John J.

Teodoro PTRP, RN
1. A home care nurse is preparing to visit a client with a
diagnosis of Menieres disease. The nurse reviews the
physicians orders and expects to note that which of the
following dietary measures will be prescribed?
A. low fiber diet with decreased fluids
B. low sodium diet and fluid restriction
C. low carbohydrate diet and elimination of red meats
D. low fat with restriction of citrus fruits
2. A nurse is assigned to care for a client who has just
undergone eye surgery. The nurse plans to instruct the client
that which of the following activities is permitted in the
postoperative period?
A. reading
B. watching television
C. bending over
D. lifting objects
3. A nurse is instilling an otic solution into an adult clients left
ear. The nurse avoids doing which of the following as part of
this procedure?
A. warming the solution to room temperature
B. placing the client in a side lying position with the ear
facing up
C. pulling the auricle backward and upward
D. placing the tip of the dropper on the edge of the
ear canal
4. A client has undergone surgery for glaucoma. The nurse
provides which discharge instructions to the clients?
A. wound healing usually takes 12 weeks
B. expected the vision will be permanently impaired
C. a shield or eye patch should be worn to protect the
eye
D. the sutures are removed after 1 week
5. Which assessment findings provide the best evidence that
a client with acute angle-closure glaucoma is responding to
drug therapy?
A. swelling of the eyelids decreases
B. redness of the sclera is reduced
C. eye pain is reduced or eliminated
D. peripheral vision is diminished
6. At the time of retinal detachment, a client most likely
describes which symptoms?
A. a seeing flashes of light
B. being unable to see light
C. feeling discomfort in light
D. seeing poorly in daylight
7. The most important health teaching the nurse can provide
to the client with conjunctivitis is to:
A. eat a well balanced, nutritious diet
B. wear sunglasses in bright light
C. cease sharing towels and washcloths
D. avoid products containing aspirin
8. When the nurse prepares the client or the myringotomy,
the best explanation as to the purpose for the procedures is
that it will:
A. prevent permanent hearing loss
B. provide a pathway for drainage
C. aid in administering medications
D. maintain motion of the ear bones
9. A nurse is reviewing the record of the client with a disorder
involving the inner ear. Which of the following would the nurse
expect to see documented as an assessment finding in this
client?
A. severe hearing loss
B. complaints of severe pain in the affected ear
C. complaints of burning in the ear
D. complaints of tinnitus

10. A client with a conduction hearing loss asks the nurse how
a hearing aid improves hearing. The nurse most accurately
informs the client that a hearing aid:
A. amplifies sound heard
B. makes sounds sharper and clearer
C. produces more distinct, crisp, speech
D. eliminates garbled background sounds
11. Which nursing action is best for controlling the clients
nosebleed?
A. have the client lay down slowly and swallow frequently
B. have the client lay down and breathe through his mouth
C. have the client lean forward and apply direct
pressure
D. have the client lean forward and clench his teeth

Situation: Benjie 59 years old male was admitted to the

hospital complaining of nausea, vomiting,
weight loss of 20 lbs, constipation and diarrhea. A diagnosis of
carcinoma of the colon was made.
12. A sigmoidoscopy was performed as a diagnostic
measures. What position Benjie should assume for hi
examination?
A. knee-chest
B. Sims
C. Fowlers
D. Trendelenburg
13. As part of the preparation of the client for sigmoidoscopy
the nurse should:
A. explain to Benjie that he will swallow a chalk-like
substance
B. administer a cathartic the night before
C. withhold fluids and foods on the day of examination
D. administer cleansing enema in the morning of the
examination
14. The doctor performed a colostomy, post operative nursing
care include:
A. keeping the skin around the opening clean and dry
B. limiting visitors
C. withholding
D. limiting fluid intake
15. During the irrigation of the colostomy, Benjie complains of
abdominal cramps, the nurse should:
A. discontinue the irrigation
B. clamp the catheter for a few minutes
C. advance the catheter about one inch
D. add color water
16. If colostomy irrigation is done, the height of the irrigator
can must be how many inches above the stoma?
A. 14-18 inches
B. 18-20 inches
C. 20-24 inches
D. 10-14 inches
17. Which of the following gastrointestinal condition is known
to predispose to Cancer of the colon?
A. hemorrhoids
B. intussusception
C. islated colonic polyps
D. pyloric stenosis
Situation: Mr. J was brought to the ER complaining of pain
located in the upper abdomen
hematemesis and melena. Diagnosis is peptic ulcer.
18. A frequent discomfort experience by Mr. J due to his peptic
ulcer is:
A. diarrhea
B. vomiting
C. eructation
D. nausea

19. Which of this diagnostic measure is not indicated for Mr. J?

A. x-ray of the abdomen
B. patients history
C. gastrointestinal series
D. gastric analysis
20. The purpose of dietary treatment of Mr. J is to:
A. neutralize the free HCL in the stomach
B. delay gastric emptying
C. prevent constipation
D. delay surgery
21. Antacids are administered to Mr. J to:
A. tranquilize the intestine
B. decrease gastric motility
C. lower the acidity of gastric secretion
D. aid in digestion
22. It is thought that emotional stress contribute to ulcer
formation through:
A. excessive stimulation of the parasympathetic
nervous system
B. increased activity of the sympathetic nervous system
C. disturbance o cerebral cortex appetite control
D. decrease of pituitary function
23. The tissue change most characteristics of peptic ulcer is:
A. a soft mass of the necrotic tissue with bleeding
B. an erosion of the mucosa covered with thick exudates
C. a sharp excavation of tissue membrane with a clean
base
D. an elevated fibrous tissue membrane with soft margins
24. The stool Guiac test was ordered to detect the presence
of:
A. hydrochloric acid
B. occult blood
C. inflammatory cells
D. undigested food
25. In addition to its antacids effects, aluminum hydroxide gel
is locally:
A. analgesic
B. astringent
C. irritating
D. depressant
26. Intervention that would help control his bleeding:
A. gastric lavage using iced cold normal saline
solution
B. gastric using warm normal saline solution
C. application of tourniquet
D. insertion of NGT
27. Since she has NGT the appropriate nursing action is:
A. render sponge bath
B. provide laxative at bedtime
C. administer enema once a day
D. provide oral hygiene 3x a day
28. He underwent total gastrectomy, dumping syndrome may
occur and the least symptoms he may experience would be:
A. feeling of soreness
B. weakness
C. feeling of fullness
D. diaphoresis
29. To prevent dumping syndrome the following includes your
nursing care except:
A. serve dry meals
B. allow him to walk for a while after eating
C. instruct him to lie down after eating
D. giving of fluids after meals must be avoided
30. Your operative nursing assessment after surgery:
A. note and report excessive bleeding only

B. assess for excessive secretions from the operative

site
C. ensure that the NG tube is detached from suction
apparatus
D. check the drainage from the NG tube everyday
31. What is the involvement of her total gastrectomy?
A. removal of the stomach only
B. removal of the stomach with anastomosis of the
esophagus to the jejunum
C. removal of the ovary and fallopian tube
D. removal of the stomach with anastomosis of the duodenal
to jejunum
32. A nurse is giving instructions to the client with peptic ulcer
disease about symptom management. The nurse tells the
client to:
A. eat slowly and chew food thoroughly
B. eat large meals to absorb gastric acid
C. limit the intake of water
D. use acetylsalicylic acid (aspirin) to relieve gastric pain
33. A client has been given a prescription for Propantheline
(Probanthine) as adjunctive treatment for peptic ulcer
disease. The nurse tells the client to take this medication:
A. with antacids
B. 30 minutes before meals
C. with meals
D. just after meals
Situation: Kim was known to be alcoholic for 15 yrs. He was
admitted in the hospital after having
vomited a large quantity of bright red blood with some coffee
ground appearance.
34. The most probable cause of Kims cirrhosis is:
A. malnutrition
B. bacterial inflammation of liver cells
C. alcoholism
D. obstruction of major bile ducts
35. Which of the following vitamins are stored by the normal
liver?
A. vit. A, vit. B and vit. C
B. vit. A, vit. B, vit. C, and vit. D
C. vit A and vit B
D. vit. A and vit. C
36. The nurse should know how that pathophysiology
predispose him to:
A. varicose veins
B. splenic rupture
C. inguinal hernia
D. umbilical hernia
37. Kims portal hypertension is the result of:
A. contraction of vascular muscles response to psychological
stress
B. compression of the liver substance due to emotional stress
C. acceleration of portal blood flow secondary to severe
anemia
D. twisting and constriction of intralobular and
interlobular blood vessels
38. Kim is scheduled for a liver biopsy. What instructions
regarding respiration is essential for the nurse to give him
prior to the biopsy:
A. exhale forcefully and to hold his breath for a few seconds
B. hold his breath when the needle has reached the liver site
C. take several deep breaths and to hold his breath
while needle is being introduced
D. flat with one pillow under his head
39. Which position in bed would be best for Kim immediately
after he has the needle biopsy of the liver?
A. on his right side, with a small pillow under the
costal margin
B. anyway that he is comfortable
C. semi-Fowlers with his knees flexed
D. flat with one pillow under his head

40. A Blakemore-Sengstaken tube is inserted to prevent

bleeding from esophageal varices. The nurse responsibility in
this instance would be to:
A. alternate inflate and deflate the esophageal balloon
B. make certain that the desired degree of pressure is
constantly maintained
C. deflate both balloons periodically
D. encourage Kim to swallow frequently while tube is I place
41. A physician orders the deflation of the esophageal balloon
of a Sengstaken-Balkemore tube in a client. The nurse
prepares for the procedure knowing that the deflation of the
esophageal balloon places. The client is at risk for:
A. increased ascites
B. esophageal necrosis
C. recurrent hemorrhage from the esophageal varices
D. gastritis
42. Foods usually omitted from diet of Kim with cirrhosis of
liver are:
A. whole grain cereals
B. milk products
C. cereal products
D. rich gravies and sauces
43. Clay colored stool are caused by:
A. improper utilization of vitamin K by the body
B. the absence of bile salt in the feces
C. the absence of bile pigments in the urine
D. rich gravies and sauces
44. Kim develop ascites, this is caused by:
A. pulmonary failure
B. portal obstruction
C. capillary obstruction
D. arterial obstruction
45. Symptoms indicating progression into hepatic coma
include:
1. flapping tremor
2. nystagmus
3. fruity odor breath
4. fetid breath
A. 2 and 4 C. 2 and 3
B. 1 and 4 D. 1 and 3
46. A client admitted to the hospital with a diagnosis of
cirrhosis has massive ascites and has difficulty breathing. A
nurse performs which intervention as a priority measure to
assist the client with breathing?
A. auscultates the lung fields every 4 hours
B. repositions side to side every 2 hours
C. encourages deep breathing exercises every 2 hours
D. elevates the head of the bed 60 degrees

Situation: Karla is confine with a diagnosis of chronic

cholecystitis.
47. After thorough examination your findings would be:
A. high red blood cell counts and fever
B. leukocyte count is low and high fever
C. leukocyte count high and pyrexia
D. leukocytosis and abdominal pain that radiates to the groin
48. The surgical intervention indicated for Karla is:
A. choledochostomy
B. cholecystostomy
C. cholecystotomy
D. cholecystectomy
49. Following exploration of the common duct is a T-tube
inserted. The rationale for this is to:
A. facilitate healing of the operative site
B. offer a route to post operative cholecystectomy

C. provide sufficient drainage to promote healing

D. ensure adequate bile drainage during duct healing
50. Upon admission her doctor ordered for cholecystoghram in
AM. The preparations of this procedure begins:
A. in early am
B. with evening meal
C. at bedtime
D. upon admission
51. The ingestion of fatty food usually precipitates rubies
episodes of the upper abdominal pain because;
A. fat in the stomach increases the rate of peristaltic
movements
B. fat in the duodenal contents initiate the reaction
that cause gallbladder contraction
C. fatty foods are likely to generate gas
D. fatty foods contain higher amount of cholesterol than do
proteins
52. Karla is having pruritus of the extremities. Which of the
following nursing measures might be most helpful in relieving
her discomfort.
A. rubbing the skin with potassium permanganate 10:1000
solution
B. bathing in weak sodium bicarbonate solution
C. dusting with liberal amount of talcum powder
D. rubbing the skin with alcohol
53. Karla is experiencing severe biliary colic. The drug of
choice during attack is:
A. ponstan
B. Demerol
C. atropine sulfate
D. morphine sulfate
54. A T-tube was inserted into the common bile duct. Her
nursing care of the T-tube is:
A. empty and measure the bile drainage every 4 hours
B. report STAT for any bile seen in the drainage system
C. secure it very well
D. irrigate the T-tube with sterile normal saline every 4 hours
55. A client with diverticulitis has just been advanced from a
liquid diet to solids. The nurse encourages the client to eat
foods that are:
A. low residue
B. high residue
C. moderate in fat
D. high roughage
56. A client has just undergone an upper gastrointestinal (GI)
series. The nurse provides which of the following upon the
clients return to the unit as an important part of routine post
procedure care?
A. increased fluids
B. bland diet
C. NPO status
D. laxative
57. A nurse is administering continuous tube feedings to the
client. The nurse takes which of the following actions as party
of routine care for this client?
A. checks the residual every 4hours
B. changes the feeding bag and tubing every 12 hours
C. pours additional feeding into bag when 25 ml are left
D. holds the feeding if greater than 200 ml are aspirated
58. A nurse is monitoring drainage from a nasogastric (NG)
tube in a client who had a gastric resection. No drainage has
been noted during the past 4 hours and the client complains
of severe nausea. The most appropriate nursing action would
be to:
A. reposition the tube
B. irrigate the tube
C. notify the physician
D. medicate for nausea

