Situation C. Preventing infection.

You are caring for patient Igaram, a patient with D. Relieving anxiety.
Addison’s disease. You utilize your knowledge on this
concept to help care for the patient. Dec. Aldosterone no water retention fluid volime
defiitshock
Adrenal gland adrenal cortex
Situation
Addisons disease: Dec. Gluccorticoids, You are a nurse tasked to care for patients with different
mineralcorticoids, androgen pituitary disorders. You are to take care of Karoo and
Koza, both diagnosed with SIADH, and Paula, who is
diagnosed with diabetes insipidus. You utilize your
1. Igaram was just recently diagnosed with Addison’s knowledge on this concept to help care for your patients
disease. He still lacks knowledge about his disease so he safely.
decided to ask you some questions. Igaram asked you,
“How does the disease happen?” You answer him SIADH: inc. Antidiuretic hormobe--. Fluid
correctly by stating that this disease results from: volume excess
6. One of the clients in your unit, Karoo, is diagnosed to
A. Insufficient secretion of growth hormone (GH). have a pituitary tumor. Karoo developed Syndrome of
dwarfism Inappropriate Antidiuretic Hormone (SIADH). Which of
B. Dysfunction of the hypothalamic pituitary. Not the following interventions should you implement as
primary disease process Karoo’s primary nurse?
C. Idiopathic atrophy of the adrenal gland.
D. Oversecretion of the adrenal A. Assess for dehydration and monitor blood glucose
medulla. pheochromocytoma levels.
B. Assess for nausea and vomiting and weigh daily.
2. Igaram is admitted to your unit. After your assessment Early symptoms of SOADH: body weight is for fluid retention
assesment
on him, you formulated the nursing diagnosis Deficient
C. Monitor potassium levels and encourage fluid intake
fluid volume related to inadequate fluid intake and to
dilutional hyponatremia.
fluid loss secondary to inadequate adrenal hormone
D. Administer vasopressin IV and conduct a fluid
secretion. As Igaram’s oral intake increases, which of the
deprivation test. Vasopressin=ADH
following fluids would be the most appropriate for him?
Fluid Deprivation--SIADH
Waetr challenge Test SIADH
A. Milk and diet soda. 7. You are reviewing the chart of Karoo who has
B. Water and eggnog. SIADH. Which of the following clinical manifestations
C. Bouillon and juice. you noted in Karoo’s chart should be reported to his
D. Coffee and milkshakes. primary care physician?

3. You are instructing Igaram how to adjust the dose of A. Serum sodium of 112 mEq/L and a headache. 135-
the glucocorticoids he is taking. As his nurse, you should 145
explain to him that he may need an increased dosage of B. Serum potassium of 5.0 mEq/L and a heightened
glucocorticoids in which of the following scenarios? awareness. 3.5-5.0
C. Serum calcium of 10 mg/dL and tented tissue turgor.
A. Completing the spring semester of school. D. Serum magnesium of 1.2 mg/dL and large urinary
B. Gaining 4 pounds. output.
C. Becoming engaged.
D. Undergoing a root canal. 8. Another patient in your unit, Koza, was diagnosed
with SIADH secondary to cancer of the lung. He tells
you that he wants to discontinue his fluid restriction and
Inc. glucocorticoidsinc. cortisol (stress hormone)inc. need during that he does not care if he dies. Which of the following
physical stress example surgeries actions by the nurse is an example of the ethical principle
of autonomy?
4. Igaram is diagnosed with Addison’s disease. As a
knowledgeable nurse, you know that this condition may
A. Discuss the information the client told the nurse with
lead to Addisonian crisis if not adequately managed.
the health-care provider and significant other.
Which of the following manifestations would be
B. Explain it is possible the client could have a seizure if
expected in Igaram if he develops this condition?
he drank fluid beyond the restrictions.
C. Notify the health-care provider of the client’s
A. Fluid retention.
wishes and give the client fluids as desired.
B. Pain. Head abdomen, extremeties, back
D. Allow the client an extra drink of water and explain
C. Peripheral edema.
the nurse could get into trouble if the client tells the
D. Hunger. Nausea, Vomiting
health-care provider.
5. If Igaram develops Addisonian crisis, which of the
9. Paula, another patient assigned to you in the unit, is
following would be your priority as Igaram’s primary
recently diagnosed with diabetes insipidus. Which of the
nurse?
following interventions should you implement as Paula’s
primary nurse?
A. Controlling hypertension. DI: ↓ADH fluid volume deficitDehydration
B. Preventing irreversible shock.
A. Administer sliding-scale insulin as ordered. B. “After this surgery you will no longer have ulcerative
B. Restrict caffeinated beverages. colitis.” UC affect only the large intestine
C. Check urine ketones if blood glucose is >250. C. “When you return from surgery you will not be able to
D. Assess tissue turgor every four (4) hours eat solid food for several days.”
D. “You will have an ileostomy when you return from
10. Following Paula’s diagnosis of diabetes insipidus, this surgery.” Temporary ileostomy
she stayed in the hospital for a few days. She is now
about to be discharged and you are conducting your 14. Wyper, a 20 year old male client, is admitted to your
health teaching regarding her condition. Which of the unit because of the exacerbation of their ulcerative
following statements made by Paula warrants further colitis. You go into Wyper’s room to complete an initial
intervention? assessment, and he yells, “Get outta here! I am tired of
you nurses and doctors looking at my body all the time!”
A. “I will keep a list of my medications in my wallet and Which of the following is your best action?
wear a Medic Alert bracelet.”
B. “I should take my medication in the morning and
leave it refrigerated at home.” Q 8-12 hours A. Leave the room and ask a male colleague to complete
C. “I should weigh myself every morning and record any the assessment.
weight gain.” B. Verbally acknowledge the client’s frustration and
D. “If I develop a tightness in my chest, I will call my anger.
health-care provider.” C. Call the health-care practitioner and ask for a sedative
order.
Situation D. Tell the client that gathering data about his current
You are a nurse caring for patients with condition will promote effective timely treatment of his
inflammatory bowel disease. health concerns
11. Pierre is a patient admitted to the hospital with a 1. Let patient verbalized feeling
diagnosis of ulcerative colitis. You are currently 2. Acknowledge patient feeling
reviewing his history and physical assessment chart.
Based on Pierre’s diagnosis, which of the following 15. You are caring for Conis, a patient admitted in your
information should you expect to see in Pierre’s medical unit who is diagnosed with Crohn’s disease. She has
records? undergone a barium enema that demonstrated the
presence of strictures in her ileum. Based on this
A. Abdominal pain and bloody diarrhea finding, you should monitor the client closely for signs
B. Weight gain and elevated blood glucose of:
C. Abdominal distension and hypoactive bowel sounds Strictions-narrowing
D. Heartburn and regurgitation
A. peritonitis.
Abdominal Paininflammation B. obstruction.
Bloody: ulcerations
Diarrhea: inflammation irritation
C. malabsorption.
D. fluid imbalance.
12. Pierre had a recent exacerbation of ulcerative colitis.
UC: affects only the large intestine: inner lining
He is put on mesalamine (Asacol), which is to be Chron’s Disease can affect the both small and large intestine all layes
administered rectally via an enema. Pierre finds this of the intestione
procedure distasteful and he asks you, “Why can't the
medication just be given orally?”. You answer Pierre Situation
correctly by saying which of the following? You are a new nurse assigned to take care of patients
with various eye disorders. You use your knowledge
Prevent Side Effects to help these patients with their condition.

