Professional Review Strategies for Nurses

AJPD
BSN-4 St Anthony College

MEDICAL SURGICAL NURSING VI

JUNE 2007 MOCK EXAMINATION

Instruction: Select the correct answer for each of the following questions.
1. Which of the following conditions is not a complication of Hodgkins disease?
a. Anemia
b. Infection
c. Myocardial infarction
d. Nausea
Hodgkins disease is a malignant lymphoma characterized by lymph node enlargement, including liver, spleen
and progressive anemia. There is no symptom that could immediately lead to heart problem.
2. Which of the following laboratory values is expected for a client just diagnosed with chronic lymphocytic
leukemia?
a. Elevated sedimentation rate
b. Uncontrolled proliferation of granulocytes
c. Thrombocytopenia and increased lymphocytes
d. Elevated aspartate aminotransferase and alanine aminotransferase levels
CLL has always an increased lymphocytes in the early stage. On late stage, anemia and thrombocytopenia
occurs.
3. At the time of diagnosis of Hodgkins lymphoma, which of the following areas is often involved?
a. Back
b. Chest
c. Groin
d. Neck
At the time of its diagnosis, chest is usually examined by chest x ray and CT scans of the chest.
4. Which of the following statements is correct about the rate of cell growth in relation to chemotherapy?
a. Faster growing cells are less susceptible to chemotherapy
b. Non-dividing cells are more susceptible to chemotherapy
c. Faster growing cells are more susceptible to chemotherapy
d. Slower growing cells are more susceptible to chemotherapy
Chemotherapy targets fast growing cell
5. Which of the following tests will not be used to diagnose tumor lysis syndrome?
a. Complete blood count (CBC)
b. Chest X-ray
c. Electrocardiogram (ECG)
d. Electrolytes
TLS test is usually based on electrolyte imbalances and on metabolic abnormalities on neurologic, cardiac, GI
and renal. Chest x ray due to its radiation more commonly induces the extent of complication.
6. Which of the following treatments is most appropriate for the client with tumor lysis syndrome?
a. Give antibiotics
b. Give IV hydration
c. Give packed red blood cells
d. Give potassium chloride IV
In TLS, hydration is the most priority to prevent renal failure and restore electrolyte imbalance.
7. Which of the following substances has abnormal values early in the course of multiple myeloma (MM)?
a. Immunoglobulins
b. Platelets
c. Red blood cells (RBC)
d. White blood cells (WBC)
In MM, malignant plasma cells produced increased amount of specific immunoglobulin that is nonfunctional.
8. For which of the following conditions is a client with multiple myeloma (MM) monitored?
a. Hypercalcemia
b. Hyperkalemia
c. Hypernatremia
d. Hypermagnesemia

Nurse Licensure Examination

Professional Review Strategies for Nurses

There is bone destruction in MM. excessive ionized calcium is lost from the bone and enters serum, thus
becomes hypercalcemic.
9. Which of the following conditions or symptoms is often a secondary complication of hypercalcemia in a
client with multiple myeloma (MM)?
a. Pneumonia
b. Muscle spasms
c. Renal dysfunction
d. Myocardial irritability
Renal failure is also seen in hypercalcemia of MM
10. Which of the following interventions is stressed in teaching about multiple myeloma (MM)?
a. Maintain bed rest
b. Enforce fluid restriction
c. Drink 3 L of fluid daily
d. Keep the lower extremities elevated
Drinking 3L/day to maintain high urine output is very necessary to prevent having the complication of renal
failure.
11. Which of the following precautions should the nurse include in the care plan for a neutropenic client
with leukemia?
a. Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for
signs of bleeding
b. Put on a mask, gown, and gloves when entering the clients room
c. Provide a clear liquid, low-sodium diet
d. Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand
washing
Neutropenic clients should initially have thorough handwashing, avoid fresh fruits and vegetables and avoid
enema- to diminish risk for infection and bleeding.
12. Which of the following actions or conditions is the number one cause of lung cancer?
a. Genetics
b. Occupational exposures
c. Smoking a pipe
d. Smoking cigarettes
Tobacco smoke is the leading cause of lung cancer. More than 85% of it are attributable to inhalation of
carcinogenic chemicals such as by cigarette smoking
13. Warning signs and symptoms of lung cancer include persistent cough, bloody sputum, dyspnea, and
which of the following other symptoms?
a. Dizziness
b. Generalized weakness
c. Hypotension
d. Recurrent pleural effusions
Pleural effusions are symptoms of lung cancer. There are times that hemoptysis or blood tinge sputum is
expectorated.
14. A definitive diagnosis of lung cancer is obtained by which of the following evaluation?
a. Bronchoscopy
b. Chest X ray
c. Computerized tomography of the chest
d. Surgical biopsy
Biopsy is almost always a definitive test for cancers. It can be by excision or aspiration.
15. Staging of lung cancer is done for which of the following reasons?
a. To identify the type of cancer
b. To identify the best treatment
c. To identify if metastasis occurred
d. To identify the location of the lesion
Staging is done to know the extent of disease or if there is already a metastasis to other distant organs.
16. A client has been diagnosed with lung cancer and requires a wedge resection. How much of the lung is
removed?