59. A nurse is performing a health history on a client with

chronic pancreatitis. The nurse expects to most likely note
which of the following when obtaining information regarding
the clients health history?
A. abdominal pain relieved with food or antacids
B. exposure to occupational chemicals
C. weight gain
D. use of alcohol
60. A home care nurse visits a client with bowel cancer
who recently received a course of chemotherapy. The client
has developed stomatitis. The nurse avoids telling the client
to:
A. drink foods and liquids that are cold
B. eat foods without spices
C. maintain a diet of soft foods
D. drink juices that are not citrus
61. A nurse is caring for a client with is receiving total
parenteral nutrition (TPN). The nurse plans which nursing
intervention to prevent infection?
A. using strict aseptic technique for intravenous site
dressing changes
B. monitoring serum blood urea nitrogen (BUN) daily
C. weighing the client daily
D. encouraging increased fluid intake
62. A nurse is caring for a client with possible cholelithiasis
who is being prepared for a cholangiogram. The nurse teaches
the client about the procedure. Which client statement
indicates that the client understands the purpose of this
procedure?
A. they are going to look at my gallbladder and
ducts.
B. this procedure will drain my gallbladder
C. my gallbladder will be irritated
D. they will put medication in my gallbladder
63. A client who has a history of chronic ulcerative colitis is
diagnosed with anemia. The nurse interprets that which of the
following factors is most likely responsible for the anemia?
A. decrease intake of dietary iron
B. intestinal malabsorption
C. blood loss
D. intestinal hookworm
64. A clients nasogastric (NG) feeding tube has become
clogged. The nurses first action is to:
A. flush the tube with warm water
B. aspirate the tube
C. flush the carbonated liquids, such as cola
D. Replace the tube
65. When the client ask the nurse why he must take the
neomycin sulfate (Mycifradin), the most accurate explanation
in this case is that the drug is given to:
A. treat any current infection he may have
B. suppress the growth of intestinal bacteria
C. prevent the onset of postoperative diarrhea
D. reduce the number of bacteria near the incision
66. If the client is typical of others with appendicitis the nurse
can expect that when the clients abdomen is palpated
midway between the umbilicus and right iliac crest, the client
will:
A. experienced more pain when pressure is released
B. lack any sensation of pain or pressure on palpation
C. have extreme discomfort with the slightest pressure
D. will feel referred pain in the opposite quadrant
67. Which factor most probably contributed to the
development of the clients hemorrhoids?
A. the client takes a daily stool softener
B. the client has a history of ulcerative colitis
C. the client is frequently constipated
D. the client works as a computer programmer

68. When the client describes her discomfort to the nurse she
is most likely to indicate that the pain she experiences
becomes worse:
A. shortly after eating
B. especially on an empty stomach
C. following periods of activities
D. before rising in the morning
69. When the nurse empties the drainage in the Jackson Pratt
bulb reservoir. Which nursing action is essential for
reestablishing the negative pressure within this drainage
device?
A. the nurse compresses the bulb reservoir and closes
the drainage valve
B. the nurse opens the drainage valve, allowing the bulb to
fill with air
C. the nurse fill the bulb reservoir with sterile normal saline
D. the nurse secures the bulb reservoir to the skin near the
wound
70. When the client asks the nurse how she acquired hepatitis
A, the best answer is that a common route of hepatitis. A
transmission is from:
A. fecal contamination
B. insect carries
C. infected blood
D. wound drainage
71. It is essential that the nurse inform the client with
hepatitis B that for the remainder of his lifetime he must
avoid:
A. sexual activity
B. donating blood
C. excessive caffeine
D. foreign travel
72. Which nursing action is appropriate prior to assisting with
the paracentesis?
A. the nurse asks the client to void
B. the nurse withholds food and water
C. the nurse cleanses the clients abdomen with Betadine
D. the nurse obtains a suction machine from storage room
73. Which statements provides the best evidence that a client
with colostomy is adjusting to the change in body image?
A. the client wears loose-fitting garments
B. the client takes a shower each day
C. the client empties the appliance
D. the client avoids foods that form gas
74. A previously health client comes to the emergency
department complaining of severe nausea and vomiting hours
after eating in a restaurant. Which assessment question best
determines if a food borne pathogen is the cause of the
clients syndrome?
A. what food did you eat?
B. did you take something for you nausea?
C. did your food look spoiled?
D. have you ever had food poisoning?
75. A nurse is caring for a client with peptic ulcer. In assessing
the client for gastrointestinal perforation (GI), the nurse
monitors for:
A. increase bowel sounds
B. sudden, severe abdominal pain
C. positive Guaiac test
D. slow, strong pulse
76. Which assessment is most important for the nurse to
make before advancing a client from liquid to solid food?
A. increase bowel sounds
B. appetite
C. presence of bowel sounds
D. chewing ability

77. What method would a nurse use to most accurately assess

the effectiveness of a weight loss diet for an obese client?
A. daily weights
B. serum protein levels
C. daily caloric counts
D. daily intake and output
78. A pregnant client has been diagnosed with a vaginal
infection from the organism Candida albicans. Which findings
would the nurse expect to note on assessment of the client?
A. absence of any and symptoms
B. pain, itching and vaginal discharge
C. proteinuria, hematuria, edema and hypertension
D. costovertebral angle pain
79. A nurse is caring for a client who is hospitalized with acute
systemic lupus erythematosus (SLE). The nurse monitors the
client knowing that which of the following clinical
manifestation is not associated with this disease?
A. fever
B. muscular aches and pains
C. butterfly rash on the face
D. bradycardia
80. A male being seen in the ambulatory care clinic has a
history of being treated for syphilis infection. The nurse
interprets that the client has been reinfected if which of the
following characteristics is noted in a penile lesion?
A. multiple vesicles, with some that have ruptured
B. popular areas and erythema
C. cauliflower-like appearance
D. induration and absence of pain
81. A nurse is preparing a poster for a booth at a health care
to promote primary prevention of cervical cancer. The nurse
includes which of the following recommendations on the
poster?
A. perform monthly breast self-examination (BSE)
B. use oral contraceptives as a preferred method of birth
control
C. use a commercial douches on a daily basis
D. seek treatment promptly for infections of the cervix
82. A nurse is caring for a client who has just had a
mastectomy. The nurse assists the client in doing which of the
following exercises during the first 24 hours following surgery?
A. elbow flexion and extension
B. shoulder abduction and external rotation
C. pendulum arm swing
D. hand wall climbing
83. Tretinoin (Retin-A) is prescribed for a client with acne. The
client calls the clinic nurse and says that the skin has become
very red and is beginning to pee. Which of the following
nursing statements to the client would be most appropriate?
A. come to the clinic immediately
B. discontinue the medication
C. notify the physician
D. this is a normal occurrence with the use of
medication
Situation: Luz 19 years old single is scheduled for mastectomy
of the right breast
84. Based on the health history and other assessment data,
Luzs nursing diagnosis includes the following except:
A. potential sexual dysfunction
B. body image disturbance
C. pain related to anesthesia
D. self-care deficit related to immobility of arm on the
operative side
85. The following are her possible post operative complication
except:
A. hematoma
B. lymphedema
C. neurovascular deficits
D. infection

86. Luz complains of pain 2 hours after receiving her

medication of Meperidine HCL 50 mg IM ordered every 4
hours for the first 24 hours only. You should:
A. tell Luz to wait for 2 hours more
B. give the medicine STAT
C. give fractional dose of Meperidine HCL
D. use nursing measure to relieve pain
87. You informed her that the most common breast tumor
occurring in young women is:
A. fibrocystic
B. papilloma
C. gynecomastia
D. fibroadenoma
88. Which of these work-up is not related to her surgery?
A. CBC
B. Urinalysis
C. B.T.
D. C.T.
89. Rationale for moderately elevating post operative affected
arm is to:
A. prevent lymphedema
B. reduce pain
C. B.T.
D. C.T.
90. Which of these maybe used to her post operatively?
A. pleural drainage
B. hemovac
C. prevent infection
D. improve coping ability
91. Which of the following is not a post operative complication
A. bronchopneumonia
B. pneumonia
C. atelectasis
D. decubitus ulcer
92. Allowing her to do deep breathing exercise every 2 hours
would prevent:
A. bronchopneumonia
B. atelectasis
C. bronchitis
D. pneumonia
93. A client has a left mastectomy with axillary lymph node
dissection. The nurse determines that client understands post
operative restrictions and arm care if the client states to:
A. use a straight razor to shave under the arms
B. allow blood pressures to be taken only on the left arm
C. carry a handbag and heavy objects on the left arm
D. use gloves when working in the garden
94. A nurse has provided instructions to a client who is
receiving external radiation therapy. Which of the following if
started by the client would indicate a need for further
instructions regarding self-care related to the radiation
therapy?
A. I need to avoid exposure to sunlight?
B. I need to wash my skin with a mild soap and pat dry
C. I need to apply pressure to the irritated area to
prevent bleeding
D. I need to eat a high-protein diet
95. A nurse is teaching a client about the modifiable risk
factors that can reduce the risk for colorectal cancer. The
nurse places highest priority on discussing which of the
following risk factors with this client?
A. personal history of ulcerative colitis or gastrointestinal (GI)
polyps
B. distant relative with colorectal cancer
C. age over 30 years
D. high-fat, low fiber diet

Situation: Fe, a 21-year-old fourth year physical therapy

student has been diagnosed with peptic
ulcer. The personal and family history shows that she has
difficulty coping with the demands of the
course and her mother is being treated for peptic ulcer to:
96. A relevant diagnosis the nurse identifies is one of the
following:
A. defensive coping
B. self-esteem disturbance
C. sensory-perceptual alteration
D. ineffective individual coping
97. Typical personality traits of a person with peptic ulcer:
A. submissive and dependent
B. competitive and aggressive
C. self-sacrificing and dependent
D. perfectionist and assertive
98. One of the nursing intervention is to teach Fe:
A. relaxation technique
B. behavior modification
C. stress management technique
D. desensitization technique
99. The following are psycho-physiological reactions except:
A. migraine
B. constipation
C. bronchial asthma
D. peptic ulcer
100. The defense mechanism usually used by patient with
peptic ulcer is:
A. denial
B. reaction formation
C. projection
D. sublimation
1. The home health nurse is visiting the client who has had a
prosthetic valve replacement for severe mitral valve
stenosis. Which statement by the client reflects an
understanding of specific postoperative care for this surgery?
A. I threw away my straight razor and brought an
electric razor.
B. I have to go to the bathroom several times at night
C. I count my pulse everyday
D. I still do my deep breathing exercise
2. A client has been diagnosed with thromboangitis
obliterans. The nurse is considering measures to help the
client cope up with lifestyle changes needed to control the
disease process. The nurse plans to refer the client to a:
A. medical social worker
B. dietician
C. smoking cessation program
D. pain management clinic
3. The nurse is implementing a plan of care for a client with
deep pain thrombosis of the right leg. Which of the following
interventions does the nurse avoid when delivering care to
this client?
A. elevation of the right leg
B. ambulation in the hall twice per shift
C. application of moist heat to the right leg
D. administration of acetaminophen (Tylenol)
4. The client was hospitalized 5 days ago have developed left
calf tenderness and have a positive Homans sign. The nurse
assigned to this client next assess to this client next assesses
the client for:
A. coolness and pallor of the affected limb
B. diminished distal peripheral pulses
C. increased calf circumference
D. bilateral edema
5. The nurse is monitoring a client with leukemia who is
receiving Doxorubicin (Adriamycin) by IV infusion. Which of
the following assessment findings indicate toxicity of the
medication?

A. Elevated BUN C. ECG changes

B. elevated creatinine D. a red coloration of the urine
6. A 45-year-old male returned to his room an hour ago
following a bronchoscopy. He is requesting for some
water. The nurse must:
A. keep the client NPO until n order is written
B. check the vital signs first
C. check the gag and swallowing reflex
D. encourage coughing and deep breathing
7. A 45-year-old client is receiving heparin sodium for a
pulmonary embolus. The nurse evaluates which of the
following laboratory reports of partial thromboplastin time as
indicative of effective heparin therapy.
A. within normal range
B. one to 1.5 times the control value
C. two to 2.5 times the control value
D. three times the control value
8. A client is taking Wafarin (coumadin) following the
placement of an artificial mitral valve. The nurse instructs this
client to avoid taking the following commonly used drug:
A. Maalox plus C. Tylenol cold and flu medication
B. sudafed D. aspirin
9. A client with insulin dependent diabetes mellitus (IDDM) is
being discharged. The nurse knows that the client has
understood essential teaching when the following statement
is heard:
A. I need to cut my nails straight across
B. I cant make any substitutions in my diet
C. my insulin should be given into my arms
D. I should eat less before exercising
10. A client is on chemotherapy for acute myelogenous
leukemia. The nurse assesses the following laboratory test
daily:
A. complete blood count C. prothrombin time
B. electrolyte studies D. BUN and creatinine
11. A client has developed depression of the bone marrow
from antineoplastic drugs. The nurse states the nursing
diagnosis of highest priority as:
A. fluid volume deficit C. ineffective thermoregulation
B. High risk for aspiration D. high risk for infection
12. Radioactive iodine is being used to treat a client with
cancer of the thyroid gland. The nurse knows that the client
has understood teaching about the treatment when the
following statement is heard:
A. only my thyroid gland will be radioactive
B. I need not be concerned about radioactivity
C. my whole body will be radioactive
D. my body fluids will be radioactive for a short
time
13. A clients TPN is 6 hours behind schedule. The nurse
would:
A. run the fluid at rate to make up the lost time.
B. report the situation to the physician
C. run the IV at the prescribed site
D. check the blood glucose level
14. A 45-year-old client is in acute congestive heart
failure. The nurse and client establish a goal of highest priority
as:
A. rest mentally as well as physically
B. learn stress management
C. train for a less demanding job
D. prevent complications of immobility
15. A client diagnosed with IDDM becomes irritable and
confused; the skin is cool and clammy and the pulse rate is
110. The first action of the nurse would be to:
A. give a half-cup of orange juice
B. check the serum glucose

