Medical-Surgical Nursing Exam Questions 5

Questions

1. A 42-year-old client admitted with an acute myocardial infarction asks to see his chart. What should the nurse do first?
a. Allow the client to view his chart
b. Contact the supervisor and physician for approval
c. Ask the client if he has concerns about his care
d. Tell the client that he isn’t permitted to view his chart.
2. A registered nurse who works in the preoperative area of the operating room notices that a client is scheduled for a partial mastectomy and axillary lymph node removal the following week. The nurse should make sure, that the client is well educated about her surgery by:
a. taking with the nursing staff at the physician’s office to find out what the client has been taught and her level of understanding
b. making sure that the post-anesthesia recovery unit nurses know what to teach the patient before discharge
c. providing all of the preoperative teaching before surgery
d. having the post-operative nurses teach the patient because she’ll be too anxious before surgery
3. A male client brings a list of his prescribed medications to the clinic. During the initial assessment, he tells the nurse that
he has been experiencing delayed ejaculation. Which drug class is associated with this problem?
a. Anticoagulants
b. Antibiotics
c.Antihypertens ive
d. Steroids
Situation: Larry was admitted at Manila Doctor’s Hospital because of a second-degree burn wound.
4. Before debriding a second-degree burn wound in the left lower leg, the nurse should do which of the following?
a. Apply Lindane (Kwell) to the affected area
b. Medicate the client with narcotic analgesic
c. Administer acylovir (Zovirax) IV
d. Apply a topical antimicrobial ointment
5. Larry’s anterior trunk, both front upper extremities, both lower extremities sustained second and third degree burn. Estimate the total percentage of body surface area burned using the Rule of Nines.
a. 60%
b.63%
c. 62%
d. 61%
Situation . Hearing, impairment appears to be common among elderly patients. But also occurs among children.
6. To assess the degree of hearing impairment of a 70-year-old client. Which communication approach would you initiate?
a. Use verbal communication and observe the response
b. Give message to client in writing
c. Asks a family member about the client’s
d. Post a sign “Patient deaf”
7. While you are mating your routine rounds you were told that there is a client in the 1CU who is in respirator and who lip- reads. To establish relationship with him, communication is best accomplished by:
a. Speaking slowly but aloud
b. Writing messages
c. Gesturing while speaking
d. Using simple “charade” approach or strategy
8. One of your client’s has just undergone an ear surgery. Which of the following would be inappropriate in planning for his care?
a. Administration of anti-emetics and analgesics as ordered
b. Daily irrigation of the ear canal
c. Walking with assistance at least 24 hours after operation
d. Teaching the patient to avoid sneezing, coughing and nose blowing
9. Which of the following conditions would an irrigation of the ear canal be appropriate intervention?
a. Foreign body in the ear canal
b. Serious otitis
c. Impacted cerumen
d. Tympanic membrane perforation
10. Children who have undetected hearing loss are likely to exhibit which of the following:
a. Indifference and lack of interest in the environment
b. Hyperactivity
c. An increased interest in reading
d. Hand gestures while speaking
Situation . One of the main fools of the nursing profession is the use of therapeutic communication. The following situation would require you of your communication skills.
11. A patient who is diagnosed to have terminal illness tells you. “I’m really scared. Am I dying?” What could be your most appropriate response?
a. “Tell me about what you think.”
b. “I’m sure you are scared; other clients in your situation feel the same way.”
c. “You should be careful not to let your family know you’re scared”
d. “Why are you scared?”
12. The nurse assessing a male client who has been admitted for treatment of alcoholism. Which question by the nurse is least appropriate?
a. “How much do you think?”
b. “What other drugs do you use?” .
c. “How is your general health?”
d. “Why do you drink so much?”
13. A 58-year-old male client tells the office nurse that his wife does not let him change his colostomy bag himself. Which response by the nurse indicates as understanding of the situation?
a. “Your wife’s need to help you is a reality you should accept”
b. “Do you think your wife might benefit from counseling?”
c. “You feel you need privacy when changing your colostomy?”
d. “Have you discussed the situation with your doctor?”
14. An 87 year old widow was hospitalized for treatment of chronic renal disease. She lives with her daughter and son-in- law and their family, who are very supportive. She is now ready for discharge. The doctor has ordered high carbohydrates, low-protein, low sodium diet for her and the family has asked for assistance in planning low-sodium diet meals. Which of the following choices best reflects the pre-discharge information the nurse should provide for the client’s family regarding low-sodium diet?
a. Avoid canned and processed foods, do not use salt replacements substitute herbs and replaces for salt in cooking and when seasoning foods, call a dietitian for help.
b. Use potassium salts in place of table salt when coking and seasoning foods, read the labels on packaged foods to determine sodium content,
and avoid snacks food
c. Limit milk and dairy products, cook separate meals that are low in sodium and encourage increased fluid intake
d. Avoid eating in a restaurant, soak vegetables well before cooking to remove sodium, omit all canned foods, and remove salt shakes from table.
15. You are encouraging your patient for major cancer operation to verbalize her fears. She remarked,” I am afraid to do”. Your appropriate response is
a. “I know how you feel about your condition”.
b. “Don’t worry, you are in good hands.”
c. “Let me call a chaplain to see you.”
d. “Let us asks your doctor about your operation.”
16. The nurse is caring for a client whose arterial blood gases indicate metabolic acidosis. The nurse knows that of the following, the least likely to cause metabolic acidosis is:
a. cardiac arrest
b. Diabetic ketoacidosis
c. decreased serum potassium level
d. renal failure
17. The nurse is caring for a client who is receiving IV fluids, Which observation the nurse makes best indicates that the IV has infiltrated?
a. Pain at the site
b. A change in flow rate
c. Coldness around the insertion site
d. Redness around the insertion site
18 A 27 y.o adult is admitted for treatment of Crohn’s disease. Which information is most significant when the nurse assesses nurtritional health?
a. Anthropometric measurements
b. bleeding gums
c. dry skin
d. facial rubor
19. ASA (aspirin) is being administered to a client. The nurse understands that the most common mechanism of action for nonnarcotic analgesic is their ability to:
a. Inhibit prostaglandin systhesis
b. After pain perception in the cerebellum
c. Directly affect the central nervous system
d. Target the pain-producing effect of kinins
20. The nurse caring for an adult client who is receiving TPN will need to be monitored for which of the following metabolic complications?
a. Hypoglycemia and Hypercalcemia
b. Hyperglycemia and Hypokalemia
c. Hyperglycemia and Kyperkalemia
d. Hyperkalemia and Hypercalcemia
21. Total parenteral nutrition is ordered for an adult. Which nutrient is not likely to be in the solution?
a. Dextrose 10%
b. Trace minerals
c. Amino acids
d. None of the above
22. A man has sprained his ankle. The physician would order cold applied to the injured area to.
a. Reduce the body’s temperature
b. Increase circulation to the area
c. Aid in absorbing the edema
d. Relieve pain and control bleeding.
23. An adult is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water?
a. 65 F
b. 90 F
c. 110 F
d. 105 F
24. An adult has chronic lower back pain and receives hot pack three times a week. The nurse knows that the treatment is given for which of the following reasons?
a. To help remove debris from the wound
b. To keep the client warm and raise his temperature
c. To improve the client’s general circulation
d. To relieve muscle spasm and promote muscle relaxation
25. A patient classification system where patients minimal therapy and less frequent observation
a. minimal care (category 1)
b. moderate care (category 2)
c. maximum care (category 3)
d. intensive care (category 4)
26. The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressing is best?
a. Dry gauze dressing
b. wet gauze dressing
c. wet to dry dressing
d. moisture vapor permeable dressing
27. The client has been placed in the trendelenburg position. The nurse knows the effects of this position to the client include which of the following.
a. increase blood flow to the feet
b. decrease blood pressure
c. increase pressure on the diaphragm
d. decrease intracranial pressure
28. A man who has been in an MVA is going into shock. Before placing the client in a modified trendelenburg position, the nurse should assess the client for:
a. long bone fracture
b. air embolus
c. head injury
d. thrombophlebitis
29. The nurse enter a room and finds a fire. Which is the best initial action?
a. Evacuate any people in the room, beginning with the most ambultory and ending with the least mobile
b. activating the fire alarm or call the operator, depending on the institutions system
c. get a fire extinguisher and put out the fire
d. close all the windows and doors and turn off any oxygen or electricity appliance.
30. The nurse is to open a sterile package from central supply. Which is the correct direction to open the first lap?
a. Toward the nurse
b. Away from the nurse
c. To the nurse’s left or right hand
d. It does not matter as long as the nurse touches only the outside edge
31. The nurse knows which of the following is the proper technique for medical asepsis?
a. gloving for all the client contact
b. changing hospital linens weekly
c. using your hands to turn off the faucet after handwashing
d. gowning to care for a 1 year old child w/ infections diarrhea
32. An adult ha a left, above the knee amputation two weeks ago. The nurse places him in a prone position tree times a day because:
a. Prevents pressure ulcer on the sacrum
b. helps the prosthesis to fit correctly
c. prevents flexion constractures
d. allow better blood flow to the heart
33. A woman is to have a pelvic exam. Which of the following should the nurse have the client do first?
a. Remove all her clothes and her socks and shoes
b. go to the bahtroom and void saving a sample
c. assume a lithotomy position on the exam table
d. assemble all the equipments needed for the examination
34. An adult is supine. Which of the ff. can the nurse to to prevent external rotation of the legs?
a. put a pillow under the clients lower legs
b. place a pillow directly under the client knee
c. use a trochanter rool alongside the client’s upper thighs
d. lower the client’s legs so that they are below hips.
35. The nurse prepares to palpate a clients maxillary sinues. For this procedure, where should the nurse place the hands?
a. On the bridge of the nose
b. below the eyebrows
c. below the cheekbones
d. over the temporal area
36. A client who receives general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
a. Pain related to the surgery
b. Fluid volume deficit related to fluid and blood loss from surgery
c. Impared physical mobility related to surgery
d. Risk for aspiration related to anesthesia
37. After a client receives an IM injection, he complains of a burning pain in the injection site. Which nursing action whould be best to take at this time?
a. apply a cold compress to decrease swelling
b. apply a warm compress to dilate the blood vessels
c. Massage the area to promote absorption of the drug
d. Instruct the client to tighten his gluteal muscles to enhance absorption of the drug
38. A patient classification system where patients need close attention and complete care in most activities and requires frequent and complex treatments and medications:
a. Minimal Care (category 1)
b. Moderate Care (category 2)
c. Maximum Care (category 3)
d. Intensive Care (category 4)
39. An observation consistent with complete-airway obstruction is:
a. Loud crowing when attempting to speak
b. Inability to cough
c. Wheezes on auscultation
d. Gradual
40. The nurse assesses the client’s home environment for the safe use crutches. Which one of the following would pose the greatest hazard to the client’s safe use of crutches at home?
a. A 4-year old cocker spaniel
b. Scatter rugs
c. Snack tables
d. Diet high in fat
41. A patient who has kaposis sarcoma has all of the following nursing diagnoses. To which one should the nurse give priority?
a. Altered thought processes related to lesions
b. Altered with maintenance related to non compliance
c. Defensive coping related to loss of boundaries
d. Hopelessness, related to inability to control disease process
42. Which of the following statements, if made by a patient who has had a basal cell carcinoma removed, would indicate to the nurse the need for further instruction?
a. “I will use sunscreen with at least a sun protection factor (SPF) of 15.”
b. “I will use tanning booths rather than sunbathing from now on.”
c. “I will stay out of the sun between 10:00 AM and 2:00 PM”
d. “I will wear a broad – brimmed heat when I am in the sun”
43. A patient who has a diagnosis is metastatic cancer of the kidney is told by the physician that the kidney needs to be removed. The patient asks the nurse. “What should I do?”Which of the following responses by the nurse would be most therapeutic?
a. “Let’s talk about your options.”
b. “You need to follow the doctor’s advice.”
c. “What does your family want you to do.”
d. “I wouldn’t have the surgery done without a second opinion.
44. Which of the following conditions, reported to a nurse by a 20 year old male patient, would indicate a risk for development of testicular cancer?
a. Genital Herpes
b. Undescended testicle
c. Measles
d. Hydrocele
45. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to:
a. Limit fluid intake for 24 hours
b. Teach muscle tightening exercises
c. Teach the procedure for irrigation of the stoma
d. Provide cleansing enemas and laxatives as ordered
46. To gain access to a vein and an artery, an external shunt may be used for clients who require hemodialysis. The most serious problem with an external shunt is.
a. Septicemia
b. Clot-formation
c. Exsanguination
d. Sclerosis of vessels
47. A client has been diagnosed as having bladder cancer, and a cystectomy and an ileal conduit are scheduled. Preoperatively, the nurse plans to:
a. Limit fluid intake for 24 hours
b. Teach the procedure for irrigation of the stoma
c. Teach muscle-tightening exercises
d. Provide cleansing enemas and laxatives as ordered
48. Intramedullary nailing is used in the treatment of:
a. Slipped epiphysis of the femur
b. Fracture of shaft of the femur
c. Fracture of the neck of the femur
d. Intertrochanteric fracture of the femur
49. The nurse should know that, following a fracture of the neck of the femur, the desirable position for the
a. Internal rotation with extension of the knee
b. Internal rotation with flexion of the knee and hip
c. External rotation with flexion of the knee and hip
d. External rotation with extension of the knee and hip
50. A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by:
a. Stimulating the cerebral cortex
b. Blocking the action of cholinesterase
c. Replacing deficient neurotransmitters
d. Accelerating transmission along neural swaths

