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Exam-Part-1
MEDICAL-SURGICAL NURSING
Part 1
1. After a cerebrovascular accident, a 75 yr old
client is admitted to the health care facility. The
client has left-sided weakness and an absent
gag reflex. He’s incontinent and has a tarry
stool. His blood pressure is 90/50 mm Hg, and
his hemoglobin is 10 g/dl. Which of the following
is a priority for this client?
a. checking stools for occult blood
b. performing range-of-motion exercises to the
left side
c. keeping skin clean and dry
d. elevating the head of the bed to 30 degrees
ANS: D
Because the client’s gag reflex is absent,
elevating the head of the bed to 30 degrees
helps minimize the client’s risk of aspiration.
Checking the stools, performing ROM exercises,
and keeping the skin clean and dry are
important, but preventing aspiration through
positioning is the priority.
2. The nurse is caring for a client with a
colostomy. The client tells the nurse that he
makes small pin holes in the drainage bag to
help relieve gas. The nurse should teach him
that this action:
a. destroys the odor-proof seal
b. wont affect the colostomy system
c. is appropriate for relieving the gas in a
colostomy system
d. destroys the moisture barrier seal
ANS: A
Any hole, no matter how small, will destroy the
odor-proof seal of a drainage bag. Removing the
bag or unclamping it is the only appropriate
method for relieving gas.
3. When assessing the client with celiac
disease, the nurse can expect to find which of
the following?
a. steatorrhea
b. jaundiced sclerae
c. clay-colored stools
d. widened pulse pressure
ANS: A
because celiac disease destroys the absorbing
surface of the intestine, fat isn’t absorbed but is
passed in the stool. Steatorrhea is bulky, fatty
stools that have a foul odor. Jaundiced sclerae
result from elevated bilirubin levels. Clay-colored
stools are seen with biliary disease when bile
flow is blocked. Celiac disease doesn’t cause a
widened pulse pressure.
4. A client is hospitalized with a diagnosis of
chronic glomerulonephritis. The client mentions
that she likes salty foods. The nurse should warn
her to avoid foods containing sodium
because:
a. reducing sodium promotes urea nitrogen
excretion
b. reducing sodium improves her glomerular
filtration rate
c. reducing sodium increases potassium
absorption
d. reducing sodium decreases edema
ANS: D
Reducing sodium intake reduces fluid retention.
Fluid retention increases blood volume, which
changes blood vessel permeability and allows
plasma to move into interstitial tissue, causing
edema. Urea nitrogen excretion can be
increased only by improved renal function.
Sodium intake doesn’t affect the glomerular
filtration rate. Potassium absorption is improved
only by increasing the glomerular filtration rate; it
isn’t affected by sodium intake.
5. The nurse is caring for a client with a cerebral
injury that impaired his speech and hearing.
Most likely, the client has experienced damage
to the:
a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe
AN:S D
and hearing is the temporal lobe. Injury to the
frontal lobe causes personality changes,
difficulty speaking, and disturbance in memory,
reasoning, and concentration. Injury to the
parietal lobe causes sensory alterations and
problems with spatial relationships. Damage to
the occipital lobe causes vision disturbances.
6. The nurse is assessing a postcraniotomy
client and finds the urine output from a catheter
is 1500 ml for the 1st hour and the same for the
2nd hour. The nurse should suspect:
a. Cushing’s syndrome
b. Diabetes mellitus
c. Adrenal crisis
d. Diabetes insipidus
ANS: D
Diabetes insipidus is an abrupt onset of extreme
polyuria that commonly occurs in clients after
brain surgery. Cushing’s syndrome is excessive
glucocorticoid secretion resulting in sodium and
water retention. Diabetes mellitus is a
hyperglycemic state marked by polyuria,
polydipsia, and polyphagia. Adrenal crisis is
undersecretion of glucocorticoids resulting in
profound hypoglycemia, hypovolemia, and
hypotension.
7. The nurse is providing postprocedure care for
a client who underwent percutaneous lithotripsy.
In this procedure, an ultrasonic probe inserted
through a nephrostomy tube into the renal pelvis
generates ultra-high-frequency sound waves to
shatter renal calculi. The nurse should instruct
the client to:
a. limit oral fluid intake for 1 to 2 weeks
b. report the presence of fine, sandlike particles
through the nephrostomy tube.
c. Notify the physician about cloudy or foulsmelling
urine
d. Report bright pink urine within 24 hours after
the procedure
ANS: C
The client should report the presence of foulsmelling
or cloudy urine. Unless contraindicated,
the client should be instructed to drink large
quantities of fluid each day to flush the kidneys.
Sand-like debris is normal because of residual
stone products. Hematuria is common after
lithotripsy.
8. A client with a serum glucose level of 618
mg/dl is admitted to the facility. He’s awake and
oriented, has hot dry skin, and has the following
vital signs: temperature of 100.6º F (38.1º C),
heart rate of 116 beats/minute, and blood
pressure of 108/70 mm Hg. Based on these
assessment findings, which nursing diagnosis
takes the highest priority?
a. deficient fluid volume related to osmotic
diuresis
b. decreased cardiac output related to elevated
heart rate
c. imbalanced nutrition: Less than body
requirements related to insulin deficiency
d. ineffective thermoregulation related to
dehydration
ANS: A
A serum glucose level of 618 mg/dl indicates
hyperglycemia, which causes polyuria and
deficient fluid volume. In this client, tachycardia
is more likely to result from deficient fluid volume
than from decreased cardiac output because his
blood pressure is normal. Although the client’s
serum glucose is elevated, food isn’t a priority
because fluids and insulin should be
administered to lower the serum glucose level.
Therefore, a diagnosis of Imbalanced Nutrition:
Less then body requirements isn’t appropriate. A
temperature of 100.6º F isn’t life threatening,
eliminating ineffective thermoregulation as the
top priority.
9. 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. The
nurse should expect the dose’s:
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a. onset to be at 2 p.m. and its peak at 3 p.m.
b. onset to be at 2:15 p.m. and its peak at 3 p.m.
c. onset to be at 2:30 p.m. and its peak at 4 p.m.
d. onset to be at 4 p.m. and its peak at 6 p.m.