Nurse Licensure Examination

Professional Review Strategies for Nurses

a. One entire lung
b. A lobe of the lung
c. A small, localized area near the surface of the lung
d. A segment of the lung, including a bronchiole and its alveoli
Wedge resection is a removal of a small, pie shaped area of the segment
17. The client with a benign tumor is treated in which of the following ways?
a. The tumor is treated with radiation only
b. The tumor is treated with chemotherapy only
c. The tumor is left alone unless symptoms are present
d. The tumor is removed, involving the least possible amount of tissue
Benign tumors are often removed for preventive surgery, to avoid possible malignancy of tumor.
18. Colon cancer is most closely associated with which of the following condition?
a. Appendicitis
b. Hemorrhoids
c. Hiatal hernia
d. Ulcerative colitis
Ulcerative colitis is a recurrent and inflammatory disease of mucosal and submucosal layers of colon and
rectum. Symptoms were alike colon cancer.
19. Which of the following diet is most associated with colon cancer?
a. Low-fiber, high fat
b. Low fat, high fiber
c. Low-protein, high carbohydrates
d. Low-carbohydrates, high protein
A low fiber , high fat diet reduces motility and increases the chance of constipation. Its end products are
carcinogenic.
20. Radiation therapy is used to treat colon cancer before surgery for which of the following reasons?
a. Reducing the size of the tumor
b. Eliminating the malignant cells
c. Curing the cancer
d. Helping heal the bowel after surgery
Radiation therapy is used to shrink the size of the tumor, to achieve better results from surgery and reduce risk
of recurrence.
21. Which of the following symptoms is a client with colon cancer most likely to exhibit?
a. A change in appetite
b. A change in bowel habit
c. An increase in body weight
d. An increase in body temperature.
The most common presenting symptom for colon cancer is change in the bowel habits.
22. A client has just had a surgery for colon cancer. Which of the following disorders might this client
develop?
a. Peritonitis.
b. Diverticulosis
c. Partial bowel obstruction.
d. Complete bowel obstruction.
Peritonitis can occur after surgery of the colon. It is an intra abdominal septic condition.
23. A client with gastric cancer may exhibit which of the following symptoms?
a. Abdominal cramping.
b. Constant hunger
c. Feeling of fullness
d. Weight gain.
Patient with gastric cancer may report feeling of fullness but not enough to cause him to seek medical care.
24. Which of the following diagnostic tests may be performed to determine if a client has gastric cancer?
a. Barium enema.
b. Colonoscopy.
c. Gastroscopy.

Nurse Licensure Examination

Professional Review Strategies for Nurses

d. Serum chemistry level.
Gastroscope is used to visualize the colon.
25. A client with rectal cancer may exhibit which of the following symptoms?
a. Abdominal fullness.
b. Gastric fullness.
c. Rectal bleeding.
d. Right upper quadrant pain.
Rectal bleeding is a common symptom of rectal cancer.
26. A client with which of the following conditions may be likely to develop rectal cancer?
a. Adenomatous polyps
b. Diverticullitis.
c. Hemorrhoids.
d. Peptic ulcer disease.
Adenomatous polyp is a risk factor for rectal cancer.
27. Which of the following treatment is used for rectal cancer but not for colon cancer?
a. Chemotherapy.
b. Colonoscopy.
c. Radiation.
d. Surgical resection.
Radiation therapy is not used for colon cancer. In rectal cancer, patient were given chemotherapy + high doses
of radiation. There is lso a surgical procedure.
28. Which of the following tests is most accurate for diagnosing liver cancer?
a. Abdominal ultrasounds.
b. Abdominal flat plate X-ray
c. Cholangiogram
d. Computed tomography (CT) scan
Confirmation of tumors histology is made by biopsy under imaging guidance (CT Scans)
29. Which of the following terms is used to describe a usually benign tumor of the adrenal medulla?
a. Apical aneurysm
b. Endemic goiter
c. Pheochromocytoma
d. Ulcerogenic tumor
Pheochromocytoma is a benign tumor that originates from chromaffin cells of adrenal medulla.
30. Tumors of the adrenal medulla usually produce which of the following symptoms?
a. Carpopedal spasm
b. Hyperglycemia
c. Hypertension
d. Moon face
Hypertension and other cardiovascular disturbance are common. Hypertension can be intermittent or
persistent.
31. A client is receiving a radiation implant for the treatment of bladder cancer. Which of the following
interventions is appropriate?
a. Flush all urine down the toilet.
b. Restrict the clients fluid intake.
c. Place the client in a semiprivate room.
d. Monitor the client for signs and symptoms of cystitis.
Cystitis is one of the complications of radiation implant. It should be monitored properly.
32. A client is diagnosed with prostate cancer. Which test is used to monitor progression of this disease?
a. Serum creatinine
b. Complete blood count (CBC)
c. Prostate specific antigen (PSA)
d. Serum potassium
PSA testing is routinely done to monitor patients response to cancer therapy and to detect local progression
and early recurrence of prostate cancer

