COMPREHENSIVE EXAM 1A

CGFNS BOOTCAMP
55) B: Speak softly before gently
touching the patient
Many patients have reported being
able to hear when being in a
comatose state.
The nurse should always converse
as if the patient was alert and
oriented.
Explain procedures even in patients
who are comatose
The family should be encouraged to
do the same
56) C: Smoking cessation
Smoking should receive the highest
priority when trying to reduce the
risk factors for with respiratory
complications.
Losing weight and decreasing salt
and caffeine intake can help to
decrease the risk factors for
hypertension
57) B: Over the central airways
Bronchoalveolar breath sounds
(loud and coarse)  central airways
Tracheal breath sounds trachea
Vesicular breath sounds
peripheral lung field
58) B: Offer him water.
Inadequate hydration can cause
sputum to become thick and
difficult to expectorate.
The patient needs to increase his
oral intake of water and fruit juices.
Milk thickens the sputum
IV fluids are necessary only if the
patient’s oral intake is inadequate
59) A: Pyridoxine (Vitamin B6)
Pyridoxine commonly is
administered to minimize
peripheral neuropathy
associated with INH.
60) A: Increased parasympathetic
tone
Vagal stimulation increases
parasympathetic tone, which
decreases the heart rate and may
slow atrioventricular conduction
61) D. Requires membership of
nursing faculty to the PNA
 Other Functions of The Board of
Nursing:
1. Conduct licensure exam
2. Monitor & enforce quality
standards of nursing practice
3. Ensure quality education by
examining facilities of
colleges/universities of nursing
4. Adopt & promulgate Code of
Ethics &
5. Recognize nursing specialty
organization
6. Prescribe , adopt, issue &
promulgate guidelines, regulations,
measures & decisions necessary for
the improvement of nursing practice
7. Submit annual report to the
Commission
8. Initiate, undertake & conduct
studies & research
62) A. A written contract can be
changed legally by an oral
agreement
REQUISITES OF A CONTRACT:
1. Two or more persons must participate to
have a contract
2. Parties involve must give consent
3. Object as subj matter must be specified
4. Cause of obligation is established
5. Contracting parties must be of legal
capacity to enter into a contract
63) D. Laws are principle and
processes that resolve dispute by
coercion
LAW IS DEFINED AS: sum total of rules &
regulations by which society is governed.
- It is man-made & regulates social conduct
in a formal & binding way
- It reflects society’s needs, attitudes &
mores
- Rule of conduct pronounced by
controlling authority & which may be
enforced
64) C. it has legal guarantee
The Code of Ethics for Filipino
Nurses requires that nurses adhere
to accepted principles of proper
decorum ( eg. wearing proper
uniform, moral principles, etc.)
Hallmark of true professionals is
their willingness to accept a set of
professional & ethical principles &
follow these in the conduct of their
duties
65) D. Professional competence
To be able to practice SAFE nursing
activities, one must have obtained
PROFESSIONAL COMPETENCE
which one can earn as a nurse
practices her own field.
 66) B. autonomous
CHARACTERISTICS OF A PROFESSION:
1. Education
2. Theory
3. Service
4. Autonomy
5. Code of ethics
6. Caring
67) C. to examine carefully
RESEARCH is defined as: to look into
thoroughly with the use of data
gathering and analysis
68) B. data analysis
Data Collection – gathering of data
thru various methods
Research Outcome – result of the
study
Conclusion –
statement/recommendations
resulting from the study
69) A. consumer & researcher
70) D. experimental design
Pre-post test design – simple design /
almost same as descriptive
Correlational – two different subjects
are studied/tested and described to
determine relations
Quasi-experimental – same as
experimental without the use of
randomization & control group
71) B. progress notes
