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Which of the following assessment findings would help confirm a diagnosis of asthma ?

Select one:
A. Circumoral cyanosis
B. Inspiratory and expiratory wheezing
C. Normal breath sounds
D. Increased forced expiratory volume

The nurse is admitting a patient to the operating room. Which of the following nursing actions should
be given highest priority by the nurse?
Select one:
A. Checking the patients identification and correct operative permit
B. Positioning and performing skin preparation to the patient
C. Assessing the patients level of consciousness
D. Checking the patients vital signs

When monitoring a client who is receiving t-PA, the nurse understands it is important to monitor vital
signs and have resuscitation equipment available because reperfusion of the cardiac tissue can
result in which of the following?
Select one:
A. Cardiac Dysrhythmias
B. Seizure
C. Hypothermia
D. Hypertension

Cystoclysis is also known as:

Select one:
A. bladder irrigation
B. catheterization
C. IV therapy
D. bowel irrigation

Bethanechol (Urecholine) has been ordered for a client with GERD. The nurse should evaluate the
client for which of the following side effects?
Select one:
A. Urinary urgency
B. Constipation
C. Dry oral mucosa
D. Hypertension

This procedure of recording the hearts electrical activity as waveforms, by interpreting these
waveforms accurately you can identify rhythm disturbances, conduction abnormalities & electrolyte
imbalances is known as :
Select one:
A. Electroencephalography
B. Electrocardiography
C. Angiography
D. Echocardiography

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes
which symptom as typical of the disease?
Select one:

A. Abdominal distention
B. Diarrhea
C. Abnormal bleeding
D. Hypermenorrhea

Which of the following dietary measures would be useful in preventing esophageal reflux?
Select one:
A. Eating small, frequent meals
B. Increasing fluid intake
C. Avoiding a bedtime snack to the dietary plan
D. Adding a bedtime snack to the dietary plan

The nurse understands that the primary symptoms of a sliding hiatal hernia are associated with
reflux. Therefore, the nurse should assess the client for which of the following symptoms?
Select one:
A. Heartburn
B. Anorexia
C. Stomatitis
D. Jaundice

The nurse is admitting a 69- year-old man to the clinical unit. The client has a history of left
ventricular enlargement. During the assessment, the nurse notes +3 pitting edema of the ankles
bilaterally. The client does not have chest pain. The nurse observes that the client does have
dyspnea at rest. The nurse infers that the client may have
Select one:

A. Heart failure
B. Chronic bronchitis
C. Acute myocardial infarction
D. Arteriosclerosis

An industrial health nurse at a large printing plant finds a male employees blood pressure to be
elevated on two occasions one month apart and refers him to his private physician. The employee is
about 25lbs overweight and has smoked a pack of cigarettes daily for more than 20 years. The
clients physician prescribes atenolol for the hypertension. The nurse should instruct the client to
Select one:
A. Monitor the blood pressure annually
B. Follow a 2g sodium diet
C. Discontinue the medication if severe headaches develop
D. Avoid sudden discontinuation of the drug

Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.
On hospital discharge, outcome criteria for the client would include:
Select one:
A. Exhibits temperature not exceeding 37.5 oC

B. Promises to do pursed-lip breathing


C. Agrees to call the physician if dyspnea on exertion occurs
D. States actions to reduce risk of respiratory infections

The nurse should be especially alert for signs and symptoms of digitalis toxicity if serum levels
indicate that the client has a
Select one:
A. High calcium level
B. Low sodium level
C. High glucose level
D. Low potassium level

A client is diagnosed with multiple myeloma. The client asks the nurse about the diagnosis. The
nurse bases the response on which of the following descriptions of this disorder?
Select one:
A. Malignant exacerbation in the number of leukocytes.
B. Altered red cell production.
C. Malignant proliferation of plasma cells and tumors within the bone.
D. Altered production of lymph nodes.

Mang Temio rushed his teenage son with blood in his abdominal area, informed you that the boy had
an operation 5 days ago. You triaged and placed him at the nearest Treatment Room #1, called ROD
immediately. Your concern is that the surgical incision might have opened and the organ from the
operation site might be coming out of the incision, This condition is :
Select one:
A. Hypovolemic Shock
B. Dehiscence
C. Evisceration
D. Bleeding with wound infection

Crackles heard on lung auscultation indicate which of the following?


Select one:
A. Bronchospasm
B. Fluid-filled alveoli
C. Airway narrowing
D. Cyanosis

When assessing the laboratory results of the client with bladder cancer and bone metastasis, the
nurse notes a calcium level of 12 mg/dl. The nurse recognizes that this is consistent with which
oncological emergency?
Select one:
A. hypercalcemia
B. Superior venca cava syndrome
C. hypekalemia
D. spinal cord compression

The client is admitted to the hospital with a suspected diagnosis of Hodgkins disease. Which of the
following assessment signs would the nurse expect to note specially in the client?
Select one:
A. Enlarged lymph nodes
B. Weight gain
C. Fatigue
D. weakness
Following lobectomy, clients should be instructed to perform deep breathing exercises to:
Select one:
A. Elevate the diaphragm, which enlarges the thorax and increases the lung surface available for
gas exchange.
B. Decrease blood flow to the lungs to allow them to rest and increase the surface available for
ventilation.
C. Control the rate of air flow to the remaining lobe so that it will not become hyper inflated.
D. Expand the alveoli and increase the lung surface available for ventilation.

In which of the following positions should the nurse place a client with suspected heart failure?
Select one:
A. Lying on the right side (Sims position)
B. Lying on the back with the head lowered (Trendelenburg position)
C. Sitting almost upright (high fowlers position)
D. Semi-sitting (low fowlers position)

The nurse is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which
of the following in the care of this client?
Select one:

A. Removal of antiembolism stockings twice daily


B. Elevating the knee gatch on the bed.
C. Assisting with range - - motion leg exercises
D. Checking placement of pneumatic compression boots.

A 69-year-old woman has a history of heart failure. She is admitted to the emergency department
with heart failure complicated by pulmonary edema. On admission of this client, which of the
following should be assessed first?
Select one:
A. Serum potassium
B. Skin breakdown
C. Blood pressure
D. Urine output

The nurse is instructing the client to perform a testicular self-examination. The nurse tells the client
Select one:
A. That testicular examinations should be done at least every 6 months.
B. To gently feel the testicle with one finger to feel for a growth.
C. That the best time for the examination is after a shower.
D. To examine the testicles while lying down.

. Which of the following would be a priority nursing diagnosis for the client with heart failure and
pulmonary edema?
Select one:
A. Impaired skin integrity related to pressure
B. Constipation related to immobility
C. Risk for infection related to stasis of alveolar secretions
D. Activity intolerance related to pump failure
The nurse teaches her client, who has recently been diagnosed with hypertension, about his dietary
restrictions; a low- calorie, low- fat, low-sodium diet. Which of the following menu selections would
best meet the clients needs?

Select one:
A. Hotdogs, baked beans, and celery and carrot sticks
B. Mixed green salad with blue cheese dressing, crackers, and cold cuts
C. Ham sandwich on rye bread and an orange
D. Baked chicken, an apple, and a slice of white bread

Which of the following foods should the nurse teach a client with heart failure to avoid or limit when
following a 2g sodium diet
Select one:
A. Apples
B. Tomato juice
C. Whole wheat bread
D. Beef tenderloin

As a knowledgeable nurse, you know that an adult patient would normally have about ______ of
extracellular fluid (ECF)in his body:
Select one:
A. 70%
B. 8%
C. 60%
D. 30%

The client reports to the nurse that when performing testicular self-exam, he found a lump the size
and shape of a pea. The most appropriate response to the client is which of the following?

Select one:
A. Thats important to report even though it might not be serious.
B. That could be cancer. Ill ask the doctor to examine you.
C. Let me know if it gets bigger next month.
D. Lumps like that are normal; dont worry.

The nurse is caring for a client with an internal radiation implant. when caring
For the client, the nurse should observe which of the following principles?
Select one:
A. Do not allow pregnant women into the clients room.
B. Individuals less than 16 years old may be allowed to go in the room as lon as they are 6 feet away
from the client.
C. Limit the time with the client to I hour per shift
D. Remove dosimeter badge when entering he room

Which of the following symptoms would be indicative of the dumping syndrome?


Select one:
A. Heartburn

B. Diaphoresis
C. Vomiting
D. Hunger

The nurse should prepare which of the following materials if a patient is for cystoclysis?
Select one:
A. foley catheter
B. straight catheter
C. 3-way catheter
D. IV Catheter

To prevent complications related to fluid and electrolytes imbalance, the nurse should collaborate
well to other health teams. Who among the following members of the health team should the nurse
talk to when asking for the result of the ABG result?
Select one:
A. Head nurse
B. Pulmonologist
C. Respiratory therapist
D. Medical technologist

The doctor ordered D5LR 1L to infuse for 12 hours. Calculate for the regulation rate if the drop
factor is 20 gtts/min.
Select one:
A. 41-42 gtts/min
B. 27-28 gtts/min
C. 20-21 gtts/min
D. 82-83 gtts/min

The nurse receives the preoperative blood work report of a client who is scheduled to undergo
surgery. Which of the following laboratory findings should be reported to the surgeon?
Select one:
A. Blood urea nitrogen, 15mg/dl
B. Creatinine, 2.6mg/dl
C. Red blood cells, 4.5million/mm3
D. Hemoglobin, 12.2g/dl

Which of the following would be most relevant in assessing the postoperative client for blood loss?
Select one:
A. decreased bowel sounds and vomiting
B. serosanguineous drainage on the dressing
C. tachycardia, tachypnea and decreased blood pressure
D. restlessness and pain
The female client who has been receiving radiation therapy for bladder cancer tells the nurse that it
feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing
Select one:

A. Rupture of the bladder


B. The development of a vesicovaginal fistula
C. Altered perineal sensation as a side effect of radiation.
D. Extreme stress caused by the diagnosis of cancer

As a scrub nurse, you know that you have to count the instruments, sponges, needles and sutures
together with the:
Select one:
A. Anesthesiologist
B. Head nurse
C. Surgeon
D. Circulating nurse

When interpreting an ECG tracing, your understanding of each configuration is important. The
tracing below with arrow pointing is the ST Segment. What is the significance of this
segment?