Nurse Licensure Examination

Professional Review Strategies for Nurses

33. Which of the following factors is the most common cause of basal cell epithelioma?
a. Burns
b. Exposure to sun
c. Immunosuppression
d. Exposure to radiation.
Sun exposure is the most common cause for skin cancer.
34. To promote healing of a laceration, which of the following interventions is correct?
a. Elevate body part
b. Monitor the blood pressure
c. Apply a pressure dressing and heat
d. Apply a pressure dressing and ice pack
Pressure dressings help clotting by promoting the localization of the microorganisms and the development of
meshworks for repair and healing. Ice decreases blood flow to site slowing the bleeding.
35. An elderly client has a wound that isnt healing normally. Interventions should be based on which of the
following principles or test results?
a. Laboratory test results
b. Kidney function test results
c. Poor wound healing expected as part of the aging process
d. Diminished immune function interfering with ability to fight infection
Immune function is important in the healing process and diminished response may slow or prevent the healing
process from taking place.
36. Corticosteroids are potent suppressors of the bodys inflammatory response. Which of the following
conditions or actions do they suppress?
a. Sympathetic response
b. Pain receptors
c. Immune response
d. Neural transmission
Corticosteroids are widely used for auto immune reactions and reducing rejection process in transplantation.
37. Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a drug
should include which of the following action first?
a. Administering oxygen
c. Obtaining a complete blood count (CBC)
b. Inserting an IV catheter
d. Taking vital signs
Airway and ventilation is the primary intervention when there is anaphylactic reaction.
38. A 19-year-old client went to a party, took some pills and drank beer. Hes brought to the emergency
department because he wont wake up. When assessing him, the nurse would expect to find which of
the following reactions?
a. Hyperreflexive reflexes
c. Shallow respirations
b. Muscle spasms
d. Tachypnea
Coma patients has shallow respirations
39. An unconscious client who overdosed on a narcotic receives naloxone (Narcan) to reverse the
overdose. After he awakens, which of the following actions by the nurse would be the best?
a. Feed the client
b. Teach the client about the effects of taking pills and alcohol together
c. Discharge the client from the hospital
d. Admit the client to a psychiatric facility
The nurse should always give health teachings.
40. A 24-year-old client comes into the clinic complaining of right-sided chest pain and shortness of breath.
He reports that it started suddenly. The assessment should include which of the following interventions?
a. Ausculation of breath sounds
c. Echocardiogram
b. Chest X-ray
d. Electrocardiogram (ECG)
Because there is SOB, listening to the breath sounds is necessary.
41. A client is about to have a chest tube inserted in the left upper chest. When the tube is inserted. It
begins to drain a large amount of serosanguineous fluid. Which of the following explanations best
describes what caused this?
a. The chest tube was inserted improperly