Medication record – where all drugs
give to the patient are documented
Flow Chart – mostly documents the
vital signs and other pertinent data
such as NVS
Discharge Summary – outlines all
care (diagnostic, medical &
nursing) given to the patient
specifically written before
discharge to serve as summary of
care
72) D. is considered care that is
not provided
73) D. she provided
74) C. the clinical instructor attests
that she has personal knowledge of the
information charted by the student
UNDER PHIL.NSG.ACT 2002 R.A.9173,
nursing students do not perform
professional nursing duties & must
be supervised by CI. The following
measures must be applied:
1. Students should always be under
the supervision of the CIs.
2. They should be given assignments
that are at their level of training,
experience & competence
 3. They are to seek guidance esp. if
they are to perform procedure for the
first time
4. They should be oriented to policies
of the unit they are assigned
5. Their performance should be
assessed frequently to determine
strengths & weaknesses
6. Frequent conferences must be
done.
75) C. owned by the hospital &
should not be given to anyone who
requests other than the doctor in
charge
76) D. descriptive (non-experimental
research to observe, describe & document
aspects of a situation as it naturally occurs)
Quasi Experimental- same as
Experimental but without use of
randomization and control group
Historical – systematic collection &
critical evaluation of data relating to
past occurrences
Experimental – where the researcher
takes an active part. 3 Properties:
manipulation, control and
randomization
77) A. descriptive research
Experimental
Exploratory – begins with a
phenomenon of interest and aimed
at exploring dimensions
Historical
78) D. quasi-experimental research
79) B. historical research
80) B. experimental research
81) A. providing a back rub at
bedtime
82) D. provide continuity of care
83) B. client’s health needs
84) D. Mr. Reyes has been
uncooperative and over-acting
during the day
85) C. the physician must sign the
order with the prescribed time
86) B. standard
87) B. the medical treatment a
client chooses to withhold if he is
rendered unable to make decisions
88) C. what all clients expect
89) C. the choices involved do not
appear to be clearly right or wrong
90) B. veracity
91) C. report the incident to the
doctor and risk her job depending
upon the doctor’s decision
92) C. seek further advice from
the spiritual adviser
93) C. interact with the patient and
continue the care and support for
the patient
94) A. evaluate the client’s LOC
and intellectual capability
95) B. she should not reveal
anything to the visitor because it is
privileged communication
96) B. detects, diagnose & treats
children with health problems
97) D. all of the above
98) C. family health record
99) C. chart is a legal document
100) D. all of the above
Good Luck Trinitians!
38) D: Pain relief with vomiting
When the obstruction is located
high in the intestinal tract, little
room exists for fluids or food.
Vomiting of the gastric contents will
relieve pressure and pain.
39) B: Light Green
 When the obstruction is located high in
the intestinal tract, vomitus will appear
light green because it contains a small
amount of bile.
 When the obstruction is in the lower
part of the intestinal tract, the vomitus
will appear dark green and have a fecal
odor.
 Bright red-colored vomitus appears with
GI bleeding.
40) A: Simple compressed
tablets
 Liquid forms and simple compressed
tablets are the only drug forms that can
be administered through an NG tube.
 Tablets are enteric-coated to prevent
stomach acids from destroying the
drug; crushing the tablets would
decrease their effectiveness.
 Time-release and controlled delivery
drugs are used to produce prolonged
effects; crushing these drugs could
result in overdose.
41)B: Avoid exposure to excessive heat,
crowds and emotional extremes.

