of the peripheral IV site
b. confirmation that the tube is in the stomach
c. assess the bowel sound
d. fluid and electrolyte monitoring
Total parenteral nutrition is a method of
providing nutrients to the body by an IV route. The
admixture is made up of proteins, carbohydrates,
fats, electrolytes, vitamins, trace minerals and
sterile water based on individual client needs. It is
intended to improve the clients nutritional status.
Because of its composition, it is important to
monitor the clients fluid intake and output
including electrolytes, blood glucose and weight.
415. Which drug would be least effective in
lowering a clients serum potassium level?
a. Glucose and insulin
b. Polystyrene sulfonate (Kayexalate)
c. Calcium glucomite
d. Aluminum hydroxide
Aluminum hydroxide binds dietary phosphorus in
the GI tract and helps treat hyperphosphatemia.
All the other medications mentioned help treat
hyperkalemia and its effects.
Kaplan NURSING REVIEW SERIES 2006, page 122
416. Maria refuses to acknowledge that her
breast was removed. She believes that her
breast is intact under the dressing. The nurse
should:
a. call the MD to change the dressing so Kathy
can see the incision
b. recognize that Kathy is experiencing
denial, a normal stage of the grieving
process
c. reinforce Kathys belief for several days until
her body can adjust to stress of surgery
d. remind Kathy that she needs to accept her
diagnosis
so
that
she
can
begin
rehabilitation exercises
Page1
c. Expect bloody urine, which will clear as

healing takes place.
d. He will be pain free
Surgical interventions involve an experience of
pain for the client which can come in varying
degrees. Telling the pain that he will be pain free is
giving him false reassurance.
409. Jarel is admitted to the hospital with a
possible diagnosis of appendicitis. On physical
examination, the nurse should be looking for
tenderness on palpation at McBurneys point,
which is located in the:
a. left lower quadrant
c.
right
lower
quadrant
b. left upper quadrant
d.
right
upper
quadrant
To be exact, the appendix is anatomically located
at the Mc Burneys point at the right iliac area of
the right lower quadrant.
410. Mr. Azarcon has undergone surgical repair
of his inguinal hernia. Discharge teaching
should include:
a. telling him to avoid heavy lifting for 4
to 6 weeks
b. instructing him to have a soft bland diet for
two weeks
c. telling him to resume his previous daily
activities without limitations
d. recommending him to drink eight glasses of
water daily
The client should avoid lifting heavy objects and
any strenuous activity for 4-6 weeks after surgery
to prevent stress on the inguinal area. There is no
special diet required. The fluid intake of eight
glasses a day is good advice but is not a priority in
this case.
411. Nursing care planning is based on the
knowledge that the first 24-48 hours post-burn
are characterized by:
a. An increase in the total volume of
intracranial plasma
b. Excessive renal perfusion with diuresis
c. Fluid shift from interstitial space
d. Fluid shift from intravascular space to
the interstitial space
This period is the burn shock stage or the
hypovolemic
phase.
Tissue
injury
causes
vasodilation that results in increase capillary
permeability making fluids shift from the
intravascular to the interstitial space. This can
lead to a decrease in circulating blood volume or
hypovolemia which decreases renal perfusion and
urine output.
412. If a client has severe bums on the upper
torso, which item would be a primary concern?
a. Debriding and covering the wounds
b. Administering antibiotics
c. Frequently observing for hoarseness,
stridor, and dyspnea
d. Establishing a patent IV line for fluid
replacement
Burns located in the upper torso, especially
resulting from thermal injury related to fires can
lead to inhalation burns. This causes swelling of
the respiratory mucosa and blistering which can

c. I will try not to cough, because the force

might make me expel the application.
d. I know that my primary nurse has to wear
one of those badges like the people in the
x-ray department, but they are not
necessary for anyone else who comes in
here.
Children have cells that are normally actively
dividing in the process of growth. Radiation acts
not only against the abnormally actively dividing
cells of cancer but also on the normally dividing
cells thus affecting the growth and development of
the child and even causing cancer itself.
421. High uric acid levels may develop in clients
who are receiving chemotherapy. This is
caused by:
a. The inability of the kidneys to excrete the
drug metabolites
b. Rapid cell catabolism
c. Toxic effect of the antibiotic that are given
concurrently
d. The altered blood pH from the acid medium
of the drugs
One of the oncologic emergencies, the tumor
lysis syndrome, is caused by the rapid destruction
of large number of tumor cells. . Intracellular
contents are released, including potassium and
purines, into the bloodstream faster than the body
can eliminate them. The purines are converted in
the liver to uric acid and released into the blood
causing hyperuricemia. They can precipitate in the
kidneys and block the tubules causing acute renal
failure.
422. Which of the following interventions would
be included in the care of plan in a client with
cervical implant?
a. Frequent ambulation
b. Unlimited visitors
c. Low residue diet
d. Vaginal irrigation every shift
It is important for the nurse to remember that
the implant be kept intact in the cervix during
therapy. Mobility and vaginal irrigations are not
done. A low residue diet will prevent bowel
movement that could lead to dislodgement of the
implant. Patient is also strictly isolated to protect
other people from the radiation emissions
423. Which nursing measure would avoid
constriction on the affected arm immediately
after mastectomy?
a.
Avoid
BP
measurement
and
constricting clothing on the affected
arm
b. Active range of motion exercises of the arms
once a day
c. Discourage feeding, washing or combing
with the affected arm
d. Place the affected arm in a dependent
position, below the level of the heart
A BP cuff constricts the blood vessels where it is
applied. BP measurements should be done on the
unaffected arm to ensure adequate circulation and
venous and lymph drainage in the affected arm
Page1
A person grieves to a loss of a significant object.

The initial stage in the grieving process is denial,
then anger, followed by bargaining, depression
and last acceptance. The nurse should show
acceptance of the patients feelings and
encourage verbalization.
417. A chemotherapeutic agent 5FU is ordered
as an adjunct measure to surgery. Which of the
ff. statements about chemotherapy is true?
a. it is a local treatment affecting only tumor
cells
b. it affects both normal and tumor cells
c. it has been proven as a complete cure for
cancer
d. it is often used as a palliative measure
Chemotherapeutic agents are given to destroy
the actively proliferating cancer cells. But these
agents cannot differentiate the abnormal actively
proliferating cancer cells from those that are
actively proliferating normal cells like the cells of
the bone marrow, thus the effect of bone marrow
depression.
418. Which is an incorrect statement pertaining
to the following procedures for cancer
diagnostics?
a. Biopsy is the removal of suspicious tissue
and the only definitive method to diagnose
cancer
b. Ultrasonography detects tissue density
changes difficult to observe by X-ray via
sound waves
c. CT scanning uses magnetic fields and
radio frequencies to provide crosssectional view of tumor
d. Endoscopy provides direct view of a body
cavity to detect abnormality
CT scan uses narrow beam x-ray to provide
cross-sectional view. MRI uses magnetic fields and
radio frequencies to detect tumors.
419. A
post-operative
complication
of
mastectomy is lymphedema. This can be
prevented by:
a. ensuring patency of wound drainage tube
b. placing the arm on the affected side in a
dependent
position
c. restricting movement of the affected
arm
d. frequently elevating the arm of the
affected side above the level of the
heart.
Elevating the arm above the level of the heart
promotes good venous return to the heart and
good lymphatic drainage thus preventing swelling.
420. Which statement by the client indicates to
the nurse that the patient understands
precautions necessary during internal radiation
therapy for cancer of the cervix?
a. I should get out of bed and walk around in
my room.
b. My 7 year old twins should not come
to visit me while Im receiving
treatment.