Answers

Here are the answers for the exam. Unfortunately, rationales are not given. If you need clarifications or disputes, please direct them to the comments section and we’ll be glad to give you an explanation.

1. C. Ask the client if he has concerns about his care
2. A. taking with the nursing staff at the physician’s office to find out what the client has been taught and her level of understanding
3. C. Antihypertensive
4. B. Medicate the client with narcotic analgesic
5. B. 63%
6. A. Use verbal communication and observe the response
7. A. Speaking slowly but aloud
8. D. Teaching the patient to avoid sneezing, coughing and nose blowing
9. C. Impacted cerumen
10. A. Indifference and lack of interest in the environment
11. A. “Tell me about what you think.”
12. D. “Why do you drink so much?”
13. C. “You feel you need privacy when changing your colostomy?”
14. A. Avoid canned and processed foods, do not use salt replacements substitute herbs and replaces for salt in cooking and when seasoning foods, call a dietitian for help.
15. A. “I know how you feel about your condition”.
16. C. decreased serum potassium level
17. C. Coldness around the insertion site
18. A. Anthropometric measurements
19. A. Inhibit prostaglandin systhesis
20. B. Hyperglycemia and Hypokalemia
21. D. Non of the above
22. D. Relieve pain and control bleeding.
23. B. 90 F
24. D. To relieve muscle spasm and promote muscle relaxation
25. A. minimal care (category 1)
26. D. moisture vapor permeable dressing
27. C. increase pressure on the diaphragm
28. C. head injury
29. A. Evacuate any people in the room, beginning with the most ambultory and ending with the least mobile
30. B. Away from the nurse
31. D. gowning to care for a 1 year old child w/ infections diarrhea
32. C. prevents flexion constractures
33. B. go to the bahtroom and void saving a sample
34. C. use a trochanter rool alongside the client’s upper thighs
35. C. below the cheekbones
36. D. Risk for aspiration related to anesthesia
37. B. apply a warm compress to dilate the blood vessels
38. D. Intensive Care (category 4)
39. B. Inability to cough
40. B. Scatter rugs
41. D. Hopelessness, related to inability to control disease process
42. B. “I will use tanning booths rather than sunbathing from now on.”
43. A. “Let’s talk about your options.”
44. B. Undescended testicle
45. D. Provide cleansing enemas and laxatives as ordered
46. C. Exsanguination
47. D. Provide cleansing enemas and laxatives as ordered
48. B. Fracture of shaft of the femur
49. A. Internal rotation with extension of the knee
50. B. Blocking the action of cholinesterase

