XEGEL F.

FOJA

**Medical Surgical Nursing 1**

1. Nurse Edward is performing discharge teaching for a newly diagnosed
diabetic patient scheduled for a fasting blood glucose test. The nurse explains
to the patient that hyperglycemia is defined as a blood glucose level above:

A. 100 mg/dl
B. 120 mg/dl
C. 130 mg/dl
D. 150 mg/dl
2. Mang Edison is on bed rest has developed an ulcer that is full thickness and
is penetrating the subcutaneous tissue. The nurse documents that this ulcer
is in which of the following stages?

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
3. A 24 year old male patient comes to the clinic after contracting genital
herpes. Which of the following intervention would be most appropriate?

A. Encourage him to maintain bed rest for several days

B. Monitor temperature every 4 hours
C. Instruct him to avoid sexual contact during acute phases of illness
D. Encourage him to use antifungal agents regularly
4. An 8 year old boy is brought to the trauma unit with a chemical burn to the
face. Priority assessment would include which of the following?

A. Skin integrity
B. BP and pulse
C. Patency of airway
D. Amount of pain
5. A client with anemia due to chemotherapy has a hemoglobin of 7.0 g/dL.
Which of the following complaints would be indicative of tissue hypoxia
related to anemia?

A. dizziness
 B. fatigue relieved by rest
C. skin that is warm and dry to the touch
D. apathy
6. Hazel Murray, 32 years old complains of abrupt onset of chest and back
pain and loss of radial pulses. The nurse suspects that Mrs. Murray may have:

A. Acute MI
B. CVA
C. Dissecting abdominal aorta
D. Dissecting thoracic aneurysm
7. Nurse Alexandra is establishing a plan of care for a client newly admitted
with SIADH. The priority diagnosis for this client would be which of the
following?

A. Fluid volume deficit

B. Anxiety related to disease process
C. Fluid volume excess
D. Risk for injury
8. Nursing management of the client with a UTI should include:

A. Taking medication until feeling better

B. Restricting fluids
C. Decreasing caffeine drinks and alcohol
D. Douching daily
9. Felicia Gomez is 1 day postoperative from coronary artery bypass surgery.
The nurse understands that a postoperative patient who’s maintained on bed
rest is at high risk for developing:

A. angina
B. arterial bleeding
C. deep vein thrombosis (DVT)
D. dehiscence of the wound
10. Which of the following statement is true regarding the visual changes
associated with cataracts?

A. Both eyes typically cataracts at the same time

B. The loss of vision is experienced as a painless, gradual blurring
C. The patient is suddenly blind
D. The patient is typically experiences a painful, sudden blurring of
vision.
11.A client with Bell’s palsy does not blink the affected eye. The nurse should:
A. Apply an eye patch to the affected eye at all times
B. Ask the client to keep both eyes closed
C. Assess pupil reaction to light and accommodation
D. Obtain medical orders for eye lubrication

12. A client has Bell’s palsy, and the nurse is planning to assess the client’s ability to hear. Of the
following, which is the best way to test for hearing?
A. Face the client directly and whisper, “Can you hear me?”
B. Hold a watch to the client’s ear and ask, “Can you hear this watch?”
C. Stand behind the client and say, “Raise your hand.”
D. Use a tuning fork to test lateralization of sound.
13. A client with right hemiplegia is awake and alert. The client is given exercises to do during
the day. One afternoon the client seems very discouraged, so the nurse plans to motivate her
by:
A. Reassuring her that there is no need for her to feel discouraged
B. Reinforcing the small gains she has made
C. Suggesting that she could rest today and exercise again tomorrow
D. Explaining that exercise is necessary to get better
14. Pupil checks every hour are ordered for a client with CVA. This is an important assessment
because:
A. Blurred vision is a sign of increasing ICP
B. Cranial nerve III exits from the brain stem
C. Dilated and fixed pupils indicate cardiac arrest
D. Pinpoint pupils result from CNS depressant drugs
15. If a cerebrovascular injury involves the pyramidal tract, the nurse expects to observe:
A. Intention tremors
B. Loss of pain and temperature sensation
 C. Loss of equilibrium
D. Paralysis of voluntary movement
16. A client has had a CVA. When placing the client on the affected side, it is important to have
pillows between the entire length of the legs to prevent:
A. Adduction of the hip
B. External rotation of the hip
C. Flexion of the knee
D. Plantarflexion
17. A client with a CVA has a diminished gag reflex. The nurse will:
A. Instill artificial tears
B. Offer small sips of clear liquids
C. Maintain a side-lying position
D. Test cranial nerves III, IV, and VI