A. “It can be given orally; I’ll contact the doctor and see
if the change can be made.” 16. One of the patients in your unit, Pagaya, is diagnosed
B. “Rectal administration delivers the medication with glaucoma. Which of the following symptoms should
directly to the affected area.” you expect the client to report during your initial
C. “Oral administration will not be as effective for the assessment with him?
disease condition.”
D. “It can be given orally, I’ll make the change and we’ll A. Loss of peripheral vision. Open angle
tell the doctor in the morning.” B. Floating spots in the vision. Retinal detachment
C. A yellow haze around everything. Digoxin toxicity
13. You overhear a licensed practical nurse (LPN) D. A curtain coming across vision. Retinal detachment
talking to one of your patients, Mousse, who is being
prepared for a total colectomy with creation of an 17. Pagaya has now been prescribed a miotic
ileoanal reservoir for her ulcerative colitis. To decrease cholinergic medication for his glaucoma. Which of the
Mousse’s anxiety, you should intervene to clarify the following data indicates that the medication has been
information given by the LPN when you hear the LPN effective on Pagaya?
saying:
A. No redness or irritation of the eyes
A. “This surgery will prevent you from developing colon B. A decrease in intraocular pressure
cancer.”
C. The pupil reacts briskly to light B. Bradycardia.
D. The client denies any type of floaters C. Wheezing.
D. Decreased bowel sounds

18. You are caring for Gan Fall, a postoperative patient, Neurogenic shock loss of SNS response PNS response only
after his retinal detachment surgery. Gas tamponade was 23. One of the patients in your unit, Hamburg, was
used to flatten the patient’s retina during the procedure. diagnosed with septicemia. The following are the orders
Which of the following interventions should you given by Hamburg’s primary physician. Which of these
implement first? orders will have the highest priority?
A. Teach the signs of increased intraocular pressure. SEPTICEMIA: systemic/ widespread bacterial infectionof
B. Position the client as prescribed by the surgeon. the blood
C. Assess the eye for signs/symptoms of
complications. A. Provide a clear liquid diet.
D. Explain the importance of follow-up visits. B. Initiate IV antibiotic therapy.
C. Obtain a STAT chest x-ray.
Increase ICP
Infection D. Perform hourly glucometer checks.
Another retinal Detachment

19. You are caring for Conis, a patient with severe 24. You wrote the nursing diagnosis of “alteration in
myopia. She is scheduled for a laser assisted in situ comfort related to chills in fever” in one of your
keratomileusis (LASIK) surgery. Which of the patients who has sepsis. Which of the following
following instructions should you discuss with Conis interventions would you include in this patient’s plan of
prior to her discharge from the surgery? care?