Nurse Licensure Examination

Professional Review Strategies for Nurses

b. This always happens when a chest tube is inserted
c. An artery was nicked when the chest tube was placed
d. The client had a hemothorax instead of a pneumothorax
Because of the traumatic cause of injury, the client had a hemothorax.
42. A hospitalized client needs a central IV catheter inserted. The physician places the catheter in the
subclavian vein. Shortly afterward, the client develops shortness of breath and appears restless. Which
of the following actions would the nurse do first?
a. Administer a sedative
b. Advise the client to calm down
c. Auscultate breath sounds
d. Check to see if the client can have medication
Because this is an acute episode, listen to the clients lungs to see if anything has changed. Dont give
medication to this client.
43. Which of the following measures would be ordered for a client who recently had a central venous
catheter inserted and who now appears short of breath and anxious?
a. Chest X-ray
c. Laboratory tests
b. Electrocardiogram
d. Sedation
Inserting an IV catheter in the subclavian vein can result in a pneumothorax, so a chest x ray should be done.
44. A client needs to have a chest tube inserted in the right upper chest. Which of the following actions is
part of the nurses role?
a. The nurse isnt needed
b. Preparing the chest tube drainage system
c. Bring the chest X-ray to the clients room
d. Insert the chest tube
The nurse will be the one to assemble the equipments needed in the procedure including the preparation.
45. Which of the following results shows that a chest tube insertion was done correctly?
a. Bronchial sounds heard at both bases
b. Vesicular sounds hear over upper lung fields
c. Bronchovesicular sounds heard over both lung fields
d. Crackles head on the affected side
Normal bronchovesicular breath sounds in the area will be heard and the clients oxygenation status will
improve.
46. Which of the following interventions should be done before a chest tube is removed?
a. Disconnect the drainage system from the tube
b. Obtain a chest X-ray to document reexpansion
c. Obtain an arterial blood gas level to document oxygen status
d. Sedate the client, and physician will slop the tube out without warning the client
Before removal of chest tube, chest x ray is done to assess for lung re expansion
47. A client with a chest tube has accidentally removed it. What should be done first?
a. Lie the client down on his left side
b. Lie the client down on his right side
c. Apply an occlusive dressing over the site
d. Reinsert the chest tube that fell out
Occlusive dressing is very important to maintain the negative pressure of lungs.
48. Which of the following statements best defines a pulmonary embolism?
a. Its a blood clot that originates in the lung
b. Its a blood clot that has occluded an alveolus
c. Its a blood clot that has occluded a bronchiole
d. Its a blood clot that has occluded pulmonary blood vessel
PE is the obstruction of pulmonary arteryon one of its branches that originates somewhere in the right side of
the heart.
49. Which of the following is the most common origin for in pulmonary embolism?
a. Amniotic fluid
b. Bone marrow
c. Septic thrombi

Nurse Licensure Examination

Professional Review Strategies for Nurses

d. Venous thrombi
Venous system is where pulmonary embolism mostly originates
50. Which of the following measures to prevent pulmonary embolism after lower extremity surgery is the
best?
a. Early ambulation
b. Frequent chest X-rays to find a pulmonary embolism
c. Frequent lower extremity scans
d. Intubation of the client
Early ambulation and active leg exercises are general preventive measures of PE
51. Which of the following physiologic effects of a pulmonary embolism would initially affect oxygenation?
a. A blood clot blocks ventilation; perfusion is unaffected
b. A blood clot blocks ventilation, producing hypoxia despite normal perfusion
c. A blood clot blocks perfusion and ventilation, producing profound hypoxia
d. A blood clot blocks perfusion, producing hypoxia despite normal or supernormal
ventilation
The blood clot blocks blood flow to a region of the lung tissue. There is a mismatch ventilation-perfusion.
52. A ventilation-perfusion scan is frequently performed to diagnose a pulmonary embolism. This test
provides what type of information?
a. Amount of perfusion present in the lung?
b. Extent of the occlusion and amount of perfusion lost
c. Location of the pulmonary embolism
d. Location and size of the pulmonary embolism
Ventilation-perfusion scan indicates areas of diminished or absent blood flow and most useful test to rule out
PE.
53. Which of the following tests can be used to definitely diagnose a pulmonary embolism?
a. Arterial blood gas (ABG) analysis
b. Computed tomography (CT) scan
c. Pulmonary angiogram
d. Ventilation-perfusion scan
Pulmonary angiography is considered the gold standard for diagnosisof PE if lung scan results are not
definitive.
54. Which of the following medications is prescribed after a pulmonary embolism is diagnosed?
a. Warfarin (Coumadin)
b. Heparin
c. Streptokinase
d. Urokinase
Anticoagulant, initially the heparin is used to prevent recurrence of the emboli.
55. IV heparin is given to clients with pulmonary embolism for which of the following reasons?
a. To dissolve the clot
b. To break up the pulmonary embolism
c. To slow the development of other clots
d. To prevent clots from breaking off and embolizing to the lung
Heparin prevents emboli recurrence. It stops or slows the thrombus formation not breaking it off.
56. Nursing management of a client with pulmonary embolism focuses on which of the following actions?
a. Assessing oxygenation status
b. Monitoring the oxygen delivery device
c. Monitoring for other sources of clots
d. Determining whether the client requires another ventilation-perfusion scan
Oxygenation status must be monitored because there are inadequate oxygenation to some tissues affected.
57. To obtain an arterial blood sample from a clients radial artery, which of the following should the nurse
do first?
a. Perform Allens test
b. Place a rolled towel under the clients wrist
c. Clean the puncture site with an alcohol or povidone-iodine pad
d. Palpate the artery with the index and middle fingers of one hand