Select one:
A. ST Segment represents the beginning of another P wave and ventricles are depolarized
B. ST Segment shows the end of ventricular repolarization and beginning of ventricular
depolarization for another cardiac cycle
C. ST Segment represents the end of ventricular depolarization & beginning of ventricular
repolarization
D. ST Segment represents the beginning of another cardiac cycle and ventricles are repolarized

Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to
promote good dental care in a client with mitral stenosis should include demonstration of the proper
use of
Select one:
A. Dental floss
B. A manual toothbrush
C. An electric toothbrush
D. An irrigation device

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported
to his physician. Based on this information, which nursing diagnosis would be appropriate for this
client?
Select one:
A. Constipation related to decreased gastric motility
B. Ineffective Coping related to fear of diagnosis of chronic illness
C. Imbalanced nutrition: less than body requirements related to gastric bleeding
D. Deficient knowledge related to unfamiliarity with significant signs and symptoms

The most effective measure the nurse can use to prevent wound infection when changing a clients
dressing after coronary artery bypass surgery is to
Select one:
A. Observe careful Handwashing procedures

B. Place soiled dressings in a waterproof bag before disposing of them


C. Clean the incisional area with an antiseptic
D. Use prepackaged sterile dressings to cover the incision

he nurse teaches a client with heart failure to take oral Furosemide in the morning. The primary
reason for this is to help
Select one:
A. Excrete excessive fluids accumulated during the night
B. Retard rapid drug absorption
C. Prevent sleep disturbances during the night
D. Prevent electrolyte imbalances

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse
determines that further teaching is necessary if the client identifies which of the following as an
associated risk factor?
Select one:
A. A history of inflammatory bowel disease
B. A high-fiber diet
C. A diet high in fats and carbohydrates
D. Family history of colon cancer

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period the
nurse notes bloody drainage from the nasogastric tube. Which of the following is the most
appropriate nursing intervention?
Select one:
A. Irrigate the nasogastric tube
B. Notify the physician
C. Measure abdominal girth
D. Continue to monitor the drainage
Which of the following symptoms is common on clients with active tuberculosis?
Select one:
A. Dyspnea on exertion
B. Mental status change
C. Increased appetite
D. Weight loss

A cervical radiation implant is placed in the client for treatment of cervical cancer. The nurse initiates
what most appropriate activity order for this client ?
Select one:
A. Out of bed in a chair only
B. Bedrest
C. Out of bed ad lib
D. Ambulate to the bathroom only

The nurse should instruct the client to avoid which of the following drugs while taking
metoclopramide HCI (Reglan)

Select one:
A. Alcohol
B. Anticoagulants
C. Antihypertensives
D. Antacids

The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by
the nurse would be most accurate?
Select one:
A. Surgery is usually required, although medical treatment is attempted first
B. A minor surgical procedure to reduces the size of the diaphragmatic opening will probably be
planned
C. Hiatal hernia symptoms can usually be successfully managed with diet modifications,
medications, and lifestyle changes
D. Surgery is not performed for this type of hernia

The nurse is caring for a client following a radical neck dissection and creation of a tracheostomy
performed for laryngeal cancer. The nurse is providing discharge instructions to the client .Which
statement if mad3 by the client indicates a need for further instructions?
Select one:
A. I need to keep powders and sprays away from the stoma.

B. I will protect the stoma from water


C. I need to use an air conditioner to provide cool air to assist in breathi.
D. I need to apply a thin layer of petrolatum to the skin around the stoma to prevent cracking .

Which of the following would be an expected nutritional outcome for a client who has undergone a
subtotal gastrectomy for cancer?
Select one:
A. Control nausea and vomiting through regular use of antiemetics
B. Regain weight loss within 1 month after surgery
C. Resume normal dietary intake of three meals a day
D. Achieve optimal nutritional status through oral or parenteral feedings

Which of the following nursing interventions would most likely promote self-care behaviors in the
client with hiatal hernia?
Select one:
A. Introduce the client to other people who are successfully managing their care
B. Ask the client to identify other situations in which he demonstrated responsibility for himself
C. Include the clients daughter in the teaching so that she can help implement the plan
D. Reassure the client that he will be able to implement all aspects pf the plan successfully.

This is a life-threatening condition that develops when cells in the body are unable to get the sugar
(glucose) they need for energy, such as when you have uncontrolled diabetes + deficiency of Insulin.
Without insulin, the body cannot use sugar for energy. When the cells do not receive sugar, the body
begins to break down fat and muscle for energy. When this happens fatty acids, are produced and
enter the bloodstream, causing the chemical imbalance. This condition is:
Select one:
A. Compensated Metabolic Acidosis- CMA
B. Diabetic Ketoacidosis-DKA
C. Type 2- Diabetis Mellitus NIDDM
D. HHNS- Hyperosmolar Hyperglycemic Non-ketotic Syndrome

The ECG tracing below was taken at the University Clinic. You are on duty. The student asked what
your interpretation is. Your response:

Select one:
a. Ventricular Rhythm @ 80/min. P- wave regular, R wave normal, vital signs normal
b. Atrial Normal Rhythm @ 80/min. P- wave regular, R wave normal, vital signs normal
c. Sinus Tachycardia at 180/min. P wave slightly peaked, R waved notched, vital signs PR-fast.
d. Sinus Rhythm at 80/min. P wave all precede QRS, rhythm regular, vital signs normal

The client with leukemia is receiving busulfan (mylean). Allopurinol ( Zyloprim ) is prescribed for the
client. The nurse tells the client that the purpose of the allopurinol (zyloprim ) is to
Select one:
a. Prevent vomiting
b. Prevent alopecia

c. Prevent nausea.
d. Prevent hyperuricemia

The client is admitted to the emergency department with chest trauma. When assessing the client,
which signs and symptoms would the nurse expect to find that support the diagnosis of
pneumothorax?
Select one:
A. Frothy bloody sputum and consolidation
B. Broncho-vesicular lung sounds and bradypnea
C. Barrel chest and polycythemia
D. Unequal lung expansion and dyspnea

When teaching the client about complications of atrial fibrillation, the nurse understands that the
complications can be caused by
Select one:
A. Decreased pulse rate
B. Stasis of blood in the atria
C. Increased cardiac output
D. Elevated blood pressure

Which of the following is an expected outcome for a client on the second day of hospitalization after
an MI? The client
Select one:

A. Has severe chest pain


B. Can identify risk factors for MI
C. Can perform personal self-care activities without pain
D. Agrees to participate in a cardiac rehabilitation walking program

The nurse understands that a priority nursing diagnosis for the client with hypertension would be
Select one:
A. Impaired Skin Integrity
B. Pain
C. Deficient Fluid Volume
D. Make a commitment to long term therapy

For a client with DKA receiving insulin to correct hyperglycemia, the nurse knows that the most
appropriate route of administration would be:
Select one:
a. intravenous
b. intradermal
c. intramuscular
d. subcutaneous

Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.

The client reports steady weight loss and that he is too tired from just breathing to eat. Which of the
following nursing diagnoses would be most appropriate when planning nutritional intervention for this
client?
Select one:
A. Ineffective breathing pattern related to alveolar hypoventilation
B. Altered nutrition: less than body requirements related to fatigue
C. Altered nutrition: less than body requirements related to COPD
D. Weight loss related to COPD

The community nurse is conducting a health promotion program and the topic of the discussion
relates to the risk factors of gastric cancer. Which risk factor if identified by a client indicates a need
for further discussion?
Select one:
A. High meat and carbohydrate consumption
B. History of gastric polyps
C. A diet of smoked, highly salted, and spiced food
D. History of gastric pernicious anemia

The major goal of therapy for a client with heart failure pulmonary edema would be to
Select one:
A. Decrease peripheral edema
B. Improve respiratory status
C. Enhance comfort

D. Increase cardiac output

A clients job involves working in a warm, dry room, frequently bending and crouching to check the
underside of a high- speed press, and wearing eye guards. Given this information, the nurse should
assess the client for which of the following?
Select one:
A. Thirst
B. Muscle aches
C. Lethargy
D. Postural hypotension

After an MI, the hospitalized client is taught to move the legs while resting in bed. This type of
exercise is recommended primarily to help
Select one:
A. Decrease the likelihood of pressure ulcer formation
B. Prevent thrombophlebitis and blood clot formation
C. Promote urinary and intestinal elimination
D. Prepare the client for ambulation
A client who has been diagnosed with GERD complains of heartburn. To decrease the heartburn,
the nurse should instruct the client to eliminate which of the following items from the diet?
Select one:
A. Lean beef
B. Hot chocolates
C. Raw vegetables
D. Air- popped popcorn

You need to prepare a calcium infusion for a patient with hypocalcemia. You should mix the drug in
which solution?
Select one:
A. Dextrose 5% in water
B. Lactated ringers solution
C. Normal saline solution
D. Half normal saline solution

Which of the following lifestyle modifications should the nurse encourage the client with a hiatal
hernia to include in activities of daily living?
Select one:
A. Balancing activity and rest
B. Eliminating smoking and alcohol use
C. Avoiding high-stress situations
D. Daily aerobic exercise

The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note
documentation of which most common symptoms of this type of cancer?
Select one:
A. Frequency of urination
B. Dysuria
C. Hematuria
D. Urgency on urination

The community health nurse conducts a health promotion program regarding testicular cancer to
community members. The nurse determines that further information needs to be provided if a
community member states that which of the following is a sign of testicular cancer?
Select one:
A. Back pain
B. Heavy sensation in the scrotum
C. Alopecia
D. Painless testicular swelling

A client who is recovering from a subtotal gastrectomy asks the nurse, When will I be able to eat
three meals a day again like I used to? Which of the following responses by the nurse is most
appropriate?
Select one:
A. Eating 6 meals a day is time-consuming, isnt?
B. You will be able to tolerate three meals a day before you are discharged
C. Most clients can resume their normal meal patterns in about 6 to 12mos
D. You will have to eat six small meals a day for the rest of your life

In the recovery room, the postoperative client suddenly becomes cyanotic. What is the most
appropriate nursing action?
Select one:
A. Insert an oral airway and suction the nasopharynx
B. Call for assistance
C. Reposition the head and determine patency of airway
D. Start administration of oxygen through a nasal cannula

The nurse is assessing the colostomy of a client who had an abdominal perineal resection for a
bowel tumor. Which of the following assessment findings indicate that the colostomy is beginning to
function?
Select one:
A. The clients ability to tolerate food.
B. The passage of flatus
C. Blood drainage from the colostomy
D. Absent bowel sounds

The nurse is developing a plan of care for the client with multiple myeloma. The nurse includes which
priority intervention in the plan of care?
Select one:
a. Monitoring the red blood cell count
b. Providing frequent oral care
c. Coughing and deep breathing
d. Encourage fluids

The client receiving chemotherapy is experiencing stomatitis. The nurse advises the client to use
which of the following as the best substance to rinse the mouth?
Select one:
a. Lemon flavored mouthwash
b. Alcohol based mouthwash
c. Weak salt and bicarbonate mouth rinse
d. Hydrogen peroxide mixture

The client suspected of an ovarian tumor is scheduled for a pelvic ultrasound.


