ANSWER AND RATIONALE

FUDAMENTALS OF NURSING
Level II-Comprehensive Review
November 2015

1. The nursing process can be defined as the:

a. Implementation of nursing care by the
nurse
b. Steps the nurse employs to provide nursing
care
c. Process the nurses uses to determine
nursing goals
d. Activities a nurse employs to identify a
clients problem

2. To utilize the nursing process, the nurse must

first:
a. Identify goals for nursing care
b. State the clients nursing needs
c. Obtain information about the client
d. Evaluate the effectiveness of nursing
actions

3. A nursing diagnosis represents the:

a. Proposed plan of care
b. Clients health problems
c. Assessment of client data
d. Actual nursing intervention

4. The nurse who collaborates directly with the

client to establish and implement a plan of
care is the:
a. primary nurse
b. nurse clinician
c. clinical specialist
d. nurse coordinator

5. The determining factor in the revision of a

nursing care plan is the:
a. Time available of care
b. Validity of the diagnoses
c. Methods for providing care
d. effectiveness of the intervention

1. Answer B. The nursing process is a step-bystep process that scientifically provides

A. This is incomplete; implementation of care
is one aspect of the nursing process
C. This is incomplete; goal establishment is one
aspect of the nursing process
D. This is incomplete; the nursing process goes
beyond identification of data

2. C. The initial step in any process using problem

solving is the collection of data
A. Goals are set after nursing needs are
established
B. Nursing needs can be determined only
after assessment
D.Evaluation is the last phase of the nursing
process
3. Answer B. Nursing diagnosis defines an actual or
potential health problem faced by the client
A. This is the plan of care made before
implantation; it follows the nursing diagnosis
but it is not part of it; it is a step in the nursing
process.
C. This is part of data collection before making
the nursing diagnosis; it is the first step of the
nursing process
D. Intervention follows the nursing diagnosis; it is
part of the nursing process but not part of the
nursing diagnosis.

4. Answer A. The primary nurse provides or

oversees all aspects of care, including
assessment, implementation and evaluation of
that care.
B.A clinician is an expert teacher or
practitioner in the clinical area
c. The title given to a specially prepared nurse
for one very specific clinical role
D. The nurse coordinator oversees all the staff
and clients on a unit and coordinates care
5. Answer D. When the plan does not effectively
produce the desired outcome, the plan should
be changed
A. Timed is not relevant in the revision of a
care plan
B. Client response is the determinant, not the
nursing diagnosis
C. Various methods may have the same
outcome effectiveness is most important
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6. A need for cognitive learning becomes

apparent when an adolescent, newly
diagnosed as having diabetes mellitus asks:
a. What is diabetes?
b. Cant I still be a cheerleader?
c. How do I give myself an injection?
d. When do I test my blood for glucose?

6. Answer A. The acquiring of knowledge or

understanding aids in developing concepts
rather than skills or attitudes and is a basic
learning task in the cognitive domain
E. The acquiring of values and self-realization
is in the effective domain
F. The acquiring
of skills and tasks is
psychomotor learning
G. Same as answer C

7. Developing independence is a primary goal for

a client with hemiplegia. The nurse can
motivate the client by:
a. Establishing long-range goals for the client
b. Reinforcing success in tasks accomplished
c. Pointing out errors and helping to correct
them
d. Demonstrating ways the client can regain
independence

7. Answer B. Success is a basic motivation for

learning. People receive satisfaction when a
goal is reached. The more frequent the
success, the greater is their satisfaction, which
in turn motivates them to continue striving
toward realistic goals

8. For an emotional balance the individual always

needs:
a. Family, work and play
b. Security and social recognition
c. Biologic satisfaction and social acceptance
d. Individual
recognition
and
group
acceptance

9. The family is most important in the emotional

development of the individual because it:
a. Provides support for the young
b. Gives rewards and punishment
c. Helps one to learn identity and roles
d. Reflects the mores of a larger society

10. To give nursing care to a client, the nurse must

first:
a. Understand the clients emotional conflict
b. Develop rapport with the clients physician
c. Recognize personal feelings toward this
client
d. Talk with the clients family or significant
other

8. Answer D. A sense of ones self and a feeling of

belonging form the basis for mental health,
because they provide comfort with self and
group
A. A person could have emotional balance
without all three
B. A person needs security but can do
without social recognition
C. A person needs to have biologic needs
met; one does not need social acceptance;
the group providing acceptance may not
be acceptable to society or to the
individual
9. Answer C. Socialization, values and role
definition are learned within the family and
help develop a sense of self. Once established
in the family the child can more easily move
into society.
A. This is true, but not as important as
identity and roles in relation to emotional
development
B. This is only a very small aspect of the
familys influence
C. Same as answer B
10. Answer C. Nurses must actively try to
understand their own feelings and prejudices
because these will affect the ability to assess a
clients behavior objectively.
A. Understanding a clients emotional conflict
can be accomplished only after dealing
with ones own feelings
B. The health team members should work
together for the benefit of all clients, not
just this client
D.Information from significant others is
beneficial, but only after nurses are able to
deal with their won feelings
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11. After having a transverse colostomy, the client

asks what effect the surgery will have on
future sexual relationships. The nurse should
explain that:
a. Sexual relationships must be curtailed for
several weeks
b. The client will be able to resume normal
sexual relationships
c. The surgery will temporarily decrease the
clients sexual impulses
d. The partner should be told about the
surgery before any sexual activity

11. Answer B. Surgery on the bowel has no direct

anatomic or physiologic effect on sexual
performance. However, psychologic factors
could hamper this function and the nurse
should encourage verbalization
A. There is no reason why sexual
relationships must be curtailed
B. Although it mat take several months to
resume satisfying sexual relationships the
surgery has no direct physiologic effect
D.Although a partner should understand the
nature of the surgery, the focus at this time
should be on the client

12. Immediately after a storm has passed, the

rescue team with which the nurse is working is
searching for injured people. A victim lying
next to a broken natural gas main is not
breathing and is bleeding heavily from a
wound on the foot. The nurses first step
would be to:
a. Treat the victim for shock
b. Start rescue breathing immediately
c. Apply surface pressure to the foot wound
d. Remove the victim from immediate vicinity

12. Answer D. The first action should be to remove

the victim form a source of further injury.
A. Preventing
further
injury
and
reestablishing breathing are priorities.
B. Breathing is the priority once further injury
is avoided
C. This wound would be treated after the
victim is moved from danger and patency
of the airway is verified

13. When a disaster occurs, the nurse may have to

treat mass hysteria first. The person or
persons to be cared for immediately would be
those in
a. Panic
c. Euphoria
b. Coma
d. Depression

13. Answer A. People in panic could initiate the

panic reaction in those who appear to be in
control
B.Comatose individuals will not cause panic in
others
C, Euphoric individuals would not adversely affect
others
D.Depressed people will be calm and not affect
others