A. Wear bilateral eye patches for three (3) days. A. Ambulate the client in the hallway every shift.
B. Wear corrective lenses until the follow-up visit. B. Monitor urinalysis, creatinine level, and BUN level.
C. Do not read any material for at least one (1) week. C. Apply sequential compression devices to the lower
D. Teach the client how to instill corticosteroid extremities.
ophthalmic drops. ↓Inflammation and edema D. Administer an antipyretic medication every four
(4) hours PRN.
20. Eneru, a 65 year old male client is complaining of
blurred vision, but denies having any type of pain. He 25. A patient named Chiqicheetah presents themselves in
reports to you, “I feel like I need to clean my glasses all the emergency department complaining of abdominal
the time”. Which of the following eye disorders should pain, is pale and clammy, and has a pulse of 110 and a
you suspect that Eneru has? blood pressure reading of 92/60. Chiqicheetah has
vertebral fractures, and she reported she has been self-
A. Corneal dystrophy medicating with Ibuprofen, a type of nonsteroidal anti-
B. Conjunctivitis inflammatory drug (NSAID). Which of the following
C. Diabetic retinopathy type of shocks should you expect in patient
D. Cataracts Opacity of the lense Chiqicheetah?

Situation
You are a nurse studying the different types of shock and A. Cardiogenic shock.
its appropriate nursing interventions. You come across B. Hypovolemic shock.
the following patients in your unit. You applied the C. Neurogenic shock. Spinal cord injuries
concepts you’ve learned to your nursing practice. D. Septic shock.
Ibuprofen GI irritant—u;ceration in GIT bleeding

21. Foxy is a client admitted to the emergency Situation

department. Assessment findings include diaphoresis, You are caring for patients in your unit with alterations
pale clammy skin, and a blood pressure reading of 90/70. in their fluid and electrolytes. As a knowledgeable nurse,
Which of the following interventions should you you apply the concepts of fluid and electrolytes in your
implement first? nursing practice.

Signs and symptoms of Shock

A. Start an IV with an 18-gauge catheter. 26. As an experienced nurse, you know that client
B. Administer dopamine intravenous infusion. incidence of hypermagnesemia is rare in comparison
C. Obtain arterial blood gases (ABGs). with hypomagnesemia. A student nurse approached you
D. Insert an indwelling urinary catheter. and asked how hypermagnesemia develops. You answer
her correctly by saying that hypermagnesemia generally
22. Porche is a patient diagnosed with neurogenic shock. occurs secondary to:
As a knowledgeable nurse, you expect to note which of
the following signs and symptoms in this client? A. Cardiac contractility.
B. Hypokalemia.
A. Cool, moist skin. Rapid fluid replacement/ transfusion of C. Liver failure.
blood products
D. Renal insufficiency. Excretion of potassium sodium D. All cancer cases more than 5 years old.
magnesium

27. You are assigned to care for Ace, a patient diagnosed 32. Gol is your patient diagnosed to have testicular
to have hypokalemia. As a knowledgeable nurse, you cancer. He expressed his concerns regarding fertility
know that the electrolyte that must be corrected in this since him and his partner desires to eventually have a
scenario is: family. As Gol’s primary nurse, you discuss the option of
sperm banking. You inform Gol and his partner that
A. Calcium. sperm banking needs to be performed when?
B. Magnesium.
C. Manganese. A. Before treatment is started. Chemotherapy
D. Zinc B. Once the client is tolerating the treatment.
C. Upon completion of treatment.
28. You are caring for a group of patients in the ward. D. When tumor markers drop to normal levels.
While reviewing each of the patient’s charts, you
determine which of the following patients is most likely
at risk for fluid volume deficit? 33. You are working with Bellamy, a client with known
risks for lung cancer. He asks you why he is scheduled
A. A client with an ileostomy stool will not go to large for a computed tomography (CT) scan as part of his
intestine anymore for water reabsorptionFVD
B. A client with heart failure FVE initial workup. You answer Bellamy correctly when you
C. A client on long-term corticosteroid therapyInc. respond by saying:
Aldosterone water retention FVE
D. A client receiving frequent wound irrigations FVE A. “CT is far superior to magnetic resonance imaging for
evaluating lymph node metastasis.”
B. “CT is noninvasive and readily available.”
29. You are refreshing your knowledge on sodium C. “CT is useful for distinguishing small differences
imbalances. As a knowledgeable nurse, you know that in tissue density and detecting nodal involvement.”
which of the following patients in the ward is most likely D. “CT can distinguish malignant adenopathy from
to develop a sodium level at 130 mEq/L (130 mmol/L)? nonmalignant adenopathy.”

Hyponatremia 135-145 34. You are caring for Cricket, a patient with pain
related to bone cancer. You conducted an assessment
A. The client who is taking diuretics Potassium magnesium on Cricket in relation to this. You know that which of the
sodium wasting hyponatremia following is the most important component of a thorough
B. The client with hyperaldosteronism pain assessment specific for patient Cricket?
C. The client with Cushing’s syndrome Pain is whatever the patient say it is
D. The client who is taking corticosteroids
A. Intensity. Indicative of pain severity  important
30. You are reviewing one of your patient’s progress for evaluation efficacy
notes. You read that the physician has documented B. Cause.
“insensible fluid loss of approximately 800mL daily”. As C. Aggravating factors.
a knowledgeable nurse, you make a notation that D. Location.
insensible fluid loss occurs through which of the
following types of excretion? Occur without the persons
awareness skin Lungs 35. Noland is a cancer patient you are tasked to care for.
He is receiving the medication vincristine (Oncovin).
A. Urinary output You plan your health teaching for Noland regarding this
B. Wound drainage medication. Which of the following should you include
C. Integumentary output in your instructions to Nolan?
D. The gastrointestinal tract
Vincristine s/e Constiption
A,B,D Fluid loss oocurs the patient is aware Vincristine a/e:

Situation A. Use of loperamide (Imodium).