An output of 30-50 ml/hr is considered adequate

and indicates good fluid balance.
428. A thoracentesis is performed on a chestinjured client, and no fluid or air is found. Blood
and fluids is administered intravenously (IV),
but the clients vital signs do not improve. A
central venous pressure line is inserted, and
the initial reading is 20 cm H^O. The most
likely cause of these findings is which of the
following?
a. Spontaneous pneumothorax
b. Ruptured diaphragm
c. Hemothorax
d. Pericardial tamponade
Pericardial tamponade occurs when there is
presence of fluid accumulation in the pericardial
space that compresses on the ventricles causing a
decrease in ventricular filling and stretching
during diastole with a decrease in cardiac output. .
This leads to right atrial and venous congestion
manifested by a CVP reading above normal.
429. Intervention for a pt. who has swallowed a
Muriatic Acid includes all of the following
except:
a. administering an irritant that will
stimulate vomiting
b. aspirating secretions from the pharynx if
respirations are affected
c. neutralizing the chemical
d. washing the esophagus with large volumes
of water via gastric lavage
Swallowing of corrosive substances causes
severe irritation and tissue destruction of the
mucous membrane of the GI tract. Measures are
taken to immediately remove the toxin or reduce
its absorption. For corrosive poison ingestion, such
as in muriatic acid where burn or perforation of
the mucosa may occur, gastric emptying
procedure is immediately instituted, This includes
gastric lavage and the administration of activated
charcoal to absorb the poison. Administering an
irritant with the concomitant vomiting to remove
the swallowed poison will further cause irritation
and damage to the mucosal lining of the digestive
tract. Vomiting is only indicated when noncorrosive poison is swallowed.
430. Which initial nursing assessment finding
would best indicate that a client has been
successfully resuscitated after a cardiorespiratory arrest?
a. Skin warm and dry
b. Pupils equal and react to light
c. Palpable carotid pulse
d. Positive Babinskis reflex
Presence of a palpable carotid pulse indicates
the return of cardiac function which, together with
the return of breathing, is the primary goal of CPR.
Pulsations in arteries indicates blood flowing in the
blood vessels with each cardiac contraction. Signs
of effective tissue perfusion will be noted after.
431. An emergency treatment for an acute
asthmatic attack is Adrenaline 1:1000 given
hypodermically. This is given to:
a. increase BP
Page1
424. A client suffering from acute renal failure

has an unexpected increase in urinary output
to 150ml/hr. The nurse assesses that the client
has entered the second phase of acute renal
failure. Nursing actions throughout this phase
include observation for signs and symptoms of:
a.
Hypervolemia,
hypokalemia,
and
hypernatremia
b.
Hypervolemia,
hyperkalemia,
and
hypernatremia
c. Hypovolemia, wide fluctuations in
serum sodium and potassium levels
d. Hypovolemia, no fluctuation in serum
sodium and potassium levels
The second phase of ARF is the diuretic phase or
high output phase. The diuresis can result in an
output of up to 10L/day of dilute urine. Loss of
fluids and electrolytes occur.
425. An adult has just been brought in by
ambulance after a motor vehicle accident.
When assessing the client, the nurse would
expect which of the following manifestations
could have resulted from sympathetic nervous
system stimulation?
a. A rapid pulse and increased RR
b. Decreased physiologic functioning
c. Rigid posture and altered perceptual focus
d. Increased awareness and attention
The fight or flight reaction of the sympathetic
nervous system occurs during stress like in a
motor vehicular accident. This is manifested by
increased in cardiovascular function and RR to
provide the immediate needs of the body for
survival.
426. Ms. Geronimo undergoes surgery and the
abdominal aortic aneurysm is resected and
replaced with a graft. When she arrives in the
RR she is still in shock. The nurses priority
should be:
a. placing her in a Trendelenburg position
b. putting several warm blankets on her
c. monitoring her hourly urine output
d. assessing her VS especially her RR
Shock is characterized by reduced tissue and
organ perfusion and eventual organ dysfunction
and failure. Checking on the VS especially the RR,
which detects need for oxygenation, is a priority to
help detect its progress and provide for prompt
management
before
the
occurrence
of
complications.
427. A major goal for the client during the first
48 hours after a severe bum is to prevent
hypovolemic shock. The best indicator of
adequate fluid balance during this period is:
a. Elevated hematocrit levels
b. Urine output of 30 to 50 ml/hr
c. Change in level of consciousness
d. Estimate of fluid loss through the burn
eschar
Hypovolemia is a decreased in circulatory
volume. This causes a decrease in tissue perfusion
to the different organs of the body. Measuring the
hourly urine output is the most quantifiable way of
measuring tissue perfusion to the organs. Normal
renal perfusion should produce 1ml/kg of BW/min.

435. A 70-year-old female comes to the clinic for

a routine checkup. She is 5 feet 4 inches tall
and weighs 180 pounds. Her major complaint
is pain in her joints. She is retired and has had
to give up her volunteer work because of her
discomfort. She was told her diagnosis was
osteoarthritis about 5 years ago. Which would
be excluded from the clinical pathway for this
client?
a. Decrease the calorie count of her daily diet
b. Take warm baths when arising
c. Slide items across the floor rather than lift
them
d. Place items so that it is necessary to
bend or stretch to reach them
Patients with osteoarthritis have decreased
mobility caused by joint pain. Over-reaching and
stretching to get an object are to be avoided as
this can cause more pain and can even lead to
falls. The nurse should see to it therefore that
objects are within easy reach of the patient.
436. A client is admitted from the emergency
department with severe-pain and edema in the
right foot. His diagnosis is gouty arthritis.
When developing a plan of care, which action
would have the highest priority?
a. Apply hot compresses to the affected joints
b. Stress the importance of maintaining good
posture to prevent deformities
c. Administer salicylates to minimize the
inflammatory reaction
d. Ensure an intake of at least 3000 ml of
fluid per day
Gouty arthritis is a metabolic disease marked by
urate deposits that cause painful arthritic joints.
The patient should be urged to increase his fluid
intake to prevent the development of urinary uric
acid stones.
437. A client had a laminectomy and spinal
fusion yesterday. Which statement is to be
excluded from your plan of care?
a. Before log rolling, place a pillow under the
clients head and a pillow between the
clients legs
b. Before log rolling, remove the pillow
from under the clients head and use
no pillows between the clients legs
c. Keep the knees slightly flexed while the
client is lying in a semi-Fowlers position in
bed
d. Keep a pillow under the clients head as
needed for comfort
Following a laminectomy and spinal fusion, it is
important that the back of the patient be
maintained in straight alignment and to support
the entire vertebral column to promote complete
healing.
438. The nurse observes that decerebrate
posturing is a comatose client's response to
painful stimuli. The client exhibits extended
and pronated arms, flexed wrists with palms
facing backward, and rigid legs extended with
plantar flexion. Decerebrate posturing as a
response to pain indicates:
a. dysfunction in the cerebrum.
Page1
b. decrease mucosal swelling