18. A female client at home with a CVA has become incontinent of urine. The nurse will teach
the caregiver to:

A. Apply powder to client’s perineum

B. Insert an indwelling catheter
C. Limit client’s fluid intake
D. Place client on a bedpan according to a schedule

19. Nursing actions directed toward restoring bowel function are effective if the home-care
client in ?
A. Can tell when she feels “constipated”
B. Finishes her prune juice and cereal every day
C. Has a soft formed stool each morning
D. Tolerates 2400 mL of fluid daily
20. A female client with CVA sometimes has difficulty “finding” the words she wants to say. The
nurse will encourage the client’s visitors to:
A. Be patient with client while she thinks of a word
B. End the visit if she becomes frustrated and angry
C. Finish her sentence for her if they know what she wants to say
D. Tactfully change the subject when she cannot find the word she wants to use
21. A client has had a CVA with expressive aphasia. When assisting the client to communicate
during the early period after the CVA, it is most important for the nurse to:
A. Create signals for client to use
B. Speak loudly and clearly
C. Stand directly in front of the client
D. Write directions in large letters
22. In a client with left hemiplegia, the nurse is applying pain by pressing on the base of the
client’s fingernail to assess level of consciousness. The client’s best response is:
A. Flexion of both arms
B. Flexion of the unaffected arm and unaffected leg
C. Grimacing (making a face)
D. Pulling the hand away
23. To best help a female client cope with a change of body image due to hemiparesis, the nurse
would:
A. Ask the client to tell how she feels
B. Encourage the client to be independent with grooming
C. Focus on ability rather than disability
D. Keep her environment free of clutter
24. After head injury, a client’s vital signs are stabilized and he is posted for a CT scan. To
prepare him for this test,the nurse needs to understand that a CT scan:
A. Involves injection of a radiopaque contrast medium into an artery, which causes a burning
sensation
B. Is a measure of electrical energy flowing away from the brain
C. Lasts only a few minutes, but he will have to remain flat for 12 hours after the test
D. Requires him to lie very still during the examination
25. A male client with herniated nucleus pulposis (HNP) had a myelogram this morning. To
prevent headache, the nurse instructs him to remain flat in bed for 6 hours, and the nurse will:
A. Dim the lights in his room
B. Force fluids
C. Offer analgesic medication
D. Turn him every 2 hours from side to side
26. After a cerebral angiogram, the nurse will encourage the client to:
A. Ask for assistance with ambulation
B. Drink fluids
C. Turn, cough, and breathe deeply
D. Void
27. To prepare a female client for an MRI, the nurse explains that the client will:
A. Be asked to lie still during the entire procedure and will hear a humming sound
B. Have an injection of a radiopaque contrast medium into her vein
C. Have many small electrodes placed on her scalp
D. Need to stay in bed with the head of the bed elevated for 6–8 hours after the
procedure

28. A client with Guillain-Barré syndrome is going to undergo plasmapheresis and is concerned
about what it means. The nurse’s response is based on the understanding that plasmapheresis:
A. Alleviates symptoms by removing autoimmune antibodies from the blood
B. May cause a mild allergic reaction with generalized
C. Prevents secondary bacterial infection to the nervous system
D. Reduces the need for O2 while the client is on a respirator

29. To help prevent tonic-clonic type seizures due to epilepsy, the nurse will teach a client to:
A. Avoid any situation that produces fatigue
 B. Refrain from participating in competitive sports
C. Take extra medication if an infection is present
D. Try to determine factors that consistently precede a seizure

30. Which of the following assessments most likely indicates a complication of total hip
replacement during the early postoperative period?
A. Both legs cool to the touch
B. Calf tenderness when the foot is dorsiflexed
C. Tenderness at the surgical site
D. Lightheadedness when standing
31. When teaching a mother not to continually lift her small child by his arms, the nurse hopes
to prevent which dangerous complication?

A. Bursitis
B. Dislocation
C. Greenstick fracture
D. Subluxation
32. To prevent recurrence of pain related to carpal tunnel syndrome, the nurse would
encourage the client to:
A. Avoid activities causing flexion and extension of the wrist joint
B. Elevate the wrist joint by wearing a sling
C. Immobilize the wrist and finger joints with a splint
D. Take aspirin every 4 hours while awake
33. The nurse expects a person with rheumatoid arthritis to have the most difficulty with pain
and stiffness after:
A. ADL
B. Heat applications
C. Meals
 D. Sleep

34. When caring for a 2-month-old child in Bryant’s traction, the nurse observes that his
buttocks are resting on the bed. The nurse should:
A. Elevate the foot of the bed
B. Increase the weights
C. Lift his buttocks off the bed
D. Take no action
35. the function of cranial nerve XII (hypoglossal) is that:
A. Eyebrows raise symmetrically
B. Tongue is symmetrical with no fasciculation
C. Trapezius and sternocleidomastoid muscles have
equal strength bilaterally
D. Uvula is in midline
36. When the nurse is testing the sensory component of cranial nerve V (trigeminal), the nurse does this
with client’s:
A. Cheeks puffed out
B. Eyes closed
C. Head turned to the side
D. Teeth clenched
37. When testing cranial nerve II (optic), the nurse should:
A. Ask the client if she or he wears glasses
B. Dim the lights in the room
C. Instruct client to keep both eyes open when visual fields are tested by confrontation
D. Use an ophthalmoscope to measure pupil size
38. The nurse would use deep pain stimuli, such as squeezing the trapezius muscle, if the client is:
A. Demonstrating signs of increased ICP
B. Flaccid on one side of the body
C. Uncooperative and demanding
D. Unresponsive to verbal commands
39. The nurse prepares a client for an EEG by:
A. Administering barbiturate medication
B. Keeping him NPO
C. Shampooing his hair and keeping his scalp damp
D. Withholding fluids containing caffeine