The nurse provides which pre- procedure instructions to the client?
Select one:
A. Wear comfortable clothing and shoes for the procedure.
B. Maintain an NPO status before the procedure.
C. Drink six to eight glasses of water without voiding before the test.
D. Eat a light breakfast only.

The client tells the nurse during the preoperative history that he is a three pack a day cigarette
smoker. This information alerts the nurse to which intraoperative and postoperative periods?
Select one:
A. an increased risk for atelectasis and hypoxia
B. a decreased tolerance to pain
C. an increased risk for excessive scar tissue formation
D. a decreased clotting ability

24. The nurse is caring for a first day postoperative surgical client. Prioritize the patients desired
dietary progression. Arrange in sequence the dietary progression from 1 to 4:
1. Full liquid;
2.NPO;

3.Clear liquid;
4. Soft
Select one:
A. 2,1,,4,3
B. 1,2,3,4,
C. 2,3,1,4
D. 4,3,2,1

As an OR nurse, how can you help improve the quality of service in the operating room?
Select one:
A. Participate in the regular activities of the OR unit
B. Call the attention of the surgical team who do not follow standard operating procedures
C. Build rapport to the patients
D. Report incidences to the head nurse by writing an incident report

To prevent complications related to fluid and electrolytes imbalance, the nurse should collaborate
well to other health teams. Who among the following members of the health team should the nurse
talk to when asking for the result of the ABG result?
Select one:
A. Head nurse
B. Medical technologist
C. Pulmonologist
D. Respiratory therapist

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. The priority
nursing intervention should be to:
Select one:
A. Restrict the clients intake of fluid
B. Observe the client for increasing confusion

C. Measure the clients urine specific gravity


D. Weigh the client daily

Situation: To ensure that the patients condition is getting better, the following evaluation results must
be seen from a patient treated due to:
edema:
Select one:
A. normal potassium level
B. normal sodium level
C. normal calcium level
D. normal hemoglobin
In the recovery room, the postoperative client suddenly becomes cyanotic. What is the most
appropriate nursing action?
Select one:
A. Insert an oral airway and suction the nasopharynx
B. Call for assistance
C. Start administration of oxygen through a nasal cannula
D. Reposition the head and determine patency of airway

Which of the following would be a priority nursing diagnosis for the client with heart failure and
pulmonary edema?
Select one:
A. Constipation related to immobility
B. Activity intolerance related to pump failure
C. Risk for infection related to stasis of alveolar secretions
D. Impaired skin integrity related to pressure

The nurse caring for a client with a history of experiencing the Somogyi effect would monitor the
clients blood sugar level between:
Select one:
a. 2 Am and 3 PM

b. 12 PM and 6 PM
c. 2 AM and 7 AM
d. 5 PM and 12 AM

Mr. Laudico expressed to the nurse that he has been smelling increased and asked for the reason.
Nurse Isabelles most appropriate response is:
Select one:
a. Food such as eggs, asparagus, fish and broccoli will increase odor
b. Changing the pouch and washing it daily will eliminate the odor
c. The odor is normal. A deodorant may be used.
d. Foods do not affect the odor

The client asks the nurse what causes a peptic ulcer to develop. The nurse responds that recent
research indicates that many peptic ulcers are the result of which of the following?
Select one:
A. H. Pylori infection
B. Diets high in fat
C. A genetic defect in the gastric mucosa
D. Work-related stres

To ensure that the patients condition is getting better, the following evaluation results must be seen
from a patient treated due to:
metabolic acidosis:
Select one:
A. normal BP
B. normal pH and PaCO2
C. normal pH and HCO3
D. normal PaO2
This is a life-threatening condition that develops when cells in the body are unable to get the sugar
(glucose) they need for energy, such as when you have uncontrolled diabetes + deficiency of Insulin.
Without insulin, the body cannot use sugar for energy. When the cells do not receive sugar, the body

begins to break down fat and muscle for energy. When this happens fatty acids, are produced and
enter the bloodstream, causing the chemical imbalance. This condition is:
Select one:
A. Compensated Metabolic Acidosis- CMA
B. Diabetic Ketoacidosis-DKA
C. Type 2- Diabetis Mellitus NIDDM
D. HHNS- Hyperosmolar Hyperglycemic Non-ketotic Syndrome
Which of the following solutions would the nurse administer for this patient with Hypernatremia?
Select one:
A. D5 LR
B. Plain NSS
C. D5W
D. 0.3 NSS
When teaching a client about Propranolol HCI, the nurse should base the information on the
knowledge that Propranolol HCI
Select one:
A. Increases Norepinephrine secretion and thus decrease blood pressure and heart rate
B. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers
blood pressure
C. Is an ACE enzyme inhibitor that reduces blood pressure by blocking the conversion of
Angiotensin I to Angiotensin II
D. Block beta adrenergic stimulation and thus causes decreased heart rate, myocardial contractility,
and conduction

24. The nurse is caring for a first day postoperative surgical client. Prioritize the patients desired
dietary progression. Arrange in sequence the dietary progression from 1 to 4:
1. Full liquid;
2.NPO;
3.Clear liquid;
4. Soft
Select one:
A. 4,3,2,1
B. 1,2,3,4,

C. 2,3,1,4
D. 2,1,,4,3

When interpreting an ECG tracing, your understanding of each configuration is important. The
tracing below with arrow pointing is the ST Segment. What is the significance of this
segment?

Select one:
A. ST Segment represents the beginning of another cardiac cycle and ventricles are repolarized
B. ST Segment represents the end of ventricular depolarization & beginning of ventricular
repolarization
C. ST Segment represents the beginning of another P wave and ventricles are depolarized
D. ST Segment shows the end of ventricular repolarization and beginning of ventricular
depolarization for another cardiac cycle

The nurse is admitting a 69- year-old man to the clinical unit. The client has a history of left
ventricular enlargement. During the assessment, the nurse notes +3 pitting edema of the ankles
bilaterally. The client does not have chest pain. The nurse observes that the client does have
dyspnea at rest. The nurse infers that the client may have
Select one:
A. Chronic bronchitis
B. Arteriosclerosis
C. Heart failure
D. Acute myocardial infarction

A 69-year-old woman has a history of heart failure. She is admitted to the emergency department
with heart failure complicated by pulmonary edema. On admission of this client, which of the
following should be assessed first?
Select one:
A. Skin breakdown
B. Serum potassium
C. Urine output

D. Blood pressure
For a client with DKA receiving insulin to correct hyperglycemia, the nurse knows that the most
appropriate route of administration would be:
Select one:
a. intradermal
b. subcutaneous
c. intravenous
d. intramuscular
Bethanechol (Urecholine) has been ordered for a client with GERD. The nurse should evaluate the
client for which of the following side effects?
Select one:
A. Urinary urgency
B. Hypertension
C. Dry oral mucosa
D. Constipation

The community nurse is conducting a health promotion program at a local school


And is discussing the risk factors associated with cancer. Which of the following if identified by the
client as a risk factor, indicates a need for further instructions?
Select one:
A. Viral factors
B. Exposure to radiation
C. Low-fat and high fiber diets
D. Stress

The client with leukemia is receiving busulfan (mylean). Allopurinol ( Zyloprim ) is prescribed for the
client. The nurse tells the client that the purpose of the allopurinol (zyloprim ) is to
Select one:
a. Prevent vomiting
b. Prevent alopecia
c. Prevent nausea.

d. Prevent hyperuricemia

The nurse should teach the client that signs of digitalis toxicity include which of the following?
Select one:
A. Increased appetite
B. Skin rash over the chest and back
C. Visual disturbances such as seeing yellow spots
D. Elevated blood pressure

The nurse counseling a 60-year-old woman with diabetes about establishing an exercise program
would encourage
Select one:
a. running
b. swimming
c. walking
d. playing tennis

The nurse counseling a 60-year-old woman with diabetes about establishing an exercise program
would encourage
Select one:
a. running
b. swimming
c. walking
d. playing tennis

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse
determines that further teaching is necessary if the client identifies which of the following as an
associated risk factor?
Select one:
A. Family history of colon cancer

B. A history of inflammatory bowel disease


C. A high-fiber diet
D. A diet high in fats and carbohydrates

As a result of a gastric resection, the client is at risk for development of dumping syndrome. The
nurse would prepare a plan of care for this client based on knowledge that this problem stems
primarily from which of the following gastrointestinal changes?
Select one:
A. Rapid emptying of stomach contents into the small intestine
B. Loss of gastric enzymes
C. Excess secretion of digestive enzymes in the intestine
D. Excess glycogen production by the liver
During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes
which symptom as typical of the disease?
Select one:
A. Hypermenorrhea
B. Diarrhea
C. Abdominal distention
D. Abnormal bleeding
You need to prepare a calcium infusion for a patient with hypocalcemia. You should mix the drug in
which solution?
Select one:
A. Half normal saline solution
B. Normal saline solution
C. Dextrose 5% in water
D. Lactated ringers solution

The client tells the nurse during the preoperative history that he is a three pack a day cigarette
smoker. This information alerts the nurse to which intraoperative and postoperative periods?
Select one:
A. a decreased clotting ability

B. an increased risk for excessive scar tissue formation


C. a decreased tolerance to pain
D. an increased risk for atelectasis and hypoxia

Furosemide is administered intravenously to a client with heart failure. How soon after administration
should the nurse begin to see evidence of the drugs desired effect?
Select one:
A. 2 to 4 hours
B. 30 to 60 minutes
C. 6 to 8 hours
D. 5 to 10 minutes
A 47-year old woman has had gastric ulcer for years. After she started vomiting blood today, her
neighbor drove her to the emergency room.
If the client had blood gases drawn while she was still in the early stage of shock, the nurse would
expect the results to indicate:
Select one:
A. metabolic alkalosis
B. respiratory acidosis
C. respiratory alkalosis
D. metabolic acidosis
The nurse is assessing the colostomy of a client who had an abdominal perineal resection for a
bowel tumor. Which of the following assessment findings indicate that the colostomy is beginning to
function?
Select one:
A. The clients ability to tolerate food.
B. Blood drainage from the colostomy
C. The passage of flatus
D. Absent bowel sounds

Before a clients discharge after mitral valve replacement surgery, the nurse should evaluate the
clients understanding of post surgery activity restrictions. Which of the following should the client not
engage in until after the one-month post discharge appointment with the surgeon?