c. relax the bronchial smooth muscle
d. decrease bronchial secretions
Acute asthmatic attack is characterized by
severe bronchospasm which can be relieved by
the immediate administration of bronchodilators.
Adrenaline or Epinephrine is an adrenergic agent
that causes bronchial dilation by relaxing the
bronchial smooth muscles.
432. A client diagnosed with cerebral thrombosis
is scheduled for cerebral angiography. Nursing
care of the client includes the following
EXCEPT:
a. Inform the client that a warm, flushed
feeling
and
a
salty
taste
may
be experienced
b. Maintain pressure dressing over the site of
puncture
c. Check pulse, color and temperature of the
extremity distal to the site of puncture
d. Kept the extremity used as puncture
site flexed to prevent bleeding
Angiography involves the threading of a catheter
through an artery which can cause trauma to the
endothelial lining of the blood vessel. The platelets
are attracted to the area causing thrombi
formation. This is further enhanced by the slowing
of blood flow caused by flexion of the affected
extremity. The affected extremity must be kept
straight and immobilized during the duration of
the bedrest after the procedure. Ice bag can be
applied intermittently to the puncture site.
433. What would be the MOST therapeutic
nursing action when a clients expressive
aphasia is severe?
a. Anticipate the client wishes so she will not
need to talk
b. Communicate by means of questions that
can be answered by the client shaking the
head
c. Keep us a steady flow rank to minimize
silence
d. Encourage the client to speak at every
possible opportunity
Expressive or motor aphasia is a result of
damage in the Brocas area of the frontal lobe. It is
a motor speech problem in which the client
generally understands what is said but is unable to
communicate verbally. The patient can best he
helped therefore by encouraging him to
communicate
and
reinforce
this
behavior
positively.
434. The client has clear drainage from the nose
and ears after a head injury. How can the nurse
determine if the drainage is CSF?
a. Measure the ph of the fluid
b. Measure the specific gravity of the fluid
c. Halos Test
d. Chlorides test
The CSF contains a large amount of glucose
which can be detected by using glucostix. A
positive result with the drainage indicates CSF
leakage.

442. The nurse is planning care for a client

during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions
would
be
most
appropriate?
a. Fluid restriction 1000cc per day
b. Ambulate in hallway 4 times a day
c. Administer
analgesic
therapy
as
ordered
d. Encourage increased caloric intake
The main general objectives in the treatment of
a sickle cell crisis is bed rest, hydration, electrolyte
replacement,
analgesics
for
pain,
blood
replacement and antibiotics to treat any existing
infection.
443. While working with an obese adolescent, it
is important for the nurse to recognize that
obesity in adolescents is most often associated
with
what?
other behavior?
a. Sexual promiscuity
c.
Dropping
out of school
b. Poor body image
d.
Drug
experimentation
As the adolescent gains weight, there is a
lessening sense of self esteem and poor body
image.
444. The emergency room nurse admits a child
who experienced a seizure at school. The
father comments that this is the first
occurrence, and denies any family history of
epilepsy. What is the best response by the
nurse?
a. "Do not worry. Epilepsy can be treated with
medications."
b. The seizure may or may not mean your
child has epilepsy."
c. "Since this was the first convulsion, it may
not happen again."
d. Long term treatment will prevent future
seizures."
There are many possible causes for a childhood
seizure. These include fever, central nervous
system conditions, trauma, metabolic alterations
and idiopathic (unknown).
445. Which oxygen delivery system would the
nurse apply that would provide the highest
concentrations of oxygen to the client?
a. Venturi mask
c.
Non-rebreather
mask
b. Partial rebreather mask
d. Simple face
mask
The non-rebreather mask has a one-way valve
that prevents exhales air from entering the
reservoir bag and one or more valves covering the
air holes on the face mask itself to prevent
inhalation of room air but to allow exhalation of
air. When a tight seal is achieved around the mask
up to 100% of oxygen is available.
446. A nurse is caring for a client who had a
closed reduction of a fractured right wrist
followed by the application of a fiberglass cast
12 hours ago. Which finding requires the
nurses immediate attention?
a. Capillary refill of fingers on right hand is 3
seconds
b. Skin warm to touch and normally colored
Page1
b. the risk of increased intracranial pressure

(ICP).
c. dysfunction in the brain stem.
d. dysfunction in the spinal column.
Decerebrate posturing indicates damage to the
upper brain stem. Decorticate posturing indicates
cerebral dysfunction. Increased ICP is a cause of
decortication and decerebration. Alterations in
sensation or paralysis indicate dysfunction in the
spinal column
439. The nursing care plan for a toddler
diagnosed
with
Kawasaki
Disease
(mucocutaneous
lymph
node
syndrome)
should be based on the high risk for
development of which problem?
a. Chronic vessel plaque formation
b. Pulmonary embolism
c. Occlusions at the vessel bifurcations
d. Coronary artery aneurysms
Kawasaki Disease involves all the small and
medium-sized blood vessels. There is progressive
inflammation of the small vessels which
progresses to the medium-sized muscular arteries,
potentially damaging the walls and leading to
coronary artery aneurysms.
NCLEX REVIEW Series, page 567
440. A nurse has just received a medication
order which is not legible. Which statement
best reflects assertive communication?
a. "I cannot give this medication as it is
written. I have no idea of what you mean."
b. "Would you please clarify what you
have written so I am sure I am reading
it correctly?"
c. "I am having difficulty reading your
handwriting. It would save me time if you
would be more careful."
d. "Please print in the future so I do not have
to spend extra time attempting to read
your writing."
Assertive communication respects the rights and
responsibilities of both parties. This statement is
an honest expression of concern for safe practice
and a request for clarification without selfdepreciation. It reflects the right of the
professional to give and receive information.
441. An ambulatory client reports edema during
the day in his feet and an ankle that
disappears while sleeping at night. What is the
most appropriate follow-up question for the
nurse to ask?
a. "Have you had a recent heart attack?"
b. "Do you become short of breath during
your normal daily activities?"
c. "How many pillows do you use at night to
sleep comfortably?"
d. "Do you smoke?"
These are the symptoms of right-sided heart
failure, which causes increased pressure in the
systemic venous system. To equalize this pressure,
the fluid shifts into the interstitial spaces causing
edema. Because of gravity, the lower extremities
are first affected in an ambulatory patient. This
question would elicit information to confirm the
nursing diagnosis of activity intolerance and fluid
volume excess both associated with right-sided
heart failure.

