Medical Surgical Nursing Exam 1 D.

Fever and Hypertension

SITUATION : Arthur, A registered nurse, witnessed SITUATION: Mr. D. Rojas, An obese 35 year old
an old woman hit by a motorcycle while crossing a MS Professor of OLFU Lagro is admitted due to
train railway. The old woman fell at the railway. pain in his weight bearing joint. The diagnosis was
Arthur rushed at the scene. Osteoarthritis.
1. As a registered nurse, Arthur knew that the first 6. As a nurse, you instructed Mr. Rojas how to use
thing that he will do at the scene is a cane. Mr. Rojas has a weakness on his right leg
A. Stay with the person, Encourage her to remain due to self immobilization and guarding. You plan to
still and Immobilize the leg while waiting for the teach Mr. Rojas to hold the cane
ambulance. A. On his left hand, because his right side is weak.
B. Leave the person for a few moments to call for B. On his left hand, because of reciprocal motion.
help. C. On his right hand, to support the right leg.
C. Reduce the fracture manually. D. On his right hand, because only his right leg is
D. Move the person to a safer place. weak.

2. Arthur suspects a hip fracture when he noticed 7. You also told Mr. Rojas to hold the cane
that the old woman’s leg is A. 1 Inches in front of the foot.
A. A. Lengthened, Abducted and Internally Rotated. B. 3 Inches at the lateral side of the foot.
B. Shortened, Abducted and Externally Rotated. C. 6 Inches at the lateral side of the foot.
C. Shortened, Adducted and Internally Rotated. D. 12 Inches at the lateral side of the foot.
D. Shortened, Adducted and Externally Rotated.
8. Mr. Rojas was discharged and 6 months later, he
3. The old woman complains of pain. John noticed came back to the emergency room of the hospital
that the knee is reddened, warm to touch and because he suffered a mild stroke. The right side of
swollen. John interprets that this signs and the brain was affected. At the rehabilitative phase
symptoms are likely related to of your nursing care, you observe Mr. Rojas use a
A. Infection cane and you intervene if you see him
B. Thrombophlebitis A. Moves the cane when the right leg is moved.
C. Inflammation B. Leans on the cane when the right leg swings
D. Degenerative disease through.
C. keeps the cane 6 Inches out to the side of the
4. The old woman told John that she has right foot.
osteoporosis; Arthur knew that all of the following D. Holds the cane on the right side.
factors would contribute to osteoporosis except
A. Hypothyroidism SITUATION: Alfred, a 40 year old construction
B. End stage renal disease worker developed cough, night sweats and fever.
C. Cushing’s Disease He was brought to the nursing unit for diagnostic
D. Taking Furosemide and Phenytoin. studies. He told the nurse he did not receive a BCG
vaccine during childhood
5. Martha, The old woman was now Immobilized 9. The nurse performs a Mantoux Test. The nurse
and brought to the emergency room. The X-ray knows that Mantoux Test is also known as
shows a fractured femur and pelvis. The ER Nurse A. PPD
would carefully monitor Martha for which of the B. PDP
following sign and symptoms? C. PDD
D. DPP
A. Tachycardia and Hypotension
B. Fever and Bradycardia
C. Bradycardia and Hypertension
10. The nurse would inject the solution in what 16. How long is the duration of the maintenance
route? phase of his treatment?
A. IM A. 2 months
B. IV B. 3 months
C. ID C. 4 months
D. SC D. 5 months