The patient should be encouraged

to avoid predisposing factors such
as stress, strenuous exercise,
infection, extreme heat, surgery,
and change in sleep habits.
42) B: Assess the patient for bowel
sounds
 Before removing the client’s NG tube,
the nurse should assess the patient for
bowel sounds.
 If bowel sounds aren't present, the
patient may still have a bowel obstruction
or paralytic ileus, so the tube should not
be removed.
 Ability to chew, hunger and residual
gastric volume of less than 100ml don’t
determine whether an NGT should be
removed.
43) C: Ventricular fibrillation
Although electrolyte disturbances
respiratory arrest, and drug toxicity
can cause cardiac arrest,
ventricular fibrillation is the most
common cause of cardiac arrest.
44) B: Normally the ventilation-
perfusion ratio is 0.8.
Because of gravity and pleural
pressure, ventilation and
perfusion are weakest at the apex
and strongest at the base.
45) D: Uncompensated metabolic
acidosis with hypoxia
 The patient is acidotic.
 The Normal PaCo2 and low HCO3
indicate a metabolic problem not
compensated by the increased
respiratory rate
 The patient may require mechanical
ventilation
46) A: Avoid walking barefoot
 Patients with neuropathy affecting the
legs and feet will have decreased
sensation and may be unaware of
temperature extremes and injury.
 The patient should be advised to wear
shoes and socks and stop smoking if
possible. Vasoconstriction will
exacerbate the problem.
47) D: Liquid to pasty stool
The effluent should be liquid
because the water wont be
removed from the stool as with an
intact colon.
The fecal material becomes more
formed and solid as it moves
through the colon.
48) D: Telling the patient to avoid a
high fiber diet
The dietary teaching plan should
include telling the patient to avoid
high fiber foods that cause
blockage.
The patient should consume plenty
of fluids and be encouraged to
maintain a high calorie diet that is
rich in potassium.
49) B: Very loud musical sound
that usually heard without a
stethoscope
 It’s caused by laryngeal spasm and
mucosal swelling, which contract the
vocal cords and narrow the airway.
 Wheeze is a continuous high pitched
sound that has musical quality.
 Crackle is a short explosive or popping
sound usually heard during inspiration.
 Pleural friction rub is a loud, grating
sound caused by inflamed or damaged
pleurae.
50) A: Decrease the risk of wound
infection
 Neomycin an antibiotic is used to
decrease the bacteria in the bowel
before surgery to reduce the risk of
wound contamination.
 Antibiotics don’t increase the immune
system's response.
 Shallow breathing causes atelectasis
51) A: Risk for injury related to
seizure activity
 Patients with hyponatremia are at high
risk for seizures.
 Nursing interventions should be aimed
at safety and protection , including
padded side rails, administering
supplemental oxygen, and keeping an
oral airway readily available.
 Peripheral edema isn’t associated with
SIADH
52) A: Air hunger and
tachypnea
The patient with left-sided heart
failure typically has air hunger,
tachypnea and orthopnea
Ascites, JVD, and pitting leg edema
are signs of right sided heart
failure, another complication of
cardiomyopathy.
 53) C: Eating lunch
 Pain may be
triggered by
touching the face,
being exposed to a
cool breeze, having
hair touch the face,
talking or chewing.
 54) B: Alteration in skin integrity
related to seepage
Alteration in skin integrity would be
the priority nursing diagnosis  the
effluent from the colostomy can be
irritating to the skin.
Diarrhea isn’t a concern at this point.
The patient will be allowed nothing by
mouth until peristalsis returns.
The patient should get out of bed on
the first postoperative day
55) D: Urinary Tract
Although microorganisms that
cause sepsis syndrome can enter
through the skin, GI tract, or
respiratory tract.
The most common portal of entry is
the urinary tract via urinary
catheters, suprapubic tubes and
cystoscopic examinations.
56) B: Ill keep a log of my daily weight and call the
doctor if I gain 2lb or more without changing my
eating habits.
 Daily weight measurement is the most
accurate means of monitoring hydration
status at home.
 The patient should be encouraged to
increase dietary intake of both sodium
and potassium, particularly if diuretics
are prescribed.
 Pulse checks and urine SG are not
necessary with chronic SIADH.
57)A: Check the position of the
chest tube
 A chest x-ray discloses the position of
the chest tube to determine the
procedure’s effectiveness.
 The x-ray isn’t done to advance the tube,
although the doctor may decide to
adjust the tube after reviewing the x-ray.
 Tomography visualizes a single layer of
the lungs.
 An UTX records sound waves that
penetrate the lung.
58) Basilar fractures
 Otorrhea and rhinorrhea are classic
signs of a basilar skull fracture
 Injury to the dura commonly occurs with
this fracture, resulting in CSF leaking
through the ears and the nose.
 Any fluid suspected of being CSF should
be check for glucose or have a halo test
done.
Signs of Basilar Fracture: Battle
and Raccoon Sign
59) Bring in familiar photographs
that include the patient
 Prosopagnosia
(face blind)
neurological
problem wherein a
person cannot
recognize faces
60) A: Ensure proper placement of the knee as
well as degree of extension and flexion