ANS: C
Regular insulin, which is a short-acting insulin,
has an onset of 15 to 30 minutes and a peak of
2 to 4 hours. Because the nurse gave the insulin
at 2 p.m., the expected onset would be from
2:15 to 2:30 p.m. and the peak from 4 p.m. to 6
p.m.
10. A client with a head injury is being monitored
for increased intracranial pressure (ICP). His
blood pressure is 90/60 mmHG and the ICP is
18 mmHg; therefore his cerebral perfusion
pressure (CPP) is:
a. 52 mm Hg
b. 88 mm Hg
c. 48 mm Hg
d. 68 mm Hg
ANS: A
CPP is derived by subtracting the ICP from the
mean arterial pressure (MAP). For adequate
cerebral perfusion to take place, the minimum
goal is 70 mmHg. The MAP is derived using the
following formula:
MAP = ((diastolic blood pressure x 2) + systolic
blood pressure) / 3
MAP = ((60 x2) + 90) / 3
MAP = 70 mmHg
To find the CPP, subtract the client’s ICP from
the MAP; in this case , 70 mmHg – 18 mmHg =
52 mmHg.
11. A 52 yr-old female tells the nurse that she
has found a painless lump in her right breast
during her monthly self-examination. Which
assessment finding would strongly suggest that
this client’s lump is cancerous?
a. eversion of the right nipple and a mobile mass
b. nonmobile mass with irregular edges
c. mobile mass that is oft and easily delineated
d. nonpalpable right axillary lymph nodes
ANS: B
Breast cancer tumors are fixed, hard, and poorly
delineated with irregular edges. Nipple retraction
—not eversion—may be a sign of cancer. A
mobile mass that is soft and easily delineated is
most often a fluid-filled benigned cyst. Axillary
lymph nodes may or may not be palpable on
initial detection of a cancerous mass.
12. A Client is scheduled to have a descending
colostomy. He’s very anxious and has many
questions regarding the surgical procedure, care
of stoma, and lifestyle changes. It would be most
appropriate for the nurse to make a referral to
which member of the health care team?
a. Social worker
b. registered dietician
c. occupational therapist
d. enterostomal nurse therapist
ANS: D
An enterostomal nurse therapist is a registered
nurse who has received advance education in
an accredited program to care for clients with
stomas. The enterostomal nurse therapist can
assist with selection of an appropriate stoma
site, teach about stoma care, and provide
emotional support.
13. Ottorrhea and rhinorrhea are most
commonly seen with which type of skull
fracture?
a. basilar
b. temporal
c. occipital
d. parietal
ANS: A
Ottorrhea and rhinorrhea are classic signs of
basilar skull fracture. Injury to the dura
commonly occurs with this fracture, resulting in
cerebrospinal fluid (CSF) leaking through the
ears and nose. Any fluid suspected of being
CSF should be checked for glucose or have a
halo test done.
14. A male client should be taught about
testicular examinations:
a. when sexual activity starts
b. after age 60
c. after age 40
d. before age 20
ANS: D
Testicular cancer commonly occurs in men
between ages 20 and 30. A male client should
be taught how to perform testicular selfexamination
before age 20, preferably when he
enters his teens.
15. Before weaning a client from a ventilator,
which assessment parameter is most important
for the nurse to review?
A. fluid intake for the last 24 hours
B. baseline arterial blood gas (ABG) levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results
ANS: B
Before weaning a client from mechanical
ventilation, it’s most important to have a baseline
ABG levels. During the weaning process, ABG
levels will be checked to assess how the client is
tolerating the procedure. Other assessment
parameters are less critical. Measuring fluid
volume intake and output is always important
when a client is being mechanically ventilated.
Prior attempts at weaning and ECG results are
documented on the client’s record, and the
nurse can refer to them before the weaning
process begins.
16. The nurse is speaking to a group of women
about early detection of breast cancer. The
average age of the women in the group is 47.
Following the American Cancer Society (ACS)
guidelines, the nurse should recommend that
the women:
A. perform breast self-examination annually
B. have a mammogram annually
C. have a hormonal receptor assay annually
D. have a physician conduct a clinical evaluation
every 2 years
ANS: B
According to the ACS guidelines, “Women older
than age 40 should perform breast selfexamination
monthly (not annually).” The
hormonal receptor assay is done on a known
breast tumor to determine whether the tumor is
estrogen- or progesterone-dependent.
17. When caring for a client with esophageal
varices, the nurse knows that bleeding in this
disorder usually stems from:
A. esophageal perforation
B. pulmonary hypertension
C. portal hypertension
D. peptic ulcers
ANS: C
Increased pressure within the portal veins
causes them to bulge, leading to rupture and
bleeding into the lower esophagus. Bleeding
associated with esophageal varices doesn’t
stem from esophageal perforation, pulmonary
hypertension, or peptic ulcers.
18. A 49-yer-old client was admitted for surgical
repair of a Colles’ fracture. An external fixator
was placed during surgery. The surgeon
explains that this method of repair:
A. has very low complication rate
B. maintains reduction and overall hand function
C. is less bothersome than a cast
D. is best for older people
ANS: B
Complex intra-articular fractures are repaired
with external fixators because they have a better
long-term outcome than those treated with
casting. This is especially true in a young client.
The incidence of complications, such as pin tract
infections and neuritis, is 20% to 60%. Clients
must be taught how to do pin care and assess
for development of neurovascular complications.
19. A client is hospitalized with a diagnosis of
chronic renal failure. An arteriovenous fistula
was created in his left arm for hemodialysis.
When preparing the client for discharge, the
nurse should reinforce which dietary instruction?
A. “Be sure to eat meat at every meal.”
B. “Monitor your fruit intake and eat plenty of
bananas.”
C. “Restrict your salt intake.”
D. “Drink plenty of fluids.”
ANS: C
In a client with chronic renal failure, unrestricted
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intake of sodium, protein, potassium, and fluids
may lead to a dangerous accumulation of
electrolytes and protein metabolic products,
such as amino acids and ammonia. Therefore,
the client must limit his intake of sodium, meat
(high in Protein), bananas (high in potassium),
and fluid because the kidneys can’t secrete
adequate urine.
20. The nurse is caring for a client who has just
had a modified radical mastectomy with
immediate reconstruction. She’s in her 30s and
has tow children. Although she’s worried about
her future, she seems to be adjusting well to her
diagnosis. What should the nurse do to support
her coping?