11. The nurse notes that a positive result for Alfred 17. Which of the following drugs is UNLIKELY given
is to Mang Alfred during the
A. 5 mm wheal maintenance phase?
B. 5 mm Induration A. Rifampicin
C. 10 mm Wheal B. Isoniazid
D. 10 mm Induration C. Ethambutol
D. Pyridoxine
12. The nurse told Alfred to come back after
A. a week 18. According to the DOH, the most hazardous
B. 48 hours period for development of
C. 1 day clinical disease is during the first
D. 4 days A. 6-12 months after
B. 3-6 months after
13. Mang Alfred returns after the Mantoux Test. The C. 1-2 months after
test result read POSITIVE. What should be the D. 2-4 weeks after
nurse’s next action?
A. Call the Physician 19. This is the name of the program of the DOH to
B. Notify the radiology dept. for CXR evaluation control TB in the country
C. Isolate the patient A. DOTS
D. Order for a sputum exam B. National Tuberculosis Control Program
C. Short Coursed Chemotherapy
14. Why is Mantoux test not routinely done in the D. Expanded Program for Immunization
Philippines?
A. It requires a highly skilled nurse to perform a 20. Susceptibility for the disease [ TB ] is increased
Mantoux test markedly in those with the
B. The sputum culture is the gold standard of PTB following condition except
Diagnosis and it will A. 23 Year old athlete with diabetes insipidus
definitively determine the extent of the cavitary B. 23 Year old athlete taking long term Decadron
lesions therapy and anabolic steroids
C. Chest X Ray Can diagnose the specific C. 23 Year old athlete taking illegal drugs and
microorganism responsible abusing substances
for the lesions D. Undernourished and Underweight individual who
D. Almost all Filipinos will test positive for Mantoux undergone gastrectomy
Test
21. Direct sputum examination and Chest X ray of
15. Mang Alfred is now a new TB patient with an TB symptomatic is in what level of prevention?
active disease. What is his A. Primary
category according to the DOH? B. Secondary
A. I C. Tertiary
B. II D. Quarterly
C. III
D. IV
SITUATION: Michiel, A male patient diagnosed with B. Slow down the irrigation
colon cancer was newly put in colostomy. C. Tell the client that cramping will subside and is
22. Michiel shows the BEST adaptation with the normal
new colostomy if he shows which of the following? D. Notify the physician
A. Look at the ostomy site
B. Participate with the nurse in his daily ostomy 28. The next day, the nurse will assess Michiel’s
care stoma. The nurse noticed
C. Ask for leaflets and contact numbers of ostomy that a prolapsed stoma is evident if she sees which
support groups of the following?
D. Talk about his ostomy openly to the nurse and A. A sunken and hidden stoma
friends B. A dusky and bluish stoma
C. A narrow and flattened stoma
23. The nurse plans to teach Michiel about D. Protruding stoma with swollen appearance
colostomy irrigation. As the nurse prepares the
materials needed, which of the following item 29. Michiel asked the nurse, what foods will help
indicates that the nurse needs further instruction? lessen the odor of his colostomy. The nurse best
A. Plain NSS / Normal Saline response would be
B. K-Y Jelly A. Eat eggs
C. Tap water B. Eat cucumbers
D. Irrigation sleeve C. Eat beet greens and parsley
D. Eat broccoli and spinach
24. The nurse should insert the colostomy tube for
irrigation at approximately 30. The nurse will start to teach Michiel about the
A. 1-2 inches techniques for colostomy irrigation. Which of the
B. 3-4 inches following should be included in the nurse’s teaching
C. 6-8 inches plan?
D. 12-18 inches A. Use 500 ml to 1,000 ml NSS
B. Suspend the irrigant 45 cm above the stoma
25. The maximum height of irrigation solution for C. Insert the cone 4 cm in the stoma
colostomy is D. If cramping occurs, slow the irrigation
A. 5 inches
B. 12 inches 31. The nurse knew that the normal color of
C. 18 inches Michiel’s stoma should be
D. 24 inches A. Brick Red
B. Gray
26. Which of the following behavior of the client C. Blue
indicates the best initial step in learning to care for D. Pale Pink
his colostomy?
A. Ask to defer colostomy care to another individual SITUATION: James, A 27 basketball player
B. Promises he will begin to listen the next day sustained inhalation burn that required him to have
C. Agrees to look at the colostomy tracheostomy due to massive upper airway edema.
D. States that colostomy care is the function of the 32. Wilma, His sister and a nurse is suctioning the
nurse while he is in tracheostomy tube of James. Which of the
the hospital following, if made by Wilma indicates that she is
committing an error?
27. While irrigating the client’s colostomy, Michiel A. Hyperventilating James with 100% oxygen
suddenly complains of severe cramping. Initially, before and after suctioning
the nurse would B. Instilling 3 to 5 ml normal saline to loosen up
A. Stop the irrigation by clamping the tube secretion
C. Applying suction during catheter withdrawal
D. Suction the client every hour A. James’ respiratory rate is 18
B. James’ Oxygen saturation is 91%
33. What size of suction catheter would Wilma use C. There are frank blood suction from the tube
for James, who is 6 feet 5 inches in height and D. There are moderate amount of tracheobronchial
weighing approximately 145 lbs? secretions
A. Fr. 5
B. Fr. 10 39. Wilma knew that the maximum time when
C. Fr. 12 suctioning James is
D. Fr. 18 A. 10 seconds
B. 20 seconds
34. Wilma is using a portable suction unit at home, C. 30 seconds
What is the amount of D. 45 seconds
suction required by James using this unit?
A. 2-5 mmHg SITUATION : Juan Miguel Lopez Zobel Ayala de
B. 5-10 mmHg Batumbakal was diagnosed with Acute Close Angle
C. 10-15 mmHg Glaucoma. He is being seen by Nurse Jet.
D. 20-25 mmHg 40. What specific manifestation would nurse Jet
see in Acute close angle glaucoma that she would
35. If a Wall unit is used, What should be the not see in an open angle glaucoma?
suctioning pressure required by James? A. Loss of peripheral vision
A. 50-95 mmHg B. Irreversible vision loss
B. 95-110 mmHg C. There is an increase in IOP
C. 100-120 mmHg D. Pain
D. 155-175 mmHg
41. Nurse jet knew that Acute close angle
36. Wilma was shocked to see that the glaucoma is caused by
Tracheostomy was dislodged. Both the inner and A. Sudden blockage of the anterior angle by the
outer cannulas was removed and left hanging on base of the iris
James’ neck. What are the 2 equipment’s at james’ B. Obstruction in trabecular meshwork
bedside that could help Wilma deal with this C. Gradual increase of IOP
situation? D. An abrupt rise in IOP from 8 to 15 mmHg
A. New set of tracheostomy tubes and Oxygen tank
B. Theophylline and Epinephrine 42. Nurse jet performed a TONOMETRY test to Mr.
C. Obturator and Kelly clamp Batumbakal. What does
D. Sterile saline dressing this test measures
A. It measures the peripheral vision remaining on
37. Which of the following method if used by Wilma the client
will best assure that the tracheostomy ties are not B. Measures the Intra Ocular Pressure
too tightly placed? C. Measures the Client’s Visual Acuity
A. Wilma places 2 fingers between the tie and neck D. Determines the Tone of the eye in response to
B. The tracheotomy can be pulled slightly away the sudden increase
from the neck in IOP.
C. James’ neck veins are not engorged
D. Wilma measures the tie from the nose to the tip 43. The Nurse notices that Mr. Batumbakal cannot
of the earlobe and to the xiphoid process. anymore determine RED from BLUE. The nurse
knew that which part of the eye is affected by this
38. Wilma knew that James have an adequate change?
respiratory condition if she notices that A. IRIS
B. PUPIL fluoroscopy. What activity is contraindicated
C. RODS [RETINA] immediately after procedure?
D. CONES [RETINA] A. Reading newsprint
B. Lying down
44. Nurse Jet knows that Aqueous Humor is C. Watching TV
produce where? D. Listening to the music
A. In the sub arachnoid space of the meninges
B. In the Lateral ventricles 51. If Mr. Batumbakal is receiving pilocarpine, what
C. In the Choroids drug should always be available in any case
D. In the Ciliary Body systemic toxicity occurs?
A. Atropine Sulfate
45. Nurse Jet knows that the normal IOP is B. Pindolol [Visken]
A. 8-21 mmHg C. Naloxone Hydrochloride [Narcan]
B. 2-7 mmHg D. Mesoridazine Besylate [Serentil]
C. 31-35 mmHg
D. 15-30 mmHg SITUATION : Wide knowledge about the human
ear, it’s parts and it’s functions will help a nurse
46. Nurse Jet wants to measure Mr. Batumbakal’s assess and analyze changes in the adult client’s
CN II Function. What test would Nurse Jet health.
implement to measure CN II’s Acuity? 52. Nurse Anna is doing a caloric testing to his
A. Slit lamp patient, Aida, a 55 year old university professor
B. Snellen’s Chart who recently went into coma after being mauled by
C. Wood’s light her disgruntled 3rd year nursing students whom
D. Gonioscopy she gave a failing mark. After instilling a warm
water in the ear, Anna noticed a rotary nystagmus
47. The Doctor orders pilocarpine. Nurse jet knows toward the irrigated ear. What does this means?
that the action of this drug is to A. Indicates a CN VIII Dysfunction
A. Contract the Ciliary muscle B. Abnormal
B. Relax the Ciliary muscle C. Normal
C. Dilate the pupils D. Inconclusive
D. Decrease production of Aqueous Humor
53. Ear drops are prescribed to an infant, The most
48. The doctor orders timolol [timoptic]. Nurse jet appropriate method to administer the ear drops is
knows that the action of this drug is A. Pull the pinna up and back and direct the
A. Reduce production of CSF solution towards the eardrum
B. Reduce production of Aquesous Humor B. Pull the pinna down and back and direct the
C. Constrict the pupil solution onto the wall of the canal
D. Relaxes the Ciliary muscle C. Pull the pinna down and back and direct the
solution towards the eardrum
49. When caring for Mr. Batumbakal, Jet teaches D. Pull the pinna up and back and direct the
the client to avoid solution onto the wall of the canal
A. Watching large screen TVs
B. Bending at the waist 54. Nurse Jenny is developing a plan of care for a
C. Reading books patient with Menieres disease. What is the priority
D. Going out in the sun nursing intervention in the plan of care for this
particular patient?
50. Mr. Batumbakal has undergone eye A. Air, Breathing, Circulation
angiography using an Intravenous dye and B. Love and Belongingness
C. Food, Diet and Nutrition
D. Safety
C. I will use straw for drinking
55. After mastoidectomy, Nurse John should be D. I should avoid air travel for a while
aware that the cranial nerve that is usually damage
after this procedure is 60. Nurse Oca will do a caloric testing to a client
A. CN I who sustained a blunt injury in the head. He
B. CN II instilled a cold water in the client’s right ear and he
C. CN VII noticed that nystagmus occurred towards the left
D. CN VI ear. What does this finding indicates?
A. Indicating a Cranial Nerve VIII Dysfunction
56. The physician orders the following for the client B. The test should be repeated again because the
with Menieres disease. Which of the following result is vague
should the nurse question? C. This is Grossly abnormal and should be reported
A. Dipenhydramine [Benadryl] to the neurosurgeon
B. Atropine sulfate D. This indicates an intact and working vestibular
C. Out of bed activities and ambulation branch of CN VIII
D. Diazepam [Valium]
61. A client with Cataract is about to undergo
57. Nurse Anna is giving dietary instruction to a surgery. Nurse Oca is preparing plan of care.
client with Menieres disease. Which statement if Which of the following nursing diagnosis is most
made by the client indicates that the teaching has appropriate to address the long term need of this
been successful? type of patient?
A. I will try to eat foods that are low in sodium and A. Anxiety R/T to the operation and its outcome
limit my fluid intake B. Sensory perceptual alteration R/T Lens
B. I must drink atleast 3,000 ml of fluids per day extraction and replacement
C. I will try to follow a 50% carbohydrate, 30% fat C. Knowledge deficit R/T the pre operative and post
and 20% protein diet operative self care
D. I will not eat turnips, red meat and raddish D. Body Image disturbance R/T the eye packing
after surgery
58. Peachy was rushed by his father, Steven into
the hospital admission. Peachy is complaining of 62. Nurse Joseph is performing a WEBERS TEST.
something buzzing into her ears. Nurse Joemar He placed the tuning fork in the patients forehead
assessed peachy and found out It was an insect. after tapping it onto his knee. The client states that
What should be the first thing that Nurse Joemar the fork is louder in the LEFT EAR. Which of the
should try to remove the insect out from peachy’s following is a correct conclusion for nurse Josph to
ear? make?
A. Use a flashlight to coax the insect out of A. He might have a sensory hearing loss in the left
peachy’s ear ear
B. Instill an antibiotic ear drops B. Conductive hearing loss is possible in the right
C. Irrigate the ear ear
D. Pick out the insect using a sterile clean forceps C. He might have a sensory hearing loss in the
right hear, and/or a conductive hearing loss in the
59. Following an ear surgery, which statement if left ear.
heard by Nurse Oca from the patient indicates a D. He might have a conductive hearing loss in the
correct understanding of the post operative right ear, and/or a sensory hearing loss in the left
instructions? ear.
A. Activities are resumed within 5 days
B. I will make sure that I will clean my hair and face
to prevent infection
63. Aling myrna has Menieres disease. What D. Give small volumes of fluid at frequent interval
typical dietary prescription would nurse Oca expect
the doctor to prescribe? 68. After nursing intervention, you will expect the
A. A low sodium , high fluid intake patient to have
B. A high calorie, high protein dietary intake 1. Maintain body temperature at 36.5 C
C. low fat, low sodium and high calorie intake 2. Exhibit return of BP and Pulse to normal
D. low sodium and restricted fluid intake 3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed
SITUATION : [ From DEC 1991 NLE ] A 45 year old A. 1,3
male construction worker was admitted to a tertiary B. 2,4
hospital for incessant vomiting. Assessment C. 1,3,4
disclosed: weak rapid pulse, acute weight loss of D. 2,3,4
.5kg, furrows in his tongue,slow flattening of the
skin was noted when the nurse released her pinch. SITUATION: A 65 year old woman was admitted for
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, Parkinson’s Disease. The
He also complains for postural hypotension. There charge nurse is going to make an initial
was no infection. assessment.
64. Which of the following is the appropriate 69. Which of the following is a characteristic of a
nursing diagnosis? patient with advanced Parkinson’s disease?
A. Fluid volume deficit R/T furrow tongue A. Disturbed vision
B. Fluid volume deficit R/T uncontrolled vomiting B. Forgetfulness
C. Dehydration R/T subnormal body temperature C. Mask like facial expression
D. Dehydration R/T incessant vomiting D. Muscle atrophy

