NURSING PRACTICE IV

Prepared by: RN Mac Dolf Aquino

Situation: Oncology Nurse Martha intends to participate in a health screening clinic and is preparing teaching materials about
colorectal cancer.

1. The nurse should plan to include which of the following in a list of risk factors for colorectal cancer?
A. age older than 30 years C. distant relative with colorectal cancer
B. high fiber, low fat diet D. personal history of GI polyps

2. When teaching a client about the signs of colorectal cancer, Nurse Martha stresses that the most common complaint of
persons with colorectal cancer is:
A. Abdominal pain C. Change in bowel habits
B. Rectal bleeding D. Change in caliber of stool

3. A client is admitted with a diagnosis of cancer of the colon. Nurse Martha knows that malignant tumors of the colon:
A. are easily detected C. occur more frequently in women than in men
B. are usually localized D. account for the majority of intestinal obstructions

4. A temporary colostomy is performed on the client with colon cancer. Nurse Martha is aware that the proximal end of a
double barrel colostomy is the opening on the:
A. client’s left side. C. client’s right side
B. distal end on the client’s left side. D. distal right side.

5.When caring for a client who has had a colon resection and colostomy, which nursing activity is most appropriate for Nurse
Martha to delegate to a Novice nurse?
A. Document the appearance of stool in the colostomy pouch.
B. Remind the client to cough and deep-breathe frequently.
C. Monitor the appearance of the colostomy stoma.
D. Teach the client how to perform leg exercises.

6. The nurse should explain to the client that primary purpose of these irrigations is to:
A. Prevent straining at passage of stool
B. Establish a regular elimination schedule
C. Decrease the amount of flatus in the bowel
D. Limit the amount of fluid lost from the intestine

7. A client having presurgical testing prior to a possible colon resection and colostomy says to the nurse, "If I have to have this
surgery, I know my husband will never come near me."The nurse's best initial response would be, "You're:
A. probably underestimating his love for you"
B. concerned that your husband will reject you"
C. wondering about the effect on your sexual relations"
D. worried that the surgery will change how others see you"

8. On the second day following an abdominoperineal resection, the nurse anticipates that the colostomy stoma will appear:
A. Dry, pale pink, and flush with the skin
B. Moist, red, and raised above the skin surface
C. Dry, purple, and depressed below the skin surface
D. Moist, pink, flush with the skin, and painful when touched

9. A client is taught how to change the dressing and how to care for a recent colostomy. On the day of discharge the client
states, "I hope I can handle all this at home; it's a lot to remember."The best response by the nurse would be:
A. "I'm sure you can do it!"
B. "Oh, a family member can do it for you"
C."You seem to be nervous about going home"
D."Perhaps you can stay in the hospital another day"
10. When teaching colostomy care, it is especially important for the nurse to teach the client to care for the skin around the
stoma by:
A. Avoiding the use of soap or irritating agents
B. Pouring saline over the stoma and rubbing to remove hardened feces
C. Rinsing the area with hydrogen peroxide and applying fresh gauze bandages
D. Washing the area gently with soap and water and applying a protective ointment

11. A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client’s
diagnosis?
A. Smoking a pack of cigarettes a day for 30 years
B. Use of nonsteroidal anti-inflammatory drugs
C. Eating foods with preservatives
D. Past employment involving asbestos

12. A client with bladder cancer is being treated with Iridium seed implants. Nurse Lilian’s discharge teaching should include
telling the client to:
A. Strain his urine C. Report urinary frequency
B. Increase his fluid intake D. Avoid prolonged sitting

13. Nurse Lilian is caring for a patient who has been diagnosed with stage III cancer of the bladder. The patient is scheduled for
a cystectomy with ureterostomy. Which of the following statements about the patient’s follow-up care is correct?
A The patient will need to self-catheterize at regular intervals.
B. The patient will have an abdominal stoma for urinary drainage.
C. The patient will have a nephrostomy tube placed to drain urine
D. The patient will have a number of options available for long term treatment.