emotional support. Since the seizure has already

started, nothing should be forced into the child''s
mouth and they should not be moved. Of the
choices given, first priority would be for safety.
451. A woman in her third trimester complains
of severe heartburn. What is appropriate
teaching by the nurse to help the woman
alleviate these symptoms?
a. Drink small amounts of liquids frequently
b. Eat the evening meal just before retiring
c. Take sodium bicarbonate after each meal
d. Sleep with head propped on several
pillows
Heartburn is a burning sensation caused by
regurgitation of gastric contents that is best
relieved by sleeping position, eating small meals,
and not eating before bedtime.
452. For a 6 year-old child hospitalized with
moderate edema and mild hypertension
associated with acute glomerulonephritis
(AGN), which one of the following nursing
interventions would be appropriate?
a. Institute seizure precautions
b. Weigh the child twice per shift
c. Encourage the child to eat protein-rich
foods
d. Relieve boredom through physical activity
The severity of the acute phase of AGN is
variable and unpredictable; therefore, a child with
edema, hypertension, and gross hematuria may
be subject to complications and anticipatory
preparation such as seizure precautions are
needed.
453. Which statement by the client with chronic
obstructive
lung
disease
indicates
an
understanding of the major reason for the use
of occasional pursed-lip breathing?
a. "This action of my lips helps to keep my
airway open."
b. "I can expel more when I pucker up my lips
to breathe out."
c. "My mouth doesn't get as dry when I
breathe with pursed lips."
d. "By prolonging breathing out with
pursed lips the little areas in my lungs
don't collapse."
Clients with chronic obstructive pulmonary
disease have difficulty exhaling fully as a result of
the weak alveolar walls from the disease process.
Alveolar collapse can be avoided with the use of
pursed-lip breathing. This is the major reason to
use it. The other options are secondary effects of
purse-lip breathing.
454. A 57 year-old male client has hemoglobin
of 10 mg/dl and a hematocrit of 32%. What
would be the most appropriate follow-up by
the home care nurse?
a. Ask the client if he has noticed any
bleeding or dark stools
b. Tell the client to call 911 and go to the
emergency department immediately
c. Schedule
a
repeat
Hemoglobin
and
Hematocrit in 1 month
d. Tell the client to schedule an appointment
with a hematologist
Page1
c. Client reports prickling sensation in the

right hand
d. Slight swelling of fingers of right hand
Prickling
sensation
is
an
indication
of
compartment syndrome and requires immediate
action by the nurse. The other findings are normal
for a client in this situation.
447. Included in teaching the client with
tuberculosis taking INH about follow-up home
care, the nurse should emphasize that a
laboratory appointment for which of the
following lab tests is critical?
a. Liver function
c. Blood sugar
b. Kidney function
d.
Cardiac
enzymes
This side effect is age-related and can be
detected with regular assessment of liver
enzymes, which are released into the blood from
damaged liver cells.
448. Which client is at highest risk for
developing a pressure ulcer?
a. 23 year-old in traction for fractured femur
b. 72 year-old with peripheral vascular disease,
who is unable to walk without assistance
c. 75 year-old with left sided paresthesia
and is incontinent of urine and stool
d. 30 year-old who is comatose following a
ruptured aneurysm
Risk factors for pressure ulcers include:
immobility, absence of sensation, decreased LOC,
poor nutrition and hydration, skin moisture,
incontinence, increased age, decreased immune
response. This client has the greatest number of
risk factors.
449. At a senior citizens meeting a nurse talks
with a client who has diabetes mellitus Type 1.
Which statement by the client during the
conversation
is:
most predictive of a potential for impaired skin
integrity?
a. "I give my insulin to myself in my thighs."
b. "Sometimes when I put my shoes on I
don't know where my toes are."
c. "Here are my up and down glucose readings
that I wrote on my calendar."
d. "If I bathe more than once a week my skin
feels too dry."
Peripheral neuropathy can lead to lack of
sensation in the lower extremities. Clients do not
feel pressure and/or pain and are at high risk for
skin impairment.
450. A 4 year-old hospitalized child begins to
have a seizure while playing with hard plastic
toys in the hallway. Of the following nursing
actions, which one should the nurse do first?
a. Place the child in the nearest bed
b. Administer IV medication to slow down the
seizure
c. Place a padded tongue blade in the child's
mouth
d. Remove the child's toys from the
immediate area
Nursing care for a child having a seizure
includes, maintaining airway patency, ensuring
safety, administering medications, and providing

hypertrophy and overriding of the aorta. Surgery is

often delayed, or may be performed in stages.
Kaplan NCLEX REVIEW Series 2006, Page 788
459. The nurse is caring for a 13 year-old
following spinal fusion for scoliosis. Which of
the following interventions is appropriate in the
immediate post-operative period?
a. Raise the head of the bed at least 30
degrees
b. Encourage ambulation within 24 hours
c. Maintain in a flat position, logrolling as
needed
d. Encourage leg contraction and relaxation
after 48 hours
The bed should remain flat for at least the first
24 hours to prevent injury. Logrolling is the best
way to turn for the client while on bed rest.
460. A nurse is caring for a 2 year-old child after
corrective surgery for Tetralogy of Fallot. The
mother reports that the child has suddenly
begun seizing. The nurse recognizes this
problem is probably due to
a. A cerebral vascular accident
b. Postoperative meningitis
c. Medication reaction
d. Metabolic alkalosis
Polycythemia occurs as a physiological reaction
to chronic hypoxemia which commonly occurs in
clients with Tetralogy of Fallot. Polycythemia and
the resultant increased viscosity of the blood
increase the risk of thromboembolic events.
Cerebrovascular accidents may occur. Signs and
symptoms include sudden paralysis, altered
speech, extreme irritability or fatigue, and
seizures.
Kaplan NURSING REVIEW Series 2008, page 222
461. A client is scheduled for a percutaneous
transluminal coronary angioplasty (PTCA). The
nurse knows that a PTCA is the:
a. Surgical repair of a diseased coronary
artery
b. Placement of an automatic internal cardiac
defibrillator
c. Procedure that compresses plaque
against the wall of the diseased
coronary artery to improve blood flow
d. Non-invasive radiographic examination of
the heart
Procedure that compresses plaque against the
wall of the diseased coronary artery to improve
blood
flow
PTCA is performed to improve coronary artery
blood flow in a diseased artery. It is performed
during a cardiac catheterization. Aorta coronary
bypass Graft is the surgical procedure to repair a
diseased coronary artery.
462. A newborn has been diagnosed with
hypothyroidism. In discussing the condition
and treatment with the family, the nurse
should emphasize
a. They can expect the child will be mentally
retarded
b. Administration of thyroid hormone will
prevent problems
c. This rare problem is always hereditary
d. Physical
growth/development
will
be
delayed
Page1
Normal hemoglobin for males is 13.0 - 18 g/100