14. The occurrence of chronic illness is greatest

on;
a. Older adults
b. Adolescents
c. Young children
d. Middle-aged adults

14. Answer A. As a result of the normal stresses on

the body, the incidence of chronic illness
increases in the elderly population
B.Younger individuals have greater physiologic
reserves and chronic illnesses
C.Same as answer A
D. Same as answer

15. When formulating nursing care plans for

elderly clients, the nurse should include special
measures to accommodate for age-related
sensory issues such as:
a. Difficulty in swallowing
b. Increased sensitivity to heat
c. Diminished sensation of pain
d. Heightened response to stimuli

15. Answer C. This may make an older individual

unaware of a serious illness, thermal extremes
or excessive pressure.
A. There should be no interference with
swallowing in older individuals
B. Older individuals tend to feel the cold and
rarely complain of the heat
D.There is a decreased response to stimuli in
the older individual
3

16. The nurse would expect an elderly client with

a hearing loss caused by aging to have:
a. Copious, moist cerumen
b. Tears in the tympanic membrane
c. Difficulty hearing womens voices
d. overgrowth of the epithelial auditory lining

17. Radium is stored in lead containers because:

a. Radium is a heavy substance
b. The lead functions as a barrier
c. Heat is produced as radium disintegrates
d. Lead prevents disintegration of the radium

18. A systemic drug that may be prescribed to

produce diuresis and inhibit formation of
aqueous humor is
a. cholorthiazide (Diuril)
b. Acetazolamide (Diamox)
c. Bendroflumethiazide (Naturetin)
d. Demecarium bromide (Humorsol)

19. A client is to be discharged on a diuretic and

digitalis. The nurse reviewing the clients diet
would be especially careful to look for
adequate sources of potassium because:
a. Potassium is a necessary ion for normal
body function
b. Potassium is a cofactor for several
important enzymes
c. Under conditions of hypokalemia, digitalis
exert toxic effects on the heart
d. Under conditions of hypoglycemia, digitalis
exerts toxic effects ob the heart

20. Before giving a client digoxin, the nurse should

assess the:
a. Apical heart rate
b. Radial pulse in both arms
c. Radial pulse on the left side
d. Difference between apical and radial
pulses

16. Answer C. Generally female voices have a

higher pitch than male voices and the elderly
with presbycusis (hearing loss caused by aging
process) have more difficulty hearing these
higher pitched sounds
A. Cerumen becomes drier and harder as a
person ages
B. There is no greater incidence of tympanic
tears caused by the aging process
D.The epithelium of the lining of the ear
becomes thinner and drier
17. Answer B. Radium atoms are unstable and
spontaneously disintegrate. This disintegration
produces potentially harmful radiation; lead is a
barrier to these radiations
A. Radium is not a heavy substance but an
unstable one
C. Heat is not produced during spontaneous
disintegration; radiation is
D. Disntegration of radium occurs in the lead
containers
18. Answer B. Acetazolamide (Diamox) is a
carbonic anhydarse inhibiter that decrease inflow
of aqueous humor and controls intraocular
pressure in an attack of closed angle glaucoma
A. This diuretic has no effect on the eye
C. same as answer A
D. This strong miotic does not affect the
production of aqueous humor
19. Answer C. Toxic levels of digitalis
overstimulate the vagus nerve, leading to
depressed conduction through the AV node (AV
block of any degree) as well as SA node depression
(sinus bradycardia). In addition, ectopic
pacemakers are accelerated leading to multiple
premature beats. Such pathologic effects are
enhanced by low serum potassium levels from
diuretics, vomiting and nasogastric drainage as
well as by chronic arterial hypoxemia and
impaired renal function
A. This is true but not specific to the situation
described
B. Vitamins act as coenzymes
D. This is an untrue statement
20. Answer A. Because digoxin slows the heart,
the apical pulse should be counted for 1 minute
before administration. If the apical rate is below
60 (bradycardia), digoxin should be withheld
because its administration could further depress
the heart rate. If the heart rate is above 120,
digoxin should be withheld because the client may
be in digitalis toxicity

21. The nurse should teach a client to suspect that

nitroglycerin SL tablets have lost their potency
when:
a. Sublingual tingling is experienced
b. The tablets are three or more months old
c. Pain is unrelieved but facial flushing is
increased
d. Onset of relief is delayed, but the duration
of relief is unchanged

22. Evaluation
of
the
effectiveness
nitroglycerine SL is based on:
a. Relief of angina pain
b. Improved cardiac output
c. A decrease in blood pressure
d. Dilation of superficial blood vessels

of

23. The drug the nurse should expect the

physician to order if symptoms of warfarin
overdose are observed would be:
a. Heparin
b. Vitamin K
c. Protamine sulfate
d. Iron-dextran (Imferon)

24. The loop diuretics alter active transport

system in the kidney tubules, resulting in
increased excretion of sodium and,
secondarily, water. The principle explaining
the secondary water loss (diuresis) is:
a. Osmosis
c. Filtration
b. Diffusion
d. Active transport

25. During a cardiac arrest, the nurse and the

arrest team must keep in mind the:
a. Age of the client
b. Time the client was anoxic
c. Emergency medications available
d. Heart rate of the client before the arrest

21. Answer B. Nitroglycerin tablets are affected by

light, hear and moisture. A loss of potency can
occur after 3 months, reducing the drugs
effectiveness in relieving pain. A new supply
should be obtained routinely.
A. This indicates the tablets have retained their
potency
C. This does not necessarily indicate a loss of
potency
D. Same as answer C
22. Answer A. Cardiac nitrates relax the smooth of
the coronary arteries; so that they dilate and
deliver more blood to relieve to relieve ischemic
pain
B. Although cardiac output may improve because
of improved oxygenation of the myocardium, this
is not the basis for evaluating drugs effectiveness
C. Although dilation of blood vessels and
subsequent drop in BP may occur, this is not the
basis for evaluating the drugs effectiveness
D. Although superficial vessels dilate, lowering BP
and creating a flushed appearance, this is not a
basis for evaluating the drugs effectiveness
23. Answer B. Warfarin depresses prothrombin
activity and inhibits the formation of several of the
clotting factors by the liver. Its antagonist is
vitamin K, which is involved in prothrombin
formation
A. Heparin is an anticoagulant
C. Protamine sulfate is the antidote fro heparin
overdose
D. Imferon is an iron supplement, not an antidote
for warfarin
24. Answer A. The presence of excess sodium (a
solute) in the nephric tubules effectively
decreases the water concentration of the
glumerular filtrate and urine, water passively
diffuses (osmosis) from the kidney tubule cells
unto the urine to equalize the water
concentration
B. Diffusion is not specific to fluid; osmosis is.
C. Filtration refers to solutes; none of being
passed
D. Active transport requires energy; water is
passively diffused from the tubule cells to the
urine
25. Answer B. Irreversible brain damage will occur
if a client is anoxic for more than 4 minutes.
A. The age of the client does not affect the code
C. Although a variety of emergency medications
must be available, their administration is ordered
by the physician
D. Earlier heart rate is of minimal importance.
Rhythm is more significant
5