Medical-Surgical Nursing Exam Questions 4

Questions

1.) A client is receiving NPH insulin 20 units subq at 7:00 AM daily, at 3 PM how would the nurse finds if the client were having a hypoglycemic reaction?
A.) Feel the client and bed for dampness
B.) Observe client kussmaul respirations
C.) Smell client’s breathe for acetone odor
D.) Check client’s pupils for dilation
2.) Postoperative thyroidectomy nursing care includes which measures?
A.) Have the client speak every 5-10 mins if hoarseness is present
B.) Provide a low calcium diet to prevent hypercalcemia
C.) Check the dressing all the back of the neck for bleeding
D.) Apply a soft cervical collar to restrict neck movement
3.) What would the nurse note as typical findings on the assessment of a client with acute pancreatitis?
A.) Steatorrhea, abd. Pain, fever
B.) Fever, hypoglycemia, DHN
C.) Melena, persistent vomiting, hyperactive bowel sounds
D.) Hypoactive bowel sounds, decreased amylase and lipase levels
4.) A client is found to be comatose and hypoglycemic with a blood suger level 50 mg/dl. What nursing action is implemented first?
A.) Infuse 1000 ml of D5W over a 12-hour period
B.) Administer 50% glucose IV
C.) Check the client’s urine for the presence of sugar and acetone
D.) Encourage the client to drink orange juice with added sugar
5.) Which medication will the nurse have available for the emergency treatment of tetany in the client who has had a thyroidectomy?
A.) Calcium chloride
B.) Potassium chloride
C.) Magnesium sulfate
D.) Sodium bicarbonate
6.) What is the primary action of insulin in the body?
A.) Enhances the transport of glucose across cell walls
B.) Aids in the process of gluconeogenesis
C.) Stimulates the pancreatic beta cells
D.) Decreases the intestinal absorption of glucose
7.) What will the nurse teach the diabetic client regarding exercise in his /her treatment program?
A.) During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin
B.) With an increase in activity the body will utilize more carbohydrates; therefore more insulin will be required.
C.) The increase in activity results in an increase in the utilization of insulin; therefore the client should decrease his/her carbohydrate intake
D.) Exercise will improve pancreatic circulation and stimulate the islet of Langerhans to increase the production of intrinsic insulin
8.) The nurse is caring for a client who has exophthalmos associated with her thyroid disease. What is the cause of exophthalmos?
A.) Fluid edema in the retro-orbital tissues which force the eyes to protrude
B.) Impaired vision, which causes the client to squint in order to see
C.) Increased eye lubrication, which makes the client blink less
D.) Decrease in extraocular eye movements, which results in the “thyroid stare.”
9.) What is characteristic symptom of hypoglycemia that should alert nurse to an early insulin reaction?
A.) Diaphoresis
B.) Drowsiness
C.) Severe thirst
D.) Coma
10.) A client is scheduled for routine glycosylated hemoglobin (HbA1c) test. What is important for the nurse to tell the client before this test?
A.) Drink only water after midnight and come to the clinic early in the morning
B.) Eat a normal breakfast and be at the clinic 2 hours because of the multiple blood draws
C.) Expect to be at the clinic for several hours because of the multiple blood draws
D.) Come to the clinic at the earliest convenience to have blood drawn
11.) A client has been inhalation vasopressin therapy. What will the nurse evaluate to determine the therapeutic response to this medication?
A.) Urine specific gravity
B.) Blood glucose
C.) Vital signs
D.) Oxygen saturation levels
12.) A client with diagnosis of type 2 diabetes has been ordered a course of prednisone for her severe arthritic pain. An expected change that requires close monitoring by the nurse is;
A.) Increased blood glucose level
B.) Increased platelet aggregation
C.) Increased ceatinine clearance
D.) Increased ketone level in urine
13.) The nurse performing an assessment on a client who has been receiving long-term steroid therapy would expect to find:
A.) Jaundice
B.) Flank pain
C.) Bulging eyes
D.) Central obesity
14.) A diabetic client receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at
A.) 1200 and 1300 hours
B.) 1100 and 1700 hours
C.) 1000 and 2200 hours
D.) 0800 and 1100 hours
15.) It is important for the nurse to teach the client that metformin (Glcucophage):
A.) May cause nocturia
B.) Should be taken at night
C.) Should be taken with meals
D.) May increase the effects of aspirin
16.) A nurse assessing a client with SIADH would expect to find laboratory values of:
A.) Serum Na= 150 mEq/L and low urine osmolality
B.) Serum K= 5 mEq/L and low serum osmolality
C.) Serum Na=120 mEq/L and low serum osmolality
D.) Serum K= 3 mEq/L and high serum osmolality
17.) A priority nursing diagnostic for a client admitted to the hospital with a diagnosis of diabetes insipidus is:
A.) Sleep pattern deprivation related nocturia
B.) Activity intolerance r/t muscle weakness
C.) Fluid volume excess r/t intake greater that output
D.) Risk for impaired skin integrity r/t generalized edema
18.) A client admitted with a pheochrocytoma returns from the operating room after adrenalectomy. The nurse should carefully assess this client for:
A.) Hypokalemia
B.) Hyperglycemia
C.) Marked Na and water intake
D.) Marked fluctuations in BP
19.) When caring for client in thyroid crisis, the nurse would question an order for:
A.) IV fluid
B.) Propanolol (Inderal)
C.) Prophylthiouracil
D.) A hyperthermia blanket
20.) A client is prescribed levothyroxine (Synthroid) daily. The most important instruction to give the client for administration of this drug is:
A.) Taper dose and discontinue if mental and emotional statuses stabilize
B.) Take it at bedtime to avoid the side effects of nausea and flatus
C.) Call the M.D. immediately at the onset of palpitations or nervousness
D.) Decrease intake of juices and fruits with high potassium and calcium contents
21.) The nurse would question which medication order for a client with acute-angled glaucoma?
A.) Atropine (Atrposil) 1-2 drops in each eye now
B.) Hydrochloride (Diuril) 25 mg PO daily
C.) Propanolol (Inderal) 20 mg PO 2 times a day
D.) Carbanyl choline (Isopto carbachol) eye drops; 1 drop 2 times a day
22.) A client tells you she has heard that glaucoma may be a hereditary problem and she is concerned about her adult children. What is the best response?
A.) “There is no need for concern; glaucoma is not hereditary order.”
B.) “Screening for glaucoma should be included in an annual eye exam for everyones over 50.”
C.) “There may be a genetic factor with glaucoma and your children over 30 y/o should be screened yearly.”
D.) “Are your grandchildren complaining of any eye problems? Glaucoma generally skips a generation.”
23.) What will be important to include in the nursing care for the client with angle-closure glaucoma?
A.) Evaluation of medications to determine if any of them cause an increase in IOP is a side effect.
B.) Observation for an increase in loss of vision; it can be reversed if promptly identified.
C.) Control BP to decrease the client’s potential
loss of peripheral vision.
D.) Assessment for a level of discomfort; the client may experience considerable pain until the optic nerve atrophies
24.) A child is scheduled for a myringotomy. What goal of this procedure will the nurse discuss with the parents?
A.) Promote drainage from the ear
B.) Irrigate the Eustachian tube
C.) Correct a malformation in the inner ear
D.) Equalize pressure on the tympanic membrane
25.) After a client’s eye has been anesthetized, what instructions will be important for the nurse to give the client?
A.) Do not watch TV for at least one day
B.) Do not rub the eye for 15-20 minutes
C.) Irrigate the eye every hour to prevent dryness
D.) Wear sunglasses when in direct sunlight for the next 6 hours
26.) A child diagnosed with conjunctivitis. Which statement reflects that the child understood the nurse’s teaching?
A.) “It’s okay for me to let my friends use my sunglasses while we are playing together.”
B.) “It’s okay for me to softly rub my eye, as long as I use the back of my hand.”
C.) “I can pick the crustly stuff out of my eyelashes with my fingers when I wake up in the morning.”
D.) “I will use my own washrag and towel while my eyes are sick.”
27.) What medication would the nurse anticipate giving a client with Meniere’s dse?
A.) Nifedipine
B.) Amoxicillin
C.) Propanolol
D.) Hydrochloride (Hydro DIURIL)
28.) When teaching a family and a client about the use of a hearing aid, the nurse will base the teaching on what information regarding the hearing aid?
A.) Provides mechanical transmission for damaged part of the ear
B.) Stimulates the neural network of the inner ear to amplify sound
C.) Amplifies sound but does not improve the ability to hear
D.) Tunes out extraneous noise in the lower-frequency sound spectrum
29.) What statement by the client recovering from cataract surgery would indicate to the nurse need for additional teaching?
A.) “I’ll call if I have a significant amount of pain.”
B.) “I’ll continue to take my Metamucil for another week.”
C.) “I’ll just do some laundry this afternoon instead of going to work.”
D.) “I’ll take my acetazolamide (Diamox) drops with my other morning medications
30.) A client is walking down the hall and begins to experience vertigo. What is the most important nursing action when this occurs?
A.) Have the client sit in a chair and lower his head
B.) Administer meclizine (Antivert) PO
C.) Assist the client to sit or lie down
D.) Assess if the occurrence is vertigo or dizziness
31.) Which client is at highest risk for retinal detachment?
A.) 4-year old with amblyopia
B.) 17 y/o who plays physical contact
C.) 33 y/o with severe ptosis and diplopia
D.) 72 y/o with nystagmus and Bell’s palsy
32.) To promote and maintain safety for a client after a stapedectomy. What would be included in the nursing care plan?
A.) Implement fall precautions
B.) Prevent aspirations
C.) Begin oxygen 2-4L/min via nasal cannula
D.) Change inner ear dressing when saturated
33.) The nurse would question the administration of which eye drop in a patient with increased ICP?
A.) Artificial tears
B.) Betaxolol (Betoptic)
C.) Acetazolamide (Diamox)
D.) Epinephrine HCL (Epirate)
34.) A client is being admitted for problems with Meniere’s disease. What is most important to the nurse to assess?
A.) Diet history
B.) Screening hearing test
C.) Effect on client’s activities of daily living (ADLs)
D.) Frequency and severity
35.) A client calls the nurse regarding an accident that just occurred during which an unknown chemical was splashed in his eyes. What is the most important for the nurse to tell the client to do immediately?
A.) Rinse the eye with large amount of water or saline solution
B.) Put a pad soaked in the sterile saline solution over the eye
C.) Go to the closest emergency room
D.) Have a co-worker visually checks the eye for a foreign body
36.) A 25- year old woman comes to the clinic complaining of dizziness, weakness and palpitations. What will be important for the nurse to initially evaluate when obtaining the health history?
A.) Activity and exercise patterns
B.) Nutritional patterns
C.) Family health status
D.) Coping and stress tolerance
37.) A child with leukemia is being discharged after beginning chemotherapy. What instructions will the nurse include in the teaching plan for the parents of this child?
A.) Provide a diet low in protein and high in carbohydrates
B.) Avoid fresh vegetables that are not cooked or peeled
C.) Notify the M.D. if the child’s temperature exceeds 101F (39C)
D.) Increase the use of humidifiers throughout the house
38.) Which client is most likely to have iron deficiency anemia?
A.) A client with cancer receiving radiation therapy twice a week
B.) A toddler whose primary nutritional intake is milk
C.) A client with peptic ulcer who had surgery 6 weeks ago
D.) A 15-year old client in sickle cell crisis
39.) A client has an order for one unit of whole blood. What is a correct nursing action?
A.) Initiate an IV with 5% dextrose in water (D5W) to maintain a patent access site
B.) Initiate the transfusion within 30 minutes of receiving the blood
C.) Monitor the client’s vital signs for the first 5 minutes
D.) Monitor V/S every 2 hours during the transfusion
40.) The nurse is caring for a client who is receiving a blood transfusion. The transfusion was started 30 mins ago at a rate of 100 ml/hr. The client begins to complain of low back pain and headache and is increasing restless, what is the first nursing action?
A.) Slow the infusion and evaluate the V/S and client’s history of transfusion reaction
B.) Stop the transfusion, disconnect the blood tubing and begin a primary infusion of normal saline solution
C.) Stop the infusion of blood and begin infusion of NSS from the Y connector
D.) Recheck the unit of blood for correct identification numbers and cross-match information
41.) The nurse is preparing to start an IV infusion before the administration of a unit of packed red blood cells, what fluid will the nurse select to maintain the infusion before hanging the unit of blood?
A.) D5W
B.) D5W/.45NaCl
C.) LR solution
D.) .9% Na Cl
42.) A client in sickle cell crisis is admitted to the emergency department what are the priorities of care?
A.) Nutrition, hydration, electrolyte balance
B.) Hydration, pain management, electrolyte balance
C.) Hydration, oxygenation, apin management
D.) Hydration, oxygenation, electrolyte balance
43.) A client in the ICU has been diagnosed with DIC. The nurse will anticipate administering which of the following fluids?
A.) Packed RBC
B.) Fresh Frozen plasma (FFP)
C.) Volume expanders, such as D10W
D.) Whole blood
44.) The nurse is assessing a client who has been given a diagnosis of polycythemia vera. What characteristics will the nurse anticipate finding when assessing this client?
A.) Increased fatigue and bleeding tendencies
B.) Hemoglobin below 13 mg/dl
C.) Headaches, dyspnea, claudication
D.) Back pain, ecchymosis, and joint tenderness
45.) A client has been diagnosed with pernicious anemia what will the nurse teach this client regarding medication he will need to take after he goes home?
A.) Monthly Vit. B12 injections will be necessary
B.) Ferrous sulfate PO daily will be prescribed
C.) Coagulation studies are important to evaluate medications
D.) Decrease intake of leafy green vegetables because of increased Vit. K
46.) First postop day after a right lower lobe (RLL) lobectomy, the client breathes and coughs but has difficulty raising mucus. What indicates that the client is not adequately clearing secretions?
A.) Chest x-ray film shows right sided pleural fluid
B.) A few scattered crackles on RLL on auscultation
C.) PCO2 increases from 35-45 mm Hg
D.) Decrease in forced vital capacity
47.) What nursing observations indicate that the cuff on an endotracheal tube is leaking?
A.) An increase in peak pressure on the ventilator
B.) Client is able to speak
C.) Increased swallowing efforts by client
D.) Increased crackles (rales) over left lung field
48.) The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home?
A.) Because of his need for oxygen, the client will have to limit activity at home
B.) The use of oxygen will eliminate the client’s shortness of breath
C.) Precautions are necessary because oxygen can spontaneously ignite and explode
D.) Use oxygen during activity to relieve the strain on the client’s heart
49.) The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information?
A.) “You should avoid emotional situations that increase his shortness of breathe.”
B.) “Help your husband arrange activities so that he does as little walking as possible.”
C.) “Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening.”
D.) “Your husband will be no more short of breath when he walks but that will not hurt him.”
50.) Which statement correctly describes suctioning through an endotracheal tube
A.) The catheter is inserted into the endotracheal tube; intermittent suction is applied until no further secretions are retrieved; the catheter is then withdrawn.
B.) The catheter is inserted through the nose, and the upper airway is suctioned; the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway
C.) With suction applied, the catheter is inserted into the endotracheal tube; when resistance is met, the catheter is slowly withdrawn
D.) The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.