ml. Normal hemotocrit for males is 42 - 52%.
These values are below normal and indicate
mild anemia. The first thing the nurse should
do is ask the client if he's noticed any bleeding
or change in stools that could indicate
bleeding from the GI tract.
455. The nurse is caring for a client in the late
stages of Amyotrophic Lateral Sclerosis
(A.L.S.). Which finding would the nurse
expect?
a. Confusion
c.
Shallow
respirations
b. Loss of half of visual field
d. Tonic-clonic
seizures
A.L.S. is a chronic progressive disease that
involves degeneration of the anterior horn of the
spinal cord as well as the corticospinal tracts.
When the intercostal muscles and diaphragm
become involved, the respirations become shallow
and coughing is ineffective.
456. The nurse is caring for a post-surgical client
at risk for developing deep vein thrombosis.
Which intervention is an effective preventive
measure?
a. Place pillows under the knees
b. Use elastic stockings continuously
c. Encourage
range
of
motion
and
ambulation
d. Massage the legs twice daily
Mobility reduces the risk of deep vein thrombosis
in the post-surgical client and the adult at risk.
457. The parents of a newborn male with
hypospadias want their child circumcised. The
best response by the nurse is to inform them
that
a. Circumcision is delayed so the foreskin
can be used for the surgical repair
b. This procedure is contraindicated because of
the permanent defect
c. There is no medical indication for performing
a circumcision on any child
d. The procedure should be
Even if mild hypospadias is suspected,
circumcision is not done in order to save the
foreskin for surgical repair, if needed.
458. The nurse is teaching parents about the
treatment plan for a 2 weeks-old infant with
Tetralogy of Fallot. While awaiting future
surgery, the nurse instructs the parents to
immediately report:
a. Loss of consciousness
c. Poor weight
gain
b. Feeding problems
d. Fatigue with
crying
While parents should report any of the
observations, they need to call the health care
provider immediately if the level of alertness
changes. This indicates anoxia, which may lead to
death. The structural defects associated with
Tetralogy of Fallot include pulmonic stenosis,
ventricular septal defect, right ventricular


467. The treatment for patients with leukemia is
bone marrow transplantation. Which statement
about bone marrow transplantation is not
correct?
a. The patient is under local anesthesia
during the procedure
b. The aspirated bone marrow is mixed with
heparin
c. The aspiration site is the posterior or
anterior iliac crest
d. The recipient receives cyclophosphamide
(Cytoxan) for 4 consecutive days before the
procedure
Before the procedure, the patient is administered
with drugs that would help to prevent infection
and rejection of the transplanted cells such as
antibiotics, cytotoxic, and corticosteroids. During
the transplant, the patient is placed under general
anesthesia.
468. After several days of admission, Marton
becomes disoriented and complains of
frequent headaches. The nurse in-charge first
action would be:
a. Call the physician
b. Document the patients status in his charts
c. Prepare oxygen treatment
d. Raise the side rails
A patient who is disoriented is at risk of falling
out of bed. The initial action of the nurse should
be raising the side rails to ensure patients safety.
Kaplan NURSING REVIEW series 2008, 344
469. During routine care, Marton asks the nurse,
How can I be anemic if this disease causes
increased my white blood cell production? The
nurse in-charge best response would be that
the increased number of white blood cells
(WBC) is:
a. Crowd red blood cells
b. Are not responsible for the anemia
c. Uses nutrients from other cells
d. Have an abnormally short life span of cells
The excessive production of white blood cells
crowd out red blood cells production which causes
anemia to occur.
470. Diagnostic assessment of Marton would
probably not reveal:
a. Predominance of lymphoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts
Chronic
Lymphocytic
leukemia
(CLL)
is
characterized
by
increased
production
of
leukocytes
and
lymphocytes
resulting
in
leukocytosis, and proliferation of these cells within
the bone marrow, spleen and liver.
471. Cathy, a 23-year old client complains of
substernal chest pain and states that her heart
feels like its racing out of the chest. She
reports no history of cardiac disorders. The
nurse attaches her to a cardiac monitor and
notes sinus tachycardia with a rate of
136beats/minutes. Breath sounds are clear and
the respiratory rate is 26 breaths/minutes.
Which of the following drugs should the nurse
question the client about using?
Page1
Early identification and continued treatment with

hormone replacement corrects this condition.
463. A client is scheduled for an Intravenous
Pyelogram (IVP). In order to prepare the client
for this test, the nurse would:
a. Instruct the client to maintain a regular diet
the day prior to the examination
b. Restrict the client's fluid intake 4 hours
prior to the examination
c. Administer a laxative to the client the
evening before the examination
d. Inform the client that only 1 x-ray of his
abdomen is necessary
Bowel prep is important because it will allow
greater visualization of the bladder and ureters.
464. Following
a
diagnosis
of
acute
glomerulonephritis (AGN) in their 6 year-old
child, the parents remark: We just dont know
how he caught the disease! The nurse's
response is based on an understanding that
a. AGN is a streptococcal infection that
involves the kidney tubules
b. The disease is easily transmissible in
schools and camps
c. The illness is usually associated with chronic
respiratory infections
d. It is not "caught" but is a response to a
previous B-hemolytic strep infection
AGN is generally accepted as an immunecomplex disease in relation to an antecedent
streptococcal infection of 4 to 6 weeks prior, and
is considered as a noninfectious renal disease.
465. Nurse Millie is talking to a male client; the
client begins choking on his lunch. Hes
coughing forcefully. The nurse should:
a. Stand him up and perform the abdominal
thrust maneuver from behind
b. Lay him down, straddle him, and perform
the abdominal thrust maneuver
c. Leave him to get assistance
d. Stay with him but not intervene at this
time
If the client is coughing, he should be able to
dislodge the object or cause a complete
obstruction. If complete obstruction occurs, the
nurse should perform the abdominal thrust
maneuver with the client standing. If the client is
unconscious, she should lay him down. A nurse
should never leave a choking client alone.
466.
Devie with acute asthma showing
inspiratory and expiratory wheezes and a
decreased forced expiratory volume should be
treated with which of the following classes of
medication right away?
a. Beta-adrenergic blockers
c.
Inhaled
steroids
b. Bronchodilators
d.
Oral
steroids
Bronchodilators are the first line of treatment for
asthma because broncho-constriction is the cause
of reduced airflow. Beta- adrenergic blockers
arent used to treat asthma and can cause
broncho-constriction. Inhaled oral steroids may be
given to reduce the inflammation but arent used
for emergency relief.