14. Nurse Lilian knows that the most common symptom in patients with cancer of the bladder is which of the following?
A. Diuresis B. Oliguria C. Pain D. Hematuria

15. A client with bladder cancer receives local radiation therapy and experiences a dry skin reaction. When teaching the client
about skin care, Nurse Lilian should instruct the client to avoid:
A. lubrication. B. cleansers C. cold packs D. cotton garments.

Situation: Community Health Nurse Joaquin is conducting a home visit and a family health survey in Pasay City. One of the
members of the family, an employee of a government agency, complains of headache almost every day for 2 months and
seems sleepy even at daytime.

16. A client is suspected of having a brain tumor after consultation as advised by Nurse Joaquin. He is scheduled for a CT scan.
Before the test, Nurse Joaquin should:
A. Withhold routine medication C. Administer that prescribed sedative
B. Describe the equipment involved D. Explain that no radiation will be involved

17. Which of the following factors, if present in the patient’s history would affect the manner in which Nurse Joaquin prepares
the patient for the scan?
A. The patient takes anticonvulsant medication.
B. The patient has difficulty recalling recent events.
C. The patient develops hives when eating shrimp.
D. The patient has paresthesias in the hands.

18. A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. The Nurse in a tertiary
hospital anticipates that the Physician will prescribe which of the following before the procedure?
A. An antihistamine C. A sedative
B. A corticosteroid D. An antibiotic

19 A Nurse’s Supervisor assigns Novice nurses to present a clinical conference to staff nurses in the ward about brain tumors
in children. The novice nurses prepare for the conference and include which of the following information in the presentation?
 A. Surgery is not normally performed because of the risk of functional deficits occurring as a result of the surgery
B. Head shaving is not required before removal of the brain tumor.
C. Chemotherapy is the treatment of choice
D. The most significant symptoms are headaches and vomiting

20. The nurse is caring for a client with an Acoustic Neuroma brain tumor. The location of this tumor warrants which of the
following nursing diagnosis as the highest priority?
A. High risk for constipation
B. Fluid volume deficit
C. Ineffective coping
D. High risk for injury

Situation:The nurse is preparing to send a client to the radiation department for his scheduled radiation therapy.

21. What action will the nurse take to determine the correct identification of the client?
A. Ask the client his name and check his armband to verify that the information correlates
B Check the armbands against the identification record on the client`s chart for the correct name and hospital
number
C. Ask the client his name and the name of his doctor and compare his response with identification records on the
client`s chart
D. Check the client`s chart for the doctor`s order and to determine whether he is to receive any medications before
the treatment

22. The nurse is evaluating a client`s reaction to external radiation. What is the common observation 3 weeks after therapy
begins?
A. A sudden weight loss C. Vertigo when sitting up quickly
B. Abnormal skin pigmentation D. Urinary retention and infection

23. What is a common side effect of radiation therapy that is not associated with the effect of radiation in the treatment field?
A. Reddened skin C. Fatigue
B. Bone marrow suppression D. Stomatitis

24. Combined therapy of radiation and chemotherapy can have a serious impact on the survival of an individual with cancer.
The nursing priority for these clients includes measures to:
A. monitor for acute renal tubular necrosis. C. prevent infection
B. control nausea and vomiting. D. maintain hydration and nutrition.

25. A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn."The best
response by the nurse would be:
A. "It will be no worse than a sunburn"
B. "A localized skin reaction usually occurs"
C. "Have they had experience with this type of radiation?"
D. "Daily application of an emollient will prevent the burn"

Situation: Fluids and electrolytes balance is a dynamic process that is crucial to life. Nurses need to recognize the physiology of
fluids to anticipate and respond to possible imbalances. Nurse Roy is a medical ward nurse reviewing the chart of newly
admitted clients.

