MEDICAL SURGICAL NURSING

1. A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse Patricia consults
the physician about withholding which regularly scheduled medication on the day before the
surgery?
a. Potassium Chloride
b. Warfarin Sodium
c. Furosemide
d. Docusate

2. A nurse is planning to assess the corneal reflex on unconscious client. Which of the
following is the safest stimulus to touch the client’s cornea?
a. Cotton buds
b. Sterile glove
c. Sterile tongue depressor
d. Wisp of cotton

3. A female client develops an infection at the catheter insertion site. The nurse in charge uses
the term “iatrogenic” when describing the infection because it resulted from:
a. Client’s developmental level
b. Therapeutic procedure
c. Poor hygiene
d. Inadequate dietary patterns

4. Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognize
bradykinesia when the client exhibits:
a. Intentional tremor
b. Paralysis of limbs
c. Muscle spasm
d. Lack of spontaneous movement

5. A client who suffered from automobile accident complains of seeing frequent flashes of light.
The nurse should expect:
a. Myopia
b. Detached retina
c. Glaucoma
d. Scleroderma

6. Kate with severe head injury is being monitored by the nurse for increasing intracranial
pressure (ICP). Which finding should be most indicative sign of increasing intracranial
pressure?
a. Intermittent tachycardia
b. Polydipsia
c. Tachypnea
d. Increased restlessness
7. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure
the nurse priority should be:
a. Hold the clients arms and leg firmly
b. Place the client immediately to soft surface
c. Protects the client’s head from injury
d. Attempt to insert a tongue depressor between the client’s teeth

8. A client has undergone right pneumonectomy. When turning the client, the nurse should
plan to position the client either:
a. Right side-lying position or supine
b. High fowlers
c. Right or left side lying position
d. Low fowler’s position

9. Nurse Jenny should caution a female client who is sexually active in taking Isoniazid (INH)
because the drug has which of the following side effects?
a. Prevents ovulation
b. Has a mutagenic effect on ova
c. Decreases the effectiveness of oral contraceptives
d. Increases the risk of vaginal infection

10. A client has undergone gastrectomy. Nurse Jovy is aware that the best position for the client
is:
a. Left side lying
b. Low fowler’s
c. Prone
d. Supine

11. During the initial postoperative period of the client’s stoma. The nurse evaluates which of the
following observations should be reported immediately to the physician?
a. Stoma is dark red to purple
b. Stoma is oozes a small amount of blood
c. Stoma is lightly edematous
d. Stoma does not expel stool

12. Kate which has diagnosed with ulcerative colitis is following physician’s order for bed rest
with bathroom privileges. What is the rationale for this activity restriction?
a. Prevent injury
b. Promote rest and comfort
c. Reduce intestinal peristalsis
d. Conserve energy

13. Nurse KC should regularly assess the client’s ability to metabolize the total parenteral
nutrition (TPN) solution adequately by monitoring the client for which of the following signs:
a. Hyperglycemia
b. Hypoglycemia
c. Hypertension
d. Elevate blood urea nitrogen concentration
14. A female client has an acute pancreatitis. Which of the following signs and symptoms the
nurse would expect to see?
a. Constipation
b. Hypertension
c. Ascites
d. Jaundice

15. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following
symptoms might indicate tetany?
a. Tingling in the fingers
b. Pain in hands and feet
c. Tension on the suture lines
d. Bleeding on the back of the dressing

16. A 58 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the
signs and symptoms of hypothyroidism include:
a. Diarrhea
b. Vomiting
c. Tachycardia
d. Weight gain

17. A client has undergone for an ileal conduit, the nurse in charge should closely monitor the
client for occurrence of which of the following complications related to pelvic surgery?
a. Ascites
b. Thrombophlebitis
c. Inguinal hernia
d. Peritonitis

18. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice
“clear”. What should be the action of the nurse?
a. Places conductive gel pads for defibrillation on the client’s chest
b. Turn off the mechanical ventilator
c. Shuts off the client’s IV infusion
d. Steps away from the bed and make sure all others have done the same

19. A client has been diagnosed with glomerulonephritis complains of thirst. The nurse should
offer:
a. Juice
b. Ginger ale
c. Milk shake
d. Hard candy