26. A client is found unconscious and

unresponsive. The nurse should first:
a. Initiate a code
b. Check for a radial pulse
c. Give four full lung inflations
d. Compress the lower sternum 15 minutes

26. Answer A. Help must be obtain immediately

B. The radial pulse is not in used
C. Before cardiac compression, open the airway,
pinch the nose, and give two, rather than four full
lung inflation.
D. This would not be done until the airway was
open, two breaths were given and reassessment
indicated that there was no carotid pulse

27. When performing cardiac compression on an

adult client, the nurse is aware that it is
essential to exert vertical downward pressure,
which depresses the lower sternum at least:
a. 1.3 to 2 cm (1/2 to inch)
b. 2 to 2.5 cm (3/4 to 1 inch)
c. 2.5 to 4 cm ( 1 to 1 inches)
d. 4 to 5 cm (1 to 2 inches)

27. Answer D. The sternum must be depressed at

least 3.7 to 5 cm (1 to 2 inches) to compress the
heart adequately between the sternum and
vertebrate and to stimulate cardiac pumping
action.
A. This distance is ineffectual for an adult
B. Same as answer A
C. Same as answer A

28. When
performing
external
cardiac
compression the nurse should exert
downward vertical pressure on the lower
sternum by placing
a. The fleshy part of a clenched fist on the
lower sternum
b. The heels of each hand side by side,
extending the fingers over the chest
c. The fingers of one hand on the sternum
and the fingers of the other hand on top of
them
d. The heel of one hand on the sternum and
the heel of the other on top of it,
interlocking the fingers

28. Answer D. This provides the best leverage for

depressing the sternum. Thus, the heart is
adequately compressed and blood is forced into
the arteries. Grasping the fingers keeps them off
the chest and concentrates the energy expended
in the heel of the hand while minimizing the
possibility of fracturing ribs.
A. Both hands must be utilized; pressure on the
lower portion of the sternum may fracture the
xiphoid process, which can injure vital underlying
organs.
B. Pressure spread over two hands may
inadequately compress the heart and fracture the
ribs.
C. Application of pressure by the fingers is less
effective
this provides inadequate cardiac
compression
29. Answer B. Elevation of an extremity promotes
venous and lymphatic drainage by gravity.
A. This is a dependent function of the nurse
C. Same as answer A
D. This procedure will have little effect on edema

29. Client is admitted to the hospital and has

edematous ankles. To best limit edema of the
feet of the nurse should prepare to:
a. Restrict fluids
b. Elevate the legs
c. Apply elastic bandages
d. Do range-of-motion exercises
30. For the client with pulmonary edema the
nurse would expect oxygen via nasal cannula
to be set at:
a. 2 L. b. 6 L.
c. 8 L.
d. 10 L.

30.Answer B. Six liters provide enough oxygen

without adversely altering the clients blood gases,
which would cause increased respiratory distress
A. This is insufficient
C. Higher concentration of oxygen may depress
CO2 and raise O2 concentrations, interfering with
the impetus to breathe
D. Same as answer C

31. To help alleviate the distress of a client with

heart failure and pulmonary edema, the nurse
should
a. Elevate the lower extremities
b. Encourage frequent coughing
c. Prepare for modified postural drainage
d. Place the client in an orthopneic position

32. Two hours after a cardiac catheterization that

was accessed via the right femoral route, an
adult client complains of numbness and pain in
the right foot. The nurse should
a. Call the physician
b. Check the clients pedal pulses
c. Take the clients blood pressure
d. Recognize that this is an expected
response

33. During a blood transfusion a client develops

chills and headache. The nurses best action is
to:
a. Lightly cover the client
b. Notify the physician stat
c. Stop the transfusion immediately
d. Slow the blood flow to keep the vein open

34. An example of primary prevention activities by

the nurse would be:
a. Prevention of disabilities
b. Correction of dietary deficiencies
c. Establishing goals for rehabilitation
d. Assisting in immunization programs

35. Antibodies are produced by:

a. Eosinophils
c. Erythrocytes
b. Plasma cells
d. Lymphocytes
36. A client has a bone marrow aspiration
performed. Immediately after the procedure,
the nurse should:
a. Position the client on the affected side
b. Begin frequent monitoring of vital signs
c. Cleanse the site with an antiseptic solution
d. Briefly apply pressure over the aspiration
site

31. Answer D. The orthopneic position allows maximum

lung expansion because gravity reduces the pressure of
the abdominal viscera on the diaphragm and lungs
A. elevation of the extremities should be avoided because
it increases venous return, placing an increased workload
on the heart
B. Excessive coughing and mucus production is
characteristic of pulmonary edema and does not need to
be encouraged
C. Positioning for postural drainage does not relieve acute
dyspnea; furthermore; it increases venous return to the
heart
32. Answer B. These symptoms are associated with
compromised arterial perfusion; a thrombus is a
complication of a femoral arterial cardiac
catheterization and must be suspected in the absence
of a pedal pulse in the extremity below the entry site.
A. A circulatory assessment should be conducted first;
the physician may or may not need to be notified
immediately concerning the results of the assessment
C. Unnecessary; the symptoms indicate a local
peripheral problem, not a systemic or cardiac problem.
D. These symptoms are not expected

33. Answer C. Chills, headache, nausea and

vomiting are all signs of a transfusion reaction.
A. The infusion must be stopped before treatment
of the symptoms begins
B. The physician should be notified after the
transfusion is stopped
D. Showing the infusion will continue the reaction;
it may lead to kidney damage

34. Answer D. Immunization programs prevent the

occurrence of disease and are considered primary
intervention
A. This is tertiary intervention
B. This is a secondary intervention
C. Same as answer A
35. Answer B. In active immunity, plasma cells
provide antibodies in response to a specific
antigen
A. Eosinophils are involved in phagocytosis of
antige-antibody complexes
C. Erythrocytes (red blood cells) carry oxygen in
the bloodstream
D. Not all lymphocytes are involved with antibody
production
36. Answer B. Brief pressure is generally enough
to prevent bleeding.
A. Complications are rare; no special positioning is
required.
B. Complication are rare; frequent monitoring is
unnecessary
C. The site is cleansed before aspiration
7

37. With Hodgkins disease the lymph nodes

usually affected first are the:
a. Axillary
c. Cervical
b. Inguinal
d. Mediastinal

37. Answer C. Painless enlargement of the cervical

lymph nodes is often the first sign of Hodgkins
disease, a malignant lymphoma of unknown
etiology.
A. Axillary enlargement occurs after cervical
B. Inguinal enlargement occurs later
D. Mediastinal involvement follows after the
disease progresses

38. The highest incidence of Hodgkins disease is

in:
a. Children
b. Young adults
c. Elderly persons
d. Middle-aged persons

38. Answer B. For reasons unknown, Hodgkins

disease occurs most frequently between 15 and
30 years of age.
A. It is less common in children
B. It is uncommon in later years
D. It is uncommon during middle years

39. Vitamin K is essential for normal blood clotting

because it promotes:
a. Platelet aggregation
b. Ionization of blood calcium
c. Fibrinogen formation by the liver
d. Prothrombin formation by the liver