65. Approximately how much fluid is lost in acute 70. The onset of Parkinson’s disease is between
weight loss of .5kg? 50-60 years old. This disorder is caused by
A. 50 ml A. Injurious chemical substances
B. 750 ml B. Hereditary factors
C. 500 ml C. Death of brain cells due to old age
D. 75 ml D. Impairment of dopamine producing cells in the
brain
66. Postural Hypotension is
A. A drop in systolic pressure less than 10 mmHg 71. The patient was prescribed with levodopa.
when patient changes position from lying to sitting. What is the action of this drug?
B. A drop in systolic pressure greater than 10 A. Increase dopamine availability
mmHg when patient changes position from lying to B. Activates dopaminergic receptors in the basal
sitting ganglia
C. A drop in diastolic pressure less than 10 mmHg C. Decrease acetylcholine availability
when patient changes position from lying to sitting D. Release dopamine and other catecholamine
D. A drop in diastolic pressure greater than 10 from neurological storage sites
mmHg when patient changes position from lying to
sitting 72. You are discussing with the dietician what food
to avoid with patients taking levodopa?
67. Which of the following measures will not help A. Vitamin C rich food
correct the patient’s condition B. Vitamin E rich food
A. Offer large amount of oral fluid intake to replace C. Thiamine rich food
fluid lost D. Vitamin B6 rich food
B. Give enteral or parenteral fluid
C. Frequent oral care
73. One day, the patient complained of difficulty in SITUATION : Knowledge of the drug
walking. Your response would be PROPANTHELINE BROMIDE
A. You will need a cane for support [Probanthine] Is necessary in treatment of various
B. Walk erect with eyes on horizon disorders.
C. I’ll get you a wheelchair 79. What is the action of this drug?
D. Don’t force yourself to walk A. Increases glandular secretion for clients affected
with cystic fibrosis
SITUATION: Mr. Dela Isla, a client with early B. Dissolve blockage of the urinary tract due to
Dementia exhibits thought process disturbances. obstruction of cystine
74. The nurse will assess a loss of ability in which stones
of the following areas?
A. Balance C. Reduces secretion of the glandular organ of the
B. Judgment body
C. Speech D. Stimulate peristalsis for treatment of constipation
D. Endurance and obstruction
80. What should the nurse caution the client when
75. Mr. Dela Isla said he cannot comprehend what using this medication
the nurse was saying. He suffers from: A. Avoid hazardous activities like driving, operating
A. Insomnia machineries etc.
B. Aphraxia B. Take the drug on empty stomach
C. Agnosia C. Take with a full glass of water in treatment of
D. Aphasia Ulcerative colitis
D. I must take double dose if I missed the previous
76. The nurse is aware that in communicating with dose
an elderly client, the nurse will 81. Which of the following drugs are not compatible
A. Lean and shout at the ear of the client when taking Probanthine?
B. Open mouth wide while talking to the client A. Caffeine
C. Use a low-pitched voice B. NSAID
D. Use a medium-pitched voice C. Acetaminophen
D. Alcohol
77. As the nurse talks to the daughter of Mr. Dela 82. What should the nurse tell clients when taking
Isla, which of the following statement of the Probanthine?
daughter will require the nurse to give further A. Avoid hot weathers to prevent heat strokes
teaching? B. Never swim on a chlorinated pool
A. I know the hallucinations are parts of the disease C. Make sure you limit your fluid intake to 1L a day
B. I told her she is wrong and I explained to her D. Avoid cold weathers to prevent hypothermia
what is right 83. Which of the following disease would
C. I help her do some tasks he cannot do for Probanthine exert the much needed
himself action for control or treatment of the disorder?
D. Ill turn off the TV when we go to another room A. Urinary retention
B. Peptic Ulcer Disease
78. Which of the following is most important C. Ulcerative Colitis
discharge teaching for Mr. Dela D. Glaucoma
Isla SITUATION : Mr. Franco, 70 years old, suddenly
A. Emergency Numbers could not lift his spoons nor
B. Drug Compliance speak at breakfast. He was rushed to the hospital
C. Relaxation technique unconscious. His diagnosis
D. Dietary prescription was CVA.
84. Which of the following is the most important pain. Upon palpation of his abdomen, Ernie jerks
assessment during the acute stage of an even on slight pressure. Blood test was ordered.
unconscious patient like Mr. Franco? Diagnosis is acute appendicitis.
A. Level of awareness and response to pain 89. Which result of the lab test will be significant to
B. Papillary reflexes and response to sensory the diagnosis?
stimuli A. RBC : 4.5 TO 5 Million / cu. mm.
C. Coherence and sense of hearing B. Hgb : 13 to 14 gm/dl.
D. Patency of airway and adequacy of respiration C. Platelets : 250,000 to 500,000 cu.mm.
D. WBC : 12,000 to 13,000/cu.mm
85. Considering Mr. Franco’s conditions, which of
the following is most important to include in 90. Stat appendectomy was indicated. Pre op care
preparing Franco’s bedside equipment? would include all of the following except?
A. Hand bell and extra bed linen A. Consent signed by the father
B. Sandbag and trochanter rolls B. Enema STAT
C. Footboard and splint C. Skin prep of the area including the pubis
D. Suction machine and gloves D. Remove the jewelries