You are a nurse assigned to care for and educate B. Fluid restriction.
patients in the cancer unit of the hospital you are C. Low fiber, bland diet.
working on. You apply the concepts you’ve learned D. Bowel regimen.
regarding cancer to ensure a safe nursing practice.
36. Sarquiss is a 57 year old client receiving
chemotherapy that has the potential to cause pulmonary
31. You are reviewing your notes on cancer. After much toxicity. Which of the following symptoms would you
reading, you know that cancer prevalence is defined as? note in Sarquiss that could indicate a toxic response to
the chemotherapy?
A. The likelihood cancer will occur in a lifetime.
B. The number of persons with cancer at a given A. Decrease in appetite.
point in time. B. Drowsiness.
C. The number of new cancers in a year. C. Spasms of the diaphragm.
D. Cough and shortness of breath. You are a nurse caring for patients with cardiac
complications. You use your knowledge on
cardiovascular concepts to help these patients.
37. Hina is one of the patients you are tasked to care for
her in the unit. She is beginning external beam radiation 41. You are working on the unit with patient Brogy. At
therapy to the right axilla after her lumpectomy for breast 7:30 AM, you received a verbal order from his primary
cancer. You plan to conduct a health teaching. Which of HCP for a cardiac catheterization to be completed on him
the following would you include in your education to by 2:00 PM. Which of the following actions should you
Hina? initiate first in Brogy?
A. Use a heating pad under the right arm. TIME ELEMENT
B. Immobilize the right arm.
C. Place ice on the area after each treatment. A. Initiate NPO (nothing per mouth) status for the
D. Apply deodorant only under the left arm. client. (6-12 hours)
B. Teach the client about the procedure.
C. Start an intravenous (IV) infusion of 0.9% NaCl.
Radiation Therapy avoid extreme temperature+ chemical D. Ask the client to sign a consent form.
applicators (Ex. Deodorant, lotions

42. You are working with Dorry, a male patient who

38. Tony Tony is a patient receiving radiation therapy for experienced a myocardial infarction a few days ago.
lung cancer. He complains that he is having difficulty You noted that patient Dorry seems unusually fatigued.
sleeping. After hearing this statement from your patient, Upon your assessment, you find that patient Dorry is
you should: dyspneic with activity, has a heart rate of 110 bpm, and
has generalized edema. Which of the following actions
ADPIE: assessment list would be most appropriate for this patient?
Complication of MI: Heart Failure
A. Suggest the client stop watching television before bed.
B. Assess the client’s usual sleep patterns, amount of A. Administer high-flow oxygen
sleep, and bedtime rituals. B. Encourage the client to rest more
C. Tell the client sleeplessness is expected with radiation C. Continue to monitor the client’s heart rhythm
therapy. D. Compare the client’s admission weight with the
D. Suggest that the client stop drinking coffee until the client’s current weight Weight is the best indicator of fluid
therapy is completed. volume retention

39. You are caring for Nico, a patient with cancer who
requires a bolus tube feeding. You prepare to administer
the bolus tube feeding and as a skilled nurse, which of
the following nursing interventions is most appropriate
to decrease the risk of aspiration in this patient?
43. You are caring for patient Whitebeard immediately
A. Place the client on bed rest with the head of the bed following an insertion of a permanent pacemaker via his
elevated to 60 degrees for 2 hours. right subclavian vein. As a skilled nurse, you know that
B. Place the client on the left side with the head of the the action that can best prevent pacemaker lead
bed at 45 degrees for 15 minutes. dislodgement is:
C. Assist the client out of bed to sit upright in a chair
for 1 hour. A. inspecting the incision site dressing for bleeding and
D. Ask the client to rest in bed with the head of the bed the incision for approximation
elevated to 30 degrees for 20 minutes. B. limiting the client’s right arm activity and
preventing the client reaching above shoulder level
40. Portgas is a cancer patient receiving chemotherapy. C. assisting the client with getting out of bed and
He is experiencing a flare up of pruritus. You are ambulating with a walker
planning to develop a care plan for Portgas. In order to D. ordering a stat chest x-ray following return from the
develop the nursing care plan, you should ask him if he implant procedure
has been:

A. Wearing clothes made from 100% cotton. Cotton is 44. You are increasing activity for patient Bon with an
least irritating in the skin admitting diagnosis of acute coronary syndrome.
B. Sleeping in a cool, humidified room. Comfort+ hydration Which of the following symptoms experienced by patient
C. Increasing fluid intake to at least 3,000 mL/ day. Bon best supports the nursing diagnosis of activity
hydration intolerance? Body is not able to adapt activity
D. Taking daily baths with a deodorant soap. Dring and
irritating skin
A. Pulse rate increased by 15 beats per minute during
Situation activity
B. Blood pressure (BP) 130/86 mm Hg before activity; A. Start an intravenous line with an 18-gauge needle.
BP 108/66 mm Hg during activity Rapid fluid replacement/ transfusion of blood products
C. Increased dyspnea and diaphoresis relieved when B. Have the UAP take the client’s vital signs.
sitting in a chair C. Ask the client to provide a stool specimen for blood.
D. A mean arterial pressure (MAP) of 80 following D. Send the client to radiology for an abdominal CT
activity scan.