39. Answer D. Vitamin K, synthesized by the

bacterial flora of the intestine, promotes the
livers synthesis of prothrombin, an important
blood clotting factor
A. Vitamin K does not promote platelet
aggregation
B. Vitamin K does not affect calcium ionization
C. Vitamin K does not promote fibrinogen
formation
40. Answer B. The orthopneic position is a setting
position that permits maximum lung expansion for
gaseous exchange, because the abdominal organs
do not provide pressure against the diaphragm
and gravity facilities the descent of the diaphragm
A. This position does not permit the diaphragm to
descend by gravity and pressure of the abdominal
organs against the diaphragm limits its movement
C. This position does not maximize lung expansion
to the same degree as the orthopneic position
D. Same as answer C
41. Answer C. Hemoptysis is expectoration of
blood stained sputum derived from the lungs,
bronchi or trachea
A. Hematuria refers to blood in the urine
B. Hematoma refers to a local accumulation of
blood in the tissues
C. Hematemesis refers to vomiting of blood
42.Answer C. Orthopneic position refers to sitting
up and leaning slightly forward, which drops the
diaphragm allowing the lungs more room
expansion
A. Horizontal positions to not allow the
gravitational effect on the diaphragm and thus do
not maximize air exchange
B. Same as answer A
D. The Trendelenburg position forces the
diaphragm up, interfering with lung expansion

40. To facilitate maximum air exchange, a client

should be placed in the:
a. Supine position
b. Orthopneic position
c. High-fowlers position
d. Semi-Fowlers position

41. A client begins to expectorate blood. The

nurse describes this episode as:
a. Hematuria
c. Hemoptysis
b. Hematoma
d. Hematemesis

42. The position in which a client with dyspnea

should be placed is:
a. Sims
c. Orthropneic
b. Supine
d. Trendelenburg

43. A client is admitted with suspected atelectasis.

When assessing this individual, the nurse
would expect:
a. Slow, deep respirations
b. Diminished breath sounds
c. A dry, unproductive cough
d. A normal oral temperature

43. Answer B. Because atelectasis involves

collapsing of alveoli of alveoli distal to the
bronchioles, breath sounds would be diminished
in the lower lobes
A. A client would have rapid, shallow respirations
to compensate for poor gas exchange
C. Atelectasis results in a loose, productive cough
D. Atelectasis results in and elevated temperature

44. A client who undergoes a submucosal

resection should be observed carefully for:
a. Periorbital crepitus
b. occipital headache
c. Spitting up or vomiting of blood
d. White areas of healing sublingually

44. Answer C. After a submucusal resection (SMR),

hemorrhage from the area is frequently detected
by vomiting of blood that has been swallowed
A. Crepitus would be caused by leakage of air into
tissue spaces; it is not usually a complication of
SMR
B. Headaches in the black of the head would not
be a complication of a submucosal resection
D. The area under the tongue is not involved inthis
surgery
45. Answer D. This minimizes pooling of
respiratory secretions and maximizes chest
expansion, which aids in the removal of
secretions; this maintains the airway and is an
independent nursing function.
A. This is part of pulmonary therapy that requires
a physicians order
B. same as answer A
C. This will remove secretions once they
accumulate not prevent their accumulation

45. An independent nursing measure that would

be helpful in preventing the accumulation of
secretions in a client who had general
anesthesia for surgery would be:
a. Postural drainage
b. Cupping the chest
c. Nasotracheal suctioning
d. Frequent changes of position

46. After a laryngectomy a client is concerned

about improving the ability to communicate.
The nurse should arrange for the client to
learn more about;
a. Sign language
b. Body language
c. Esophageal speech
d. An external electronic larynx

47. An example of a rapidly acting diuretic that

can be administered intravenously to clients
with acute pulmonary edema is:
a. Furosemide
c. Chlorthalidone
b. Chlorothiazide
d. Spironolactone

46. Answer C. This is one method for the client to

communicate following a laryngectomy; speech is
produced by expelling swallowed air across
constricted tissue is the pharyngoesophageal
A. This is used for individuals who wish to
communicate with someone who is deaf
B. Although this may be an adjunct to verbal
speech it should not be the primary means of
communication
D. This is an alternative method used if a client
cannot learn esophageal speech or for a short
period of time during the early postoperative
period
47. Answer A. Furosemide (Lasix) acts on the loop
of Henle by increasing the excretion of chloride
and sodium
B. Although used in the treatment of edema and
hypertension, this drug is not as potent as
furosemide
C. Same as answer B
D. This is a potassium sparing diuretic it is less
potent than thiazide diuretics

48. The nurse should position a client recovering

form general anesthesia in a:
a. Supine position
b. Side-lying position
c. High-Fowlers position
d. Trendelenburg position

49. During the immediate postoperative period

the nurse should give the highest priority to;
a. Observing for hemorrhage
b. Maintaining a patent airway
c. Recording the intake and output
d. Checking the vital signs every 15 minutes

48. Answer B. Turning the client to the side promotes

drainage of secretions and prevents aspirations,
especially when the gag reflex is not intact. This
position also brings the tongue forward, preventing it
form occluding the airway in the relaxed state.
A. The risk of aspiration is increased when this position
is assumed by a semialert client
C. This increases the risk of aspiration; this position
may flex the neck in an individual who is not alert,
interfering with respirations
D. This position is not generally used for a
postoperative client because it interferes with
breathing

49. Answer B. Maintenance of a patent airway is

always the priority because airway obstruction
impedes breathing and may result in death
A. This is important in the clients postoperative
care; however oxygenation is the priority
C. Same as answer A
D. Same as answer A

50. A client has a bronchoscopy in ambulatory

surgery. To prevent laryngeal edema, the
nurse should:
a. Place ice chips in the clients mouth
b. Offer the client liberal amounts of fluid
c. Keep the client in the semi-Fowlers
position
d. Tell the client to suck on medicated
lozenges

50. Answer C. With the head elevated, rather than

horizontal or dependent, fluid will not collect in
the interstitial spaced around the trachea
A. This may cause aspiration if the gag reflex has
not returned
B. Same as answer A
D. Same as answer a

51. After a bronchoscopy because of suspected

cancer of the lung, a client develops pleural
effusion. This is most likely the result of:
a. Excessive fluid intake
b. Inadequate chest expansion
c. Extension of cancerous lesions
d. Irritation from the bronchoscopy

51. Answer C. Cancerous lesions in the pleural

space increase the osmotic pressure, causing a
shift of fluid to that space.
A. Excessive intake is normally balanced by
increased urine output
B. Inadequate chest expansion results from
pleural effusion and is not the cause of it.
D. A bronchoscopy does not involve the pleural
space

52. A client has a right pneumonectomy. During

surgery the phrenic nerve is accidentally
served. This will
a. Produce a partially atonic diaphragm
b. Limit postoperative pain considerably
c. Allow the diaphragm to partially descend
d. Permit greater excursion of the thoracic
cavity