86. What is the rationale for giving Mr. Franco 91. Pre-anesthetic med of Demerol and atrophine
frequent mouth care? sulfate were ordered to :
A. He will be thirsty considering that he is doesn’t A. Allay anxiety and apprehension
drink enough fluids B. Reduce pain
B. To remove dried blood when tongue is bitten C. Prevent vomiting
during a seizure D. Relax abdominal muscle
C. The tactile stimulation during mouth care will
hasten return to consciousness 92. Common anesthesia for appendectomy is
D. Mouth breathing is used by comatose patient A. Spinal
and it’ll cause oral mucosa dying and cracking. B. General
C. Caudal
87. One of the complications of prolonged bed rest D. Hypnosis
is decubitus ulcer. Which of the following can best
prevent its occurrence? 93. Post op care for appendectomy include the
A. Massage reddened areas with lotion or oils following except
B. Turn frequently every 2 hours A. Early ambulation
C. Use special water mattress B. Diet as tolerated after fully conscious
D. Keep skin clean and dry C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise
88. If Mr. Franco’s Right side is weak, What should
be the most accurate analysis by the nurse? 94. Peritonitis may occur in ruptured appendix and
A. Expressive aphasia is prominent on clients with may cause serious problems which are
right sided weakness 1. Hypovolemia, electrolyte imbalance
B. The affected lobe in the patient is the Right lobe 2. Elevated temperature, weakness and
C. The client will have problems in judging distance diaphoresis
and proprioception 3. Nausea and vomiting, rigidity of the abdominal
D. Clients orientation to time and space will be wall
much affected 4. Pallor and eventually shock
A. 1 and 2
SITUATION : a 20 year old college student was B. 2 and 3
rushed to the ER of PGH after he fainted during C. 1,2,3
their ROTC drill. Complained of severe right iliac D. All of the above
95. If after surgery the patient’s abdomen becomes Medical Surgical Nursing Exam 2
distended and no bowel sounds appreciated, what
would be the most suspected complication? 1. After a cerebrovascular accident, a 75 yr old
A. Intussusception client is admitted to the health
B. Paralytic Ileus care facility. The client has left-sided weakness and
C. Hemorrhage an absent gag reflex. He’s
D. Ruptured colon incontinent and has a tarry stool. His blood
pressure is 90/50 mm Hg, and his
96. NGT was connected to suction. In caring for the hemoglobin is 10 g/dl. Which of the following is a
patient with NGT, the nurse must priority for this client?
A. Irrigate the tube with saline as ordered A. checking stools for occult blood
B. Use sterile technique in irrigating the tube B. performing range-of-motion exercises to the left
C. advance the tube every hour to avoid kinks side
D. Offer some ice chips to wet lips C. keeping skin clean and dry
D. elevating the head of the bed to 30 degrees
97. When do you think the NGT tube be removed? 2. The nurse is caring for a client with a colostomy.
A. When patient requests for it The client tells the nurse
B. Abdomen is soft and patient asks for water that he makes small pin holes in the drainage bag
C. Abdomen is soft and flatus has been expelled to help relieve gas. The
D. B and C only nurse should teach him that this action:
A. destroys the odor-proof seal
Situation: Amanda is suffering from chronic B. wont affect the colostomy system
arteriosclerosis Brain syndrome she fell while C. is appropriate for relieving the gas in a
getting out of the bed one morning and was brought colostomy system
to the hospital, and she was diagnosed to have D. destroys the moisture barrier seal
cerebrovascular thrombosis thus transferred to a 3. When assessing the client with celiac disease,
nursing home. the nurse can expect to find
98. What do you call a STROKE that manifests a which of the following?
bizarre behavior? A. steatorrhea
A. Inorganic Stroke B. jaundiced sclerae
B. Inorganic Psychoses C. clay-colored stools
C. Organic Stroke D. widened pulse pressure
D. Organic Psychoses 4. A client is hospitalized with a diagnosis of
chronic glomerulonephritis. The
99. The main difference between chronic and client mentions that she likes salty foods. The nurse
organic brain syndrome is that the former should warn her to avoid
A. Occurs suddenly and reversible foods containing sodium because:
B. Is progressive and reversible A. reducing sodium promotes urea nitrogen
C. tends to be progressive and irreversible excretion
D. Occurs suddenly and irreversible B. reducing sodium improves her glomerular
filtration rate
100. Which behavior results from organic C. reducing sodium increases potassium
psychoses? absorption
A. Memory deficit D. reducing sodium decreases edema
B. Disorientation 5. The nurse is caring for a client with a cerebral
C. Impaired Judgement injury that impaired his
D. Inappropriate affect speech and hearing. Most likely, the client has
experienced damage to the:
A. frontal lobe
 diagnosed with diabetic ketoacidosis. Insulin is
B. parietal lobe administered using a scale of
C. occipital lobe regular insulin according to glucose results. At 2
D. temporal lobe p.m., the client has a
6. The nurse is assessing a postcraniotomy client capillary glucose level of 250 mg/dl for which he
and finds the urine output receives 8 U of regular
from a catheter is 1500 ml for the 1st hour and the insulin. The
same for the 2nd hour. The nurse should expect the dose’s:
nurse should suspect: A. onset to be at 2 p.m. and its peak at 3 p.m.
A. Cushing’s syndrome
B. Diabetes mellitus B. onset to be at 2:15 p.m. and its peak at 3 p.m.
C. Adrenal crisis C. onset to be at 2:30 p.m. and its peak at 4 p.m.
D. Diabetes insipidus D. onset to be at 4 p.m. and its peak at 6 p.m.
7. The nurse is providing postprocedure care for a 10. A client with a head injury is being monitored for
client who underwent increased intracranial
percutaneous lithotripsy. In this procedure, an pressure (ICP). His blood pressure is 90/60 mmHG
ultrasonic probe inserted and the ICP is 18 mmHg;
through a nephrostomy tube into the renal pelvis therefore his cerebral perfusion pressure (CPP) is:
generates ultra-high- A. 52 mm Hg
frequency sound waves to shatter renal calculi. The B. 88 mm Hg
nurse should instruct the C. 48 mm Hg
client to: D. 68 mm Hg
A. limit oral fluid intake for 1 to 2 weeks 11. A 52 yr-old female tells the nurse that she has
B. report the presence of fine, sandlike particles found a painless lump in her
through the right breast during her monthly self-examination.
nephrostomy tube. Which assessment finding
C. Notify the physician about cloudy or foul smelling would strongly suggest that this client’s lump is
urine cancerous?
D. Report bright pink urine within 24 hours after the A. eversion of the right nipple and a mobile mass
procedure B. nonmobile mass with irregular edges
8. A client with a serum glucose level of 618 mg/dl C. mobile mass that is oft and easily delineated
is admitted to the facility. D. nonpalpable right axillary lymph nodes
He’s awake and oriented, has hot dry skin, and has 12. A Client is scheduled to have a descending
the following vital signs: colostomy. He’s very anxious
temperature of 100.6º F (38.1º C), heart rate of 116 and has many questions regarding the surgical
beats/minute, and blood procedure, care of stoma, and
pressure of 108/70 mm Hg. Based on these lifestyle changes. It would be most appropriate for
assessment findings, which the nurse to make a
nursing diagnosis takes the highest priority? referral to which member of the health care team?
A. deficient fluid volume related to osmotic diuresis A. Social worker
B. decreased cardiac output related to elevated B. registered dietician
heart rate C. occupational therapist
C. imbalanced nutrition: Less than body D. enterostomal nurse therapist
requirements related to insulin 13. Ottorrhea and rhinorrhea are most commonly
deficiency seen with which type of skull
D. ineffective thermoregulation related to fracture?
dehydration A. basilar
9. Capillary glucose monitoring is being performed B. temporal
every 4 hours for a client C. occipital
D. parietal instruction?
14. A male client should be taught about testicular A. “Be sure to eat meat at every meal.”
examinations: B. “Monitor your fruit intake and eat plenty of
A. when sexual activity starts bananas.”
B. after age 60 C. “Restrict your salt intake.”
C. after age 40 D. “Drink plenty of fluids.”
D. before age 20
20. The nurse is caring for a client who has just had
15. Before weaning a client from a ventilator, which a modified radical
assessment parameter is mastectomy with immediate reconstruction. She’s
most important for the nurse to review? in her 30s and has tow
A. fluid intake for the last 24 hours children. Although she’s worried about her future,
B. baseline arterial blood gas (ABG) levels she seems to be adjusting
C. prior outcomes of weaning well to her diagnosis. What should the nurse do to
D. electrocardiogram (ECG) results support
16. The nurse is speaking to a group of women her coping?
about early detection of breast A. Tell the client’s spouse or partner to be
cancer. The average age of the women in the group supportive while she
is 47. Following the recovers.
American Cancer Society (ACS) guidelines, the B. Encourage the client to proceed with the next
nurse should recommend that phase of treatment.
the women: C. Recommend that the client remain cheerful for
A. perform breast self-examination annually the sake of her
B. have a mammogram annually children.
C. have a hormonal receptor assay annually D. Refer the client to the American Cancer
D. have a physician conduct a clinical evaluation Society’s Reach for Recovery program or another
every 2 years support program.
17. When caring for a client with esophageal
varices, the nurse knows that 21. A 21 year-old male has been seen in the clinic
bleeding in this disorder usually stems from: for a thickening in his right
A. esophageal perforation testicle. The physician ordered a human chorionic
B. pulmonary hypertension gonadotropin (HCG) level.
C. portal hypertension The nurse’s explanation to the client should include
D. peptic ulcers the fact that:
18. A 49-yer-old client was admitted for surgical A. The test will evaluate prostatic function.
repair of a Colles’ fracture. An B. The test was ordered to identify the site of a
external fixator was placed during surgery. The possible infection.
surgeon explains that this C. The test was ordered because clients who have
method of repair: testicular cancer has elevated levels of HCG.
A. has very low complication rate D. The test was ordered to evaluate the
B. maintains reduction and overall hand function testosterone level.
C. is less bothersome than a cast 22. A client is receiving captopril (Capoten) for
D. is best for older people heart failure. The nurse should
19. A client is hospitalized with a diagnosis of notify the physician that the medication therapy is
chronic renal failure. An ineffective if an
arteriovenous fistula was created in his left arm for assessment reveals:
hemodialysis. When A. A skin rash.
preparing the client for discharge, the nurse should B. Peripheral edema.
reinforce which dietary C. A dry cough.
D. Postural hypotension. C. reticulocytes
23. Which assessment finding indicates D. leukocytes
dehydration? 29. The nurse is performing wound care on a foot
A. Tenting of chest skin when pinched. ulcer in a client with type 1
B. Rapid filling of hand veins. diabetes mellitus. Which technique demonstrates
C. A pulse that isn’t easily obliterated. surgical asepsis?
D. Neck vein distention A. Putting on sterile gloves then opening a
24. The nurse is teaching a client with a history of container of sterile saline.
atherosclerosis. To B. Cleaning the wound with a circular motion,
decrease the risk of atherosclerosis, the nurse moving from outer
should encourage the client to: circles toward the center.
A. Avoid focusing on his weight. C. Changing the sterile field after sterile water is
B. Increase his activity level. spilled on it.
D. Placing a sterile dressing ½” (1.3 cm) from the
C. Follow a regular diet. edge of the sterile
D. Continue leading a high-stress lifestyle. field.
25. For a client newly diagnosed with
radiationinduced thrombocytopenia, the 30. A client with a forceful, pounding heartbeat is
nurse should include which intervention in the plan diagnosed with mitral valve
of care? prolapse. This client should avoid which of the
A. Administer aspirin if the temperature exceeds following?
38.8º C. A. high volumes of fluid intake
B. Inspect the skin for petechiae once every shift. B. aerobic exercise programs
C. Provide for frequent periods of rest. C. caffeine-containing products
D. Place the client in strict isolation. D. foods rich in protein
26. A client is chronically short of breath and yet 31. A client with a history of hypertension is
has normal lung ventilation, diagnosed with primary
clear lungs, and an arterial oxygen saturation hyperaldosteronism. This diagnosis indicates that
(SaO2) 96% or better. The client the client’s hypertension is
most likely has: caused by excessive hormone secretion from which
A. poor peripheral perfusion organ?
B. a possible Hematologic problem A. adrenal cortex
C. a psychosomatic disorder B. pancreas
D. left-sided heart failure C. adrenal medulla
27. For a client in addisonian crisis, it would be very D. parathyroid
risky for a nurse to 32. A client has a medical history of rheumatic
administer: fever, type 1 (insulin
A. potassium chloride dependent) diabetes mellitus, hypertension,
B. normal saline solution pernicious anemia, and
C. hydrocortisone appendectomy. She’s admitted to the hospital and
D. fludrocortisone undergoes mitral valve
28. The nurse is reviewing the laboratory report of a replacement surgery. After discharge, the client is
client who underwent a scheduled for a tooth
bone marrow biopsy. The finding that would most extraction. Which history finding is a major risk
strongly support a factor for infective
diagnosis of acute leukemia is the existence of a endocarditis?
large number of immature: A. appendectomy
A. lymphocytes B. pernicious anemia
B. thrombocytes C. diabetes mellitus
D. valve replacement and an irregular heartbeat. An electrocardiogram
33. A 62 yr-old client diagnosed with pyelonephritis shows a heart rate of 110
and possible septicemia beats/minute (sinus tachycardia) with frequent
has had five urinary tract infections over the past premature ventricular
two years. She’s fatigued contractions. Shortly after admission, the client has
from lack of sleep; urinates frequently, even during ventricular tachycardia
the night; and has lost and becomes unresponsive. After successful
weight recently. Test reveal the following: sodium resuscitation, the client is taken
level 152 mEq/L, osmolarity to the intensive care unit. Which nursing diagnosis
340 mOsm/L, glucose level 125 mg/dl, and is appropriate at this time?
potassium level 3.8 mEq/L. which A. Deficient knowledge related to interventions
of the following nursing diagnoses is most used to treat acute
appropriate for this client? illness
A. Deficient fluid volume related to inability to B. Impaired physical mobility related to complete
conserve water bed rest
B. Imbalanced nutrition: less than body C. Social isolation related to restricted visiting hours
requirements related to in the intensive
hypermetabolic state care unit
C. Deficient fluid volume related to osmotic diuresis D. Anxiety related to the threat of death
induced by 37. A client is admitted to the health care facility
hypernatremia with active tuberculosis. The
D. Imbalanced nutrition: less than body nurse should include which intervention in the plan
requirements related to of care?
catabolic effects of insulin deficiency A. Putting on a mask when entering the client’s