C. administer regular insulin

D. call the physician
16. A client with IDDM is recovering from DKA. Information of
the serum level of the following substance will be very
important to the nurse:
A. sodium C. potassium
B. calcium D. magnesium
17. A 17-year-old clients mother has been recently diagnosed
with pulmonary tuberculosis. The nurse would expect the
doctor to order which of the following tests initially?
A. the mantoux C. a sputum culture
B. an X-ray D. gram stain of the sputum
18. The nurse injects 0.1 ml. of purified protein derivative
(PPD) intradermally into the inner aspect of the forearm of a
client. This nurse will interpret the reaction to this test as
positive when the following is seen:
A. redness greater than 5mm.
B. swelling greater than 7mm.
C. induration greater than 10mm.
D. exudates covering more than 12mm
19. A 29-year-old has been taking Prednisone 60 mg. daily for
an inflammatory condition for the past 6 months. The
physician just wrote an order to discontinue the
medication. The nurse should:
A. stop the medication as ordered
B. continue the medication until physician is available
C. call the physician and question the order
D. hold the medication until the physician is available
20. A 55 year old has a chest tube connected to a Pleur Evac
system to remove blood from the pleural cavity. While turning
the client the nurse remembers to:
A. keep the Pleur Evac below the level of the wound
B. Remove the suction from the Pleur vac
C. Clamp the tubing connected to the Pleur Evac
D. drain the sterile water from the Pleur Evac
21. A client on anti-neoplastic therapy has a platelet count of
20,000/cu.mm. An appropriate intervention for the nurse to
use would be:
A. administering Vit. K IM
B. massaging injection sites to avoid absorption
C. encouraging the use of firm toothbrushes and vigorous
flossing
D. avoiding rectal temperatures and other rectal
procedures
22. A nurse assumes responsibility for the care of the client at
7 A.M. NPH insulin is ordered for 7:30 A.M. Before giving the
insulin, the nurse checks to see if the client will eat that day
and for the:
A. signs and symptoms of hypoglycemia
B. previous sites of injection
C. serum glucagons level
D. serum glucose level
23. A nurse is teaching a client to observe for signs of
hypoxia. The nurse explains that cyanosis is not reliable
indicator of the amount that tissues are receiving because the
blue color is caused by:
A. reduced hemoglobin
B. a low partial pressure of oxygen in the blood
C. inability of oxygen to enter the cell
D. increased pH of the blood
24. A client has ARDS. The lowest fraction of inspired oxygen
possible for optimizing gas exchange is used. The nurse
explains to the family that the reason for this precaution is to:
A. avoid respiratory depression
B. prevent oxygen toxicity
C. increase lung compliance
D. promote production of surfactant

25. A client who is recovering from a myocardial infarction

demonstrates that touching has been effective with the
statements:
A. if my chest pain lasts for more than 5 minutes, I should
get myself to the emergency room
B. I just need to avoid salty foods and not add salt to my
food
C. I need to avoid constipation and all activities that
have caused me chest pain in the past
D. I need to get to the drugstore to get some medicine for
my cold
26. A client is admitted to the hospital complaining of
nervousness, heat intolerance and muscle weakness. Her
pulse rate is 118 and she has exopthalmos. An essential part
of her assessment will be:
A. palpation of the thyroid gland
B. evaluation of fluid and electrolyte balance
C. evaluation of deep tendon reflexes
D. use of the Glasgow Coma Scale
27. A client is scheduled for thyroidectomy. The nurse explains
that PTU or an iodine preparation is given prior to surgery in
order to:
A. increase the size of the thyroid gland
B. render the parathyroid glands visible
C. induce a euthyroid state in the body
D. Separate the thyroid from the laryngeal nerve
28. A client is being evaluated for the possibility of Graves
disease. The nurse teaches that the best laboratory test for
evaluating whether a client has hypothyroidism or
hyperthyroidism is the serum level of:
A. thyroxine (T4) C. TSH
B. triiodothyroinine (T3) D. epinephrine
29. A client is taking Levothyroxine (synthroid) for
hypothyroidism. The nurse teaches the client to:
A. monitor the pulse regularly
B. restrict sodium in the diet
C. take the drug with meals
D. measure urinary output
30. A client with NIDDM is admitted to the hospital. The client
is confused and has dry mucus membranes and poor skin
turgor. The serum sodium is 149; the blood pressure 90/60
mmHg; the pulse is 118; and the serum glucose 465
mg/dl. The nurse anticipates that insulin and the following will
be needed:
A. a potassium drip C. intravenous fluids
B. sodium bicarbonate D. calcium gluconate
31. A nurse is teaching a diabetic client how to attain the
optimal level of health. When assessing for other risk factors
stroke and heart attack, this nurse looks for:
A. hypervolemia C. proteinuria
B. hypokalemia D. hypertension
32. A nurse stops at the sight of a motor vehicle accident to
find a young woman slumped over the wheel. She is breathing
with a regular rhythm at a rate of 22; ventilation efforts
normal. Her pulse rate is 110. The nurses next action would
be:
A. check the level of consciousness
B. immobilize the spine
C. call the rescue squad
D. check for bleeding
33. A 57-year-old client is being prepared for discharge
following a myocardial infarction. The nurse knows that her
teaching has been understood when she hears:
A. I guess my sex life is over
B. depression is bad for me. I must stay happy and
optimistic

C. the best way to know the amount of exercise I

should take is to watch my pulse
D. the injured area will be replaced with a new heart tissue
34. A client with IDDM has just been admitted to the ER after
hitting a telephone pole with her car. Bystanders said she
acted as if she has been drinking. Her temperature is 37.4
degrees Celsius, pulse 80, resp. 44 and deep. She complained
of headache and acted confused. A fruity odor was noted on
her breath. Her ABG report read= pH= 7.32, pCO2= 36, and
bicarbonate= 18. The nurse prepared for the treatment of:
A. metabolic acidosis C. respiratory acidosis
B. metabolic alkalosis D. respiratory alkalosis
35. A client with peptic ulcer is taking Maalox, Amoxicillin and
Famotidine. The nurse teaches the client to take the Maalox:
A. 1-2 hours before meals C. hour before meals
B. with meals
D. 1-2 hours after meals
36. A client with varicose veins tells the nurse, I am afraid
they will burst while I am walking. Which response by the
nurse would be the BEST?
A. the only way to prevent rupture is to have surgery
B. you must find another job, one that requires less walking
C. if that happens, you could bleed to death
D. rupture of varicose veins rarely occur
37. A client asks why is it important to check the pupils. The
nurse replies that changes in the pupils are a reflection of how
well the following area of the nervous system is functioning:
A. spinal cord
C. midbrain
B. brain stem
D. cerebellum
38. A 32-year-old client is being evaluated in the clinic today
for possible Addisons disease. The nurse knows that the most
common cause of the disease is attributed to:
A. autoimmune response C. disseminated tuberculosis
B. blastomycosis D. diabetes mellitus

with the client, the nurse explains to him that the one food
that caused this problem was:
A. cabbage
C. tapioca
B. eggs
D. fried chicken
45. The nurse is caring for a client with folic acid
deficiency. The nurse recalls that one of the most frequent
causes of folic acid deficiency is:
A. poor nutritional intake due to alcoholism
B. lack of absorption of the intrinsic factor
C. a diet that consists of vegetables only and no meat
D. a complicated pregnancy during the second trimester
46. When planning care for a patient who is pancytopenic, the
major goal should be:
A. prevent hemorrhage and infection
B. administering an oral iron preparation
C. preventing fatigue and fluid overload
D. encouraging consumption of a neutropenic diet
47. when explaining different effects of chemotherapy to
students, the nurse correctly identifies which group of
chemotherapy drugs that does not affect DNA synthesis to kill
tumor cells?
A. hormones
C. antimetabolites
B. vinca alkalosis D. alkylating agents
48. The nurse evaluates the clients ability to self-monitor
blood glucose level at home. What information BEST indicates
the average degree of diabetes control during the past 2 to 4
months?
A. serum glycosylated hemoglobin
B. postprandial blood glucose level
C. a written record of daily blood glucose levels
D. a written record of daily double voided urine glucose levels

39. The nurse knows that the recommended diet for a client
with Addisons disease includes:
A. 1 mg. Na
C. low fat, low cholesterol
B. 3 gms. Na
D. high potassium, high cholesterol

49. Which of the findings would the nurse most likely note
during an Addisonian crisis?
A. serum potassium of 3 mEq/L, BP=158/72 mmHg
B. serum potassium of 5.8 mEq/L, BP=62/48 mmHg
C. serum sodium of 150 mEq/L, BP= 158/72
D. serum sodium of 135 mEq/L, BP=62/48

40. A 36-year-old client with a history of Cushings disease is

being seen in the ER for complaints of anorexia, vomiting,
weakness and muscle cramps for the past 24 hours. The nurse
recognizes that these clinical findings are a result of:
A. hypernatremia C. hyperglycemia
B. hypoglycemia D. hypokalemia

50. Propanolol (Inderal) is commonly prescribed for clients

with hyperthyroidism to:
A. block formation of the thyroid hormone
B. decrease the vascularity of the thyroid gland
C. inhibit peripheral conversion of T4 and T3
D. decrease CNS stimulation

41. When teaching a patient about home care related to

outpatient corticosteroid therapy, the nurse emphasizes that
side effects of corticosteroid therapy include:
A. hyperglycemia and weight loss
B. hyponatremia and hypotension
C. hypoglycemia and gastric ulcers
D. hyperglycemia and weight gain

51. The client with cancer is receiving chemotherapy and

develops thrombocytopenia. Which goal should be given the
highest priority in the NCP?
A. ambulation tree times a day
B. monitoring temperature
C. monitoring hemoglobin and hematocrit
D. monitoring for pathologic fractures

42. Additional teaming to a newly diagnosed diabetic client

related to the effects of regular insulin is necessary when the
client asks, if I take my regular insulin at 8 A.M., when might I
experience signs of low blood sugar reaction?
A. 8:30 am
B. 11 am
C. 1:30 pm
D. 4 pm

52. The nurse assesses the oral cavity of a client with cancer
and notes white patches on the mucous membranes. The
nurse determines that this occurrence:
A. is common
B. is characteristic of thrush infection
C. indicates that oral hygiene need to be improved
D. suggests that the client is anemic

43. The nurse recognizes which of the following as signs of

early hypoxia?
A. bradycardia, hypotension, facial flushing
B. confusion, bradycardia, headache
C. hypotension, tachypnea, lethargy
D. restlessness, yawning, tachycardia
44. A 68-year-old client has a new colostomy and is being
treated today at the clinic for diarrhea. When discussing diet

53. The nurse is monitoring the laboratory results of a client

preparing to receive chemotherapy. The nurse determines
that the WBC count is normal if which of the following results
is present?
A. 3,000 to 8,000/cu.mm.
B. 4,000 to 9,000/cu.mm.
C. 7,000 to 15,000/cu.mm.
D. 2,000 to 5,000/cu. Mm.

54. The client suspected of having an abdominal tumor is

scheduled for a CT scan with dye injection. Which of the
following is an accurate description of the scan?
A. the test maybe painful
B. the dye injected may cause a warm, flushing,
sensation
C. fluids will be restricted following the test
D. the test takes approximately 2 hours
55. The client is diagnosed as having a bowel tumor. Several
diagnostic test are prescribed. Which of the following test will
confirm the diagnosis of the malignancy?
A. MRI
C. abdominal ultrasound
B. CT scan D. biopsy of the tumor
56. The oncology nurse is preparing to administer
chemotherapy to the client with Hodgkins disease. A
multiagent medication regimen known as MOPP is
prescribed. The medications included in the therapy are:
A. belomycin, oncovin, vincristine, prednisone
B. adrimycin, vincristine, oncovin, prednisone
C. adriamycin, cytoxan, prednisone, oncovin
D. procarbazine, mechlorethemine, oncovin,
prednisone
57. The nurse is analyzing the laboratory results of a client
with leukemia who received a regimen of
chemotherapy. Which of the following laboratory values does
the nurse note specifically as a result of massive cell
destruction that occurred from chemotherapy?
A. anemia C. decrease platelets
B. decreased WBC D. increased uric acid level
58. The client is receiving external radiation to the neck for
cancer of the larynx. The MOST likely side effect to be
expected is:
A. constipation C. sore throat
B. dyspnea D. diarrhea
59. The nurse is providing instructions to the client receiving
external radiation therapy. Which of the following is NOT a
component of the instructions?
A. avoid exposure to sunlight
B. wash the skin with a mild soap and pat dry
C. apply pressure on the irritated area to prevent
bleeding
D. eat a high protein diet
60. The nurse teaches skin care to the client receiving
external radiation therapy. Which of the following statements,
if made by the client indicates the need for further
instruction?
A. I will handle the area gently
B. I will avoid the use of deodorants
C. I will limit sun exposure to 1 hour daily
D. I will wear loose fitting clothing
61. The nurse is reviewing the laboratory results of a client
receiving chemotherapy. The platelet count is
10,000/cu.mm. Based on this laboratory value, the priority
nursing assessment is which of the following?
A. assess level of consciousness
B. assess temperature
C. assess bowel sounds
D. assess skin turgor

B. prevent stomatitis

D. prevent diarrhea

64. A gastrectomy is performed on a client with gastyric

cancer. In the immediate postoperative period, the nurse
notes bloody drainage from the NGT. Which of the ff. is the
MOST appropriate nursing intervention?
A. notify the physician C. continue to monitor the
drainage
B. measure abdominal girth D. irrigate the NGT
65. The nurse is reviewing the history of a client with bladder
cancer. The MOST common symptom of this type of cancer is
which of the following?
A. frequency of urination C. hematuria
B. urgency of urination D. dysuria
66. The nurse is assessing the stoma of a client following a
ureterostomy. Which of the following does the nurse expect to
note?
A. a pale stoma
C. a red and moist stoma
B. a dry stoma
D. a dark-colored stoma
67. The nurse is caring for a client following a radical
mastectomy. Which of the following nursing interventions
would assist in preventing lymphedema of the affected arm?
A. placing cool compress on the affected arm
B. elevating the affected arm on pillow below the
heart level
C. maintaining an IV site below the antecubital area of the
affected side
D. avoiding arm exercises in the immediate post-operative
period
68. The nurse is teaching BSE to a client who had a
hysterectomy. The MOST appropriate instruction regarding
BSE should be performed is:
A. 7 to 10 days after menstruation
B. just before menses begin
C. at ovulation time
D. at a specific day of the month and on the same day every
month thereafter
69. The nurse is instructing the client, Ben how to perform
testicular self-examination. Which instruction is correct?
A. examine testicles when lying down
B. the best time for the examination is after a shower
C. gently feel the testicle with one finger to feel for a growth
D. testicular examination should be done at least every 6
months
70. The nurse is instructing a group of female about BSE. The
nurse instructs the clients to perform the examination:
A. at the onset of menstruation
B. one week after menstruation begins
C. every month during ovulation
D. weekly at the same time of the day
71. The client has undergone esophagogastroduodenoscopy
(EGD). The nurse places highest priority on which of the
following items as apart of the clients care plan?
A. assessing for the return of the gag reflex
B. giving warm gargle for sore throat
C. monitoring temperature
D. monitoring complaints of heartburn