26. To better understand fluid balance, Nurse Roy needs to recognize that:
A. Glomerular filtration occurs in the glomeruli, which are small arteries in the kidneys
B. A decrease in blood protein concentration tends to increase the glomerular filtration rate
C. The volume of urine secreted is regulated mainly by mechanisms that control the glomerular filtration rate
D. An increase in the hydrostatic pressure in Bowman's capsule tends to increase the glomerular filtration rate
27. An adult client with renal insufficiency has been placed on a fluid restriction of 1200 mL per day. Nurse Roy discusses the
fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 AM to 3:00
PM?
A 400 B. 600 C. 800 D. 1000

28. When caring for a patient in renal failure, Nurse Roy would expect elevated levels of which of the following electrolytes?
A. potassium, phosphate, magnesium
B. calcium, potassium, phosphate
C. bicarbonate, calcium, magnesium
D. chloride, sodium, phosphate

29. Nurse Roy expects which of the following laboratory results from a patient with renal failure?
A. K+ 5.8 mEq/L; Mg++ 3.2 mg/dl; Ca ++ 7.9 mg/dl
B. K+ 5.8 mEq/L; Mg++ 2.0 mg/dl; Ca ++ 9.0 mg/dl
C K+ 4.2 mEq/L; Mg++ 2.2 mg/dl; Ca ++ 9.2 mg/dl
D K+ 4.6 mEq/L; Mg++ 2.0 mg/dl; Ca ++ 11 mg/dl

30. Nurse Roy is preparing the prescribed order of intravenous fluids for the client with renal problems. He is to receive a 1000 ml
of D5NSS infusing at 10 micro drips per minute. What is the parenteral intake for 8 hours?
A. 80 ml in 8 hours B. 80 ml in 6 hours C. 50 ml in 8 hours D. 50 ml in 6 hours
31. Nurse Paolo recalls that the intravenous drip factor is the:
A. Actual rate at which the IV should flow
B. Amount per hour that a patient receives
C. Number of drops per milliliter
D. Milliliters per minute that a patient receives

32. The reason an intravenous bolus is the most dangerous route of medication administration is because:
A. Larger amounts of the drug are given by this route than by any of the other routes.
B. The drug remains in the body for a longer period.
C. Results are unpredictable.
D. A concentrated amount of drug is injected into the circulatory system in a short time.

33. Nurse Paolo is collaborating with the Novice nurses that the primary reason why many IV additives are given in large
amounts of solution is because:
A. The drugs dissolve better in large amounts of fluid.
B. The drugs are very potent and are safer when diluted.
C. The patient is often dehydrated and needs the additional fluid.
D. Additives in solution are more convenient for the health care provider.

34. The reason serum potassium must be monitored by Nurse Paolo when a patient is receiving IV potassium is because:
A. Hyperkalemia is untreatable.
B. There is a fine line between too little potassium and too much potassium.
C. Excess potassium can cause life-threatening dysrhythmia.
D. If hypokalemic, the patient must be treated with insulin.

35. The Physician has prescribed a continuous infusion of sodium bicarbonate in lactated Ringer’s solution. You know that this
solution is incompatible with sodium bicarbonate. Your best action is to:
A. Call the pharmacy and ask for a recommendation of a substitute solution.
B. Start the drug in 5% dextrose solution and inform the physician when making rounds.
C. Start the drug in normal saline and allow it to drip slowly while you try to reach the physician.
D. Notify the physician.

36. The patient is considered to have severe hypertension when the :

A. diastolic blood pressure is less than 90 mm Hg and there are no end-organ effects
B. systolic blood pressure is 140 to 159 mm Hg and there are no end-organ effects
C. diastolic blood pressure is greater than 110 mm Hg with end-organ effects
 D. systolic blood pressure is 140 to 159 with end-organ

37. Which of the following statements is true for the patients with chronic mild-to-moderate hypertension?
A. Acute elevations in diastolic blood pressure will decrease cardiac afterload and myocardial workload
B. Aggressive management of the patient’s blood pressure may impair his cerebral blood flow
C.The kidneys are subject to arterioral vasolidation, which will decrease renal function
D.Excessive elevation of the patient’s blood pressure produces cerebral hyperperfusion

38. The emergency Physician orders Labetalol 20 mg IV push for the patient. A possible side effect of this drug is:
A. Orthostatic hypotension
B. Tachycardia
C. Excessive salivation
D. Headache