20. A client with acute renal failure is aware that the most serious complication of this condition
is:
a. Constipation
b. Anemia
c. Infection
d. Platelet dysfunction
21. Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic
function that the client loss during the induction of anesthesia is:
a. Consciousness
b. Gag reflex
c. Respiratory movement
d. Corneal reflex

22. The nurse is assessing a client with pleural effusion. The nurse expect to find:
a. Deviation of the trachea towards the involved side
b. Reduced or absent of breath sounds at the base of the lung
c. Moist crackles at the posterior of the lungs
d. Increased resonance with percussion of the involved area

23. A client admitted with newly diagnosed with Hodgkin’s disease. Which of the following would
the nurse expect the client to report?
a. Lymph node pain
b. Weight gain
c. Night sweats
d. Headache

24. A client has suffered from fall and sustained a leg injury. Which appropriate question would
the nurse ask the client to help determine if the injury caused fracture?
a. “Is the pain sharp and continuous?”
b. “Is the pain dull ache?”
c. “Does the discomfort feel like a cramp?”
d. “Does the pain feel like the muscle was stretched?”

25. The Nurse is assessing the client’s casted extremity for signs of infection. Which of the
following findings is indicative of infection?
a. Edema
b. Weak distal pulse
c. Coolness of the skin
d. Presence of “hot spot” on the cast

26. Nurse Rhia is performing an otoscopic examination on a female client with a suspected
diagnosis of mastoiditis. Nurse Rhia would expect to note which of the following if this
disorder is present?
a. Transparent tympanic membrane
b. Thick and immobile tympanic membrane
c. Pearly colored tympanic membrane
d. Mobile tympanic membrane

27. Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low suction.
Nurse Jocelyn assesses the client for symptoms of which acid-base disorder?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
28. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for
analysis. Which of the following values should be negative if the CSF is normal?
a. Red blood cells
b. White blood cells
c. Insulin
d. Protein

29. A client is suspected of developing diabetes insipidus. Which of the following is the most
effective assessment?
a. Taking vital signs every 4 hours
b. Monitoring blood glucose
c. Assessing ABG values every other day
d. Measuring urine output hourly

30. A 58 year old client is suffering from acute phase of rheumatoid arthritis. Which of the
following would the nurse in charge identify as the lowest priority of the plan of care?
a. Prevent joint deformity
b. Maintaining usual ways of accomplishing task
c. Relieving pain
d. Preserving joint function

31. Among the following, which client is autotransfusion possible?

a. Client with AIDS
b. Client with ruptured bowel
c. Client who is in danger of cardiac arrest
d. Client with wound infection

32. Which of the following is not a sign of thromboembolism?

a. Edema
b. Swelling
c. Redness
d. Coolness

33. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action
should the nurse implement to prevent aspiration?
a. Position the client on the side with head flexed forward
b. Elevate the head
c. Use tongue depressor between teeth
d. Loosen restrictive clothing

34. A client has undergone bone biopsy. Which nursing action should the nurse provide after
the procedure?
a. Administer analgesics via IM
b. Monitor vital signs
c. Monitor the site for bleeding, swelling and hematoma formation
d. Keep area in neutral position
35. A client is suffering from low back pain. Which of the following exercises will strengthen the
lower back muscle of the client?
a. Tennis
b. Basketball
c. Diving
d. Swimming

36. A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The
nurse should monitor for:
a. (+) guaiac stool test
b. Slow, strong pulse
c. Sudden, severe abdominal pain
d. Increased bowel sounds

37. A client has undergone surgery for retinal detachment. Which of the following goal should be
prioritized?
a. Prevent an increase intraocular pressure
b. Alleviate pain
c. Maintain darkened room
d. Promote low-sodium diet

38. A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is
for:
a. Constricting pupil
b. Relaxing ciliary muscle
c. Constricting intraocular vessel
d. Paralyzing ciliary muscle

39. When suctioning an unconscious client, which nursing intervention should the nurse
prioritize in maintaining cerebral perfusion?
a. Administer diuretics
b. Administer analgesics
c. Provide hygiene
d. Hyperoxygenate before and after suctioning

40. When discussing breathing exercises with a postoperative client, Nurse Hazel should
include which of the following teaching?
a. Short frequent breaths
b. Exhale with mouth open
c. Exercise twice a day
d. Place hand on the abdomen and feel it rise

41. Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s
comfort, the nurse should:
a. Maintain room humidity below 40%
b. Place top sheet on the client
c. Limit the occurrence of drafts
d. Keep room temperature at 80 degrees
42. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because this
graft will:
a. Relieve pain and promote rapid epithelialization
b. Be sutured in place for better adherence
c. Debride necrotic epithelium
d. Concurrently used with topical antimicrobials

43. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, “I
can’t eat all this food”. The food that the nurse should suggest to be eaten first should be:
a. Meat loaf and coffee
b. Meat loaf and strawberries
c. Tomato soup and apple pie
d. Tomato soup and buttered bread

44. Tony returns form surgery with permanent colostomy. During the first 24 hours the
colostomy does not drain. The nurse should be aware that:
a. Proper functioning of nasogastric suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery

45. When teaching a client about the signs of colorectal cancer, Nurse Trish stresses that the
most common complaint of persons with colorectal cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits

46. Louis develops peritonitis and sepsis after surgical repair of ruptures diverticulum. The nurse
in charge should expect an assessment of the client to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds

47. Immediately after liver biopsy, the client is placed on the right side, the nurse is aware that
that this position should be maintained because it will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary ducts
c. Position with greatest comfort
d. Promote circulating blood volume

48. Tony has diagnosed with hepatitis A. The information from the health history that is most
likely linked to hepatitis A is:
a. Exposed with arsenic compounds at work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants
49. Nurse Trish is aware that the laboratory test result that most likely would indicate acute
pancreatitis is an elevated:
a. Serum bilirubin level
b. Serum amylase level
c. Potassium level
d. Sodium level

50. Dr. Marquez orders serum electrolytes. To determine the effect of persistent vomiting, Nurse
Trish should be most concerned with monitoring the:
a. Chloride and sodium levels
b. Phosphate and calcium levels
c. Protein and magnesium levels
d. Sulfate and bicarbonate levels

51. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the
development of cerebral edema after surgery, the nurse should expect the use of:
a. Diuretics
b. Antihypertensive
c. Steroids
d. Anticonvulsants

52. Halfway through the administration of blood, the female client complains of lumbar pain.
After stopping the infusion Nurse Hazel should:
a. Increase the flow of normal saline
b. Assess the pain further
c. Notify the blood bank
d. Obtain vital signs.

53. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which
of the following:
a. A history of high risk sexual behaviors.
b. Positive ELISA and western blot tests
c. Identification of an associated opportunistic infection
d. Evidence of extreme weight loss and high fever

54. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure
recognizes an adequate amount of high-biologic-value protein when the food the client
selected from the menu was:
a. Raw carrots
b. Apple juice
c. Whole wheat bread
d. Cottage cheese

55. Kenneth who has diagnosed with uremic syndrome has the potential to develop
complications. Which among the following complications should the nurse anticipates:
a. Flapping hand tremors
b. An elevated hematocrit level
c. Hypotension
d. Hypokalemia
56. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant
assessment would be:
a. Flank pain radiating in the groin
b. Distention of the lower abdomen
c. Perineal edema
d. Urethral discharge

57. A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was
edematous and painful. The nurse should:
a. Assist the client with sitz bath
b. Apply war soaks in the scrotum
c. Elevate the scrotum using a soft support
d. Prepare for a possible incision and drainage.

58. Nurse hazel receives emergency laboratory results for a client with chest pain and
immediately informs the physician. An increased myoglobin level suggests which of the
following?
a. Liver disease
b. Myocardial damage
c. Hypertension
d. Cancer

59. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms
associated with congestion in the:
a. Right atrium
b. Superior vena cava
c. Aorta
d. Pulmonary

60. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would
be:
a. Ineffective health maintenance
b. Impaired skin integrity
c. Deficient fluid volume
d. Pain

61. Nurse Hazel teaches the client with angina about common expected side effects of
nitroglycerin including:
a. high blood pressure
b. stomach cramps
c. headache
d. shortness of breath