52.Answer A. The phrenic nerve stimulates the

diaphragm; accidental severance of one phrenic
nerve would result in partial paralysis of the
diaphragm.
B. Because the phrenic nerve stimulates the
diaphragm, its effect on postoperative pain would
be negligible
C. The diaphragm would ascend, not descend
D. There is less excursion because the nerve has
been served
10

53. The factor that would have little influence in

predisposing an individual to cancer of the
larynx would be:
a. Air pollution
b. Poor dental hygiene
c. Heavy alcohol ingestion
d. Chronic respiratory infections

53. Answer B. Inadequate dental hygiene may

predispose a person to oral infections but would
be only remotely involved in laryngeal neoplasma
because of the anatomical relationship of the oral
cavity and the larynx
A. Irritation by air pollutants may initiate a tissue
change that can lead to malignancy
C. Alcohol is an irritant in a malignant neoplasm
D. Plasma alterations caused by repeated
microbiologic stress may result

54. Immediate postoperative management for a

client with a total laryngectomy would include:
a. Instructing the client to whisper
b. Placing the client in the orthopneic
position
c. Removing the outer tracheostomy tube
prn
d. Suctioning
the
tracheostomy tube
whenever necessary

54. Answer D. Secretions are increased because of

alterations in structure and function. A patent
airway must be maintained.
A. Whispering can put tension on the suture line;
initially nonverbal and written forms of
communication should be encouraged.
B. The orthopneic position may cause neck flexion
and block the airway
C. The outer tube is not removed because the
stoma may close

55. When suctioning a client with tracheostomy

the nurse must remember to:
a. Use a new sterile catheter with each
insertion
b. Initiate suction as the catheter is being
withdrawn
c. Insert the catheter until the cough reflex is
stimulated
d. Remove the inner cannula before inserting
the suction catheter

55. Answer B. During suctioning of a client, negative

pressure (suction) should not be applied until the
catheter is ready to be drawn out because, in addition
to the removal of secretions, oxygen is being depleted
A. The sterility of the catheter can be maintained
during one suctioning session; a new sterile catheter
should be used for each new session of suctioning
C. A cough reflex may be absent or diminished in some
clients; the catheter should be inserted approximately
12 cm (4 to 5 inches0 or just pst the end of the
tracheostomy tube
D. The inner cannula is not removed during suctioning
it may be removed during trachesotomy

56. A thoracentesis is performed. Following the

procedure it is most important for the nurse
to observe the client for:
a. Periods of confusion
b. Expectoration of blood
c. Increased breath sounds
d. Decreased respiratory rate

56. Answer B. Expectoration of blood is an indication

that the lung itself was damaged during the procedure;
a pneumothorax or hemothorax may occur.
a. Increased lung expansion should improve cerebral
oxygenation and decrease confusion if present
C. Increased breath sounds are anticipated as the lung
is closer to the chest wall after the fluid in the pleural
space is removed
D. A decreased rate may indicate improved gaseous
exchange and is not evidence that the client is in
danger

57. The food group lowest in natural sodium is:

a. Milk
c. Fruits
b. meat
d. Vegetables

57. Answer C. Fruits contain less natural sodium

than do other foods
A. Milk is higher in natural sodium than is fruit
B. Meat is higher in natural sodium than is fruit
D. Vegetables are higher in natural sodium than is
fruit

11

58. Megadoses of vitamin A are taken by a client.

The nurse should question this practice
because
a. This vitamin is highly toxic even in small
amounts
b. The liver has great storage capacity for the
vitamin, even to toxic amounts
c. This vitamin cannot be stored, and the
amount would saturate the general body
tissues.
d. Although the bodys requirement for the
vitamin is very large, the cells can
synthesize more as needed

58. Answer B. Vitamin A is a fat-soluble vitamin

that accumulates in the body and is not
significantly excreted even if extremely large
amounts are ingested, After prolonged ingestion
of extremely large doses, toxic effects (irritability,
increased intracranial pressure, fatigue, night
sweats, severe headache) can occur.
A. Vitamin A is toxic only after prolonged large
dosages
C. Vitamin A can be stored in the liver
D. Vitamin A cannot be synthesized by the body

59. Vitamin A is a fat-soluble vitamin produced by

humans and other animals from its precursor
carotene-provitamin A. One of the main
sources of this vitamin is:
a. Oranges
c. tomatoes
b. Skim milk
d. leafy greens

59. Answer D. Deep green and yellow vegetables

contain large quantities of the pigments alpha-,
beta- and gamma-carotene; betacortene is the
major chemical precursor of vitamin A in human
nutrition
A. Oranges are considered a good source of both
vitamin C and potassium
B. levels of vitamin A are higher in whole milk than
is skim milk
C. Tomatoes are a good source of vitamin C

60. A client is to have gastric gavage. When the

gavage tube is being inserted the nurse should
place the client in the:
a. Supine position
b. Mid-Fowlers position
c. High-Fowlers position
d. Trendelenburg position

60. Answer C. The high-fowlers position promotes

optimal entry into the esophagus aided by gravity
A. This position does not take full advantage of the
effect of gravity
B. Same as answer A
D. This is opposite to the desired position

61. A client expresses to meals and eats only small

amounts. The nurse should provide:
a. Nourishment between meals
b. Small portions more frequently
c. Only foods the client likes in small portions
d. Supplementary vitamins to stimulate
appetite

61. Answer B. Small meals are not as psychologically

over whelming and do not upset the stomach as easily.
They are therefore better tolerated.
A. If no attempts are made to decrease portions at
regular mealtimes, aversion will usually persist
C. This does not ensure adequate nutrition; if the
portion size is decreased, frequency must be increased
D. Administration of vitamins is a dependent nursing
function; vitamins do not stimulate appetite

62. The term used to most accurately describe a

clients lack if interest in food is:
a. Apathy
c. Anorexia
b. Anoxia
d. Dysphagia

62.Answer C. Anorexia refers to loss of appetite .

A. Apathy refers to lack of concern or emotion
B. Anorexia refers to lack of oxygen
D. Dysphagia refers to difficulty in swallowing

12

63. A flat plate radiograph of the abdomen is

ordered. The nurse recognizes that the client
should receive:
a. no special preparation
b. A low soapsuds enema
c. Nothing by mouth for 8 hours
d. A laxative the evening before the x-ray

63. Answer A. A flat plate film of the abdomen

visualizes abdominal organs as they are.
B. No bowel preparation is indicated
C. The client may eat and drink as tolerated
D. Same as answer B

64. Barium salts in the GI series and barium

enemas serve to:
a. Fluoresce and thus illuminate the
alimentary tract
b. Give off visible light and illuminate the
alimentary tract
c. Dye the alimentary tract and thus provide
for color contrast
d. Absorb x-rays and thus give contrast to the
soft tissues of the alimentary

64. Answer D. Barium salts used in a GI series and

barium enemas coat the inner lining of the GI tract
and then absorb x-rays passing through. They thus
outline the surface features of the tract on a
photographic plate
A. Barium does not fluoresce
B. barium has no light emitting properties
C. Barium does not have properties of a dye

65. As part of the preparation of a client for a

sigmoid-oscopy, the nurse should:
a. Administer an enema the morning of the
test
b. Provide a container for the collection of a
stool specimen
c. Withhold all fluids and foods for 24 hours
before the examination
d. Explain to the client that a chalklike
substance will have to be swallowed

65. Answer A. The permit adequate visualization

of the mucosa during the sigmoidoscopy, the
bowel must be cleaned with a nonirritating enema
before examination
B. stool should be eliminated from the colon by an
enema before the examination
C. Because only the lower bowel is being
visualized, keeping the client NPO is unnecessary
and debilitating; clear liquids and a laxative may
be given the day before to limit fecal residue
D. The client does not drink such a substance in
preparation for a sigmoidoscopy.