62. The client is admitted to the hospital with a diagnosis of

suspected Hodgkins disease. Which of the following
assessment signs would the nurse MOST likely to note in the
client?
A. weakness
C. weight gain
B. fatigue
D. enlarged lymph nodes

72. The client being seen in a physicians office has just been
schedule for a barium swallow the next day. The nurse writes
down which of the following instructions for the client to follow
before the test?
A. removal all metal and jewelry before the test
B. eat regular supper and breakfast
C. continue to take all oral medication as scheduled
D. monitor own bowel movement pattern for constipation

63. The client with leukemia is receiving Busulfan

(myleran). Allopurinol (Zyloprim) is prescribed for the
client. The purpose of Allopurinol (Zyloprim) is to:
A. preventgouty arthritis C. prevent hyperuricemia

73. The client is diagnosed with bleed and the bleeding has
been controlled antacid are prescribed to be administered
every hour. The nurse should plan on maintaining an
approximately gastric pH of:

A. 3 B. 9 C. 6 D. 15
74. The nurse is caring for a client following a Billroth II
Procedure. On review of the post-operative orders, which of
the following, if prescribed, does the nurse question and
verify?
A. irrigating the NG tube
B. coughing and deep breathing exercises
C. leg exercises
D. early ambulation
75. A client who has a peptic ulcer is schedule for a
vagotomy. The client asks about the purpose of this
procedure. The BEST nursing response is which of the
following?
A. decreases food absorption in the stomach
B. heal the gastric mucosa
C. halts stress reaction
D. reduces the stimulus to acid secretion
76. The nurse ins monitoring a client for the early signs and
symptoms of dumping syndrome. Which of the following
syndrome indicate this occurrence?
A. abdominal cramping and pain
B. bradycardia and indigestion
C. sweating and pallor
D. double vision and chest pain
77. The nurse is caring for a hospitalized patient with a
diagnosis of ulcerative colitis. When assessing the client,
which finding, if noted, would the nurse report to the
physician?
A. bloody diarrhea C. hemoglobin level of 12 mg/dl
B. hypotension
D. rebound tenderness
78. The nurse is providing discharge instruction to a client
following gastrectomy which of the following measures will
the nurse instruct the client to the following assist in
preventing dumping syndrome?
A. eat high carbonated food
B. limit the fluid taking with food
C. ambulate following a meal
D. sit in a high-fowlers position during meals
79. The nurse is caring for a client post-operatively following
the creation of a colostomy. Which of the ff. nursing diagnosis
does the nurse include in the plan of care?
A. altered nutrition; more than body requirements
B. body image disturbance
C. fear related to poor diagnosis
D. sexual dysnfunction
80. The nurse is reviewing the record of the client with
Crohns disease. Which of the following stool characteristic
does the nurse expect to note in this client?
A. bloody stool
B. diarrhea
C. constipation alternating with diarrhea
D. stool constantly oozing from the rectum
81. The client with cirrhosis has ascites and a fluid volume
excess. Which measure will the nurse include in the plan of
care for this client?
A. increase the amount of sodium in diet
B. restrict the amount of fluids consumed
C. encourage ambulation frequently
D. administer magnesium antacids
82. The client with ascites is schedule for a paracentesis. The
nurse is assisting the physician in performing the
procedure. Which of the following positions will the nurse
assist the client to assume for this procedure?
A. supine
C. right side lying
B. left side lying D. upright
83. An ultrasound of the gallbladder is schedule for the client
with a suspect diagnosis of cholecystitis. The nurse explain to
the client that this test:

A. requires the client to lie still for short intervals

B. requires that the client be NPO
C. requires the administration of oral tables
D. is uncomfortable
84. The nurse is providing preoperative teaching to a client
scheduled for a cholecystectomy. Which of the following
interventions is of highest priority in the preoperative
teaching plan?
A. teaching coughing and deep breathing exercises
B. teaching leg exercises
C. instructions regarding fluid restrictions
D. frequent need to work overtime on short notice
85. A client with peptic ulcer states that stress frequently
causes exacerbation of the disease. The nurse interprets that
which of the following items mentioned by the client is most
likely responsible for the exacerbations?
A. sleeping 8 hours a night
B. eating 5 to 6 small meals per day
C. ability to work at home periodically
D. frequent need to work overtime on short notice
86. The client with peptic ulcer disease needs dietary
modification to reduce episode of epigastric pain. The nurse
plans to teach the client that which of the following items,
which the client enjoys, does not need to be limited or
eliminated with this disease?
A. wine
C. coffee
B. baked chicken D. fresh fruit
87. The medication history of a client with peptic ulcer disease
reveals intermittent use of the following medications. The
nurse teaches the client to avoid which of these medications
altogether because of the irritating effects on the lining of the
GI tract?
A. (Prilosec)
B. ibuprofen (Motrin)
C. sucralfate (Carafate)
D. Nizatidine (Axid)
88. The nurse instructs the ileostomy client to do which of the
following as part of essential care of the stoma?
A. cleanse the peristomal skin meticulously
B. take in high-fiber foods such as nuts
C. massage the area below the stoma
D. limit fluid intake to prevent diarrhea
89. The client who has undergone creation of a colostomy has
a nursing diagnosis of Body Image disturbance. The nurse
evaluates that he client is making the most significant
progress toward identified goals if the client:
A. watches the nurse empty the ostomy bag
B. looks at the ostomy site
C. reads the ostomy product literature
D. practices cutting the ostomy appliance
90. The client with a new colostomy is concerned about odor
from stool in the ostomy drainage bag. The nurse should
teach the client to include which of the following foods in the
diet to reduce odor?
A. yogurt
C. cucumbers
B. broccoli
D. eggs
91. The nurse is giving dietary instruction for the client who
has a new colostomy. The nurse encourages the client to eat
foods representing which of the following diets for the first 4
to 6 weeks postoperatively?
A. high protein C. low calorie
B. high carbohydrates D. low residue
92. The nurse has given instructions to the client with an
ileostomy about foods to eat to thicken the stool. The nurse
evaluates that the client did not fully understand the
instructions if the client stated that eating which of the
following foods makes the stool less watery?
A. pasta C. bran

B. boiled rice

D. low-fat cheese

D. an individual can read 30 out of 50 total letters on the

chart at 20 feet

93. The client has just had surgery to create an ileostomy. The
nurse assesses the client in the immediate postoperatively
period for which of the following most frequent complications
of this type of surgery?
A. intestinal obstruction
B. fluid and electrolyte imbalance
C. malabsorption of fat
D. folate deficiency

2. Damage to the visual area of the occipital love of cerebrum,

on the left side, would produce what type of visual loss?
A. left eye only
B. right eye only
C. medial half of the right eye and lateral half of the
left eye
D. medial half of the left eye and lateral half of the right eye

94. The client with acute pancreatitis is experiencing severe

pain from the disorder. The nurse teaches the client to avoid
which of the following positions that could aggravate the
pain?
A. sitting up C. leaning forward
B. lying flat D. flexing the left leg

3. An anterior chamber of the eye refers to all the space in

what area?
A. anterior to the retina
B. between the iris and the cornea
C. between the lens and the cornea
D. between the lens and the iris

95. The nurse is evaluating the effect of dietary counseling on

the client with cholecystitis. The nurse evaluates that the
client understands the instructions given if the client stated
that which of the following food items is acceptable in the
diet?
A. baked scrod C. fried chicken
B. sauces and gravies D. fresh whipped cream

4. What condition results when rays of light are focused in

front of the retina?
A. myopia
B. hyperopia
C. presbyopia
D. emmetropia

96. The nurse assesses the client experiencing an acute

episode of cholecystitis for pain that is located in the right:
A. upper quadrant and radiates to the left scapula and
shoulder
B. upper quadrant and radiates to the right scapula
and shoulder
C. lower quadrant and radiates to the umbilicus
D. lower quadrant and radiates to the back
97. The client is beginning to show signs of hepatic
encephalopathy. The nurse plans a dietary consult to limit the
amount of which of the following ingredients in the clients
diet?
A. fat
C. protein
B. carbohydrates D. minerals
98. The client with Crohns disease has an order to begin
taking antispasmodic medication. The nurse should time the
medication so that each dose is taken:
A. 30 minutes before meals
B. during meals
C. 60 minutes after meals
D. upon arising and at bedtime
99. The client with ulcerative colitis is diagnosed with mild
case of the disease. The nurse doing dietary teaching gives
the client examples of foods to eat that represent which of the
following therapeutic diets?
A. high-fat with milk
B. high-protein without milk
C. low-roughage without milk
D. low-roughage with milk
100. It has been determined that the client with hepatitis has
contracted the infection from contaminated food. What type
of hepatitis is this client most likely experiencing?
A. hepatitis A
B. hepatitis B
C. hepatitis C
D. hepatitis D
Situation: The head nurse of an eye and ear clinic is ordering
nursing students.
1. Normal visual acuity as measured with a Snellen eye chart
is 20/20. What does a visual acuity of 20/30 indicate?
A at 20 feet, an individual can only read letters large
enough to be read at 30 feet
B. at 30 feet, an individual can read letters large enough to
be read at 20 feet
C. an individual can read 20 out of 30 total letters on the
chart

5. As the person grows older, the lens losses its elasticity,

causing which kind of farsightedness?
A. emmetropia
B. presbyopia
C. diplopia
D. myopia
6. If a person has a foreign object of unknown material that is
not readily seen in one eye, what would the first action be?
A. irrigate the eye with a boric acid solution
B. examine the lower eyelid and then the upper eyelid
C. irrigate the eye with opious amounts of water
D. shield the eye from pressure, and seek medical
help
7. A sudden loss of an area of vision, as if a curtain were being
drawn, is a principal symptom of?
A. retinal detachment
B. glaucoma
C. cataracts
D. keratitis
8. Postoperative care following stapedectomy would not
include which of the following
A. out of bed as desired
B. no moisture in the affected ear
C. avoid sneezing
D. no bending over or lifting
9. Dimenhydrinate (Dramamine) is given after a
stapedectomy
A. to accelerate the auditory process
B. to dull the pain experienced with the semicircular canal is
disturbed
C. to minimize the sensations of equilibrium
disturbances and imbalance
D. to prevent an increase tendency toward nausea
10. A client with Menieres syndrome is extremely
uncomfortable because of which of these?
A. severe earache
B. many perceptual difficulties
C. vertigo and resultant nausea
D. facial paralysis
11. What is the cataract of the eyes?
A. opacity of the cornea
B. clouding of the aqueous humor
C. opacity of the lens
D. papilledema

12. Treating a cataract primarily involves which of the

following?
A. instillation of miotics
B. installation of mydriatics
C. removal of the lens
D. enucleation
13. Preoperative instruction will not need to include
A. type of surgery
B. how to use the call bell
C. how to prevent paralytic illeus
D. how to prevent respiratory infetins
14. In preparing to teach patient about adjustment to cataract
lenses, the nurse needs to know that the lenses will.
A. magnify objects by one-third- with central vision
B. magnify objects by one-third with peripheral vision
C. reduce objects by one-third with central vision
D. reduce objects by one-third with peripheral vision
15. In the immediate postoperative period the one action that
is contraindicated for patient compared with clients after most
other operations is which of the following?
A. coughing
B. turning on the unoperative side
C. measures to control nausea and vomiting
D. eating after nausea passes
16. Immediate nursing care following cataract extraction is
directed primarily toward preventing
A. Atelectasis
B. infection of the cornea
C. hemorrhage
D. prolapse of the iris
17. The patient is confused during her first night after eye
surgery. What would the nurse do?
A. tell her to stay in bed
B. apply restraints to keep her in bed
C. explain why she cannot get out of bed, keep side
rails up, and check her frequently
D. sedate her
18. Discharge teaching would probably not need to include
A. staying in a darkened room as much as possible
B. avoiding alcoholic drinks,; limiting the use of tea and
coffee
C. using no eye washes or drops unless they were prescribed
by the physician
D. avoiding being excessively sedentary

19. Patient also needs to be instructed to limit.

A. sewing
B. watching TV
C. walking
D. weeding her garden
Situation: Lea visit her ophthalmologist and receives a
mydriatic drug in order to facilitate the
examination. After returning home, she experiences severe
pain, nausea and vomiting, and blurred
vision. During a visit to the emergency room, a diagnosis of
acute glaucoma is made.
20. Leas glaucoma has been caused by the dilation of the
pupil.
A. blockage of he outflow of aqueous humor by the
dilation of the pupil
B. blockage of the outflow of aqueous humor by the
constriction of the pupil
C. increase intraocular pressure resulting from the increased
production of aqueous humor
D. decrease intraocular pressure resulting from decrease
production of aqueous humor

21. Intraocular pressure is measured clinically by

tonometer. What tonometer reading would be indicative of
glaucoma?
A. pressure of 10 mmHg
B. pressure of 15 mmHg
C. pressure of 20 mmHg
D. pressure of 25 mmHg
22. Which cranial nerve transmits visual impulses?
A. I (olfactory)
B. II (optic)
C. III (oculomotor)
D. IV (abducens)
23. Untreated or uncontrolled glaucoma damages the optic
nerve. Three of the following signs and symptoms result from
optic nerve atrophy; which one does not?
A. colored halos around lights
B. severe pain in the eye
C. dilated and fixed pupils
D. opacity of the lens
24. Glaucoma is conservatively managed with miotic eye
drops. Mydriatic eye drops are contraindicated for
glaucoma. Which of the following drugs is a mydriatic?
A. neostigmine
B. pilocarpine
C. physostigmatine
D. atropine
25. Glaucoma may require surgical treatment. Preoperatively,
the client would be taught to expect which of the following
postoperatively?
A. cough and deep-breathing qh.
B. turn only to the unaffected side
C. medication for severe eye pain
D. restriction of fluids for the first 24 hours
Situation: Roy, a 55-year-old man, is admitted to the hospital
with wide-angle glaucoma
26. What was the symptom that probably brought Roy to the
ophthalmologist initially?
A. decreasing vision
B. extreme pain in eye
C. redness and tearing of the eye
D. seeing colored flashes of light
27. The teaching plan for Roy would include which of the
following?
A. reduce fluid intake
B. add extra lighting in the home
C. wear dark glasses/during the day
D. avoid exercise
28. Miotics are used in the treatment of glaucoma. What is an
example of a commonly used miotic?
A. atropine
B. pilocarpine
C. acetazolamide (Diamox)
D. scopolamine
29. What is the rationale for using miotics in the treatment of
glaucoma?
A. they decrease the rate of aqueous humor production
B. pupil constriction increases outflow of aqueous
humor
C. increased pupil size relaxes the ciliary muscles
D. the blood flow to the conjunctiva is increased
30. When instilling eye drops for a client with glaucoma, what
procedure would the nurse follow?
A. place the medication in the middle of the lower lid,
and put pressure on the lacrimal duct after
instillation.
B. Instill the drug to the outer angle of the eye, have client tilt
head back
C. instill the drug at the innermost angle; wipe with cotton
away from inner aspect

