MS PREBOARD

NLE NOVEMBER 2016

PERI-OP

Situation 1- Perioperative nursing refers to activities performed by the professional nurse before, during, and after operation. In the OR,
there are safety protocols that should be followed. The OR nurse should be well versed with all these to safeguard the safety and quality
of patient delivery outcome. The following questions apply.

1. You are assigned to a client who will undergo right leg amputation. Which of the following should you perform before the surgery?
A. Clean the right leg
B. Cover the leg
C. Elevate the leg
D. Mark the leg

Rationale: In order to eliminate wrong site surgery, it is important to mark the site of the procedure.

2. A nurse manager is reviewing the principles of surgical asepsis with the nursing staff. The nurse manager should tell the staff that it
is necessary to use the principles of surgical asepsis in which situations?
1. Removing a dressing
2. Reapplying sterile dressings
3. Inserting an intravenous line
4. Inserting a urinary (Foley) catheter
5. Suctioning the tracheobronchial airway
6. Caring for an immunosuppressed client

A. 1, 3, 5 and 6
B. 1, 2, 5 and 6
C. 2, 3, 4 and 5
D. 3, 4, 5 and 6

Rationale: Surgical asepsis involves the use of sterile technique. Some examples of procedures in which surgical asepsis is
necessary include reapplying sterile dressings, inserting an IV or urinary catheter, and suctioning the tracheobronchial airway.
Medical asepsis, or clean technique, includes procedures to reduce and prevent the spread of microorganisms. Removing a
dressing can be done by clean technique using clean gloves (although reapplying the dressing requires surgical asepsis).
Caring for an immunosuppressed client requires medical asepsis techniques. Medical and surgical asepsis are measures
instituted to protect both the client and health care workers. Medical asepsis is intended to reduce and prevent the spread of
microorganisms in a particular environment. (Saunders)

3. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include
which piece of information during the discussion with the client?
A. Inhale as rapidly as possible
B. Keep a loose seal between the lips and the mouthpiece
C. After maximum inspiration, hold the breath for 15 seconds and exhale
D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler’s or high-Fowler’s
position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the
unit. The breath should be held for 5 seconds before exhaling slowly. (Saunders)

4. A client who has had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse
removes the dressing and noted the presence of a loop of bowel protruding through the incision. Which nursing interventions should
the nurse take?
I. Contact the surgeon
II. Instruct the client to remain quiet
III. Prepare the client for wound closure
IV. Document the finding and actions taken
V. Place a sterile saline dressing and ice packs over the wound
VI. Place the client in supine position without a pillow under the head

A. I, I, III, IV
B. I, II, IV, V
 C. I, I, III, IV, V
D. I, II, IV, V, VI

Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is the protrusion of the internal organs
through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another
nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler’s
position, and the client is kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is
not applied because of its vasoconstrictive effect. The treatment for evisceration Is usually immediate wound closure under local or
general anesthesia. The nurse also documents the findings and actions taken. (Saunders)

5. The nurse is receiving a client being transferred from the postanesthesia care unit following an above-the-knee amputation. The
nurse should take which action to safely position the client at this time?
A. Elevate the foot of the bed
B. Put the bed in reverse Trendelenburg
C. Position the residual limb flat on the bed
D. Keep the residual limb flat with the client lying on the operative side

Rationale: Edema of the residual limb is controlled by elevating the foot of the bed for the first 24 hours only after surgery. After the
first 24 hours, the residual limb is usually placed flat on the bed (as prescribed) to reduce hip contracture. Edema is also controlled
by residual limb wrapping techniques. Reverse trendelenburg does not provide direct limb elevation. After amputation, assess the
client for phantom limb sensation and pain. Explain these feelings of sensation and pain to the client and medicate the client as
prescribed. (Saunders)

RESPI

SITUATION 2– Respiratory disease is a medical term that encompasses pathological conditions affecting the organs and tissues that
make gas exchange possible in higher organisms, and includes conditions of the upper respiratory tract, trachea, bronchi, bronchioles,
alveoli, pleura and pleural cavity, and the nerves and muscles of breathing. The following questions apply.

6. The nurse is reviewing the parts of the respiratory system. Which part of the lungs found at the end of the terminal bronchioles does
gas exchange occurs?
A. Alveoli
B. Bronchi
C. Bronchioles
D. Carina

Rationale: Alveolar ducts branch from the respiratory bronchioles. Alveolar sacs, which arise from the ducts, contains clusters of
alveoli, which are the basic unit of gas exchange. Mainstem bronchi divide into secondary or lobar bronchi that enter each of the
five lobes of the lung. The bronchi are lined with cilia, which propel mucus up and away from the lower airway to the trachea, where
it can be expectorated or swallowed. The terminal bronchioles contain no cilia and do not participate in gas exchange (Saunders)

7. A nurse was assigned to an elderly patient with pneumonia. He is aware that the factor MOST likely contributing to the patient’s
development of pneumonia is:
A. Malnutrition
B. Group living
C. Dehydration
D. Severe periodontal disease

Rationale: Clients with chronic illness generally have poor immune systems. Often, residing in group living situations increases the
chance of disease transmission. Adequate fluid intake, adequate nutrition, and proper oral hygiene help maintain normal defenses
and can reduce the incidence of getting such diseases as pneumonia. (NCLEX-RN Questions and Answers Made Incredibly Easy,
p. 224)

8. An elderly client developed pneumonia. The nurse is aware that the INITIAL symptom the client may manifest is:
A. Fever and chills
B. Altered mental status and dehydration
C. Hemoptysis and dyspnea
D. Pleuritic chest and cough
 Rationale: Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common symptoms of pneumonia, but elderly
clients may first appear with only an altered mental status and dehydration and due to a blunted immune response. (NCLEX-RN
Questions and Answers Made Incredibly Easy, p. 225)

9. The nurse is assessing a 69-year-old client who appears thin and cachectic. The client is short of breath at rest, dyspneic with the
slightest exertion, and has diminished breath sounds with deep inspiration. The nurse interprets these assessment findings as
indicative of:
A. Acute respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema

Rationale: In emphysema, the wall integrity of the individual air sacs is damaged, reducing the surface area available for gas
exchange. Very little air movement occurs in the lungs because of bronchiole collapse as well. In ARDS, the client’s condition is
more acute and typical requires mechanical ventilation. In asthma and bronchitis, wheezing is prevalent. (NCLEX-RN Questions
and Answers Made Incredibly Easy, p. 249)

10. A client has received a preliminary diagnosis of tuberculosis. In order to obtain a definitive diagnosis, the nurse anticipates that the
physician will order which test?
A. Chest X-ray
B. Mantoux test
C. Sputum culture
D. Tuberculin test

Rationale: The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis. Lesions in the lung
may not be big enough to be seen on X-ray. Skin tests may be falsely positive or falsely negative. (NCLEX-RN Questions and
Answers Made Incredibly Easy, p. 236)

SITUATION 3– Nurse Tel is assigned in Humihinga ward taking care of patients with different respiratory problems . The following
questions apply.

11. The mother asked Nurse Tel what will be the BEST position for her daughter when an asthmatic attack occurs:
A. Prone position with head turned to side
B. High-fowler’s position with extended legs
C. Supine position with legs elevated
D. Sim’s position

Rationale: During an acute asthma episode, position the client in a high Fowler’s position or sitting to aid in breathing. (Saunders)

12. A client with chronic obstructive bronchitis asks Nurse Tel why is he receiving diuretic therapy. What is the best response by Nurse
Tel?
A. Reducing fluid volume reduces oxygen demand
B. Reducing fluid volume improves client’s mobility
C. Reducing fluid volume reduces sputum production
D. Reducing fluid volume improves respiratory function

Rationale: Reducing fluid volume reduces the workload of the heart, which reduces oxygen demand and, in turn, reduces the
respiratory rate. It also may reduce edema and improve mobility a little, but exercise tolerance will still be poor. Sputum may get
thicker and make it harder to clear airways. Reducing fluid volume won’t improve respiratory function but may improve oxygenation.
(NCLEX-RN Questions and Answers Made Incredibly Easy, p. 249)

13. The nurse has placed a client diagnosed with acute respiratory distress syndrome in the prone position. The nurse determined that
this positioning of the client would:
A. Improve cardiac output
B. Make the client more comfortable
C. Prevent skin breakdown
D. Recruit more alveoli

Rationale: A supine position may reduce the ability of posterior alveoli to open and remain open. Turning the client to the prone
position may recruit new alveoli in the posterior region of the lung and improve oxygenation status. Cardiac output shouldn’t be
affected by the prone position. The prone position doesn’t make the client more comfortable, and he often requires sedation to
 tolerate it. Skin breakdown can still occur over the new pressure points. (NCLEX-RN Questions and Answers Made Incredibly
Easy, p. 264)

14. The client is receiving positive-end expiratory pressure (PEEP) therapy. The nurse anticipates that the client will exhibit which of the
following?
A. Bradycardia
B. Tachycardia
C. Increased blood pressure
D. Reduced cardiac output

Rationale: PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left
side of the heart, thereby reducing cardiac output. It doesn’t affect the heart rate, but a decrease in cardiac output may reduce
blood pressure, commonly causing a compensatory tachycardia. (NCLEX-RN Questions and Answers Made Incredibly Easy, p.
263)

15. Nurse Vanessa, friend of Nurse Tel, is assessing a client who has sustained a blunt injury to the chest wall. Which finding would
indicate the presence of pneumothorax in this client?
A. A low respiratory rate
B. Diminished breath sounds
C. The presence of a barrel chest
D. A sucking sound at the site of injury

Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of
breath and chest pain. A larger pneumothorax may cayuse tachypnea, cyanosis, diminished breath sounds, and subcutaneous
emphysema. Hyperresonance also may occur on the affected side. A sucking wound at the site of injury would be noted with open
chest injury. (Saunders)

CARDIO

SITUATION 4 – Nurse Carl assigned in the medical unit of the Balita Medical Center and was tasked to take care of 5 patients with
various cardiovascular conditions. The following questions apply.

16. Nurse Carl is aware that a client who has just experienced a myocardial infarction (MI) is most at risk for developing:
A. Cardiogenic shock
B. Heart failure
C. Arrhythmias
D. Pericarditis

Rationale: Arrhythmias, caused by oxygen deprivation to the myocardium are the most common complication of an MI. Cardiogenic
shock, another complication of MI, is defined as the end stage of left ventricular dysfunction. He condition occurs in approximately
15% of clients with MI. Because the pumping function of the heart is compromised by an MI, heart failure is the second most
common complication. Pericarditis most commonly results from a bacterial or viral infection but may occur after MI.

17. Nurse Carl is assessing a client with heart failure. The client is experiencing tachycardia, decreased blood pressure, and decreased
peripheral pulses. The nurse interprets these symptoms as indicative of what?
A. Anaphylactic shock
B. Cardiogenic shock
C. Distributive shock
D. Myocardial infarction

Rationale: Cardiogenic shock is chock related to reduced cardiac output and ineffective pumping of the heart. Anaphylactic shock
results from an allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually
associated with increased cardiac output. MI isn’t a shock state, although severe MI can lead to shock. (NCLEX-RN Questions and
Answers Made Incredibly Easy)

18. A client is diagnosed with cardiomyopathy. If medical treatment for cardiomyopathy fails, Nurse Carl should prepare the client for
which of the following procedures?
A. Cardiac catheterization
B. Coronary artery bypass graft (CABG)
C. Heart transplantation
D. Intra-aortic balloon pump (IABP)
 Rationale: The only definitive treatment for cardiomyopathy that can’t be controlled medically is a heart transplant because the
damage to the heart muscle is irreversible. Cardiac catheterization is an invasive diagnostic procedure for coronary artery disease.
CABG is a surgical intervention used for atherosclerotic vessels. AN IABP is an invasive treatment that assists the failing heart;
however; it’s only a temporary solution. (NCLEX-RN Questions and Answers Made Incredibly Easy, p. 110)

19. Nurse Carl is assessing a client with angina pectoris. Which of the following are characteristics of the substernal chest pain that
occurs with this condition?
I. Occurs without cause
II. Radiates to the left arm
III. Lasts less than 15 minutes
IV. Usually occurs in the morning
V. Is relieved by rest and nitroglycerine
VI. Is precipitated by exertion or stress

A. I, II, III, IV
B. I, II, III, V
C. II, III, IV, V
D. II, III, V, VI

Rationale: Angina pectoris is a temporary imbalance between the coronary artery’s ability to supply oxygen and the cardiac
muscle’s demand for oxygen. He substernal chest pain that occurs in angina radiates to the left arm, is precipitated by exertion or
stress, is relieved by rest or nitroglycerin, and last less than 15 minutes. Myocardial infarction occurs when myocardial tissue is
abruptly and severely deprived of oxygen. The substernal chest pain that occurs in myocardial infarction radiates to the left arm,
back or jaw; occurs without cause, usually in the morning; is relieved only by opioids; and lasts 30 minutes or longer. (NCLEX-RN
Questions and Answers Made Incredibly Easy, p. 75)

20. Which blood gas abnormality is initially most suggestive of pulmonary edema?
A. Anoxia
B. Hypercapnia
C. Hyperoxygenation
D. Hypocapnia

Rationale: In an attempt to compensate for increased work of breathing due to hyperventilation, carbon dioxide (CO2) decreases,
causing hypocapnia. If the condition persists, CO2 retention occurs and hypercapnia results. Although oxygenation is relatively low,
the client isn’t anoxia. Hyperoxygenation would result if the client was given oxygen in excess. However, secondary to fluid buildup,
the client would have a low oxygenation level. (NCLEX-RN Questions and Answers Made Incredibly Easy, p. 140)

SITUATION 5 – Certain procedures and treatment are done to help the medical professionals diagnosed and treat different
cardiovascular problems. Nurse Kim is assigned in Wasak na Puso Unit and is taking care of patients with cardiovascular conditions.
The following conditions apply.