Answers

Here are the answers for the exam. Unfortunately, rationales are not given. If you need clarifications or disputes, please direct them to the comments section and we’ll try to explain it to you.

1. A
2. C
3. A
4. B
5. A
6. A
7. A
8. A
9. A
10. D
11. A
12. A
13. D
14. B
15. C
16. C
17. B
18. D
19. D
20. C
21. A
22. C
23. A
24. A
25. B
26. D
27. D
28. C
29. C
30. C
31. B
32. A
33. D
34. D
35. A
36. B
37. B
38. B
39. B
40. B
41. D
42. C
43. B
44. C
45. A
46. C
47. B
48. A
49. C
50. D

Medical-Surgical Nursing Exam Questions 3

Questions

1. A client is scheduled for insertion of an inferior vena cava (IVC) filter. Nurse Patricia consults the physician about withholding which regularly scheduled medication on the day before the surgery?
a. Potassium Chloride
b. Warfarin Sodium
c. Furosemide
d. Docusate
2. A nurse is planning to assess the corneal reflex on unconscious client. Which of the following is the safest stimulus to touch the client’s cornea?
a. Cotton buds
b. Sterile glove
c. Sterile tongue depressor
d. Wisp of cotton
3. A female client develops an infection at the catheter insertion site. The nurse in charge uses the term “iatrogenic” when describing the infection because it resulted from:
a. Client’s developmental level
b. Therapeutic procedure
c. Poor hygiene
d. Inadequate dietary patterns
4. Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognize bradykinesia when the client exhibits:
a. Intentional tremor
b. Paralysis of limbs
c. Muscle spasm
d. Lack of spontaneous movement
5. A client who suffered from automobile accident complains of seeing frequent flashes of light. The nurse should expect:
a. Myopia
b. Detached retina
c. Glaucoma
d. Scleroderma
6. Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure?
a. Intermittent tachycardia
b. Polydipsia
c. Tachypnea
d. Increased restlessness
7. A hospitalized client had a tonic-clonic seizure while walking in the hall. During the seizure the nurse priority should be:
a. Hold the clients arms and leg firmly
b. Place the client immediately to soft surface
c. Protects the client’s head from injury
d. Attempt to insert a tongue depressor between the client’s teeth
8. A client has undergone right pneumonectomy. When turning the client, the nurse should plan to position the client either:
a. Right side-lying position or supine
b. High Fowler’s position
c. Right or left side lying position
d. Low Fowler’s position
9. Nurse Jenny should caution a female client who is sexually active in taking Isoniazid (INH) because the drug has which of the following side effects?
a. Prevents ovulation
b. Has a mutagenic effect on ova
c. Decreases the effectiveness of oral contraceptives
d. Increases the risk of vaginal infection
10. A client has undergone gastrectomy. Nurse Jovy is aware that the best position for the client is:
a. Left side lying
b. Low fowler’s
c. Prone
d. Supine
11. During the initial postoperative period of the client’s stoma. The nurse evaluates which of the following observations should be reported immediately to thephysician?
a. Stoma is dark red to purple
b. Stoma is oozes a small amount of blood
c. Stoma is lightly edematous
d. Stoma does not expel stool
12. Kate which has diagnosed with ulcerative colitis is following physician’s order for bed rest with bathroom privileges. What is the rationale for this activity restriction?
a. Prevent injury
b. Promote rest and comfort
c. Reduce intestinal peristalsis
d. Conserve energy
13. Nurse KC should regularly assess the client’s ability to metabolize the total parenteral nutrition (TPN) solution adequately by monitoring the client for which of the following signs:
a. Hyperglycemia
b. Hypoglycemia
c. Hypertension
d. Elevate blood urea nitrogen concentration
14. A female client has an acute pancreatitis. Which of the following signs and symptoms the nurse would expect to see?
a. Constipation
b. Hypertension
c. Ascites
d. Jaundice
15. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following symptoms might indicate tetany?
a. Tingling in the fingers
b. Pain in hands and feet
c. Tension on the suture lines
d. Bleeding on the back of the dressing
16. A 58 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of hypothyroidism include:
a. Diarrhea
b. Vomiting
c. Tachycardia
d. Weight gain
17. A client has undergone for an ileal conduit, the nurse in charge should closely monitor the client for occurrence of which of the following complications related to pelvic surgery?
a. Ascites
b. Thrombophlebitis
c. Inguinal hernia
d. Peritonitis
18. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice “clear”. What should be the action of the nurse?
a. Places conductive gel pads for defibrillation on the client’s chest
b. Turn off the mechanical ventilator
c. Shuts off the client’s IV infusion
d. Steps away from the bed and make sure all others have done the same
19. A client has been diagnosed with glomerulonephritis complains of thirst. The nurse should offer:
a. Juice
b. Ginger ale
c. Milk shake
d. Hard candy
20. A client with acute renal failure is aware that the most serious complication of this condition is:
a. Constipation
b. Anemia
c. Infection
d. Platelet dysfunction
21. Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic function that the client loss during the induction of anesthesia is:

a. Consciousness
b. Gag reflex
c. Respiratory movement
d. Corneal reflex
22. The nurse is assessing a client with pleural effusion. The nurse expect to find:
a. Deviation of the trachea towards the involved side
b. Reduced or absent of breath sounds at the base of the lung
c. Moist crackles at the posterior of the lungs
d. Increased resonance with percussion of the involved area
23. A client admitted with newly diagnosed with Hodgkin’s disease. Which of the following would the nurse expect the client to report?
a. Lymph node pain
b. Weight gain
c. Night sweats
d. Headache
24. A client has suffered from fall and sustained a leg injury. Which appropriate question would the nurse ask the client to help determine if the injury caused fracture?
a. “Is the pain sharp and continuous?”
b. “Is the pain dull ache?”
c. “Does the discomfort feel like a cramp?”
d. “Does the pain feel like the muscle was stretched?”
25. The Nurse is assessing the client’s casted extremity for signs of infection. Which of the following findings is indicative of infection?
a. Edema
b. Weak distal pulse
c. Coolness of the skin
d. Presence of “hot spot” on the cast
26. Nurse Rhia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia would expect to note which of the following if this disorder is present?
a. Transparent tympanic membrane
b. Thick and immobile tympanic membrane
c. Pearly colored tympanic membrane
d. Mobile tympanic membrane
27. Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low suction. Nurse Jocelyn assesses the client for symptoms of which acid-base disorder?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
28. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following values should be negative if the CSF is normal?
a. Red blood cells
b. White blood cells
c. Insulin
d. Protein
29. A client is suspected of developing diabetes insipidus. Which of the following is the most effective assessment?
a. Taking vital signs every 4 hours
b. Monitoring blood glucose
c. Assessing ABG values every other day
d. Measuring urine output hourly
30. A 58 year old client is suffering from acute phase of rheumatoid arthritis. Which of the following would the nurse in charge identify as the lowest priority of the plan of care?
a. Prevent joint deformity
b. Maintaining usual ways of accomplishing task
c. Relieving pain
d. Preserving joint function
31. Among the following, which client is autotransfusion possible?
a. Client with AIDS
b. Client with ruptured bowel
c. Client who is in danger of cardiac arrest
d. Client with wound infection
32. Which of the following is not a sign of thromboembolism?
a. Edema
b. Swelling
c. Redness
d. Coolness
33. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration?
a. Position the client on the side with head flexed forward
b. Elevate the head
c. Use tongue depressor between teeth
d. Loosen restrictive clothing
34. A client has undergone bone biopsy. Which nursing action should the nurse provide after the procedure?
a. Administer analgesics via IM
b. Monitor vital signs
c. Monitor the site for bleeding, swelling and hematoma formation
d. Keep area in neutral position
35. A client is suffering from low back pain. Which of the following exercises will strengthen the lower back muscle of the client?
a. Tennis
b. Basketball
c. Diving
d. Swimming
36. A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for:
a. (+) guaiac stool test
b. Slow, strong pulse
c. Sudden, severe abdominal pain
d. Increased bowel sounds
37. A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized?
a. Prevent an increase intraocular pressure
b. Alleviate pain
c. Maintain darkened room
d. Promote low-sodium diet
38. A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is for:
a. Constricting pupil
b. Relaxing ciliary muscle
c. Constricting intraocular vessel
d. Paralyzing ciliary muscle
39. When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion?
a. Administer diuretics
b. Administer analgesics
c. Provide hygiene
d. Hyperoxygenate before and after suctioning
40. When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching?
a. Short frequent breaths
b. Exhale with mouth open
c. Exercise twice a day
d. Place hand on the abdomen and feel it rise
41. Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:
a. Maintain room humidity below 40%
b. Place top sheet on the client
c. Limit the occurrence of drafts
d. Keep room temperature at 80 degrees
42. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because this graft will:
a. Relieve pain and promote rapid epithelialization
b. Be sutured in place for better adherence
c. Debride necrotic epithelium
d. Concurrently used with topical antimicrobials
43. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, “I can’t eat all this food”. The food that the nurse should suggest to be eaten first should be:
a. Meat loaf and coffee
b. Meat loaf and strawberries
c. Tomato soup and apple pie
d. Tomato soup and buttered bread
44. Tony returns form surgery with permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should be aware that:
a. Proper functioning of nasogastric suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery
45. When teaching a client about the signs of colorectal cancer, Nurse Trish stresses that the most common complaint of persons with colorectal cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits
46. Louis develops peritonitis and sepsis after surgical repair of ruptures diverticulum. The nurse in charge should expect an assessment of the client to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds
47. Immediately after liver biopsy, the client is placed on the right side, the nurse is aware that that this position should be maintained because it will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary ducts
c. Position with greatest comfort
d. Promote circulating blood volume
48. Tony has diagnosed with hepatitis A. The information from the health history that is most likely linked to hepatitis A is:
a. Exposed with arsenic compounds at work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants
49. Nurse Trish is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated:
a. Serum bilirubin level
b. Serum amylase level
c. Potassium level
d. Sodium level
50. Dr. Marquez orders serum electrolytes. To determine the effect of persistent vomiting, Nurse Trish should be most concerned with monitoring the:
a. Chloride and sodium levels
b. Phosphate and calcium levels
c. Protein and magnesium levels
d. Sulfate and bicarbonate levels

Answers and Rationale

Here are the answers and rationale for this exam. Counter check your answers to those below and tell us your scores. If you have any disputes or need more clarification to a certain question, please direct them to the comments section.
1. B. In preoperative period, the nurse should consult with the physician about withholding Warfarin Sodium to avoid occurrence of hemorrhage.
2. D. A client who is unconscious is at greater risk for corneal abrasion. For this reason, the safest way to test the cornel reflex is by touching the cornea lightly with a wisp of cotton.
3. B. Iatrogenic infection is caused by the heath care provider or is induced inadvertently by medical treatment or procedures.
4. D. Bradykinesia is slowing down from the initiation and execution of movement.
5. B. This symptom is caused by stimulation of retinal cells by ocular movement.
6. D. Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.
7. C. Rhythmic contraction and relaxation associated with tonic-clonic seizure can cause repeated banging of head.
8. A. Right side lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump.
9. C. Isoniazid (INH) interferes in the effectiveness of oral contraceptives and clients of childbearing age should be counseled to use an alternative form of birth control while taking this drug.
10. B. A client who has had abdominal surgery is best placed in a low fowler’s position. This relaxes abdominal muscles and provides maximum respiratory andcardiovascular function.
11. A. Dark red to purple stoma indicates inadequate blood supply.
12. C. The rationale for activity restriction is to help reduce the hypermotility of the colon.
13. A. During Total Parenteral Nutrition (TPN) administration, the client should be monitored regularly for hyperglycemia.
14. D. Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct.
15. A. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed.
16. D. Typical signs of hypothyroidism includes weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, constipation and numbness.
17. B. After a pelvic surgery, there is an increased chance of thrombophlebitits owing to the pelvic manipulation that can interfere with circulation and promote venous stasis.
18. D. For the safety of all personnel, if the defibrillator paddles are being discharged, all personnel must stand back and be clear of all the contact with the client or the client’s bed.
19. D. Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid.
20. C. Infection is responsible for one third of the traumatic or surgically induced death of clients with renal failure as well as medical induced acute renal failure (ARF)
21. C. There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present.
22. B. Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.
23. C. Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph node, fever, malaise and night sweats.
24. A. Fractured pain is generally described as sharp, continuous, and increasing in frequency.
25. D. Signs and symptoms of infection under a casted area include odor or purulent drainage and the presence of “hot spot” which are areas on the cast that are warmer than the others.
26. B. Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick and immobile tymphanic membrane with or without perforation.
27. D. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid which is a potent acid in the body.
28. A. The adult with normal cerebrospinal fluid has no red blood cells.
29. D. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus.
30. B. The nurse should focus more on developing less stressful ways of accomplishing routine task.
31. C. Autotransfusion is acceptable for the client who is in danger of cardiac arrest.
32. D. The client with thromboembolism does not have coolness.
33. A. Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.
34. C. Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding, swelling and hematoma formation.
35. D. Walking and swimming are very helpful in strengthening back muscles for the client suffering from lower back pain.
36. C. Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the nurse maybe unable to hear bowel sounds at all.
37. A. After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal.
38. A. Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased out flow of aqueous humor.
39. D. It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion.
40. D. Abdominal breathing improves lungs expansion
41. C. A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.
42. A. The graft covers the nerve endings, which reduces pain and provides framework for granulation
43. B. Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.
44. C. This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics.
45. D. Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common symptoms of colorectal cancer.
46. B. With increased intraabdominal pressure, the abdominal wall will become tender and rigid.
47. A. Pressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after liver biopsy.
48. B. Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus.
49. B. Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems.
50. A. Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with vomiting. Chloride, which balances cations in the extracellular compartments, is also lost with vomiting, because sodium and chloride are parallel electrolytes, hyponatremia will accompany.