62. The following are lipid abnormalities. Which of the following is a risk factor for the
development of atherosclerosis and PVD?
a. High levels of low density lipid (LDL) cholesterol
b. High levels of high density lipid (HDL) cholesterol
c. Low concentration triglycerides
d. Low levels of LDL cholesterol.
63. Which of the following represents a significant risk immediately after surgery for repair of
aortic aneurysm?
a. Potential wound infection
b. Potential ineffective coping
c. Potential electrolyte balance
d. Potential alteration in renal perfusion

64. Nurse Josie should instruct the client to eat which of the following foods to obtain the best
supply of Vitamin B12?
a. dairy products
b. vegetables
c. Grains
d. Broccoli

65. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which
of the following physiologic functions?
a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
d. Intake and out put

66. Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in
charge final assessment would be:
a. signed consent
b. vital signs
c. name band
d. empty bladder

67. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
a. 4 to 12 years.
b. 20 to 30 years
c. 40 to 50 years
d. 60 60 70 years

68. Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical
manifestations may indicate all of the following except
a. effects of radiation
b. chemotherapy side effects
c. meningeal irritation
d. gastric distension

69. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of
the following is contraindicated with the client?
a. Administering Heparin
b. Administering Coumadin
c. Treating the underlying cause
d. Replacing depleted blood products
70. Which of the following findings is the best indication that fluid replacement for the client with
hypovolemic shock is adequate?
a. Urine output greater than 30ml/hr
b. Respiratory rate of 21 breaths/minute
c. Diastolic blood pressure greater than 90 mmhg
d. Systolic blood pressure greater than 110 mmhg

71. Which of the following signs and symptoms would Nurse Maureen include in teaching plan
as an early manifestation of laryngeal cancer?
a. Stomatitis
b. Airway obstruction
c. Hoarseness
d. Dysphagia

72. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse
understands that this therapy is effective because it:
a. Promotes the removal of antibodies that impair the transmission of impulses
b. Stimulates the production of acetylcholine at the neuromuscular junction.
c. Decreases the production of autoantibodies that attack the acetylcholine receptors.
d. Inhibits the breakdown of acetylcholine at the neuromuscular junction.

73. A female client is receiving IV Mannitol. An assessment specific to safe administration of the
said drug is:
a. Vital signs q4h
b. Weighing daily
c. Urine output hourly
d. Level of consciousness q4h

74. Patricia a 20 year old college student with diabetes mellitus requests additional information
about the advantages of using a pen like insulin delivery devices. The nurse explains that
the advantages of these devices over syringes includes:
a. Accurate dose delivery
b. Shorter injection time
c. Lower cost with reusable insulin cartridges
d. Use of smaller gauge needle.

75. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To
assess for damage to major blood vessels from the fracture tibia, the nurse in charge should
monitor the client for:
a. Swelling of the left thigh
b. Increased skin temperature of the foot
c. Prolonged reperfusion of the toes after blanching
d. Increased blood pressure

76. After a long leg cast is removed, the male client should:
a. Cleanse the leg by scrubbing with a brisk motion
b. Put leg through full range of motion twice daily
c. Report any discomfort or stiffness to the physician
d. Elevate the leg when sitting for long periods of time.
77. While performing a physical assessment of a male client with gout of the great toe, Nurse
Vivian should assess for additional tophi (urate deposits) on the:
a. Buttocks
b. Ears
c. Face
d. Abdomen

78. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was
understood when the client places weight on the:
a. Palms of the hands and axillary regions
b. Palms of the hand
c. Axillary regions
d. Feet, which are set apart

79. Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in
bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose
should encourage:
a. Active joint flexion and extension
b. Continued immobility until pain subsides
c. Range of motion exercises twice daily
d. Flexion exercises three times daily

80. A male client has undergone spinal surgery, the nurse should:
a. Observe the client’s bowel movement and voiding patterns
b. Log-roll the client to prone position
c. Assess the client’s feet for sensation and circulation
d. Encourage client to drink plenty of fluids

81. Marina with acute renal failure moves into the diuretic phase after one week of therapy.
During this phase the client must be assessed for signs of developing:
a. Hypovolemia
b. renal failure
c. metabolic acidosis
d. hyperkalemia

82. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury.
Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
a. Protein
b. Specific gravity
c. Glucose
d. Microorganism

83. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client
asks the nurse, “What caused me to have a seizure? Which of the following would the nurse
include in the primary cause of tonic clonic seizures in adults more the 20 years?
a. Electrolyte imbalance
b. Head trauma
c. Epilepsy
d. Congenital defect
84. What is the priority nursing assessment in the first 24 hours after admission of the client with
thrombotic CVA?
a. Pupil size and papillary response
b. cholesterol level
c. Echocardiogram
d. Bowel sounds

85. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to
home. Which of the following instruction is most appropriate?
a. “Practice using the mechanical aids that you will need when future disabilities arise”.
b. “Follow good health habits to change the course of the disease”.
c. “Keep active, use stress reduction strategies, and avoid fatigue.
d. “You will need to accept the necessity for a quiet and inactive lifestyle”.

86. The nurse is aware the early indicator of hypoxia in the unconscious client is:
a. Cyanosis
b. Increased respirations
c. Hypertension
d. Restlessness

87. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder
to be which of the following?
a. Normal
b. Atonic
c. Spastic
d. Uncontrolled

88. Which of the following stage the carcinogen is irreversible?

a. Progression stage
b. Initiation stage
c. Regression stage
d. Promotion stage

89. Among the following components thorough pain assessment, which is the most significant?
a. Effect
b. Cause
c. Causing factors
d. Intensity

90. A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could
aggravate the cause of flare ups?
a. Sleeping in cool and humidified environment
b. Daily baths with fragrant soap
c. Using clothes made from 100% cotton
d. Increasing fluid intake
91. Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
a. A client with high blood
b. A client with bowel obstruction
c. A client with glaucoma
d. A client with U.T.I

92. Among the following clients, which among them is high risk for potential hazards from the
surgical experience?
a. 67-year-old client
b. 49-year-old client
c. 33-year-old client
d. 15-year-old client
93. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the
following would the nurse assess next?
a. Headache
b. Bladder distension
c. Dizziness
d. Ability to move legs

94. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to
control the symptoms of Meniere’s disease except:
a. Antiemetics
b. Diuretics
c. Antihistamines
d. Glucocorticoids

95. Which of the following complications associated with tracheostomy tube?

a. Increased cardiac output
b. Acute respiratory distress syndrome (ARDS)
c. Increased blood pressure
d. Damage to laryngeal nerves

96. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase
in the:
a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules

97. 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

98. 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
99. 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

100. 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
ANSWERS and RATIONALES:

1. B. In preoperative period, the nurse should consult with the physician about withholding
Warfarin Sodium to avoid occurrence of hemorrhage.
2. D. A client who is unconscious is at greater risk for corneal abrasion. For this reason, the
safest way to test the cornel reflex is by touching the cornea lightly with a wisp of cotton.
3. B. Iatrogenic infection is caused by the heath care provider or is induced inadvertently by
medical treatment or procedures.
4. D. Bradykinesia is slowing down from the initiation and execution of movement.
5. B. This symptom is caused by stimulation of retinal cells by ocular movement.
6. D. Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular
activating system.
7. C. Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause
repeated banging of head.
8. A. Right side lying position or supine position permits ventilation of the remaining lung and
prevent fluid from draining into sutured bronchial stump.
9. A. Isoniazid (INH) interferes in the effectiveness of oral contraceptives and clients of
childbearing age should be counseled to use an alternative form of birth control while taking
this drug.
10. B. A client who has had abdominal surgery is best placed in a low fowler’s position. This
relaxes abdominal muscles and provides maximum respiratory and cardiovascular function.
11. A. Dark red to purple stoma indicates inadequate blood supply.
12. C. The rationale for activity restriction is to help reduce the hypermotility of the colon.
13. A. During Total Parenteral Nutrition (TPN) administration, the client should be monitored
regularly for hyperglycemia.
14. D. Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct.
15. A. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or
removed.
16. D. Typical signs of hypothyroidism includes weight gain, fatigue, decreased energy, apathy,
brittle nails, dry skin, cold intolerance, constipation and numbness.
17. B. After a pelvic surgery, there is an increased chance of thrombophlebitits owing to the
pelvic manipulation that can interfere with circulation and promote venous stasis.
18. D. For the safety of all personnel, if the defibrillator paddles are being discharged, all
personnel must stand back and be clear of all the contact with the client or the client’s bed.
19. D. Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid.
20. C. Infection is responsible for one third of the traumatic or surgically induced death of clients
with renal failure as well as medical induced acute renal failure (ARF)
21. C. There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration
is depressed but present.
22. B. Compression of the lung by fluid that accumulates at the base of the lungs reduces
expansion and air exchange.
23. C. Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless
lymph node, fever, malaise and night sweats.
24. A. Fractured pain is generally described as sharp, continuous, and increasing in frequency.
25. D. Signs and symptoms of infection under a casted area include odor or purulent drainage
and the presence of “hot spot” which are areas on the cast that are warmer than the others.
26. B. Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick and immobile
tymphanic membrane with or without perforation.
27. D. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis
because of the loss of hydrochloric acid which is a potent acid in the body.
28. A. The adult with normal cerebrospinal fluid has no red blood cells.
29. D. Measuring the urine output to detect excess amount and checking the specific gravity of
urine samples to determine urine concentration are appropriate measures to determine the
onset of diabetes insipidus.
30. B. The nurse should focus more on developing less stressful ways of accomplishing routine
task.
31. C. Autotransfusion is acceptable for the client who is in danger of cardiac arrest.
32. D. The client with thromboembolism does not have coolness.
33. A. Positioning the client on one side with head flexed forward allows the tongue to fall
forward and facilitates drainage secretions therefore prevents aspiration.
34. C. Nursing care after bone biopsy includes close monitoring of the punctured site for
bleeding, swelling and hematoma formation.
35. D. Walking and swimming are very helpful in strengthening back muscles for the client
suffering from lower back pain.
36. C. Sudden, severe abdominal pain is the most indicative sign of perforation. When
perforation of an ulcer occurs, the nurse maybe unable to hear bowel sounds at all.
37. A. After surgery to correct a detached retina, prevention of increased intraocular pressure is
the priority goal.
38. A. Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the
filtration angle and permit increased out flow of aqueous humor.
39. D. It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia
and to maintain cerebral perfusion.
40. D. Abdominal breathing improves lungs expansion
41. C. A Client with burns is very sensitive to temperature changes because heat is loss in the
burn areas.
42. A. The graft covers the nerve endings, which reduces pain and provides framework for
granulation
43. B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.
44. C. This is primarily caused by the trauma of intestinal manipulation and the depressive
effects anesthetics and analgesics.
45. D. Constipation, diarrhea, and/or constipation alternating with diarrhea are the most
common symptoms of colorectal cancer.
46. B. With increased intraabdominal pressure, the abdominal wall will become tender and rigid.
47. A. Pressure applied in the puncture site indicates that a biliary vessel was puncture which is
a common complication after liver biopsy.
48. B. Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the
virus.
49. B. Amylase concentration is high in the pancreas and is elevated in the serum when the
pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute
abdominal problems.
50. A. Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with
vomiting. Chloride, which balances cations in the extracellular compartments, is also lost
with vomiting, because sodium and chloride are parallel electrolytes, hyponatremia will
accompany.
51. C. Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases
the development of edema.
52. A. The blood must be stopped at once, and then normal saline should be infused to keep
the line patent and maintain blood volume.
53. B. These tests confirm the presence of HIV antibodies that occur in response to the
presence of the human immunodeficiency virus (HIV).
54. D. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of
fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV)
 contain optimal levels of amino acids essential for life.