40. A nursing diagnosis for a client with Guillain-Barré syndrome is potential ineffective gas exchange
related to:

A. Increased ICP
B. Insufficient acetylcholine
C. Muscle weakness
 D. Sustained seizures

41. A client admitted to the emergency room with a head injury is being hyperventilated with 100% O2.
The nurse explains that the reason for this is to:
A. Fully aerate the alveoli
B. Increase PaO2
C. Lower PaCO2
D. Stimulate the reticular activating system
42. The nurse observes for “Battle’s sign” or “raccoon sign” in a client with a head injury. The nurse
should also look for:
A. Aphasia
B. Hemiparesis
C. Paresthesia of the distal extremities
D. Spinal fluid leak
43. The nurse is caring for a client with an occipital lobe tumor. All of the following were documented on
admission. Which should be documented by the nurse daily?
A. Difficulty in voiding
B. Insomnia
C. Irregular pupil size
D. Loss of appetite
44. A nursing diagnosis in the emergency treatment of any client with a fractured spine includes high risk
for injury related to:

A. Elevating the legs

B. External rotation of the hips
C. Spinal movement
D. Supine position
45. A teenager dove off a pier into 3 feet of water. During transport to the emergency room, it is most
important for the nurse to:
A. Begin IV therapy with isotonic saline
B. Assess pupil reaction to light frequently
C. Prevent spinal movement
D. Reorient the client to person, place, and time

46. A 28-year-old man has injured his neck in a diving accident. A neurological exam reveals that he has
lost sensation and motion of both upper and lower extremities. His family is very concerned and wants
to know if he will regain function. The nurse explains to them that:
A. Full recovery is likely if he has a good rehabilitation
program
B. He probably has spinal shock
C. His spinal cord will be sutured together
D. No regain in function is possible
47. Before discharge, a client is scheduled for an EEG. To prepare him for this test, the nurse explains to
him that he will feel:
A. A sensation of warmth during the test
B. A tiny prickly sensation when the current is turned on
C. No discomfort during the procedure
D. Somewhat dizzy after the test is completed
48. After tube feeding, the nurse should irrigate a percutaneous endoscopic gastrostomy tube with:

A. 30 mL of air
B. 45 mL of normal saline
C. 15 mL of sterile solution (saline or water)
D. 30 mL of tap water

49. The nurse is observing a client with a percutaneous endoscopic gastrostomy tube administer his own
tube feeding. He needs further instruction if he:
A. Checks for residual before the feeding
B. Instills the feeding at room temperature
C. Lies down after the feeding
D. Takes 15 minutes to instill 500 mL of feeding
50. An 86-year-old client is receiving IV lipid emulsions.The nurse gives IV lipid emulsions:
A. At a rate of 10 mL/min
B. Through a filter
C. Warmed to body temperature
D. Without piggyback additives
51. A serious complication of total parenteral nutrition (TPN) is hyperosmolar diuresis. The nurse
evaluates the cause of this as:
A. Allergy to certain amino acids
B. Insufficient carbohydrates
C. Precipitates in the solution
D. Rapid infusion

52. The nurse evaluates the teaching of a client taking liquid iron medication as effective if he tells the
nurse that he will take his medicine with:
A. Antacid
B. Milk
C. Orange juice
D. Water

53 dumping syndrome if he tells the nurse that he will:

A. Avoid concentrated carbohydrates

B. Ambulate after meals
C. Eliminate fats from the diet
D. Take fluids with meals
54. The nurse evaluates discharge teaching of a client with peptic ulcer as effective if she tells the nurse
that she will read labels of over-the-counter drugs and will avoid those containing:
A. Aspirin
B. Calcium
C. Magnesium
D. Sodium
55. The nurse evaluates the teaching of a client with hiatal hernia as effective if the client tells the nurse
that she will:
A. Avoid bending over after eating
 B. Avoid highly concentrated carbohydrates
C. Lie down after meals
D. Sleep on her left side