66. Specific nursing responsibility in preparing a

client for a sigmoidoscopy and barium enema
includes:
a. Giving castor oil the afternoon before
b. Withholding food and fluid for 8 hours
c. Administering soapsuds enemas until clear
d. Ensuring the clients understanding of the
procedure

66.Answer D. To promote understanding and allay

anxiety all diagnostic test should be explained to
the client
A. Preparations for tests may vary depending on
the clients condition
B. Same as answer A
C. Same as answer A

13

67. The maximum height at which the container of

fluid should be held when administering a
cleansing enema is:
a. 30 cm (12 inches)
b. 37 cm (15 inches)
c. 45 cm (18 inches)
d. 66 cm (26 inches)

67. Answer A. If the height of the enema fluid

container above the anus is increased, the force and
rate of flow also increase. If the container is raised
excessively, damage to the mucosa may result and the
procedure will be much more difficult for the client to
tolerate.
B. The enema container can be held this high above
the anus only if a high cleansing enema is to be given
This would be too high and could cause mucosal injury
D.Same as answer C.

68. During administration of an enema a client

complains of intestinal cramps. The nurse
should:
a. Give it at a shower rate
b. Discontinue the procedure
c. Stop until cramps are gone
d. Lower the height of the container

68. Answer C. Administration of additional fluid when a

client complains of abdominal cramps adds to comfort
because of additional pressure. By clamping the tubing
a few minutes the nurse allows the cramps generally to
subside and the enema can be continued
A. slowing the rate decreases pressure but does not
reduce it entirely
B. Cramps are not a reason to discontinue the enema
entirely; temporary clamping and the tubing usually
relieves the cramps and the procedure can be
continued.
D. This will reduce the flow of the solution, which will
decrease pressure but not reduce it entirely

69. The nurse explains that visualization of the GI

tract a barium enema is made possible by:
a. Barium physically coloring the intestinal
wall
b. The high x-ray absorbing properties of
barium
c. The high x-ray transmitting properties of
barium
d. The chemical interaction between barium
and the electrolytes

70. The sigmoIdoscopy is preformed as a

diagnostic measure. For this examination the
client may be placed in the position known as:
a. Sims
c. Lithotomy
b. Prone
d. Knee-chest

71. During
a
percutaneous
endoscopic
gastrostomy (PEG) tube feeding, the
observation that indicates that the client is
unable to tolerate a continuation of the
feeding would be:
a. A passage of flatus
b. Epigastric tenderness
c. A rise of formula in the tube
d. The rapid flow of feeding

69. Answer B. Because the soft tissues of the GI

tract lack sufficient quantities of x-ray absorbing
atoms (as are naturally, present in the dense
calcium salts of bone), an x-ray absorbing coating
of barium is used for radiologic studies
A. barium does not color the intestinal wall
C. Barium absorbs x-ray
D. Barium does not interact with electrolytes
70. Answer D. This position maximally exposes the
rectal area and facilities entry of the sigmoid
oscope.
A. The Sims position does not expose the rectal
area to the same extent as the knee-chest position
does but can still be used for a sigmoid, oscopy if
the client is unable to maintain the knee-chest
position
B. Although prone refers to a face-down position,
the rectal area is not exposed
C. The lithotomy position is appropriate for
gynecologic examination
71. Answer C. A rise in the level of formula within
tube indicates a full stomach.
A. Passage of flatus reflects intestinal motility
which does not pose a potential problem
B. Episgastric tenderness is no necessarily caused
by a full stomach
D. A rapid inflow is the result of positioning the
container too high or using a feeding tube with
too large a lumen

14

72. Clients receiving hypertonic tube feedings

most commonly develop diarrhea because of:
a. Increased fiber intake
b. Bacterial contamination
c. Inappropriate positioning
d. High osmolarity of the feedings

73. The nurse should administer a nasogastric

tube feeding slowly to reduce the hazard of:
a. Distention
c. Indigestion
b. Flatulence
d. Regurgiatation

74. Clients with fractured mandibles usually have

them immobilized with wires. The lifethreatening problem that can develop
postoperatively is:
a. Infection
c. Osteomyelitis
b. Vomiting
d. Bronchospasm

75. After an incision and drainage of an oral

abscess, the client should be instructed to
notify the physician if there is
a. Foul odor to the breath
b. Pain and swelling after 1 week
c. Pain associated with swallowing
d. Tenderness in the mouth when chewing

76. When assessing a client with cancer of the

tongue the specific adaptation the nurse
should expect to find is
a. Halitosis
c. Bleeding gums
b. Leukoplakia
d. Substernal pain

77. The nurse recognizes that a client has an

increased risk of developing cancer of the
tongue if there is a history of
a. Nail biting
b. poor dental habits
c. Frequent gum chewing
d. Heavy consumption of alcohol

72.
Answer D.
The
increased osmolarity
(concentration) of many formulas draws fluid into the
intestinal tract, which would cause diarrhea; such
feedings may need to be diluted initially until the client
develops tolerance
A. Formulas frequently have reduced fiber content,
causing problems with constipation
B. bascterial contamination is not a factor if feedings
are administered as recommended by the
manufacturer
C. Inappropriate positioning may increase the risk of
aspiration, but does not cause diarrhea
73. Answer D. because the cardiac sphincter of the
stomach is slightly opened to admit the nasogastric
tube, rapid feeding could result in regurgitation
A. Distention can be diminished by avoiding the
instillation of air with the feeding
B. The speed of feeding does not cause flatulence but
the administration of air may
C. Indigestion is not hazardous to client

74. Answer B. Vomiting may result in aspiration of

vomitus, because it cannot be expelled; this could
cause pneumonia or asphyxia
A. This is not a life threatening problem
C. Same as answer A
D. Same as answer A