D. instill medication in middle eye, have client blink for better

absorption
31. Carbonic anhydrase inhibitors are sometimes used in the
treatment of glaucoma because they:
A. depress secretion of a aqueous humor
B. dilate the pupil
C. paralyze the power of accommodation
D. increase the power of accommodation
32. Teaching a client with glaucoma will not include which of
the following?
A. vision can be restored only if the client remains
under a physicians care
B. avoid stimulant (eg., caffeine)
C. take all medications conscientiously
D. prevent constipation and avid heavy lifting and emotional
excitement
33. Glaucoma is a progressive disease that can lead to
blindness. It can be managed if diagnosed early. Preventive
health teaching would best include which of the points?
A. early surgical action may be necessary
B. all clients over 40 years of age should have an
annual tonometry exam
C. the use of contract lances in older clients is not advisable
D. clients should seek early treatment for eye infections
34. A client with progressive glaucoma may be experiencing
sensory deprivation. Which of the following actions would best
minimize this problem?
A. speak in a louder voice
B. ensure that a sedative is ordered
C. orient the client to time, place, and person
D. use touch frequently when providing care
Situation: 5-Gary is seen in the emergency room with the
diagnosis of epitaxis.
35. It is unlikely that Garys history will include
A. minor trauma to the nose
B. a deviated septum
C. acute sinusitis
D. hypotension
36. Which of the following medications would be used with in
order to promote vasoconstriction and control bleeding?
A. epinephrine
B. lidocaine
C. pilovarpine
D. cylospentolate
37. Which of the following positions would be most desirable
for Gary?
A. trendelenburgs to control shock
B. a sitting position, unless he is hypotensive
C. side-lying, to prevent aspiration
D. prone, to prevent aspiration
38. The physician decides to insert nasal packing. Of the
following nursing actions, which would have the highest
priority?
A. encourage Gary to breath through his mouth, because he
may feel panicky after the insertion.
B. advice Gary to expectorate the blood in the nasopharynx
gently and not to swallow it
C. periodically check the position of the nasal packing,
because airway obstruction can occur if the packing
accidentally slip out of place
D. take rectal temperature, because he must rely on mouth
breathing and would be unable to keep his mouth closed on
the thermometer.
39. After bleeding has been controlled, Gary taken to surgery
to correct a deviated nasal septum. Which of the following is
likely complication of this surgery?
A. loss of the ability to smell

B. inability to breath through the nose

C. infection
D. hemorrhage
40. Upon his discharge, the nurse instructs Gary on the use of
vasoconstrictive nose drops and cautions him to avoid too
frequent, and excessive use to these drugs, which of the
following provides the best rationale for this caution
A. A rebound effect occurs in which stuffness worsens
after each successive dose
B. cocaine, a frequent ingredient in nose drops, may lead to
psychological addiction
C. these medications may be absorbed systematically,
causing severe hypotension
D. persistent vasoconstriction of the nasal mucosa can lead
to alterations in the olfactory nerve
Situation: Brix had redial and neck surgery for cancer of the
larynx.
41. Brix has tracheostomy. When suctioning and suctioning
through laryngectomy tube. When doing these two procedures
at the same time, the nurse would not do which of the ff:
A. Use sterile technique
B. turn head to right to suction left bronchus
C. suction for no longer then 10 to 15 seconds
D. observe for tachycardia
42. Brix requires both nasopharyngeal suctioning and
suctioning through laryngectomy tube. When doing these two
procedures at the same time, the nurse would not do which of
the ff:
A. use a sterile suction setup
B. suction the nose first, then the laryngectomy tube
C. suction the laryngectomy tube first, then the nose
D. lubricate the catheter with saline
43. A nasogastric tube is used to provide Brix with fluids and
nutrient for approximately 10 days, for which of the following
reasons?
A. to prevent pain while swallowing
B. to prevent contamination of the suture line
C. to decrease need for swallowing
D. to prevent need for holding head up to ear
44. Brixs children are concerned about their own risk of
developing cancer. All but one of the following are facts that
describe malignant neoplasia and must be considered by the
nurse in her responses. Which one is correct?
A. family factors may influence an individuals susceptibility
to neoplasia
B. long-term use of corticosteroids enhances the
bodys defense
C. Sexual differences influence an individuals susceptibility to
specific neoplasm
D. living in industrialized areas increase an individuals
susceptibility to a malignant neoplasm
45. When would Brix best begin speech rehabilitation?
A. when he leaves the hospital
B. when the esophageal suture line is healed
C. three months after surgery
D. when he regains all his strength
46. The nurse is complaining the initial morning assessment
on the client. Which physical examination technique would be
used first when assessing the abdomen?
A. inspection
B. light palpation
C. auscultation
D. percussion
47. The client has orders for a nasogastric (NG) tube
insertion. During the procedure, instruction that will assist in
insertion would be:
A. instruct the client to tilt his head back for insertion
into the nostril, then flex his neck for final insertion

B. after insertion into the nostril, instruct the client to extend

his neck
C. introduce the tube with the clients head tilted back, then
instruct him to keep his head upright for final insertion
D. instruct the client to hold his chin down, then back for
insertion of the tube
48. The most important pathophysiologic factor contributing
to the formation of esophageal varices is:
A. decreased prothrombin formation
B. decreased albumin formation by the liver
C. portal hypertension
D. increased central venous pressure
49. The nurse analyzes the results of the blood chemistry
tests done on a client with acute pancreatitis. Which of the
following results would the nurse expect to find?
A. low glucose
B. low alkaline phosphatase
C. elevated amylase
D. elevated creatinine
50. A client being treated for esophageal varices has a
Sengstaken-Blakemore tube inserted to control the
bleeding. The most important assessment is for the nurse to:
A. check that a hemostat is at the bedside
B. monitor IV fluids for the shift
C. regularly assess respiratory status
D. check that the balloon is deflated on a regular basis
51. A female client complains of gnawing midepigastric pain
for a few hours after meals. At times, when the pain is severe,
vomiting occurs. Specific tests are indicated to rule out:
A. cancer of the stomach
B. peptic ulcer disease
C. chronic gastritis
D. pylorospasm
52. When a client has peptic ulcer disease, the nurse would
expect a priority intervention to be:
A. assisting in inserting a Miller-Abbott tube
B. assisting in inserting an atrial pressure line
C. inserting a nasogastric tube
D. inserting an IV
53. A 40-year-old male client has been hospitalized with
peptic ulcer disease. He is being treated with a histamine
receptor antagonists (cimetidine), antacids, and diet. The
nurse doing discharge planning will teach him that the action
of cimetidine is to:
A. reduce gastric acid output
B. protect the ulcer surface
C. inhibit the production of hydrochloric acid (HCl)
D. inhibit vagal nerve stimulation
54. The nurse is admitting a client with Crohns disease who is
scheduled for intestinal surgery. Which surgical procedure
would the nurse anticipate for the treatment of this condition:
A. ileostomy with total colectomy
B. sigmoid colostomy with mucous fistula
C. intestinal resection with end-to-end anastomosis
D. colonoscopy with biopsy and polypectomy
55. A client who has just returned home following ileostomy
surgery will need a diet that is supplemented:
A. potassium
B. vitamin B12
C. sodium
D. fiber
56. A client scheduled for colostomy surgery. An appropriate
preoperative diet will include:
preoperative diet will include:
A. broiled chicken, baked potato, and wheat bread
B. ground hamburger, rice, and salad
C. broiled fish, rice, squash, and tea
D. steak, mashed potatoes, raw carrots, and celery

57. As the nurse is completing evening care for a client, he

observes that the client is upset, quiet, and withdrawn. The
nurse knows that the client is scheduled for diagnostic tests
the following day. An important assessment question to ask
the client is:
A. would you like to go to the dayroom to watch TV?
B. are you prepared for the test tomorrow?
C. have you talked with anyone about the test
tomorrow?
D. have you asked your physician to give you a sleeping pill
tonight?
58. Following abdominal surgery, a client complaining of gas
pains will have a rectal tube inserted. The client should be
positioned on his:
A. left side, recumbent
B. left side, sims
C. right side, semi-fowlers
D. left side, semi-Fowlers
59. Which of the following statements is most correct
regarding colostomy irrigations?
A. the solution temperature should be 100 deg. F
B. 1000 ml is the usual amount of solution for the
irrigation
C. the solution container should be placed 10 inches above
the stoma
D. the irrigation cone is inserted in an upward direction in
relation to the stoma
60. The nurse is teaching a client with a new colostomy how
to apply an appliance to a colostomy. How much skin should
remain exposed between the stoma and the ring of the
appliance?
A. 1/8 inch
B. inch
C. inch
D. 1 inch
61. Following a liver biopsy, the highest priority assessment of
the clients condition is to check for:
A. pulmonary edema
B. uneven respiratory pattern
C. hemorrhage
D. pain
62. A client has a bile duct obstruction and is
jaundiced. Which intervention will be most effective in
controlling the itching associated with his jaundice?
A. keep the clients nails clean and short
B. maintain the clients room temperature at 72 to 75 deg. F
C. provide tepid water for bathing
D. use alcohol for back rubs

63. When a client is in liver failure, which of the following

behavioral changes is the most important assessment to
report?
A. shortness of breath
B. lethargy
C. fatigue
D. nausea
64. A client with a history of cholecystitis is now being
admitted to the hospital for possible surgical intervention. The
orders include NPO, IV therapy, and bed rest. In addition to
assessing for nausea, vomiting and anorexia, the nurse should
observe for pain:
A. in the right lower quadrant
B. after ingesting food
C. radiating to the left shoulder
D. in the upper quadrant

65. The nurse taking a nursing history from a newly admitted

client learns that he has a Denver shunt. This suggest that he
has a history of:
A. hydrocephalus
B. renal failure
C. peripheral occlusive disease
D. cirrhosis
66. A female client had a laparoscopic cholecystectomy this
morning. She is now complaining of right shoulder pain. The
nurse would explain to the client this symptom is:
A. common following this operation
B. expected after general anesthesia
C. unusual and will be reported to the surgeon
D. indicative of a need to use the incentive spirometer
67. For a client with the diagnosis of acute pancreatitis, the
nurse would plan for which critical component of his care?
A. testing for Homans sign
B. measuring the abdominal girth
C. performing a glucometer test
D. straining the urine
68. After removing a fecal impaction, the client complains of
feeling lightheaded and the pulse rate is 44. The priority
intervention is:
A. monitoring vital signs
B. place in shock position
C. call the physician
D. begin CPR
69. Peritoneal reaction to acute pancreatitis results in a shift
of fluid from the vascular space into the peritoneal cavity. If
this occurs, the nurse would evaluate for:
A. decreased serum albumin
B. abdominal pain
C. oliguria
D. peritonitis
70. The assessment finding should be reported immediately
should it develop in the client with acute pancreatitis is:
A. nausea and vomiting
B. abdominal pain
C. decreased bowel sounds
D. shortness of breath
71. Following brain surgery, the client suddenly exhibits
polyuria and begins voiding 15 to 20 L/day. Specific gravity of
the urine is 1.006. The nurse will recognize these symptoms
as the possible development of:
A. diabetes insipidus
B. diabetes, type 1
C. diabetes, type 2
D. Addisons disease

72. A person with a diagnosis of adult Diabetes, type 2, should

understand the symptoms of a hyperglycemic reaction. The
nurse will know this client understands if she says these
symptoms are:
A. thirst, polyuria and decreased appetite
B. flushed cheeks, acetone breath, and increased
thirst
C. nausea, vomiting and diarrhea
D. weight gain, normal breath and thirst
73. The non-insulin dependent diabetic who is obese is best
controlled by weight loss because obesity:
A. reduces the number of insulin receptors
B. causes pancreatic islet cell exhaustion
C. reduces insulin binding t receptor sites
D. reduces pancreatic insulin production
74. A nursing assessment for initial signs of hypoglycemia will
include:
A. Pallor, blurred vision, weakness, behavioral changes

B. frequent urination, flushed face, pleural friction rub

C. abdominal pain, diminished deep tendon reflexes, double
vision
D. weakness, lassitude, irregular pulse, dilated pupils
75. Which of the following nursing diagnosis would be most
appropriate for the client with decreased thyroid function:
A. alteration in growth and development related to increased
growth hormone production
B. alteration in thought processes related to decreased
neurologic function
C. fluid volume deficit related to polyuria
D. hypothermia related to decreased metabolic rate
76. The RN should assess for which of the following clinical
manifestations in the client with Cushings syndrome?
A. hypertension, diaphoresis, nausea and vomiting
B. tetany, irritability, dry skin and seizures
C. unexplained weight gain, energy loss, and cold
intolerance
D. water retention, moon face, hirsutism and purple striae
77. The client hyperparathyroidism should have extremities
handled gently because:
A. decreased calcium bone deposits can lead to
pathologic fractures
B. edema causes stretched tissue to tear easily
C. hypertension can lead to stroke with residual paralysis
D. polyuria leads to dry skin and mucous membrane that can
breakdown
78. Which of the following priority nursing implementation for
a client with a tumor of the posterior lobe of the pituitary
gland who has had a urine output of 3 L in the last hour with a
specific gravity of 1.002?
A. measure and record vital signs each shift
B. turn client every 2 hours to prevent skin breakdown
C. administer Pitressin Tannate as ordered
D. maintain a dark and quiet room
79. A client has a diagnosis of diabetes. His physician has
ordered short and long acting insulin. When administering two
type of insulin, the nurse would:
A. withdraw the long acting insulin into the syringe before the
short acting insulin
B. withdraw the short acting insulin into the syringe
before the long acting insulin
C. draw up in two separate syringes, then combine in one
syringe
D. withdraw long acting insulin, inject air into regular insulin,
and withdraw insulin
80. Certain physiological changes will result from the
treatment for myxedem. The symptoms that may indicate
adverse changes in the body that the nurse should observe
for are:
A. increased respiratory excursion
B. increased the frequency of rest periods
C. initiate postural drainage
D. continue with routine nursing care
81. A client with myxedema has been in the hospital for 3
days. The nursing assessment reveals the following clinical
manifestations: respiratory rate 8/min, diminished breath
sounds in the right lower lobe, crackles in the left lower
lobe. The most appropriate nursing intervention is to:
A. increased the use of ROM, turning, deep breathing
exercises
B. increased the frequency of rest periods
C. initiate postural drainage
D. continue with routine nursing care
82. In an individual with the diagnosis of hyperparathyroidism,
the nurse will assess for which primary symptom:
A. fatigue, muscular weakness
B. cardiac arrhytmias
C. tetany