56. The nurse explains to a client that the client is NPO immediately after an
esophagogastroduodenoscopy (EGD) because she:
A. Received topical local anesthesia
B. Must keep her stomach empty for 4 hours
C. Must remain flat for 12 hours
D. Will have a sore throat
57. A client has a history of dumping syndrome following gastric surgery. Anticipated assessment findings
for the client with dumping syndrome include:
A. Bradycardia, perspiration, confusion
B. Dizziness, tachycardia, palpitations
C. Pallor, dry skin, constipation
D. Drowsiness, epigastric burning, flushed skin
58. The nurse evaluates the teaching of an elderly client on a low-sodium diet and taking antacids for
peptic ulcer as effective if he tells the nurse:
A. Aluminum antacids should be avoided
B. Antacids cause acid imbalance
C. Chewable antacids are more effective than liquids
D. Sodium bicarbonate relieves ulcer pain
59. After hemorrhoidectomy, a client asks for a rubber ring to sit on. The nurse’s response is based on
the understanding that a partially inflated rubber ring may:
A. Contaminate the operative site
B. Impede circulation to the operative area
C. Restrict full mobility in ADL
D. Rupture, causing trauma to the operative site
60. Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse
report to the physician immediately?
A. Pitting edema of the legs
B. An irregular apical pulse
C. Dry mucous membranes
D. Frequent urination

61. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit.
Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to
suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes
insipidus?
A. Above-normal urine and serum osmolality levels
B. Below-normal urine and serum osmolality levels
C. Above-normal urine osmolality level, below-normal serum osmolality level
D. Below-normal urine osmolality level, above-normal serum osmolality level

62. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and
prepared for discharge. When preparing the client for discharge and home management, which of the
following statements indicates that the client understands her condition and how to control it?
 A. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate,
drink, or eat more than usual.”
B. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains
sugar.”
C. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly
elevated.”
D. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”

63. A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness,
irritability, depression, and bone pain that interferes with her going outdoors. Based on these
assessment findings, the nurse would suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism

64. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to take
fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an
understanding of the instructions?
A. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
B. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
C. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
D. “I’ll take the entire dose at bedtime.”

65. Which of the following laboratory test results would suggest to the nurse Len that a client has a
corticotropin-secreting pituitary adenoma?
A. High corticotropin and low cortisol levels
B. Low corticotropin and high cortisol levels
C. High corticotropin and high cortisol levels
D. Low corticotropin and low cortisol levels

66. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor.
Preoperatively, the nurse should assess for potential complications by doing which of the following?
A. Testing for ketones in the urine
B. Testing urine specific gravity
C. Checking temperature every 4 hours
D. Performing capillary glucose testing every 4 hours

67. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic
ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2
p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin.
Nurse Mariner should expect the dose’s:
A. onset to be at 2 p.m. and its peak to be at 3 p.m.
B. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. onset to be at 4 p.m. and its peak to be at 6 p.m.
68. The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs
and symptoms of this disorder. Which test result would confirm the diagnosis?
A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH
stimulation test
B. A decreased TSH level
C. An increase in the TSH level after 30 minutes during the TSH stimulation test
D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by
radioimmunoassay

69. Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10
U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before
breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should
provide which instruction?
A. “Inject insulin into healthy tissue with large blood vessels and nerves.”
B. “Rotate injection sites within the same anatomic region, not among different regions.”
C. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
D. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”

70. Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar
hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse
anticipate?
A. Elevated serum acetone level
B. Serum ketone bodies
C. Serum alkalosis
D. Below-normal serum potassium level

71. For a client with Graves’ disease, which nursing intervention promotes comfort?
A. Restricting intake of oral fluids
B. Placing extra blankets on the client’s bed
C. Limiting intake of high-carbohydrate foods
D. Maintaining room temperature in the low-normal range

72. Patrick is treated in the emergency department for a Colles’ fracture sustained during a fall. What is a
Colles’ fracture?
A. Fracture of the distal radius
B. Fracture of the olecranon
C. Fracture of the humerus
D. Fracture of the carpal scaphoid

73. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this
disorder?
A. Calcium and sodium
B. Calcium and phosphorous
C. Phosphorous and potassium
D. Potassium and sodium
74. Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke
inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical
ventilation. He most likely has developed which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Atelectasis
C. Bronchitis
D. Pneumonia

75. A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right
femur. The hypoxia was probably caused by which of the following conditions?
A. Asthma attack
B. Atelectasis
C. Bronchitis
D. Fat embolism

76. A client with shortness of breath has decreased to absent breath sounds on the right side, from the
apex to the base. Which of the following conditions would best explain this?
A. Acute asthma
B. Chronic bronchitis
C. Pneumonia
D. Spontaneous pneumothorax

77. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the
emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung
field, no breath sounds are present in the upper lobe. This client may have which of the following
conditions?
A. Bronchitis
B. Pneumonia
C. Pneumothorax
D. Tuberculosis (TB)

78. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
A. The space remains filled with air only
B. The surgeon fills the space with a gel
C. Serous fluids fills the space and consolidates the region
D. The tissue from the other lung grows over to the other side

79. Hemoptysis may be present in the client with a pulmonary embolism because of which of the
following reasons?
A. Alveolar damage in the infracted area
B. Involvement of major blood vessels in the occluded area
C. Loss of lung parenchyma
D. Loss of lung tissue

80. Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to
determine the extent of hypoxia. The acid-base disorder that may be present is?
A. Metabolic acidosis
B. Metabolic alkalosis
 C. Respiratory acidosis
D. Respiratory alkalosis

81. After a motor vehicle accident, Armand an 22-year-old client is admitted with a pneumothorax. The
surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the
water seal chamber. Which of the following is the most likely cause of the bubbling?
A. Air leak
B. Adequate suction
C. Inadequate suction
D. Kinked chest tube

82. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of
Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per
milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?
A. 18
B. 21
C. 35
D. 40

83. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure.
Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1
ml of solution. What amount should the nurse administer to the child?
A. 1.2 ml
B. 2.4 ml
C. 3.5 ml
D. 4.2 ml

84. Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made
by the client, indicates to the nurse that the teaching was successful?
A. “I will wear the stockings until the physician tells me to remove them.”
B. “I should wear the stockings even when I am sleep.”
C. “Every four hours I should remove the stockings for a half hour.”
D. “I should put on the stockings before getting out of bed in the morning.”

85. Two days after surgery, a client has a temperature of 40- Celsius (C). How would you report this in
Fahrenheit (F)?

A. 104F
B. 98.6F
C. 100.4F
D. 99F
86. A male client has received several IV injections of morphine for complaints of chest pain. The nurse
should have resuscitative equipment and which of the following drugs to reduce adverse effects
of morphine?
A. Naloxone (Narcan)
B. Niacin (Nicobid)
C. Nitroglycerin
D. Nitroprusside (Nipride)
87. A client is alert and oriented and knows his name and where he is. The nurse assesses him using the
expression “oriented 3.” This means the client is oriented to:
A. His total surroundings for 3 days in a row
B. His total surroundings 3 times in a row
C. Self, hospital, and season
D. Person, place, and time
88. A 49-year-old client has been under extreme job stress for about 10 years. He is diagnosed as having
an enlarged heart. Which of the following factors in his history is a modifiable risk factor?

A. He has a family history of heart attacks.

B. He has smoked one pack per day of cigarettes for 1 year.
C. He exercises 4 times a week.
D. He uses corn oil margarine and eats beef once a week.
89. A 24-year-old client has diminished popliteal and pedal pulses; his lower extremities are dusky red in
the dependent position; and his skin is cool to touch, shiny, thin, and atrophic, with hair loss over the
feet and toes. Based on these characteristics, the nurse suspects:
A. Arterial insufficiency
B. Venous insufficiency
C. Varicose veins
D. Raynaud’s disease

90. A client complains of indigestion. The nurse begins an abdominal assessment. When obtaining
subjective data (the client’s history), the initial priority questions would pertain to:
A. Diet history, oral care, and bowel patterns
B. Skin care, sleep patterns, and reproduction
C. Coping patterns, oral intake, and oral care
D. Family risk factors, self-care, and exercise patterns
91. A 76-year-old male client slipped and fell when he was alone in the house. He managed to get
himself up and into a chair, where he sat for several hours. His son came home later and took him to the
hospital, where the client was diagnosed as having a broken right hip. Which of the following is
appropriate to check for his lower extremities?
A. Skin color of both lower extremities
B. Edema of the right ankle
C. Passive mobility of the right hip
D. Sensitivity to temperature changes in both feet
92. A client is admitted for possible respiratory infection. His admission orders include: regular diet,
ambulation ad lib, vital signs every 4 hours, ampicillin po 250 mg q6h. While the nurse is collecting a
medical history, the client states that he is allergic to penicillin. The nurse should take which of the
following actions?

A. Note the allergy on the chart, and administer medication as ordered.

B. Withhold the medication and note the allergy on the chart.
C. Withhold the medication, and notify the physician of the client’s allergies.
D. Administer the medication while closely monitoring the client.
93. A 26-year-old woman is admitted for chemotherapy totreat Hodgkin’s disease. Part of her drug
therapy in cludes vincristine 0.01 mg/kg per week. The nurse should counsel the client on which of the
following common adverse effects?
A. Alopecia
 B. Fluid retention
C. Diarrhea
D. Polycythemia
94. The nurse should assess a client corticotropic hormone (ACTH) drug therapy for which of the
following?
A. Elevated calcium levels
B. Dehydration
C. New infections
D. Changes in urine color

95. The physician has prescribed aminophylline (theo-phylline ethylenediamine) 450 mg (continuous
release) q6h for a client with bronchial asthma. The medication is available in 225-mg continuous-release
tablets. The nurse calculates that the client will receive one tablet every 6 hours. The client states: “I will
not skip any doses of this medicine. I will call my doctor if I have palpitations, vomiting, or trouble
sleeping.” After double-checking the dosage calculation, the nurse decides to:
A. Not administer the medication as prescribed and calculated
B. Administer two tablets of the medication instead of the dosage calculated
C. Administer the medication as prescribed and calculated, and monitor for theophylline blood
levels and cardiorespiratory status
D. Administer the medication as prescribed and calculated, and proceed with further client
teaching

96. The nurse instructs a client being discharged after a vaginal hysterectomy 4 days ago. Which of the
following statements by the client indicates a need for further health teaching?
A. “I must complete the antibiotics as the physician ordered.”
B. “I should not have alcohol while I’m on narcotic pain medications.”
C. “I should not douche or have intercourse for 6 weeks.”
D. “I should not exercise for 6 weeks.”