Nurse Licensure Examination

Professional Review Strategies for Nurses

Allens test is done to assess the circulation.
58. Three days after an abdominal aortic aneurysm repair, a client develops a pulmonary embolus. Which
nursing diagnosis takes priority?
a. Ineffective tissue perfusion (cardiopulmonary)
b. Impaired physical mobility
c. Ineffective airway clearance
d. Risk for aspiration
Pulmonary embolus occurs when a thrombus lodges in a branch of the pulmonary artery, partially or totally
occluding it. The lung is adequately ventilated but cant be perfused.
59. A client with cancer develops pleural effusion. During chest auscultation, which of the following breath
sounds should the nurse expect to hear?
a. Crackles
b. Ronchi
c. Diminished breath sounds
d. Wheezes
Theres a decreased or absent breath sounds in pleural effusion when percussed during initial assessment.
60. A heparin infusion at 1,500 unit/hour is ordered for a 65-year-old client with a stroke in evolution. The
infusion contains 25,000 units of heparin in 500ml of saline solution. How many milliliters per hour
should be given?
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
61. Which of the following medications may be prescribed to prevent a thromboembolic stroke?
a. Acetaminophen
b. streptokinase
c. Ticlopidine
d. Methylprednisone
Ticlopidine (ticlid) is an antiplatelet meds which decreases incidence of stroke
62. Clear fluid draining from the nose of a client who had a head trauma 3 hours ago. This may indicate
which of the following conditions?
a. Basilar skull fracture
b. Cerebral concussion
c. Cerebral Palsy
d. Sinus infection
Basilar skull fracture has the manifestations of CSF leakage in nose or ears
63. A 33-year-old client undergoes an L4-L5 laminectomy. Which of the following methods would be best to
prevent skin breakdown & hypostatic pneumonia?
a. Apply an alternating air mattress to the bed.
b. Use a foam wedge when propping the client on his side
c. Logroll the client with assistance, if necessary, to keep his back in alignment
d. Teach the client to reach for the side of the rail with his dominant hand to pull himself onto his
side
Logrolling...turn the client as a unit by logrolling to prevent stress on the intra-diskal area...DEFINITELY DO
NOT teach the client to reach for the side rail because this may cause lordosis of the spine
64. Which of the following adverse effects may occur during phenytoin (Dilantin) therapy?
a. Dry mouth
b. Furry tongue
c. Somnolence
d. Tachycardia
Adverse effects of phenytoin are gingival hyperplasia, hypotension, nausea, hypertrichosis, rashes and
drowsiness or somnolence.
65. Which of the following precautions must be taken when giving phenytoin (Dilantin) to a client with
nasogastric (NG) tube for feeding?
a. Check the phenytoin level after giving the drug to check for toxicity

Nurse Licensure Examination

Professional Review Strategies for Nurses

b. Elevate the head of the bed before giving phenytoin through the NG tube.
c. Give phenytoin 1 hour before or 2 hours after Ng tube feedings to ensure absorption.
d. Verify proper placement of the NG tube by placing the end of the tube in a glass of water &
observing for bubbles.
If patient is receiving enteral feeding, 2 hours should be relased.
66. Whats the most important concern for clients who drink alcohol while taking phenytoin?
a. Alcohol increases the phenytoin activity
b. Alcohol raises the seizure threshold.
c. Alcohol impairs judgment & coordination
d. Alcohol decreases the effectiveness of phenytoin
Combining Dilantin and alcohol may reduce the effectiveness of the medication and increase the risk and
severity of side effects.
67. A client with cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?
a. To hasten wound healing
b. To immobilize the surgical spine
c. To prevent autonomic dysreflexia
d. To hold bony fragments of the skull together
Gardner-Wells tong is a traction which functions for immobilization
68. Which of the following statements best describes the purpose of a Harrington rod?
a. It immobilizes the surgical spine.
b. It permits ambulation.
c. It stabilizes the knee joints.
d. It stabilizes the thoracolumbar spine.
Harrington rod stabilize the spine affected in scoliosis which are tha thoracic or lumbar spine.
69. A client is scheduled for magnetic resonance imaging (MRI) of the head. Which of the following areas is
essential to assess before the procedure?
a. Food or drink intake within the past 8 hours
b. Metal fillings, prostheses, or a pacemaker.
c. The presence of carotid artery disease
d. Voiding before the procedure.
Metals and prosthesis are always removed because these will alter the magnetic field of procedure
70. When giving IV phenytoin (Dilantin), which of the following methods should be used?
a. Administering rapidly
b. Withholding other anticonvulsants
c. Mixing the drug with saline solution only
d. Flushing the IV catheter with dextrose solution
Phenytoin, to prevent precipitation and minimize local venous irritation, follow infusion with 0.9 NaCl because it
is caustic tto tissues, avoid extravasation.
71. A 35-year-old client with subarachnoid hemorrhage undergoes cerebral angiography. Which action
should the nurse take immediately after this procedure?
a. Assess for signs and symptoms of cerebral vasospasm
b. Instruct the client to lie in a supine position for 4 hours after the procedure
c. Check neurovascular status of the extremity distal to the insertion site
d. Restrict the clients fluids to reduce cerebral edema
Cerebral vasospasm is a complication of cerebral angiography, so signs and its symptoms should be
assessed.
72. Which of the following signs and symptoms can occur with fat emboli?
a. Tachypnea, tachycardia, shortness of breath, paresthesia
b. Paresthesia, bradypnea, bradycardia, petechial rash on chest and neck
c. Bradypnea, bradycardia, shortness of breath, petechial rash on chest and neck
d. Tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck
Tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck are all symptoms and signs of
fat emboli.
73. Which of the following diagnostic tests should be performed annually after age 50 to screen for colon
cancer