Select one:
A. Showering
B. Light housework
C. A program of gradually progressive walking
D. Lifting anything heavier than 10lbs

Which of the following is an expected outcome for a client on the second day of hospitalization after
an MI? The client
Select one:
A. Can perform personal self-care activities without pain
B. Can identify risk factors for MI
C. Has severe chest pain
D. Agrees to participate in a cardiac rehabilitation walking program
A 68-year-old female client on day 2 after hip surgery has no cardiac history but starts to complain of
chest heaviness. The first nursing action should be to
Select one:
A. Inquire about the onset, duration, severity, and precipitating factors of heaviness
B. Administer oxygen via nasal cannula
C. Offer pain medication for the chest heaviness
D. Inform the physician of the client heaviness
Which of the following symptoms is common on clients with active tuberculosis?
Select one:
A. Mental status change
B. Dyspnea on exertion
C. Weight loss
D. Increased appetite

In preparing for the operating room mayo table, which of the following should the nurse do if she
sees a small wet area on the packaging of the sterile linen?
Select one:
A. Keep and use to handle clean cases only

B. Dispose and consider unsterile


C. Open carefully, it is just a small area and it is still considered sterile
D. Dry it quickly, it is still considered sterile

A client who has been diagnosed with GERD complains of heartburn. To decrease the heartburn,
the nurse should instruct the client to eliminate which of the following items from the diet?
Select one:
A. Raw vegetables
B. Lean beef
C. Hot chocolates
D. Air- popped popcorn

Contraindications to the administration of t-PA include which of the following?


Select one:
A. Age greater than 60 years
B. Cigarette smoking
C. History of heart failure
D. History of cerebral hemorrhage

An exercise program is prescribed for the client with hypertension. Which intervention would be most
likely to assist the client in maintaining an exercise program?
Select one:
A. Explaining the exercise program to the clients spouse
B. Tailoring a program to the clients needs and abilities
C. Reassuring the client that he or she can do the exercise program
D. Giving the client a written exercise program

As part of the clients discharge planning after a subtotal gastrectomy, the nurse has identified
Imbalanced nutrition: Less than body requirements as a major nursing diagnosis. To help the client
meet nutritional goals at home, the nurse should develop a plan of care that includes which of the
following interventions?

Select one:
A. Encourage the client to eat smaller amounts more frequently
B. Explain that if vomiting occurs after a meal nothing more should be eaten that day
C. Instruct the client to increase the amount eaten at each meal
D. Inform the client that bland foods are typically less nutritional and should be used minimally

The nurse is developing a plan of care for the client with multiple myeloma. The nurse includes which
priority intervention in the plan of care?
Select one:
a. Encourage fluids
b. Monitoring the red blood cell count
c. Coughing and deep breathing
d. Providing frequent oral care
The female client who has been receiving radiation therapy for bladder cancer tells the nurse that it
feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing
Select one:
A. Altered perineal sensation as a side effect of radiation.
B. Extreme stress caused by the diagnosis of cancer
C. Rupture of the bladder
D. The development of a vesicovaginal fistula
An elderly male is suffering from respiratory acidosis. Which of the following signs indicates bodys
response to negate respiratory acidosis?
Select one:
A. Increasing the rate of contractility of the heart to facilitate removal of acids
B. Decrease rate of respiration to retain carbon dioxide in the body
C. Increase regeneration of bicarbonate to alter the bicarbonate carbonic ratio @ 1:20
D. Increase formation of ammonia resulting to large excretion of acidic urine

When monitoring a client who is receiving t-PA, the nurse understands it is important to monitor vital
signs and have resuscitation equipment available because reperfusion of the cardiac tissue can
result in which of the following?

Select one:
A. Seizure
B. Hypertension
C. Cardiac Dysrhythmias
D. Hypothermia

The nurse is caring for a client following a radical neck dissection and creation of a tracheostomy
performed for laryngeal cancer. The nurse is providing discharge instructions to the client .Which
statement if mad3 by the client indicates a need for further instructions?
Select one:
A. I will protect the stoma from water
B. I need to apply a thin layer of petrolatum to the skin around the stoma to prevent cracking .
C. I need to keep powders and sprays away from the stoma.
D. I need to use an air conditioner to provide cool air to assist in breathi.
Which of the following lifestyle modifications should the nurse encourage the client with a hiatal
hernia to include in activities of daily living?
Select one:
A. Eliminating smoking and alcohol use
B. Balancing activity and rest
C. Avoiding high-stress situations
D. Daily aerobic exercise
Crackles heard on lung auscultation indicate which of the following?
Select one:
A. Cyanosis
B. Fluid-filled alveoli
C. Airway narrowing
D. Bronchospasm
The nurse is instructing the client to perform a testicular self-examination. The nurse tells the client
Select one:
A. That testicular examinations should be done at least every 6 months.
B. To gently feel the testicle with one finger to feel for a growth.

C. To examine the testicles while lying down.


D. That the best time for the examination is after a shower.

A client is diagnosed with multiple myeloma. The client asks the nurse about the diagnosis. The
nurse bases the response on which of the following descriptions of this disorder?
Select one:
A. Malignant exacerbation in the number of leukocytes.
B. Malignant proliferation of plasma cells and tumors within the bone.
C. Altered red cell production.
D. Altered production of lymph nodes.

The client is diagnosed as having a bowel tumor. Several diagnostic tests are
Prescribed. The nurse understands that which of the following tests will confirm the diagnosis of
malignancy?
Select one:
A. Magnetic resonance imaging
B. Computerized tomography scan
C. Biopsy of the tumor
D. Abdominal ultrasound

An ambulatory care client with diabetes mellitus is being scheduled for a fasting blood glucose level
prior to her follow up check up. If the blood sample will be drawn at 7 AM, the nurse would instruct
the client only to drink water after:
Select one:
a. 11 PM the night before
b. 4Am on the day of the test
c. 12 midnight before the test
d. 5 PM the night before

As a knowledgeable nurse, you would expect that patient with pyelonephritis has flank pain and
changes in the urine. When the patient asks, What does pyelonephritis means? You would say:
Select one:
A. It is an infection affecting your urethra and urinary bladder.
B. It means you did not drink enough that is why your kidney is blocked.
C. It is an infection affecting your kidneys and ureters.
D. You have to ask your doctor to explain it to you

The client has been taking magnesium hydroxide (milk of magnesia) at home in an attempt to control
hiatal hernia symptoms. The nurse should assess the client for which of the following conditions
most commonly associated with the ongoing use of magnesium-based antacids?
Select one:
A. Constipation
B. Diarrhea
C. Anorexia
D. Weight gain
When a client cannot read or write but is of sound mind, the nurse should read the consent to the
client in the presence of two witnesses and:
Select one:
A. Have the client put an X on the signature line
B. Have a court appoint a guardian for the client
C. Have a hospital quality management coordinator sign for the client
D. Have the clients next of kin sign the consent
Situation: Nurse Isabel is working as a staff nurse in Chen Medical Center. She is assigned to the
Medical Ward of the Hospital. Recently, she had many patients with Gastro intestinal disorders. The
following questions are related to the cases she handled.
One of the patients is to undergo upper gastrointestinal endoscopy. Nurse Isabel remembers that
one the priority interventions would be?
Select one:
A. Administer the prescribed bulk forming laxative
B. Provide the client with a fatty meal
C. The patient should be kept on the right side lying position.

D. The client should be on NPO until the gag reflex returns

Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows
pneumonia to develop?
Select one:
A. Atelectasis
B. Bronchiectasis
C. Effusion
D. Inflammation
In an underwater seal drainage system, cessation of fluid fluctuation in the chest and drainage
tubes generally means that the:
Select one:
A. Mediastinal space has decreased
B. Lung has collapsed
C. Lung has fully expanded
D. Chest tube is in the pleural space
The nurses discharge teaching plan for the client with heart failure would stress the significance of
which of the following?
Select one:
A. Obtaining daily weights at the same time each day
B. Remaining sedentary for most of the day
C. Maintaining a high-fiber diet
D. Walking 2 miles every day
The nurse is caring for a client with an internal radiation implant. when caring
For the client, the nurse should observe which of the following principles?
Select one:
A. Remove dosimeter badge when entering he room
B. Do not allow pregnant women into the clients room.
C. Individuals less than 16 years old may be allowed to go in the room as lon as they are 6 feet away
from the client.
D. Limit the time with the client to I hour per shift

A client who is recovering from a subtotal gastrectomy asks the nurse, When will I be able to eat
three meals a day again like I used to? Which of the following responses by the nurse is most
appropriate?
Select one:
A. You will be able to tolerate three meals a day before you are discharged
B. Eating 6 meals a day is time-consuming, isnt?
C. You will have to eat six small meals a day for the rest of your life
D. Most clients can resume their normal meal patterns in about 6 to 12mos
Which of the following foods should the nurse teach a client with heart failure to avoid or limit when
following a 2g sodium diet
Select one:
A. Apples
B. Whole wheat bread
C. Tomato juice
D. Beef tenderloin
A 65 y/o woman is brought to the hospital after vomiting excessively at home. After checking pt.s
ABG levels, the doctor diagnoses severe dehydration. Using ABG guide, which acid-base imbalance
would you expect to patient to have?
Select one:
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis

When assessing a patient with Hypernatremia, the nurse will expect to find:
Select one:
A. Serum Sodium level of 135 mEq / L
B. Thirst
C. Hypoactive reflexes
D. Moist mucous membranes

A Full Thickness burn is describe as:


Select one:
A. Moist, shiny in appearance, pearly gray or charred black color and is painful when exposed to air
B. Moist, shiny in appearance, salmon pink to red color, and is painful when exposed to air
C. Thick, dry in appearance, pearly gray or charred black color and painless
D. Reddened skin, with edema but no blistering, burn blanches under pressure
The nurse teaches her client, who has recently been diagnosed with hypertension, about his dietary
restrictions; a low- calorie, low- fat, low-sodium diet. Which of the following menu selections would
best meet the clients needs?
Select one:
A. Mixed green salad with blue cheese dressing, crackers, and cold cuts
B. Hotdogs, baked beans, and celery and carrot sticks
C. Ham sandwich on rye bread and an orange
D. Baked chicken, an apple, and a slice of white bread
Which of the following reflects the principle on which a clients diet will most likely be based during
the acute phase of MI?
Select one:
A. Nothing by mouth
B. Small, easily digested meals
C. Three regular meals per day
D. Liquids as desired

The client suspected of an ovarian tumor is scheduled for a pelvic ultrasound.