A. Tell the client’s spouse or partner to be
supportive while she recovers.
B. Encourage the client to proceed with the next
phase of treatment.
C. Recommend that the client remain cheerful
for the sake of her children.
D. Refer the client to the American Cancer
Society’s Reach for Recovery program or
another support program.
ANS: D
The client isn’t withdrawn or showing other signs
of anxiety or depression. Therefore, the nurse
can probably safely approach her about talking
with others who have had similar experiences,
either through Reach for Recovery or another
formal support group. The nurse may educate
the client’s spouse or partner to listen to
concerns, but the nurse shouldn’t tell the client’s
spouse what to do. The client must consult with
her physician and make her own decisions
about further treatment. The client needs to
express her sadness, frustration, and fear. She
can’t be expected to be cheerful at all times.
21. A 21 year-old male has been seen in the
clinic for a thickening in his right testicle. The
physician ordered a human chorionic
gonadotropin (HCG) level. The nurse’s
explanation to the client should include the fact
that:
A. The test will evaluate prostatic function.
B. The test was ordered to identify the site of a
possible infection.
C. The test was ordered because clients who
have testicular cancer has elevated levels of
HCG.
D. The test was ordered to evaluate the
testosterone level.
ANS: C
HCG is one of the tumor markers for testicular
cancer. The HCG level won’t identify the site of
an infection or evaluate prostatic function or
testosterone level.
22. A client is receiving captopril (Capoten) for
heart failure. The nurse should notify the
physician that the medication therapy is
ineffective if an assessment reveals:
A. A skin rash.
B. Peripheral edema.
C. A dry cough.
D. Postural hypotension.
ANS: B
Peripheral edema is a sign of fluid volume
overload and worsening heart failure. A skin
rash, dry cough, and postural hypotension are
adverse reactions to captopril, but the don’t
indicate that therapy isn’t effective.
23. Which assessment finding indicates
dehydration?
A. Tenting of chest skin when pinched.
B. Rapid filling of hand veins.
C. A pulse that isn’t easily obliterated.
D. Neck vein distention
ANS: A
Tenting of chest skin when pinched indicates
decreased skin elasticity due to dehydration.
Hand veins fill slowly with dehydration, not
rapidly. A pulse that isn’t easily obliterated and
neck vein distention indicate fluid overload, not
dehydration.
24. The nurse is teaching a client with a history
of atherosclerosis. To decrease the risk of
atherosclerosis, the nurse should encourage the
client to:
A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.
ANS: B
The client should be encouraged to increase his
activity level. Maintaining an ideal weight;
following a low-cholesterol, low-sodium diet; and
avoiding stress are all important factors in
decreasing the risk of atherosclerosis.
25. For a client newly diagnosed with
radiationinduced
thrombocytopenia, the nurse should
include which intervention in the plan of care?
A. Administer aspirin if the temperature exceeds
38.8º C.
B. Inspect the skin for petechiae once every
shift.
C. Provide for frequent periods of rest.
D. Place the client in strict isolation.
ANS: B
Because thrombocytopenia impairs blood
clotting, the nurse should assess the client
regularly for signs of bleeding, such as
petechiae, purpura, epistaxis, and bleeding
gums. The nurse should avoid administering
aspirin because it can increase the risk of
bleeding. Frequent rest periods are indicated for
clients with anemia, not thrombocytopenia. Strict
isolation is indicated only for clients who have
highly contagious or virulent infections that are
spread by air or physical contact.
26. A client is chronically short of breath and yet
has normal lung ventilation, clear lungs, and an
arterial oxygen saturation (SaO2) 96% or better.
The client most likely has:
A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure
ANS: B
SaO2 is the degree to which hemoglobin is
saturated with oxygen. It doesn’t indicate the
client’s overall Hgb adequacy. Thus, an
individual with a subnormal Hgb level could have
normal SaO2 and still be short of breath. In this
case, the nurse could assume that the client has
a Hematologic problem. Poor peripheral
perfusion would cause subnormal SaO2. There
isn’t enough data to assume that the client’s
problem is psychosomatic. If the problem were
left-sided heart failure, the client would exhibit
pulmonary crackles.
27. For a client in addisonian crisis, it would be
very risky for a nurse to administer:
A. potassium chloride
B. normal saline solution
C. hydrocortisone
D. fludrocortisone
ANS: A
Addisonian crisis results in Hyperkalemia;
therefore, administering potassium chloride is
contraindicated. Because the client will be
hyponatremic, normal saline solution is
indicated. Hydrocortisone and fludrocortisone
are both useful in replacing deficient adrenal
cortex hormones.
28. The nurse is reviewing the laboratory report
of a client who underwent a bone marrow
biopsy. The finding that would most strongly
support a diagnosis of acute leukemia is the
existence of a large number of immature:
A. lymphocytes
B. thrombocytes
C. reticulocytes
D. leukocytes
ANS: D
Leukemia is manifested by an abnormal
overpopulation of immature leukocytes in the
bone marrow.
29. The nurse is performing wound care on a
foot ulcer in a client with type 1 diabetes
mellitus. Which technique demonstrates surgical
asepsis?
A. Putting on sterile gloves then opening a
container of sterile saline.
B. Cleaning the wound with a circular motion,
moving from outer circles toward the center.
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C. Changing the sterile field after sterile water is
spilled on it.
D. Placing a sterile dressing ½” (1.3 cm) from
the edge of the sterile field.
ANS: C
A sterile field is considered contaminated when it
becomes wet. Moisture can act as a wick,
allowing microorganisms to contaminate the
field. The outside of containers, such as sterile
saline bottles, aren’t sterile. The containers
should be opened before sterile gloves are put
on and the solution poured over the sterile
dressings placed in a sterile basin. Wounds
should be cleaned from the most contaminated
area to the least contaminated area—for
example, from the center outward. The outer
inch of a sterile field shouldn’t be considered
sterile.
30. A client with a forceful, pounding heartbeat is
diagnosed with mitral valve prolapse. This client
should avoid which of the following?
A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein
ANS: C
Caffeine is a stimulant, which can exacerbate
palpitations and should be avoided by a client
with symptomatic mitral valve prolapse. Highfluid
intake helps maintain adequate preload and
cardiac output. Aerobic exercise helps in
increase cardiac output and decrease heart rate.