21. Nurse Kim is providing instructions to a client attached to a Holter monitor. Which client statement indicates an understanding of the
nurse’s instructions concerning a Holter monitor?
a. “The only times the monitor should be taken off is for showering and sleep.”
b. “The monitor will record my activities and symptoms if an abnormal rhythm occurs.”
c. “The results from the monitor will be used to determine the size and shape of my heart.”
d. “The monitor will record any abnormal heart rhythms while I go about my usual activities.”

Rationale: The cardiac rhythm is monitored and rhythm disturbances documented; disturbances are stored, printed, and then
analyzed in relation to the client’s activity/symptom diary. The monitor must remain in place constantly for accurate recordings. The
client must keep a record of activities and symptoms while the monitor records cardiac rhythm disturbances, and then an analysis of
correlations between the two is made. A chest radiograph, not a Holter monitor, will reveal the size and contour of the heart.
(NCLEX-RN Questions and Answers Made Incredibly Easy, p. 81)

22. Nurse Kim is caring for a client scheduled to undergo a cardiac catheterization for the first time. The nurse tells the client that the:
A. Procedure is performed in the operating room
B. Initial catheter insertion is quite painful; after that there is little or no pain
C. Client may feel fatigue and have various aches, because it is necessary to lie quietly on a hard x-ray table for about 4 hours
D. Client may feel certain sensations at various points during the procedure, such as fluttery feeling, flushed warm feeling, desire
to cough or palpitations
 Rationale: Cardiac catheterization is an invasive test that involves the insertion of a catheter and the injection of dye into the heart
and surrounding vessel to obtain information about the structure and function of the heart chambers and valves and the coronary
circulation. Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that
ECG leads are attached to the client. A local anesthetic is used so there is little to no pain with catheter insertion. The x-ray table is
hard and may be tilted periodically. The procedure may take up to 2 hours and the client may feel various sensations with catheter
passage and dye injection. (Saunders)

23. A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a
client. Nurse Kim should implement which actions in the post-procedure period?
1. Restricting visitors
2. Checking the client’s groin for bleeding
3. Encouraging the client to increase fluid intake
4. Placing the client’s bed in the high Fowler’s position
5. Instructing the client to move the toes when checking circulation, motion and sensation

A. All except 1 and 3

B. All except 1 and 4
C. All except 3 and 4
D. All except 4 and 5

Rationale: Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend
the affected leg to avoid blood vessel occlusion or hemorrhage. Placing the client in the high Fowler’s position (flexion) increases
the risk of occlusion or hemorrhage. The groin is checked for bleeding and if any occurs the nurse immediately places pressure on
the site and asks another health care provider to contact the physician. Fluids are encouraged to assist in removing the contrast
medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or
thrombus was developing. There is no need to restrict visitors. Inform the client that he or she may experience a fluttery feeling as
the catheter is passed through the heart, a flushed warm feeling when the dye is injected, a desire to cough, and palpitations
caused by heart irritability. (Saunders)

24. The client with congestive heart failure is receiving digoxin (Lanoxin). Which of the following manifestations correlate with a digoxin
level of 2.3 ng/dL?
1. Nausea
2. Yellow or green color perception
3. Anorexia
4. Increased appetite
5. Increased energy level
6. Seeing halos around bright objects

A. 2, 3
B. 1, 2, 3
C. 1, 2, 3, 6
D. 1, 2, 3, 4, 6

Rationale: Digoxin is a cardiac glycoside used to manage and treat heart failure. The therapeutic range of digoxin is 0.8 to 2.0 ng/dL.
Signs of toxicity include gastrointestinal disturbances, including anorexia, nausea and vomiting; neurological abnormalities such as
fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares; facial pain, personality changes; and eye
disturbances such as photophobia, halos around bright lights, yellow or green color perception. (NCLEX-RN Questions and Answers
Made Incredibly Easy, p. 81)

25. A paradoxical pulse occurs in a client who has had coronary artery bypass graft (CABG) surgery 2 days ago. Which surgical
complication should Nurse Kim suspect?
A. Left-sided heart failure
B. Aortic regurgitation
C. Complete heart block
D. Pericardial tamponade

Rationale: A paradoxical pulse (a palpable decrease in pulse amplitude on quite inspiration) signals pericardial tamponade, a
complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (pulse amplitude alternation from beat to beat,
with a regular rhythm). Aortic regurgitation may cause bisferious pulse (an increased arterial pulse with a double systolic peak).
Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure). (NCLEX-RN Questions and
Answers Made Incredibly Easy, p. 140)
SITUATION 6 – Nurse Randy is a licensed cardiology nurse in a special training hospital which caters to a wide variety of patients with
cardiovascular and peripheral problems. He received special trainings in caring for these patients. The following questions apply.

26. A client in ventricular fibrillation is about to be defibrillated. Nurse Randy knows that to convert this rhythm effectively, the
monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery?
A. 50J
B. 120J
C. 200J
D. 360J

Rationale: The energy level used for all defibrillation attempts with a monophasic defibrillator is 360J. (Saunders)

27. A client with abdominal aortic aneurysm is scheduled for surgery. Which is the most common complication after an abdominal aortic
aneurysm resection?
A. Enteric fistula
B. Graft occlusion
C. Hemorrhage and shock
D. Renal failure

Rationale: LOWER BACK PAIN strongly suggests presence of Abdominal Aortic Aneurysm (AAA). Following abdominal aortic
aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury or renal failure. Acute kidney injury can
occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be
hypoperfused for a short period during surgery. (Saunders)

28. Nurse Randy anticipated that a client with intermittent claudication will receive which medication?
A. Analgesics
B. Warfarin (Coumadin)
C. Heparin
D. Pentoxifylline (Trental)

Rationale: Pentoxifylline decreases blood viscosity, increases red blood cell flexibility, and improves flow through small vessles.
Analgesics are administered for pain relief. Warfarin and heparin are anticoagulants. (NCLEX-RN Questions and Answers Made
Incredibly Easy, p. 138)

29. A client with a newly developed deep vein thrombosis (DVT) complains of pain. How does Nurse Randy expect the client to
describe the pain?
A. Dull ache
B. No pain
C. Sudden onset
D. Tingling

Rationale: DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A dull ache is more
commonly associated with varicose veins. If the thrombus is large enough, it will cause pain. A tingling sensation is associated with
an alteration in arterial blood flow. (NCLEX-RN Questions and Answers Made Incredibly Easy, p. 136)

30. Nurse Randy is aware that client with Buerger’s disease experiences which of the following signs or symptoms?
A. Thickening of the intima and media of the artery
B. Inflammation and fibrosis of arteries, veins, and nerves
C. Vasospasm lasting several minutes
D. Pain, pallor, and pulselessness

Rationale: Buerger’s disease is characterized inflammation and fibrosis of arteries, veins, and nerves. White blood cells infiltrate
the area and become fibrotic, which results in occlusion of the vessels/ Symptoms include slowly developing claudication,
cyanosis, coldness, and pain at rest. Option A is a characteristic of atherosclerosis. Option C is Raynaud’s disease. Option D are
symptoms of acute occlusion of an artery by an embolus or other cause.

HEMA

STUATION 7 – Anemia is the most common type among all hematologic conditions. Anemia may occur in different forms. Nurse Dugo is
assigned to take care of patients suffering from different types of anemia. The following questions apply.
31. A client asks Nurse Dugo about what commonly causes anemia. The best response by the nurse would be?
A. Blood loss
B. Lack of dietary iron
C. Virus
D. Hereditary disorders of the red blood cells

Rationale: Anemia can commonly be caused by lack of vitamin B12, iron, and folic acid as well as inflammation caused by some
chronic diseases. But the most common type of anemia is iron deficiency anemia. Blood loss, viruses, and hereditary disorders are
less common causes of anemia. (NCLEX RN Questions and Answers Made Incredibly Easy, p. 174)

32. Nurse Dugo determines that a client is at risk for developing anemia if which of the following predisposing factors is identified?
A. Colostomy following colon resection
B. Gastroesophageal reflux disease
C. Gastrectomy
D. Bouts of dumping syndrome

Rationale: Lack of intrinsic factor following gastrectomy would cause pernicious anemia due to the client’s inability to absorb vitamin
B12. The presence of a colostomy, GERD, or dumping syndrome would not place a client at risk for developing anemia. (NCLEX
RN Questions and Answers Made Incredibly Easy, p. 178)

33. Nurse Dugo is reviewing client’s charts. Select the client who would be most at risk for developing anemia?
A. A 2-year old in daycare
B. A 22-year-old college student
C. A 55-year-old neighbor
D. An elderly nursing home resident

Rationale: Elderly people are most at risk for developing anemia, often due to financial concerns affecting protein intake or poor
dentition that interferes with chewing meat. (NCLEX RN Questions and Answers Made Incredibly Easy, p. 181)

34. Nurse Dugo is reviewing a client’s complete blood count and notes a decreased number of erythrocytes, leukocytes, and platelets.
The nurse interprets this as indicative of what condition?
A. Pernicious anemia
B. Aplastic anemia
C. Sickle cell anemia
D. Polycythemia

Rationale: Aplastic anemia is a pathology of bone marrow dysfunction. Red blood cells, white blood cells, and platelets are
decreased. (NCLEX RN Questions and Answers Made Incredibly Easy, p. 174)

35. A client with sickle cell disease is discussing his therapeutic regimen. Which statement by the client indicates further teaching is
needed?
A. “I should avoid vacationing or traveling in areas of high altitude.”
B. “Cigarette smoking can cause a sickle cell crisis.”
C. “I should drink 4 to 6 L of fluid each day.”
D. “I should take one baby aspirin daily to help prevent sickle cell crisis.”

Rationale: Aspirin inhibits platelet aggregation and won’t help prevent sickle cell crisis. Hydroxyurea is prescribe for some people to
help prevent sickle cell crisis. High altitude increases oxygen demand and therefore can also precipitate a crisis. Tobacco, alcohol,
dehydration can precipitate a sickle cell crisis and should be avoided. (NCLEX RN Questions and Answers Made Incredibly Easy,
p. 187)

STUATION 8 – Nurse Don is assigned at the Medical Surgical Ward of Dugong Pinagkait Provincial Hospital. He was tasked to take
care of clients with different hematological disorders. The following questions apply.

36. The client has developed disseminated intravascular coagulation (DIC). Nurse Don is aware that the client has an increased risk for
what?
A. Ineffective breathing pattern
B. Risk for aspiration
C. Risk for infection
D. Risk for ineffective cerebral tissue perfusion
 Rationale: DIC affects cerebral, cardiopulmonary, and peripheral tissues with clotting that obstructs tissue perfusion. This can result
in damage to these tissues. Although risk for infection is a problem for this client following surgery, it is nt the most critical diagnosis.
Ineffective breathing pattern and risk for aspiration would not be problems initially. (NCLEX RN Questions and Answers Made
Incredibly Easy, p. 183)

37. Nurse Don is reviewing assessment data of clients who may be at risk for developing malignant lymphoma. Nurse Don determines
that the client at highest risk would be?
A. A 22-year old man with a history of infectious mononucleosis
B. A 25-year old man who smokes a pack of cigarettes a day
C. A 33-year-old man with a cousin with Hodgkin’s lymphoma
D. A 40-year-old woman with a history of HIV

Rationale: Malignant lymphoma has a peak incidence between ages 20 and 30 and after age 50. It’s more common in men than
women and is associated with a history of Epstein-Barr virus (which causes mononucleosis). There is also an increased incidence
of the disease among siblings. There is no reported association between malignant lymphoma and smoking or HIV infection.
(NCLEX RN Questions and Answers Made Incredibly Easy, p. 189)

38. A nurse is assessing a client newly diagnosed with stage I Hodgkin’s lymphoma. Which area of the body is most likely to be
involved?
A. Back
B. Chest
C. Groin
D. Neck

Rationale: At the time of diagnosis of stage I Hodgkin’s lymphoma, a painless cervical lesion is often present. The back, chest, groin
areas may be involved in later stages. (NCLEX RN Questions and Answers Made Incredibly Easy, p. 197)

39. A client diagnosed with acute lymphocytic leukemia is about to begin chemotherapy. The nurse recognizes that further teaching is
necessary when the client makes which statement?
A. “I’ll have treatments only once a month.”
B. “I’ll be getting high doses of chemotherapy.”
C. “I won’t get sick at this stage of the treatment.”
D. “The purpose of these treatments is to induce a remission.”