Medical-Surgical Nursing Exam Questions 2

Topics

Covered topics in this exam include:

• Cardiovascular diseases
• Anemias
• Cancer
• Tracheostomy

Questions

1. Marco who was diagnosed with brain tumor was scheduled for craniotomy. In preventing the development of cerebral edema after surgery, the nurse should expect the use of:
a. Diuretics
b. Antihypertensive
c. Steroids
d. Anticonvulsants
2. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should:
a. Increase the flow of normal saline
b. Assess the pain further
c. Notify the blood bank
d. Obtain vital signs.
3. Nurse Maureen knows that the positive diagnosis for HIV infection is made based on which of the following:
a. A history of high risk sexual behaviors.
b. Positive ELISA and western blot tests
c. Identification of an associated opportunistic infection
d. Evidence of extreme weight loss and high fever
4. Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an adequate amount of high-biologic-value protein when the food the client selected from the menu was:
a. Raw carrots
b. Apple juice
c. Whole wheat bread
d. Cottage cheese
5. Kenneth who has diagnosed with uremic syndrome has the potential to develop complications. Which among the following complications should the nurse anticipates:
a. Flapping hand tremors
b. An elevated hematocrit level
c. Hypotension
d. Hypokalemia
6. A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be:
a. Flank pain radiating in the groin
b. Distention of the lower abdomen
c. Perineal edema
d. Urethral discharge
7. A client has undergone with penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and painful. The nurse should:
a. Assist the client with sitz bath
b. Apply war soaks in the scrotum
c. Elevate the scrotum using a soft support
d. Prepare for a possible incision and drainage.
8. Nurse hazel receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
a. Liver disease
b. Myocardial damage
c. Hypertension
d. Cancer
9. Nurse Maureen would expect the a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
a. Right atrium
b. Superior vena cava
c. Aorta
d. Pulmonary
10. A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
a. Ineffective health maintenance
b. Impaired skin integrity
c. Deficient fluid volume
d. Pain
11. Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin including:
a. high blood pressure
b. stomach cramps
c. headache
d. shortness of breath
12. The following are lipid abnormalities. Which of the following is a risk factor for the development of atherosclerosis and PVD?
a. High levels of low density lipid (LDL) cholesterol
b. High levels of high density lipid (HDL) cholesterol
c. Low concentration triglycerides
d. Low levels of LDL cholesterol.
13. Which of the following represents a significant risk immediately after surgery for repair of aortic aneurysm?
a. Potential wound infection
b. Potential ineffective coping
c. Potential electrolyte balance
d. Potential alteration in renal perfusion
14. Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of Vitamin B12?
a. dairy products
b. vegetables
c. Grains
d. Broccoli
15. Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the following physiologic functions?
a. Bowel function
b. Peripheral sensation
c. Bleeding tendencies
d. Intake and out put
16. Lydia is scheduled for elective splenectomy. Before the clients goes to surgery, the nurse in charge final assessment would be:
a. signed consent
b. vital signs
c. name band
d. empty bladder
17. What is the peak age range in acquiring acute lymphocytic leukemia (ALL)?
a. 4 to 12 years.
b. 20 to 30 years
c. 40 to 50 years
d. 60 60 70 years
18. Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations may indicate all of the following except:
a. effects of radiation
b. chemotherapy side effects
c. meningeal irritation
d. gastric distension
19. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is contraindicated with the client?
a. Administering Heparin
b. Administering Coumadin
c. Treating the underlying cause
d. Replacing depleted blood products
20. Which of the following findings is the best indication that fluid replacement for the client with hypovolemic shock is adequate?
a. Urine output greater than 30ml/hr
b. Respiratory rate of 21 breaths/minute
c. Diastolic blood pressure greater than 90 mmhg
d. Systolic blood pressure greater than 110 mmhg
21. Which of the following signs and symptoms would Nurse Maureen include in teaching plan as an early manifestation of laryngeal cancer?
a. Stomatitis
b. Airway obstruction
c. Hoarseness
d. Dysphagia
22. Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:
a. Promotes the removal of antibodies that impair the transmission of impulses
b. Stimulates the production of acetylcholine at the neuromuscular junction.
c. Decreases the production of autoantibodies that attack the acetylcholine receptors.
d. Inhibits the breakdown of acetylcholine at the neuromuscular junction.
23. A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
a. Vital signs q4h
b. Weighing daily
c. Urine output hourly
d. Level of consciousness q4h
24. Patricia a 20 year old college student with diabetes mellitus requests additional information about the advantages of using a pen like insulin delivery devices. The nurse explains that the advantages of these devices over syringes includes:
a. Accurate dose delivery
b. Shorter injection time
c. Lower cost with reusable insulin cartridges
d. Use of smaller gauge needle.
25. A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
a. Swelling of the left thigh
b. Increased skin temperature of the foot
c. Prolonged reperfusion of the toes after blanching
d. Increased blood pressure
26. After a long leg cast is removed, the male client should:
a. Cleanse the leg by scrubbing with a brisk motion
b. Put leg through full range of motion twice daily
c. Report any discomfort or stiffness to the physician
d. Elevate the leg when sitting for long periods of time.
27. While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should assess for additional tophi (urate deposits) on the:
a. Buttocks
b. Ears
c. Face
d. Abdomen
28. Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood when the client places weight on the:
a. Palms of the hands and axillary regions
b. Palms of the hand
c. Axillary regions
d. Feet, which are set apart
29. Mang Jose with rheumatoid arthritis states, “the only time I am without pain is when I lie in bed perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
a. Active joint flexion and extension
b. Continued immobility until pain subsides
c. Range of motion exercises twice daily
d. Flexion exercises three times daily
30. A male client has undergone spinal surgery, the nurse should:
a. Observe the client’s bowel movement and voiding patterns
b. Log-roll the client to prone position
c. Assess the client’s feet for sensation and circulation
d. Encourage client to drink plenty of fluids
31. Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this phase the client must be assessed for signs of developing:
a. Hypovolemia
b. renal failure
c. metabolic acidosis
d. hyperkalemia
32. Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
a. Protein
b. Specific gravity
c. Glucose
d. Microorganism
33. A 22 year old client suffered from his first tonic-clonic seizure. Upon awakening the client asks the nurse, “What caused me to have a seizure? Which of the following would the nurse include in the primary cause of tonic clonic seizures in adults more the 20 years?
a. Electrolyte imbalance
b. Head trauma
c. Epilepsy
d. Congenital defect
34. What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
a. Pupil size and papillary response
b. cholesterol level
c. Echocardiogram
d. Bowel sounds
35. Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instruction is most appropriate?
a. “Practice using the mechanical aids that you will need when future disabilities arise”.
b. “Follow good health habits to change the course of the disease”.
c. “Keep active, use stress reduction strategies, and avoid fatigue.
d. “You will need to accept the necessity for a quiet and inactive lifestyle”.
36. The nurse is aware the early indicator of hypoxia in the unconscious client is:
a. Cyanosis
b. Increased respirations
c. Hypertension
d. Restlessness
37. A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which of the following?
a. Normal
b. Atonic
c. Spastic
d. Uncontrolled
38. Which of the following stage the carcinogen is irreversible?
a. Progression stage
b. Initiation stage
c. Regression stage
d. Promotion stage
39. Among the following components thorough pain assessment, which is the most significant?
a. Effect
b. Cause
c. Causing factors
d. Intensity
40. A 65 year old female is experiencing flare up of pruritus. Which of the client’s action could aggravate the cause of flare ups?
a. Sleeping in cool and humidified environment
b. Daily baths with fragrant soap
c. Using clothes made from 100% cotton
d. Increasing fluid intake
41. Atropine sulfate (Atropine) is contraindicated in all but one of the following client?
a. A client with high blood
b. A client with bowel obstruction
c. A client with glaucoma
d. A client with U.T.I
42. Among the following clients, which among them is high risk for potential hazards from the surgical experience?
a. 67-year-old client
b. 49-year-old client
c. 33-year-old client
d. 15-year-old client
43. Nurse Jon assesses vital signs on a client undergone epidural anesthesia. Which of the following would the nurse assess next?
a. Headache
b. Bladder distension
c. Dizziness
d. Ability to move legs
44. Nurse Katrina should anticipate that all of the following drugs may be used in the attempt to control the symptoms of Meniere’s disease except:
a. Antiemetics
b. Diuretics
c. Antihistamines
d. Glucocorticoids
45. Which of the following complications associated with tracheostomy tube?
a. Increased cardiac output
b. Acute respiratory distress syndrome (ARDS)
c. Increased blood pressure
d. Damage to laryngeal nerves
46. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:
a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules
47. An 83-year-old woman has several ecchymotic areas on her right arm. The bruises are probably caused by:
a. increased capillary fragility and permeability
b. increased blood supply to the skin
c. self inflicted injury
d. elder abuse
48. Nurse Anna is aware that early adaptation of client with renal carcinoma is:
a. Nausea and vomiting
b. flank pain
c. weight gain
d. intermittent hematuria
49. A male client with tuberculosis asks Nurse Brian how long the chemotherapy must be continued. Nurse Brian’s accurate reply would be:
a. 1 to 3 weeks
b. 6 to 12 months
c. 3 to 5 months
d. 3 years and more
50. A client has undergone laryngectomy. The immediate nursing priority would be:
a. Keep trachea free of secretions
b. Monitor for signs of infection
c. Provide emotional support
d. Promote means of communication