The nurse provides which pre- procedure instructions to the client?
Select one:
A. Maintain an NPO status before the procedure.
B. Eat a light breakfast only.
C. Drink six to eight glasses of water without voiding before the test.

D. Wear comfortable clothing and shoes for the procedure.

A patient who undergo hemodialysis has a distinct characteristic of pulse which is:
Select one:
A. increased pulse
B. thready pulse
C. weak pulse
D. pulse with bruit

The community health nurse is instructing a group of female clients about breast
Self-examination. The nurse would instruct the clients to perform the examination.
Select one:
A. Weekly at the same time of day
B. Every month during ovulation
C. At the onset on menstruation.
D. 1 week after menstruation begins

The nurse receives emergency laboratory results for a client with chest pain and immediately informs
the physician. An increased myoglobin level suggests which of the following?
Select one:
A. Hypertension
B. Cancer
C. Myocardial infarction
D. Liver disease

Which of the following assessment data is most important to determine when caring for a patient
who has received spinal anesthesia?
Select one:
A. The time of return of motion and sensation in the patients legs and toes

B. The patients level of consciousness


C. The amount of wound drainage
D. The character if the patients respiration
To ensure that the patients condition is getting better, the following evaluation results must be seen
from a patient treated due to:
Hyperkalemia:
Select one:
A. normal ECG result
B. normal abdominal girth
C. normal pH
D. normal lung x-ray
When teaching the client about complications of atrial fibrillation, the nurse understands that the
complications can be caused by
Select one:
A. Elevated blood pressure
B. Increased cardiac output
C. Decreased pulse rate
D. Stasis of blood in the atria

The nurse understands that a priority nursing diagnosis for the client with hypertension would be
Select one:
A. Deficient Fluid Volume
B. Impaired Skin Integrity
C. Make a commitment to long term therapy
D. Pain

Which of the following symptoms would be indicative of the dumping syndrome?


A. Vomiting

B. Diaphoresis
C. Heartburn
D. Hunger
The nurse finds the apical impulse below the 5thintercostals space. The nurse suspects
Select one:
A. Right ventricular enlargement
B. Left atrial enlargement
C. Left ventricular enlargement
D. Right atrial enlargement
The client receiving chemotherapy is experiencing stomatitis. The nurse advises the client to use
which of the following as the best substance to rinse the mouth?
Select one:
a. Lemon flavored mouthwash
b. Hydrogen peroxide mixture
c. Alcohol based mouthwash
d. Weak salt and bicarbonate mouth rinse
Poison is a substance that has toxic effects and may injure you or make you sick if you are exposed
to it ; can be found everywhere, from simple household cleaners, or to cosmetics and to houseplants
to industrial chemicals. Even medicines that are taken in the wrong dose, at the wrong time, or by
the wrong person can cause a toxic effect. Generally, any product that gives off fumes or is an
aerosol that can be inhaled should be considered a possible poison. More than 90% of poisonings
occur in the home.
Select one:
A. The above statement is inaccurate, because cosmetics are considered safe for use and
medications taken at the wrong time can be readjusted in giving the next dose. No cause for alarm,
but monitoring is needed.
B. All of the statements are incorrect.
C. The above statement is wrong, because products that gives off fumes such an aerosol, is not a
poison, it was meant to be inhaled anyway.
D. The above statement is correct, thus never leave a poisonous product unattended around
children, even for a moment. Many poisonings occur when an adult who is using a poisonous
product becomes distracted by telephone & others.
Which of the following assessment findings would help confirm a diagnosis of asthma ?

Select one:
A. Circumoral cyanosis
B. Normal breath sounds
C. Increased forced expiratory volume
D. Inspiratory and expiratory wheezing

The nurse should be especially alert for signs and symptoms of digitalis toxicity if serum levels
indicate that the client has a
Select one:
A. High glucose level
B. High calcium level
C. Low sodium level
D. Low potassium level

The nurse would instruct a client who is on a rowing team to avoid injecting insulin in his arms on
rowing practice days because:
Select one:
a. increased circulation in the arms will dilute the insulin
b. exercise increases the absorption rate of insulin
c. the arms will become painful
d. the arms have increased muscle mass.
This condition is the most serious, fatal & acute form of Ischemic Heart Disease, it occurs when the
heart muscle is deprived of oxygen sustained over a long period and blood supply interruption over a
stretched period at which irreversible cell death & necrosis take place. This deprivation then leads to
structural & functional changes within the affected area of myocardial tissue. This condition is:
Select one:
A. Acute Pulmonary Embolism APE
B. Hemorrhagic Cerebrovascular Accident- CVA- Hemorrhagic Type
C. Acute Myocardial Infarction- AMI
D. Transient Ischemic Attacks TIA

The nurse teaches the client who is receiving warfarin sodium that
Select one:
A. Partial thromboplastin time values determine the dosage of warfarin sodium
B. Warfarin sodium will facilitate clotting of the blood
C. The international normalized ratio (INR) is used to assess effectiveness
D. Protamine sulfate is used to reverse the effects of warfarin sodium
Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.
For a client with COPD who has trouble raising respiratory secretions, which of the following nursing
measures would help reduce the tenacity of secretions?
Select one:
A. Keeping the client in a semi-sitting position as much as possible
B. Helping the client maintain a high fluid intake
C. Ensuring that the clients diet is low in salt
D. Ensuring that the clients oxygen therapy is continuous
The nurse is reviewing the laboratory results of a client receiving chemotherapy.The platelet count is
10,000 cells / mm3. Based on this laboratory value, the priority nursing assessment is which of the
following?
Select one:
A. Assess temperature
B. Assess bowel sounds
C. Assess level of consciousness
D. Assess skin turger
The nurse should instruct the client to avoid gs while taking metoclopramide HCI (Reglan)
Select one:
A. Antihypertensives
B. Anticoagulants
C. Antacids
D. Alcohol

The nurse is transferring the patient from the post-anesthesia care unit to the surgical unit. Which of
the following is the primary reason for gradual change of position of the patient?
Select one:
A. To prevent muscle injury
B. To prevent respiratory distress
C. To promote comfort
D. To prevent sudden drop of blood pressure
The most effective measure the nurse can use to prevent wound infection when changing a clients
dressing after coronary artery bypass surgery is to
Select one:
A. Clean the incisional area with an antiseptic
B. Use prepackaged sterile dressings to cover the incision
C. Place soiled dressings in a waterproof bag before disposing of them
D. Observe careful Handwashing procedures
The physician prescribes metoclopramide HCI (Reglan) for the client with hiatal hernia. The nurse
plans to instruct the client that this drug is used in hiatal hernia therapy to accomplish which of the
following objectives?
Select one:
A. Increase the resting tone of the esophageal sphincter
B. Reduce secretion of digestive juices
C. Delay gastric emptying
D. Neutralize gastric secretions
Situation: Nurse Isabel is working as a staff nurse in Chen Medical Center. She is assigned to the
Medical Ward of the Hospital. Recently, she had many patients with Gastro intestinal disorders. The
following questions are related to the cases she handled.
One of the clients had hemorrhoidectomy. Which is an important assessment finding;
Select one:
a. Degree of embarrassment of the patient
b. Presence of nausea and vomiting
c. The ability to assume a sitting position
d. Presence of rectal bleeding

Nurse tells a client that the regular insulin the client has taken this morning will begin to act in?
Select one:
a. 2 4 hrs
b. 6 to 8 hrs
c. 30 minutes to 1 hour
d. a few minutes
After monitoring the clients in the ICU, you noticed significant changes indicating that they are
improving. The following are indicators of adequate fluid balance you have observe on these clients
EXCEPT one.
Select one:
A. Systolic Blood Pressure of < 90 100
B. Heart rate of < 110 per minute in adults
C. Urine output of 30 -50 cc per hour in an adult
D. Absence of ileus and nausea
A client is presumed to be in the early stages of hypovolemic shock. All of the following assessment
findings indicate early shock EXCEPT:
Select one:
A. decreasing level of consciousness
B. Anxiety
C. restlessness
D. Tachycardia
AORN or the American Operating Room Nurses Association issues a periodic journal showing
recent studies about perioperative nursing. Which of the following will help you implement the new
discoveries or do an evidence-based nursing practice?
a. Safety
b. Applicability
c. Resources
d. Acceptability
Select one:
A. C, D
B. A and B
C. A, B, C
D. A, B, C, D

The nurse should prepare which of the following materials if a patient is for cystoclysis?
Select one:
A. 3-way catheter
B. straight catheter
C. IV Catheter
D. foley catheter
Situation: An industrial health nurse at a large printing plant finds a male employees blood pressure
to be elevated on two occasions, one month apart and refers him to his private physician. The
employee is about 25 pounds overweight and has smoked a pack of cigarettes daily for 20 years.
The client asks whether he should begin an exercise program. When teaching him about appropriate
exercise, the nurse should emphasize which of the following instructions?
Select one:
A. Follow exercise sessions with soaks or steam baths to prevent muscle cramping
B. Avoid acute exercise; it will increase the hearts workload to a dangerous level
C. Perform isometric exercises to reduce the hearts workload and improve the blood flow
D. Practice muscle pumping exercise for the legs when standing for prolonged periods
This procedure of recording the hearts electrical activity as waveforms, by interpreting these
waveforms accurately you can identify rhythm disturbances, conduction abnormalities & electrolyte
imbalances is known as :
Select one:
A. Electrocardiography
B. Angiography
C. Echocardiography
D. Electroencephalography
For a client who has undergone transsphenoidal hypophysectomy, the aspect of usual postoperative
care that the nurse would modify is:
Select one:
a. administration of oxygen.
b. leg exercises
c. oral care.
d. nutrition