room.
34. A 20 yr-old woman has just been diagnosed B. Instructing the client to wear a mask at all times
with Crohn’s disease. She has C. Wearing a gown and gloves when providing
lost 10 lb (4.5 kg) and has cramps and occasional direct care
diarrhea. The nurse should D. Keeping the door to the client’s room open to
include which of the following when doing a observe the client
nutritional assessment? 38. The nurse is caring for a client who underwent
A. Let the client eat as desired during the a subtotal gastrectomy 24
hospitalization. hours earlier. The client has a nasogastric (NG)
B. Weight the client daily. tube. The nurse should:
C. Ask the client to list what she eats during a A. Apply suction to the NG tube every hour.
typical day. B. Clamp the NG tube if the client complains of
D. Place the client on I & O status and draw nausea.
blood for electrolyte levels. C. Irrigate the NG tube gently with normal saline
35. When instructions should be included in the solution.
discharge teaching plan for a
client after thyroidectomy for Grave’s disease? D. Reposition the NG tube if pulled out.
A. Keep an accurate record of intake and output. 39. Which statement about fluid replacement is
B. Use nasal desmopressin acetate DDAVP). accurate for a client with
C. Be sure to get regulate follow-up care. hyperosmolar hyperglycemic nonketotic syndrome
D. Be sure to exercise to improve cardiovascular (HHNS)?
fitness. A. administer 2 to 3 L of IV fluid rapidly
36. A client comes to the emergency department B. administer 6 L of IV fluid over the first 24 hours
with chest pain, dyspnea, C. administer a dextrose solution containing normal
saline solution
D. administer IV fluid slowly to prevent circulatory intermittent claudication, a condition associated
overload and with chronic arterial
collapse occlusive disease, the nurse should recommend
which additional measure?
40. Which of the following is an adverse reaction to A. Taking daily walks.
glipizide (Glucotrol)? B. Engaging in anaerobic exercise.
A. headache C. Reducing daily fat intake to less than 45% of
B. constipation total calories
C. hypotension D. Avoiding foods that increase levels of
D. photosensitivity highdensity lipoproteins
41. The nurse is caring for four clients on a (HDLs)
stepdown intensive care unit. The
client at the highest risk for developing nosocomial 45. A physician orders gastric decompression for a
pneumonia is the one client with small bowel
who: obstruction. The nurse should plan for the suction
A. has a respiratory infection to be:
B. is intubated and on a ventilator A. low pressure and intermittent
C. has pleural chest tubes B. low pressure and continuous
D. is receiving feedings through a jejunostomy tube C. high pressure and continuous
42. The nurse is teaching a client with chronic D. high pressure and intermittent
bronchitis about breathing 46. Which nursing diagnosis is most appropriate for
exercises. Which of the following should the nurse an elderly client with
include in the teaching? osteoarthritis?
A. Make inhalation longer than exhalation. A. Risk for injury
B. Exhale through an open mouth. B. Impaired urinary elimination
C. Use diaphragmatic breathing. C. Ineffective breathing pattern
D. Use chest breathing. D. Imbalanced nutrition: less than body
43. A client is admitted to the hospital with an requirements
exacerbation of her chronic 47. Parathyroid hormone (PTH) has which effects
systemic lupus erythematosus (SLE). She gets on the kidney?
angry when her call bell isn’t A. Stimulation of calcium reabsorption and
answered immediately. The most appropriate phosphate excretion
response to her would be: B. Stimulation of phosphate reabsorption and
A. “You seem angry. Would you like to talk about calcium excretion
it?” C. Increased absorption of vit D and excretion of vit
B. “Calm down. You know that stress will make your E
symptoms D. Increased absorption of vit E and excretion of Vit
worse.” D
C. “Would you like to talk about the problem with 48. A visiting nurse is performing home assessment
the nursing for a 59-yr old man
supervisor?” recently discharged after hip replacement surgery.
D. “I can see you’re angry. I’ll come back when Which home assessment
you’ve calmed down.” finding warrants health promotion teaching from the
nurse?
44. On a routine visit to the physician, a client with A. A bathroom with grab bars for the tub and toilet
chronic arterial occlusive B. Items stored in the kitchen so that reaching up
disease reports stopping smoking after 34 years. To and bending down
relive symptoms of aren’t necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with switches to the B. Anginal pain
top and bottom of C. Respiratory alkalosis
the stairs D. Metabolic acidosis
53. A client with type 1 diabetes mellitus has been
49. A client with autoimmune thrombocytopenia on a regimen of multiple
and a platelet count of daily injection therapy. He’s being converted to
800/uL develops epistaxis and melena. Treatment continuous subcutaneous
with corticosteroids and insulin therapy. While teaching the client bout
immunoglobulins has been unsuccessful, and the continuous subcutaneous
physician recommends a
splenectomy. The client states, “I don’t need insulin therapy, the nurse would be accurate in
surgery—this will go away on its telling him the regimen
own.” In considering her response to the client, the includes the use of:
nurse must depend on the A. intermediate and long-acting insulins
ethical principle of: B. short and long-acting insulins
A. beneficence C. short-acting only
B. autonomy D. short and intermediate-acting insulins
C. advocacy 54. a client who recently had a cerebrovascular
D. justice accident requires a cane to
50. Which of the following is t he most critical ambulate. When teaching about cane use, the
intervention needed for a client rationale for holding a cane on
with myxedema coma? the uninvolved side is to:
A. Administering and oral dose of levothyroxine A. prevent leaning
(Synthroid) B. distribute weight away from the involved side
B. Warming the client with a warming blanket C. maintain stride length
C. Measuring and recording accurate intake and D. prevent edema
output 55. A client with a history of an anterior wall
D. Maintaining a patent airway myocardial infarction is being
51. Because diet and exercise have failed to control transferred from the coronary care unit (CCU) to
a 63 yr-old client’s blood the cardiac stepdown unit
glucose level, the client is prescribed glipizide (CSU). While giving report to the CSU nurse, the
(Glucotrol). After oral CCU nurse says, “His
administration, the onset of action is: pulmonary artery wedge pressures have been in
A. 15 to 30 minutes the high normal range.” The
B. 30 to 60 minutes CSU nurse should be especially observant for:
C. 1 to 1 ½ hours A. hypertension
D. 2 to 3 hours B. high urine output
52. A client with pneumonia is receiving C. dry mucous membranes
supplemental oxygen, 2 L/min via D. pulmonary crackles
nasal cannula. The client’s history includes chronic 56. The nurse is caring for a client with a fractures
obstructive pulmonary hip. The client is
disease (COPD) and coronary artery disease. combative, confused, and trying to get out of bed.
Because of these findings, the The nurse should:
nurse closely monitors the oxygen flow and the A. leave the client and get help
client’s respiratory status. B. obtain a physician’s order to restrain the client
Which complication may arise if the client receives C. read the facility’s policy on restraints
a high oxygen D. order soft restraints from the storeroom
concentration? 57. For the first 72 hours after thyroidectomy
A. Apnea surgery, the nurse would assess
the client for Chvostek’s sign and Trousseau’s sign 63. A woman whose husband was recently
because they indicate diagnosed with active pulmonary tuberculosis (TB)
which of the following? is a tuberculin skin test converter. Management of
A. hypocalcemia her care would include:
B. hypercalcemia A. scheduling her for annual tuberculin skin testing
C. hypokalemia B. placing her in quarantine until sputum cultures
D. Hyperkalemia are negative
C. gathering a list of persons with whom she has
58. In a client with enteritis and frequent diarrhea, had recent contact
the nurse should anticipate D. advising her to begin prophylactic therapy with
an acidbase imbalance of: isoniazid (INH)
A. respiratory acidosis
B. respiratory alkalosis 64. The nurse is caring for a client who ahs had an
C. metabolic acidosis above the knee amputation. The client refuses to
D. metabolic alkalosis look at the stump. When the nurse attempts to
59. When caring for a client with the nursing speak with the client about his surgery, he tells the
diagnosis Impaired swallowing nurse that he doesn’t wish to discuss it. The client
related to neuromuscular impairment, the nurse also refuses to have his family visit. The nursing
should: diagnosis that best describes the client’s problem
A. position the client in a supine position is:
B. elevate the head of the bed 90 degrees during A. Hopelessness
meals B. Powerlessness
C. encourage the client to remove dentures C. Disturbed body image
D. encourage thin liquids for dietary intake D. Fear
60. A nurse is caring for a client who has a
tracheostomy and temperature of 65. A client with three children who is still I the child
39º C. which intervention will most likely lower the bearing years is admitted for surgical repair of a
client’s arterial blood prolapsed bladder. The nurse would find that the
oxygen saturation? client understood the surgeon’s preoperative
A. Endotracheal suctioning teaching when the client states:
B. Encouragement of coughing A. “If I should become pregnant again, the child
C. Use of cooling blanket would be delivered by
D. Incentive spirometry cesarean delivery.”
B. “If I have another child, the procedure may need
61. A client with a solar burn of the chest, back, to be repeated.”
face, and arms is seen in urgent care. The nurse’s C. “This surgery may render me incapable of
primary concern should be: conceiving another child.”
A. fluid resuscitation D. “This procedure is accomplished in two separate
B. infection surgeries.”
C. body image
D. pain management 66. A client experiences problems in body
temperature regulation associated with a skin
62. Which statement is true about crackles? impairment. Which gland is most likely involved?
A. They’re grating sounds. A. Eccrine
B. They’re high-pitched, musical squeaks. B. Sebaceous
C. They’re low-pitched noises that sound like C. Apocrine
snoring. D. Endocrine
D. They may be fine, medium, or course.
67. A school cafeteria worker comes to the 72. The nurse is caring for client with a new donor
physician’s office complaining of site that was harvested to treat a new burn. The
severe scalp itching. On inspection, the nurse finds nurse position the client to:
nail marks on the scalp and small light-colored A. allow ventilation of the site
round specks attached to the hair shafts close to B. make the site dependent
the scalp. These findings suggest that the client C. avoid pressure on the site
suffers from: D. keep the site fully covered
A. scabies
B. head lice 73. a 45-yr-old auto mechanic comes to the
C. tinea capitis physician’s office because an exacerbation of his
D. impetigo psoriasis is making it difficult to work. He tells the
nurse that his finger joints are stiff and sore in the
68. Following a small-bowel resection, a client morning. The nurse should respond by:
develops fever and anemia. The surface A. Inquiring further about this problem because
surrounding the surgical wound is warm to touch psoriatic arthritis can accompany psoriasis vulgaris
and necrotizing fasciitis is suspected. Another B. Suggesting he take aspirin for relief because it’s
manifestation that would most suggest necrotizing probably early rheumatoid arthritis
fasciitis is: C. Validating his complaint but assuming it’s an
A. erythema adverse effect of his vocation
B. leukocytosis D. Asking him if he has been diagnosed or treated
C. pressure-like pain for carpal tunnel syndrome
D. swelling
74. The nurse is providing home care instructions
69. A 28 yr-old nurse has complaints of itching and to a client who has recently had a skin graft. Which
a rash of both hands. Contact dermatitis is initially instruction is most important for the client to
suspected. The diagnosis is confirmed if the rash remember?
appears: A. Use cosmetic camouflage techniques.
A. erythematous with raised papules B. Protect the graft from direct sunlight.
B. dry and scaly with flaking skin C. Continue physical therapy.
C. inflamed with weeping and crusting lesions D. Apply lubricating lotion to the graft site.
D. excoriated with multiple fissures
75. a 28 yr-old female nurse is seen in the
70. When assessing a client with partial thickness employee health department for mild itching and
burns over 60% of the body, which of the following rash of both hands. Which of the following could be
should the nurse report immediately? causing this reaction?
A. Complaints of intense thirst A. possible medication allergies
B. Moderate to severe pain B. current life stressors she may be experiencing
C. Urine output of 70 ml the 1st hour C. chemicals she may be using and use of latex
D. Hoarseness of the voice gloves
D. recent changes made in laundry detergent or
71. A client is admitted to the hospital following a bath soap.
burn injury to the left hand and arm. The client’s
burn is described as white and leathery with no 76. The nurse assesses a client with urticaria. The
blisters. Which degree of severity is this burn? nurse understands that urticaria is another name
A. first-degree burn for:
B. second-degree burn A. hives
C. third-degree burn B. a toxin
D. fourth-degree burn C. a tubercle
D. a virus
77. A client with psoriasis visits the dermatology D. A plastic sheet-type dressing should cover the
clinic. When inspecting the affected areas, the wet dressing.
nurse expects to see which type of secondary
lesion? 82. While in skilled nursing facility, a client
A. scale contracted scabies, which is diagnosed the day
B. crust after discharge. The client is living at her
C. ulcer daughter’s home with six other persons. During her
D. scar visit to the clinic, she asks a staff nurse, “What
should my family do?” the most accurate response
78. The nurse is caring for a bedridden, elderly from the nurse is:
adult. To prevent pressure ulcers, which A. “All family members will need to be treated.”
intervention should the nurse include in the plan of B. “If someone develops symptoms, tell him to see
care? a physician right away.”
A. Turn and reposition the client a minimum of C. “Just be careful not to share linens and towels
every 8 hours. with family members.”
B. Vigorously massage lotion into bony D. “After you’re treated, family members won’t be at
prominences. risk for contracting scabies.”
C. Post a turning schedule at the client’s bedside.
D. Slide the client, rather than lifting when turning. 83. In an industrial accident, client who weighs 155
lb (70.3 kg) sustained full-thickness burns over 40%
79. Following a full-thickeness (3rd degree) burn of of his body. He’s in the burn unit receiving fluid
his left arm, a client is treated with artificial skin. resuscitation. Which observation shows that the
The client understands postoperative care of the fluid resuscitation is benefiting the client?
artificial skin when he states that during the first 7 A. A urine output consistently above 100 ml/hour.
days after the procedure, he’ll restrict: B. A weight gain of 4 lb (1.8 kg) in 24 hours.
A. range of motion C. Body temperature readings all within normal
B. protein intake limits
C. going outdoors D. An electrocardiogram (ECG) showing no
D. fluid ingestion arrhythmias.