Protein-rich foods aren’t restricted but highcalorie
foods are.
31. A client with a history of hypertension is
diagnosed with primary hyperaldosteronism.
This diagnosis indicates that the client’s
hypertension is caused by excessive hormone
secretion from which organ?
A. adrenal cortex
B. pancreas
C. adrenal medulla
D. parathyroid
ANS: A
Excessive of aldosterone in the adrenal cortex is
responsible for the client’s hypertension. This
hormone acts on the renal tubule, where it
promotes reabsorption of sodium and excretion
of potassium and hydrogen ions. The pancreas
mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes the
cathecolamines—epinephrine and
norepinephrine. The parathyroids secrete
parathyroid hormone.
32. A client has a medical history of rheumatic
fever, type 1 (insulin dependent) diabetes
mellitus, hypertension, pernicious anemia, and
appendectomy. She’s admitted to the hospital
and undergoes mitral valve replacement surgery.
After discharge, the client is scheduled for a
tooth extraction. Which history finding is a major
risk factor for infective endocarditis?
A. appendectomy
B. pernicious anemia
C. diabetes mellitus
D. valve replacement
ANS: D
A heart valve prosthesis, such as a mitral valve
replacement, is a major risk factor for infective
endocarditis. Other risk factors include a history
of heart disease (especially mitral valve
prolapse), chronic debilitating disease, IV drug
abuse, and immunosuppression. Although
diabetes mellitus may predispose a person to
cardiovascular disease, it isn’t a major risk factor
for infective endocarditis, nor is an
appendectomy or pernicious anemia.
33. A 62 yr-old client diagnosed with
pyelonephritis and possible septicemia has had
five urinary tract infections over the past two
years. She’s fatigued from lack of sleep; urinates
frequently, even during the night; and has lost
weight recently. Test reveal the following: sodium
level 152 mEq/L, osmolarity 340 mOsm/L,
glucose level 125 mg/dl, and potassium level 3.8
mEq/L. which of the following nursing diagnoses
is most appropriate for this client?
A. Deficient fluid volume related to inability to
conserve water
B. Imbalanced nutrition: less than body
requirements related to hypermetabolic state
C. Deficient fluid volume related to osmotic
diuresis induced by hypernatremia
D. Imbalanced nutrition: less than body
requirements related to catabolic effects of
insulin deficiency
ANS: A
The client has signs and symptoms of diabetes
insipidus, probably caused by the failure of her
renal tubules to respond to antidiuretic hormone
as a consequence of pyelonephritis. The
hypernatremia is secondary to her water loss.
Imbalanced nutrition related to hypermetabolic
state or catabolic effect of insulin deficiency is an
inappropriate nursing diagnosis for the client.
34. A 20 yr-old woman has just been diagnosed
with Crohn’s disease. She has lost 10 lb (4.5 kg)
and has cramps and occasional diarrhea. The
nurse should include which of the following
when doing a nutritional assessment?
A. Let the client eat as desired during the
hospitalization.
B. Weight the client daily.
C. Ask the client to list what she eats during a
typical day.
D. Place the client on I & O status and draw
blood for electrolyte levels.
ANS: C
When performing a nutritional assessment, one
of the first things the nurse should do is to
assess what the client typically eats. The client
shouldn’t be permitted to eat as desired.
Weighing the client daily, placing her on I & O
status, and drawing blood to determine
electrolyte level aren’t part of a nutritional
assessment.
35. When instructions should be included in the
discharge teaching plan for a client after
thyroidectomy for Grave’s disease?
A. Keep an accurate record of intake and output.
B. Use nasal desmopressin acetate DDAVP).
C. Be sure to get regulate follow-up care.
D. Be sure to exercise to improve cardiovascular
fitness.
Regular follow-up care for the client with Grave’s
disease is critical because most cases
eventually result in hypothyroidism. Annual
thyroid-stimulating hormone tests and the
client’s ability to recognize signs and symptoms
of thyroid dysfunction will help detect thyroid
abnormalities early. Intake and output is
important for clients with fluid and electrolyte
imbalances but not thyroid disorders. DDAVP is
used to treat diabetes insipidus. While exercise
to improve cardiovascular fitness is important,
for this client the importance of regular follow-up
is most critical.
36. A client comes to the emergency department
with chest pain, dyspnea, and an irregular
heartbeat. An electrocardiogram shows a heart
rate of 110 beats/minute (sinus tachycardia) with
frequent premature ventricular contractions.
Shortly after admission, the client has ventricular
tachycardia and becomes unresponsive. After
successful resuscitation, the client is taken to
the intensive care unit. Which nursing diagnosis
is appropriate at this time?
A. Deficient knowledge related to interventions
used to treat acute illness
B. Impaired physical mobility related to complete
bed rest
C. Social isolation related to restricted visiting
hours in the intensive care unit
D. Anxiety related to the threat of death
ANS: D
Anxiety related to the threat of death is an
appropriate nursing diagnosis because the
client’s anxiety can adversely affect hear rate
and rhythm by stimulating the autonomic
nervous system. Also, because the client
required resuscitation, the threat of death is a
real and immediate concern. Unless anxiety is
dealt with first, the client’s emotional state will
impede learning. Client teaching should be
limited to clear concise explanations that reduce
anxiety and promote cooperation. An anxious
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client has difficulty learning, so the deficient
knowledge would continue despite attempts t
teaching. Impaired physical mobility and social
isolation are necessitated by the client’s critical
condition; therefore, they aren’t considered
problems warranting nursing diagnoses.
37. A client is admitted to the health care facility
with active tuberculosis. The nurse should
include which intervention in the plan of care?
A. Putting on a mask when entering the client’s
room.
B. Instructing the client to wear a mask at all
times
C. Wearing a gown and gloves when providing
direct care
D. Keeping the door to the client’s room open to
observe the client
ANS: A
Because tuberculosis is transmitted by droplet
nuclei from the respiratory tract, the nurse
should put on a mask when entering the client’s
room. Having the client wear a mask at all the
times would hinder sputum expectoration and
make the mask moist from respirations. If no
contact with the client’s blood or body fluids is
anticipated, the nurse need not wear a gown or
gloves when providing direct care. A client with
tuberculosis should be in a room with laminar air
flow, and the door should be closed at all times.