45. Cobra is a patient who suffered an inferior septal wall

myocardial infarction. Which of the following 49. You are working as a triage nurse in a large trauma
complications would you suspect in Cobra when you center. The center has been notified of an explosion in a
note on your assessment a jugular venous distention nearby major chemical manufacturing plant. Which of
and ascites? the following actions should you implement first when
the injured patients arrive at the emergency department?
A. Left-sided heart failure polmunic manifestations
A. Triage the clients and send them to the appropriate
B. Pulmonic valve malfunction
areas.
C. Right-sided heart failure systemic manifestations
B. Thoroughly wash the clients with soap and water and
D. Ruptured septum
then rinse.
Situation C. Remove the clients’ clothing and have them
You are an emergency nurse tasked to work shower.
with patients with medical emergencies. You D. Assume the clients have been decontaminated at the
plant.
utilize your knowledge to help these patients.
50. You are attending a seminar on codes. After the
46. A patient’s wife is allowed to be present during session, you recall that which of the following
resuscitation efforts for a patient in the ICU. Which of interventions is the most important for you to implement
the following statements made by you would be the most when participating in a code?
correct and appropriate?
A. Elevate the arm after administering medication.
A. “You can hold your loved one’s hand; sometimes a B. Maintain sterile technique throughout the code.
recovering person remembers that touch.” C. Treat the client’s signs/symptoms; do not treat the
B. “Another staff member will be with you; I will monitor.
show you where you can stand near your husband.” D. Provide accurate documentation of what happened
Provide Support during the code.
C. “Because the resuscitation team needs to work
quickly, you need to stay out of their way and not \
interfere.” insensitive Situation
D. “If the resuscitation efforts fail, the health-care Ms. Hange is the charge nurse of a medical unit. She is
provider will ask you if you want to terminate responsible for the management and supervision of the
resuscitation efforts.” unit.

47. An apartment fire broke out near the hospital. The 51. Ms. Hange observes that one of the female staff
injured victims are sent to the emergency department of nurses is not performing her duties very well. Which of
the hospital. Five families of the injured patients arrived the following strategies will she implement to assist the
in the ED subsequently to inquire about the health status staff nurse?
of their family members. Which of the following is your
best action? A. Discuss with the staff nurse her performance and
ways she can improve.
A. Take the families to the triage area so they can be with B. Allow the staff nurse to select own assignment.
their loved ones C. Assign the staff nurse several clients with various
B. Ask the families to wait in the waiting area until illnesses.
information is available D. Ask the staff nurse to work as an assistant charge
C. Ensure that there is a designated area for family nurse.
staffed by available social workers or clergy Support
D. Direct families to a lounge where a receptionist will
be keeping families informed 52. Ms. Hange notes one of the male staff nurse is
frequently absent and his absence has adversely affected
the quality of care given to the clients unit. Which of the
48. Patient Aokiji is a male client that presented themself following would be the BEST approach?
in the emergency department after vomiting a “large”
amount of bright red blood. Which of the following A. Talk with the staff nurse regarding the concern
actions should you implement first? and remind him of the standards of the agency.
Bright red blood arterial bleedinghigh pressure B. Write the staff nurse a memorandum regarding his
bleeding hemorrhage shock absence.
C. Inform the staff nurse that his absence will be a
ground for termination.
D. Record the absence of the staff nurse in a log book.
58. Which of the following statement is TRUE about
53. Ms. Hange assigns a new staff nurse to administer terminally ill clients?
the medications of a client. Which detail of the client’s
drug therapy is the staff nurse legally responsible to A. Terminally ill clients require minimum physical care.
document? The ________. B. Health care personnel do not understand their own
feelings about death and dying therefore they avoid
A. Peak concentration time of the drug. caring for terminally clients.
B. Safe ranges of the drug. C. Terminally ill clients have the right to die with
C. Client’s socio-economic status. dignity. Treat patient with honor and respect
D. Client’s reaction to the drug.
D. Terminally ill client’s experiences pain most of the
54. Ms. Hange decides what is best for a recovering time.
client and acts on the decision without consulting the
client. Ms. Hange is applying a moral principle which is 59. The dying client wishes to donate her eyes after she
_________. dies. Which of the following statements is NOT TRUE
about organ donation?
A. Paternalism the HCP decide
B. Beneficence A. Any individual, at least 15 years old of age and of a
C. Fidelity sound mind may donate a part of his body to take the
D. Autonomy effect after transplantation needed by the recipient.
B. Sharing of human organs or tissues shall be made only
Situation through exchange programs duly approved by the
The nurse cares for a female client who is Department of Health.
C. The choice to donate an organ must be a written
terminally ill and is experiencing pain.
document.
D. Laws do not require the consent of a family members
55. The nurse prepares a care plan for the client. The to retrieve organs if the donor has expressed his last wish
overall goal for the client is ________. to donate.