The patient having peritoneal dialysis is about to go home and needs to be guided on how to make
sure there is continuous peritoneal dialysis even at home. The following are ways on how patient can
have continuous dialysis at home, except:
Select one:
A. Refer to social service to ensure continuous supply of dialysate fluids needed for dialysis.
B. Teach the patient and significant others about the procedure so they can alternate in changing
and measuring fluids.
C. Provide the patient with the number of the hospital in case of emergency.
D. Give your personal number to the patient so they can contact you in case they need help.
Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to
promote good dental care in a client with mitral stenosis should include demonstration of the proper
use of
Select one:
A. A manual toothbrush
B. Dental floss
C. An irrigation device
D. An electric toothbrush
Essential hypertension would be diagnosed in a 40-year-old man whose blood pressure readings
were consistently at or above which of the following?
Select one:
A. 160/80 mmHg
B. 140/90 mmHg
C. 120/90 mmHg
D. 130/85 mmHg
The client is admitted to the emergency department with chest trauma. When assessing the client,
which signs and symptoms would the nurse expect to find that support the diagnosis of
pneumothorax?
Select one:
A. Broncho-vesicular lung sounds and bradypnea
B. Frothy bloody sputum and consolidation
C. Unequal lung expansion and dyspnea
D. Barrel chest and polycythemia

Preoperative assessment of a clients alcohol habits is important for which of the following reasons?
Select one:
A. assess for possibility of hypercoagulability
B. assess for the stability of the blood glucose level
C. potential for unpredictable reactions to anesthesia
D. predict kidney function
The community nurse is conducting a health promotion program and the topic of the discussion
relates to the risk factors of gastric cancer. Which risk factor if identified by a client indicates a need
for further discussion?
Select one:
A. High meat and carbohydrate consumption
B. A diet of smoked, highly salted, and spiced food
C. History of gastric pernicious anemia
D. History of gastric polyps
Which position would be preferred for the (child) client with hypovolemic shock?
Select one:
A. Flat on bed
B. With the head of the bed elevated 45 degrees
C. Flat with legs elevated above the heart
D. Flat with the head elevated and the head below the level of the heart
The client is receiving external radiation to the neck for cancer of the larynx. The most likely side
effect to be expected is
Select one:
A. Sore throat
B. Constipation
C. Dyspnea
D. Diarrhea

To ensure safety of the patient after he is positioned on the operating room table, which of the
following nursing action should you perform?
Select one:
A. Instruct the patient not to move a lot as the table is narrow
B. Proceed with the skin preparation to shorten the stay of the patient in the OR therefore minimizing
the risk
C. Place the cautery ground pad to avoid electrical injury to the patient
D. To ensure safety of the patient after he is positioned on the operating room table, which of the
following nursing action should you perform?
The client is scheduled to have an upper gastrointestinal tract series. Which of the following
treatments should the nurse anticipate after the examination?
Select one:
A. Starting an IV infusion
B. Placing the client on a clear liquid diet
C. Giving the client a tapwater enema
D. Adminsitering a laxative
There was another victim who sustained burns of the entire left leg and left arm. According to the
Rule of Nine, how many percent total body surface area of burn (%TBSA) did this client sustain?
Select one:
A. 9% TBSA
B. 27% TBSA
C. 45% TBSA
D. 36% TBSA
After an MI, the hospitalized client is taught to move the legs while resting in bed. This type of
exercise is recommended primarily to help
Select one:
A. Decrease the likelihood of pressure ulcer formation
B. Prevent thrombophlebitis and blood clot formation
C. Promote urinary and intestinal elimination
D. Prepare the client for ambulation

The nurse is caring for a client experiencing hematologic toxicity as a result of chemotherapy. The
nurse develops a plan of care for the client. The nurse plans to
Select one:
A. Insert an indwelling urinary catheter to prevent skin breakdown
B. Restrict fresh fruits and vegetables in the diet
C. Restrict all visitors
D. Restrict fluid intak
Mang Temio rushed his teenage son with blood in his abdominal area, informed you that the boy had
an operation 5 days ago. You triaged and placed him at the nearest Treatment Room #1, called ROD
immediately. Your concern is that the surgical incision might have opened and the organ from the
operation site might be coming out of the incision, This condition is :
Select one:
A. Evisceration
B. Hypovolemic Shock
C. Bleeding with wound infection
D. Dehiscence
A client experiences some initial signs of excitation after having an intravenous infusion of lidocaine
HCI started. The nurse would assess that the client is demonstrating a typical adverse reaction to
lidocaine HCI when the client complains of
Select one:
A. Palpitations
B. Lethargy
C. Urinary frequency
D. Tinnitus
Prior to the operation of a patient for general anesthesia, you noticed that the clients vital sign is
above normal and quite anxious about the procedure. As a circulating nurse, to whom should you
refer this assessment?
Select one:
A. Surgeon
B. Scrub nurse
C. Relative of the patient
D. Anesthesiologist

When evaluating whether the patient understands your post-operative discharge teaching you should
be worried if the patient states that:
Select one:
A. Im glad the operation is done and over. Now, I dont need to come back again to the hospital
because it already makes me afraid seeing people dressed in all white.
B. I will need help to have my wound dressing changed everyday.
C. I would have to eat my meal first before I take in my pain medication.
D. I need to come back after 2 weeks so my surgeon can remove the sutures in my skin.
The nurse is reviewing the preoperative orders of a client with a colon tumor who is scheduled for
abdominal perineal resection. The nurse notes that the physician has prescribed neomycin
( Mycifradin ) for the client. The nurse determines that this medication has been prescribed primarily.
Select one:
A. Because the client has an infection
B. To decrease the bacteria in the bowel
C. Because the client is allergic to penicillin
D. To prevent an infection
The nurse is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which
of the following in the care of this client?
Select one:
A. Assisting with range - - motion leg exercises
B. Elevating the knee gatch on the bed.
C. Removal of antiembolism stockings twice daily
D. Checking placement of pneumatic compression boots.
Cimetidine (Tagamet) may also be used to treat hiatal hernia. The nurse should understand that the
drug is used to prevent which of the following?
Select one:
A. Dysphagia
B. Esophagitis
C. Esophageal reflux
D. Ulcer formation
Which of the following dietary measures would be useful in preventing esophageal reflux?
Select one:

A. Adding a bedtime snack to the dietary plan


B. Increasing fluid intake
C. Eating small, frequent meals
D. Avoiding a bedtime snack to the dietary plan
To help maintain a normal blood serum level of potassium, the client receiving a loop diuretic should
be encouraged to eat foods, such as bananas, orange juice, and
Select one:
A. Skimmed milk
B. Baked chicken
C. Spinach
D. Brown rice
Upon admission, Lolo Ikengs ABG results are as follows: pH is 7.28, PaCO2 is 56.4 and HCO3 is at
23.2. The nurse knows that this is indicative of:
Select one:
A. Respiratory acidosis, uncompensated
B. Respiratory acidosis, partially compensated
C. Metabolic acidosis, uncompensated
D. Metabolic acidosis, partially compensated
Captopril, an ACE inhibitor, may be administer to a client with heart failure because it acts as a
Select one:
A. Vasodilator
B. Volume expander
C. Potassium- sparing diuretic
D. Vasopressor
Which of the following would be most relevant in assessing the postoperative client for blood loss?
Select one:
A. restlessness and pain
B. tachycardia, tachypnea and decreased blood pressure
C. decreased bowel sounds and vomiting
D. serosanguineous drainage on the dressing

As a knowledgeable nurse, you know that an adult patient would normally have about ______ of
extracellular fluid (ECF)in his body:
Select one:
A. 70%
B. 8%
C. 60%
D. 30%
When the nurse serves the gloves to another person, the nurses thumb should be outward while
stretching the gloves. What is the primary rationale for this?
Select one:
A. So that the nurse can support the sleeves of the gown of the other person
B. So that the nurse can stretch the gloves easily for proper donning of the other person
C. So that the sterile hand of the nurse will not touch the unsterile hand of the other person
D. So that the sterile hand of the surgeon will not touch the unsterile hand of the nurse
The client realizes the importance of quitting smoking, and the nurse develops a plan to help the
client achieve this goal. Which of the following nursing interventions should be the initial step in this
plan?
Select one:
A. Discuss the effects of passive smoking on environmental pollution
B. Explain how smoking worsens high blood pressure
C. Review the negative effects of smoking on the body
D. Establish the clients daily smoking pattern
For a client who excretes excessive amounts of calcium during the postoperative period after open
heart surgery, which of the following measures should the nurse institute to help prevent
complications associated with excessive calcium excretion?
Select one:
A. Enrich the clients diet with dairy products
B. Ensure a liberal fluid intake
C. Provide an alkaline ash diet
D. Prevent constipation
The underlying pathophysiologic alteration present in all types of shock is:
Select one:

A. inadequate tissue perfusion


B. decreased cardiac output
C. vasodilation of vascular beds
D. hemorrhage of blood or body fluids
Situation: A 48 year old client was admitted with a diagnosis of lung cancer. She enjoyed good health
until 2 months ago, when she developed a persistent cough that became productive of blood-tinged
sputum 1 week ago. She has also experienced increasing fatigue over the past month. She reports
no anorexia and appears well-nourished (57 tall, 140 lbs.). She has smoked a pack of cigarette a
day for 28 years. A chest x-ray and sputum cytology done a week ago are the basis of diagnosis.
The client is to have a left lung lobectomy. Certain data are more important than the others in
planning her post-operative nursing care. Of the following assessment data obtained in the nurses
admission interview and nursing history, which would increase the clients risk for developing postoperative complications?
Select one:
A. Tends to keep her real feelings to herself
B. Has decreased vital capacity
C. Is 57 tall and weighs 140 lbs.
D. Ambulates and can climb one flight of stairs without dyspnea
The nurse understands that the best position for the client who has undergone a gastrectomy is
Select one:
A. Right or left sims
B. Supine
C. Low Fowlers
D. Prone
To reduce the risk of dumping syndrome, the nurse should teach the client which of the following
interventions?
Select one:
A. Sit upright for 30minutes after meal
B. Decrease the carbohydrate content of meals
C. Drink liquids with meals, avoiding caffeine
D. Avoid milk and other dairy products