The purpose of a CPM is to

facilitate joint mobility.
The degree of flexion will be
increased daily to help the patient
regain normal range of motion.
It’s the nurse responsibility to
monitor the degree of flexion
according to the doctor’s orders.
61) B: Inhibit the activity of
osteoclast
 Osteoclasts break down the matrix of
bone and bring about resorption of the
mineral contents.
 Inhibiting osteoclast activity slows the
demineralization of bone.
 Osteoblasts synthesize collagen and
enhance the mineralization of bone.
 Nonhormonal drugs have no effect on
estrogen or vitamin D, both of which are
important
62) C: Blood pressure increases
 Cardiac tamponade is associated with
decreased cardiac output, resulting in
decreased blood pressure.
 Removing a small amount of blood may
improve cardiac output and BP.
 Pericardial blood doesn’t clot rapidly because
its defibrinated by cardiac motion within the
cardiac sac.
 If the blood clots rapidly, the needle may have
entered the heart.
 Patients with cardiac tamponade may have
muffled heart sounds.
63) B: The pain is relieved by rest
and worsened by activity
 The effects of rest and activity on pain is
one of the significant differences
between rheumatoid arthritis and
osteoarthritis.
 A patient with rheumatoid arthritis
experiences morning joint stiffness.
 A patient with osteoarthritis experiences
more pain as the day progresses and
may function better after a night of rest.
64) C: Limiting fluids to 1½ qt in
24 hours
 Minimal IV fluids are provided to reduce
cerebral edema.
 The head of the bed should be at 300 to
facilitate venous return, thus decreasing
intracranial pressure.
 Neurologic assessment should be
performed every 1-2 hours.
 A pillow may be used to promote
comfort
65) B: Apex of the heart
 S1 is best heard
at the apex of the
heart.
 S2-over the base
of the heart
66) C: Restricting fluid intake
 Fluid restriction is essential in treating
chronic SIADH.
 If diuretics are prescribed, sodium and
potassium supplements may be needed.
 A hypertonic sodium chloride IV
solution might be used in the acute
phase of treatment if the patient is
severely hyponatremic
67) C: A severe head injury
The best possible GCS score is 15,
the lowest is 3.
A score of 8 or less indicates coma.
When associated with a new head
injury, it indicates a serious
traumatic injury and the airway may
be compromised and need
intubation.
Glasgow Coma Scale
Best Eye Response.
(4) Best Verbal Response. (5)
 No eye opening.  No verbal response
 Eye opening to  Incomprehensible
pain. sounds.
 Eye opening to  Inappropriate words.
verbal command. Confused
 Eyes open  Orientated
spontaneously.
Continuation
 Best Motor
Response. (6)
– No motor response.
– Extension to pain.
– Flexion to pain.
– Withdrawal from
pain.
– Localizing pain.
– Obeys Commands.
68) B: Prostatic hyperplasia
Promethazine requires cautious
use in a patient with hepatic or
cardiovascular disease, respiratory
or seizure disorder, glaucoma and
prostatic hyperplasia.
69) A: Yogurt and buttermilk
During therapy with any
cephalosporin, the patient should
ingest yogurt or buttermilk, which
replenishes normal GI flora, to
prevent intestinal superinfection
70) B: Hearing loss
Vancomycin is ototoxic
Contraindicated in a pregnant
patient or one with known
hypersensitivity
71) D: Altered tissue perfusion
 Angina is caused by altered tissue
perfusion to the myocardium, which
results in ischemia.
 Treatment is aimed at reversing
ischemia.
 Pain and anxiety should also be
addressed but they don’t take priority
over altered tissue perfusion
 Cardiac output may or may not be
affected with angina.
72) D: Breastmilk
The primary mode of transmission
for Hepatitis A is through fecal
contamination of food or water.
Percutaneous: rare
Sexual transmission: rare and
usually among homosexuals
No known transmission through
breastmilk
73) B: Barky cough
Croup
a group of conditions involving
inflammation of the upper airway
that leads to a characteristic
barking cough, particularly when a
child is crying
74) A: Oxygen therapy
 The patient should be monitored closely
and given low flow oxygen to decrease
chances of depressing the respiratory
drive.
 Increasing fluids to the liquefy
secretions, humidifying the air, and
performing postural drainage are also
important for a patient with acute
bronchitis.
75) C: 30 ml per hour
76) B: Maintaining airway patency
Signs and Symptoms  Asthma symptoms
 An itchy nettlerash  Vomiting
(urticaria, hives)  Cramping tummy pains
 Faintness and  Diarrhea
unconsciousness due to  A tingling feeling in the lips
very low blood pressure. or mouth if the cause was a
Unlike an ordinary food such as nuts
fainting attack, this does
not improve so  Death due to obstruction to
dramatically on lying breathing or extreme low
down. blood pressure
(anaphylactic shock)
 Swelling (angioedema)
 Swelling in the throat,
causing difficulty in
swallowing or breathing
77) C: reddened lesion with central
clearing
78) B: Increased epithelial cells
An increase in epithelial cells
indicate contamination of the urine
sample by the pathogens from the
woman’s vagina or labia.
Bacteria, increased WBC, and pus
are abnormal findings in urine
samples and indicate pathology.
79) A: Myoglobinuria
Myoglobinuria describes the
presence of myoglobin (a muscle
protein) in the urine.
Myoglobin is released if there is
muscle injury or necrosis
(rhabdomyolysis).
Causes of myoglobinuria include
trauma, electrocution, drugs (e.g:
statins, fibrates), toxins (e.g: snake
bite, carbon monoxide, alcohol,
ecstasy
80) B: Narcotic analgesic for
severe pain
Kidney stones are associated with
moderate to severe pain due to
renal colic (pain associated with the
passage of stones
Analgesics can be used to control
renal colic.