39. The Labetalol has not effectively lowered the patient’s blood pressure. His chest pain continues, but a 12-lead ECG shows no
acute changes with evidence to left ventricular hypertrophy. A nitropusside drip is initiated at 0.2mcg/kg/min. The most
accurate blood pressure readings would be obtained by:
A. Placing a noninvasive blood pressure cuff on the patient’s left arm
B. Placing a noninvasive blood pressure cuff on the patient’s right arm
C.Placing an arterial line for continuous blood pressure monitoring
D Connecting the patient to a continuous 12-lead ECG monitor

Situation : Mr. Diaz, arrives by squad in the emergency department, complaining of intense lower back and lower abdominal pain
for one hour. Nausea or vomiting not noted. His wife states he fainted while sitting on the commode at home. The patient is
positive for mild hypertension. The patient is rapidly being evaluated for a dissecting abdominal aortic aneurysm. B/P
100/52, P 120, R 30, Temp 964 oF.

41. In the diagnosis of a dissecting abdominal aortic aneurysm, which emergency diagnostic test would be of
most value?
A. Diagnostic peritoneal lavage C. Abdominal ultrasonography
B. CT scan of abdomen D. MRI

42. The most applicable nursing diagnosis for this patient would be:
A. Tissue perfusion, altered C. Airway clearance, ineffective
B. Infection, potential for D. Injury, potential for

43. The pain associated with a dissecting abdominal aortic aneurysm is described frequently as:
A. Stabbing B. Dull ache C. Sharp, tearing D. Crushing. 56

44. Mr. Diaz wants to see his wife, who is out in the waiting room. The best response would be to say:
A. “You are too sick to have any visitors.” C. “Ask the doctor if you can have visitors.”
B. “You can see her after you have surgery.” D. “I’ll bring her now.”

45. Which of the following statements is true about the care of the patient with a ruptured abdominal aortic
aneurysm?
A. A ruptured abdominal aortic aneurysm should be the primary diagnosis in the patients less than 50
years of age with abdominal or back pain
B. Only large aneurysms will rupture and cause symptoms that would bring the patient to the emergency department.
C. The patient with a ruptured abdominal aortic aneurysm who arrives in the emergency department
hemodynamically stable generally will remain stable.
D. The patient with a ruptured abdominal aortic aneurysm should remain in the emergency department until a definitive
diagnosis is made

Situation:Abby, a community health nurse is preparing public health information about exposure to Hepatitis.

46. Nurse Abby knows that which of the following groups should be vaccinated against both Hepatitis A and Hepatitis B virus?
 A. residents of elderly housing C. library workers
B. day care workers D. computer programmers

47. Nurse Abby who received an accidental needle stick injury while drawing blood from a patient with hepatitis B. Nurse Abby
should receive what type of post exposure care?
A. Two doses of immune globulin- within 1 week of exposure and at 1 month
B. Two doses of immune globulin- within 2 weeks of exposure and at 3 months
C. Hepatitis B vaccine booster shot with a dose of immune globulin
D. Hepatitis B vaccine booster shot with two doses immune globulin

48. Nurse Abby is caring for a patient with Hepatitis A. She understands that this patient most likely acquired the disease from
which of the following sources?
A. Donating blood within the past three months
B. Having hemodialysis treatments for renal failure
C. Eating food contaminated by an infected individual
D. Sharing needles for intravenous drug use

49. Nurse Abby is providing dietary teaching for a patient with Hepatitis. The nurse realizes that the material has been
understood when the patient makes which of the following statements?
A. “I will eat more whole grains, egg whites, and fat-free yogurt.”
B. “I will increase my intake of sausage, butter, and whole milk.”
C. “I will still be able to have a few beers each day.”
D. “I will try to reduce my alcohol intake to 2 liters per day.”

50. Nurse Abby is also providing care for a patient who is admitted in the prodromal phase of Hepatitis. Upon assessment,
Nurse Abby expects to find which of the following symptoms?
A. fever, petechiae, easy bruising
B. flu-like symptoms, malaise, fatigue
C. ascites, jaundice, hemangiomas
D. splenomegaly, hypoalbuminemia, GI bleeding

Situation: Nurse Bea is providing care for a patient who has hepatic encephalopathy with orders for lactulose to be
administered via a nasogastric tube.

