LORMA COLLEGES

College of Nursing
RLE MICU
Write the letter of your choice. Choose the best
answer.
1. A client is wearing a continuous cardiac
monitor, which begins to sound its
alarm. A nurse sees no
electrocardiographic complexes on the
screen. Which of the following should be
the priority action of the nurse?
a. Call a code blue.
b. Call the physician.
c. Check the client status and lead
placement.
d. Press the recorder button on the
electrocardiogram console.
2. A nurse notices frequent artifact on the
electrocardiographic monitor for a client
whose leads are connected by cable to a
console at the bedside. The nurse
examines the client to determine the
cause. Which of the following items is
unlikely to be responsible for the
artifact?
a. Frequent movement of the client
b. Tightly secured cable connections
c. Leads applied over hairy areas
d. Leads applied to the limbs
3. A client who had cardiac surgery 24
hours ago has a urine output averaging
20 mL/hr for 2 hours. The client received
a single bolus of 500 mL of intravenous
fluid. Urine output for the subsequent
hour was 25 mL. Daily laboratory results
indicate that the blood urea nitrogen
level is 45 mg/dL and the serum
creatinine level is 2.2 mg/dL. Based on
these findings, the nurse would
anticipate that the client is at risk for
which of the following?
a. Hypovolemia
b. Acute renal failure
c. Glomerulonephritis
d. Urinary tract infection
4. A client with myocardial infarction is
developing cardiogenic shock. Because
of the risk of myocardial ischemia, for
which of the following should the nurse
carefully assess the client?
a. Bradycardia
b. Ventricular dysrhythmias
c. Rising diastolic blood pressure

d. Falling central venous pressure

5. A client with myocardial infarction
suddenly becomes tachycardic, shows
signs of air hunger, and begins coughing
frothy, pink-tinged sputum. Which of the
following would the nurse anticipate
when auscultating the client's breath
sounds?
a. Stridor
b. Crackles
c. Scattered rhonchi
d. Diminished breath sounds
6. A nurse is caring for a client who had a
resection of an abdominal aortic
aneurysm yesterday. The client has an
intravenous infusion with a rate of 150
mL/hr, unchanged for the last 10 hours.
The client's urine output for the last 3
hours was 90, 50, and 28 mL (28 mL
most recent). The client's blood urea
nitrogen level is 35 mg/dL and serum
creatinine level is 1.8 mg/dL, measured
this morning. Which of the following
actions should the nurse take next?
a. Call the physician.
b. Check the urine specific gravity.
c. Check to see if the client had a
sample for serum albumin level
drawn.
d. Put the intravenous line on a
pump so that the infusion rate is
sure to stay stable.
7. A client with angina complains that the
anginal pain is erratic and occurs at
lower levels of activity. How would the
nurse best describe this type of anginal
pain knowing that this is usually the
precursor to myocardial infarction?
a. Stable angina
b. Unexpected angina
c. Unstable angina
d. Nonanginal pain
8. A nurse in a medical unit is caring for a
client with heart failure. The client
suddenly develops extreme dyspnea,
tachycardia, and lung crackles and the
nurse suspects pulmonary edema. The
nurse immediately asks another nurse
to contact the physician and prepares to
implement which priority interventions?
Select all that apply.
a. Administering oxygen
b. Inserting a Foley catheter
c. Administering furosemide (Lasix)

d. Administering digoxin via infusion

pump
e. Transporting the client to the
coronary care unit
f. Placing the client in a low
Fowler's side-lying position
9. A client with atrial fibrillation is receiving
a continuous heparin infusion at 1000
units/hr. The nurse would determine that
the client is receiving the therapeutic
effect based on which of the following
results?
a. Prothrombin time of 12.5 seconds
b. Activated partial thromboplastin
time of 60 seconds
c. Activated prothrombin time of 28
seconds
d. Activated partial thromboplastin
time longer than 120 seconds
10. A nurse provides discharge instructions
to a postoperative client who is taking
warfarin sodium (Coumadin). Which
statement, if made by the client, reflects
the need for further teaching?
a. "I will take my pills every day at
the same time."
b. "I will avoid alcohol
consumption."
c. "I have already called my family
to pick up a Medic-Alert bracelet."
d. "I will take Ecotrin (enteric-coated
aspirin) for my headaches
because it is coated."
11. A client is diagnosed with an acute
myocardial infarction and is receiving
tissue plasminogen activator, alteplase
(Activase, tPA). Which of the following is
a priority nursing intervention?
a. Monitor for renal failure.
b. Monitor psychosocial status.
c. Monitor for signs of bleeding.
d. Have heparin sodium available.
12. Intravenous heparin therapy is
prescribed for a client. While
implementing this prescription, a nurse
ensures that which of the following
medications is available on the nursing
unit?
a. Protamine sulfate
b. Potassium chloride
c. Aminocaproic acid (Amicar)
d. Vitamin K (AquaMEPHYTON)