80. A client received burns to his entire back and 84. The nurse is reviewing the laboratory results of
left arm. Using the Rule of Nines, the nurse can a client with rheumatoid arthritis. Which of the
calculate that he has sustained burns on what following laboratory results should the nurse expect
percentage of his body? to find?
A. 9% A. Increased platelet count
B. 18% B. Elevated erythrocyte sedimentation rate (ESR)
C. 27% C. Electrolyte imbalance
D. 36% D. Altered blood urea nitrogen (BUN) and
creatinine levels
81. The nurse is providing care for a client who has
a sacral pressure ulcer with wet-to-dry dressing. 85. Which nursing diagnosis takes the highest
Which guideline is appropriate for a wet-to-dry priority for a client with Parkinson’s crisis?
dressing? A. Imbalanced nutrition: less than body
A. The wound should remain moist form the requirements
dressing. B. Ineffective airway clearance
B. The wet-to-dry dressing should be tightly packed C. Impaired urinary elimination
into the wound. D. Risk for injury
C. The dressing should be allowed to dry out before 86. A client with a spinal cord injury and
removal. subsequent urine retention receives intermittent
catheterization every 4 hours. The average 91. The nurse is formulating a teaching plan for a
catheterized urine volume has been 550 ml. The client who has just experienced a transient
nurse should plan to: ischemic attack (TIA). Which fact should the nurse
A. Increase the frequency of the catheterizations. include in the teaching plan?
B. Insert an indwelling urinary catheter A. TIA symptoms may last 24 to 48 hours.
C. Place the client on fluid restrictions B. Most clients have residual effects after having a
D. Use a condom catheter instead of an invasive TIA.
one. C. TIA may be a warning that the client may have
cerebrovascular
87.The nurse is caring for a client who is to accident (CVA)
undergo a lumbar puncture to assess for the D. The most common symptom of TIA is the
presence of blood in the cerebrospinal fluid (CSF) inability to speak.
and to measure CSF pressure. Which result would
indicate an abnormality? 92. The nurse has just completed teaching about
A. The presence of glucose in the CSF. postoperative activity to a client who is going to
B. A pressure of 70 to 200 mm H2O have a cataract surgery. The nurse knows the
C. The presence of red blood cells (RBCs) in the teaching has been effective if the client:
first specimen tube A. coughs and deep breathes postoperatively
D. A pressure of 00 to 250 mmH2O B. ties his own shoes
C. asks his wife to pick up his shirt from the floor
88. The nurse is administering eyedrops to a client after he drops it.
with glaucoma. To achieve maximum absorption, D. States that he doesn’t need to wear an eyepatch
the nurse should instill the eyedrop into the: or guard to bed
A. conjunctival sac
B. pupil 93. The least serious form of brain trauma,
C. sclera characterized by a brief loss of consciousness and
D. vitreous humor period of confusion, is called:
A. contusion
89. A 52 yr-old married man with two adolescent B. concussion
children is beginning rehabilitation following a C. coup
cerebrovascular accident. As the nurse is planning D. contrecoup
the client’s care, the nurse should recognize that
his condition will affect: 94. When the nurse performs a neurologic
A. only himself assessment on Anne Jones, her pupils are dilated
B. only his wife and children and don’t respond to light.
C. him and his entire family A. glaucoma
D. no one, if he has complete recovery B. damage to the third cranial nerve
C. damage to the lumbar spine
90. Which action should take the highest priority D. Bell’s palsy
when caring for a client with hemiparesis caused by
a cerebrovascular accident (CVA)? 95. A 70 yr-old client with a diagnosis of leftsided
A. Perform passive range-of-motion (ROM) cerebrovascular accident is admitted to the facility.
exercises. To prevent the development of diffuse osteoporosis,
B. Place the client on the affected side. which of the following objectives is most
C. Use hand rolls or pillows for support. appropriate?
D. Apply antiembolism stockings A. Maintaining protein levels.
B. Maintaining vitamin levels.
C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises
 D. Try to reason with the client as much as
96. A client is admitted with a diagnosis of possible.
meningitis caused by Neisseria meningitides. The
nurse should institute which type of isolation 100. For a client with a head injury whose neck has
precautions? been stabilized, the preferred bed position is:
A. Contact precautions A. Trendelenburg’s
B. Droplet precautions B. 30-degree head elevation
C. Airborne precautions C. flat
D. Standard precautions D. side-lying
97. A young man was running along an ocean pier,
tripped on an elevated area of the decking, and
struck his head on the pier railing. According to his
friends, “He was unconscious briefly and then
became alert and behaved as though nothing had
happened.” Shortly afterward, he began
complaining of a headache and asked to be taken
to the emergency department. If the client’s
intracranial pressure (ICP) is increasing, the nurse
would expect to observe which of the following
signs first?
A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness

98. Emergency medical technicians transport a 28

yr-old iron worker to the emergency department.
They tell the nurse, “He fell from a two-story
building. He has a large contusion on his left chest
and a hematoma in the left parietal area. He has
compound fracture of his left femur and he’s
comatose. We intubated him and he’s maintaining
an arterial oxygen saturation of 92% by pulse
oximeter with a manual-resuscitation bag.” Which
intervention by the nurse has the highest priority?
A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness

99. Alzheimer’s disease is the secondary diagnosis

of a client admitted with myocardial infarction.
Which nursing intervention should appear on this
client’s plan of care?
A. Perform activities of daily living for the client to
decrease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
 5. Trousseau’s sign is associated with which
electrolyte imbalance?
A. hyponatremia
B. hypocalcemia
C. hypernatremia
D. hypercalcemia
6. A 36 year old female complains of headache and
neck pain. The nurse’s
assessments reveal painful flexion of the neck to
the chest. The nurse
understands that nuchal rigidity is associated with:
A. brain tumor
Medical Surgical Nursing Exam 3 B. CVA
C. meningitis
1. Lisa is newly diagnosed with asthma and is D. subdural hematoma
being discharged from the hospital after an episode 7. The nurse teaching the client about behavioral
of status asthmaticus. Discharge teaching should changes, which can affect
include which of the following: development of atherosclerosis, should discuss
A. Limitations in sports that will be imposed by the which of the following as a
illness non-modifiable risk factor for atherosclerosis?
B. Specific instructions on staying cal during an A. cigarette smoking
attack B. hyperlipidemia
C. The relationship of symptoms and a specific C. female over 55 years of age
trigger such as physical exercise D. sedentary lifestyle
D. Incidence of status asthmaticus in children and 8. A 76 year old man enters the ER with complaints
teens of back pain and feeling fatigued. Upon
2. Which of the following symptoms is most examination, his blood pressure is 190/100, pulse
characteristic of a client with a is 118, and hematocrit and hemoglobin are both
cancer of the lung? low. The nurse palpates the abdomen which is soft,
A. air hunger non-tender and auscultates an abdominal pulse.
B. exertional dyspnea The most likely
C. cough with night sweats diagnosis is:
D. persistent changing cough A. Buerger’s disease
3. The client has ST segment depression on his B. CHF
12-lead ECG. The nurse determines that this would C. Secondary hypertension
indicate the following: D. Aneurysm
A. necrosis 9. Nurse Fiona is caring a patient with Raynaud’s
B. injury disease. Which of the
C. ischemia following outcomes concerning medication regimen
D. nothing significant is of highest priority?
4. Red has just returned from the postanesthesia A. Controlling the pain once vasospasm occur
care unit (PACU) from a hemorrhidectomy. His B. Relaxing smooth muscle to avoid vasospasms
postoperative orders include sitz baths every C. Preventing major disabilities that may occur
morning. The nurse understands that sitz bath is D. Avoiding lesions on the feet
use for: 10. Mr. Roberto Robles complains of a severe
A. promote healing headache and is extremely anxious. The nurse
B. relive tension checks his vital signs and finds him to have a heart
C. lower body temperature rate of 57 bpm and a blood pressure of 230/110
D. cause swelling mmHg. The nurse should also assess for?
A. presence of bowel sounds D. vitamin deficiency
B. presence of babinski reflex 17. A client with rheumatoid arthritis may reveal
C. fecal incontinence which of the following assessment data:
D. urinary catheter patency A. Heberden’s nodes
11. A 40n year old male patient is complaining of B. Morning stiffness no longer than 30 minutes
chronic progressive and mental deterioration is C. Asymmetric joint swelling
admitted to the unit. The nurse recognizes that D. Swan neck deformities
these characteristics indicate a disease that results 18. Elsa Santos is a 18 year old student admitted to
in degeneration of the basal the ward with a diagnosis of epilepsy. She tells the
ganglia and cerebral cortex. The disease is called: nurse that she is experiencing a generalized
A. multiple sclerosis tingling sensation and is “smelling roses”. The
B. myasthenia gravis nurse understands that Esla is probably
C. Huntington’s disease experiencing:
D. Guillain-Barre syndrome A. an acute alcohol withdrawal
12. Dianne Hizon is a 27 year old woman who has B. an acute CVA
been admitted to the ER due to severe vomiting. C. an aura
Her ABG values are pH= 7.50, PaCO2= 85, D. an olfactory hallucination
HCO3= 31, and SaO2= 93%. The nurse 19. Mr. Lucas, a 63 year old, went to the clinic
interpretation of this ABG analysis is: complaining of hoarseness of voice and a cough.
A. respiratory acidosis His wife states that his voice has changed in the
B. respiratory alkalosis last few months. The nurse interprets that Mr.
C. metabolic acidosis Lucas’s symptoms are consistent with
D. metabolic alkalosis which of the following disorders:
13. Mr. Perkson has a parkinson’s disease and he A. chronic sinusitis
finds the resting tremor he is experiencing in his B. laryngeal cancer
right hand very frustrating. The nurse advises him C. gastroesophageal reflux disease
to: D. coronary artery disease
A. take a warm bath 20. Sarah complains of a nursing sensation,
B. hold an object cramping pain in the top part of her abdomen that
C. practice deep breathing becomes worse in the afternoon and sometimes
D. take diazepam as needed awakes her at night. She reports that when she
14. A shuffling gait is typically associated with the eats, it helps the pain go away but that pain is now
patient who has: becoming more intense. Which of the following is
A. Parkinson’s disease the best condition for the nurse to draw:
B. Multiple sclerosis A. these symptoms are consistent with an ulcer
C. Raynaud’s disease B. The client probably has indigestion
D. Myasthenia gravis C. A snack before going to bed should be advised
15. The priority in preparing the room for a client D. The client probably developing cholelithiasis
with a C7 spinal cord injury is having: 21. Nurse Cynthia is providing a discharge teaching
A. the halo brace device to a client with chronic cirrhosis. His wife asks her
B. a catheterization tray to explain why there is so much emphasis on
C. a ventilator on stand by bleeding precautions. Which of the following
D. the spinal kinetic bed provides the most appropriate
16. A 47 year old man with liver failure who has response?
developed ascites. The nurse understands that A. “The low protein diet will result in reduced
ascites is due to: clotting.”
A. dehydration B. “The increased production of bile decreases
B. protein deficiency clotting factors.”
C. bleeding disorders
C. “The liver affected by cirrhosis is unable to Medical Surgical Nursing Exam 4
produce clotting
factors.” 1. A patient is admitted to the medical surgical unit
D. “The required medications reduce clotting following surgery. Four
factors.” days after surgery, the patient spikes a 38.9
22. Betty Lee is a 58 year old woman who is being degrees C oral temperature and
admitted to the medical ward with trigeminal exhibits a wet, productive cough. The nurse
neuralgia. The nurse anticipates that Mr. Lee will assesses the patient with
demonstrate which of the following major understanding that an infection that is acquired
complaints? during hospitalization is
A. excruciating, intermittent, paroxysmal facial pain known as:
B. unilateral facial droop A. a community acquired infection
C. painless eye spasm B. an iatrogenic infection
D. mildly painful unilateral eye twitching C. a nosocomial infection
23. A 38 year old woman returns from a subtotal D. an opportunistic infection
thryroidectomy for the treatment of hyperthyroidism. 2. A client with anemia has a hemoglobin of 6.5
Upon assessment, the immediate priority that g/dL. The client is experiencing symptoms of
the nurse would include is: cerebral tissue hypoxia. Which of the following
A. Assess for pain nursing interventions would be most important in
B. Assess for neurological status providing care?
C. Assess fluid volume status A. Providing rest periods throughout the day
D. Assess for respiratory distress B. Instituting energy conservation techniques
24. Nurse Shiela is teaching self-care to a client C. Assisting in ambulation to the bathroom
with psoriasis. The nurse should encourage which D. Checking temperature of water prior to bathing
of the following for his scaled lesion? 3. A client was involved in a motor vehicular
A. Importance of follow-up appointments accident in which the seat belt was not worn. The
B. Emollients and moisturizers to soften scales client is exhibiting crepitus, decrease breath sounds
C. Keep occlusive dressings on the lesions 24 on the left, complains of shortness of breath, and
hours a day has a respiratory rate of 34 breaths per minute.
D. Use of a clean razor blade each time he shaves Which of the following assessment findings would
25. A 48 year old woman presents to the hospital concern the nurse most?
complaining of chest pain, A. Temperature of 102 degrees F and productive
tachycardia and dyspnea. On exam, heart sounds cough
are muffled. Which of the B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg
following assessment findings would support a C. Trachea deviating to the right
diagnosis of cardiac D. Barrel-chested appearance
tamponade? 4. The proper way to open an envelop-wrapped
A. A deviated trachea sterile package after removing
B. Absent breath sounds to the lower lobes the outer package or tape is to open the first
C. Pulse 40 with inspiration position of the wrapper:
D. Blood pressure 140/80 A. away from the body
B. to the left of the body
C. to the right of the body
D. toward the body
5. Assessment of a client with possible
thrombophlebitis to the left leg and a
deep vein thrombosis is done by pulling up on the
toes while gently holding
down on the knee. The client complains of extreme associated with hepatic encephalopathy are also
pain in the calf. This known as:
should be documented as: A. aphasia
A. positive tourniquet test B. ascites
B. positive homan’s sign C. astacia
C. negative homan’s sign D. asterixis
D. negative tourniquet test 11. Hyperkalemia can be treated with
6. Thomas Elison is a 79 year old man who is administration of 50% dextrose and
admitted with diagnosis of insulin. The 50% dextrose:
dementia. The doctor orders a series of laboratory A. causes potassium to be excreted
tests to determine whether B. causes potassium to move into the cell
Mr. Elison’s dementia is treatable. The nurse C. causes potassium to move into the serum
understands that the most D. counteracts the effects of insulin
common cause of dementia in this population is: 12. Which of the following findings would strongly
A. AIDS indicate the possibility of
B. Alzheimer’s disease cirrhosis?
C. Brain tumors A. dry skin
D. Vascular disease B. hepatomegaly
7. Which of the following nursing interventions is C. peripheral edema
contraindicated in the care D. pruritus
of a client with acute osteomyelitis? 13. Aling Puring has just been diagnosed with
A. Apply heat compress to the affected area close-angle (narrow-angle)
B. Immobilize the affected area glaucoma. The nurse assesses the client for which
C. Administer narcotic analgesics for pain of the following common
D. Administer OTC analgesics for pain presenting symptoms of the disorder?
8. A client with congestive heart failure has digoxin A. halo vision
(Lanoxin) ordered everyday. Prior to giving the B. dull eye pain
medication, the nurse checks the digoxin level C. severe eye and face pain
which is therapeutic and ausculates an apical D. impaired night vision
pulse. The apical pulse is 63 bpm for 1 full minute. 14. Chvostek’s sign is associated with which
The nurse should: electrolyte impabalnce?
A. Hold the Lanoxin A. hypoclacemia
B. Give the half dose now, wait an hour and give B. hypokalemia
the other half C. hyponatremia
C. Call the physician D. hypophosphatenia
D. Give the Lanoxin as ordered 15. What laboratory test is a common measure of
9. Nurse Marian is caring for a client with haital the renal function?
hernia, which of the following A. CBC
should be included in her teaching plan regarding B. BUN/Crea
causes: C. Glucose
A. To avoid heavy lifting D. Alanine amino transferase (ALT)
B. A dietary plan based on soft foods 16. Nurse Edward is performing discharge teaching
C. Its prevalence in young adults for a newly diagnosed
D. Its prevalence in fair-skinned individuals diabetic patient scheduled for a fasting blood
10. Joseph has been diagnosed with hepatic glucose test. The nurse explains
encephalopathy. The nurse to the patient that hyperglycemia is defined as a
observes flapping tremors. The nurse understands blood glucose level above:
that flapping tremors A. 100 mg/dl
B. 120 mg/dl
C. 130 mg/dl with SIADH. The priority diagnosis for this client
D. 150 mg/dl would be which of the
17. Mang Edison is on bed rest has developed an following?
ulcer that is full thickness A. Fluid volume deficit
and is penetrating the subcutaneous tissue. The B. Anxiety related to disease process
nurse documents that this C. Fluid volume excess
ulcer is in which of the following stages? D. Risk for injury
A. Stage 1 23. Nursing management of the client with a UTI
B. Stage 2 should include:
C. Stage 3 A. Taking medication until feeling better
D. Stage 4 B. Restricting fluids
18. A 24 year old male patient comes to the clinic C. Decreasing caffeine drinks and alcohol
after contracting genital D. Douching daily
herpes. Which of the following intervention would 24. Felicia Gomez is 1 day postoperative from
be most appropriate? coronary artery bypass surgery.
A. Encourage him to maintain bed rest for several The nurse understands that a postoperative patient
days who’s maintained on bed
B. Monitor temperature every 4 hours rest is at high risk for developing:
C. Instruct him to avoid sexual contact during acute A. angina
phases of illness B. arterial bleeding
D. Encourage him to use antifungal agents C. deep vein thrombosis (DVT)
regularly D. dehiscence of the wound
19. An 8 year old boy is brought to the trauma unit 25. Which of the following statement is true
with a chemical burn to the regarding the visual changes
face. Priority assessment would include which of associated with cataracts?
the following? A. Both eyes typically cataracts at the same time
A. Skin integrity B. The loss of vision is experienced as a painless,
B. BP and pulse gradual blurring
C. Patency of airway C. The patient is suddenly blind
D. Amount of pain D. The patient is typically experiences a painful,
20. A client with anemia due to chemotherapy has sudden blurring of
a hemoglobin of 7.0 g/dL. vision.
Which of the following complaints would be
indicative of tissue hypoxia
related to anemia?
A. dizziness
B. fatigue relieved by rest
C. skin that is warm and dry to the touch
D. apathy
21. Hazel Murray, 32 years old complains of abrupt
onset of chest and back
pain and loss of radial pulses. The nurse suspects
that Mrs. Murray may have:
A. Acute MI
B. CVA
C. Dissecting abdominal aorta
D. Dissecting thoracic aneurysm
22. Nurse Alexandra is establishing a plan of care
for a client newly admitted
PNLE III for Medical Surgical 6. A client is admitted to the hospital with benign
Nursing prostatic hyperplasia, the nurse most relevant
1. Marco who was diagnosed with brain tumor was assessment would be:
scheduled for craniotomy. In preventing the A. Flank pain radiating in the groin
development of cerebral edema after surgery, the B. Distention of the lower abdomen
nurse should expect the use of: C. Perineal edema
A. Diuretics D. Urethral discharge
B. Antihypertensive
C. Steroids 7. A client has undergone with penile implant. After
D. Anticonvulsants 24 hrs of surgery, the client’s scrotum was
edematous and painful. The nurse should:
2. Halfway through the administration of blood, the A. Assist the client with sitz bath
female client complains of lumbar pain. After B. Apply war soaks in the scrotum
stopping the infusion Nurse Hazel should: C. Elevate the scrotum using a soft support
A. Increase the flow of normal saline D. Prepare for a possible incision and drainage.
B. Assess the pain further
C. Notify the blood bank 8. Nurse hazel receives emergency laboratory
D. Obtain vital signs. results for a client with chest pain and immediately
informs the physician. An increased myoglobin
3. Nurse Maureen knows that the positive diagnosis level suggests which of the following?
for HIV infection is made based on which of the A. Liver disease
following: B. Myocardial damage
A. A history of high risk sexual behaviors. C. Hypertension
B. Positive ELISA and western blot tests D. Cancer
C. Identification of an associated opportunistic
infection 9. Nurse Maureen would expect the a client with
D. Evidence of extreme weight loss and high fever mitral stenosis would demonstrate symptoms
associated with congestion in the:
4. Nurse Maureen is aware that a client who has A. Right atrium
been diagnosed with chronic renal failure B. Superior vena cava
recognizes an adequate amount of C. Aorta
high-biologic-value protein when the food the client D. Pulmonary
selected from the menu was:
A. Raw carrots 10. A client has been diagnosed with hypertension.
B. Apple juice The nurse priority nursing diagnosis would be:
C. Whole wheat bread A. Ineffective health maintenance
D. Cottage cheese B. Impaired skin integrity
C. Deficient fluid volume
5. Kenneth who has diagnosed with uremic D. Pain
syndrome has the potential to develop
complications. Which among the following 11. Nurse Hazel teaches the client with angina
complications should the nurse anticipates: about common expected side effects of
A. Flapping hand tremors nitroglycerin including:
B. An elevated hematocrit level A. high blood pressure
C. Hypotension B. stomach cramps
D. Hypokalemia C. headache
D. shortness of breath
12. The following are lipid abnormalities. Which of 18. Marie with acute lymphocytic leukemia suffers
the following is a risk factor for the development of from nausea and headache. These clinical
atherosclerosis and PVD? manifestations may indicate all of the following
A. High levels of low density lipid (LDL) cholesterol except
B. High levels of high density lipid (HDL) A. effects of radiation
cholesterol B. chemotherapy side effects
C. Low concentration triglycerides C. meningeal irritation
D. Low levels of LDL cholesterol. D. gastric distension