51. Within 24 hours of the start of therapy, the patient develops diarrhea. The best response by Nurse Bea is to:
A. withhold further doses of lactulose and notify the physician
B. discontinue the lactulose because diarrhea is a severe side effect
C. continue to administer lactulose as ordered for this is the desired effect.
D. hold the current dose and obtain further orders from the physician

52. Nurse Bea is providing treatment for a patient with hepatic encephalopathy. Which of the following clinical manifestations
indicates that the patient’s condition is deteriorating?
A. frequent liquid diarrhea
B. decreased serum ammonia levels
C. increased serum potassium levels
D. asterixis

53. Nurse Bea is assisting the client with hepatic encephalopathy to fill out the dietary menu. Nurse Bea advises the client to
avoid which of the following entrée items that could aggravate the client’s condition?
A. Fresh fruit plate
B. Tomato soup
C. Vegetable lasagna
D. Ground beef patty

54. The medical treatment of hepatic encephalopathy is directed toward:

A. raising hemoglobin
 B. reducing ammonia formation
C. decreasing urea
D. increasing prothrombin time

55. Which information obtained when assessing a client with acute hepatitis is most important to report to the Physician?
A. The client is difficult to arouse.
B. The client’s stools are pale in color.
C. The client has abdominal tenderness.
D. The client complains of feeling depressed.

Situation: Nurse Myrna assigned in an infectious ward is reviewing the laboratory reports of a client who is HIV positive.

56. Which laboratory report provides information regarding the effectiveness of the client’s medication regimen?
A. ELISA B. Western Blot C. Viral load D. CD4 count

57. The client at risk for developing AIDS should be advised to:
A. Abstain from anal intercourse.
B. Have an ELISA test for antibodies.
C. Have a semen analysis done.
D. Inform all sexual contacts.

58. Which of the following is the best indicator of diagnosis of HIV?

A. White blood cell count C. Western Blot
B. ELISA D. Complete blood count

59. Which laboratory data about a client who is HIV-positive will be of most concern to Nurse Myrna ?
A. CD4+ cell count 180/mm3 C. White blood cells (WBCs) 3600/mm3
B. Positive Western blot test D. Positive enzyme immunoassay test

60. Nurse Myrna is caring for another pregnant client with a history of human immunodeficiency virus (HIV). Which nursing
diagnosis formulated by the nurse has the highest priority for this client?
A. Self-Care Deficit C. Imbalanced Nutrition
B. Risk for Infection D. Activity Intolerance

Situation: Nurse Kaye has undergone training and exposure from Jose Reyes Hospital, a well known infectious facility. She is
assigned in a special unit to attend to the special needs of clients with infectious diseases.

61. Miss Dina arrives at the out- patient department after being bitten by a stray dog in an area where rabies is endemic. Nurse
Kaye recalls that rabies is:
A. An acute bacterial infection characterized by encephalopathy and opisthotonos
B. An acute bacterial septicemia that results in convulsions and a morbid fear of water
C. A nonspecific immunoresponse to organisms deposited under the skin by an animal bite
D. An acute viral infection, characterized by convulsions and difficulty swallowing, that affects the nervous system

62. The bite involved injury. Miss Dina says the dog was foaming at the mouth and afterward ran way. The first nursing action is
to:
A. Ask the client about horse serum allergy C. Assess the client's injury, vital signs, and past history
B. Notify the police department to capture the dog D. Inoculate the client with human rabies immune globulin

63. Nurse Kaye performs a focused assessment, to a newly admitted child brought by the mother, cleanses the wound on the
forearm as prescribed, and continues to perform a thorough assessment on the child. Which of the following is the priority
question for the nurse to ask the mother of the child?
A. “How old is the dog?” C. “Are the child’s immunizations up-to-date?”
B. “Did the dog have rabies?” D. “Did the dog have all of its recommended shots?”
64. A mother calls the Pediatrician’s office because there’s an outbreak of scabies the child’s day-care center. Nurse Kaye should
instruct the mother to check her child for which findings associated with scabies infestation?
A. Pruritic papules, pustules, and linear burrows of the fingers and toe webs
B. Oval white dots adhered to the hair shafts
C. Diffuse pruritic wheals
D. Pain, erythema, and edema at the site of the bite