97. A 64-year-old client is admitted with dyspnea, “heartburn,” and pain in the left shoulder. A total
history and physical examination should be done, but which immediate mini assessment is a priority at
this time?

A. The heart
B. The abdomen
C. Current stressors
D. Recent life changes
98. In assessing a client’s apical pulse, you know that the point of maximal impulse (PMI) is usually at
which area of the heart?
A. LMCL, 5ICS
B. LMCL, 4ICS
C. LMCL, 2ICS
D. RMCL, 2ICS

99. A client who is considered to be an older adult is believed to be experiencing the developmental
crisis (Erikson) of:
A. Ego integrity versus despair
B. Generativity versus stagnation
 C. Identity versus role confusion
D. Intimacy versus isolation
100. The nurse palpates a client’s left arm as he moves it.The nurse feels a grating sensation and hears a
crackling sound. The nurse identifies this as:

A. Pruritus
B. Crepitus
C. Rales
D. Effusion
101. As the nurse inspects a client’s skin, the nurse notes and records which of the following factors?
A. The location of any lesions
B. The client’s allergies
C. Her family history
D. Her exposure to communicable disease
102. As the nurse continues to assess a client’s skin, the nurse finds a blister. This is a serous fluid-filled
area less than 1 cm in diameter, rising from below the skin surface. It is also called:
A. Macule
B. Papule
C. Pustule
D. Vesicle

103. A 44-year-old client has had to have both legs amputated because of peripheral vascular
insufficiency. He has been told that he can eventually be fitted with prosthetic legs. How may the nurse
best help him with his ambulation efforts after he gets his prosthesis?
A. Encourage his adjustment to a changed body image.
B. Allay his feelings of guilt about his injury.
C. Discourage his blaming of others for his plight.
D. Promote safe ambulation.
104. A 60-year-old man has a medical diagnosis of BPH. Which of the following signs and symptoms
would the nurse expect to find during this assessment?
A. Urinary hesitancy, frequency, dribbling
B. Nocturia, increased force of the urinary stream
C. Bladder spasms, hematuria
D. Flank pain, hematuria
105. A spry 80-year-old woman has had glaucoma for many years. Even though she instills her eye drops
regularly as ordered, the nurse should assess for which of the following complaints?
A. Decreasing visual acuity, eye pain
B. Increased blood pressure
C. Decreased vision at night
D. Nystagmus
106. A construction worker is seen by the occupational health nurse for a piece of glass lodged in his eye
from an exploding light bulb. It would be most important for the nurse to:
A. Carefully remove the glass from the eye.
B. Offer reassurance that everything is OK.
C. Give a sedative to help relieve pain.
D. Encourage the client to rest in a sitting position.
107. A client with a spinal cord injury is at risk for a phenomenon called autonomic dysreflexia, once
reflex activity below the level of the lesion occurs, causing visceral reflex activity. If symptoms occur, the
nurse should:

A. Assess for distended bowel or bladder.

B. Assess for urinary continence.
C. Assess for coping behaviors.
D. Promote assessment for skin disruption.

108. A client is receiving rifampin (Rifadin) po for treatment of tuberculosis. The nurse should instruct
the client on which of the following?
A. Avoid taking with milk.
B. Avoid taking with alcohol.
C. Avoid breaking capsule.
D. Avoid taking on an empty stomach.

109. An ACE inhibitor is prescribed for a client with hypertension by his physician. The nurse should
expect to administer which of the following drugs?
A. Inderal (propranolol)
B. Procardia (nifedipine)
C. Capoten (captopril)
D. Apresoline (hydralazine)

110. A client with coronary artery disease complains of substernal chest pain. After assessing the client’s
vital signs, the nurse administers nitroglycerin sublingually (SL) 1/150. After 5 minutes, the client
indicates that he is still having chest pain. If his vital signs are stable following the usual dosage regimen
(ordered by the physician), the nurse should:
A. Wait 5 more minutes and then reassess
B. Apply O2 per nasal cannula
C. Administer another nitroglycerin tablet SL
D. Wait 10 minutes, and then administer a second nitroglycerin tablet

111. A client returns to your unit after a coronary angiogram. She complains of fever, itching, and chills.
Which of the following drugs should the nurse plan to administer after notifying the physician of
the client’s complaints?
A. Diphenhydramine (Benadryl)
B. Dipyridamole (Persantine)
C. Dobutamine hydrochloride (Dobutrex)
D. Droperidol (Inapsine)
112. A client is admitted with a low potassium level and is prescribed parenteral KCl 40 mEq/L stat.
Which of the following would be an appropriate method to administer the drug?