D. constipation
83. The nurse explains to a client who has just received the
diagnosis of type 2 non-insulin dependent diabetes mellitus
(NIDDM) that sulfonylureas, one group of oral hypoglycemic
agents, as act by:
A. stimulating the pancreas to produce or release
insulin
B. making the insulin that is produce more available for use
C. lowering the blood sugar by facilitating the uptake and
utilization of glucose
D. altering both fat and protein metabolism
84. A client has been admitted to the hospital with a tentative
diagnosis of adrenocortical hyperfucntion. In assessing the
client, an observable sign the nurse would chart is:
A. butterfly rash on the face
B. moon face
C. positive Chvosteks sign
D. bloated extremities
85. The nurse is teaching a diabetic client to monitor glucose
using a glucometer. The nurse will know the client is
competent in performing her finger-stick to obtain blood when
she:
A. uses a ball of a finger as the puncture site
B. uses the side of fingertip as the puncture site
C. avoid using the fingers of her dominant hand as puncture
sites
D. avoid using the thumbs as puncture sites

92. the most appropriate nursing intervention, based on

physicians orders, for treating metabolic acidosis is to:
A. replace potassium ions immediately to prevent
hypokalemia
B. administer oral sodium bicarbonate to act as a buffer
C. administer IV cathecholamines (Levophed) to
prevent hypertension
D. administer fluids to prevent dehydration
93. IV is attached to a controller to maintain the flow rate. If
the alarm sounds on the controller:
A. ensure that drip chamber is full
B. assess that height of IV container is at least 30 inches
above venipuncture site
C. ensure that the drop sensor is properly placed on the drip
chamber
D. evaluate the needle and IV tubing to determine if they are
patent and positioned appropriately
94. A 76-year-old woman who has been in good health
develops urinary incontinence over a period of several days
and is admitted to the hospital for a diagnostic workup. The
nurse would assess the client for other indicators of:
A. renal failure
B. urinary tract infection
C. fluid volume excess
D. dementia

86. A client is scheduled for a voiding cystogram. Which

nursing intervention would be essential to carry put several
hours before the test?
A. maintain NPO status
B. medicating with urinary antiseptics
C. administering bowel preparations
D. forcing fluids

95. A 60-year-old male clients physician schedules a

prostatectomy and orders a straight urinary drainage system
to be inserted preoperatively. For the system to be effective,
the nurse would:
A. coil the tubing above the level of the bladder
B. position the collection bag above the level of the bladder
C. check that the collection bag is vented and
distensible
D. determine that the tubing is less that 3 feet in length

87. A retention catheter for a male client is correctly taped if it

is:
A. on the lower abdomen
B. on the umbilicus
C. under the thigh
D. on the inner thigh

96. During a retention catheter insertion or bladder irrigation,

the nurse must use:
A. sterile equipment and wear sterile gloves
B. clean equipment and maintain surgical asepsis
C. sterile equipment and maintain medical asepsis
D. clean equipment and technique

88. A client with a diagnosis of gout will betaking colchicines

and allopurinol BID to prevent recurrence. The most common
early sign of colchicines toxicity that the nurse assess for is:
A. blurred vision
B. anorexia
C. diarrhea
D. fever

97. The physician has ordered a 24 hours urine

specimen. After explaining the procedure to the client, the
nurse collects the first specimen. This specimen. This
specimen is the:
A. discarded, then collection begins
B. saved as part of the 24 hours collection
C. tested, then discarded
D. placed in a separate container and later added to
collection

89. A clients laboratory results have been returned and the

creatinine level is 7 mg/dl. This finding would lead the nurse
to place the highest priority on assessing:
A. temperature
B. intake andoutput
C. capillary refill
D. pupillary reflex
90. After the lungs, the kidneys work to maintain body pH. The
best explanation of how the kidneys accomplish regulation of
pH is that they:
A. secrete hydrogen ions and sodium
B. secrete ammonia
C. exchange hydrogen and sodium in the kidney
tubules
D. decrease sodium ions, hold on to the hydrogen ions, and
then secrete sodium bicarbonate
91. Conditions known to predispose to renal calculi formation
include:
A. Polyuria
B. dehydration, immobility
C. glycosuria
D. presence of an indwelling Foley catheter

98. The most common cause of bladder infection in the client

with a retention catheter is contamination:
A. due to insertion technique
B. at the time of the catheter removal
C. of the urethral/ catheter interface
D. of the internal lumen of the catheter
99. A client in acute renal failure receive an IV infusion of 10
percent dextrose in water with 20 units of regular insulin. The
nurse understands that the rational for this therapy is to:
A. correct the hyperglycemia that occurs with acute renal
failure
B. facilitate the intracellular movement of potassium
C. provide calories to prevent tissue catabolism and azotemia
D. force potassium into cells to prevent arrhythmias
100. A client with chronic renal failure is on continuous
ambulatory peritoneal dialysis (CAPD). Which nursing
diagnosis should have the highest priority?
A. powerlessness
B. high risk for infection
C. altered nutrition: less than body requirements

D. high risk for fluid volume deficit

AM-CARE Review Academy for Nurses
Room 301 3rd Floor P & J Lim Bldg.
Tiano Brothers Kalambaguhan Sts., Cagayan de Oro City
Tel. No. (08822) 721-805
NLE DECEMBER 2005
MEDICAL SURGICAL NURSING IV
Situation: John Lee is an 18-year old high school student who
suffered an injury to his cervical spine in a football game.
1. In directing emergency care until the ambulance arrives, it
is most important that the school nurse
A. place a small makeshift pillow under his head
B. check to see if he can move all of his extremities
C. keep him flat and immobilized in a natural
position
D. cover him with a blanket
2. A primary goal of nursing care when John is brought into
the emergency room will be
A. prevention of spinal shock
B. maintenance of respiration
C. maintenance of orientation
D provision for pain relief
Situation: Crutchfield tongs are used to apply traction to
realign the spinal cord.
3. A nursing measure for john while he is in cervical traction
should be to
A. massage the back of his head
B. position him from side to side
C. remove the weights at least once a shift
D. encourage involvement in his own care
Situation: John is found to have a temperature of 36C
(96.8F).
4. The most appropriate initial nursing measure for John in
response to his hypothermia would be to
A. cover him with additional blankets
B. place a hot-water bottle at his feet
C. check for signs of shock
D. notify his physician
Situation: John has a tracheostomy performed and is on
assisted ventilation.
5. The alarm on the ventilator sounds. The initial response by
the nurse should be to quickly
A. notify the respiratory therapist
B. check all connections from the respirator
C. notify the respiratory therapist to come immediately
D. use a self-inflating bag to ventilate John
6. When suctioning John, the nurse should
A. ensure that he is able to take a breath between
insertions of the catheter
B. suction him for at least 30 seconds with each catheter
insertion
C. apply suction and gently rotate the catheter while
inserting it into the bronchial bifurcation
D. use clean technique during the suction procedure
7. John suddenly becomes diaphoretic, his blood pressure
rises to 190/110, and he complains of a headache. The nurse
should assess the patient for signs of
A. increased intracranial pressure
B. spinal meningitis
C. pulmonary congestion
D. fecal impaction
8. Upon admission John had a complete loss of motor
ability. Within 48 hours he is noted to be having muscle
spasms. His family becomes very excited when they notice
these movements. Which of the following choices would be
the most appropriate response by the nurse?
A. at this stage, muscle spasms are expected, but it is
too soon to evaluate the extent of the injury or its
permanent effects
B. I can understand your excitement. These movements
are a good sign that he is making progress

C. these movements are an indication that he is trying to

move and that his will is very strong
D. these movements are reflex activities that indicate that
his spinal cord is intact
Situation: Mark Richards has a compound fracture of the
temporal bone.
9. The nurse notices bleeding from the orifice of the
ear. Which of the following actions by the nurse can be safely
used to determine if the drainage contains cerebrospinal fluid
(CSF)? The nurse should
A. swab the orifice of the ear with sterile applicator and
send the specimen to the laboratory
B. blot the drainage with a sterile gauze pad and
look for a clear halo or ring around the spot of
blood
C. gently suction the ear an send the specimen to the
laboratory
D. test the CSF with a Tes-Tape and get a negative reading
for sugar
10. The nursing care plans states Observe for early signs of
increased intracranial pressure (IIP). Early symptoms of IIP
include
A. widening pulse pressure and dilated pupils
B. rising blood pressure and bradycardia
C. elevated temperature and decerebrate posturing
D. nausea, vomiting, and restlessness
11. During the initial period after a head injury, nursing
intervention for Mr. Richards should include
A. packing the ear with cotton balls to stop bleeding
B. awakening the patient every 2 hours to
determine his level of consciousness
C. placing the patient in Trendelenburgs position
D. forcing fluids to restore hydration
12. Before discharge, a computerized axial tomogram will be
performed to rule out any intracranial or extracranial
bleeding. Mr. Richards should be told that
A. the procedure is noninvasive and he will not feel
any pain
B. he will experience a burning sensation as the dye is
being injected
C. the procedure is done in the operating room under
anesthesia
D. local anesthetic is used before injecting air into the
ventricles of the brain via the spinal canal
Situation: Tonnie Miccio is a 43-year old divorced man who has
been rushed to the emergency room with an acute gouty
arthritis.
13. While admitting Mr. Miccio to the hospital, the nurse
should recognize those factors that can precipitate an acute
attack. They include
A. excessive smoking
B. large alcohol intake
C. emotional stress
D. improper rest
14. A serum uric acid level is performed by the hospital
laboratory. In acute gout, the uric acid level is approximately
A. 1.0 mg/100 ml
B. 2.1 mg/100 ml
C. 6.5 mg/100 ml
D. 10 mg/100 ml

15. Colchicine is the standard drug used to treat acute

gout: The physician orders colchicines, 1.0 mg every 2
hours. After receiving the third dose, the patient complains of
nausea, vomiting, and diarrhea. The nurse should recognize
that this is
A. a transient side effect and give the next dose
B. a sign of toxicity and withhold the medication
C. an allergic response to the drug and notify the
physician

D. a psychogenic response to the severe pain

16. The expected outcome for colchicine is to
A. reduce uric acid levels
B. relieve joint pain and inflammation
C. increase blood flow to the kidney
D. detoxify purines in the liver
17. During the night, Mr. Miccio complains of severe pain in
his toe and asks the nurse for 2 aspirin tablets. The nurse
should
A. give the patient the 2 aspirin tablets
B. elevate the foot on a pillow
C. notify the physician
D. offer the patient a cup of tea
18. Some physicians prescribe an alkali-ash diet to enhance
the effect of the medications. Which of the following foods
are allowed?
A. liver, shellfish, and fats
B. cranberries, cheese, and whole grain cereals
C. milk, vegetables, and most fruits
D. eggs, milk, prunes, and plums
19. After the acute attack subsides, the physician orders
allopurinol (Zyloprim), 300 mg/day. The expected outcome for
this drug is to
A. lower the plasma and urinary uric acid level
B. reduce inflammation of the affected joints
C. produce diuresis
D. relieve pain
20. A teaching program for Mr. Miccio should include
A. emphasizing that aspirin is contraindicated in patients
taking allopurinol
B. restricting fluid intake to 1,000 ml/day
C. explaining that acute gouty attacks often occur
during initiation of allopurinol therapy
D. stating that a low-purine diet should be followed while
taking allopurinol
21. About 2 months after taking the allopurinol, Mr. Miccio
develops a skin rash. The nurse should
A. recognize this as a minor side effect that will subside
B. ask the patient if he has been taking any aspirin while
taking the allopurinol
C. recognize this is an indication to discontinue the
drug
D. be aware that concomitant use of colchicines with
allopurinol causes this reaction
22. One day, Jennifer asks her roommate, Erin, how her
scoliosis was first recognized. Erin replies, The school health
nurse told me that there may be a problem after all the girls
in my class were asked to stand erect while she examined our
backs. The nurse suspected scoliosis when she observed that
Erins shoulder on one side was elevated and her
A. head appeared aligned to the opposite side
B. leg on the same side appeared shorter
C. hip on the opposite side appeared prominent
D. arm on the same side appeared longer
23. When Erins scoliosis was diagnosed after x-ray
examination of her spine, she was fitted with a Milwaukee
brace. Erin asks the nurse when it could be removed each
day. Which of the following would be the best response?
A. only when you are lying flat, either resting or sleeping
B. for 1 hour a day when you bathe, shower, or go
swimming
C. only for special occasions, such as a party
D. for 3 hours a day: one in the morning, one in the
afternoon, and one in the evening
Situation: Erins admission to the hospital for spinal fusion was
necessary because hr scoliosis did not respond to the
Milwaukee brace.