The client with GERD complains of a chronic cough. The nurse understands that in a client with
GERD this symptom may be indicative of which of the following conditions?
Select one:
A. Irritation of the esophagus
B. Esophageal scar tissue formation
C. Development of laryngeal cancer
D. Aspiration of gastric contents
A semi conscious client in the post anesthesia care unit (PACU) is experiencing difficulty of
breathing. Which of the following immediate actions should the nurse perform first?
Select one:
A. apply oxygen by mask
B. place a pillow under the clients head
C. remove the oropharyngeal airway
D. reposition the client to keep the tongue forward
25 year old, Jack suffered from motorcycle accident was bleeding on upper right arm, burned on both
legs. Vital signs PR- 140/min, RR- 38/min, BP-92/50 & is oliguric. Level of consciousness lethargic,.
Doctor ordered intravenous fluid to run at fast drip to replace his loss fluid. Foley catheter inserted.
Your immediate Nursing Diagnosis is:
Select one:
A. Fluid Volume Deficit
B. Decreased sensory perception
C. Decreased Cardiac output
D. Impaired Physical Mobility
When assessing the laboratory results of the client with bladder cancer and bone metastasis, the
nurse notes a calcium level of 12 mg/dl. The nurse recognizes that this is consistent with which
oncological emergency?
Select one:
A. Superior venca cava syndrome
B. hypekalemia
C. hypercalcemia
D. spinal cord compression
The nurse is teaching the relative of a patient who just had a kidney transplant about intake and
output monitoring. You will be worried if the patients relative stated that:

Select one:
A. I do not know how much his vomitus was this morning.
B. I will drain the foley catheter every hour and record it.
C. He moved her bowel this morning twice!
D. I will make sure he uses measuring cup every time he takes in fluid.
After a subtotal gastrectomy, care of the clients NGT and drainage system should include which of
the following nursing interventions?
Select one:
A. Monitor the client for nausea, vomiting, and abdominal distention
B. Irrigate the tube with 30ml of sterile water every hour, if needed
C. Reposition the tube if it is not draining well
D. Turn the machine to high suction if the drainage is sluggish on low suction
A clients job involves working in a warm, dry room, frequently bending and crouching to check the
underside of a high- speed press, and wearing eye guards. Given this information, the nurse should
assess the client for which of the following?
Select one:
A. Muscle aches
B. Thirst
C. Postural hypotension
D. Lethargy
The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises.
When is the best time to provide the preoperative teachings?
Select one:
A. Upon admission of the client in the recovery room
B. The afternoon or evening prior to surgery
C. Several days prior to surgery
D. Before administration of preoperative medications
The nurse understands that the primary symptoms of a sliding hiatal hernia are associated with
reflux. Therefore, the nurse should assess the client for which of the following symptoms?
Select one:
A. Heartburn
B. Anorexia

C. Jaundice
D. Stomatitis
The nurse instructs the client on health maintenance activities to help control symptoms from her
hiatal hernia. Which of the following statements would indicate that the client has understood the
instructions?
Select one:
A. I wish I didnt have to give up swimming
B. Ill avoid lying down after a meal
C. If I wear a girdle, Ill have more support for my stomach
D. I can still enjoy my potato chips and cola at bedtime
Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery?
Select one:
A. To prevent aspiration pneumonia
B. To prevent malnutrition
C. To prevent intestinal obstruction
D. To prevent electrolyte imbalance
An industrial health nurse at a large printing plant finds a male employees blood pressure to be
elevated on two occasions one month apart and refers him to his private physician. The employee is
about 25lbs overweight and has smoked a pack of cigarettes daily for more than 20 years. The
clients physician prescribes atenolol for the hypertension. The nurse should instruct the client to
Select one:
A. Avoid sudden discontinuation of the drug
B. Discontinue the medication if severe headaches develop
C. Monitor the blood pressure annually
D. Follow a 2g sodium diet
The nurse is admitting a patient to the operating room. Which of the following nursing actions should
be given highest priority by the nurse?
Select one:
A. Checking the patients vital signs
B. Checking the patients identification and correct operative permit
C. Assessing the patients level of consciousness
D. Positioning and performing skin preparation to the patient

The nurse is completing the admission on a 13 year old client diagnosed with asthma. Which signs
and symptoms would the nurse expect to find?
Select one:
A. Dyspnea and wheezing
B. Normal chest shape and eupnea
C. Fever and crepitus
D. Rales and hives
The client with cancer is receiving chemotherapy and develops thrombocytopenia. The nurse
identifies which intervention as the highest priority in the nursing plan of care.?
Select one:
A. Monitoring the platelet count
B. Ambulation 3 times daily
C. Monitoring temperature
D. Monitoring for pathological fractures
Cystoclysis is also known as:
Select one:
A. catheterization
B. bladder irrigation
C. bowel irrigation
D. IV therapy
Which of the following statements contains one of the basic rules to follow when caring for a client
with a chest tube and water-seal drainage system?
Select one:
A. Ensure that the collection and suction bottles are below the chest level at all times
B. Strip the chest and drainage tubes at least every 4 hours if excessive bleeding occurs
C. Ensure that the air vent on the water-seal drainage system is capped when the suction is off
D. Ensure that the collection and suction bottles are at the clients chest level at all times
Situation: A 48 year old client was admitted with a diagnosis of lung cancer. She enjoyed good health
until 2 months ago, when she developed a persistent cough that became productive of blood-tinged
sputum 1 week ago. She has also experienced increasing fatigue over the past month. She reports
no anorexia and appears well-nourished (57 tall, 140 lbs.). She has smoked a pack of cigarette a
day for 28 years. A chest x-ray and sputum cytology done a week ago are the basis of diagnosis.

The next morning, the client had a left lower lobectomy. She has two chest tubes to underwater-seal
drainage. Doctors orders include having the client cough and deep breathe every hour, turning the
client every 2 hours and administer Demerol PRN. When the client coughs, she complains of pain in
her left thorax. To help control the pain during coughing, the nurse should:
Select one:
A. Keep the bed flat and tell the client to place her hands over the incision before taking a deep
breath.
B. Place the bed in slight trendelenburgs position and help the client turn onto her operative side to
splint the incision.
C. Raise the bed to semi-fowlers position and place one hand on the clients back on the left side
and one hand under the incision.
D. Keep the bed flat and tell the client turn onto her operative side to splint the incision.
The client attends two sessions with the dietitian to learn about diet modifications to minimize
gastroesophageal reflux. The teaching would be considered successful if the client says that she will
decrease her intake of which of the following foods?
Select one:
A. Carbohydrates
B. High-sodium foods
C. Fats
D. High-calcium foods
The ECG tracing below was taken at the University Clinic. You are on duty. The student asked what
your interpretation is. Your response:

Select one:
a. Sinus Tachycardia at 180/min. P wave slightly peaked, R waved notched, vital signs PR-fast.
b. Sinus Rhythm at 80/min. P wave all precede QRS, rhythm regular, vital signs normal
c. Atrial Normal Rhythm @ 80/min. P- wave regular, R wave normal, vital signs normal
d. Ventricular Rhythm @ 80/min. P- wave regular, R wave normal, vital signs normal
Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.
On hospital discharge, outcome criteria for the client would include:
Select one:

A. States actions to reduce risk of respiratory infections


B. Exhibits temperature not exceeding 37.5 oC
C. Promises to do pursed-lip breathing
D. Agrees to call the physician if dyspnea on exertion occurs
The client is now in the End-Stage Renal Disease, which of these following data supports this?
Select one:
A. The client has 50% remaining nephrons
B. The client has 80% non - functioning nephrons
C. The client has 25 % remaining functional nephrons
D. The client has only less than 10% functioning nephrons
Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.
The client reports steady weight loss and that he is too tired from just breathing to eat. Which of the
following nursing diagnoses would be most appropriate when planning nutritional intervention for this
client?
Select one:
A. Ineffective breathing pattern related to alveolar hypoventilation
B. Altered nutrition: less than body requirements related to COPD
C. Altered nutrition: less than body requirements related to fatigue
D. Weight loss related to COPD
The home healthy care nurse is caring for a client with cancer. The client is
Complaining of acute pain. The most appropriate nursing assessment of the clients pain would
include which of the following?
Select one:
A. Pain relief after appropriate nursing intervention.
B. Non verbal cues from the client
C. The nurses impression of the clients pain.
D. The clients pain rating
While caring for a client who was sustained an MI, the nurse notes eight PVCs in 1 minute on the
cardiac monitor. The client is receiving an intravenous infusion of 5% dextrose in water (D5W) and
oxygen at 2L/min. The nurses first course of action should be to

Select one:
A. Administer prescribed analgesic
B. Notify the physician promptly
C. Increase the intravenous infusion rate
D. Increase the oxygen concentration
The nurse receives the preoperative blood work report of a client who is scheduled to undergo
surgery. Which of the following laboratory findings should be reported to the surgeon?
Select one:
A. Blood urea nitrogen, 15mg/dl
B. Hemoglobin, 12.2g/dl
C. Creatinine, 2.6mg/dl
D. Red blood cells, 4.5million/mm3
Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.
When assessing the client with COPD, which health promotion would be most important for the
nurse to obtain?
Select one:
A. Risk factors for complications.
B. Number of years the client has smoked.
C. Ability to administer inhaled medication.
D. Possibility for lifestyle changes.
The patient who is suffering from pleural effusion has a CTT tube inserted today. What will be the
long-term goal of the nurse in the care of this patient?
Select one:
A. Maintain oxygen saturation at 95% or higher
B. Normalize ABG result
C. Identify high-risk patients
D. Ensure that the client is free from complications
Which of the following data gathered during history taking will support the doctors diagnosis of
Glomerulonephritis?
Select one:

A. Excessive intake of sodium


B. Streptococcal infection
C. Staphylococcal infection
D. Benign Prostatic Hypertrophy
A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported
to his physician. Based on this information, which nursing diagnosis would be appropriate for this
client?
Select one:
A. Imbalanced nutrition: less than body requirements related to gastric bleeding
B. Constipation related to decreased gastric motility
C. Deficient knowledge related to unfamiliarity with significant signs and symptoms
D. Ineffective Coping related to fear of diagnosis of chronic illness
he nurse teaches a client with heart failure to take oral Furosemide in the morning. The primary
reason for this is to help
Select one:
A. Prevent sleep disturbances during the night
B. Excrete excessive fluids accumulated during the night
C. Retard rapid drug absorption
D. Prevent electrolyte imbalances
In making emergency equipment available at the bedside of a client who has undergone subtotal
thyroidectomy, the nurse would include?
Select one:
a. a defibrillator
b. a tracheostomy set
c. an electrocardiogram
d. an intra-aortic balloon pump
As a scrub nurse, you know that you have to count the instruments, sponges, needles and sutures
together with the:
Select one:
A. Surgeon
B. Circulating nurse

C. Head nurse
D. Anesthesiologist
A cervical radiation implant is placed in the client for treatment of cervical cancer. The nurse initiates
what most appropriate activity order for this client ?
Select one:
A. Bedrest
B. Out of bed in a chair only
C. Ambulate to the bathroom only
D. Out of bed ad lib
In which of the following positions should the nurse place a client with suspected heart failure?
Select one:
A. Sitting almost upright (high fowlers position)
B. Lying on the back with the head lowered (Trendelenburg position)
C. Semi-sitting (low fowlers position)
D. Lying on the right side (Sims position)
The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note
documentation of which most common symptoms of this type of cancer?
Select one:
A. Urgency on urination
B. Hematuria
C. Frequency of urination
D. Dysuria
Following lobectomy, clients should be instructed to perform deep breathing exercises to:
Select one:
A. Elevate the diaphragm, which enlarges the thorax and increases the lung surface available for
gas exchange.
B. Decrease blood flow to the lungs to allow them to rest and increase the surface available for
ventilation.
C. Expand the alveoli and increase the lung surface available for ventilation.
D. Control the rate of air flow to the remaining lobe so that it will not become hyper inflated.
The doctor ordered D5LR 1L to infuse for 12 hours. Calculate for the regulation rate if the drop
factor is 20 gtts/min.