Rationale: The initial phase of chemotherapy is called the induction phase and is designed to put the client into remission by giving
high doses of the drugs; however, treatments will be closer together than once each month. Monthly treatments usually occur
during the maintenance phase of chemotherapy. The other options indicate that the client understands chemotherapy. (NCLEX RN
Questions and Answers Made Incredibly Easy, p. 198)

40. The nurse is providing information to a client diagnosed with systemic lupus erythematosus (SLE). The client asks the nurse if any
type of blood dyscrasia may develop. What is the best response by the nurse?
A. Dressler’s syndrome
B. Polycythemia
C. Essential thrombocytopenia
D. Von Willebrand’s disease

Rationale: Essential thrombocytopenia is linked to immunological disorders, such as SLE and HIV. Dressler’s syndrome is
pericarditis that occurs after a myocardial infarction and isn’t linked to SLE. Moderate to severe anemia is associated with SLE, not
polycythemia. The disorder known as von Willebrand’s disease is a type of hemophilia and isn’t linked to SLE. (NCLEX RN
Questions and Answers Made Incredibly Easy, p. 192)

ONCO

SITUATION 9 – Almost every cancer type has been shown to run in families. This may be due to genetics, shared environments, cultural
or lifestyle factors or chance alone. The following questions apply.

41. Using the TNM staging classification system, a tumor staged as T4N3M1 would mean:
A. No evidence of primary tumor, lymph node involvement, distant metastasis
B. Carcinoma in situ, regional lymph node involvement, metastasis to one site
C. Large tumor, lymph node involvement, distant metastasis
D. Medium – sized tumor, no lymph node involvement, distant metastasis
 Rationale: Staging determines the size of the tumor and the existence of metastasis. Several systems exist for classifying the
anatomic extent of disease. The TNM system is frequently used. In this system, T refers to the extent of the primary tumor, N refers
to lymph node involvement, and M refers to the extent of metastasis. (Brunner and Suddarth, Medical Surgical Nursing, p. 323.)

Primary tumor (T)

•TX: Main tumor cannot be measured.
•T0: Main tumor cannot be found.
•T1, T2, T3, T4: Refers to the size and/or extent of the main tumor. The higher the number after the T, the larger the tumor or the
more it has grown into nearby tissues.

Regional lymph nodes (N)

•NX: Cancer in nearby lymph nodes cannot be measured.
•N0: There is no cancer in nearby lymph nodes.
•N1, N2, N3: Refers to the number and location of lymph nodes that contain cancer. The higher the number after the N, the more
lymph nodes that contain cancer.

Distant metastasis (M)

•MX: Metastasis cannot be measured.
•M0: Cancer has not spread to other parts of the body.
•M1: Cancer has spread to other parts of the body.

42. The nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places the
highest priority on discussing which risk factor with this client?
A. Age older than 30 years
B. High fat and low fiber diet
C. Distant relative with colorectal cancer
D. Personal history of ulcerative colitis or GI polyps

Rationale: Common risk factors for colorectal cancer that cannot be changed include age older than 40, first degree relative with
colorectal cancer, and history of bowel problems such as ulcerative colitis or familial polyposis. Clients should be aware of
modifiable risk factors as part of general health maintenance and primary disease prevention. Modifiable risk factors are those that
can be reduced and include a high fat and low fiber diet. (Saunders)

43. The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct
the clients to perform the examination at which time?
A. At the onset of menstruation
B. Every month during ovulation
C. Weekly at the same time of day
D. 1 week after menstruation begins

Rationale: The breast self-examination should be performed monthly, 7 days after the onset of the menstrual period. Performing the
examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may later
the breast tissue.
(Saunders)

44. Mr. Cantoni is suspected to have testicular cancer. Which of the following tumor markers is expected to elevate in testicular cancer?
A. CEA and AFP
B. PSA and CEA
C. BRCA 1 and BRCA 1
D. AFP and beta HCG

Rationale: Human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) are tumor markers that may be elevated in patients
with testicular cancer. (Tumor markers are substances synthesized by the tumor cells and released into the circulation in abnormal
amounts.) Tumor marker levels in the blood are used for diagnosis, staging, and monitoring the response to treatment. Option A, B,
and C is for colon cancer, prostate cancer, and breast cancer respectively. (Brunner)

45. Evaluation of the effectiveness and toxic potential of promising new modalities for preventing, diagnosing, and treating cancer is
accomplished through clinical trials. Which phase of clinical trial establishes the effectiveness of new medications or procedures as
compared with conventional approaches?
A. Phase I
B. Phase II
C. Phase III
 D. Phase IV

Rationale:
 Phase I clinical trials determine optimal dosing, scheduling, and toxicity.
 Phase II trials determine effectiveness with specific tumor types and further define toxicities. Participants in these early trials
are most often those who have not responded to standard forms of treatment. Because phase I and II trials may be viewed as
last-chance efforts, patients and families are fully informed about the experimental nature of the trial therapies. Although it is
hoped that investigational therapy will effectively treat the disease, the purpose of early phase trials is to gather information
concerning maximal tolerated doses, adverse effects, and effects of the antineoplastic agents on tumor growth.
 Phase III clinical trials establish the effectiveness of new medications or procedures as compared with conventional
approaches. Nurses may assist in the recruitment, consent, and education processes for patients who participate. In many
cases, nurses are instrumental in monitoring adherence, assisting patients to adhere to the parameters of the trial, and
documenting data describing patients’ responses. The physical and emotional needs of patients in clinical trials are addressed
in much the same way as those of patients who receive standard forms of cancer treatment.
 Phase IV testing further investigates medications in terms of new uses, dosing schedule, and toxicities.

SITUATION 10 – Nurse Prince is an oncology nurse in a special training hospital which caters to a wide variety of cancer patients. He
received special trainings in caring for patients receiving cancer treatments.

46. A client with renal cancer is being treated preoperatively with radiation therapy. Nurse Prince evaluates that the client has an
understanding of proper care of the skin over the treatment site if the client states to:
A. Wash the ink marks off the skin
B. Avoid skin exposure to direct sunlight
C. Apply perfumed lotion to the affected skin
D. Wear tight clothing over the skin site to provide support

Rationale: The client undergoing radiation therapy should wash the site using mild soap and warm or cool water and pat the area
dry. No lotions, creams, alcohol, perfumes or deodorants should be placed on the skin over the treatment site. Lines or ink marks
that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from
temperature extremes, direct sunlight, and chlorinated water. The client should wear cotton clothing over the skin site and guard
against irritation from tight or rough clothing such as belts or bras. (Saunders)

47. A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. Nurse Prince interprets that the
client understands how to manage the urine as a biohazard of the client states to:
A. Void into a bedpan and then empty the urine into the toilet
B. Purchase extra bottles of scented disinfectant for daily bathroom cleansing
C. Have one bathroom strictly set aside for the client’s use for the next 8 weeks
D. Disinfect the toilet with household bleach after voiding for 6 hours after a treatment

Rationale: Intravesical instillation involves instilling a chemotherapeutic agent into the bladder via a urethral catheter. This method
of treatment provides a concentrated topical treatment with minimal systemic absorption. The client retains the medication for
approximately 2 hours. After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the
toilet after voiding with household bleach for 6 hours after a treatment. There is no value in using a bedpan for voiding. Scented
disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use. After intravesical
instillation with a chemotherapeutic agent to treat bladder cancer, the client is instructed to increase the fluid intake to flush the
bladder. (Saunders)

48. Nurse Prince is caring for a client with a diagnosis of metastatic breast carcinoma who is receiving tamoxifen citrate (Nolvadex) 10
mg orally twice daily. Which of the following would indicate to the nurse that the client is experiencing a side effect related to the
medication?
A. Hypertension
B. Vaginal bleeding
C. Diarrhea
D. Nose bleeds

Rationale: Tamoxifen is a nonsteroidal antiestrogen used as adjunctive treatment of breast cancer. It competes with estrogen
receptors in tumor cells for binding to target tissues (such as breast); reduces DNA synthesis and estrogen response.
SIDE EFFECTS:
CNS: confusion, depression, headache, weakness, fatigue, light-headedness
CV: chest pain, deep-vein thrombosis
EENT: blurred vision, ocular lesion, retinopathy, corneal opacity
GI: nausea, vomiting, abdominal cramps, anorexia
 GU: vaginal bleeding, discharge, or dryness; irregular menses; amenorrhea; oligomenorrhea; ovarian cyst;
pruritus vulvae; endometrial or uterine cancer
Hematologic: leukopenia, thrombocytopenia
Metabolic: hypercalcemia, fluid retention
Musculoskeletal: bone pain
Respiratory: cough, pulmonary embolism
Skin: skin changes, hair thinning or partial hair loss
Other: altered taste, weight loss, tumor flare, tumor pain, hot flashes, edema (McGraw Nursing Drug Handbook)

49. Upon reading the chart of a patient, Nurse John noted that the physician ordered a cell-cycle-specific chemotherapeutic agent.
Which of the following is included in this type of chemotherapeutic agent?
A. Nitrogen mustard
B. Doxorubicin (Doxil)
C. Methotrexate
D. Cyclophosphamide (Cytoxan)

Rationale: Methotrexate is an antimetabolites which belongs to cell-cycle specific (S phase) category. Nitrogen mustard is alkylating
agents (cell cycle non-specific); doxorubicin is an antitumor antibiotic (cell cycle non-specific); cyclophosphamide is an alkylating
agents (cell cycle non-specific). (Brunner)

50. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks Nurse Prince if he can
spend the night with his wife. The nurse should explain that:
A. Overnight stays by family members is against hospital policy.
B. There is no need for him to stay because staffing is adequate.
C. His wife will rest much better knowing that he is at home.
D. Visitation is limited to 30 minutes when the implant is in place.

Rationale: Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time
spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium.
Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address
the question; therefore, they are incorrect.

IMMUNO

SITUATION 11 – The nurse has been caring patient with autoimmune disorders and disorders that involve the immunologic system. The
following questions apply.

51. A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. The nurse
explains that the diagnostic criterion for acquired immunodeficiency syndrome (AIDS) has been met when the client:
A. Contracts HIV-specific antibodies
B. Develops an acute retroviral syndrome
C. Is capable of transmitting the virus to others
D. Has a CD4+ T lymphocyte level of less than 200 cells/uL.

Rationale: Three criteria must be met for an adult client to be diagnosed with AIDS. He must be HIV-positive (confirmed by Western
Blot test), have a CD4+ T-cell count below 200 cells/uL, and have one or more specific conditions that include acute infections with
HIV. (NCLEX RN Questions and Answers Made Incredibly Easy, p. 169)

52. The nurse determines that the initial blood test used to identify a response to human immunodeficiency virus (HIV) infection would
be::
A. Western blot
B. CD4+ T-cell count
C. Erythrocyte sedimentation rate
D. Enzyme-linked immunosorbent assay (ELISA)

Rationale: The ELISA is the first screening test for HIV. A WESTERN BLOT confirms a positive Elisa test. Other blood test that
support the diagnosis of HIV include CD4+ and CD8+ counts, complete blood counts, immunoglobulin levels, p24 antigen assay,
and quantitative ribonucleic acid assays.. (NCLEX RN Questions and Answers Made Incredibly Easy, p. 169)

53. A child is seen in the health care clinic, and initial testing for HIV is performed because of the child’s exposure to HIV infection.
Which home care instructions should the nurse provide to the parents of the child?
A. Avoid sharing toothbrushes
 B. Avoid all immunizations until the diagnosis is established
C. Wipe any blood spills with a rag and allow them to air dry
D. Wash your hands with half-strength bleach if they become in contact with the child’s blood

Rationale: Immunizations must be kept up to date. Blood spills are wiped up with a paper towel; the area is then washed with soap
and water, rinsed with bleach and water, and allowed to air dry. Hands are washed with soap and water if they come in contact with
blood. Parents are instructed that toothbrushes are not to be shared. HIV infects CD4 T cells. A gradual decrease in the count
occurs and this results in a progressive immunodeficiency. The risk for opportunistic infections is present. (Saunders)

54. A client with AIDS is receiving Retrovir (zidovudine). The client asked the nurse, “How does this drug work?” The nurse determines
that teaching was effective when the client makes which of the following statements?
A. “It kills the HIV virus.”
B. “It suppresses the HIV virus.”
C. “It won’t infect anyone else when I take this drug.”
D. “It’s the only drug for HIV I need to take.”