24. Preoperative preparation for Erin includes explaining that

for 2 weeks after surgery she will be positioned
A. on either side or prone
B. sitting upright
C. flat and will be logrolled
D. on her back
25. When Erin is told that after surgery she will wear a body
cast for about 1 year, she begins to sob. She tells the nurse
she will look like a football player, not a girl. Which of the
following is the best response the nurse can make?
A. the people who really care about you wont even notice
your cast
B. it only will be for a year. Youre mature enough to wait
C. just ignore any comments that people make
D. a pretty hairstyle and some loose peasant
blouses will keep you looking feminine
26. After surgery, the nurse applies slight pressure to Erins
toes and asks Erin is he can feel her foot being touched. Erin
replies, No, I dont feel anything. The nurse should then
A. wait 1 hour and supply pressure again
B. record Erins expected response
C. ask Erin if her toes feel cold
D. report Erins response to the surgeon
Situation: Virginia K is a 25- year old woman who works as a
lifeguard at the local beach. On her way to work she is in an
automobile accident and is rushed to the hospital by
ambulance. A diagnosis of complete transaction of the spinal
cord at the third lumbar (L3) level is made.
27. While assess Ms. K for neurologic function, the nurse can
expect she will be unable to
A. shrug her shoulders
B. tighten her abdominal muscles
C. bend her elbow
D. straighten her legs
28. Long-term goals for Ms. K include developing skills in
A. performing wheelchair ambulation
B. activating an electric wheelchair
C. walking with leg braces and crutches
D. walking without aids
29. observing for symptoms of which of the following is the
priority of care for Ms. K in the acute stages of complete
transaction of the lumbar cord?
A. spinal shock
B. respiratory insufficiency
C. autonomic hyperreflexia
D. hypertensive crisis
30. To prevent the complication of urinary tract infections,
which of the following measures should be included in the
nursing care plan?
A. encouraging extra fluid intake
B. offering at least two servings of citrus fruit juice per day
C. telling the patient to avoid fruit juices such as plum,
prune, and cranberry
D. notifying the dietician to include a container of milk at
all meals
Situation: Jim, a 17-year old senior in high school, has
sustained a simple fracture of the mandible after falling from
his motorbike.
31. Upon admission to the emergency room, which of the
following choices should the nurse expect to observe?
A. bleeding in the external auditory canal
B. dropped prominence of the cheek on the affected side
C. edema of the eyes and cheeks
D. teeth unevenly lined up
Situation: An open reduction with wiring of the lower jaw to
the upper jaw has been done by the surgeon.
32. In anticipating the postoperative needs o the patient,
which of the following actions has the priority for Jim?
A. placing paper and pencil at the bedside

B. providing a tracheostomy set for tracheostomy care

C. taping a wire cutter to the head of the bed
D. inserting a gauze wick in the inside of the cheek
33. While teaching Jim mouth care the nurse should
A. show him how to use moistened gauze sponges to
clean his mouth and tongue
B. demonstrate how an oral irrigation can be
performed by inserting the catheter along the inside
of the mouth between the teeth and the cheek
C. explain to him that mouth care should not be done until
the wires are removed
D. tell him to use an astringent mouthwash to remove all
the debris
Mrs. Marian H is a 50-year old woman who has a spinal cord
lesion at the fourth thoracic (T4) vertebra.
34. When there are lesions above T4 and T6, the patient may
experience autonomic hyperreflexia. This condition can be
prevented by
A. avoiding bladder distention
B. changing the patients position hourly
C. wearing supportive elastic hose
D. doing a neurologic check
35. Mrs. H complains of severe headache and is extremely
anxious. The nurse checks her blood pressure and finds it is
210/110. The nurse should then
A. check the patency of the urinary catheter
B. apply ice packs to her head
C. place the patient in a flat position
D. sit with the patient until the symptoms subside
Situation: Dorothy C, RN, age 35, is at work. After moving a
particularly heavy patient, she suddenly develops severe pain
in the lumbosacral area that radiates down her right leg. The
preliminary diagnosis is rupture of an intervertebral disk.
36. Proper body mechanics may have prevented this injury to
Ms. C. If she had adhered to the correct method of turning a
patient from the supine position to the left side, she would
have crossed the patients right arm over chest, and crossed
the right leg over the left leg. Then, while standing with her
feet
A. together at the patients right side, she would gently turn
the patient by pushing at the shoulder and sacral areas
B. apart at the right side of the bed, she would turn the
patient by gently pushing at the shoulder and center of the
back
C. apart at the left side of the bed, she would gently roll
the patient toward her while keeping her legs straight
D. apart at the left side of the bed, she would
gently roll the patient toward her while flexing her
knees
37. Instructions for Ms. Cs recuperation at home should
include the use of a bed board, firm mattress, and rest in
which of the following positions?
A. completely flat in bed
B. head elevated on a pillow, and knees and feet
elevated with pillows
C. head elevated with several pillows, and her legs flat
D. Head elevated with several pillows, and several pillows
under her knees
38. Ms. C should be reminded that if she is turning on her
side, it is best if she
A. grasps a chair leg by the side of the bed, and slowly
pulls herself over, flexing the uppermost knee
B. keeps her legs extended while crossing them to the
side to which she is turning, and then uses her
arms to help turn the upper portion of her body
C. crosses her arms, flexes the uppermost knee
toward the side to which she is turning, and then
rolls over
D. crosses her arms, crosses her legs while they are
extended to the side toward which she is turning,

and then rolls over

39. The physician gives Ms. C a prescription for
methocarbamol (Robaxin). Because of her nursing
background, Ms. C will know that the mediation is having the
desired effects if which of the following occurs?
A. She feels drowsy, and is sleeping more
B. she has a feeling of euphoria
C. there is a decrease in muscle spasms
D. there is an increase in the knee-jerk reflex
Situation: After a week of bed rest at home, Ms. Cs condition
remains about the same. She is admitted to the hospital for
further treatment and diagnostic tests.
40. Phenylbutazone (Butazolidin) is ordered for Ms.
C. Planning for the administration of this medication should
include directions to
A. administer it immediately before or after eating
B. avoid administering it with dairy products
C. administer it at least 2 hours after eating
D. administer it at specific time intervals, without regard
to meals
41. In addition to the order for phenylbutazone, Ms. C is
placed on bed rest and in pelvic traction. To diminish adverse
responses to this treatment, the nurse should request an
order for
A. acetylsalicylic acid (aspirin)
B. diphenoxylate hydrochloride (Lomotil)
C. prochlorpeazine (Compazine)
D. dioctyl sodium sulosuccinate (Colace)
42. A myelogram is performed on Mrs. C with a water-soluble
contrast medium. Care after this procedure should include
A. limiting fluid intake and elevating the head of the bed
to 15 to 30 degrees
B. not allowing anything by mouth and keeping the bed
flat
C. encouraging fluid intake and keeping the bed flat
D. encouraging fluid intake and raising the head of
the bed to 15 to 30 degrees
43. Ms. C has a laminectomy. Postoperatively, she complains
that the pain is no different now than it was before
surgery. The nurse should
A. administer analgesics as ordered, and explain
that the pain is to be expected because of the edema
that results from the surgery
B. administer the analgesics as ordered, but request that
the physician check the patient immediately
C. withhold the analgesic and notify the physician
D. administer the analgesics as ordered, and tell Ms. C it
will give her relief shortly
44. Rehabilitation will be facilitated if Ms. C is encouraged to
do which of the following?
A. sleep in prone position
B. sit up for at least part of he day
C. perform abdominal-strengthening exercise
D. perform full trunk range-of-motion exercises
Situation: Martha S is a 27-year old patient who has
experienced increasing generalized stiffness, especially in the
morning, fatigue, general malaise, and swelling and pain in
the finger joints. She has a tentative diagnosis of rheumatoid
arthritis.
45. Upon admission, Mrs. S is noted to have a rectal
temperature of 37.7C (100F). A white blood count is
ordered, and the report comes back at 8,500/mm. The nurse
should recognize this as being consistent with rheumatoid
arthritis because it is
A. within normal limits
B. evidence of leukopenia
C. only slightly elevated
D. indicative of a generalized infectious process
46. Which of the following blood-analysis tests would be
consistent with diagnosis of rheumatoid arthritis?

A. an elevated erythrocyte sedimentation rate and

negative C-reactive protein
B. an elevated erythrocyte sedimentation rate and
positive C-reactive protein
C. a low erythrocyte sedimentation rate and negative Creactive protein
D. a low erythrocyte sedimentation rate and positive Creactive protein
47. The primary goal of nursing care for Mrs. S during this
initial acute phase of rheumatoid arthritis should be to
A. prevent deformity and reduce inflammation
B. prevent the spread of the inflammation to other joints
C. provide for comfort and relief of pain
D. assist her to accept the fact that rheumatoid arthritis is
a log-term illness
48. During hospitalization, the nurse should explain to Mrs.
Samuel that analgesics of choice would be
A. codeine
B. acetylsalicylic acid (aspirin)
C. acetaminophen (Tylenol)
D. proppoxyphene hydrochloride (Darvon)
49. During the acute phase of Mrs. Ss illness, which of the
following measures would be the most appropriate?
A. frequent periods of active exercises
B. frequent periods of bed rest
C. rest for he affected joints only
D. encouragement to perform activities of daily living
independently
50. The nurse understands that the main nursing goal in
helping Mrs. S adapt to her chronic illness and plan is to
A. provide the care she is unable to give herself
B. provide guidance so that she will not repress her
illness
C. plan for social contacts so that she will not feel alone
D. arrange for her after-care with the home health aide
51. Mrs. S is given instructions for using paraffin for her
hands. The nurse should include the fact that the dips will be
most effective if they are performed
A. before exercising her hands
B. after exercising her hands
C. instead of exercising her fingers
D. while exercising her fingers
52. Whenever Mrs. S feels pain from her arthritis, she tells the
nurse she feels not only the pain but that her whole body
feels threatened. Which response by the nurse is the most
therapeutic?
A. I will have someone stay with you so you wont harm
yourself
B. I will teach you some relaxing exercises so you
wont be so tense
C. you must have some medication to help you gain control
D. arthritic pain will lessen if you try to grin and bear it
53. When Mrs. S is discharged, she is instructed to take aspirin
at home. It is important that she be told to take the drug
A. on a regular basis throughout the day
B. only when other measures are not effective
C. upon arising and again at bedtime
D. between meals to promote its absorption
54. When Mrs. S is discharged, the nursing staff refers her to a
nurse therapist who will assist her in dealing with the anxiety
over her arthritis and the changes it has made in her life. The
nursing team recognizes that the role of the nurse therapist is
to
A. work in conjunction with a psychiatrist
B. provide individual nursing psychotherapy
C. lead groups in therapy for those with similar problems
D. give family nursing psychotherapy
Situation: Twenty years after Mrs. S was first diagnosed with
rheumatoid arthritis, she is admitted for a right total hip

replacement. She has experienced severe right hip pain that

has not responded to treatment for several years, and has
had increasing difficulty moving about because of damage to
the right hip joint.
55. Preoperative teaching for Mrs. S should include
A. isometric exercises of the quadriceps and gluteal
muscles
B. instructions on the necessity for keeping the right leg
perfectly straight after surgery
C. the need to flex the involved hip postoperatively to
maintain mobility
D. the avoidance of aspirin for 4 days prior to surgery
56. Which of the following should the nurse consider to be
most significant if noted when checking Mrs. S 3 days
postoperatively?
A. pain in the operative site
B. swelling of the operative sites
C. pain and tenderness in the calf
D. orthostatic hypotension
57. The physical therapist orders exercises of Mrs. Ss right
hip, knee, and foot to gradually increase range of motion to
the right hip. The nurse can best assist Mrs. S by
A. administering an analgesic before the exercises
B. stopping the exercises if Mrs. S experiences pain
C. performing the exercises for Mrs. S
D. observing Mrs. Ss ability to perform the exercises
58. Mrs. S should be instructed to avoid
A. adduction of her right leg
B. abduction of hr right leg
C. bearing any weight on her right leg
D. the prone position in bed
59. The nurse and Mrs. S plan for her rehabilitation. Mrs. S
asks the nurse, What do I have to do in therapy? Which
reply by the nurse most accurately describes the task of the
patient in rehabilitation? To
A. follow the instructions of the rehabilitation team
B. regain some function that was lost
C. prevent further loss of your ability to function
D. learn to deal realistically with your disability
60. When the rehabilitation therapist tells Mrs. S that the
outcome of her therapy depends on the ability of the
nursing staff as well as on her motivation, Mrs. S questions
the nurse on the meaning of this phrase. The nurse should
reply that the nurses role in rehabilitation is to
A. make the patient as comfortable as possible
B. follow the directions of the rehabilitation therapist
C. supervise the patients therapy appointments and
exercise program
D. assist the patient in establishing therapy
priorities and goals
61. Mrs. S asks the nurse if her new joint will function
normally. The nurse can best answer this by saying that
A. the new joint will be stronger than the old one
B. the new joint wont function as well as a normal joint,
but it will be better than the arthritic joint
C. the new joint will function almost as well as a
normal joint, particularly if you perform your
exercise faithfully
D. the doctor will be able to assess your limitations in 6
weeks and then explain them to you
Situation: Mr. Lee is a 20-year-old patient who sustains a
compound fracture of the right shaft of the femur and a
simple fracture of the ulna in a motorcycle accident.
62. While serving as a member of a first aid squad, Mary V,
RN, reaches the scene of the motorcycle accident and
administers emergency treatment, which includes the
application of a splint. It is important that the splint
A. be applied while the limb is in good alignment

B. be applied to the limb in the position in which it

is found
C. extend from the fracture site downward
D. extend from the fracture site upward
63. While Mr. Lee is being transported in the ambulance to the
hospital, he should be positioned with the affected limbs
A. elevated
B. in a flat position
C. lower than his heart
D. slightly abducted
64. While taking a history from the patient, the nurse
determines that his last booster injection for tetanus
immunization was 5 years ago. The nurse should recognize
that this information is important because it
means that he should receive
A. a full tetanus immunization program
B. nothing, because he is sufficiently immunized against
tetanus
C. an additional booster injection
D. human tetanus immune globulin
Situation: Mr. Lee is taken to the operating room and the
wound caused by the fracture of the femur is cleansed and
debrided. The fracture is then reduced, and a Steinmann pin
for skeletal traction is inserted. A closed reduction of the ulna
is performed, and a cast is applied.
65. The most important nursing measure in the immediate
postoperative period will be
A. encouragement of isometric exercises
B. cleansing of the area around the Steinmann pin
C. careful observation of vital signs
D. massage of pressure areas
66. After Mr. Lee returns to his room, he complains of pain in
his right arm. The initial action of the nurse should be to
A. administer analgesics as ordered
B. check his fingers
C. notify his physician immediately
D. pad the edges of the cast
67. To maintain proper alignment and immobilization of the
femur, the physician has ordered skeletal traction with a
Thomas splint. While caring for Mr. Lee, the nurse should
explain to him that he
A. cannot turn or sit up
B. cannot turn but can sit up
C. can turn but cannot sit up
D. can turn and can sit up
68. In dealing with the weights that are applying the traction,
the nurse should
A. allow them to hang freely in place
B. hold them up if the patient is shifting position in bed
C. remove them if the patient is being moved up in bed
D. lighten them for short periods if the patient complains
of pain
69. Mr. Lee has a Thomas knee splint in place. In addition to
the usual measures for a patient in traction, it will be
important that the nurse observe
A. the groin area for pressure
B. for constipation
C. his skin for sings of decubiti
D. for signs of hypostatic pneumonia
70. If Mr. Lee should show an increase in blood pressure and
signs of confusion and increased restlessness, the nurse
should suspect
A. a concussion
B. impending shock
C. fat emboli
D. anxiety