Nurse Licensure Examination

Professional Review Strategies for Nurses

a. Abdominal computed tomography (CT) scan
b. Abdominal X-ray
c. Colonoscopy
d. Fecal occult blood test.
FOBT is needed to visualize invisible fecal blood.
74. Which of the following complications of gastric resection should the nurse teach the client to watch for?
a. Constipation.
b. Dumping syndrome
c. Gastric spasm
d. Intestinal spasm.
Dumping syndrome is an unpleasant set of vasomotor and GI symptoms that sometimes occur in patientswho
had gastric surgery.
75. Immediately after liver biopsy, which of the following complications should the client closely monitored
for?
a. Abdominal cramping.
b. Hemorrhage
c. Nausea and vomiting
d. Potential infection
Liver is very vascularized so bleeding is expected after the procedure.
76. When a client who has a liver disorder is having an invasive procedure, the nurse helps assure safety
by assessing the results of which of the following tests?
a. Coagulation study
b. Liver enzymes level
c. Serum chemistries.
d. White blood cell count
The liver produces coagulation factors so if liver is affected negatively, production of these factors will be
altered.
77. For which of he following symptoms should a client at risk for evisceration be monitored after an
abdominal hysterectomy?
a. Tachycardia accompanied by a weak, thready pulse.
b. Hypotension with a decreased level of consciousness
c. Shallow, rapid respirations and increasing vaginal drainage
d. Low-grade fever with increasing serosanguineous incisional drainage.
Signs of impending evisceration are low grade fever and increasing serosanguinous drainage.
78. A client is describing how she palpates her breasts for breast self-examination. Which of the following
statements indicates the need for further teaching?
a. I put lotion on my breasts before I begin to palpate them.
b. I palpate both breasts standing up and then lying on my back.
c. Im careful to palpate under each arm and up to 2 inches below my collarbone.
d. I start at the outer edge of the breast and work in to the nipple in smaller and smaller circles.
BSE requires palpation of all breast tissue. Lotions facilitate palpation.
79. During a routine physical examination, a firm mass is palpated in the right breast of a 35-year-old
woman. Which of the following findings or client history would suggest cancer of the breast as opposed
to fibrocystic disease?
a. History of early menarche.
b. Cyclic change in mass size.
c. History of anovulatory cycles.
d. Increased vascularity of the breast
Increase in the breast size or vascularity is consistent with cancer of the breast.
80. A client has undergone a radical cystectomy and has an ileal conduit for the treatment of bladder
cancer. Which of the following postoperative assessment findings must be reported to the physician
immediately?
a. A red, moist stoma.
b. A dusky-colored stoma.
c. Urine output more then 30 ml/hour
d. Slight bleeding from the stoma when changing the appliance.