a. "At least 2 full meals a day should be

eaten."
b. "We go to a group discussion every week at
our community center."
c. "We have safety bars installed in the
bathroom and have 24 hour alarms on
the doors."
d. "Taking the medication 3 times a day is not
a problem."
Ensuring safety of the client with increasing
memory loss is a priority of home care. Note all
options are positive statements, however safety is
most important to reinforce.
476. A nurse is to administer meperidine

hydrochloride (Demerol) 100 mg, atropine
sulfate (Atropisol) 0.4 mg, and promethazine
hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse
take first?
a. Raise the side rails on the bed
b. Place the call bell within reach
c. Instruct the client to remain in bed
d. Have the client empty bladder
The first step in the process is to have the client
void prior to administering the pre-operative
medication. The other actions follow this initial
step in this sequence: D, C, B, A. Note: It is much
easier to administer IM meds with the side rails
down, and then raising them when the nurse is
done. Other activities can then be carried out
more safely.
477. A client has a Swan-Ganz catheter in place.
The nurse understands that this is intended to
measure:
a. right heart function
c. renal tubule
function
b. left heart function
d.
carotid
artery function
The Swan-Ganz catheter is placed in the
pulmonary artery to obtain information about the
left side of the heart. It can provide hemodynamic
information such as intracardiac pressure readings
and oxygen saturation data, and even transvenous
pacing. Information about left ventricular function
is important because it directly affects tissue
perfusion. Right-sided heart function is assessed
through the evaluation of the central venous
pressure (CVP).
478. 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
c. Tall peaked T
waves
b. Shortened "PR" interval
d.
Prominent
"U"
waves
A tall peaked T wave is a sign of hyperkalemia.
The provider should be notified regarding
discontinuing the medication.
Text Book of Medical Surgical Nursing by
Brunner and Suddarth 11 ed. Page 816
479. Jema, with hyperthyroidism is to receive
Lugols iodine solution before a subtotal
Page1
a. Barbiturates
c. Cocaine
b. Opioids
d. Benzodiazepines
Because of the clients age and negative medical
history, the nurse should question her about
cocaine use. Cocaine increases myocardial oxygen
consumption and can cause coronary artery
spasm, leading to tachycardia, ventricular
fibrillation, myocardial ischemia, and myocardial
infarction. Barbiturate overdose may trigger
respiratory depression and slow pulse. Opioids can
cause marked respiratory depression, while
benzodiazepines can cause drowsiness and
confusion.
472. A 51-year-old female client tells the nurse
in-charge that she has found a painless lump in
her right breast during her monthly selfexamination. Which assessment finding would
strongly suggest that this client's lump is
cancerous?
a. Eversion of the right nipple and mobile mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily
delineated
d. Nonpalpable right axillary lymph nodes
Breast cancer tumors are fixed, hard, and poorly
delineated with irregular edges. A mobile mass
that is soft and easily delineated is most often a
fluid-filled benign cyst. Axillary lymph nodes may
or may not be palpable on initial detection of a
cancerous mass. Nipple retraction not eversion
may be a sign of cancer
473. 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
Thrombus formation in the coronary arteries is a
potential problem in the initial 24 hours after a
cardiac catheterization. A falling BP occurs along
with hemorrhage of the insertion site which is
within the first 12 hours after the procedure.
474. During an assessment of a client with
cardiomyopathy, the nurse finds that the
systolic blood pressure has decreased from
145 to 110 mm Hg and the heart rate has risen
from 72 to 96 beats per minute and the client
complains of periodic dizzy spells. The nurse
instructs the client to:
a. increase fluids that are high in protein
b. restrict fluids
c. force
fluids
and
reassess
blood
pressure
d. limit fluids to non-caffeine beverages
Postural hypotension, a decrease in systolic
blood pressure of more than 15 mm Hg and an
increase in heart rate of more than 15 percent
usually accompanied by dizziness indicates
volume depletion, inadequate vasoconstrictor
mechanisms, and autonomic insufficiency.
475. A nurse is evaluating the quality of home
care for a client with Alzheimer's disease. It
would be a priority to reinforce which
statement by a family member?

c. Increase oral intake of cheese and milk

d. Administer large amounts of normal saline
via I.V.
Kayexalate, a potassium exchange resin, permits
sodium to be exchanged for potassium in the
intestine, reducing the serum potassium level.
484. During the admission assessment on a
client with chronic bilateral glaucoma, which
statement by the client would the nurse
anticipate since it is associated with this
problem?
a. "I have constant blurred vision."
b. "I can't see on my left side."
c. "I have to turn my head to see my
room."
d. "I have specks floating in my eyes."
Intraocular pressure becomes elevated which
slowly produces a progressive loss of the
peripheral visual field in the affected eye along
with rainbow halos around lights. Intraocular
pressure becomes elevated from the microscopic
obstruction of the trabeculae meshwork. If left
untreated or undetected blindness results in the
affected eye.
485. A client with asthma has low pitched
wheezes present on the final half of exhalation.
One hour later the client has high pitched
wheezes extending throughout exhalation. This
change in assessment indicates to the nurse
that the client
a. Has increased airway obstruction
b. Has improved airway obstruction
c. Needs to be suctioned
d. Exhibits hyperventilation
The higher pitched a sound is, the more narrow
the airway. Therefore, the obstruction has
increased or worsened. With no evidence of
secretions no support exists to indicate the need
for suctioning.
486. The nurse is providing care to a 32-year-old
male who suffered a traumatic amputation of
the left leg due to a crushing injury in an
industrial accident. The client states that he is
experiencing pain and tingling in his left leg
and foot. What is the most appropriate
response to the client at this time?
a. Tell the client that he cant be experiencing
pain in the left leg and foot because the leg
has been amputated
b. Tell the client he is experiencing "phantom
pain", but you can't administer pain
medication for this phenomenon
c. Tell the client he is experiencing
"phantom
pain",
and
you
will
administer his prn pain medication.
a.
b.
c.
d. Tell the client he is experiencing "phantom
pain" and it will only last a short while.
Phantom pain often accompanies a surgical or
traumatic amputation of a limb. Even though the
client understands the limb is gone, they may
experience pain, itching, tingling, pressure,
burning, or stabbing sensations. Phantom pain
Page1
thyroidectomy is performed. The nurse is

aware that this medication is given to:
a. Decrease the total basal metabolic rate
b. Maintain the function of the parathyroid
glands
c. Block the formation of thyroxine by the
thyroid gland
d. Decrease the size and vascularity of
the thyroid
Lugols solution provides iodine, which aids in
decreasing the vascularity of the thyroid gland,
which limits the risk of hemorrhage when surgery
is performed.
480. The nurse is caring for a 20 lbs (9 kg) 6
month-old with a 3 day history of diarrhea,
occasional vomiting and fever. Peripheral
intravenous therapy has been initiated, with
5% dextrose in 0.33% normal saline with 20
mEq of potassium per liter infusing at 35 ml/hr.
Which finding should be reported to the health
care provider immediately?
a. 3 episodes of vomiting in 1 hour
b. Periodic crying and irritability
c. Vigorous sucking on a pacifier
d. No measurable voiding in 4 hours
The concern is possible hyperkalemia, which
could
occur
with
continued
potassium
administration and a decrease in urinary output
since potassium is excreted via the kidneys.
481. The nurse is assessing an infant with
developmental dysplasia of the hip. Which
finding would the nurse anticipate?
a. Unequal leg length
b. Limited adduction
c. Diminished femoral pulses
d. Symmetrical gluteal folds
Shortening of a leg is a sign of developmental
dysplasia of the hip.
482. To prevent a valsalva maneuver in a client
recovering
from
an
acute
myocardial
infarction, the nurse would
a. Assist the client to use the bedside
commode
b. Administer stool softeners every day as
ordered
c. Administer antidysrhythmics prn as ordered
d. Maintain the client on strict bed rest
Administering stool softeners every day will
prevent straining on defecation which causes the
Valsalva maneuver. If constipation occurs then
laxatives would be necessary to prevent straining.
If straining on defecation produced the valsalva
maneuver and rhythm disturbances resulted then
antidysrhythmics would be appropriate.
483. Melvin is in the oliguric phase of acute
tubular necrosis and is experiencing fluid and
electrolyte imbalances. The client is somewhat
confused and complains of nausea and muscle
weakness. As part of the prescribed therapy to
correct this electrolyte imbalance, the nurse
would expect to:
a. Administer Kayexalate
b. Restrict foods high in protein