38. The nurse is caring for a client who
underwent a subtotal gastrectomy 24 hours
earlier. The client has a nasogastric (NG) tube.
The nurse should:
A. Apply suction to the NG tube every hour.
B. Clamp the NG tube if the client complains of
nausea.
C. Irrigate the NG tube gently with normal saline
solution.
D. Reposition the NG tube if pulled out.
ANS: C
The nurse can gently irrigate the tube but must
take care not to reposition it. Repositioning can
cause bleeding. Suction should be applied
continuously, not every hour. The NG tube
shouldn’t be clamped postoperatively because
secretions and gas will accumulate, stressing
the suture line.
39. Which statement about fluid replacement is
accurate for a client with hyperosmolar
hyperglycemic nonketotic syndrome (HHNS)?
A. administer 2 to 3 L of IV fluid rapidly
B. administer 6 L of IV fluid over the first 24
hours
C. administer a dextrose solution containing
normal saline solution
D. administer IV fluid slowly to prevent
circulatory overload and collapse
ANS: A
Regardless of the client’s medical history, rapid
fluid resuscitation is critical for maintaining
cardiovascular integrity. Profound intravascular
depletion requires aggressive fluid replacement.
A typical fluid resuscitation protocol is 6 L of fluid
over the first 12 hours, with more fluid to follow
over the next 24 hours. Various fluids can be
used, depending on the degree of hypovolemia.
Commonly prescribed fluids include dextran (in
case of hypovolemic shock), isotonic normal
saline solution and, when the client is stabilized,
hypotonic half-normal saline solution.
40. Which of the following is an adverse reaction
to glipizide (Glucotrol)?
A. headache
B. constipation
C. hypotension
D. photosensitivity
ANS: D
Glipizide may cause adverse skin reactions,
such as pruritus, and photosensitivity. It doesn’t
cause headache, constipation, or hypotension.
41. The nurse is caring for four clients on a stepdown
intensive care unit. The client at the
highest risk for developing nosocomial
pneumonia is the one who:
A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a jejunostomy
tube
ANS: B
When clients are on mechanical ventilation, the
artificial airway impairs the gag and cough
reflexes that help keep organisms out of the
lower respiratory tract. The artificial airway also
prevents the upper respiratory system from
humidifying and heating air to enhance
mucociliary clearance. Manipulations of the
artificial airway sometimes allow secretions into
the lower airways. Whit standard procedures the
other choices wouldn’t be at high risk.
42. The nurse is teaching a 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.
ANS: C
In chronic bronchitis, the diaphragmatic is flat
and weak. Diaphragmatic breathing helps to
strengthen the diaphragm and maximizes
ventilation. Exhalation should longer than
inhalation to prevent collapse of the bronchioles.
The client with chronic bronchitis should exhale
through pursed lips to prolong exhalation, keep
the bronchioles from collapsing, and prevent air
trapping. Diaphragmatic breathing—not chest
breathing—increases lung expansion.
43. A client is admitted to the hospital with an
exacerbation of her chronic systemic lupus
erythematosus (SLE). She gets angry when her
call bell isn’t answered immediately. The most
appropriate response to her would be:
A. “You seem angry. Would you like to talk about
it?”
B. “Calm down. You know that stress will make
your symptoms worse.”
C. “Would you like to talk about the problem with
the nursing supervisor?”
D. “I can see you’re angry. I’ll come back when
you’ve calmed down.”
ANS: A
Verbalizing the observed behavior is a
therapeutic communication technique in which
the nurse acknowledges what the client is
feeling. Offering to listen to the client express
her anger can help the nurse and the client
understand its cause and begin to deal with it.
Although stress can exacerbate the symptoms
of SLE, telling the client to calm down doesn’t
acknowledge her feelings. Offering to get the
nursing supervisor also doesn’t acknowledge the
client’s feelings. Ignoring the client’s feelings
suggest that the nurse has no interest in what
the client has said.
44. On a routine visit to the physician, a client
with chronic arterial occlusive disease reports
stopping smoking after 34 years. To relive
symptoms of intermittent claudication, a
condition associated with chronic arterial
occlusive disease, the nurse should recommend
which additional measure?
A. Taking daily walks.
B. Engaging in anaerobic exercise.
C. Reducing daily fat intake to less than 45% of
total calories
D. Avoiding foods that increase levels of highdensity
lipoproteins (HDLs)
ANS: A
Daily walks relieve symptoms of intermittent
claudication, although the exact mechanism is
unclear. Anaerobic exercise may exacerbate
these symptoms. Clients with chronic arterial
occlusive disease must reduce daily fat intake to
30% or less of total calories. The client should
limit dietary cholesterol because hyperlipidemia
is associated with atherosclerosis, a known
cause of arterial occlusive disease. However,
HDLs have the lowest cholesterol concentration,
so this client should eat foods that raise HDL
levels.
45. A physician orders gastric decompression for
a client with small bowel obstruction. The nurse
should plan for the suction to be:
A. low pressure and intermittent
5
B. low pressure and continuous
C. high pressure and continuous
D. high pressure and intermittent
ANS: A
Gastric decompression is typically low pressure
and intermittent. High pressure and continuous
gastric suctioning predisposes the gastric
mucosa to injury and ulceration.
46. Which nursing diagnosis is most appropriate
for an elderly client with osteoarthritis?
A. Risk for injury
B. Impaired urinary elimination
C. Ineffective breathing pattern
D. Imbalanced nutrition: less than body
requirements
ANS: A
In osteoarthritis, stiffness is common in large,
weight bearing joints such as the hips. This joint
stiffness alters functional ability and range of
motion, placing the client at risk for falling and
injury. Therefore, client safety is in jeopardy.
Osteoporosis doesn’t affect urinary elimination,
breathing, or nutrition.
47. Parathyroid hormone (PTH) has which
effects on the kidney?
A. Stimulation of calcium reabsorption and
phosphate excretion
B. Stimulation of phosphate reabsorption and
calcium excretion
C. Increased absorption of vit D and excretion of
vit E
D. Increased absorption of vit E and excretion of
Vit D
ANS: A
PTH stimulates the kidneys to reabsorb calcium
and excrete phosphate and converts vit D to its
active form: 1 , 25 dihydroxyvitamin D. PTH
doesn’t have a role in the metabolism of Vit E.