13. The nurse is monitoring a client who is

taking digoxin (Lanoxin) for adverse
effects. Which findings are characteristic
of digoxin toxicity. Select all that apply.
a. Diplopia
b. Diarrhea
c. Irritability
d. Blurred vision
e. Nausea and vomiting
14. A client with no history of cardiovascular
disease comes to the ambulatory clinic
with flu-like symptoms. The client
suddenly complains of chest pain. Which
of the following questions would best
help a nurse discriminate pain caused
by a noncardiac problem?
a. "Can you describe the pain to
me?"
b. "Have you ever had this pain
before?"
c. "Does the pain get worse when
you breathe in?"
d. "Can you rate the pain on a scale
of 1 to 10, with 10 being the
worst?"
15. A nurse is conducting a health history of
a client with a primary diagnosis of
heart failure. Which of the following
disorders reported by the client is
unlikely to play a role in exacerbating
the heart failure?
a. Atrial fibrillation
b. Nutritional anemia
c. Peptic ulcer disease
d. Recent upper respiratory
infection
16. A client who has developed severe
pulmonary edema would most likely
exhibit which of the following?
a. Mild anxiety
b. Slight anxiety
c. Extreme anxiety
d. Moderate anxiety
17. A client with pulmonary edema has been
on diuretic therapy. The client has an
order for additional furosemide (Lasix) in
the amount of 40 mg intravenous push.
Knowing that the client will also be
started on digoxin (Lanoxin), the nurse
should review which laboratory result?
a. Sodium level
b. Digoxin level
c. Creatinine level
d. Potassium level

18. The most important action the nurse

should do before and after suctioning a
client is
a. Placing the client in a supine position
b. Making sure that suctioning takes only
10-15 seconds
c. Evaluating for clear breath sounds
d. Hyperventilating the client with 100%
oxygen
19. The position of a conscious client during
suctioning is:
a. Fowler's
b. Supine position
c. Side-lying
d. Prone
20. Presence of overdistended and nonfunctional alveoli is a condition called:
a. Bronchitis
b. Emphysema
c. Empyema
d. Atelectasis
21. A nurse is preparing to obtain a sputum
specimen from a male client. Which of
the following nursing actions will facilitate
obtaining the specimen?
a. Limiting fluid
b. Having the client take deep breaths
c. Asking the client to spit into the
collection container
d. Asking the client to obtain the
specimen after eating
22. A nurse is suctioning fluids from a male
client via a tracheostomy tube. When
suctioning, the nurse must limit the
suctioning time to a maximum of:
a.
b.
c.
d.

1 minute
5 seconds
10 seconds
30 seconds

23. A nurse is suctioning fluids from a

female client through an endotracheal
tube. During the suctioning procedure,
the nurse notes on the monitor that the
heart rate is decreasing. Which if the
following is the appropriate nursing
intervention?
a.
b.
c.

Continue to suction
Notify the physician immediately
Stop the procedure and reoxygenate

the client
d. Ensure that the suction is limited to
15 seconds
24. The nurse is teaching a male client with
chronic bronchitis about breathing
exercises. Which of the following should
the nurse include in the teaching?
a. Make inhalation longer than
exhalation.
b. Exhale through an open mouth.
c. Use diaphragmatic breathing.
d. Use chest breathing.
25. Which phrase is used to describe the
volume of air inspired and expired with a
normal breath?
a.
b.
c.
d.

Total lung capacity

Forced vital capacity
Tidal volume
Residual volume

26. A female client must take streptomycin

for tuberculosis. Before therapy begins,
the nurse should instruct the client to
notify the physician if which health
concern occurs?
a.
b.
c.
d.

Impaired color discrimination

Increased urinary frequency
Decreased hearing acuity
Increased appetite

27. A male client is asking the nurse a

question regarding the Mantoux test for
tuberculosis. The nurse should base her
response on the fact that the:
a. Area of redness is measured in 2
days and determines whether
tuberculosis is present.
b. Skin test doesnt differentiate
between active and dormant tuberculosis
infection.
c. Presence of a wheal at the injection
site in 2 days indicates active
tuberculosis.
d. Test stimulates a reddened response
in some clients and requires a second
test in 3 months.
28. A female adult client has a tracheostomy
but doesnt require continuous mechanical
ventilation. When weaning the client from the

tracheostomy tube, the nurse initially should

plug the opening in the tube for:
a.
b.
c.
d.