A. IV push
B. Concentrated IV infusion
C. Diluted IV infusion
D. IM
113. A client who has had repeated HIV antibody tests is found to be HIV infected and asymptomatic.
Which of these statements about this person’s ability to transmit HIV is accurate?
 A. The virus is dormant and the person is not infectious.

B. The person is infectious only if symptoms are present.

C. The person is considered infectious for life.

D. Further laboratory tests are needed to determine infectious state.

114. An oral manifestation of AIDS clients is hairy leukoplakia. The nurse should assess for this
manifestation on:
A. The conjunctiva of the eye
B. The inner surface of the nares
C. The lateral margins of the tongue
D. Posterior chest
115. A patient is admitted to the medical surgical unit following surgery. Four
days after surgery, the patient spikes a 38.9 degrees C oral temperature and
exhibits a wet, productive cough. The nurse assesses the patient with
understanding that an infection that is acquired during hospitalization is
known as:

A. a community acquired infection

B. an iatrogenic infection
C. a nosocomial infection
D. an opportunistic infection
116. A client with anemia has a hemoglobin of 6.5 g/dL. The client is
experiencing symptoms of cerebral tissue hypoxia. Which of the following
nursing interventions would be most important in providing care?

A. Providing rest periods throughout the day

B. Instituting energy conservation techniques
C. Assisting in ambulation to the bathroom
D. Checking temperature of water prior to bathing
117. A client was involved in a motor vehicular accident in which the seat belt
was not worn. The client is exhibiting crepitus, decrease breath sounds on the
left, complains of shortness of breath, and has a respiratory rate of 34 breaths
per minute. Which of the following assessment findings would concern the
nurse most?

A. Temperature of 102 degrees F and productive cough

B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg
C. Trachea deviating to the right
 D. Barrel-chested appearance
118. The proper way to open an envelop-wrapped sterile package after
removing the outer package or tape is to open the first position of the
wrapper:

A. away from the body

B. to the left of the body
C. to the right of the body
D. toward the body
119. Assessment of a client with possible thrombophlebitis to the left leg and
a deep vein thrombosis is done by pulling up on the toes while gently holding
down on the knee. The client complains of extreme pain in the calf. This
should be documented as:

A. positive tourniquet test

B. positive homan’s sign
C. negative homan’s sign
D. negative tourniquet test
120. Thomas Elison is a 79 year old man who is admitted with diagnosis of
dementia. The doctor orders a series of laboratory tests to determine whether
Mr. Elison’s dementia is treatable. The nurse understands that the most
common cause of dementia in this population is:

A. AIDS
B. Alzheimer’s disease
C. Brain tumors
D. Vascular disease
121. Which of the following nursing interventions is contraindicated in the
care of a client with acute osteomyelitis?

A. Apply heat compress to the affected area

B. Immobilize the affected area
C. Administer narcotic analgesics for pain
D. Administer OTC analgesics for pain
122. A client with congestive heart failure has digoxin (Lanoxin) ordered
everyday. Prior to giving the medication, the nurse checks the digoxin level
which is therapeutic and ausculates an apical pulse. The apical pulse is 63
bpm for 1 full minute. The nurse should:

A. Hold the Lanoxin

 B. Give the half dose now, wait an hour and give the other half
C. Call the physician
D. Give the Lanoxin as ordered
123. Nurse Marian is caring for a client with haital hernia, which of the
following should be included in her teaching plan regarding causes:

A. To avoid heavy lifting

B. A dietary plan based on soft foods
C. Its prevalence in young adults
D. Its prevalence in fair-skinned individuals
124. Joseph has been diagnosed with hepatic encephalopathy. The nurse
observes flapping tremors. The nurse understands that flapping tremors
associated with hepatic encephalopathy are also known as:

A. aphasia
B. ascites
C. astacia
D. asterixis
125. Hyperkalemia can be treated with administration of 50% dextrose and
insulin. The 50% dextrose:

A. causes potassium to be excreted

B. causes potassium to move into the cell
C. causes potassium to move into the serum
D. counteracts the effects of insulin
126. Which of the following findings would strongly indicate the possibility of
cirrhosis?

A. dry skin
B. hepatomegaly
C. peripheral edema
D. pruritus
127. Aling Puring has just been diagnosed with close-angle (narrow-angle)
glaucoma. The nurse assesses the client for which of the following common
presenting symptoms of the disorder?

A. halo vision
B. dull eye pain
C. severe eye and face pain
D. impaired night vision
128. Chvostek’s sign is associated with which electrolyte impabalnce?

A. hypoclacemia
B. hypokalemia
C. hyponatremia
D. hypophosphatenia
129. What laboratory test is a common measure of the renal function?