Rationale: Zidovudine is an antiviral drug that suppresses the replication of the HIV virus. It is most commonly used for HIV clients
in conjunction with other antiretroviral drugs. It also helps prevent maternal-fetal transmission of HIV. However, it is not a cure, it
doesn’t kill the HIV virus, and clients taking this medication remain infectious. (NCLEX RN Questions and Answers Made Incredibly
Easy, p. 172)

55. The nurse assesses the client with acquired immunodeficiency syndrome (AIDS) for early signs of Kaposi’s sarcoma. The nurse
observes for lesion(s) that are:
A. Unilateral, raised, and bluish-purple in color
B. Unilateral, red, raised, and resembling a blister
C. Bilateral, flat, and brownish and scaly in appearance
D. Bilateral, flat, and pink, turning to dark violet or black in color

Rationale: Kaposi’s sarcoma generally starts with an area that is flat and pink that changes to a dark violet or black color. The
lesions are usually present bilaterally. They may appear in many areas of the body and are treated with radiation, chemotherapy,
and cryotherapy. (Saunders)

SITUATION 12 – Arthritis is a common condition that causes pain and inflammation in a joint. The symptoms of arthritis will vary
depending on the type of arthritis. The following questions apply.

56. Mr. Canor is complaining pain on his right knee especially during movement. The pain in osteoarthritis is due to:
A. Uric acid deposits
B. Autoimmune reaction in the synovium
C. An inflamed synovium and irritation of nerve endings by patient’s own antibodies
D. Muscle spasm, tendinitis and inflamed synovium

Rationale: The primary clinical manifestations of OA are pain, stiffness, and functional impairment. The pain is due to an inflamed
synovium, stretching of the joint capsule or ligaments, irritation of nerve endings in the periosteum over osteophytes, trabecular
microfracture, intraosseous hypertension, bursitis, tendinitis, and muscle spasm. Option A refers to gouty arthritis; option B and C
refers to rheumatoid arthritis. (Brunner)

57. The nurse is discussing the importance of an exercise program for pain control with a client diagnosed with OA. Which information
should the nurse include in the teaching plan?
1. Wear supportive walking shoes with white socks when walking
2. Carry a complex carbohydrate to eat while exercising
3. Alternate walking briskly and jogging when exercising
4. Be sure to ambulate at least 20-30 minutes everyday
5. Instruct to use a walker when ambulating if unsteady or weak

A. 1, 4, 5
B. 1, 2, 5
C. 1, 3, 5
D. 1, 3, 4

58. A client is admitted with a possible diagnosis of rheumatoid arthritis (RA). Which of the following screening tests should the nurse
expect to be ordered?
A. Complete blood count
 B. Erythrocyte sedimentation rate (ESR)
C. Antinuclear antibody (ANA) titer
D. Rheumatoid factor (RF)

Rationale: ANA is commonly used as a screening tool rather than a diagnostic tool for RA because many people without RA can
have elevated titers. CBC, ESR, and RF are all used as diagnostic tools and to monitor progress of the disease or response to
therapy. (Saunders)

59. Mr. Antonio complains of severe pain and edema in the right foot. The physician diagnosed him of having gouty arthritis. When
caring for Mr. Antonio, which of the following should receive the highest priority when developing a plan of care?
A. Apply hot compress to the affected joints
B. Ensure an intake of at least 3000 ml of fluid per day
C. Emphasize the importance of maintaining good posture to prevent deformities
D. Prepare to administer salicylates to minimize the inflammatory reaction

60. A nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). The nurse explains to the client that a common
but life-threatening complication of SLE is:
A. Arthritis
B. Nephritis
C. Pericarditis
D. Pleural effusion

Rationale: About 50% of the clients with SLE have some type of nephritis, and kidney failure is the most common cause of death for
clients with SLE. Pericarditis is the most common cardiovascular manifestations of SLE, but it isn’t usually life-threatening. Arthritis
is very common (95%), as are pleural effusions (50%), but neither is life-threatening. (NCLEX RN Questions and Answers Made
Incredibly Easy, p. 194)

GI/HEPATO

SITUATION 13 – An individual’s nutritional status depends not only on the type and amount of intake but also on the functioning of the
gastric and intestinal portions of the gastrointestinal (GI) system. A nurse is assigned in the Medical-Surgical Unit and is taking care of
patients with gastrointestinal conditions. The following questions apply.

61. The nurse is reviewing the record of a client with a diagnosis of Crohn’s disease. Which stool characteristic should the nurse expect
to note documented in the client’s record?
A. Diarrhea
B. Chronic constipation
C. Constipation alternating with diarrhea
D. Stool constantly oozing from the rectum

Rationale: Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Overtime, the
diarrhea episodes increase in frequency, duration and severity. (Saunders)

62. The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the
nurse include on this list?
a. Coffee
b. Chocolate
c. Peppermint
d. Nonfat milk
e. Fried chicken
f. Scrambled eggs

A. 1, 2, & 3
B. 1, 2, & 4
C. 1, 2, 3, & 5
D. 1, 2, 5, & 6

Rationale: Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and
exacerbate the symptoms of GERD and therefore should be avoided. Aggravating substances include chocolate, coffee, fried or
fatty foods, peppermint, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect. (Saunders)
63. Clark, a client admitted 4 hours ago presents with low grade fever, nausea, vomiting and vague pain in the abdominal region. The
physician noted upon palpation of the McBurney’s point localized and rebound tenderness. Which of the following demonstrates this
observation?
A. Rigid board-like abdomen
B. Pain aggravated by coughing
C. Pain increased with internal rotation of the right hip
D. Relief of pain with direct palpation and pain on release of pressure

Rationale: In assessing for appendicitis, local tenderness is elicited at McBurney’s point when pressure is applied. Rebound
tenderness (ie, production or intensification of pain when pressure is released) may be present. Option A, B, and C are not related
to rebound tenderness. (Brunner)

64. A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which
most frequent complication of this type of surgery?
A. Folate deficiency
B. Malabsorption of fat
C. Intestinal obstruction
D. Fluid and electrolyte imbalance

Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant
monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client
can tolerate a diet orally. Intestinal obstruction is less frequent complication. Fat malabsorption and folate deficiency are
complications that could occur later in the postoperative period. (Saunders)

65. A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client’s pain. What
type of pain is consistent with this diagnosis?
A. Burning and aching, located in the left lower quadrant and radiating to the hip.
B. Severe and unrelenting, located in the epigastric area and radiating to the back
C. Burning and aching, located in the epigastric area and radiating to the umbilicus
D. Severe and unrelenting, located in the left lower quadrant and radiating to the groin

Rationale: Alcohol abuse is most commonly associated with the development of pancreatitis. The pain associated with acute
pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are
incorrect. (Saunders)

SITUATION 14 – Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be
suggestive. Patients with gastric ulcers are at risk of developing gastric malignancy. Nurse Justin is assigned to care for Vanessa who
has been recently diagnosed with peptic ulcer disease after several assessments.

66. Nurse Justin is providing instructions to a client with peptic ulcer disease about symptom management. Client learning is evident if
Vanessa makes which of the following statements?
A. “I should eat a snack at bedtime.”
B. “I can take aspirin to relieve gastric pain.”
C. “It is important that I eat slowly and chew my food thoroughly.”
D. “I should take my antacid and famotidine (Pepcid) at the same time.”

Rationale: Eating slowly and chewing thoroughly helps to prevent overdistention and reflux. Bedtime snacks are avoided because
they can promote night time acid secretion. Acetaminophen is administered for routine pain relief during treatment. All NSAIDS and
aspirin are avoided. Antacids will interfere with the absorption of the famotidine (pepcid), a histamine 2 (H2) receptor antagonist, so
they should not be taken at the same time. (Saunders)

67. Nurse Justin is monitoring Vanessa with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate
perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, board-like abdomen

Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning
in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur.
Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. (Saunders)
68. Vanessa is undergoing an extensive diagnostic workup for a suspected GI problem. Nurse Justin discovers that the Vanessa has a
family history of ulcer disease. Which blood type also is a risk factor for duodenal ulcer?
A. Type A
B. Type B
C. Type AB
D. Type O

Rationale: Familial tendency may be a significant predisposing factor. A further genetic link is noted in the finding that people with
blood type O are more susceptible to peptic ulcers than are those with blood type A, B, or AB. (Brunner)

69. Nurse Justin is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is
currently active, the nurse should assess the client for which symptom(s) of duodenal ulcer?
A. Weight loss
B. Nausea and vomiting
C. Pain relieved by food intake
D. Pain radiating down the right arm

Rationale: A frequent symptom of ulcer is pain that is relieved by food intake. These clients generally describe the pain as burning,
heavy, sharp, or “hungry” pain that often localizes in the mid-epigastric area. The client with duodenal ulcer is usually does not
experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer. (Saunders)

70. Billroth II procedure is done to another client, named Anjo, with gastric ulcer. Anjo is now resuming a diet after a Billroth II
procedure. To minimize complications from eating, the nurse teaches the client to do which of the following?
1. Lying down after eating
2. Eating a diet high in protein
3. Drinking liquids with meals
4. Eating six small meals per day
5. Eating concentrated sweets between meals only

A. 1, 2 and 3
B. 1, 2 and 4
C. 2, 3 and 4
D. 2, 3 and 5

Rationale: In Billroth II procedure, part of stomach is anastomosed to the jejunum. The client who has had a Billroth II procedure is
at risk for dumping syndrome. The client should lie down after eating and avoid drinking liquids with meals to prevent this syndrome.
The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are
encouraged, and the client should avoid concentrated sweets. (Saunders)

SITUATION 15 – An understanding of the structure and function of the biliary tract and pancreas is essential, along with an
understanding of the close link of biliary tract disorders with liver disease. Nurse Paul has been assigned to care for clients with various
cases involving the hepatobiliary tract.

71. A patient needs to undergo gallbladder ultrasound. What instructions would Nurse Paul give to the patient?
A. Inform the patient to empty his bladder before the procedure.
B. Ask the patient to drink a full glass of water
C. Inform the patient not eat or drink anything 4 hours prior to procedure
D. No special preparations needed

72. Nurse Paul is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the
location of the pain?
A. Right lower quadrant, radiating to the back
B. Right lower quadrant, radiating to the umbilicus
C. Right upper quadrant, radiating to the left scapula and shoulder
D. Right upper quadrant, radiating to the right scapula and shoulder

Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the
right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect.
(Saunders)

73. Nurse Paul is assessing a client 24 hours following cholecystectomy. He notes that the T-tube has drained 750ml of green-brown
drainage since the surgery. Which nursing intervention is most appropriate?
 A. Clamp the T-tube
B. Irrigate the T-Tube
C. Document the findings
D. Notify the physician

Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The
drainage is measured as output. The amount of expected drainage will range from 500 to 1000 ml/day. The nurse would document
the output. (Saunders)

74. Nurse Paul assists the doctor with a liver biopsy performed at the bedside. Which position does the nurse place the client in after
the biopsy?
A. Supine with the head elevated on one pillow
B. Semi-Fowlers\’s with two pillows under the legs
C. Left side-lying with a small pillow under the puncture site
D. Right side-lying with a folded towel under the puncture site

Rationale: The liver is located on the right side of the body after a liver biopsy, the nurse positions the client on the right side with a
small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the chest wall at the
biopsy site. (Saunders)

75. A client has developed hepatitis after eating contaminated oysters. Nurse Paul assesses the client for which expected assessment
finding?
A. Malaise
B. Dark stools
C. Weight gain
D. Left upper quadrant discomfort

Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss.
Fatigue and malaise are common. Stools will be light-or-clay colored if conjugated bilirubin is unable to flow out of the liver because
of inflammation or obstruction of the bile ducts. (Saunders)

MUSCULO

SITUATION 16 – Certain musculoskeletal system problems arise due to accidents involving human errors. Nurse Laboy is assigned to
the Ortho Ward.