SITUATION
The client will:
The nurse in the emergency department admits
A. Achieve control of pain and discomfort. a 45 year old female for vomiting blood.
B. Receive adequate cerebral oxygenation and perfusion. According to a family member who
C. Be free from infection. accompanied the client, the client had a gastric
D. Receive life sustaining food and liquids.
ulcer for several years. The nurse assesses that
the client is in shock.
60. Which of the following assessment findings indicate
56. The nurse is aware of the document that expresses a hypovolemic shock?
client’s wish for life sustaining treatment in the event of
terminal illness or permanent unconsciousness. This A. Systolic blood pressure is less than 90 mmHg. Later
document is the ______; stages of the shock when compensatory mechanism fail

A. No-code order B. Pupils are unequally dilated.

B. Durable power of attorney C. Respiratory rate is more than 30 breaths per minute
C. Living will Tachypnea
D. Last will and testament D. Pulse is less than 60 beats per minute tachycardia

57. The client nears death and requests that no 61. In the early stages of shock, the nurse expects the
medication be given that would cause a loss of result of arterial blood gas (ABG) analysis to indicate
consciousness, including pain medication. The nurse which of the following conditions ____________:
would promote the best end-of-life care for the client by
which of the following? A. Respiratory alkalosis
B. Respiratory acidosis
Promotion of clients dignity respect wishes of the C. Metabolic alkalosis
client D. Metabolic acidosis

Tachypnea/Hyperventilation more O2 going into the lung

A. Discuss the request of the dying client with family
more being breathed out
members and respect their wishes.
B. Comfort is the highest priority in this situation so give
medications as ordered. 62. The physician orders intravenous infusion of packed
C. Respect the client’s wishes and withhold pain red blood cells and normal saline solutions. The nurse
medications and other medications ordered. assesses the client for which of the following
D. Be compassionate and give half of dose of the _____________:
medication ordered.
A. Hypovolemia Hypervolemia
B. Anaphylactic reaction occurs within the first 10 mins of C. Increase the amount of circulating androgens.
blood transfusion D. Increase testosterone level.
C. Altered level of consciousness
D. Pain
68. The nurse writes a nursing diagnosis of Fear and
Anxiety secondary to the diagnosis of prostate
63. The nurse understands that the best indication that cancer. Which of the following interventions would be
fluid replacement for the client in hypovolemic shock is BEST for the nurse?
adequate is when the ___________:
A. Encourage the client to keep his feelings to himself so
A. Systolic blood pressure is above 110 mmHg. his family will not be affected.
B. Diastolic blood pressure is above 90 mmHg. B. Establish a nurse patient therapeutic relationship.
C. Urine output of 20- 30 mL/Hour. C. Advise the client to have a positive outlook
D. Urine output is greater than 30 mL/Hour. relationship.
Goal of fluid replacement ensure adequate tissue perfusion
D. Provide spiritual support to the client.

64. The physician schedules the client for surgery Situation

within six hours. The nurse minimize anxiety of the Nurse Petra works in the oncology unit. She
client by answering the client’s questions regarding the takes care of cancer patients in pain. She is
surgery in calm manner, keeps the client warm, advise aware that cancer pain management is one of
the client to be on bed rest and dims the lights in the her responsibilities.
room. The reason for these interventions is to ________:

A. Increase comfort of the client and her family. 69. Nurse Petra plans care for a cancer client
B. Minimize oxygen consumption. experiencing pain. She is aware that an important
C. Prevent infection. principle of using medication to manage pain is to:
D. Stabilize fluid and electrolyte balance.
A. Individualize the medication therapy to the client.
B. Provide the medication as soon as the client
Situation requests for it.
C. Discontinue the medications periodically to
A 60 year old male is admitted to the oncology discourage the development of drug tolerance.
unit. According to the client, he felt a growth D. Avoid giving client addictive medications.
during a routine digital prostate examination.
He complains of pain on urination and frequent
urination. 70. Nurse Petra collaborates with the physician in the
development of a drug regimen for the clients. Which of
the following medications should be avoided in the
65. The nurse understands that the function of the treatment of cancer pain?
prostate gland is primarily to ______;
A. Morphine
A. Regulate the acidity and alkalinity environment for B. Acetaminophen (Tylenol) non opioid analgesic
proper sperm development. indicated for mild pain
B. Produce a secretion that aids the nourishment and C. Meperidine (Demerol)
passage of sperm. D. Hydrocodone
C. Secrete a hormone that stimulates the production
and maturation of sperm.
71. When titrating a drug for the client in pain, which of
D. Store undeveloped sperm before ejaculation.
the following actions is MOST appropriate?
66. The nurse analyzes the laboratory values and notes
A. Ask the physician to include a medication order for
that the serum phosphate level is elevated. This finding
breakthrough pain.
indicates which of the following:
B. Follow the physician’s order for the first 24 hours.
C. Reassess the client every 8 hours for drug
A. It confirms the diagnosis of prostate cancer. BIOPSY
effectiveness.
B. The progression or regression of prostate cancer.
BLOOD TEST or IMAGING SCAN D. Seek a new order after 2 doses that do not achieve
C. The likelihood of metastasis to the bones. a tolerable level of pain relief. Drug in effected due to drug
tolerance
D. There are complications associated with cancer.