81) C: Take the medication on an
empty stomach with water
Didanosine is an antiviral agent.
Decreased absorption and
effectiveness of the drug occurs if
taken with food.
WOF for bone marrow depression
and pancreatitis.
Take the drug 1 hour or 2 hours
before meals.
82) B: Candida albicans
 Other factors that may increase the
incidence of yeast infections are:
– the use of douches
– perfumed feminine hygiene sprays
– topical antimicrobial agents
– tight, poorly ventilated clothing and
underwear.

Whether or not yeast infections can be transmitted

sexually is unknown.
83. D: Alcoholics
 Alcoholics have a decreased intake of
folate.
 Megaloblastic Anemias (MGA)
– rare blood disorders characterized by the
presence of large, structurally and visually
abnormal, immature red blood cells
(megaloblasts).
– decreased numbers and immaturity of white
blood cells (leukocytes) and blood platelets
(thrombocytes) may also occur.
– usually caused by a deficiency or defective
absorption of either vitamin B12 (cobalamin)
or folic acid
84) B: I’ll need to take my
coumadin for awhile
Patients who require valve
replacement must take warfarin
(Coumadin) preoperatively to
prevent clot formation.
The patient wont need an iron
supplement, and she should not
take aspirin while taking warfarin
because of its anticoagulant effect.
85) D: Itching, nausea , vomiting
and urine retention
Narcotics can be given by any
route
Causes sedation, respiratory
depression, hypotension and
confusion
Inadequate pain relief means
inappropriate dosing
86) A: Improve mobility
 The CPM machine flexes and extends
the knee through controlled range of
motion, lessening postoperative
stiffness.
 The motion may increase the amount of
blood evacuated at the joint
86) Continuation
 The CPM machine flexes and extends
the knee through controlled range of
motion
 Lessens stiffness
 Motion may increase the amount of pain
 Motion may also increase the amount of
blood evacuated from the joint
 Anticoagulants are given to reduce the
risk of clot formation
87) B: Take antibiotics before
dental procedures
After joint replacement surgery,
prophylactic use of antibiotics is
recommended before dental
procedure and any time transient
bacteremia is expected.
Prosthesis will be removed if
infected
88. B: Splitting or removing the
cast
Compartment syndrome (CS) is a
limb-threatening and life-
threatening condition observed
when perfusion pressure falls
below tissue pressure in a closed
anatomic space
Long bone fractures are a common
cause of CS
After initial symptoms of pain with
passive stretching or burning
89. C: The Skin is left open
 Fasciotomy is a
surgical
procedure that
cuts away the
fascia to relieve
tension or
pressure
90. B: Uric Acid and ESR
Males: 4.5-8 mg/dl
Females: 2.5-6.2 mg/dl
91. A: His long term use of
hydrodiuril
Side effects: Thiazide diuretics
– Hypokalemia
– Hyperuricemia
– Hyperglycemia
– hypercholesterolemia
92. A: Relieve pain and
inflammation as soon as possible
93. A: Made up of four muscles
and tendons
 The rotator cuff
muscles control
rotation of the
shoulder.
 They consist of the
infraspinatus, teres
minor and
supraspinatus which
rotate the shoulder
outwards and the
subscapularis which
is one of the muscles
which rotate the
shoulder inwards.
94. A: Applying ice initially followed by heat
application and rest for at least one week
 Symptoms also include:
 Pain on overhead activity such as
throwing or racket sports.
 Pain when you bend the arm and rotate it
outwards against resistance.
 Pain on the outside of the shoulder
possibly radiating down into the arm.
 Pain in the shoulder which is worse at
night.
 Stiffness in the shoulder joint.
Conservative treatment for a rotator cuff injury
involves:

– Applying ice initially followed by heat

application and rest for at least 1 week
– Pain medication administration and
resumption of normal activities
– Heat application and range of motion
exercises
– Range of motion exercises and anti-
inflammatory mediation
administration
95. C: With food before 8am
96. D: Wear sunscreen and avoid
exposure to sunlight
Rashes are photosensitive.
Raynaud’s phenomenon is also a
possible outcome for staying in the
sun too long.
97.D: Your fasting blood sugar was abnormal
and needs to be tested once again
98. C: Insulin resistance
99. A: Enhance insulin
sensitivity
100. D: Help him find an option
that fits his lifestyle.
101. A: Edrophonium chloride;
worsening of symptoms
 Edrophonium chloride is a short-acting
anticholinesterase agent. It is the drug of
choice for differentiating between the
two types of crisis in a patient with
myasthenia gravis.
 Administration of Tensilon to a patient in myasthenic crisis
resulting from inadequate anticholinesterase would improve the
symptoms.
 Ambenonium chloride is a long-acting anticholinesterase agent.
Administration of Mytelase to a patient who has been
overmedicated with anticholinesterase drugs would intensify or
worsen the symptoms.
102. C: The patient will gain no
more than 4 lbs/week.
Rapid weight gain in a patient who
has had an MI commonly is a sign
of fluid retention and the
development of heart failure.
All the other goals are appropriate
for this patient.
103. C: Enlarged, hard, painless
mass
In advanced cirrhosis, the liver has
turned into scar tissue and is hard;
auscultation does not cause pain.
 Rebound tenderness is found in acute
appendicitis.
 An enlarged, soft, painful mass is seen in
hepatitis.
 An enlarged, soft mass usually indicates some
type of cancer or tumor.
104. B: IV Nitroglycerin infusion
Nitroglycerin counteracts the
adverse vasoconstricting effects of
vasopressin and helps maintain
coronary perfusion.

 Dopamine will exacerbate the vasoconstriction.

 Vitamin K may be given, but it has no effect on
vasopressin.
 Lidocaine is not indicated for GI bleeding.
105. A: Increased BP with widening pulse
pressure, bradycardia, and abnormal
respiratory pattern
106. A: Chest pain and low blood
pressure
Most rejected organs begin to swell
or enlarge, causing pain and poor
functioning.
 Temperature would be elevated during a
rejection episode. Dizziness and
weakness are not associated with
rejection. Rejection causes weak pulses
and pale skin.
107. B: Pulls the endotracheal tube back 1
inch.

These findings indicate that the

endotracheal tube has been
inserted too far and has entered the
right bronchus.
 Increasing the tidal volume may cause
pneumothorax.
 The patient is not likely to have a mucus
plug immediately after intubation.
108. D: Impaired gas exchange related to
depressed respirations

Nursing diagnoses related to the

airway and breathing have the
highest priority.
 Altered cerebral perfusion diagnoses
have the next highest priority, followed
by the nursing diagnoses relating to
infection and knowledge deficit.
109. A: Be administered after ipecac syrup has been
administered and after vomiting has stopped.

Activated charcoal works in the

intestine to adsorb medications and
toxic substances. It would be
vomited if administered after ipecac
syrup.
 Mixing activated charcoal with ipecac
syrup and water reduces its
effectiveness.
110. D: Assessing changes in the
circumference of the neck
Changes in
neck size
indicate edema
and potential
airway
problems. The
other options
have a lower
priority.
111. D: Second-degree burns over
22% of the body
Boiling water usually produces
second-degree burns.
 According to the Rule of Nines, the
anterior chest makes up 18% of the
body surface area and the thigh
makes up 4%, for a total of 22% of
the body.
112. B: Performing a thorough
psychological assessment
 Long-term lung disease has a significant
psychological component, and
psychological support is an essential part
of the treatment and recovery process.
 Prophylactic antibiotics may or may not be
used, depending on the underlying
disease.
 Exercise levels should be increased in the
later rehabilitative stages of treatment.
 Patients with lung disease respond better
to small, high-calorie meals.
113. D: Maintaining adequate oxygenation and
eliminating the underlying cause of ARDS