Cold is contraindicated for use on ischemic

tissues as it constricts vessels and further
impeded blood flow. There is no contraindication
for massage and vuse of bare hands on low back
pain, nor is there contraindication for hot water
bottles on knee pain given the information
provided.
Medical-Surgical Nursing Critical Client Care 3rd
ed by Lemone 243
490. The husband of a client with chronic pain
informs the nurse that the client has
withdrawn from her family and friends and that
she states she has no control over her own life.
In planning care for this client, which of the
following would be a priority nursing
diagnosis?
a. Anxiety related to pain
b. Ineffective family coping related to inability
to control pain
c. Self care deficit related to chronic pain
d. Powerlessness related to inability to
control chronic pain
Clients, experiencing chronic pain, may become
withdrawn and have feelings of powerlessness
over their own lives because of their inability to
control the pain. Anxiety, ineffective family coping,
and self-care deficits may also be experienced by
the client with chronic pain, but the information
provided suggests powerlessness.
ed by Lemone 221
491. A home health nurse is visiting a client
dying from liver failure. The client's family
expresses their concern that the client is
"giving up" because he wishes to make his
funeral and burial arrangements now. Which of
the following is the nurse's best response to
this situation?
a. I will ask his physician for an anti anxiety
medication
b. Making these arrangements allow him
to have a sense of control
c. Wanting to make these arrangements
means he has given up hope
d. I will talk to him and ask him why he
wants to make those arrangements now
Dying clients may express personal wishes such
as where they want to die, and their funeral and
burial arrangements. It is not uncommon for them
to do so, and it does not mean the client has given
up, but rather it means the client is accepting
imminent death. Making these arrangements
provides the client with a sense of control as they
approach death. The family should be informed of
this, and encouraged to support the client in these
decisions.
Medical-Surgical Nursing Critical Client Care 3rd ed
by Lemone 221
492. A nurse has been caring for a dying client
for the past week. As the nurse is leaving her
shift, the client begins to rapidly decline with
minimal respirations. The family is distraught
and crying since they recognize that the client
is dying. The nurse chooses to stay with the
client's family in the waiting room after she
has clocked out. Which of the following best
describes the nurse's actions?
a. The nurses action was appropriate
b. The nurses action was inappropriate and
may require disciplinary action
Page1
should be explained to the client. However, the

pain must be treated as any other pain. All pain
that clients experience is real. Phantom pain is
often difficult to manage.
ed by Lemone 243
487. A 58-year-old client is receiving intravenous
morphine sulfate for relief of severe pain
related to cancer. The nurse assesses the
client 15 minutes after the intravenous
morphine was administered. The client is found
to be non-responsive, and respirations are 8
per minute and shallow. The nurse's immediate
action would be which of the following?
a. Initiate oxygen therapy and notify the
physician
b. Initiate cardio pulmonary resuscitation
(CPR)
c. Notify the physician
d. Administer
Naloxone
(Narcan)
intravenously
Morphine sulfate causes respiratory depression,
a
life-threatening
situation.
Treatment
for
respiratory depression should be immediate to
avoid severe, irreversible damage or death.
Naloxone (Narcan) is a narcotic antagonist used to
treat respiratory depression and is the first
immediate action to take. The physician should be
notified after the administration of Narcan, as the
administration of morphine may need to be
adjusted or changed to another drug that does not
cause respiratory depression.
ed by Lemone 243
488. . The nurse is preparing to provide wound
care and dressing change to a client with
multiple decubitus ulcers. The wound care and
dressing change are extremely painful to the
client. The nurse's best course of action would
be which of the following?
a. Administer the prn pain medication
before the wound care dressing
change
b. Administer the prn pain medication after
the wound care and dressing change
c. Administer the prn pain medication only of
the client complains of pain and request
the medication
d. Delay the wound care dressing change
because it is painful dor the client
Administering pain medication before a painful
procedure may reduce the amount of pain
experienced by the client, as well as promoting
the client's cooperation with the procedure. The
wound care and dressing change must be done to
promote wound healing and decrease risk of
infection, and should not be delayed.
ed by Lemone 243
489. Which of the following actions a client's
caregiver implemented to relieve a client's
pain would require further education?
a. Massage back of client with a history of low
back pain
b. Applies hot water to clients knee with
history of knee pain
c. Applies bare hands on the back with history
of back pain
d. Applies cold pack to clients with
history of low back pain
The nurses action interfered with the

grieving process of the family
d.
The
nurses
action
though
not
inappropriate, is not encouraged
Family members of the deceased or dying client
are often comforted by the presence of the nurse
who provided care to the client during the final
days. The nurse remained in the waiting room with
the client's family and did not interfere with the
nursing care provided by other staff nurses. Due to
these
factors,
the
nurse's
actions
were
appropriate.
ed by Lemone 220
493. The wife of an elderly male who died 2
weeks ago is expressing concern to a nurse in
the health clinic that her adult son has not
cried since the death of his father. The nurse's
response is based on the knowledge of which
of the following?
a. It is normal for males to avoid crying when
they have lost loved one
b. The son is probably in shock from the death
of his father
c. There is nothing to worry about, as
everyone exhibits different from of grief
d. Persons who are unable to cry may
have
difficulty
completing
the
mourning process
Crying is observed during normal grief states. If
grief is not expressed, somatic symptoms may
occur. Those who have difficulty mourning may
need counseling or other interventions in order to
complete the mourning process
ed by Lemone 220
494. The nurse is providing care to a client with
an end-stage terminal illness who is
experiencing pain and difficulty breathing. The
client angrily states, "God did this to me, he is
punishing me." Which of the following is the
nurse's best response to the client's
statement?
a. This must be difficult for you
b. Why do you feel God is punishing you?
c. God isnt punishing you
d. would you like me to pray with you
Clients may feel they are being punished, and
may feel anger towards their faith. Statements,
such as, "This must be difficult for you" conveys
interest in the client and allows them the
opportunity to express their concerns and fears.
The other statements do not allow the client the
opportunity for further expression and are nontherapeutic.
by Lemone 220
495. A 38-year-old female is diagnosed with
metastatic cancer. When seen in the oncology
clinic, the client tells the nurse that she hopes
God will let her "hold on until her children
graduate high school". According to KublerRoss, the client is in which stage of coping with
loss?
a. Denial
c. bargaining
b. Depression
d. anger
Kubler-Ross identified 5 stages of coping with
loss. Denial, anger, bargaining, depression, and
acceptance. Bargaining is an attempt to postpone
the loss or change the prognosis. Making a bargain
with God is typical for this stage.