13. Which of the following represents a significant 19. A client has been diagnosed with Disseminated
risk immediately after surgery for repair of aortic Intravascular Coagulation (DIC). Which of the
aneurysm? following is contraindicated with the client?
A. Potential wound infection A. Administering Heparin
B. Potential ineffective coping B. Administering Coumadin
C. Potential electrolyte balance C. Treating the underlying cause
D. Potential alteration in renal perfusion D. Replacing depleted blood products

14. Nurse Josie should instruct the client to eat 20. Which of the following findings is the best
which of the following foods to obtain the best indication that fluid replacement for the client with
supply of Vitamin B12? hypovolemic shock is adequate?
A. dairy products A. Urine output greater than 30ml/hr
B. vegetables B. Respiratory rate of 21 breaths/minute
C. Grains C. Diastolic blood pressure greater than 90 mmhg
D. Broccoli D. Systolic blood pressure greater than 110 mmhg

15. Karen has been diagnosed with aplastic 21. Which of the following signs and symptoms
anemia. The nurse monitors for changes in which would Nurse Maureen include in teaching plan as
of the following physiologic functions? an early manifestation of laryngeal cancer?
A. Bowel function A. Stomatitis
B. Peripheral sensation B. Airway obstruction
C. Bleeding tendencies C. Hoarseness
D. Intake and out put D. Dysphagia

16. Lydia is scheduled for elective splenectomy. 22. Karina a client with myasthenia gravis is to
Before the clients goes to surgery, the nurse in receive immunosuppressive therapy. The nurse
charge final assessment would be: understands that this therapy is effective because
A. signed consent it:
B. vital signs A. Promotes the removal of antibodies that impair
C. name band the transmission of impulses
D. empty bladder B. Stimulates the production of acetylcholine at the
neuromuscular junction.
17. What is the peak age range in acquiring acute C. Decreases the production of autoantibodies that
lymphocytic leukemia (ALL)? attack the acetylcholine receptors.
A. 4 to 12 years. D. Inhibits the breakdown of acetylcholine at the
B. 20 to 30 years neuromuscular junction.
C. 40 to 50 years
D. 60 60 70 years 23. A female client is receiving IV Mannitol. An
assessment specific to safe administration of the
said drug is:
A. Vital signs q4h C. Axillary regions
B. Weighing daily D. Feet, which are set apart
C. Urine output hourly
D. Level of consciousness q4h 29. Mang Jose with rheumatoid arthritis states, “the
only time I am without pain is when I lie in bed
24. Patricia a 20 year old college student with perfectly still”. During the convalescent stage, the
diabetes mellitus requests additional information nurse in charge with Mang Jose should encourage:
about the advantages of using a pen like insulin A. Active joint flexion and extension
delivery devices. The nurse explains that the B. Continued immobility until pain subsides
advantages of these devices over syringes C. Range of motion exercises twice daily
includes: D. Flexion exercises three times daily
A. Accurate dose delivery
B. Shorter injection time 30. A male client has undergone spinal surgery, the
C. Lower cost with reusable insulin cartridges nurse should:
D. Use of smaller gauge needle. A. Observe the client’s bowel movement and
voiding patterns
25. A male client’s left tibia is fractures in an B. Log-roll the client to prone position
automobile accident, and a cast is applied. To C. Assess the client’s feet for sensation and
assess for damage to major blood vessels from the circulation
fracture tibia, the nurse in charge should monitor D. Encourage client to drink plenty of fluids
the client for:
A. Swelling of the left thigh 31. Marina with acute renal failure moves into the
B. Increased skin temperature of the foot diuretic phase after one week of therapy. During
C. Prolonged reperfusion of the toes after blanching this phase the client must be assessed for signs of
D. Increased blood pressure developing:
A. Hypovolemia
26. After a long leg cast is removed, the male client B. renal failure
should: C. metabolic acidosis
A. Cleanse the leg by scrubbing with a brisk motion D. hyperkalemia
B. Put leg through full range of motion twice daily
C. Report any discomfort or stiffness to the 32. Nurse Judith obtains a specimen of clear nasal
physician drainage from a client with a head injury. Which of
D. Elevate the leg when sitting for long periods of the following tests differentiates mucus from
time. cerebrospinal fluid (CSF)?
A. Protein
27. While performing a physical assessment of a B. Specific gravity
male client with gout of the great toe, NurseVivian C. Glucose
should assess for additional tophi (urate deposits) D. Microorganism
on the:
A. Buttocks 33. A 22 year old client suffered from his first
B. Ears tonic-clonic seizure. Upon awakening the client
C. Face asks the nurse, “What caused me to have a
D. Abdomen seizure? Which of the following would the nurse
include in the primary cause of tonic clonic seizures
28. Nurse Katrina would recognize that the in adults more the 20 years?
demonstration of crutch walking with tripod gait was A. Electrolyte imbalance
understood when the client places weight on the: B. Head trauma
A. Palms of the hands and axillary regions C. Epilepsy
B. Palms of the hand D. Congenital defect
34. What is the priority nursing assessment in the 40. A 65 year old female is experiencing flare up of
first 24 hours after admission of the client with pruritus. Which of the client’s action could
thrombotic CVA? aggravate the cause of flare ups?
A. Pupil size and papillary response A. Sleeping in cool and humidified environment
B. cholesterol level B. Daily baths with fragrant soap
C. Echocardiogram C. Using clothes made from 100% cotton
D. Bowel sounds D. Increasing fluid intake

35. Nurse Linda is preparing a client with multiple 41. Atropine sulfate (Atropine) is contraindicated in
sclerosis for discharge from the hospital to home. all but one of the following client?
Which of the following instruction is most A. A client with high blood
appropriate? B. A client with bowel obstruction
A. “Practice using the mechanical aids that you will C. A client with glaucoma
need when future disabilities arise”. D. A client with U.T.I
B. “Follow good health habits to change the course
of the disease”. 42. Among the following clients, which among them
C. “Keep active, use stress reduction strategies, is high risk for potential hazards from the surgical
and avoid fatigue. experience?
D. “You will need to accept the necessity for a quiet A. 67-year-old client
and inactive lifestyle”. B. 49-year-old client
C. 33-year-old client
36. The nurse is aware the early indicator of D. 15-year-old client
hypoxia in the unconscious client is:
A. Cyanosis 43. Nurse Jon assesses vital signs on a client
B. Increased respirations undergone epidural anesthesia. Which of the
C. Hypertension following would the nurse assess next?
D. Restlessness A. Headache
B. Bladder distension
37. A client is experiencing spinal shock. Nurse C. Dizziness
Myrna should expect the function of the bladder to D. Ability to move legs
be which of the following?
A. Normal 44. Nurse Katrina should anticipate that all of the
B. Atonic following drugs may be used in the attempt to
C. Spastic control the symptoms of Meniere’s disease except:
D. Uncontrolled A. Antiemetics
B. Diuretics
38. Which of the following stage the carcinogen is C. Antihistamines
irreversible? D. Glucocorticoids
A. Progression stage
B. Initiation stage 45. Which of the following complications associated
C. Regression stage with tracheostomy tube?
D. Promotion stage A. Increased cardiac output
B. Acute respiratory distress syndrome (ARDS)
39. Among the following components thorough pain C. Increased blood pressure
assessment, which is the most significant? D. Damage to laryngeal nerves
A. Effect
B. Cause 46. Nurse Faith should recognize that fluid shift in
C. Causing factors an client with burn injury results from increase in
D. Intensity the:
A. Total volume of circulating whole blood
B. Total volume of intravascular plasma
C. Permeability of capillary walls
D. Permeability of kidney tubules

47. An 83-year-old woman has several ecchymotic

areas on her right arm. The bruises are probably
caused by:
A. increased capillary fragility and permeability
B. increased blood supply to the skin
C. self inflicted injury
D. elder abuse

48. Nurse Anna is aware that early adaptation of

client with renal carcinoma is:
A. Nausea and vomiting
B. flank pain
C. weight gain
D. intermittent hematuria

49. A male client with tuberculosis asks Nurse

Brian how long the chemotherapy must be
continued. Nurse Brian’s accurate reply would be:
A. 1 to 3 weeks
B. 6 to 12 months
C. 3 to 5 months
D. 3 years and more

50. A client has undergone laryngectomy. The

immediate nursing priority would be:
A. Keep trachea free of secretions
B. Monitor for signs of infection
C. Provide emotional support
D. Promote means of communication