76. A patient is to be assessed for scoliosis. How would Nurse Laboy position the patient during assessing the scoliosis’ degree of
curvature?
A. In sitting position, feet together and bend
B. In standing position, feet apart and bend
C. In standing position, feet together and bend
D. In standing position only

Rationale: Shoulder and hip symmetry, as well as the line of the vertebral column, are inspected with the patient erect and with the
patient bending forward (flexion). (Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not level, an
asymmetric waistline, and a prominent scapula, accentuated by bending forward.) (Brunner)

77. Nurse Laboy is now performing screening examinations for scoliosis. Nurse Laboy assesses for which signs of scoliosis:
1. Chest asymmetry
2. Equal waist angles
3. Unequal rib heights
4. Equal rib prominences
5. Equal shoulder heights
6. Lateral deviation and rotation of each vertebrae

A. 1, 3 and 6
B. 2, 3 and 4
C. 3, 5 and 6
D. 4, 5 and 6

Rationale: Scoliosis is a lateral curvature of the spine. To ensure early detection and treatment, children ages 9 through 15 years
should be screened for scoliosis; those at greatest risk are girls from 10 years of age through adolescence. The child should be
 unclothed or wearing only underpants so that the chest, back and hips can be clearly seen. The child should stand with her or his
weight equally on both feet, legs straight and arms hanging loosely at the sides. The nurse then observes for the signs of scoliosis.
These signs include non-painful lateral curvature of the spine, a curve with one turn (C curve) or two compensating curves (S
curves), lateral deviation and rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences
and chest asymmetry and unequal rib heights. If scoliosis is suspected, radiographs will be done to confirm the diagnosis.
(Saunders)

78. Nurse Laboy has taught a client with a below-the-knee amputation about monitoring for and preventing complications related to
prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client stated that he
should:
A. Wear a clean nylon sock over the residual limb every day.
B. Use a mirror to inspect all areas of the residual limb each day
C. Toughen the skin of the residual limb by rubbing it with alcohol
D. Prevent cracking of the skin of the residual limb by applying lotion daily

Rationale: The client should inspect all surfaces of the residual limb daily for irritation, blisters and breakdown. The client should
wear a clean woolen (not nylon) sock each day. The residual limb is cleansed daily with a gentle soap and water and dried
carefully. Alcohol is avoided, because it could cause drying or cracking of the skin. Oils and creams are also avoided, because they
are too softening to the skin for safe prosthesis use. Encourage the client who underwent an amputation to verbalize feelings
regarding the loss of the body part and assist the client to identify coping mechanisms to deal with the loss. (Saunders)

79. Nurse Laboy is performing an admission assessment of a new client with osteoarthritis. Which of the following clinical
manifestations would he expect to find?
A. Joint pain after exercise relieved by rest
B. Symmetrical swelling of the joints of both hands
C. Morning stiffness lasting longer than 30 minutes
D. Fever

Rationale: The most common symptom of osteoarthritis is joint pain after exercise or weight-bearing, usually relieved by rest. The other
options are all symptoms of rheumatoid arthritis. (NCLEX-RN Questions and Answers Made Incredibly Easy)

80. Allopurinol (Zyloprim) has been prescribed for a client to treat gouty arthritis. Nurse Laboy teaches the client to anticipate which of
the following prescriptions if an acute attack occurs?
A. Doubling the dose of the allopurinol
B. Stopping the allopurinol an taking acetylsalicylic acid (aspirin)
C. Stopping the allopurinol and taking NSAID
D. Adding colchicine or NSAID to the treatment plan

Rationale: Allopurinol helps prevent an attack of gouty arthritis, but it does not relieve the pain. Therefore, another medication such
as colchicine or NSAID must be added if an acute attack occurs. Because acute attacks may occur more frequently early during
the course of therapy with allopurinol, some physicians recommend taking the two products concurrently during the first 3 to 6
months. (Saunders)

SITUATION 17 – Prince, a 27 year old patient was rushed in Philippine General Hospital because of a vehicular accident, he had a
fracture on his left leg and some bruises on his both arms. Nurse Vanessa further assessed the patient. The following questions apply.

81. Nurse Vanessa knows that which of the following signs and symptoms when manifested by Prince indicates possible development
of fat embolus?
A. Sudden headache
B. Muscle spasm in the left thigh
C. Numbness in the left leg
D. Dyspnea

Rationale: A fat embolism usually presents as an acute respiratory distress. Symptoms include chest pain, cyanosis, dyspnea,
tachypnea and apprehension. A sudden headache is not a symptom of a fat embolism. Muscle spasms in the left thigh are a
neuromuscular response of the local muscle around the femoral fracture. Numbness would be a neurovascular response. (Saunders Q
& A Review for the NCLEX-RN Examination, p. 468)

82. Prince is now in traction. Nurse Vanessa ensures a safe environment for the client by::
A. Monitoring the weights to be sure that they are resting on a firm surface
B. Checking the weights to be sure that they are off the floor
 C. Making sure that the knots are at the pulleys
D. Making sure that the head of the bed is kept at 90-dgree angle

Rationale: To achieve proper traction, weights need to be free-hanging with knots kept away from the pulleys. Weights are not to be kept
resting on a firm surface. The head of the bed is usually kept low to provide counteraction. (Saunders Q & A Review for the NCLEX-RN
Examination, p. 357)

83. Another patient is in the emergency department with a suspected fracture of the right hip. Which assessment findings would Nurse
Vanessa expect?
1. The right leg is longer than the left leg
2. The right leg is shorter than the left leg
3. The right leg is abducted
4. The right leg is adducted
5. The right leg is externally rotated
6. The right leg is internally rotated

A. 1, 4, 6
B. 2, 3, 5
C. 1, 3, 6
D. 2, 4, 5

Rationale: In hip fracture, the affected leg is shorter, adducted, and externally rotated. (. (NCLEX-RN Questions and Answers Made
Incredibly Easy, p. 488)

84. A client with hip fracture asks Nurse Vanessa why Buck’s (extension) traction is being applied before surgery. Nurse Vanessa
provides a response based on which purpose of Buck’s (extension) traction?
A. Allow bony healing to begin before surgery
B. Provides rigid immobilization of the fracture site
C. Lengthens the fractured leg to prevent severing of blood vessels
D. Provides comfort by reducing muscle spasms and provides fracture immobilization

Rationale: Buck’s (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery.
Traction reduces muscle spasms and helps immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid
immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance.

85. A client is diagnosed with osteomyelitis. He is being treated with IV antibiotics. The treatment has not been effective. Which
intervention would be the most appropriate for this client?
A. Bone grafts
B. Hyperbaric oxygen therapy
C. Amputation of the extremity
D. Debridement of necrotic tissue

Rationale: The tissues may need to be debrided to eliminate necrotic tissue and allow new tissue to form. A bone graft would be done
after debridement. Hyperbaric oxygen therapy is a new treatment modality that has been used in the successful treatment of
osteomyelitis, but it is not universally available. Amputation is not indicated in the treatment of cute osteomyelitis. . (NCLEX-RN
Questions and Answers Made Incredibly Easy, p. 472)

NEURO

SITUATION 18 – Nurse Miho has been a Neuro Ward nurse for the past 2 years. One of her initial activities is to gather data about her
patients. The following questions apply to patients with neurological disorders.

86. You are a nurse assigned to care for a client who is on intracranial pressure (ICP) monitoring. As a knowledgeable nurse, you
should watch out for which major complication of ICP monitoring?
A. Apnea
B. Coma
C. High blood pressure
D. Infection

Rationale: The purposes of ICP monitoring are to identify increased pressure early in its course (before cerebral damage occurs), to
quantify the degree of elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to
evaluate the effectiveness of treatment. When a ventriculostomy or ventricular catheter monitoring device is used for monitoring
 ICP, a fine-bore catheter is inserted into a lateral ventricle, usually in the nondominant hemisphere of the brain. Complications
include ventricular infection, meningitis, ventricular collapse, occlusion of the catheter by brain tissue or blood, and problems with
the monitoring system. (Brunner)

87. A client who suffered from head injury is at risk of increased intracranial pressure. Which cardiovascular findings are late indicators
of increased ICP?
A. Widening pulse pressure and bradycardia
B. Rising blood pressure and tachycardia
C. Hypotension and tachycardia
D. Hypertension and narrowing pulse pressure

Rationale: Clinical phenomenon known as the Cushing’s response (or Cushing’s reflex) is seen when cerebral blood flow decreases
significantly. When ischemic, the vasomotor center triggers a rise in arterial pressure in an effort to overcome the increased ICP. A
sympathetically mediated response causes a rise in the systolic blood pressure with a widening of the pulse pressure and cardiac
slowing. This response, which is mediated by the sympathetic nervous system, is seen clinically as a rise in systolic blood pressure,
widening of the pulse pressure, and reflex slowing of the heart rate. This is a sign requiring immediate intervention; however,
perfusion may be recoverable if treated rapidly. (Brunner)

88. A client has a neurologic deficit involving the limbic system. Which assessment finding is specific to this type of deficit?
A. Is disoriented to person, place, time
B. Affect is flat, with periods of emotional lability
C. Cannot recall what was eaten for breakfast today
D. Demonstrates inability to add and subtract; does not know who is the president of the Philippines

Rationale: The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events
relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent
events is controlled by hippocampus. (Saunders)

89. A client has experienced a brain stem infarction. It is most important for the nurse to assess the client for:
A. Aphasia
B. Bradypnea
C. Contralateral hemiplegia
D. Numbness and tingling to the face or arm

Rationale: The brain stem contains the medulla and the vital cardiac, vasomotor, and respiratory centers. A brain stem infarction
leads to vital sign changes such as bradypnea. Contralateral hemiplegia and numbness or tingling in the face or arm may occur,
depending on the level of injury. Aphasia is associated with lobar strokes in the cerebral hemispheres. (NCLEX RN Questions and
Answers Made Incredibly Easy)

90. The nurse is caring for a client with homonymous hemianopsia. The most important information for the nurse to teach the client is:
A. Scan the environment on the affected side
B. Use memory aids such as pictures
C. Plan for adequate rest
D. Make simple, nonrisky decisions

Rationale: Scanning the environment can help a client with visual field deficit (also known as a homonymous hemianopsia)
overcome this loss in visual perception and prevent injury. Clients with other types of perceptual or memory loss may benefit from
answers B to D, but these interventions are not specific for a visual field loss. (NCLEX RN Questions and Answers Made Incredibly
Easy)

SITUATION 19 – Management of certain neurological disorders involves both aggressive and conservative treatment. Nursing
intervention focuses on rehabilitation and prevention of recurrence of the problems. The following questions apply.

91. A nurse receives a telephone call from the emergency department and is told that child with a diagnosis of tonic-clonic seizures will
be admitted to the pediatric unit. The nurse prepares for the admission of the child and instructs the nursing assistant to place which
items at the bedside?
A. A tracheostomy set and oxygen
B. Suction apparatus and an airway
C. An endotracheal tube and an airway
D. An emergency cart and laryngoscope
 Rationale: Tonic-clonic seizures cause tightening of all body muscles followed by tremors. Obstructed airway and increased oral
secretions are the major complications during and after a seizure. Suction is helpful to prevent choking and cyanosis. Options A and
C are incorrect because inserting an endotracheal tube or a tracheostomy is not done. It is not necessary to have an emergency
cart (which contains a laryngoscope) at the bedside, but a cart should be available in the treatment room or on the nursing unit.
(Saunders)

92. Luminal is an anticonvulsant drug that is given once a day. What category is this?
A. Fast Acting
B. Intermediate Acting
C. Long Acting
D. Very Long Acting

Rationale: Phenobarbital (Luminal) is a long-acting anticonvulsant drug used in the treatment of seizure. (Brunner)

93. A client who is receiving phenytoin (Dilantin) to control a seizure disorder questions the nurse regarding this medication after
discharge. The nurse’s best response is “This medication:
A. Will probably be continued for life.”
B. Prevents the occurrence of seizures.”
C. Needs to be taken during periods of emotional stress.”
D. Can usually be stopped after a year’s absence of seizures.”

Rationale: Medications for seizure will probably be continued for life in order to control seizures, The medication may need to be
adjusted because of concurrent illness, weight changes, or increases in stress. Sudden withdrawal of these medications can cause
seizures to occur with greater frequency or can precipitate the development of status epilepticus. (Brunner)

94. Bed rest is ordered after a client’s brain attack results in right hemiplegia. Which exercises should the nurse incorporate into the
client’s plan of care 24 hours after the brain attack?
A. Passive range-of-motion exercises
B. Active exercises of the extremities
C. Light weight-lifting exercises of the right side
D. Isotonic exercises that will capitalize on returning muscle function

Rationale: Hemiplegia is paralysis of one side of the body due to a lesion of the opposite side of the brain. This motor loss results to
inability to perform exercise on the affected side by himself. Therefore, passive ROM is appropriate for the patient with hemiplegia.