48. A visiting nurse is performing home
assessment for a 59-yr old man recently
discharged after hip replacement surgery. Which
home assessment finding warrants health
promotion teaching from the nurse?
A. A bathroom with grab bars for the tub and
toilet
B. Items stored in the kitchen so that reaching
up and bending down aren’t necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with switches t the
top and bottom of the stairs
ANS: C
The presence of unsecured area rugs poses a
hazard in all homes, particularly in one with a
resident at high risk for falls.
49. A client with autoimmune thrombocytopenia
and a platelet count of 800/uL develops epistaxis
and melena. Treatment with corticosteroids and
immunoglobulins has been unsuccessful, and
the physician recommends a splenectomy. The
client states, “I don’t need surgery—this will go
away on its own.” In considering her response to
the client, the nurse must depend on the ethical
principle of:
A. beneficence
B. autonomy
C. advocacy
D. justice
ANS: B
Autonomy ascribes the right of the individual to
make his own decisions. In this case, the client
is capable of making his own decision and the
nurse should support his autonomy. Beneficence
and justice aren’t the principles that directly
relate to the situation. Advocacy is the nurse’s
role in supporting the principle of autonomy.
50. Which of the following is t he most critical
intervention needed for a client with myxedema
coma?
A. Administering and oral dose of levothyroxine
(Synthroid)
B. Warming the client with a warming blanket
C. Measuring and recording accurate intake and
output
D. Maintaining a patent airway
ANS: D
Because respirations are depressed in
myxedema coma, maintaining a patent airway is
the most critical nursing intervention. Ventilatory
support is usually needed. Thyroid replacement
will be administered IV. Although myxedema
coma is associated with severe hypothermia, a
warming blanket shouldn’t be used because it
may cause vasodilation and shock. Gradual
warming blankets would be appropriate. Intake
and output are very important but aren’t critical
interventions at this time.
MEDICAL-SURGICAL PART2
51. Because diet and exercise have failed to
control a 63 yr-old client’s blood glucose level,
the client is prescribed glipizide (Glucotrol). After
oral administration, the onset of action is:A. 15
to 30 minutes
B. 30 to 60 minutes
C. 1 to 1 ½ hours
D. 2 to 3 hours
ANS: A
Glipizide begins to act in 15 to 30 minutes. The
other options are incorrect.
52. A client with pneumonia is receiving
supplemental oxygen, 2 L/min via nasal cannula.
The client’s history includes chronic obstructive
pulmonary disease (COPD) and coronary artery
disease. Because of these findings, the nurse
closely monitors the oxygen flow and the client’s
respiratory status. Which complication may arise
if the client receives a high oxygen
concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis
ANS: A
Hypoxia is the main breathing stimulus for a
client with COPD. Excessive oxygen
administration may lead to apnea by removing
that stimulus. Anginal pain results from a
reduced myocardial oxygen supply. A client with
COPD may have anginal pain from generalized
vasoconstriction secondary to hypoxia; however,
administering oxygen at any concentration
dilates blood vessels, easing anginal pain.
Respiratory alkalosis results from alveolar
hyperventilation, not excessive oxygen
administration. In a client with COPD, high
oxygen concentrations decrease the ventilatory
drive, leading to respiratory acidosis, not
alkalosis. High oxygen concentrations don’t
cause metabolic acidosis.
53. A client with type 1 diabetes mellitus has
been on a regimen of multiple daily injection
therapy. He’s being converted to continuous
subcutaneous insulin therapy. While teaching
the client bout continuous subcutaneous insulin
therapy, the nurse would be accurate in telling
him the regimen includes the use of:
A. intermediate and long-acting insulins
B. short and long-acting insulins
C. short-acting only
D. short and intermediate-acting insulins
ANS: C
Continuous subcutaneous insulin regimen uses
a basal rate and boluses of short-acting insulin.
Multiple daily injection therapy uses a
combination of short-acting and intermediate or
long-acting insulins.
54. a client who recently had a cerebrovascular
accident requires a cane to ambulate. When
teaching about cane use, the rationale for
holding a cane on the uninvolved side is to:
A. prevent leaning
B. distribute weight away from the involved side
C. maintain stride length
D. prevent edema
ANS: B
Holding a cane on the uninvolved side
distributes weight away from the involved side.
Holding the cane close to the body prevents
leaning. Use of a cane won’t maintain stride
length or prevent edema.
55. A client with a history of an anterior wall
myocardial infarction is being transferred from
the coronary care unit (CCU) to the cardiac stepdown
unit (CSU). While giving report to the CSU
nurse, the CCU nurse says, “His pulmonary
artery wedge pressures have been in the high
normal range.” The CSU nurse should be
6
especially observant for:
A. hypertension
B. high urine output
C. dry mucous membranes
D. pulmonary crackles
ANS: D
High pulmonary artery wedge pressures are
diagnostic for left-sided heart failure. With leftsided
heart failure, pulmonary edema can
develop causing pulmonary crackles. In leftsided
heart failure, hypotension may result and
urine output will decline. Dry mucous
membranes aren’t directly associated with
elevated pulmonary artery wedge pressures.
56. The nurse is caring for a client with a
fractures hip. The client is combative, confused,
and trying to get out of bed. The nurse should:
A. leave the client and get help
B. obtain a physician’s order to restrain the client
C. read the facility’s policy on restraints
D. order soft restraints from the storeroom
ANS: B
It’s mandatory in most settings to have a
physician’s order before restraining a client. A
client should never be left alone while the nurse
summons assistance. All staff members require
annual instruction on the use of restraints, and
the nurse should be familiar with the facility’s
policy.
57. For the first 72 hours after thyroidectomy
surgery, the nurse would assess the client for
Chvostek’s sign and Trousseau’s sign because
they indicate which of the following?A.
hypocalcemia
B. hypercalcemia
C. hypokalemia
D. Hyperkalemia
ANS: A
The client who has undergone a thyroidectomy
is t risk for developing hypocalcemia from
inadvertent removal or damage to the
parathyroid gland. The client with hypocalcemia
will exhibit a positive Chvostek’s sign (facial
muscle contraction when the facial nerve in front
of the ear is tapped) and a positive Trousseau’s
sign (carpal spasm when a blood pressure cuff
is inflated for few minutes). These signs aren’t
present with hypercalcemia, hypokalemia, or
Hyperkalemia.