75. Answer B. Pain and swelling should subside

before A week postoperative. Continued pain may
indicate infection
A. The breath may have an odor because of dried
blood in the oral cavity; this is to be expected
during the postoperative period.
C.painful swallowing may occur because of
generalized trauma resulting from surgery and is
to be expected
D. Tenderness is expected during the
postoperative period
76. Answer B. Luekopia are white thickened
patches that tend to fissure and to become
malignant; ulcerations in the mouth or on the
tongue may indicate cancer
A. Halitosis would not be an early sign or specific
to cancer of the mouth
C. Bleeding gums occur in gingival diseases
D. Pain associated with cancer of the tongue
would not radiate to the substernal area
77. Answer D. Heavy alcohol ingestion predisposes
an individual to the development of oral cancer
A. Nail biting has no effect on the development of
oral cancer
B. Dental hygiene does not affect the
development of oral cancer
C. Gum chewing is not a contributing factor to
development of oral cancer
15

78. To limit symptoms of gastroesophageal reflux

(GERD), the nurse should advise the client to:
a. Avoid heavy lifting
b. Lie down after eating
c. Increase fluid intake with meals
d. Wear an abdominal binder or girdle

79. Most peptic ulcers occurring in the stomach

are in the:
a. Pyloric potion
b. Cardiac portion
c. Esophageal junction
d. Body of the stomach

80. The basic goal underlying the unique dietary

management of gastritis is to
a. Provide optimal amounts of all important
nutrients
b. Increase the amount of bulk and roughage
in the diet
c. Eliminate chemical, mechanical and
thermal irritation
d. Promote psychologic support by offering a
wide variety of foods

81. The nurse expect an antrectomy may be

performed if a client has a diagnosis of:
a. cataracts
c. gastric ulcers
b. otosclerosis d. trigeminal neuralgia

82. Two after a subtotal gastrectomy the nurse

notes that the drainage from the clients
nasogastric tube is bright red. The nurse
should:
a. Notify the physician immediately
b. Clamp the nasogastric tube for one hour
c. Recognize that this is an expected finding
d. Irrigate the nasogastric tube with iced
saline

78. Answer A. Heavy lifting increases

intraabdominal pressure, allowing gastric contents
to move up through the lower esophageal
sphincter (regurgitation) causing heartburn
B. This encourages regurgitation and should be
avoided
C. Increasing fluids with meals increases gastric
volume, causing distention and reflux
D. Constrictive garments such as belts, binders
and girdles increase intraabdominal oressure and
could lead to reflux
79. Answer A. Almost all peptic in the stomach
develop along the lesser curvature of the antral
(pyloric ) region. About 85% of all peptic ulcers
occur within the first 2 cm of the duodenum.
These regions are most exposed to acid conditions
B. This is less exposed to gastric secretions
C. This is less exposed to gastric secretions;
however erosion may occur after repeated
episodes of gastric reflux
D. Same as answer B
80. Answer C. Irritation of the mucosa may cause
increased bleeding or perforation and therefore
should be avoided
A. All clients diets should be nutritionally
balanced; this is not specific to this clients
problem.
B. Bulk and roughage may irritate the mucosa and
should be decreased
D. Psychologic support is not the primary goal,
efforts should be made to include foods that are
psychologically beneficial, but do not include
foods that are irritating to the mucosa
81. Answer C. The antrum is responsible for gastrin
production; which stimulates hydrochloric acid
secretion; its removal reduces HCI secretion and thus
reduces irritation of the gastric mucosa
A. Removed by means of a laser beam, cryotechnique,
or surgery is used when cataracts occur
B. A stapedectomy, mobilization of the stapes, or a
prosthetic implant would be used with otosclerosis
D. A resection of the firth cranial nerve would be done
in trigeminal neuralgia

82.Answer C. Nasogastric drainage is expected to

be bright red at first and gradually darken within
he first 24 hours after surgery
A. Bloody drainage is expected this soon after
surgery and the physician does not need to be
notified
B. Nasogastric suction must be working and the
tube must remain patent to prevent stress on the
suture line
D. The nasogastric tube is only irrigated if the
physician orders it because of the danger or injury
to the suture line; generally saline at room
temperature would be ordered
16

83. When caring for a client with nasogastric tube

attached to suction, the nurse should
a. Irrigate the tube with normal saline
b. Use sterile technique when irrigating the
tube
c. Withdraw the tube quickly when
decompression is terminated
d. Allow the client to have small chips of ice
or sips of water unless nauseated

84. After a partial gastrectomy is performed, a

client is returned to the unit with an IV
solution infusing and a nasogastric tube in
place. The nurse notes that there has been no
nasogastric drainage for hour. There is an
order to irrigate the nasogastric tube prn. The
nurse should insert:
a. 30 ml of normal saline and withdraw
slowly
b. 20 ml of air and clamp off suction fro 1
hour
c. 50 ml of saline and increase pressure of
suction
d. 15 ml of distilled water and disconnect
suction for 30 minutes

83.Answer A. To ensure continued suction, the

patency of the tube should be maintained. Normal
saline is used to prevent fluid and electrolyte
disturbances during irrigation
B. The stomach is not considered a sterile body
cavity, so medical asepsis is indicated
C. Care must be taken to avoid traumatizing the
mucosa
D. Ice chips and water represent fluid intake,
which must be approved buy the physician; being
hypotonic in nature, such as intake may lower the
serum electrolyte
84. Answer A. Physiologic normal saline is used in
gastric irrigation to prevent electrolyte imbalance.
Because of the fresh gastric sutures, slow and
gentle irrigation should be performed. Most
surgeons, however prefer gastric instillations
B. The purpose of irrigation is to maintain the
patency of the tube for gastric decompression;
with disconnection from suction a buildup of
sections and air can occur or the tube can become
blocked by viscous drainage
C. Increasing the pressure may cause damage to
the suture line.
D. Same as answer B

85. The most therapeutic diet for

a client
recovering from an acute episode of
alcoholism would be:
a. High protein, low carbohydrates, low fat
b. Low protein, high carbohydrate, high fat,
soft
c. High carbohydrate , low saturated fat,
1800 calories
d. Protein to tolerance, moderate fat, high
calorie, high vitamin, soft

85. Answer D. Protein helps correct severe

malnutrition; moderate fat limits need for bile; a
high calorie, high vitamin diet prevents tissue
breakdown
A. A diet high in protein carbohydrates and
calories is needed to improve nutritional status
B. A high protein diet is essential in repairing
tissues and restoring nutritional status
C. This diet does not offer enough fat or calories

86. The physician orders thiamine chloride and

nicotinic acid for a client with alcoholism. The
nurse should teach the client that these
vitamins are needed for the maintenance of:
a. Elimination
b. Efficient circulation
c. The nervous system
d. Prothrombin formation

86.Answer C. Thiamine and nicotinic acid help

convert glucose for energy and therefore
influence nerve activity
A. These vitamins do not affect elimination
B. These vitamins are not related to circulatory
activity
D. Vitamin K, not thiamine and niacin is essential
for the manufacture of prothrombin in the liver

17

87. Because the detoxification of alcohol of

alcohol damages tissues, a high-calorie diet
fortified with vitamins should be encouraged
to protect the clients
a. Liver
c. Adrenals
b. Kidneys
d. Pancreas