65. Miss Tessie is an elementary school nurse in a poor rural town. A mother brings an 8-year-old girl to her because she has a
rash. Miss Tessie examines her and noticed areas of widespread pimples and thin, pencil-mark lines on her head, neck,
shoulders, and palms along with abrasions on her skin from scratching and digging. The girl states that she has to sleep on
the couch now because she was keeping her two sisters (who she normally sleeps with) awake with her itching at night.
She says her mom put on a “lotion” on the rash, but it isn’t improving. She says her sisters are itching now also, but she’s
the worst. She further reports that she has three cats and two dogs and all of them are itching as well. What would Miss
Tessie suspect in this case?
A. Contact dermatitis B. Fleas C. Scabies D. Rubella

Situation: Nurses prepare different forms of topical medications depending on the prescription of the Physician. Mrs.
Tomberlin is using an over-the-counter corticosteroid cream to decrease the itching associated with an outbreak of
poison ivy on several areas of her body.

66. She calls to ask you if she may cover the medicated areas with waterproof bandages so they won’t look so bad. You should
advise her:
A. That if she covers the areas with any type of dressing, they will become further inflamed
B. That absorption of the drug may increase significantly if she covers the area with a waterproof dressing, and systemic
effects may result
C. That she may use any type of dressing she wishes because absorption of corticosteroid is not affected by the type of
dressing used
D. That the plastic used in the manufacture of waterproof bandages interacts with corticosteroids to produce systemic
reactions

67. You are wearing sterile gloves and applying an emollient cream to your patient’s back. To warm the cream, you should:
A. Put it in the microwave for 15 seconds. C. Run hot water over the cream.
B. Palpate the tube vigorously. D. Rub your gloved hands together.

68. The health care practitioner prescribes Mycitracin Plus ointment, containing bacitracin, neomycin, polymyxin B, and
lidocaine for a patient with an infected ingrown toenail. You know you have taken the proper precautions and instructed your
patient to use the medication correctly if he or she states:
A. “I am not allergic to any of the drugs listed on the label.”
B. “I will not use a bandage over this medicine.”
C. “I don’t need to wash the old ointment off before applying the new ointment.”
D. “This ointment won’t leave a residue on anything.”

69. When administering a debriding enzyme preparation, you should avoid applying the cream to:
A. The center of a necrotic lesion C. The darker tissue at the edge of a lesion
B. The bright pink tissue at the edge of the lesion D. The blanched tissue with exudate

70. You have been asked to administer a thin layer of Travase cream (a débriding enzyme preparation) followed by application
of a wet to dry dressing to a decubitus ulcer on your patient’s right heel. You should apply the cream:
A. Before your patient’s whirlpool treatment C. Liberally, with a 4 x 4 gauze pad
B. In a patting motion D. Using sterile gloves or a tongue blade

Situation: A client with chronic renal failure is accepted for a kidney transplant and attends a group educational program
for potential transplant candidates.

71. The client asks the nurse which kidney will be removed. The nurse's best response would be:
A. "Neither of your kidneys will be removed unless they are infected"
 B. "It is up to the surgeon as to which kidney is replaced with the new one"
C. "The kidney that is the most diseased is removed and replaced with the new one"
D. "Your right kidney will be removed because it has a longer renal vein making transplant easier"

72. The most important test used to determine whether a client's newly transplanted kidney is working is a:
A. A. Renal scan B. Serum creatinine C. 24-hour urine output D. White blood cell count

73. When a client returns from the recovery room after a kidney transplant, the nurse should plan to measure the client's urinary
output every:
A. 15 minutes B. 30 minutes C. 60 minutes D. 2 hours

74. A client who has had a kidney transplant develops leucopenia 3 weeks after surgery. The nurse should be aware that the
leucopenia is probably caused by:
A. A bacterial infection C. Rejection of the kidney
B. High creatinine levels D. The antirejection medications