58. In a client with enteritis and frequent
diarrhea, the nurse should anticipate an acidbase
imbalance of:
A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis
ANS: C
Diarrhea causes a bicarbonate deficit. With loss
of the relative alkalinity of the lower GI tract, the
relative acidity of the upper GI tract
predominates leading to metabolic acidosis.
Diarrhea doesn’t lead to respiratory acid-base
imbalances, such as respiratory acidosis and
respiratory alkalosis. Loss of acid, which occurs
with severe vomiting, may lead to metabolic
alkalosis.
59. When caring for a client with the nursing
diagnosis Impaired swallowing related to
neuromuscular impairment, the nurse should:
A. position the client in a supine position
B. elevate the head of the bed 90 degrees
during meals
C. encourage the client to remove dentures
D. encourage thin liquids for dietary intake
ANS: B
The head of the bed must be elevated while the
client is eating. The client should be placed in a
recumbent position—not a supine position—
when lying down to reduce the risk of aspiration.
Encourage the client to wear properly fitted
dentures to enhance his chewing ability.
Thickened liquids, not thin liquids, decrease
aspiration risk.
60. A nurse is caring for a client who has a
tracheostomy and temperature of 39º C. which
intervention will most likely lower the client’s
arterial blood oxygen saturation?
A. Endotracheal suctioning
B. Encouragement of coughing
C. Use of cooling blanket
D. Incentive spirometry
ANS: A
Endotracheal suctioning secretions as well as
gases from the airway and lowers the arterial
oxygen saturation (SaO2) level. Coughing and
incentive spirometry improve oxygenation and
should raise or maintain oxygen saturation.
Because of superficial vasoconstriction, using a
cooling blanket can lower peripheral oxygen
saturation readings, but SaO2 levels wouldn’t be
affected.
61. A client with a solar burn of the chest, back,
face, and arms is seen in urgent care. The
nurse’s primary concern should be:A. fluid
resuscitation
B. infection
C. body image
D. pain management
ANS: D
With a superficial partial thickness burn such as
a solar burn (sunburn), the nurse’s main concern
is pain management. Fluid resuscitation and
infection become concerns if the burn extends to
the dermal and subcutaneous skin layers. Body
image disturbance is a concern that has a lower
priority than pain management.
62. Which statement is true about crackles?
A. They’re grating sounds.
B. They’re high-pitched, musical squeaks.
C. They’re low-pitched noises that sound like
snoring.
D. They may be fine, medium, or course.
ANS: D
Crackles result from air moving through airways
that contain fluid. Heard during inspiration and
expiration, crackles are discrete sounds that
vary in pitch and intensity. They’re classified as
fine, medium, or coarse. Pleural friction rubs
have a distinctive grating sound. As the name
indicates, these breath sounds result when
inflamed pleurae rub together. Continuous,
highpitched,
musical squeaks, called wheezes, result
when air moves rapidly through airways
narrowed by asthma or infection or when an
airway is partially obstructed by a tumor or
foreign body. Wheezes, like gurgles, occur on
expiration and sometimes on inspiration. Loud,
coarse, low-pitched sounds resembling snoring
are called gurgles. These sounds develop when
thick secretions partially obstruct airflow through
the large upper airways.
63. A woman whose husband was recently
diagnosed with active pulmonary tuberculosis
(TB) is a tuberculin skin test converter.
Management of her care would include:
A. scheduling her for annual tuberculin skin
testing
B. placing her in quarantine until sputum
cultures are negative
C. gathering a list of persons with whom she has
had recent contact
D. advising her to begin prophylactic therapy
with isoniazid (INH)
Individuals who are tuberculin skin test
converters should begin a 6-month regimen of
an antitubercular drug such as INH, and they
should never have another skin test. After an
individual has a positive tuberculin skin test,
subsequent skin tests will cause severe skin
reactions but won’t provide new information
about the client’s TB status. The client doesn’t
have active TB, so can’t transmit, or spread, the
bacteria. Therefore, she shouldn’t be
quarantined or asked for information about
recent contacts.
64. The nurse is caring for a client who ahs had
an above the knee amputation. The client
refuses to look at the stump. When the nurse
attempts to speak with the client about his
surgery, he tells the nurse that he doesn’t wish
to discuss it. The client also refuses to have his
family visit. The nursing diagnosis that best
describes the client’s problem is:
A. Hopelessness
B. Powerlessness
7
C. Disturbed body image
D. Fear
ANS: C
Disturbed body image is a negative perception
of the self that makes healthful functioning more
difficult. The defining characteristics for this
nursing diagnosis include undergoing a change
in body structure or function, hiding or
overexposing a body part, not looking at a body
part, and responding verbally or nonverbally to
the actual or perceived change in structure or
function. This client may have any of the other
diagnoses, but the signs and symptoms
described in he case most closely match the
defining characteristics for disturbed body
image.
65. A client with three children who is still I the
child bearing years is admitted for surgical repair
of a prolapsed bladder. The nurse would find
that the client understood the surgeon’s
preoperative teaching when the client states:
A. “If I should become pregnant again, the child
would be delivered by cesarean delivery.”
B. “If I have another child, the procedure may
need to be repeated.”
C. “This surgery may render me incapable of
conceiving another child.”
D. “This procedure is accomplished in two
separate surgeries.”
ANS: B
Because the pregnant uterus exerts a lot of
pressure on the urinary bladder, the bladder
repair may need to be repeated. These clients
don’t necessarily have to have a cesarean
delivery if they become pregnant, and this
procedure doesn’t render them sterile. This
procedure is completed in one surgery.
66. A client experiences problems in body
temperature regulation associated with a skin
impairment. Which gland is most likely involved?
A. Eccrine
B. Sebaceous
C. Apocrine
D. Endocrine
ANS: A
Eccrine glands are associated with body
temperature regulation. Sebaceous glands
lubricate the skin and hairs, and apocrine glands
are involved in bacteria decomposition.