Answers and Rationale

Below are the answers and rationale for this examination. If you have any disputes or clarifications needed, please comment below.
1. C. Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema.
2. A. The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.
3. B. These tests confirm the presence of HIV antibodies that occur in response to the presence of the human immunodeficiency virus (HIV).
4. D. One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg cholesterol, and 6 g of carbohydrate. Proteins of high biologic value (HBV) contain optimal levels of amino acids essential for life.
5. A. Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
6. B. This indicates that the bladder is distended with urine, therefore palpable.
7. C. Elevation increases lymphatic drainage, reducing edema and pain.
8. B. Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
9. D. When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure.
10. A. Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat.
11. C. Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as headache, hypotension and dizziness.
12. A. An increased in LDL cholesterol concentration has been documented at risk factor for the development of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the blood vessels.
13. D. There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-clamping during the surgery.
14. A. Good source of vitamin B12 are dairy products and meats.
15. C. Aplastic anemia decreases the bone marrow production of RBC’s, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies.
16. B. An elective procedure is scheduled in advance so that all preparations can be completed ahead of time. The vital signs are the final check that must be completed before the client leaves the room so that continuity of care and assessment is provided for.
17. A. The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years of age.
18. D. Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous system, and clients experience headaches and vomiting from meningeal irritation.
19. B. Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such as Coumadin.
20. A. Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic shock. Urine output should be consistently greater than 30 to 35 mL/hr.
21. C. Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of the most common warning signs.
22. C. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
23. C. The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
24. A. These devices are more accurate because they are easily to used and have improved adherence in insulin regimens by young people because the medication can be administered discreetly.
25. C. Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack of blood supply to the extremity.
26. D. Elevation will help control the edema that usually occurs.
27. B. Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow is least active, including cartilaginous tissue such as the ears.
28. B. The palms should bear the client’s weight to avoid damage to the nerves in the axilla.
29. A. Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints relieves stiffness and pain.
30. C. Alteration in sensation and circulation indicates damage to the spinal cord, if these occurs notify physician immediately.
31. A. In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily, hypovolemia may occur and fluids should be replaced.
32. C. The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose.
33. B. Trauma is one of the primary cause of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease.
34. A. It is crucial to monitor the pupil size and papillary response to indicate changes around the cranial nerves.
35.  C. The nurse most positive approach is to encourage the client with multiple sclerosis to stay active, use stress reduction techniques and avoid fatigue because it is important to support the immune system while remaining active.
36. D. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in unconscious client who suddenly becomes restless.
37. B. In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is catheterized.
38. A. Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a fast growing tumor that cannot be reversed.
39. D. Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
40. B. The use of fragrant soap is very drying to skin hence causing the pruritus.
41. C. Atropine sulfate is contraindicated with glaucoma patients because it increases intraocular pressure.
42. A. A 67 year old client is greater risk because the older adult client is more likely to have a less-effective immune system.
43. B. The last area to return sensation is in the perineal area, and the nurse in charge should monitor the client for distended bladder.
44. D. Glucocorticoids play no significant role in disease treatment.
45. D. Tracheostomy tube has several potential complications including bleeding, infection and laryngeal nerve damage.
46. C. In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
47. A. Aging process involves increased capillary fragility and permeability. Older adults have a decreased amount of subcutaneous fat and cause an increased incidence of bruise like lesions caused by collection of extravascular blood in loosely structured dermis.
48. D. Intermittent pain is the classic sign of renal carcinoma. It is primarily due to capillary erosion by the cancerous growth.
49. B. Tubercle bacillus is a drug resistant organism and takes a long time to be eradicated. Usually a combination of three drugs is used for minimum of 6 months and at least six months beyond culture conversion.
50. A. Patent airway is the most priority; therefore removal of secretions is necessary.