95. The nurse is caring for a client who had a stroke and now has residual dysphagia. What is the most appropriate diet for this client?
A. Clear liquid
B. Full liquid
C. Mechanical soft
D. Thickened liquid

Rationale: Thickened liquids are easiest to form into a bolus and swallow. Clear and full liquids are amorphous and can’t easily form
a bolus. A mechanical soft diet may be too hard to chew and too dry to swallow when dysphagia is present. (NCLEX RN Questions
and Answers Made Incredibly Easy)

SITUATION 20 – Autoimmune nervous system disorders include multiple sclerosis, myasthenia gravis, and Guillain-Barré syndrome.
Nurse Jeremy reviews the important considerations for clients with these conditions. The following questions apply.

96. Patient Maramba is diagnosed with Parkinson’s disease. Which symptom occurs initially in Parkinson’s disease?
A. Akinesia
B. Aspiration of food
C. Dementia
D. Pill rolling movements of the hand

Rationale: Early symptoms of Parkinson’s disease include coarse resting tremors of the fingers and thumb. Akinesia and aspiration
are late signs of Parkinson’s disease Dementia occurs only in only 20% of clients with Parkinson’s disease (NCLEX RN Questions
and Answers Made Incredibly Easy)

97. A 20-year old client is diagnosed with Guillain-Barré syndrome. Which of the following statements is NOT true about this condition?
A. Guillain-Barré is the result of a cell-mediated immune attack.
B. The patient with this condition presents with symmetric weakness, diminished reflexes, and upward progression of motor
weakness.
 C. Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function and adequate oxygenation.
D. Guillain-Barré is an immune-mediated progressive demyelinating disease of the CNS.

Rationale: Guillain-Barré is an immune-mediated progressive demyelinating disease of the PNS, not CNS, causing symmetric
weakness, diminished reflexes, and upward progression of motor weakness. Other options are correct statement about the disease.
(Brunner)

98. A client is newly diagnosed with myasthenia gravis. The nurse is teaching the client about the cause of this disease. The nurse
determines that teaching has been effective when the client states:
A. A postviral illness characterized by ascending paralysis
B. Loss of myelin sheath surrounding peripheral nerves
C. Inability of basal ganglia to produce sufficient dopamine
D. Destruction of acetylcholine receptors causing muscle weakness

Rationale: Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of
weakness of the voluntary muscles. Women tend to develop the disease at an earlier age (20 to 40 years of age) compared to men
(60 to 70 years of age), and women are affected more frequently. In myasthenia gravis autoantibodies directed at the acetylcholine
receptor sites impair transmission of impulses across the myoneural junction. Therefore, fewer receptors are available for
stimulation, resulting in voluntary muscle weakness that escalates with continued activity. (Brunner)

99. A client with multiple sclerosis (MS) is started on 20mg of glatiramer (Copaxone) subcutaneously daily. Immediately after the
injection, the client experiences flushing and chest pain. What is the most appropriate nursing intervention?
A. Call a code
B. Call the physician to inform him of the client’s adverse reaction
C. Administer oxygen to relieve chest pain
D. Monitor the client to see if the symptoms quickly dissipate

Rationale: Copaxone helps to decrease the number of relapses in the MS client. Flushing, chest pain, palpitations, anxiety,
shortness of breath, and itching occur in some clients following administration of the medication. They typically are transient and
self-limiting and don’t need specific treatment (NCLEX RN Questions and Answers Made Incredibly Easy, p. 354)

100. The nurse is planning care for a client with a T3 spinal cord injury. The nurse includes which intervention in the plan to prevent
autonomic dysreflexia (hyperreflexia)?
A. Administer dexamethasone (Decadron) as per the physician’s prescription
B. Assist the client to develop a daily bowel routine to prevent constipation
C. Teach the client that this condition is relatively minor with few symptoms
D. Assess vital signs and observe for hypotension, tachycardia, and tachypnea

Rationale: Autonomic dysreflexia is a potentially life-threatening condition and may be triggered by bladder distention, bowel
distention, visceral distention, or stimulation of pain receptors in the skin. A daily bowel program eliminates this trigger. A client with
autonomic dysreflexia would be hypertensive and bradycardic. Removal of the stimuli results in prompt resolution of the signs and
symptoms. Option A is unrelated to this specific condition. (Saunders)

ENDO

SITUATION 21 – Disorders of the endocrine system are common and have the potential to affect the function of every organ system in
the body. Nurse Paul reviews the special consideration for clients with endocrine problems. The following questions apply.

101. The nurse is assessing a newly admitted client who is diagnosed with hypocalcemia. In order to assess the thyroid gland properly,
which of the following techniques would the nurse use?
A. Have the client flex his neck onto his chest and cough while the nurse palpates the anterior neck with her fingertips
B. Place hands around the client’s neck, with the thumbs in the front of the neck, and gently massage the anterior neck
C. Ask the client to slightly flex his neck forward and toward the side being examined and then to swallow
D. Have the client hyperextend his neck and take slow, deep inhalations while the nurse palpates the neck with her fingertips

Rationale: This approach is the correct method for palpating the thyroid gland. This allows relaxation of the sternocleidomastoid
muscle. Having the client flex his neck onto his chest wouldn’t allow for palpation. Massaging the area or checking during inhalation
doesn’t allow for the movement of tissue that swallowing provides. (NCLEX-RN Questions and Answers Made Incredibly Easy, p.
569)

102. A client is admitted with a diagnosis of hyperparathyroidism. The nurse anticipates the client to present with which of the following?
A. Exophthalmos
 B. Renal calculi
C. Weight gain
D. Weight loss

Rationale: Hyperparathyroidism is overproduction of parathyroid hormone, characterized by elevated serum calcium, none
calcification, or renal calculi. Exophthalmos and weight loss are signs of hyperthyroidism and weight gain is a sign of
hypothyroidism. (NCLEX RN Questions and Answers Made Incredibly Easy, p. 595)

103. A 39-year-old client complains of muscle weakness, anorexia, and darkening of his skin. The nurse reviews his laboratory data and
notes findings of low serum sodium and high serum potassium levels. The nurse recognizes that these signs and symptoms are
associated with which condition?
A. Addison’s disease
B. Cushing’s disease
C. Diabetes insipidus
D. Thyrotoxic crisis

Rationale: The clinical picture of Addison’s disease includes muscle weakness, anorexia, darkening of the skin’s pigmentation, low
sodium level, and high potassium level. Cushing’s syndrome presents with obesity, “buffalo hump”, “moon face”, and thin
extremities. Symptoms of diabetes insipidus include excretion of large volumes of dilute urine, leading to hypernatremia and
dehydration. Thyrotoxic crisis can occur with severe hyperthyroidism. (NCLEX RN Questions and Answers Made Incredibly Easy,
p. 575)

104. The nurse is caring for a postoperative client who has undergone removal of the pituitary gland and tumor (hypophysectomy). The
nurse is aware that the client may be at risk for:
a. Hypernatremia and concentrated urine
b. Dilute urine with a low specific gravity
c. Hyponatremia and concentrated urine
d. Dilute urine with a high specific gravity

Rationale: DI results from lack of antidiuretic hormone (ADH). This causes the kidneys to excrete a very dilute urine with a low
specific gravity. Sodium is high in clients with DI due to hemoconcentration. Very concentrated urine is a sign of SIADH. (NCLEX
RN Questions and Answers Made Incredibly Easy)

105. The nurse is caring for a client with pheochromocytoma and is scheduled for surgery to remove the left adrenal gland. The nurse is
aware that the main manifestation of this disease process is which of the following?
A. Hypertension
B. Renal failure
C. Hyponatremia
D. Heart failure

Rationale: A pheochromocytoma is usually a benign tumor of the adrenal medulla that secretes epinephrine and norepinephrine,
resulting in hypertension and paroxysmal tachycardia The other conditions are not directly associated with pheochromocytoma. (NCLEX
RN Questions and Answers Made Incredibly Easy, p. 607)

SITUATION 22 – Mr. Mata who is complaining of heat intolerance is admitted to Exopthalmia de Hospital. Series of examinations were
done to the client and it was found out that he has hyperthyroidism. The following questions apply.

106. What is the first line of drug used in hyperthyroidism?

A. Beta Blockers
B. Levothyroxine
C. Methimazole
D. PTU (Propylthiouracil)

Rationale: PTU is the first line of drug used in hyperthyroidism. The alternative drug is Methimazole (Tapazole). Because
antithyroid medications do not interfere with release or activity of previously formed thyroid hormones, it may take several weeks
for relief of symptoms. Beta-adrenergic blocking agents are important in controlling the sympathetic nervous system effects of
hyperthyroidism. For example, propranolol (Inderal) is used to control nervousness, tachycardia, tremor, anxiety, and heat
intolerance. At this time the maintenance dose is established, followed by a gradual withdrawal of the medication over the next
several months. Levothyroxine is the drug of choice for hypothyroidism. (Brunner)

107. Mr. Mata had undergone thyroidectomy. As the nurse, what should you prepare and keep at the bedside?
 A. Ambubag
B. Nasogastric tube
C. Oxygen set
D. Tracheostomy set

Rationale: After thyroidectomy, difficulty in respiration occurs as a result of edema of the glottis, hematoma formation, or injury to
the recurrent laryngeal nerve. This complication requires that an airway be inserted. Therefore, a tracheostomy set is kept at the
bedside at all times, and the surgeon is summoned at the first indication of respiratory distress. If the respiratory distress is due to
hematoma, surgical evacuation is required. (Brunner)

108. After thyroidectomy, Mr. Mata developed thyroid storm. Which classic signs and symptoms associated with thyroid storm indicate
the priority need for immediate nursing intervention?
A. Polyuria, nausea and severe headaches
B. Hypotension, translucent skin and obesity
C. Fever, tachycardia and systolic hypertension
D. Profuse diaphoresis, flushing and constipation

Rationale: The excessive amounts of thyroid hormone cause a rapid increased in the metabolic rate, thereby causing the classic
signs and symptoms of thyroid storm such as fever, tachycardia and hypertension. When these signs present themselves, the
nurse must take quick action to prevent deterioration of the client’s health because death can ensure. Priority interventions include
maintaining a patent airway and stabilizing the hemodynamic status. Maintaining a patent airway and monitoring vital signs closely
are priority interventions for the client with thyroid storm. (Saunders)

109. Another patient is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which of
findings?
1. Weight loss
2. Bradycardia
3. Hypotension
4. Dry, scaly skin
5. Heat intolerance
6. Decreased body temperature

A. All except 1 and 2

B. All except 1 and 5
C. All except 3 and 4
D. All except 4 and 6

Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some
of these manifestations are cool, dry, scaly skin; dry coarse, brittle hair; decreased hair growth; bradycardia; hypotension;
decreased body temperature; cold intolerance; slowing of intellectual functioning; lethargy; weight gain and constipation. (Saunders)

110. As a knowledgeable nurse, you know that thyroid medications such as Levothyroxine is given, EXCEPT:
A. Before breakfast
B. With meals
C. 1 hour before meals
D. 3-4 hours after meals

Rationale: Synthetic levothyroxine (Synthroid or Levothroid) is the preferred preparation for treating hypothyroidism and
suppressing nontoxic goiters.

SITUATION 23 – Mrs. Cris was admitted at the hospital with a diagnosis of type 2 Diabetes Mellitus. Nurse Fritz was the one assigned to
care for him. The following questions apply.