67. The nurse knows that hormone therapy is the mode 72. One of the clients experiences severe, intractable
of treatment for a client with prostate cancer. The goal of pain and complains that the pain medication is not
this form of treatment is to ______: working for him. Which of the following actions is
MOST appropriate for Nurse Petra?
Prostate Ca.: Androgen dependent cancer
A. Suggest to the client to try deep breathing to cope
A. Limit the amount of circulating androgens. with the pain.
B. Increase prostaglandin level.
B. Explore the nature of the pain and encourage the client 78. The following statements are true about patients and
to perceive it in a different way. hospital records EXCEPT:
C. Support the client emotionally and tell him he will a. Confidential records must be protected against loss,
receive the next dose of medication as soon as possible. damage , unauthorized access, modification and
D. Refer the client to the attending physician disclosure
immediately and report that the pain medication is b. Patients have the right to confidential treatment of
not providing adequate pain relief. information they provide to health professional
c. Health records are the property of community
where the patient is treated HOSPITAL
73. Nurse Petra assesses a client complaining of acute d. Hospital records maybe released without the patient’s
pain. The MOST appropriate nursing assessment would consent when required in investigation for serious
include which of the following? criminal offenses
PAIN IS WHATEVER THE PATIENT’S Says it is
A. The nurses’ impression of clients’ pain.
B. The clients’ pain rating. Severely of the painhelps Situation
evaluation of pain/ pain management technique
C. Nonverbal cues from the client.
Ms. Mika is a director of the critical care unit of
D. Pain relief after appropriate nursing interventions. hospital x. She utilizes the nursing process to
communicate care to the client.
Situation
Ms. Helen is a nurse supervisor of three
departments in hospital X. She attends an 79. She is called to the bedside of a client who is
orientation seminar on hospital records scheduled to have laparoscopic cholecystectomy. The
client’s pulse is slightly irregular. Ms. Mika confers with
management.
the primary nurse regarding the client’s condition, which
step of the nursing process is Ms. Mika applying?
74. Ms. Helen understands that good client care relies Collaborate for problem solving and decision making
on good record keeping. Which of the following is NOT
a purpose of hospital record keeping? A.Implementation
b. Evaluation
a. Records provide evidence of a hospital’s c. Planning
accountability. d. Assessment
b. Records are a key source of data for medical research
or statistical reports. 80. Ms. Mika calls for a conference with the staff
c. Records provide data on health information system. members who are attending to the client. They decide to
d. Records provide personal information on the obtain a 12-lead ECG for a more definitive picture. They
physicians and nurses caring for the clients. conclude that the client has no serious cardiac or
pulmonary problems. Which step of the nursing process
is in effect in this situation?
75. Ms. Helen is aware that when a client is readmitted
to a hospital, the client’s file is retrieved from the ECG provide objective dataASSESMENT
_______________. a. nursing diagnosis
b. assessment
a. physician’s file c. evaluation
b. civil service file d. planning
c. master patient index file
d. hospital library record file 81. Ms. Mika consults with the attending physician and
the anesthesiologist. She advises the primary nurse to
proceed with the preparations and to remain alert for any
76. Ms. Helen is aware that when a client is readmitted adverse symptoms. Which step of the nursing process is
to a hospital, the client’s file is retrieved from this?
the__________.
Collaborate for problem solving and decision making
a. Physician’s file a. Assessment
b. Civil service file b. nursing diagnosis
c. Master patient index file electronic medical c. planning
record/database that maintains unique id of each patient d. evaluation
d. Hospital library record file
82. Ms. Mika confers with the client’s primary nurse
the following morning. Together they determine that the
77. Ms. Helen is aware that when a client is discharged client is ready for surgery. This step of the nursing
or dies, the following details should be entered in the process is:
client’s record which is the_______________. Judjement was doneconclude that care rendered in the patient is
effective
a. Final diagnosis a. evaluation
b. Outcomes classification b. planning
c. Educational attainment c. nursing diagnosis
d. Religion d. assessment
83. Ms. Mika applies the human relations approach in a. void before the procedure dec. risk of bladder puncture
this situation. She is aware that the key to productivity is b. a laxative the evening before the procedure
_________________. c. nothing by mouth for 8 hours before the procedure
d. a low soapsuds enema the morning of the procedure

a. the degree of independence allowed Situation

b. meeting the objectives of the critical care unit In a Medical ward there are clients with
c. Firm control of the situation
potential or actual disorders of fluids and
d. the behavior of people under direction
electrolytes disturbance and homeostatic
Situation mechanisms.
A mother with the diagnosis of AIDS states that she has
been caring for her baby even though she has not been
feeling well. 89. The nurse is caring for a client with chronic kidney
failure. The nurse understands that ammonia is normally
exerted by the kidney to help maintain:
84. What important information should the nurse
determine? a. osmotic pressure of the blood
b. acid-base balance of the body
c. low bacterial level in the urine
a. is she has kissed the baby d. normal red blood cell production
b. if the baby is breastfeeding ammonia(NH3)hydrogen ions (acidic in nature)
c. when the baby last received antibiotics
d. how long she has been caring for the baby 90. Which finding best suggests that nursing
interventions for a client with an excess fluid volume
85. The nurse is planning to provide discharge teaching have been effective?
to the family of a client with AIDS. Which statement
should the nurse include in the teaching plan? FVECrackles