87. Answer A. The liver detoxifies alcohol and is

the organ most often damaged in chronic
alcoholism. The high-calorie diet prevents tissue
breakdown, which produces additional amino
acids.
B. These organs are not involved detoxification of
alcohol
C. Same as answer B
D. This organ is not involved in detoxification of
alcohol

88. If intubation is indicated for a client with

bleeding esophageal varices, the type of tube
most likely to be used would be a (an):
a. Levin tube
b. Salem sump
c. Miller-Abbort tube
d. Blakemore-Sengstaken tube

88. Answer D. This tube includes an esophageal

balloon that on inflation exerts pressure, which
retards hemorrhage.
A. This is used for gastric decompression; gavage
or lavage; it has one lumen
B. This is used for gastric decompression, it has
two lumens one for decompression; and one fro
an air vent
C. This is used for intestinal decompression

89. When planning dietary teaching for a client

with a malabsorption syndrome the nurse
should include the need to avoid:
a. Rice or corn
c. Fruit or fruit juices
b. Milk or cheese
d. wheat, rye or oats

89. Answer D. Gluten is found in rye, wheat and

oat products
A. gluten is not found in these foods; they do not
have to be avoided
B. Same as answer A
C. Same as answer A

90. A typical food combination that can be served

to a client with malabsorption syndrome
would be:
a. Roast beef, baked potato, carrots, tea
b. Cheese omelet, noodles, green beans,
coffee
c. Creamed turkey on toast, rice, green peas,
milk
d. Baked chicken, mashed potatoes with
gravy, zucchini, postum

90. Answer A. These foods are low in gluten

B. Flours used in the production of noodles are
high in gluten
C. Flours used in the production of bread are high
in gluten
D. Postum is a cereal drink high in gluten

91. A client has an appendectomy and develops

peritonitis. The nurse should assess the client
for an elevated temperature and:
a. Hyperactivity
b. Extreme hunger
c. Urinary retention
d. Local muscular rigidity

91.Answer D. Muscular rigidity over the affected

area is a classic sign of peritonitis
A. Malaise, rather than hyperactivity is often
associated with peritonitis
B. Nausea is a common occurrence with peritonitis
C. Urinary retention may occur following surgery
as a complication of anesthesia

18

92. The position that is indicated for a client after

surgery for a perforated appendix with
localized peritonitis is the:
a. Sims position
b. Semi-Fowlers position
c. Trendelenburg position
d. Dorsal recumbent position

93. Four days after abdominal surgery a client has

not passed any flatus and there are no bowel
sounds. Paralytic ilues is suspected. In this
condition there is an intereference caused by:
a. Decreased blood supply
b. Impaired neural functioning
c. Perforation of the bowel wall
d. Obstruction of the bowel lumen

94. The physician has ordered a rectal tube to help

a client relieve abdominal distention following
surgery. To achieve maximum effectiveness
the nurse should leave it in place:
a. 15 minutes
c. 45 minutes
b. 30 minutes
d. 60 minutes

95. A client is to have an enema to reduce flatus.

The rectal catheter should be inserted:
a. 2 inches
c. 6 inches
b. 4 inches
d. 8 inches

96. Vitamins are administered parentally for

clients with an inflamed intestine because:
a. More rapid action results
b. They are ineffective orally
c. They decrease colon irritability
d. Intestinal absorption may be inadequate

97. Neomycin is especially useful before colon

surgery because it:
a. Will not affect the kidneys
b. Acts systemically without delay
c. Is poorly absorbed from the GI tract
d. Is effective against many organisms

92. Answer B. The semi-Fowlers position aids in

drainage and prevents spread of infection throughout
the abdominal cavity
A. The Sims position is generally used for
administration of enemas or rectal examination; it
would not be helpful in draining the area
C. The trendelenburg postion would contribute to the
spread of infection throughout the abdominal cavity
D. The dorsal recumbent position would not allow for
localization of drainage

93. Answer B. Paralytic ileus occurs, when

neurologic impulses are diminished, as from
anesthesia, infection or surgery
A. Interference in blood supply would results in
necrosis of the bowel
C. Perforation of the bowel would results in pain
and peritonitis
D. Obstruction of the bowel lumen would initially
cause increased peristalsis and bowl sounds
94. Answer B. Rectal tube promotes maximum
benefits in 30 minutes. This allows adequate time
for gas escape
A. Fifteen minutes is not adequate time to permit
removal of flatus
C. After 30 minutes the release of flatus would be
minimal
D. Same as answer C
95. Answer B. a rectal catheter should be inserted
approximately 4 inches to pass the rectal
sphincter
A. A catheter inserted just 2 inches will not be
passed beyond the rectal sphincter
C. Deep insertion may damage the intestinal
mucosa
D. Same as answer C
96.Answer D. Because the mucosa of the intestinal
tract is damaged, its ability to absorb vitamins
taken orally is greatly impaired
A. Although this is true, the risks associated with
IV administration will outweigh the benefits
B. Vitamins are effective orally unless there is
disease involving the GI tract that hampers
absorption
C. IV vitamins do not decrease colonic irritability
97.Answer C. Because Neomycin is poorly absorbed
form the GI tract, most remains in the intestines and
exerts its antibiotic effect on the intestinal mucosa. In
preparation for GI surgery the level of microbial
organisms will be reduced
A. Neomycin is nephrotoxic

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B. Because it is poorly absorbed from the GI tract, the

systemic effect is minimal
D. Neomycin is mainly effective in suppression of
intestinal bacteria

98. The nurse should protect the clients skin

surrounding a colostomy opening by using:
a. Alcohol
c. Skin barriers
b. Mineral oil
d. Tincture of benzoin

98. Answer C. A skin barrier provides a coating

that creates a barrier to gastrointestinal enzymes
and protects against allergic reactions to the tape
on the appliance
A. neomycin in nephrotoxic
B. Because it is poorly absorbed from the GI tract,
the systemic effect is minimal
D. Neomycin is mainly effective in supresssion of
intestinal bacterial

99. The primary step toward long-range goals in

the rehabilitation of a client with a new
colostomy involves the clients
a. Mastery of techniques of colostomy care
b. Readiness to accept an altered body
function
c. Awareness of available community
resources
d. Knowledge of the necessary dietary
modifications

99.Answer B. The client must be ready to accept

changes in body image and function; this
acceptance will facilitate mastery of the
techniques of colostomy care, special diets, and
optimal use of community resources
A. Specific knowledge can be imparted only when
an individual is ready to learn; it requires
acceptance of a new body image
C. Same as answer A
D. Same as answer A

100. Postoperatively, if a clients colostomy

stoma is viable the nurse would expect the
color to be:
a. Gray
c. Pale pink
b. Brick red
d. Dark purple

100.Answer B. This describes the stoma that has

adequate vascular perfusion
A. Indicates inadequate perfusion of the stoma
C. Same as answer A
D. Same as answer A.

Far better is it to dare mighty things, to win glorious

triumphs, even though checkered by failure...than to
rank with those poor spirits who neither enjoy much
nor suffer much, because they live in a gray twilight
that knows not victory nor defeat.
- Theodore Roosevelt

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