Nurse Licensure Examination

10

Professional Review Strategies for Nurses

The stoma should be red and moist indicating adequate blood flow. Dusky stoma indicates insufficient blood
supply and an emergency.
81. Which of the following instructions should be given to a client with an ileal conduit about skin care at the
stoma site?
a. Change the appliance at bedtime.
b. Leave the stoma open to air while changing the appliance.
c. Clean the skin around the stoma with mild soap and water ad dry it thoroughly.
d. Cut the faceplate or water of the appliance no more than 4 mm larger than the stoma.
Cleaning the periostoma with soap and water and drying it thoroughly helps area clean from urine.
82. Care for an indwelling urinary catheter should include which of the following interventions?
a. Insert the catheter using clean technique.
b. Keep the drainage bag on the bed with the client.
c. Clean around the catheter at the meatus with soap and water.
d. Lay the drainage bag on the floor to allow for maximum drainage through gravity.
It is important to clean around the meatus at the catheter site to decrease the chance of infection.
83. Which of the following methods should be used to collect specimen for urine culture?
a. Have the client void in a clean container.
b. Clean the foreskin of the penis of uncircumcised men before specimen collection.
c. Have the client void a urinal, and then pour the urine into the specimen container.
d. Have the client begin the stream of urine in the toilet and catch the urine in a sterile container
midstream.
The patient is instructed to urinate on a clean cup collected anytime of the day over 24 hour period.
84. Whet is he best time of day to give diuretics
a. Anytime.
b. Bedtime.
c. Morning.
d. Noon.
Administration of diuretics is at time conducive to patients lifestyle ex: early in the day to prevent nocturia
85. Which of the following interventions would be inappropriate to help a client with postoperative urinary
retention?
a. Give a diuretic.
b. Pour warm water over the perineum
c. Consider inserting a bladder catheter
d. Place the client in a sitting or semi-Fowler position.
Urinary retention reflects bladder distention from urine. A diuretic isnt necessary.
86. A client is injected with radiographic contrast medium and immediately shows signs of dyspnea,
flushing, and pruritis. Which of the following interventions should take priority?
a. Check vital signs.
b. Make sure the airway is present.
c. Apply a cold pack to the I.V. site.
d. Call the physician.
Airway is properly assessd when there is sensitivity to iodine in the contrast medium.
87. Adverse reactions of prednisone therapy include which of the following?
a. Acne and bleeding gums
b. Sodium retention and constipation
c. Mood swings and increased temperature
d. Increased blood glucose levels and decreased wound healing
Prednisone, a systemic glucocorticoid has a side effect of immunosuppression like decreased wound healing
and hyperglycemia.
88. Steroids, such has prednisone and methylprednisolone, are used to suppress the inflammatory immune
response following a kidney transplant. Which of the following pieces of information should be given to
a client with a transplant?
a. Alopecia may occur
b. Orthostatic hypotension is common
c. Cholesterol levels may become elevated

Nurse Licensure Examination

11

Professional Review Strategies for Nurses

d. Blood glucose levels may become elevated
Hyperglycemia is a side effect of immunosuppressant drugs.
89. The nurse suspects that a client with polyuria is experiencing water diuresis. Which laboratory value
suggests water diuresis?
a. High urine specific gravity
b. High urine osmolarity
c. Normal to low urine specific gravity
d. Elevated urine pH
Water dieresis causes low urine specific gravity, low osmolality and norma to elevated serum sodium level.
90. A 27-year-old client, who became paraplegic after a swimming accident, is experiencing autonomic
dysreflexia. Which condition is the most common cause of autonomic dysreflexia?
a. Upper respiratory infection
b. Incontinence
c. Bladder distention
d. Diarrhea
Bladder distention is the most common cause to trigger autonomic dysreflexia
91. Which of the following methods is best for making sure a client receives an ordered dressing change
each shift?
a. Write the order in the clients care plan
b. Put a sign above the head of the clients bed.
c. Tell the nurse about the treatment in the report.
d. Document the dressing change in the narrative note.
Writing the order in the clients care plan notifies everyone of the treatment.
92. Which of the following nursing diagnosis is correct for a client with a reddened sacrum unrelieved by
position change?
a. Risk for pressure ulcer.
b. Risk for impaired skin integrity
c. Impaired skin integrity related to infrequent turning and positioning.
d. Impaired skin integrity related to the effects of pressure and shearing forces.
The clients impaired skin integrity is the result of pressure and shearing forces.
93. A surgical client has just been admitted to the recovery room after a colon resection. The nurse checks
the dressing for indications of which of the following complications?
a. Peritonitis
c. Dehiscense
b. Paralytic ileus
d. Hemorrhage
In the immediate postoperative phase, hemorrhage is a possibility.
94. Which of the following techniques is incorrect when giving a client a bath?
a. Close the bed curtain to provide privacy
b. Change the bath water when it becomes tepid.
c. Wash the female perineum from pubis toward the anus
d. Wash the client without gloves to improve the nurse-client relationship.
Latex gloves should be worn to wash a client to prevent transmission of the microorganisms from client to
nurse and from nurse to client.
95. Which of the following techniques is correct for obtaining a wound culture from a surgical site?
a. Thoroughly irrigate the wound before collecting the culture.
b. Use a sterile swab and wipe the crusty area around the outside of the wound.
c. Gently role a sterile swab from the center of the wound outward to collect drainage.
d. Use one sterile swab to collect drainage from several possible infected sites along the incision.
Rolling a swab from the center outward is the right way to culture a wound.
96. Which of the following characteristics of an abdominal incision would indicate a potential for delayed
wound healing?
a. Sutures dry and intact.
b. Wound edges in close approximation
c. Purulent drainage on soiled wound dressing.
d. Sanguineous drainage in wound collection drainage beg
Purulent discharge contains WBC which fight the infection so the healing will be altered.