a. “Wash the dishes in hot soap as you usually do.” a. clear breath sounds
b. “Let the dishes soak in hot water overnight before b. positive pedal pulses
washing.” c. normal potassium level
c. “You should boil the client’s dishes for 30 minutes d. increased urine specific gravity more solute, less fluid
after use.”
d. “have the client eat from paper plates so they can be 91. The nurse understands that a client with
discharged.” albuminuria has edema because of:

Albumine in urine
86. During an AIDS education class a client states,
“Vaseline works great when I use condoms.” Which a. fall in tissue hydrostatic pressure
conclusions about the client’s knowledge of condom use b. rise in plasma hydrostatic pressure
can the nurse draw this statement? c. rise in tissue colloid osmotic pressure
d. fall in plasma colloid oncotic pressure
Vaseline Petreleum jelly --? Breakdown condom
integrity inc risk condom failure 92. When the nurse uses the clamp on the
administration set to manually adjust the flow of IV fluid
a. an understanding of safer sex
into a client by gravity, what change in energy takes
b. an ability to assume self-responsibility
place?
c. ignorance concerning correct condom use
d. ignorance concerning the transmission of HIV a. potential energy is converted to kinetic energy
b. kinetic energy is converted to potential energy
87. The client with AIDS is experiencing nausea and c. chemical energy is converted to kinetic energy
vomiting. The Nurse would make which of the following d. potential energy is converted to chemical energy
dietary alterations for this client to enhance nutritional
intake? 93. The client with which condition has an increased
risk for developing Hyperkalemia?
a. Avoid dairy products and red meat dairy, red
meat(high fat GI irritant inc. HCl acid secretion in the a. Crohn’s disease diarrhealoss of potassium
stomach reflux
hyperkalemia
b. Plan large nutritious meals
b. Cushing’s syndrome
c. Add spices to food to enhance flavour
c. Chronic heart failure
d. Serve foods while they are warm
d. End-stage renal disease no excretion of potassium

88. The Physician orders a Paracentesis. (to drain out Situation

excess fluid in the peritoneum) How should the nurse The nurse assists in the care of a 15 year old
instruct the client to prepare for the radiograph? female experiencing anaphylaxis due to insect
bite by honeybees.
94. Upon assessment, the nurse observes the client b. Total volume of circulating whole blood
reacting to the insect bites. The following are common c. Permeability of capillary walls
reactions to an insect sting EXCEPT: (-) d. Permeability of the kidney tubules

a. Swelling 99. The client receives fluid resuscitation therapy.

b. Redness The nurse adjusts the infusion rate by evaluating the
c. Appearance of lesions client’s __________:
d. Pain
a. Hourly urine output Best indicator of fluid
Situation replacement
Nurse Gab is a staff nurse in the oncology unit b. Daily body weight
of a tertiary hospital. An activity in the unit for c. Hourly urine specific gravity iv fluid
continuing professional development is to d. Hourly body temperature gastric decompression
disseminate information among the personnel GOAL of FLUID RESUCITATION therapy: adequate tissue
and staff in the unit regarding trends and perfussion
treatment for cancer. Nurse Gab read an article
entitled “Understanding Colorectal Cancer” 100. The client receives total parenteral nutrition
(TPN). The nurse understands this therapy will help the
which was recently published in a national
client__________.
newspaper.
Hypermetabolic stateInc Metabolism they need more calorie
95. According to the Philippine Cancer Facts and and protiens
Estimates for 2010, one of the most common cancer a. Provide adequate nutrition
among men is colorectal cancer. It ranks ______ among b. Ensure adequate caloric and protein intake
all the diseases: c. Correct water and electrolyte imbalances
d. Allow the gastrointestinal tract to rest
a. First
b. Fourth
c. Second
d. Third

Situation
A 21 year old male is admitted to the burn unit of x
hospital. He sustained burns on the chest, abdomen, right
arm and right leg.

96. The nurse assigned to his care anticipates that the

client would be particularly susceptible to which of the
following fluid and electrolyte imbalances during the
emergent phase of burn case.

a. Metabolic acidosis burn injurydmage of cells--.

Release of components into the
circulationmetabolite, potassium
b. Hypernatremia Hyponatremia
c. Hypokalemia Hyperkalemia
d. Metabolic alkalosis

97. The nurse assesses the client for fluid shifting.

During the emergent phase of a burn injury, shifts occur
due to fluid moving from the_______________.

a. Extracellular to intracellular space.

b. Intracellular to extracellular space.
c. Vascular to interstitial space.
d. Interstitial to vascular space

98. The nurse understands that the fluid shift results

from an increase in the_____________.:

a. Total volume of intravascular plasma