Select one:
A. 20-21 gtts/min
B. 82-83 gtts/min
C. 41-42 gtts/min
D. 27-28 gtts/min
Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.
Oxygen at the rate of 2L/min. via nasal cannula is prescribed for the client. Which of the following
statements best describes why the oxygen therapy is maintained at a relatively low concentration?
Select one:
A. The clients long history of respiratory problems indicates that he would be unable to absorb
oxygen given at a higher rate.
B. The cells in the alveoli are so damaged by the long history of respiratory problems that increased
oxygen levels and reduced carbon dioxide.
C. The clients respiratory center is so accustomed to high carbon dioxide and low blood oxygen
concentrations that changing these concentrations with oxygen may eliminate his stimulus for
breathing.
D. The oxygen will be lost at the clients nostrils if given at a higher level with a nasal cannula.
The client is hospitalized for insertion of an internal cervical radiation implant while giving care, the
nurse finds the radiation implant in the bed. The initial action by the nurse is to
Select one:
A. Reinsert the implant into the vagina immediately
B. Pick up the implant with long handled forceps and place it in a lead container.
C. Call the physician
D. Pick up the implant with gloved hands and flush it down the toilet.
Which of the following factors would most likely contribute to the development of a clients hiatal
hernia?
Select one:
A. Having a sedentary desk job
B. Being 5 feet 3 inches tall and weighing 190lbs
C. Using laxatives frequently
D. Being 40 years old

A 47-year old woman has had gastric ulcer for years. After she started vomiting blood today, her
neighbor drove her to the emergency room.
As a nurse on duty, which of the following is not a priority?
Select one:
A. Visualize the patient
B. Verbalize the patient
C. Get the vital sign
D. Extract blood for laboratory examination
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period the
nurse notes bloody drainage from the nasogastric tube. Which of the following is the most
appropriate nursing intervention?
Select one:
A. Measure abdominal girth
B. Notify the physician
C. Irrigate the nasogastric tube
D. Continue to monitor the drainage
To render a cost-effective perioperative care to the patient, nurses should make sure:
Select one:
A. to do daily inventory of supplies to ensure its availability
B. that sterile supplies are labeled correctly
C. to document all supplies used primarily for proper charging
D. to open needed sterile supplies correctly and as needed only
Situation: An industrial health nurse at a large printing plant finds a male employees blood pressure
to be elevated on two occasions, one month apart and refers him to his private physician. The
employee is about 25 pounds overweight and has smoked a pack of cigarettes daily for 20 years.
The client realizes the importance of quitting smoking, and the nurse develops a plan to help him
achieve his goal. Which of the following nursing interventions should be the initial step in this plan?
Select one:
A. Review the negative effects of smoking on the body
B. Establish the clients daily smoking pattern
C. Explain how smoking worsens high blood pressure
D. Discuss the effects of passive smoking on environmental pollution

The nurse is caring for a client following a modified radical mastectomy, Which assessment finding
would indicate that the client is experiencing a complication related to the surgery?
Select one:
A. Complaints of decreased sensation near the operative site
B. Pain at the incisional site
C. Sanguineous drainage in the Jackson- Pratt drain
D. Arm edema on the operative side
The client receives an IV infusion of packed red blood cells and normal saline solution. Which of the
following would be a priority assessment for the client receiving a blood product?
Select one:
A. Anaphylactic reaction
B. Pain
C. Altered level of consciousness
D. Hypovolemia
In caring for a client returning from surgery for a thyroid disorder, the nurse would have available, in
case of emergency, the medication
Select one:
a. Epinephrine
b. Rectal Aspirin
c. Calcium Gluconate
d. Potassium Chloride
Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.
The client is admitted to room 13, but he states that he does not want to be in this room because it
will bring him bad luck. The admitting office say that a change can be made if the nurse decides that
is wise to do so. Which of the following statements offer the best guide for the nurse in this situation?
Select one:
A. Move the client; the clients fears even when founded, can improve recovery.
B. Do not move the client; having the client use the room will help him overcome an unwarranted
fear.
C. Move the client; superstitions have a good chance of coming true for those who believe them.

D. Do not move the client; the client may become unmanageable and demanding when he knows he
can have his way.
Mr. Laudico is one week postop following colostomy. Which of the following is an important
assessment findings;
Select one:
a. The color of the stoma is dusky blue.
b. The client appears depressed
c. The client is experiencing flatulence
d. The skin under the colostomy bag is red.
Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts to
Select one:
A. Decrease cardiac dysrhythmia
B. Increase myocardial contractility
C. Dilate coronary arteries
D. Decrease electrical conductivity in the heart
A student nurse asked you her Patients ECG tracing shows the tracing below. You called for Code
Blue vital signs showed PR imperceptible, BP cannot be determined. Your interpretation of the
tracing:

Select one:
A. Atrial Fibrillation
B. Atrial Tachycardia
C. Ventricular Fibrillation
D. Ventricular Tachycardia
The client is admitted to the hospital with a suspected diagnosis of Hodgkins disease. Which of the
following assessment signs would the nurse expect to note specially in the client?
Select one:
A. Weight gain
B. Fatigue
C. weakness
D. Enlarged lymph nodes

The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by
the nurse would be most accurate?
Select one:
A. Hiatal hernia symptoms can usually be successfully managed with diet modifications,
medications, and lifestyle changes
B. A minor surgical procedure to reduces the size of the diaphragmatic opening will probably be
planned
C. Surgery is usually required, although medical treatment is attempted first
D. Surgery is not performed for this type of hernia
The client reports to the nurse that when performing testicular self-exam, he found a lump the size
and shape of a pea. The most appropriate response to the client is which of the following?
Select one:
A. Lumps like that are normal; dont worry.
B. Thats important to report even though it might not be serious.
C. Let me know if it gets bigger next month.
D. That could be cancer. Ill ask the doctor to examine you.
A client has driven himself to the emergency room. He is 50 years old, has a history of hypertension
and informs the nurse that his father died from a heart attack at 60 years of age. The client is
presently complaining of indigestion. The nurse connects him to an ECG monitor and begins
administering oxygen at 2L/min per nasal cannula. The nurses next action would be to
Select one:
A. Call for the doctor
B. Obtain a portable chest radiograph
C. Start an intravenous line
D. Draw blood for laboratory studies
The nurse is monitoring the laboratory results of a client preparing to receive
Chemotherapy. The nurse would determine that the white blood cell count is normal if which of the
following results were present ?
Select one:
A. 2000 to 5000 cells / min.
B. 5000 to 10,000 cells/ min.
C. 3000 to 8000 cells / min.
D. 7000 to 15,000 cells / min.

Situation: A client is admitted to the hospital with an acute exacerbation of long standing chronic
obstructive pulmonary disease (COPD) brought on by an upper respiratory infection. He is
tachypneic and acutely short of breath. Both he and his wife are extremely anxious.
During postural drainage, movement of secretions from the lower respiratory tract to upper
respiratory tract occurs due to:
Select one:
A. Friction between the cilia
B. Involuntary muscle contractions
C. The sweeping motion of cilia
D. The force of gravity
Situation: Nurse Isabel is working as a staff nurse in Chen Medical Center. She is assigned to the
Medical Ward of the Hospital. Recently, she had many patients with Gastro intestinal disorders. The
following questions are related to the cases she handled.
Nurse Isabel assesses her clients gastrointestinal tract. Which among the following subjective
assessment findings is included?
Select one:
A. Hematuria
B. Diarrhea
C. Rebound tenderness
D. Generalized red abdominal rash
Which of the following would be an expected nutritional outcome for a client who has undergone a
subtotal gastrectomy for cancer?
Select one:
A. Control nausea and vomiting through regular use of antiemetics
B. Achieve optimal nutritional status through oral or parenteral feedings
C. Regain weight loss within 1 month after surgery
D. Resume normal dietary intake of three meals a day
The hospice nurse visits a client dying of ovarian cancer. During the visit, the client expresses that if
I can just live long enough to attend my daughters graduation. Ill be ready to die. Which phase of
coping is this client experiencing
Select one:
A. Denial

B. Depression
C. Bargaining
D. Anger
Which of the following is most dangerous complication during induction of spinal anesthesia?
Select one:
A. Respiratory paralysis
B. Cardiac arrest
C. Hyperthermia
D. Hypotension
Pain threshold can best be defined as:
Select one:
A. a persons experience with pain in the past
B. the amount of pain a person is willing to endure
C. the lowest perceivable intensity of stimuli transmitted as pain
D. an interpretation of the pain experience
Common assessment finding in a patient with abdominal aneurysm:
Select one:
a. Decrease urine output
b. Low Back Pain
c. Dysphagia
d. Dyspnea
The community health nurse conducts a health promotion program regarding testicular cancer to
community members. The nurse determines that further information needs to be provided if a
community member states that which of the following is a sign of testicular cancer?
Select one:
A. Heavy sensation in the scrotum
B. Painless testicular swelling
C. Alopecia
D. Back pain

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