Nurse Licensure Examination

12

Professional Review Strategies for Nurses

97. Which of the following interventions is most appropriate for preventing pressure ulcers in a bedridden
elderly client?
a. Slide instead of lift the client when turning.
b. Turn and reposition the client at least every 8 hours.
c. Apply lotion after bathing the client, and vigorously massage the skin.
d. Post a turning schedule at the clients bedside, and adapt position changes to the clients
situation.
A turning schedule with a signing sheet will make sure the client gets turned.
98. Which of the following instructions is the most important to give a client who has recently has a skin
graft?
a. Continue physical therapy
b. Protect the graft from direct sunlight.
c. Use cosmetic camouflage techniques.
d. Apply lubricating lotion to the graft site.
To avoid burning and sloughing, the client must protect the graft from direct sunlight.
99. Which of the following statements is correct regarding skin turgor?
a. Overhydration causes the skin to tent.
b. Normal skin turgor is moist and boggy
c. Inelastic skin turgor is a normal part of aging.
d. Dehydration causes the skin to appear edematous and spongy.
Inelastic skin turgor is really normal in aging process
100.
A client has stage 2 sacral pressure ulcer thats receiving a transparent film dressing. Which of
the following statements is correct for this type of dressing?
a. The dressing will maintain a moist, environment for the wound.
b. The dressing should be allowed to dry out before removal.
c. A gauze dressing should cover the transparent film dressing.
d. The transparent film dressing should be tightly packed into the wound.
A transparent film dressing keeps the wound moist and enhances autolysis of necrotic tissues
101.

Which of the following techniques will maintain surgical asepsis?

a. Change the sterile field after sterile water is spilled on it
b. Put on sterile gloves, then open a container of sterile saline
c. Place a sterile dressing 1/2 (1.3 cm) from the edge of the sterile field.
d. Clean the wound with a circular motion, moving from outer circles towards the center.
A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick, allowing
microorganisms to contaminate the field.
102.

Which of the following information is not critical during an assessment of skin integrity?
a. Family history of pressure ulcers.
b. Presence of existing pressure ulcers.
c. Overall risk for developing pressure ulcers.
d. Potential areas of pressure ulcer development.
Family history is not important for assessment of skin integrity.
103.
Which of the following interventions is inappropriate for the treatment of postoperative wound
eviscerations?
a. Give prophylactic antibiotics as ordered.
b. Have the client drink as much fluid as possible.
c. Explain the client whats happening and give support
d. Cover the protruding internal organs with sterile gauze moistened with sterile saline.
NPO is assured when theres abdominal surgery most specially when there complication in the wound.
104.
Which of the following interventions is performed first when changing a dressing or giving
wound care?
a. Put on gloves
b. Wash hands thoroughly
c. Slowly removed the soiled dressing.
d. Observed the dressing for the amount, type, and odor of drainage.
Handwashing is always the first when giving care for patients.

Nurse Licensure Examination

13

Professional Review Strategies for Nurses

105.
When caring for a client who spends all or most of the time in bed, a turning schedule prevents
the development of complications. Which of the following schedules is best for most clients?
a. Turn every half hours
b. Turn every 1 to 2 hours
c. Turn once every 8 hours
d. Keep the client on his back as much as possible.
1 to 2 hours are the standard time for changing of positions.
106.
Which of the following instructions is most important when teaching a client about
hypersensitivity skin test results?
a. Wash the sites daily with mild soap
b. Have the sites read on the correct date.
c. Keep the skin test areas moist with a mild lotion
d. Stay out of direct sunlight until the test is read.
An important facet of evaluating skin test is to read the skin test result at the proper time. Too early or too late
evaluation is unreliable and inaccurate.
107.
A client has an inflamed area on the right forearm thats causing considerable discomfort. The
nurse should expect the physician to order which of the following treatments?
a. Warm, moist compresses.
b. An elastic bandage.
c. Hydrocortisone cream.
d. Non-adherent dressing.
Warm, moist compresses increase circulation to the area, reducing discomfort and redness.
108.
An elderly client has a sore on the inside of her ankle that she says wont heal. After noting
varicosities, and coarse discoloration around the sore, the nurse should suspect which of the following?
a. Acute venous insufficiency
b. Chronic venous insufficiency
c. Acute arterial occlusive disease.
d. Chronic arterial occlusive disease.
Classic signs of chronic venous insufficiency include skin discoloration and stasis ulcers.
109.
The physician orders a wet-to-dry dressing for a client who has pressure ulcer with infected
necrotic tissue. Whats the rationale for this treatment?
a. To prevent extension of the infection.
b. To debride the wound
c. To keep the wound moist.
d. To reduce pain.
A wet to dry dressing placed over a necrotic area adheres to the dead tissue and is debrided as the dressing is
removed.
110.
When changing a dressing on a pressure ulcer, the nurse notes necrotic wound tissue. Which
treatment should the nurse expect the physician to order?
a. Wound incision and drainage.
b. Wound culturing.
c. Wound debridement.
d. Wound irrigation with an antiseptic.
A keloid results from a defect in the healing process in which excessive collagen develops at the healing site.
- END -

Nurse Licensure Examination

14