111. Why is glycosylated hemoglobin blood test (A1C) done in addition to the daily capillary blood glucose tests?
A. It provides hemoglobin level for the past 3 to 4 months in addition to blood glucose level
B. It is used to assess long-term glycemic control
C. It provides information about a red blood cell’s life span
D. It provides information about serum protein and albumin

Rationale: The glycosylate hemoglobin is a good indicator of the average blood glucose level during the previous 120 days, which is
the life span of red blood cells. It is used to assess long-term glycemic control. It does not provide a hemoglobin or serum blood
 glucose level. It does not provide information about serum protein or albumin. (NCLEX RN Questions and Answers Made Incredibly
Easy, p. 565)

112. Mrs. Cris who has type 2 diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic
hyperosmolar nonketotic syndrome (HHNS). Nurse Fritz develops a discharge teaching plan for the client and identifies which of the
following as a priority?
A. Exercise routines ‘
B. Controlling dietary intake
C. Keeping follow-up appointments
D. Monitoring for signs of dehydration

Rationale: Clients at risk for HHNS should immediately report signs and symptoms of dehydration to health care providers.
Dehydration can be severe, and it may progress rapidly. Although options A, B and C are components of the teaching plan for the
client with HHNS, dehydration is the priority. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) most often occurs in
individuals with type 2 diabetes mellitus. The major difference between HHNS and diabetic ketoacidosis is that ketosis and acidosis
do not occur with HHNS. (Saunders)

113. Nurse Fritz is teaching Mrs. Cris about chronic complications associated with the disease. Which information should be included in
the teaching?
A. Buy shoes that are half size larger
B. Annual eye examinations are recommended
C. Excessive exercise increases insulin resistance
D. Podiatry visits are necessary every 2 years

Rationale: Retinopathy is a chronic complication of diabetes mellitus. Therefore, yearly eye examinations are recommended.
Because the risk of serious foot injuries, shoes should fit properly and be the correct size. Exercise decreases insulin resistance. A
podiatrist should be seen on a yearly basis or more often, as needed. (NCLEX RN Questions and Answers Made Incredibly Easy,
p. 565)

114. Nurse Fritz is preparing an insulin infusion for a client in diabetic ketoacidosis (DKA). Which of the following would be the
appropriate type of insulin to use for IV infusion?
A. Lantus
B. NPH
C. Humalog
D. Regular

Rationale: Regular insulin can be given intravenously. The other types listed can only be given by the subcutaneous route. (NCLEX
RN Questions and Answers Made Incredibly Easy, p. 603)

115. A nurse is preparing to administer “Regular insulin 4 units subcutaneously” to a client with type 1 diabetes mellitus. Which
equipment does the nurse need to perform the injection?
A. 27-gauge, ½” needle
B. 22-gauge, ½” needle
C. 27-gauge, 1” needle
D. 22-gauge, 1” needle

Rationale: To administer medication, the nurse will be using a subcutaneous injection, which should be administered with a 25-
gauge to 27-gauge, 5/8” to ½” needle A 22-gauge needle is too large for subcutaneous injection. A 10 needle will deliver the
medication into the muscle of most clients, rather than subcutaneous tissue. (NCLEX RN Questions and Answers Made Incredibly
Easy, p. 616)

RENAL

SITUATION 24 – Nurse Kim was assigned in the Medical Surgical Ward and was tasked to take care of patients with renal problems.

116. A nurse is caring for a client with a diagnosis of benign prostatic hyperplasia (BPH). Which information about this condition is
important for the nurse to consider when caring for this client?
A. It is a congenital abnormality
B. A malignancy usually results
C. It predisposes to hydronephrosis
D. An increase in the acid phosphatase level occurs
 Rationale: Inability to empty the bladder as a result of pressure exerted by the enlarging prostate on the urethra causes a backup of
urine and finally the kidneys (hydronephrosis). BPH develops over the client’s life span; it is not congenital. It is uncommon for BPG
to become malignant. The acid phosphatase level is increased in prostatic carcinoma. (Mosby)

117. A nurse is assessing for the early symptom of benign prostatic hyperplasia. The nurse is correct if she documents that the early
symptom of BPH is:
A. Nocturia
B. Urinary retention
C. Urge incontinence
D. Decreased force in the stream of urine

Rationale: Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia. The stream later becomes
weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated,
complete obstruction and urinary retention can occur. (Saunders)

118. The client has an indwelling triple catheter to continuous irrigation (CBI) with Normal Saline Solution (NSS) infusing at 200 mL per
hour. After three hours, the nurse emptied the drainage bag and obtained an output of 1280 mL. Which of the following will the
nurse record as the client’s urinary output?
A. 600 mL
B. 1280 mL
C. 680 mL
D. 200 mL

Rationale: In computing for the client’s urinary output, subtract the amount solution infused from output obtained from the bag.
200mL x 3 hours= 600mL; 1,280mL- 600mL= 680 mL. (Saunders)

119. A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy. Nurse Kim ensures that the client understands the
procedure and tells the client that:
A. There is no discomfort at all involved with this procedure
B. There are no side effects or complications associated with this procedure
C. The stone granules are passed in the urine within a few days after the procedure
D. The procedure involves breaking up the stone by a vibrating needle that is inserted into one urinary tract

Rationale: In extracorporeal shock wave lithoripsy, a non-invasive procedure, shock waves are administered that shatter the stone
without damaging the surrounding tissues. The stone is broken into fine sand, which is secreted into the client’s urine within a few
days after the procedure. The client may feel some discomfort from the shock waves. Hematuria is common after the procedure.
The presence of clots in the urine needs to be reported to the physician. Clots could indicate a complication such as a hematoma.
After extracorporeal shock wave lithotripsy, the client is instructed to increase fluid intake to flush out stone fragments. (Saunders)

120. A client is admitted to the emergency department following a motor vehicle accident. The client has hematuria and lower back pain.
To assess further whether the pain is caused by bladder trauma, the nurse should ask the client if the pain is referred to which
area?
A. Hip
B. Shoulder
C. Umbilicus
D. Costovertebral angle

Rationale: Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders due to phrenic
nerve irritation. Bladder injury pain does not radiate to the umbilicus, costovertebral angle, or hip. (Mosby)

SITUATION 25 – Renal problems lead to the kidney’s inability to metabolize and excrete wastes from the body. Prompt management
and interventions are then necessary to avoid further aggravation of the problem. Nurse Julian was assigned to take care of patients with
chronic renal failure. The following questions apply.

121. A client has an indwelling urinary catheter, and urine is leaking from a hole in the collection bag. Which nursing intervention would
be most appropriate?
A. Cover the hole with tape
B. Remove the catheter and insert a new one using sterile technique
C. Disconnect the drainage bag from the catheter and replace it with a new bag
D. Place a towel under the bag to prevent spillage of urine on the floor, which could cause the client to slip and fall.
 Rationale: The system is no longer a closed system and bacteria might have been introduced into the system, so a new sterile
catheter should be inserted Taping up the hole and placing a towel under the bag leave the system open, which increases the risk
of infection. Replacing the drainage bag by disconnecting the old one from the catheter opens up the entire system and isn’t
recommended because of the increased risk of infection. (NCLEX RN Questions and Answers Made Incredibly Easy)

122. Nurse Julian is caring for a client with end-stage renal disease who has a mature arteriovenous (AV) fistula. What nursing care
should be included in the client’s plan of care?
i. Auscultate for a bruit
ii. Palpate the site to identify a thrill
iii. Irrigate with saline to maintain patency
iv. Avoid drawing blood from the affected extremity
v. Keep the fistula clamped until ready to perform dialysis

A. ii, iii, iv
B. iii, iv, v
C. i, ii, iv
D. ii, iii, v

Rationale: In AV fistula or graft, teach the client that the extremity should not be used for monitoring blood pressure, drawing blood,
placing IV lines, or administering injections. To ensure patency, palpate the thrill or auscultate for a bruit over the fistula or graft.
Option V is performed only if AV shunt is used. (Saunders)

123. After months of hemodialysis, it was changed to peritoneal dialysis for home management. During the procedure, Julian noted that
the flow of the dialysate stops before the full amount of solution has drained out. The most suitable action he should take would be:
A. Call the doctor immediately
B. Take note of the observation
C. Change the patient’s position
D. Reposition of the peritoneal catheter

Rationale: If the flow of the dialysate stops before the full amount of solution has drained out, there might be occlusion of the
catheter. If this happens, change the patient’s position first. Option A is not correct because you have to intervene first before calling
the physician. Option B is wrong because it requires a nursing intervention. Option D is not within the scope of nursing practice, it’s
the doctor’s responsibility.

124. A client is to undergo kidney transplantation with a living donor. What is the most important preoperative assessment by Nurse
Julian?
A. Urine output
B. Signs of graft rejection
C. Signs and symptoms of infection
D. Client’s support system and understanding of lifestyle changes

Rationale: The client undergoing a renal transplantation will need vigilant follow-up care and must adhere to the medical regimen.
The client is most likely anuric or oliguric preoperatively but postoperatively will require close monitoring of urine output to make use
the transplanted kidney is functioning optimally. Rejection can occur postoperatively. Although the client will always need to be
monitored for signs and symptoms of infection, it’s most important postoperatively because of the initiation of immunosuppressive
therapy. (Mosby)

125. A home care nurse is making follow-up visits to a client after renal transplant. The nurse assesses the client for which signs of acute
graft rejection?
A. Hypotension, graft tenderness, and anemia
B. Hypertension, oliguria, thirst, and hypothermia
C. Fever, hypertension, graft tenderness, and malaise
D. Fever, vomiting, hypotension, and copious amounts of dilute urine output

Rationale: Acute rejection usually occurs within the first 3 months after transplant, although it can occur for up to 2 years
posttransplant. The client exhibits fever, hypertension, malaise, and graft tenderness Treatment is immediately begun with
corticosteroids and possibly also with monoclonal antibodies and antilymphocyte agents. (Saunders)

F and E
SITUATION 26 – The nurse needs to understand the physiology of fluid and electrolyte balance and acid-base balance to anticipate,
identify and respond to possible imbalances in each. The nurse also must use effective teaching and communication skills to help
prevent and treat various fluid and electrolyte disturbances. The following questions apply.

126. As a knowledgeable nurse, you know that which adverse effect must be watched for carefully when Furosemide (Lasix) is
administered?
A. High serum sodium level
B. Increase in blood pressure
C. Increase in blood volume
D. Low serum potassium level

Rationale: Furosemide is a potassium-wasting diuretic that may cause hypokalemia or low serum potassium level.

127. Which of the following sign best signifies presence of hypokalemia?

A. Constipation
B. Weakness
C. Hyperactive bowel sounds
D. Diarrhea

Rationale: Hypokalemia is a low serum potassium level lower than 3.5 mEq/L. Manifestations of hypokalemia include fatigue,
anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility (constipation), paresthesia (numbness and
tingling), dysrhythmias, and increased sensitivity to digitalis. In hyperkalemia, during early phase, the client may have muscle
twitches, paresthesia but in the later phase, the client may have profound weakness, ascending flaccid paralysis in the arms and
legs. Additionally, GI manifestations, such as nausea, intermittent intestinal colic, and diarrhea, may occur in hyperkalemic patients.
Since weakness may happen in both conditions (hypokalemia or hyperkalemia), the sign that would suggest hypokalemia in the
choices is CONSTIPATION. (Bruner)

128. A client has a total serum calcium level of 7.5 mg/dL. Which clinical manifestations would the nurse expect to note on assessment
of the client?
1. Constipation
2. Muscle twitches
3. Hypoactive bowel sounds
4. Hyperactive deep tendon reflexes
5. Positive Trousseau’s sign and positive Chvostek’s sign
6. Prolonged ST interval and QT interval on electrocardiogram (ECG)

A. 1, 2, 3, 5
B. 2, 4, 5, 6
C. 1, 2, 3, 4, 5
D. 2, 3, 4, 5, 6

Rationale: Hypocalcemia is a total serum calcium level less than 8.5 mg/dL. Clinical manifestations of hypocalcemia include
decreased heart rate, diminished peripheral pulses, hypotension, and prolonged ST interval and QT interval on ECG.
Neuromuscular manifestations include anxiety and irritability; paresthesia followed by numbness; muscle twitches, cramps, tetany,
and seizures; hyperactive deep tendon reflexes; and positive Trousseau’s sign and positive Chvostek’s sig. Gastrointestinal
manifestations include increased gastric motility; hyperactive bowel sounds, abdominal crmaping, and diarrhea (Saunders)

129. What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?
A. Rapid, thread pulse
B. Distended jugular veins
C. Elevated hematocrit level
D. Increased serum sodium level

Rationale: Because of fluid overload in the intravascular space, the neck veins become visibly distended. Options A and C occur
with a fluid deficit. In option D, if sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of
sodium, its concentration is decreased. (Mosby)

130. A client reports vomiting and diarrhea for 3 days. What clinical finding will most accurately indicate that the client has a fluid deficit?
A. Presence of dry skin
B. Loss of body weight
C. Decrease in blood pressure
D. Altered general appearance
 Rationale: Dehydration is most readily and accurately measured by serial assessments of body weight; 1 L of fluid weighs 2.2 lb.
Although dry skin may be associated with dehydration, it is also associated with aging and some disorders (e.g. hypothyroidism).
Although hypovolemia will eventually result in a decrease in blood pressure; it is not an accurate, reliable measure because there
are many other causes of hypotension. Option D is too general and not an objective determination of fluid volume deficit. (Mosby)

SITUATION 27 – Many critical illnesses can upset a patient’s acid-base balance, and a disturbance in acid-base equilibrium may
indicate other underlying diseases or organ damage. The following questions apply.