55. A. Elevation of uremic waste products causes irritation of the nerves, resulting in flapping
hand tremors.
56. B. This indicates that the bladder is distended with urine, therefore palpable.
57. C. Elevation increases lymphatic drainage, reducing edema and pain.
58. B. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has
occurred.
59. D. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the
left ventricle because there is no valve to prevent back ward flow into the pulmonary vein,
the pulmonary circulation is under pressure.
60. A. Managing hypertension is the priority for the client with hypertension. Clients with
hypertension frequently do not experience pain, deficient volume, or impaired skin integrity.
It is the asymptomatic nature of hypertension that makes it so difficult to treat.
61. C. Because of its widespread vasodilating effects, nitroglycerin often produces side effects
such as headache, hypotension and dizziness.
62. A. An increased in LDL cholesterol concentration has been documented at risk factor for the
development of atherosclerosis. LDL cholesterol is not broken down into the liver but is
deposited into the wall of the blood vessels.
63. D. There is a potential alteration in renal perfusion manifested by decreased urine output.
The altered renal perfusion may be related to renal artery embolism, prolonged hypotension,
or prolonged aortic cross- clamping during the surgery.
64. A. Good source of vitamin B12 are dairy products and meats.
65. C. Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and
platelets. The client is at risk for bruising and bleeding tendencies.
66. B. An elective procedure is scheduled in advance so that all preparations can be completed
ahead of time. The vital signs are the final check that must be completed before the client
leaves the room so that continuity of care and assessment is provided for.
67. A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is
uncommon after 15 years of age.
68. D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the
central nervous system, and clients experience headaches and vomiting from meningeal
irritation.
69. B. Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral
anticoagulants such as Coumadin.
70. A. Urine output provides the most sensitive indication of the client’s response to therapy for
hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
71. C. Early warning signs of laryngeal cancer can vary depending on tumor location.
Hoarseness lasting 2 weeks should be evaluated because it is one of the most common
warning signs.
72. C. Steroids decrease the body’s immune response thus decreasing the production of
antibodies that attack the acetylcholine receptors at the neuromuscular junction
73. C. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal
function or heart failure because it increases the intravascular volume that must be filtered
and excreted by the kidney.
74. A. These devices are more accurate because they are easily to used and have improved
adherence in insulin regimens by young people because the medication can be
administered discreetly.
75. C. Damage to blood vessels may decrease the circulatory perfusion of the toes, this would
indicate the lack of blood supply to the extremity.
76. D. Elevation will help control the edema that usually occurs.
77. B. Uric acid has a low solubility, it tends to precipitate and form deposits at various sites
 where blood flow is least active, including cartilaginous tissue such as the ears.
78. B. The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
79. A. Active exercises, alternating extension, flexion, abduction, and adduction, mobilize
exudates in the joints relieves stiffness and pain.
80. C. Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs
notify physician immediately.
81. A. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3
to 5 liters daily, hypovolemia may occur and fluids should be replaced.
82. C. The constituents of CSF are similar to those of blood plasma. An examination for glucose
content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally
contains glucose.
83. B. Trauma is one of the primary cause of brain damage and seizure activity in adults. Other
common causes of seizure activity in adults include neoplasms, withdrawal from drugs and
alcohol, and vascular disease.
84. A. It is crucial to monitor the pupil size and papillary response to indicate changes around
the cranial nerves.
85. C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay
active, use stress reduction techniques and avoid fatigue because it is important to support
the immune system while remaining active.
86. D. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in
unconscious client who suddenly becomes restless.
87. B. In spinal shock, the bladder becomes completely atonic and will continue to fill unless the
client is catheterized.
88. A. Progression stage is the change of tumor from the preneoplastic state or low degree of
malignancy to a fast growing tumor that cannot be reversed.
89. D. Intensity is the major indicative of severity of pain and it is important for the evaluation of
the treatment.
90. B. The use of fragrant soap is very drying to skin hence causing the pruritus.
91. C. Atropine sulfate is contraindicated with glaucoma patients because it increases
intraocular pressure.
92. A. A 67 year old client is greater risk because the older adult client is more likely to have a
less-effective immune system.
93. B. The last area to return sensation is in the perineal area, and the nurse in charge should
monitor the client for distended bladder.
94. D. Glucocorticoids play no significant role in disease treatment.
95. D. Tracheostomy tube has several potential complications including bleeding, infection and
laryngeal nerve damage.
96. C. In burn, the capillaries and small vessels dilate, and cell damage cause the release of a
histamine-like substance. The substance causes the capillary walls to become more
permeable and significant quantities of fluid are lost.
97. A. Aging process involves increased capillary fragility and permeability. Older adults have a
decreased amount of subcutaneous fat and cause an increased incidence of bruise like
lesions caused by collection of extravascular blood in loosely structured dermis.
98. D. Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary
erosion by the cancerous growth.
99. B. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated.
Usually a combination of three drugs is used for minimum of 6 months and at least six
months beyond culture conversion.
100. A. Patent airway is the most priority; therefore removal of secretions is necessary.