15 to 60 seconds.
5 to 20 minutes.
30 to 40 minutes.
45 to 60 minutes.

29. For a male client with an endotracheal (ET)

tube, which nursing action is most essential?
a. Auscultating the lungs for bilateral
breath sounds
b. Turning the client from side to side
every 2 hours
c. Monitoring serial blood gas values
every 4 hours
d. Providing frequent oral hygiene
30. The nurse assesses a male clients
respiratory status. Which observation indicates
that the client is experiencing difficulty
breathing?
a.
b.
c.
d.

Diaphragmatic breathing
Use of accessory muscles
Pursed-lip breathing
Controlled breathing

31. A male client with chronic obstructive

pulmonary disease (COPD) is recovering from a
myocardial infarction. Because the client is
extremely weak and cant produce an effective
cough, the nurse should monitor closely for:
a.
b.
c.
d.

Pleural effusion.
Pulmonary edema.
Atelectasis.
Oxygen toxicity.

32. The nurse in charge is teaching a client

with emphysema how to perform pursed-lip
breathing. The client asks the nurse to explain
the purpose of this breathing technique. Which
explanation should the nurse provide?
a. It helps prevent early airway
collapse.
b. It increases inspiratory muscle
strength.
c. It decreases use of accessory
breathing muscles.
d. It prolongs the inspiratory phase of
respiration.
33. A male client suffers adult respiratory
distress syndrome as a consequence of shock.

The clients condition deteriorates rapidly, and

endotracheal (ET) intubation and mechanical
ventilation are initiated. When the highpressure alarm on the mechanical ventilator
sounds, the nurse starts to check for the cause.
Which condition triggers the high-pressure
alarm?
a. Kinking of the ventilator tubing
b. A disconnected ventilator tube
c. An ET cuff leak
d. A change in the oxygen
concentration without resetting the
oxygen level alarm
34. The nurse in charge formulates a nursing
diagnosis of Activity intolerance related to
inadequate oxygenation and dyspnea for a
client with chronic bronchitis. To minimize this
problem, the nurse instructs the client to avoid
conditions that increase oxygen demands.
Such conditions include:
a. Drinking more than 1,500 ml of fluid
daily.
b. smoking and being overweight.
c. Eating a high-protein snack at
bedtime.
d. Eating more than three large meals a
day.
35. A nurse is caring for a male client
hospitalized with acute exacerbation of chronic
obstructive pulmonary disease. Which of the
following would the nurse expect to note on
assessment of this client?
a. Hypocapnia
b. A hyperinflated chest noted on the chest
x-ray
c. Increase oxygen saturation with exercise
d. A widened diaphragm noted on the
chest x-ray
36. A community health nurse is conducting an
educational session with community members
regarding tuberculosis. The nurse tells the
group that one of the first symptoms
associated with tuberculosis is:
a. Dyspnea
b. Chest pain
c. A bloody, productive cough
d. A cough with the expectoration of
mucoid sputum
37. A nurse is caring for a male client with
emphysema who is receiving oxygen. The
nurse assesses the oxygen flow rate to ensure
that it does not exceed:

a.
b.
c.
d.

1 L/min
2 L/min
6 L/min
10 L/min

38. A nurse instructs a female client to use the

pursed-lip method of breathing and the client
asks the nurse about the purpose of this type
of breathing. The nurse responds, knowing that
the primary purpose of pursed-lip breathing is
to:
a. Promote oxygen intake.
b. Strengthen the diaphragm.
c. Strengthen the intercostal muscles.
d. Promote carbon dioxide elimination.
39. A nurse is assessing a male client with
chronic airflow limitations and notes that the
client has a "barrel chest." The nurse interprets
that this client has which of the following forms
of chronic airflow limitations?
a. Emphysema
b. Bronchial asthma
c. Chronic obstructive bronchitis
d. Bronchial asthma and bronchitis
40. In planning a patient education session, the
nurse sees one area of focus for Healthy People
2010 is chronic obstructive pulmonary disease
(COPD). Which of the following information
should the nurse include in the education
session to address this focus area?
a. Screening for environmental triggers
b. Smoking cessation
c. Develop action plans
d. Identify those at risk
GOOD LUCK NURSES!!!