Medical-Surgical Nursing Exam 1: Cardiovascular Nursing

Topics

• Cardiovascular diseases
• Diabetes
• Hepatitis

Questions

1. Mrs. Chua a 78 year old client is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear when listening to client’s lungs indicative of chronic heart failure would be:
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs
2. Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine:
a. Decrease anxiety and restlessness
b. Prevents shock and relieves pain
c. Dilates coronary blood vessels
d. Helps prevent fibrillation of the heart
3. Which of the following should the nurse teach the client about the signs of digitalis toxicity?
a. Increased appetite
b. Elevated blood pressure
c. Skin rash over the chest and back
d. Visual disturbances such as seeing yellow spots
4. Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. The reason for this is to help…
a. Retard rapid drug absorption
b. Excrete excessive fluids accumulated at night
c. Prevents sleep disturbances during night
d. Prevention of electrolyte imbalance
5. What would be the primary goal of therapy for a client with pulmonary edema and heart failure?
a. Enhance comfort
b. Increase cardiac output
c. Improve respiratory status
d. Peripheral edema decreased
6. Nurse Linda is caring for a client with head injury and monitoring the client with decerebrate posturing. Which of the following is a characteristic of this type of posturing?
a. Upper extremity flexion with lower extremity flexion
b. Upper extremity flexion with lower extremity extension
c. Extension of the extremities after a stimulus
d. Flexion of the extremities after stimulus
7. A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following maybe experienced as side effects of this medication:
a. GI bleeding
b. Peptic ulcer disease
c. Abdominal cramps
d. Partial bowel obstruction
8. Dr. Marquez orders a continuous intravenous nitroglycerin infusion for the client suffering from myocardial infarction. Which of the following is the most essential nursing action?
a. Monitoring urine output frequently
b. Monitoring blood pressure every 4 hours
c. Obtaining serum potassium levels daily
d. Obtaining infusion pump for the medication
9. During the second day of hospitalization of the client after a Myocardial Infarction. Which of the following is an expected outcome?
a. Able to perform self-care activities without pain
b. Severe chest pain
c. Can recognize the risk factors of Myocardial Infarction
d. Can Participate in cardiac rehabilitation walking program
10. A 68 year old client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to:
a. Application of elastic stockings to prevent flaccid by muscle
b. Use hand roll and extend the left upper extremity on a pillow to prevent contractions
c. Use a bed cradle to prevent dorsiflexion of feet
d. Do passive range of motion exercise
11. Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be…
a. Hourly urine output
b. Temperature
c. Able to turn side to side
d. Able to sips clear liquid
12. A 64 year old male client with a long history of cardiovascular problem including hypertension and angina is to be scheduled for cardiac catheterization. During pre cardiac catheterization teaching, Nurse Cherry should inform the client that the primary purpose of the procedure is…..
a. To determine the existence of CHD
b. To visualize the disease process in the coronary arteries
c. To obtain the heart chambers pressure
d. To measure oxygen content of different heart chambers
13. During the first several hours after a cardiac catheterization, it would be most essential for nurse Cherry to…
a. Elevate clients bed at 45°
b. Instruct the client to cough and deep breathe every 2 hours
c. Frequently monitor client’s apical pulse and blood pressure
d. Monitor clients temperature every hour
14. Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during postoperative period. Which of the following pharmaceutical agents should Nurse Aiza prepare to administer to Kate?
a. Protamine Sulfate
b. Quinidine Sulfate
c. Vitamin C
d. Coumadin
15. In reducing the risk of endocarditis, good dental care is an important measure. To promote good dental care in client with mitral stenosis in teaching plan should include proper use of…
a. Dental floss
b. Electric toothbrush
c. Manual toothbrush
d. Irrigation device
16. Among the following signs and symptoms, which would most likely be present in a client with mitral gurgitation?
a. Altered level of consciousness
b. Exceptional Dyspnea
c. Increase creatine phospholinase concentration
d. Chest pain
17. Kris with a history of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the…
a. Urinary meatus
b. Pain in the Labium
c. Suprapubic area
d. Right or left costovertebral angle
18. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, Nurse Perry assesses which signs as the best indicator of renal function.
a. Blood pressure
b. Consciousness
c. Distension of the bladder
d. Pulse rate
19. John suddenly experiences a seizure, and Nurse Gina notice that John exhibits uncontrollable jerking movements. Nurse Gina documents that John experienced which type of seizure?
a. Tonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Clonic seizure
20. Smoking cessation is critical strategy for the client with Burgher’s disease, Nurse Jasmin anticipates that the male client will go home with a prescription for which medication?
a. Paracetamol
b. Ibuprofen
c. Nitroglycerin
d. Nicotine (Nicotrol)
21. Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology of the disease is unknown but it is characterized by:
a. Episodic vasospastic disorder of capillaries
b. Episodic vasospastic disorder of small veins
c. Episodic vasospastic disorder of the aorta
d. Episodic vasospastic disorder of the small arteries
22. Nurse Jamie should explain to male client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because…
a. More accurate
b. Can be done by the client
c. It is easy to perform
d. It is not influenced by drugs
23. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs 205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost…
a. 0.3 L
b. 1.5 L
c. 2.0 L
d. 3.5 L
24. Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin occurs in the process of:
a. Osmosis
b. Diffusion
c. Active transport
d. Filtration
25. Myrna a 52 year old client with a fractured left tibia has a long leg cast and she is using crutches to ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with crutch walking?
a. Left leg discomfort
b. Weak biceps brachii
c. Triceps muscle spasm
d. Forearm weakness
26. Which of the following statements should the nurse teach the neutropenic client and his family to avoid?
a. Performing oral hygiene after every meal
b. Using suppositories or enemas
c. Performing perineal hygiene after each bowel movement
d. Using a filter mask
27. A female client is experiencing painful and rigid abdomen and is diagnosed with perforated peptic ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client before surgery in
a. Sims position
b. Supine position
c. Semi-fowlers position
d. Dorsal recumbent position
28. Which nursing intervention ensures adequate ventilating exchange after surgery?
a. Remove the airway only when client is fully conscious
b. Assess for hypoventilation by auscultating the lungs
c. Position client laterally with the neck extended
d. Maintain humidified oxygen via nasal canula
29. George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should…
a. “Strip” the chest tube catheter
b. Check the system for air leaks
c. Recognize the system is functioning correctly
d. Decrease the amount of suction pressure
30. A client who has been diagnosed of hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that…
a. I can eat celery sticks and carrots
b. I can eat broiled scallops
c. I can eat shredded wheat cereal
d. I can eat spaghetti on rye bread
31. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The nurse should be aware that the ascites is most likely the result of increased…
a. Pressure in the portal vein
b. Production of serum albumin
c. Secretion of bile salts
d. Interstitial osmotic pressure
32. A newly admitted client is diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?
a. Vital signs
b. Incision site
c. Airway
d. Level of consciousness
33. A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic shock?
a. Systolic blood pressure less than 90mm Hg
b. Pupils unequally dilated
c. Respiratory rate of 4 breath/min
d. Pulse rate less than 60bpm
34. Nurse Lucy is planning to give pre operative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?
a. Results of the surgery will be immediately noticeable postoperatively
b. Normal saline nose drops will need to be administered preoperatively
c. After surgery, nasal packing will be in place 8 to 10 days
d. Aspirin containing medications should not be taken 14 days before surgery
35. Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The nurse prepares which of the following medications as an initial treatment for this problem?
a. Regular insulin
b. Potassium
c. Sodium bicarbonate
d. Calcium gluconate
36. Dr. Marquez tells a client that an increase intake of foods that are rich in Vitamin E and beta-carotene are important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:
a. Fish and fruit jam
b. Oranges and grapefruit
c. Carrots and potatoes
d. Spinach and mangoes
37. A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every meals, the client should…
a. Rest in sitting position
b. Take a short walk
c. Drink plenty of water
d. Lie down at least 30 minutes
38. After gastroscopy, an adaptation that indicates major complication would be:
a. Nausea and vomiting
b. Abdominal distention
c. Increased GI motility
d. Difficulty in swallowing
39. A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood when the client tells a family member that:
a. “Most people need to eat a high protein diet for 12 months after surgery”
b. “I should not eat those foods that upset me before the surgery”
c. “I should avoid fatty foods as long as I live”
d. “Most people can tolerate regular diet after this type of surgery”
40. Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs and symptoms related to Hepatitis that may develop. The one that should be reported immediately to the physician is:
a. Restlessness
b. Yellow urine
c. Nausea
d. Clay- colored stools
41. Which of the following antituberculosis drugs can damage the 8th cranial nerve?
a. Isoniazid (INH)
b. Paraoaminosalicylic acid (PAS)
c. Ethambutol hydrochloride (myambutol)
d. Streptomycin
42. The client asks Nurse Annie the causes of peptic ulcer. Nurse Annie responds that recent research indicates that peptic ulcers are the result of which of the following:
a. Genetic defect in gastric mucosa
b. Stress
c. Diet high in fat
d. Helicobacter pylori infection
43. Ryan has undergone subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
a. Bile green
b. Bright red
c. Cloudy white
d. Dark brown
44. Nurse Joan is assigned to come for client who has just undergone eye surgery. Nurse Joan plans to teach the client activities that are permitted during the post operative period. Which of the following is best recommended for the client?
a. Watching circus
b. Bending over
c. Watching TV
d. Lifting objects
45. A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a prominent deformity to the lower aspect of the leg, and the injured leg appears shorter that the other leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that the client is experiencing:
a. Fracture
b. Strain
c. Sprain
d. Contusion
46. Nurse Jenny is instilling an otic solution into an adult male client left ear. Nurse Jenny avoids doing which of the following as part of the procedure
a. Pulling the auricle backward and upward
b. Warming the solution to room temperature
c. Pacing the tip of the dropper on the edge of ear canal
d. Placing client in side lying position
47. Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptom?
a. Absence of drainage from the ileostomy for 6 or more hours
b. Passage of liquid stool in the stoma
c. Occasional presence of undigested food
d. A temperature of 37.6 °C
48. Jerry has diagnosed with appendicitis. He develops a fever, hypotension and tachycardia. The nurse suspects which of the following complications?
a. Intestinal obstruction
b. Peritonitis
c. Bowel ischemia
d. Deficient fluid volume
49. Which of the following compilations should the nurse carefully monitors a client with acute pancreatitis.
a. Myocardial Infarction
b. Cirrhosis
c. Peptic ulcer
d. Pneumonia
50. Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the client to inhibit?
a. Watery stool
b. Yellow sclera
c. Tarry stool
d. Shortness of breath

Answers & Rationale

Here are the answers and rationale for this exam. Counter check your answers to those below and tell us your scores. If you have any disputes or need more clarification to a certain question, please direct them to the comments section.

1. B. Left sided heart failure causes fluid accumulation in the capillary network of the lung. Fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.
2. B. Morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.
3. D. Seeing yellow spots and colored vision are common symptoms of digitalis toxicity
4. C. When diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.
5. B. The primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention.
6. C. Decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury.
7. C. The most frequent side effects of Cascara Sagrada (Laxative) is abdominal cramps and nausea.
8. D. Administration of Intravenous Nitroglycerin infusion requires pump for accurate control of medication.
9. A. By the 2^nd day of hospitalization after suffering a Myocardial Infarction, Clients are able to perform care without chest pain
10. B. The left side of the body will be affected in a right-sided brain attack.
11. A. After nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early.
12. B. The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries.
13. C. Blood pressure is monitored to detect hypotension which may indicate shock or hemorrhage. Apical pulse is taken to detect dysrhythmias related to cardiac irritability.
14. A. Protamine Sulfate is used to prevent continuous bleeding in client who has undergone open heart surgery.
15. C. The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.
16. B. Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation.
17. D. Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side.
18. A. Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of cardiac output.
19. C. Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple muscle group.
20. D. Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome.
21. D. Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.
22. A. Urine testing provides an indirect measure that maybe influenced by kidney function while blood glucose testing is a more direct and accurate measure.
23. C. One liter of fluid approximately weighs 2.2 pounds. A 4.5 pound weight loss equals to approximately 2L.
24. A. Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.
25. D. Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the axillae.
26. B. Neutropenic client is at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract.
27. C. Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.
28. C. Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of secretions and oxygen and carbon dioxide exchange can occur.
29. B. Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion.
30. C. Wheat cereal has a low sodium content.
31. A. Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting to ascites.
32. C. Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange.
33. A. Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
34. D. Aspirin containing medications should not be taken 14 days before surgery to decrease the risk of bleeding.
35. A. Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating glucose. Administration of insulin corrects this problem.
36. D. Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the following foods: wheat germ, corn, nuts, seeds, olives,spinach, asparagus and other green leafy vegetables. Food sources of beta-carotene include dark green vegetables, carrots, mangoes and tomatoes.
37. A. Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus.
38. B. Abdominal distension may be associated with pain, may indicate perforation, a complication that could lead to peritonitis.
39. D. It may take 4 to 6 months to eat anything, but most people can eat anything they want.
40. D. Clay colored stools are indicative of hepatic obstruction
41. D. Streptomycin is an aminoglycoside and damage on the 8^th cranial nerve (ototoxicity) is a common side effect of aminoglycosides.
42. D. Most peptic ulcer is caused by Helicopter pylori which is a gram negative bacterium.
43. D. 12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested food.
44. C. Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does not increase intraocular pressure.
45. A. Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus and swelling.
46. C. The dropper should not touch any object or any part of the client’s ear.
47. A. Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the physician because it could mean that obstruction has been developed.
48. B. Complications of acute appendicitis are peritonitis, perforation and abscess development.
49. D. A client with acute pancreatitis is prone to complications associated with respiratory system.
50. B. Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and sclera yellow and the urine dark and frothy.