71. Because of the nature of Mr. Lees wound and the insertion
of a Steinmann pin, it is especially important that the nurse
observe for
A. a foul odor
B. foot drop
C. pulmonary congestion
D. fecal impaction
72. Mr. Lee develops an acute localized osteomyelitis. He is
placed on intravenous antibiotic therapy. The wound is
incised and drained, and neomycin irrigations are ordered four
times a day. It is important that these irrigations be
performed
A. with strict aseptic techniques
B. with a warm solution
C. for at least 5 minutes
D. at equal time intervals
Situation: Maria Alfredo is a 30-year old married woman who
has systemic lupus erythematosus (SLE).
73. While doing as nursing history on Mrs. Alfredo, the nurse
should recognize that the most common initial symptoms of
SLE are
A. petechiae in the skin, nosebleeds, and pallor
B. hematuria, increased blood pressure, and edema
C. tachycardia, tremors, and loss of weight
D. painful muscles and joints, stiffness, and
inflammation of joints
74. Mrs. Afredo is instituted on long-term prednisone
therapy. Her daily maintenance dose is 5 mg/day. In the
instructions to Mrs. Alfredo, the nurse should emphasize that
A. once the symptoms of SLE subside, the medication will
be discontinued gradually
B. a weight gain 2 pounds per week should be reported to
the physician
C. the maintenance dose will be the lowest dose
that controls symptoms
D. if adrenal atrophy occurs, adrenocorticotropic hormone
(ACTH) will have to be prescribed
75. Mrs. Alfredo questions the nurse about family planning
and birth control. Which of the following choices should the
nurse include in her answer?
A. oral contraceptives can precipitate an acute
exacerbation of your condition
B. Intrauterine devices are the recommended brithcontrol
measures
C. there are no contraindications for pregnancy, as long as
the disease is being treated
D. studies indicate that the corticosteroids produce fetal
damage
76. The nursing care plan states, Observe for signs of
Raynauds phenomenon. The nurse should recognize that
this phenomenon
A. occurs as a side effect of prednisone
B. is aggravated by smoking
C. is relieved by application of cold compresses to the
hands
D. is the priority care
77. Although many abnormal laboratory findings are found in
SLE, there is no one specific diagnostic test. The test that is
positive in over 95 percent of all patients with SLE is the blood
test for
A. the lupus erythematosus (LE) factor
B. the rheumatoid factor
C. antinuclear antibodies (ANA)
D. C-reactive protein (CRP)
78. The teaching program for Mrs. Alfredo planned by the
nurse should include emphasis on which of the following?
A. once the symptoms are controlled, the corticosteroids
will be discontinued
B. if hair loss occurs, it is irreversible

C. overexposure to the sun can produce an

exacerbation of symptoms
D. a low-potassium, low-protein diet is recommended
79. Mrs. Alfredo tells the nurse that she has had black, tarry
stools. The nurse should
A. reassure the patient that this is a minor side effect of
prednisone
B. tell the patient that if she takes the prednisone with
milk, black, tarry stools will be avoided
C. tell the patient that she will ask the physician to
prescribe aluminum hydroxide
D. notify the physician because black, tarry
stools can be an indication of bleeding peptic ulcer
80. Mrs. Alfredo calls the physicians office and complains that
she has chills, a fever, and a cough. The nurse should
A. advise that she remain in bed, drink extra fluids, and
take aspirin every 4 hours
B. recommended that she increase her dose of prednisone
until her temperature is normal
C. recommended that she come to the office to be
examined by the physician
D. tell Mrs. Alfredo to call for an appointment when she is
feeling better
Situation: Irene P is being treated in the emergency room for
an acute attack of Menieres syndrome
81. The nurse should recognize that the triad of symptoms
associated with Menieres syndrome is
A. nystagmus, arthralgia, and vertigo
B. nausea, vomiting, and arthralgia
C. syncope, headache, and hearing loss
D. hearing loss, vertigo, and tinnitus
82. Patient teaching for Mrs. P includes helping her to
recognize that
A. Menieres syndrome is psychogenic and is brought on
by stress
B. most patients can be successfully treated with a
low-salt diet and diuretics
C. acute infection can precipitate an attack
D. a labyrinthectomy is the preferred treatment for
relieving symptoms and restoring hearing
83. Nursing intervention during an acute attack includes
A. encouraging the patient to walk
B. placing the patient in a semi-Fowlers position
C. Having the patient lie flat
D. placing the patient in Trendelenburgs position
Situation: Mrs. C, 30 years old, has symptoms of diplopia,
fatigue, slight vertigo, and a lack of coordination. After a
neurological work-up she is diagnosed as having multiple
sclerosis.
84. The main goal of nursing care for Mrs. C during the acute
phase of the disease should be to
A. promotes rest
B. prevent constipation
C. maintain normal functioning
D. encourage activities of daily living
85. Mrs. C is note d to be having mood swings. In deciding
what approach to use with her, the nursing staff should
recognize that this
A. is probably the result of an underlying mental disorder
B. indicates that Mrs. C is having difficulty accepting her
diagnosis
C. may be a result of pathology and involvement of
the limbic system in the disease
D. indicates that Mrs. Cs intellectual capacity has been
compromised
86. Mrs. C questions the nurse concerning the usual course of
multiple sclerosis. Which would be the best reply by the
nurse?

A. each individual is very different; we cannot tell what will

happen
B. I know you are worried, but it is too soon to predict
what will happen
C. usually, acute episodes like this are followed by
remissions, which may last a long time
D. the future will take care of itself; lets concentrate on
the present

87. As Mrs. Cs condition improves, it is most important that

she be given guidance in
A. developing a program of exercise
B. learning to handle stressful situations
C. seeking vocational rehabilitation
D. limiting her activities to those that are absolutely
necessary
Situation: Barbara is a 23-year-old woman who lives with her
mother, sister, and brother in a private residence. She is
attending the neurological out-patient clinic for the first
time. Her health history includes two grand mal seizures./ A
diagnosis of idiopathic epilepsy has been made. The physician
has ordered an electroencephalogram (EEG) and phenytoin
sodium (Dilantin), 300 mg/day
88. While doing a nursing history on Barbara, the nurse should
recognize that
A. persons with idiopathic epilepsy have a lower
intelligence level
B. grand mal seizures do not cause mental
deterioration
C. a common characteristic of idiopathic epilepsy is
committing acts of violence
D. idiopathic epilepsy is a form of mental illness
89. To prepare Barbara for EEG, the nurse should explain that
A. during the test she will experience small electric shocks
that feels like pin pricks
B. the test measures mental status as well as electrical
brain waves
C. during the hyperventilation portion of the test,
she may experience dizziness
D. she will be unconscious during the test
90. Health teaching for Barbara includes ensuring that she
understands that
A. proper prophylactic medication can control the
incidence of seizures
B. moderate use of alcohol is permitted
C. forcing fluids helps to reduce the incidence of seizures
D. the incidence of seizures is related to hyperglycemia
91. During a follow-up clinic visit, Barbara tells the nurse that
her urine has had a reddish-brown color. The nurse should
A. reassure Barabara that this is a harmless side
effect of phenytoin sodium (Dilantin)
B. tell Barbara that this is a sign of hepatic toxicity
C. recommend that Barbara go to the laboratory for a
serum Dilantin concentration test
D. notify the physician that Barbara has hematuria
92. A long-term goal for Barbara is to minimize the gingival
hyperplasia associated with Dilantin therapy. The nurse
should recognize that
A. another anticonvulsant will be prescribed if it occurs
B. the physician will reduce the dosage at the first sign of
hyperplasia
C. a regular plan of good oral hygiene is essential
D. vitamin C should be taken daily with the Dilantin
93. Barbaras serum concentration level Dilantin is 15
g/ml. The nurse should recognize this as
A. a desired therapeutic serum level
B. below the desired therapeutic level
C. above the recommended serum level
D. a toxic serum level

94. Family members should be instructed about caring

Barbara during a grand mal seizure. Immediate care during a
seizure should include
A. restraining Barbaras arms and legs
B. forcing the mouth open to insert an airway
C. giving orange juice before the clonic stage begins
D. turning Barbaras head to the side
95. The nurse explains to Barbara that safety precautions can
be taken by those who have warning symptoms before the
seizure. (These symptoms are not part of the seizure, as the
aura is.) What warning symptoms should the nurse tell
Barbara to be aware of?
A. Hot and cold sensations, gastrointestinal
problems, anxiety, and mood changes
B. Muscle twitching, lapse of consciousness, anxiety, and
gastrointestinal problems
C. tingling in a local region, anxiety, and lapse of
consciousness
D. increased tonicity of muscles and autonomic behavior
96. The nurse should tell Barbaras family that after a seizure
she will be in a confused state and will need some
supervision. It is most important for the caring one to be calm
because the confused state of the epileptic is considered to
be
A. One mood swings and a feeling of general inadequacy
and fatigue that result in a decrease of interest
B. an adaptive period, when one slowly learns to
cope with the devastating insults to ones
psychological and physical integrity
C. a gross impairment in social and intellectual functioning
with crude, tactless, and impulsive
behavior
D. a helpless state, with intellectual deterioration,
difficulty in communication, and regression to the
infantile state
97. Barbara asks the nurse if it is true that there is an
epileptic personality. Which of the following choices would
be the nurses best response/
A. the person must be aware that anxiety over
anticipation of a seizure may cause personality problems
B. No, deviation in personality is caused by restrictions
imposed by society
C. Yes, one may learn to induce seizures as a way of
getting attention from others
D. the person may take on a sick role if
mismanaged at home or in the community
Situation: Ms. R, a 35-year old woman, has myasthenia
gravis. She has been referred to the neurology clinic by her
physician.
98. While doing a nursing history on Ms. R, the nurse should
expect her to complain of which of the following symptoms?
A. passive tremors, cogwheel rigidity, and drooling
B. spastic weakness of the limbs, intention tremors, and
incontinence
C. diplopia, ptosis, and fatigue
D. nystagmus, ataxia, and tinnitus
99. In preparing a teaching plan for Ms. R, the nurse should
emphasize that
A. the anticholinesterase medications cause fewer side
effects when taken on an empty stomach
B. physical activity should be planned for the late
afternoon early evening
C. a member of the family should be taught how to
use suction for emergency use
D. edrophonium chloride (Tensilon) is the drug of choice in
the treatment of myasthenia gravis
100. Respiratory distress is common in people with
myasthenic crisis? Marked improvement of respirations
occurs after the administration of intravenous
A. diazepam (Valium)

B. hydrocortisone
C. atropine sulfate
D. edrophonium chloride (Tensilon)
101. The medication used to treat cholinergic crisis
A. atropine sulfate
B. neostigmine (Prostigmin)
C. aminophylline
D. hydrocortisone
102. The physician has prescribed pyridostigmine (Mestinon),
180 mg/day. Ms. R tells the nurse that each time she takes
the medication she feels nauseated. The nurse should tell Ms.
R to
A. crush the tablet before taking it
B. take the tablet with food or milk
C. take the tablet on an empty stomach
D. not to take the medication until she notifies the
physician
Mr. Go, who has had Parkinsosns disease for 4 years, visits his
wife daily during her hospital stay. His illness is being treated
with levodopa (L-dopa).
103. When Mr. Go visits his wife, he is observed to be walking
rather slowly. The nurse should recognize that Mr. Go is
A. exhibiting a long-range side effect of L-dopa
B. exhibiting a symptom that is characteristic of
stage II Parkinsons disease
C. beginning to experience atrophy of the cerebral cortex
and cellular changes
D. probably doing this on purpose as a way of
104. The nurse can help him to be more comfortable by
A. discussing this problem and how he handles it,
and discussing hygiene measures with him
B. opening the windows and providing as much ventilation
as possible while he is visiting
C. suggesting that he is probably dressing too warmly for
the hospital environment
D. explaining that this is a side effect of his medication,
and encouraging increased intake of fluids
Situation: Mr. go has a sudden exacerbation of symptoms. He
develops tachycardia, a respiratory rate of 40, and appears
extremely anxious. He is hospitalized with a diagnosis of
parkinsonian crisis.
105. Planning for Mr. Gos care should include measures to
A. provide a quiet, restful environment
B. maintain joint range of motion
C. decrease social isolation
D. improve his nutritional status
106. Mr. Go responds to treatment, and his condition gradually
improves. However, he complains that he feels dizzy
whenever he tries to stand up from a lying position. The nurse
should
A. explain that this is just part of his illness
B. tell him that his doctor will be notified of this symptom
C. encourage him to change his position slowly
D. discuss his feelings about his wifes hospitalization
107. Mr. Go has problems in dressing himself as a result of
tremors, but he refuses all assistance. Which of the following
is the best initial action by the nurse in response to this
complaint?
A. tell him he needs assistance, and gradually help him
B. give him more time and encouragement to dress
himself
C. suggest that for the present he wear only the hospital
gown
D. listen to his refusal, but give him assistance as needed
108. Mr. Go discusses his work as an accountant with the
nurse. He states that he his glad that he will be able to
continue working. An appropriate initial response would be
based on the nurses recognition that he
A. should be encouraged to be active

B. should be cautioned against overfatigue

C. is being unrealistic about his future
D. needs to recognize that his situation is unique
109. Mr. Go tells the nurse that someone told him that people
with Parkinsons disease develop early senility. In response,
the nurse should explain that
A. Parkinsons disease progresses very slowly over
a period of years, and it is only in the late stages
that any mental changes might take place
B. his information is false, because Parkinsons disease
does not cause any changes in the individuals
intellectual capacities
C. he does not have to worry about senility because he is
responding so well to treatment
D. although Parkinsons disease does cause mental
confusion, this condition is clinically different from senility