75. A community health nurse is making follow- up visits to a client following renal transplant. The nurse assesses the client for
which signs of acute graft rejection?
A. Hypotension, graft tenderness, and anemia
B. Hypertension, oliguria, thirst, and hypothermia
C. Fever, vomiting, hypotension, and copious amounts of diluted urine
D. Fever, hypertension graft tenderness, and malaise

SITUATION: Three patients come to the triage nurse at one time. The first patient is a 48-year-old man complaining of left-sided
chest pain radiating down to his left arm. He is awake, diaphoretic, and pale. The second patient is a 3-year-old boy who is
drooling and pale and can breathe only while sitting straight up in his mother’s lap. The third patient has sustained a
laceration on his right hand. He currently has a dressing in place, and bright red blood is noted on the dressing. His vital
signs are B/P 100/70 and P 100.

76. Which patient should be taken into the emergency department first?
A. The patient with the chest pain. C. The patient with the laceration.
B. The child who is drooling. D. Any patient who is bleeding.

77. The nurse is reviewing the laboratory data that have just been obtained for a client who was admitted with chest pain. Which of
the following will be of most concern?
A. WBCs are elevated. C. Troponin-I is high
B. HDL-C level is low. D. CRP is increased.

78. The triage nurse suspects that the child may have an illness that can cause airway obstruction. What care
should be provided in the triage area?
A. Immediately remove the child from his mother and take him back to the treatment area to prevent an airway emergency.
B. Take an oral temperature to determine if he has a fever and may require a dose of acetaminophen in the triage area.
C. Leave the child in his most comfortable position and take him as quickly as possible back to the patient care area.
D. Immediately start an intraosseous infusion to administer methylprednisolone and a normal saline bolus.

79. The triage nurse should base the initial care of this child on which of the following nursing diagnoses?
A. Self-care deficit, feeding, related to the patient not being able to swallow any liquids
for several days.
B. Infection, high risk for related to his exposure to the influenza virus and possible of having epiglottitis.
C. Airway clearance ineffective, related to the patient’s inability to keep his airway clear.
D.Family processes, Altered, related to the patient’s inability to interact with his mother because he is ill.

80. Focused triage documentation for a patient with potential airway problems (as in this case) should
include documentation of:
A. Insurance coverage and family physician. C.Chest and lateral neck radiography results.
 B. The intravenous site and catheter size used. D.The patient’s respiratory rate and effort.

Situation: The patient is admitted to a nursing unit with acute Osteomyelitis. Nurse Olive is attending to the clients admitted with
complaints of pain on their joints.

81. Which of the following symptoms would the Nurse Olive expect to find upon physical examination?
A. nausea and vomiting C. paresthesia of the extremity
B. erythema and fever D. generalized bone pain

82. Nurse Olive is caring for a patient at risk of developing osteomyelitis. Which of the following symptoms would indicate
presence of the condition?
A. increased urine output C. pain unrelieved by analgesics
B. elevated serum Ca++ D. temperature of 100.4oF

83. A client with osteomyelitis of the leg is to have a debridement of the infected bone. When planning for postoperative care,
Nurse Olive knows that:
A. frequent range-of-motion exercises will be needed C. the client's leg will be immobilized in a cast or splint
B. septicemia is a common postoperative complication D. the client will be allowed out of bed after the first day

84. Nurse Olive is providing care for a patient with Osteomyelitis. In preparing to teach the patient about medications, the nurse
should plan to focus on which medication categories?
A. diuretics and calcium channel blockers C. anesthetics and glucocorticoids
B. antibiotics and analgesics D. antihelmintics and stool softeners

85. Nurse Olive prepares the medications prescribed by Physician for the treatment of Osteomyelitis. Antibiotic Ancef 225mgs
would be given IM every 6 hours. The available vial bought by the family is in 500 mgs with an instruction of the amount of
diluents in 2 ml.
A. 2 ml B. 1.5 ml C. 1 ml D.0.5 ml

Situation: The nurse is caring for Mrs. Leonor, 63 years old admitted with a right hip fracture.