131. A nurse inadvertently allows an IV solution containing potassium to infuse too rapidly. The health care provider prescribes insulin
added to 10% dextrose in water solution. What is the rationale for the order?
A. Potassium moves into body cells with glucose and insulin
B. Increased insulin accelerates excretion of glucose and potassium
C. Glucose with insulin increases metabolism, which accelerates potassium excretion
D. Increased potassium causes a temporary slowing of pancreatic production of insulin

132. A nurse is assessing a patient for the signs and symptoms of metabolic acidosis. Which of the following is NOT included?
A. Seizure
B. Kussmaul’s respiration
C. Nausea, vomiting
D. Warm, flushed skin

Rationale: Seizure is a manifestation of respiratory acidosis. The other options are manifestations of metabolic acidosis. Other
manifestations are drowsiness, confusion, headache, coma, decreased blood pressure, dysrhythmias, diarrhea, abdominal pain.
(Saunders)

133. Which of the following arterial blood gases (ABGs) should the nurse anticipate in the client with a nasogastric tube attached to
continuous suction?
A. pH 7.25, pCO2 55, HCO3 24
B. pH 7.30, pCO2 38, HCO3 20
C. pH 7.48, pCO2 30, HCO3 23
D. pH 7.49, pCO2 38, HCO3 30

Rationale: The anticipated arterial blood gas in the client with a nasogastric tube to continuous suction is metabolic alkalosis
resulting from loss of acid. In uncompensated metabolic alkalosis the pH will be elevated (greater than 7.45), bicarbonate will be
elevated (greater than 27 mEq/L), and the pCO2 will most likely be within normal limits (35 to 45 mm Hg). Therefore options 1, b,
and C are incorrect. (Saunders)

134. The nurse reviews the client’s most recent blood gas results that include a pH of 7.43, pCO2 of 31 mmHg, and HCO3 of 21 mEq/L.
Based on these results, the nurse determines that which acid-base imbalance is present?
A. Compensated metabolic acidosis
B. Compensated respiratory alkalosis
C. Uncompensated respiratory acidosis
D. Uncompensated metabolic alkalosis

Rationale: The normal pH is 7.35 to 7.45, the normal pCO2 is 35 to 45 mmHg, and the normal HCO3 is 22 to 26 mEq/L. The pH is
elevated in alkalosis and low in acidosis. In a respiratory condition, the pH and the pCO2 move in opposite directions; that is, the pH
rises and pCO2 drops. In this client the pH is at the high end of normal, indicating compensation and alkalosis. The pCO2 is low,
indicating a respiratory condition. (Saunders)

135. A client with diabetes mellitus has a blood glucose level of 644 mg/dL The nurse interprets that this client is most at risk of
developing which type of acid-base imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Rationale: Diabetes mellitus can lead to metabolic acidosis When the body does not have sufficient circulating insulin, the blood
glucose level rises. At the same time, the cells of the body use all available glucose. The body then break s down glycogen and fat
for fuel. The byproducts of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options, B, C,
& D are incorrect. (Saunders)
EENT

SITUATION 28 – You are assigned in the EENT unit of the CBRC Provincial Hospital. You perform assessment and provides safe and
quality care to these clients. The following questions apply.

136. A patient comes to you with a complaint of vertigo. As a knowledgeable nurse, you know that the client may have problem with
which portion of the ear?
A. External ear
B. Inner ear
C. Middle ear
D. Tympanic membrane

Rationale: Vertigo is usually the most troublesome complaint of patient with Meniere’s disease. Meniere’s disease is an abnormal
inner ear fluid balance caused by a malabsorption in the endolymphatic sac. Evidence indicates that many people with Meniere’s
disease may have a blockage in the endolymphatic duct. Regardless of the cause, endolymphatic hydrops, dilation in the
endolymphatic space, develops. Either increased pressure in the system or rupture of the inner ear membrane occurs, producing
symptoms of Ménière’s disease. (Brunner)

137. A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department,
frantic and screaming for help. You should instruct the woman to take which immediate action?
A. Irrigate the eyes with water
B. Come to the emergency department
C. Call the health care provider
D. Irrigate the eyes with diluted hydrogen peroxide

Rationale: In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes,
or until the emergency medical service personnel arrive. In the emergency department, the cleansing agent of choice is usually
normal saline. Calling the health care provider and going to the emergency department delays necessary intervention. Hydrogen
peroxide is never placed in the eyes.
(Saunders)

138. A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. You
assess the eye and note a piece of wood protruding from the eye. What is your initial nursing action?
A. Apply an eye patch
B. Perform visual acuity tests
C. Irrigate the eye with sterile saline
D. Remove the piece of wood using a sterile eye clamp

Rationale: If the injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never
be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or
irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. Note the strategic word initial and note the
word penetrating. This should indicate that a laceration has occurred and that interventions are directed at preventing further
disruption of the integrity of the eye. (Saunders)

139. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated
immediately?
A. Apply ice to the affected eye
B. Irrigate the eye with cool water
C. Notify the health care provider
D. Accompany the client to the emergency department

Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a
health care provider and receive a thorough eye examination to rule out the present of other eye injuries. (Saunders)

140. When assessing the client with glaucoma, you expect which of the following findings?
A. Complaints of double vision
B. Complaints of halos around lights
C. Intraocular pressure of 15 mmHg
D. Soft globe on palpation

Rationale: Complaints of halos around lights is a common finding in a client with glaucoma. Symptoms of glaucoma don’t include
double vision but can include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, halos
 around lights, and occasional eye pains, but clients may be asymptomatic Normal intraocular pressure is 10 to 21 mmHg. (NCLEX
RN Questions and Answers Made Incredibly Easy)

EMERGENCY

SITUATION 29 – Nurse Ten-Ten, a newly hired nurse in the Sagada Medical Center was attending a seminar about Emergency Nursing.
Different situations were given to them and questions were also had been asked.

141. Which of the following is one of the four key components of an Emergency preparedness program?
A. Analysis
B. Mitigation
C. Intervention
D. Reassimilation

Rationale: The Federal Emergency Management Agency (FEMA0 identifies four disaster management phases: mitigation,
preparedness, response, and recovery. Analysis, intervention, reassimilation are not part of the 4 phases. (Saunders)

142. Mr. Binagyo lost his family after Typhoon Yolanda. Nurse Ten-Ten is evaluating the appropriateness of a family member’s initial
response to grief. What is the most important factor for the nurse to consider?
A. Personality traits
B. Educational level
C. Cultural background
D. Past experiences with death

Rationale: In the initial stage of grief the degree of anguish experienced is influenced by cultural background. Although optionA
enters into the grief process, they are not as important as culture. Option B is not directly related to grief. While past experience is
important, it is not as significant as culture. (Mosby)

143. Nurse Ten-Ten is assigned as the triage nurse in the Emergency Department. Four clients injured in a vehicular accident were
brought to the ED at the same time. To whom will Nurse Ten-Ten assign the highest priority?
A. Ylona, 3 months pregnant with premature labor contractions
B. Bailey, with maxillofacial injury and gurgling respiration
C. Franco, with severe head injury but with no perceptible blood pressure
D. Jimboy, with lumbar spinal cord injury with lower extremity paralysis

Rationale: Hospital EDs use various triage systems with differing terminology, but all share this characteristic of a hierarchy based
on the potential for loss of life. A basic and widely used system uses three categories: emergent, urgent, and non-urgent. Emergent
patients have the highest priority—their conditions are life threatening, and they must be seen immediately. Urgent patients have
serious health problems, but not immediately life-threatening ones; they must be seen within 1 hour. Non-urgent patients have
episodic illnesses that can be addressed within
24 hours without increased morbidity. A fourth, increasingly used class is “fast-track.” These patients require simple first aid or basic
primary care. They may be treated in the ED or safely referred to a clinic or physician’s office. Among the choices, option B requires
an emergent treatment because of respiratory distress. (Brunner)

144. For a client admitted with head injury whose neck has been stabilized, the preferred bed position is:
A. 30 degree head elevation
B. Flat
C. Side-lying
D. Trendelenburg’s

Rationale: One of the most important nursing goals in the management of the patient with a head injury is to establish and maintain
an adequate airway. The brain is extremely sensitive to hypoxia, and a neurologic deficit can worsen if the patient is hypoxic.
Therapy is directed toward maintaining optimal oxygenation to preserve cerebral function. An obstructed airway causes CO2
retention and hypoventilation, which can produce cerebral vessel dilation and increased ICP. Interventions to ensure an adequate
exchange of air include the following:
• Keep the unconscious patient in a position that facilitates drainage of oral secretions, with the head of the bed elevated about 30
degrees to decrease intracranial venous pressure (Bader & Palmer, 2000).
• Establish effective suctioning procedures (pulmonary secretions produce coughing and straining, which increase ICP).
• Guard against aspiration and respiratory insufficiency.
• Closely monitor arterial blood gas values to assess the adequacy of ventilation. The goal is to keep blood gas values within the
normal range to ensure adequate cerebral blood flow.
• Monitor the patient who is receiving mechanical ventilation.
 • Monitor for pulmonary complications such as acute respiratory distress syndrome (ARDS) and pneumonia (Munro, 2000).
(BRUNNER)

145. An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client’s vital signs are:
pulse 106 beats per minute, blood pressure of 158/88 mmHg and respirations of 28 breaths per minute. After cleaning the injury
and reassuring the client, the nurse rechecks the vital sings and notes a pulse of 82 beats per minute, BP of 130/80 mmHg and
respirations of 20 breaths per minute. The nurse determines that the change in vital signs is caused by:
A. Cooling effects of the cleansing agent
B. Client’s adaptation to the air conditioning
C. Early clinical indicators of cardiogenic shock
D. Fall in sympathetic nervous system

Rationale: Physical or emotional stress triggers sympathetic nervous system stimulation. Increased epinephrine and norepinephrine
cause tachycardia, high blood pressure and tachypnea. Stress reduction then returns these parameters to baseline as the
sympathetic discharge falls.

SITUATION 30 –Triage trauma to facilitate care of clients in the emergency room, various management strategies have been devised to
address the survival needs of patients. As an ER nurse you should be equipped with knowledge, skills and attitude to cope with
unexpected problems. The following questions apply.

146. You assessed that the client is edematous in both burned and unburned body areas. This assessment finding is expected because
the edema is caused by:
A. An increase in capillary permeability and hypoproteinemia
B. A decrease in capillary permeability and hypoproteinemia
C. A decrease in capillary permeability and hyperproteinemia
D. An increase in capillary permeability and hyperproteinemia

Rationale: The initial systemic event after a major burn injury is hemodynamic instability, resulting from loss of capillary integrity and
a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. Edema can occur from
increased capillary fluid pressure, decreased capillary oncotic pressure, or increased interstitial oncotic pressure, thus expanding
the interstitial fluid compartment. (BRUNNER)

147. What acid-base imbalance is present when an individual experiences irreversible shock?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Rationale: The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is
so severe that the patient does not respond to treatment and cannot survive. Despite treatment, blood pressure remains low.
Complete renal and liver failure, compounded by the release of necrotic tissue toxins, creates an overwhelming metabolic acidosis.
Anaerobic metabolism contributes to a worsening lactic acidosis. (BRUNNER)

148. A patient suffering from shock has a cold sweaty pallid skin, a weak rapid pulse, irregular breathing, dry mouth, dilated pupils, and a
reduced flow of urine. Which of the following assessment findings indicates hypovolemic shock?
A. Pulse less than 60 bpm
B. Pupils unequally dilated
C. Respiratory rate more than 30 bpm
D. Systolic blood pressure less than 90 mmHg

Rationale: The sequence of events in hypovolemic shock begins with a decrease in the intravascular volume. This results in
decreased venous return of blood to the heart and subsequent decreased ventricular filling. Decreased ventricular filling results in
decreased stroke volume (amount of blood ejected from the heart) and decreased cardiac output. When cardiac output drops, blood
pressure drops and tissues cannot be adequately perfused (BRUNNER)

149. Which of the following would be an indication that fluid replacement for the client with hypovolemic shock is inadequate?
A. Diastolic blood pressure above 90 mmHg
B. Systolic blood pressure above 110 mmHg
C. Urine output greater than 30 ml per hour
D. Urine output of 20 to 30 ml per hour
 Rationale: The normal urine output is greater than 30mL per hour. Having a urine output less than the normal amount would
suggest that renal perfusion is inadequate.

150. A client involved in a house fire is experiencing respiratory distress, and an inhalation injury is suspected. You monitor which of the
following for the presence of carbon monoxide poisoning?
A. Pulse oximetry
B. Urine myoglobin
C. Sputum carbon levels
D. Serum carboxyhemoglobin levels

Rationale: Serum carboxyhemoglobin levels are the most direct measure of carbon monoxide poisoning provide the level of
poisoning, and thus determine the appropriate treatment measures. The carbon monoxide molecule has a 200 times greater affinity
for binding with haemoglobin than an oxygen molecule, causing decreased availability of oxygen to the cells. Clients are treated
with 100% oxygen. (Saunders)