A. CBC
B. BUN/Crea
C. Glucose
D. Alanine amino transferase (ALT)
130. A male client with a gunshot wound requires an emergency blood transfusion. His blood
type is AB negative. Which blood type would be the safest for him to receive?
A. AB Rh-positive
B. A Rh-positive
C. A Rh-negative
D. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
131. Stacy is discharged from the hospital following her chemotherapy treatments. Which
statement of Stacy’s mother indicated that she understands when she will contact the
physician?
A. “I should contact the physician if Stacy has difficulty in sleeping”.
B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
C. “My physician should be called if Stacy is irritable and unhappy”.
D. “Should Stacy have continued hair loss, I need to call the doctor”.

132. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best
response for the nurse is:
A. “Stacy looks very nice wearing a hat”.
B. “You should not worry about her hair, just be glad that she is alive”.
C. “Yes it is upsetting. But try to cover up your feelings when you are with her or else she may
be upset”.
D. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in
texture”.

133. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-charge
should:
A. Provide frequent mouthwash with normal saline.
B. Apply viscous Lidocaine to oral ulcers as needed.
C. Use lemon glycerine swabs every 2 hours.
D. Rinse mouth with Hydrogen Peroxide.
134. During the administration of chemotherapy agents, Nurse Oliver observed that the IV site
is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action to take
is:
A. Notify the physician
B. Flush the IV line with saline solution
C. Immediately discontinue the infusion
D. Apply an ice pack to the site, followed by warm compress.

135. The term “blue bloater” refers to a male client which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema

136. The term “pink puffer” refers to the female client with which of the following conditions?
A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema

137. Jose is in danger of respiratory arrest following the administration of a narcotic analgesic.
An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the
following values?
A. 15 mm Hg
B. 30 mm Hg
C. 40 mm Hg
D. 80 mm Hg

138. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2
46 mm Hg; HCO3- 24mEq/L; Sao2 81%. This ABG result represents which of the following
conditions?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respirator y alkalosis

139. Norma has started a new drug for hypertension. Thirty minutes after she takes the drug,
she develops chest tightness and becomes short of breath and tachypneic. She has a decreased
level of consciousness. These signs indicate which of the following conditions?
A. Asthma attack
B. Pulmonary embolism
C. Respiratory failure
D. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out
cirrhosis of the liver:
140. Which laboratory test indicates liver cirrhosis?
A. Decreased red blood cell count
B. Decreased serum acid phosphate level
C. Elevated white blood cell count
D. Elevated serum aminotransferase

141.The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased
risk for excessive bleeding primarily because of:
A. Impaired clotting mechanism
B. Varix formation
C. Inadequate nutrition
D. Trauma of invasive procedure

142. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most
common with this condition?
A. Increased urine output
B. Altered level of consciousness
C. Decreased tendon reflex
D. Hypotension

143. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactose p.o.
every 2 hours. Mr. Gozales develops diarrhea. The nurse best action would be:
A. “I’ll see if your physician is in the hospital”.
B. “Maybe your reacting to the drug; I will withhold the next dose”.
C. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
D. “Frequently, bowel movements are needed to reduce sodium level”.

144. Which of the following groups of symptoms indicates a ruptured abdominal aortic
aneurysm?
A. Lower back pain, increased blood pressure, decreased re blood cell (RBC) count, increased
white blood (WBC) count.
B. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC
count.
C. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC
count, decreased WBC count.
D. Intermitted lower back pain, decreased blood pressure, decreased RBC count, increased
WBC count.

145. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his
buttocks. Which of the following steps should the nurse take first?
A. Call for help.
B. Obtain vital signs
C. Ask the client to “lift up”
D. Apply gloves and assess the groin site

146. Which of the following treatment is a suitable surgical intervention for a client with
unstable angina?
A. Cardiac catheterization
B. Echocardiogram
C. Nitroglycerin
D. Percutaneous transluminal coronary angioplasty (PTCA)

147. The nurse is aware that the following terms used to describe reduced cardiac output and
perfusion impairment due to ineffective pumping of the heart is:
A. Anaphylactic shock
B. Cardiogenic shock
C. Distributive shock
D. Myocardial infarction (MI)

148. A client with hypertension ask the nurse which factors can cause blood pressure to drop to
normal levels?
A. Kidneys’ excretion to sodium only.
B. Kidneys’ retention of sodium and water
C. Kidneys’ excretion of sodium and water
D. Kidneys’ retention of sodium and excretion of water

149. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is
administered to treat hypertension is:
A. It dilates peripheral blood vessels.
B. It decreases sympathetic cardioacceleration.
C. It inhibits the angiotensin-coverting enzymes
D. It inhibits reabsorption of sodium and water in the loop of Henle.

150. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus
erythematosus (SLE) is:
A. Elavated serum complement level
B. Thrombocytosis, elevated sedimentation rate
C. Pancytopenia, elevated antinuclear antibody (ANA) titer
D. Leukocysis, elevated blood urea nitrogen (BUN) and creatinine levels