Decreased compliance of the

lungs in ARDS reduces the body’s
ability to oxygenate tissues.
Patients are intubated and
mechanically ventilated, with
positive end-expiratory pressure
used to maintain oxygenation.
 The other nursing goals have lower
priority.
114. A: A client with late-stage acquired
immunodeficiency syndrome (AIDS)
Hospices provide supportive,
palliative care to terminally ill
clients (such as those with late-
stage AIDS) and their families.
 Hospice services would not be
appropriate for the other clients
because their health problems are not
necessarily terminal.
115. D: Evaluation
 Although the nurse is assessing pain
relief, this action is considered part
of the evaluation – not assessment-
because the nurse has performed an
intervention and is evaluating
whether the goal has been met.
 During the planning step, the nurse
identifies steps to implement a plan of
care.
 During the implementation step, the nurse
performs interventions to meet the client’s
needs, such as administering medication.
116. C: Avoid aspirin and products
that contain aspirin.
 Aspirin is a gastric irritant and so
should be avoided by clients with
peptic ulcer to prevent further erosion
of the stomach lining.
 The client should eat small, frequent meals
during the day rather than three large ones.
 Antacids and ranitidine prevent acid
accumulation in the stomach; they should be
taken even after symptoms subside.
 Caffeine should be avoided because it
increases acid production in the stomach.
117. C: Administer metoclopramide (Reglan) and
dexamethasone (Decadron) as prescribed.

 Administration of an antiemetic, such

as metoclopramide, and an anti-
inflammatory, such as dexamethasone,
can reduce the severity of
chemotherapy-induced nausea and
vomiting. This, in turn, helps prevent
dehydration, a common complication
of chemotherapy.
 The remaining options are unlikely to be as
successful in achieving this outcome.
118. A: Pain that radiates down the
posterior thigh
Disk herniation may compress
spinal nerve roots, causing sciatic
nerve inflammation, which
produces pain that radiates down
the leg. Slight knee flexion should
relieve low back pain.
 If nerve root compression remains untreated,
weakness or paralysis of the innervated
muscle group may result; lower leg atrophy
may occur if muscles are not used. Positive
Homan’s sign is more indicative of
phlebothrombosis.
119. D: Irritability and drowsiness
 Although all of these options are
associated with hepatitis B, the onset of
irritability and drowsiness suggests a
decrease in liver function.
 To detect signs of such disease
progression, the nurse should observe for
the development of disorientation,
behavioral changes, and decreased level
of consciousness and should monitor the
results of liver function tests, including the
blood ammonia level.
 If decreased liver function is present, the
nurse should take safety precautions.
120. A: Hypercalcemia

 Calcium is released
when bone is
destroyed.
 This causes an
increase in serum
calcium levels does
not affect potassium,
sodium, or
magnesium levels.
121. C:10 years
 Epidemiologic
studies show
the average time
from initial
contact with HIV
to the
development of
AIDS is 10
years.
122. B: It interferes with viral
replication
 Zidovidine
inhibits
Deoxyribonucleic
acid synthesis in
HIV, thus
interfering with
viral replication.
123. C: Surgical asepsis
 Intact skin is the
first line of
defense against
entry of
microorganisms.
 A surgical
incision is a portal
of entry so a
technique that
requires the
absence of all
microorganisms
is essential.
124. C: Ascorbic acid
 Vitamin C plays a
major role in wound
healing.
 It is necessary for the
maintenance and
formation of strong
collagen, major
protein of most
connective tissues.
125. C: Shiny, scaly lesions
 Psoriasis is characterized by
dry, scaly lesions that occur
most frequently on the
elbows, knees, scalp and
torso.
126. A: Highly contagious
 Scabies are caused
by the itch mite
(sarcoptes scabei),
the female of which
burrows under the
skin to deposit eggs.
 It is intensely pruritic
and is transmitted by
direct contact or in a
limited way, by soiled
sheets or
undergarments.
127. A: Butterfly rash
 The connective
tissue
degeneration of
SLE leads to
involvement of
the basal cell
layer, producing a
butterfly rash over
the bridge of the
nose and in the
malar region.
128. B: The nurse provided supportive
nursing care for the well-being of the
client
 According to the
Nurse Practice
Act, a nurse may
independently
treat human
responses to
actual or potential
health problems.
 129. D: Ultraviolet radiation
exposure