by Lemone 220
496. A 22-year-old male was killed in a motor
vehicle accident. Upon arrival to the
emergency room, the client's family is
informed of his death. The mother refuses to
view the body, stating that she knows it is not
her son. She leaves the emergency room
stating she is going home to call her son.
According to Kubler-Ross, the mother's reaction
is defined as which of the following stages of
coping with loss?
a. Denial
c. depression
b. Anger
d. bargaining
The initial reaction to a sudden loss or death is
shock and disbelief. This is an expected reaction,
and it does allow time for the person and family to
mobilize their defenses to cope with the situation
by Lemone 220
497. An elderly client, dying from heart failure,
states that he knows he is dying and is worried
about what will happen to his wife when he is
gone. In planning care for this client, which of
the following is the priority nursing diagnosis?
a. Dysfunctional grieving
b. Death anxiety
c. Anticipatory grieving
d. Altered thought processes
The client has stated acceptance of his
impending death. He expresses concern about
his wife's well being after his death. This is a
normal concern for clients and they should be
supported during this time
by Lemone 241
498. A dying client's spouse is afraid to leave
the client's room to get a meal in the cafeteria
for fear the client will die while she is gone.
There are no other family members or visitors
present. The client is non-responsive, pulse is
irregular and bradycardic, and has CheyneStokes respirations. Which of the following
represents the best course of action for the
nurse?
a. Encourage the clients spouse to take a
break and go to the cafeteria and eat. He
us non responsive and wont know she is
gone
b. Make arrangements for the clients
spouse to receive a meal in the
clients room
c. Tell the clients spouse a nurse aid will sit
with the client while she is gone to the
cafeteria , and she will be called if there are
any changes
d. Do not interfere with the spouses decision
The client is exhibiting manifestations of
impending death. The client's spouse should be
with him during this time if she desires. Obtaining
a meal for the client's spouse while she remains at
the bedside, and supporting her during the client's
impending death, demonstrates compassion and
concern for the client and spouse
by Lemone 243
499. The family of a client diagnosed with
terminal cancer has been informed that he is
not expected to live more than 2 months.
Which of the following statements made by the
Page1
c.
family indicates to the nurse that the family

understands the client's prognosis?
a. Hospice nurses are going to help care for
him at home to make him more
comfortable
b. Hospice nurses are going to help care for
him at home until he gets better
c. Hospice nurses are going to help care for
him until we learn how to provide the care
d. Hospice nurses are going to help
care for him until he can take care of
himself
Hospice care is provided to those clients who
have 6 months or less to live. Hospice nurses are
skilled in pain and symptom management, as well
as in emotional support to the dying clients and
their families. The other statements indicate the
family expects improvement in the client's
condition.
by Lemone 242
500. A young female in the gynecology clinic
has just been told she has breast cancer,
based on results of a recent biopsy. The client
is obviously distraught, crying and stating "this
can't be happening to me". In planning care for
this client, which of the following represents
the nurse's best action?
a. Refer the client to a breast cancer support
group
b. Refer the client to a mental health facility
c. Request a sedative for the client
d. Allow the client the opportunity to
express her feelings
The client is in the initial stage of shock. During
this time, she requires emotional support.
Referring her to a breast cancer support group is
not the immediate intervention. A sedative is not
necessary, because the client's reaction is a
normal response and she should be allowed to
express it.
by Lemone 243
"Nurses are not servants. They are professionals that should be treated with respect."
- Christina Hawthorne
TO GOD BE THE GLORY IN THE NAME OF JESUS CHRIST!
WHAT IS YOUR GOAL?
Page1
TO TOP THE BOARD EXAM!!!


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THE SULTAN REVIEW GROUPNURSING REVIEW

1. A two-year-old child who experienced a head

c. eat high fat, low protein diet

SULTAN REVIEW GROUP NURSING REVIEW

following behaviors would indicate that the

An increase in urine output with low specific

SULTAN REVIEW GROUP NURSING REVIEW

swallowing, and presents a danger of choking and

16. A nurse is caring for a patient who underwent

SULTAN REVIEW GROUP NURSING REVIEW

c. Prone, with his head turned to the left side.

Paresthesias after a cast is applied indicate that

SULTAN REVIEW GROUP NURSING REVIEW

d. A sensation of painful pressure in the

complications. Which among the following

SULTAN REVIEW GROUP NURSING REVIEW

Text Book of Medical Surgical Nursing by Brunner

c. Improve respiratory rate

SULTAN REVIEW GROUP NURSING REVIEW

that the ascites is most likely the result of

Text Book of Medical Surgical Nursing by Brunner

SULTAN REVIEW GROUP NURSING REVIEW

Kaplan NCLEX RN Exam 2008 edition, Page 364

62. Nurse Rachel teaches a client who has been

76. After having several stroke attacks over 4

and programming magnet may trigger the metal

An increased in LDL cholesterol concentration

SULTAN REVIEW GROUP NURSING REVIEW

b. Stoma is oozes a small amount of blood

Text Book of Medical Surgical Nursing by Brunner

SULTAN REVIEW GROUP NURSING REVIEW

d. Place the client on CBR a day before the

SULTAN REVIEW GROUP NURSING REVIEW

The client shouldn't receive a complete bed bath

nails, dry skin, cold intolerance, constipation and

SULTAN REVIEW GROUP NURSING REVIEW

c. "I'll gradually increase the amount of heavy

urobilinogen, and chloride are normally found in

SULTAN REVIEW GROUP NURSING REVIEW

Text Book of Medical Surgical Nursing by Brunner

Assessment of a client with Hodgkins disease

SULTAN REVIEW GROUP NURSING REVIEW

Uric acid has a low solubility, it tends to

Steroids decrease the bodys immune response

SULTAN REVIEW GROUP NURSING REVIEW

active ROM exercises shouldn't be performed on

b. Ask the physician to obtain a psychiatric

SULTAN REVIEW GROUP NURSING REVIEW

antidote that is specific to heparin. Which

a gradual decrease in arm and pelvic muscle

SULTAN REVIEW GROUP NURSING REVIEW

152. Rafael is admitted for treatment of a

a. Leads I, aVL, V5, and V6

SULTAN REVIEW GROUP NURSING REVIEW

Systolic phase is the period when the heart

156. Forty-eight hours after a burn injury, the

SULTAN REVIEW GROUP NURSING REVIEW

168. The nurse is caring for a client with a

varying from 24% to 40% or 4 to 6 liters per

SULTAN REVIEW GROUP NURSING REVIEW

174. A client is diagnosed with lung cancer and

noted that the fluid level bubbles constantly in

SULTAN REVIEW GROUP NURSING REVIEW

like effect that causes them to constrict thereby