86. Based on the diagnosis, the nurse realizes that the priority nursing diagnosis for this patient is:
A. Risk for peripheral neurovascular dysfunction C. Decreased cardiac output
B. Risk for fluid volume deficit D. Anxiety

87. The nurse should anticipate which of the following findings upon assessment of the patient?
A. The injured leg is externally rotated and shorter C. Pedal pulses are absent and the skin is ruddy
B. The injured leg is internally rotated and shorter D. Pedal pulses are intact and the skin is pale

88. The nurse is providing information about activity limitations upon discharge to a patient following repair of a hip fracture.
Which of the following statements by the patient indicates the need for further teaching?
A. “I can go up the stairs as soon as I feel ready.” C. “I will need to use a raised toilet seat.”
B. “I should not sit on very low chairs.” D. “I will not be able to bend more than 90 degrees.”

89. Another 48 year old client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery,
the nurse should give priority to assessing the:
A. Serum collection (Davol) drain C. Nutrition status
B. Client’s pain D. Immobilizer

90. The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
A. Pain B. Disalignment C. Cool extremity D. Absence of pedal pulses

Situation: Mr. Guanco, 56 years old seeks admission due to bus accident that greatly affected his knee. After a comprehensive
assessment he was advised by the Physician to have a below-the knee amputation (BKA).

91. A major advantage of an immediate postoperative prosthesis is that it:

 A. decreases phantom limb sensations C. reduces the incidence of would infection
B. encourages a normal walking pattern D. allows for the fitting of the prosthesis before discharge

92. After an amputation, the client's residual limb is snugly bandaged throughout the postoperative period. The main purpose for
this is to:
A. A. Promote shrinkage C. Prevent suture line infection
B. Prevent injury to the area D. Promote drainage of secretions

93. The major improvement in the body image of clients following early fitting with prostheses after amputation is usually related
to:
A. Their improvement functional abilities C. The acceptance they receive from others
B. The feeling that they look more "whole" D. The fact that something is being done to help

94. When assessing a client using a prosthesis following an above-the-knee amputation, the finding that indicates that the
prosthesis fits correctly is:
A. Shrinking of the stump C. Darkened skin areas on the stump
B. Absence of phantom limb pain D. Uneven wearing down of the heels

95. The nurse is providing teaching to a patient who has had an amputation of the left lower leg. Which of the following
statements by the patient indicates understanding of proper care for the incision and left upper leg?
A. “I can use powder inside my limb sock to keep it cool.”
B. “I need to lie on my abdomen for 30 minutes several times per day.”
C. “I will have some foul-smelling drainage because I had gangrene.”
D. “I can elevate my stump on 2 or 3 pillows to help decrease edema.”

Situation: The nurse is aware that autonomic dysreflexia is a complication associated with some spinal cord injuries.

96. The nurse plans to observe for signs of this problem in a client who sustained a spinal cord injury at the T2 level because:
A. The injury has resulted in loss of all reflexes C. There has been a partial transaction of the cord
B. The injury is above the sixth thoracic vertebra D. There is a flaccid paralysis of the lower extremities

97. The nurse is aware that a client with a spinal cord injury is developing autonomic dysreflexia when the client has:
A. flaccid paralysis and numbness C. escalating tachycardia and shock
B. absence of sweating and pyrexia D. paroxysmal hypertension and bradycardia

98. During the first week after a spinal injury at the T3 level, a male client and the nurse identify a short-term goal. An
appropriate short-term goal for this client would be, "The client will:
A. understand his limitations" C. carry out personal hygiene activities"
B. perform independent ambulation" D. Consider alternate life-styles"

99. A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. In preparation for this
activity, the client should be taught:
A. Leg lifts to prevent hip contractures C. Balancing exercises to promote equilibrium
B. Push-ups to strengthen arm muscles D. Quadriceps-setting exercises to maintain muscle tone

100. Crushing of the spinal cord above the level of phrenic nerve origin will have significance for the nurse because it will result
in:
A. Ventricular fibrillation C. Retention of sensation but paralysis of the lower extremities
B. Dysfunction of the vagus nerve D. Respiratory paralysis and cessation of diaphragmatic contractions