 Basal cell carcinoma, the most common

type of skin cancer is most closely linked
to solar UV radiation
130. A: Sarcomas
Sarcoma: a malignant tumor whose
cells resemble those of the
supportive (connective) tissues of
the body.
Carcinoma: malignant epithelial
neoplasm that tends to invade
surrounding tissue and metastasize
to distant regions of the body.
131. A: weak acid

 Immediate therapy includes continuous

washing with at least 1 liter of water or
for at least 10 minutes
 Carefully neutralize
 Caution: neutralization can cause more
burn because of the reaction; wash the
chemical off with water before
neutralization
 Source: emedicine ”Burns, chemical”
 132. C: Hematocrit

An increased
hematocrit
indicates
hemoconcentratio
n secondary to
fluid loss.
133. A: Severe pain
 The severe pain
experienced by
the client during
debridement of
burns places an
emotional strain
on the
relationship.
 134. D. Superficial partial-
thickness burns
 Superficial partial thickness:
These burns are superficial
with injury to the epidermis
and superficial dermis.
 These are second-degree
burns and are characterized
by ruptured weeping blisters.
 They are also erythematous
and painful.
 Superficial partial-thickness
burns heal spontaneously
within 1-3 weeks, usually
without scarring
135. C: Slowing of a previously
rapid pulse
 The pulse rate is one indicator of
optimum vascular fluid volume; the
pulse rate decreases as intravascular
volume normalizes.
136) A: The fluid level in the manometer
fluctuates with each respiration

 The fluid level in

the manometer
fluctuates with
respiration
because the
changes in
thoracic pressure
affect the
pressure in the
right atrium.
137. C: Cerebral hypoxia
 Extreme
restlessness in a
severely burned
client usually
indicates cerebral
hypoxia.
138. D: Keeping the skin around
the stoma clean and dry
 If the area is not
kept both clean
and dry, drainage
from the
colostomy can
quickly cause a
breakdown of the
skin around the
stoma.
 139. A: At the time of puberty
 Primitive sex cells,
called spermatogonia,
are present in
newborn males. At
puberty these cells
mature and form
spermatozoa
(spermatogenesis)
140. C: Venereal warts
 Condylomata
acuminata are
variably sized
cauliflower like
warts occurring
principally on the
genitals or the
anogenital skin or
mucosa of both
females and
males. They are
transmitted by
sexual activity.
141. C: Can produce sterility
 In males the
inflammatory
process associated
with the infection
may lead to
destruction of the
epididymis.
 In females the
gonorrheal infection
causes destruction
of the tubal mucosa
and eventually
tuboovarian
abscesses.
142. D: Dorsal recumbent
Dorsal recumbency takes
advantage of the anatomic position
of the vaginal tract and prevent
undue retention or too rapid return
of the douche.
Patient lies on back, knees flexed,
with soles of feet flat on bed.
143. C: Gonorrhea
 Gonorrhea
frequently is an
ascending
infection and
affects the
fallopian tubes.

Epididymitis, complication
of gonorrhea in male
144. D: It requires at least 20 ejaculations or
at least 3 months (whichever comes first) to
clear the tract of sperm
Some spermatozoa will remain
viable in the vas deferens for a
variable time after vasectomy.
3 sperm counts are needed to be
100% sure that sex can be resumed
without the danger of pregnancy
145. D: Prostate specific antigen
The PSA is an indication of cancer
of the prostate; the higher the level,
the higher the tumor burden
146. C: Predisposes to
hydronephrosis
 Inability to empty
the bladder as a
result of pressure
exerted by the
enlarging prostate
on the urethra,
causes a backup
of urine into the
ureters and finally
the kidneys
147. C. 2-6 weeks
Although the usual incubation
period of syphillis is about 3 weeks,
clinical symptoms may appear as
early as 9 days or as long as 3
months after exposure.
148. A: Tertiary stage
Noncontagious
Occurs at least 10 years after the
initial infection
Symptomatic
– Neurosyphilis
– cardiovascular syphilis
– Gumma
149. D: Playing with the child
everyday
 Eczema is stress
related. This will
reduce the child’s
stress.
 Stress commonly
triggers eczema. By
playing with their
children at athletic
games such as tag,
jump rope, and
soccer, parents can
help their children to
work out their
anxieties in a healthy
way.
150. B: Co-trimoxazole
Given orally or IV for PCP.
Sulfadiazine-treat toxoplasmosis
Fluconazole and amphotericin B-
coccidioidomycosis