Endocrine glands secrete hormones responsible
for the regulation of body processes, such as
metabolism and glucose regulation.
67. A school cafeteria worker comes to the
physician’s office complaining of severe scalp
itching. On inspection, the nurse finds nail marks
on the scalp and small light-colored round
specks attached to the hair shafts close to the
scalp. These findings suggest that the client
suffers from:
A. scabies
B. head lice
C. tinea capitis
D. impetigo
ANS: B
The light-colored spots attached to the hair
shafts are nits, which are the eggs of head lice.
They can’t be brushed off the hair shaft like
dandruff. Scabies is a contagious dermatitis
caused by the itch mite, Sacoptes scabiei, which
lives just beneath the skin. Tinea capitis, or
ringworm, causes patchy hair loss and circular
lesions with healing centers. Impetigo is an
infection caused by Staphylococcus or
Sterptococcus, manifested by vesicles or
pustules that form a thick, honey-colored crust.
68. Following a small-bowel resection, a client
develops fever and anemia. The surface
surrounding the surgical wound is warm to touch
and necrotizing fasciitis is suspected. Another
manifestation that would most suggest
necrotizing fasciitis is:
A. erythema
B. leukocytosis
C. pressure-like pain
D. swelling
ANS: C
Severe pressure-like pain out of proportion to
visible signs distinguishes necrotizing fasciitis
from cellulites. Erythema, leukocytosis, and
swelling are present in both cellulites and
necrotizing fasciitis.
69. A 28 yr-old nurse has complaints of itching
and a rash of both hands. Contact dermatitis is
initially suspected. The diagnosis is confirmed if
the rash appears:
A. erythematous with raised papules
B. dry and scaly with flaking skin
C. inflamed with weeping and crusting lesions
D. excoriated with multiple fissures
ANS: A
Contact dermatitis is caused by exposure to a
physical or chemical allergen, such as cleaning
products, skin care products, and latex gloves.
Initial symptoms of itching, erythema, and raised
papules occur at the site of the exposure and
can begin within 1 hour of exposure. Allergic
reactions tend to be red and not scaly or flaky.
Weeping, crusting lesions are also uncommon
unless the reaction is quite severe or has been
present for a long time. Excoriation is more
common in skin disorders associated with a
moist environment.
70. When assessing a client with partial
thickness burns over 60% of the body, which of
the following should the nurse report
immediately?
A. Complaints of intense thirst
B. Moderate to severe pain
C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice
ANS: D
Hoarseness indicate injury to the respiratory
system and could indicate the need for
immediate intubation. Thirst following burns is
expected because of the massive fluid shifts and
resultant loss leading to dehydration. Pain,
either severe or moderate, is expected with a
burn injury. The client’s output is adequate.
71. A client is admitted to the hospital following a
burn injury to the left hand and arm. The client’s
burn is described as white and leathery with no
blisters. Which degree of severity is this burn?
A. first-degree burn
B. second-degree burn
C. third-degree burn
D. fourth-degree burn
ANS: C
Third-degree burn may appear white, red, or
black and are dry and leathery with no blisters.
There may be little pain because nerve endings
have been destroyed. First-degree burns are
superficial and involve the epidermis only. There
is local pain and redness but no blistering.
Second-degree burn appear red and moist with
blister formation and are painful. Fourth-degree
burns involve underlying muscle and bone
tissue.
72. The nurse is caring for client with a new
donor site that was harvested to treat a new
burn. The nurse position the client to:
A. allow ventilation of the site
B. make the site dependent
C. avoid pressure on the site
D. keep the site fully covered
ANS: C
A universal concern I the care of donor sites for
burn care is to keep the site away from sources
of pressure. Ventilation of the site and keeping
the site fully covered are practices in some
institutions but aren’t hallmarks of donor site
care. Placing the site in a position of
dependence isn’t a justified aspect of donor site
care.
73. a 45-yr-old auto mechanic comes to the
physician’s office because an exacerbation of
his psoriasis is making it difficult to work. He tells
the nurse that his finger joints are stiff and sore
in the morning. The nurse should respond by:
A. Inquiring further about this problem because
psoriatic arthritis can accompany psoriasis
vulgaris
B. Suggesting he take aspirin for relief because
it’s probably early rheumatoid arthritis
C. Validating his complaint but assuming it’s an
adverse effect of his vocation
D. Asking him if he has been diagnosed or
8
treated for carpal tunnel syndrome
ANS: A
Anyone with psoriasis vulgaris who reports joint
pain should be evaluated for psoriaic arthritis.
Approximately 15% to 20% of individuals with
psoriasis will also develop psoriatic arthritis,
which can be painful and cause deformity. It
would be incorrect to assume that his pain is
caused by early rheumatoid arthritis or his
vocation without asking more questions or
performing diagnostic studies. Carpal tunnel
syndrome causes sensory and motor changes in
the fingers rather than localized pain in the
joints.
74. The nurse is providing home care
instructions to a client who has recently had a
skin graft. Which instruction is most important for
the client to remember?
A. Use cosmetic camouflage techniques.
B. Protect the graft from direct sunlight.
C. Continue physical therapy.
D. Apply lubricating lotion to the graft site.
ANS: B
To avoid burning and sloughing, the client must
protect the graft from sunlight. The other three
interventions are all helpful to the client and his
recovery but are less important.
75. a 28 yr-old female nurse is seen in the
employee health department for mild itching and
rash of both hands. Which of the following could
be causing this reaction?
A. possible medication allergies
B. current life stressors she may be
experiencing
C. chemicals she may be using and use of latex
gloves
D. recent changes made in laundry detergent or
bath soap.
ANS: C
Because the itching and rash are localized, an
environmental cause in the workplace should be
suspected. With the advent of universal
precautions, many nurses are experiencing
allergies to latex gloves. Allergies to
medications, laundry detergents, or bath soaps
or a dermatologic reaction to stress usually elicit
a more generalized or widespread rash.
76. The nurse assesses a client with urticaria.
The nurse understands that urticaria is another
name for:
A. hives
B. a toxin
C. a tubercle
D. a virus
ANS: A
Hives and urticaria are two names for the same
skin lesion. Toxin is a poison. A tubercle is a tiny
round nodule produced by the tuberculosis
bacillus. A virus is an infectious parasite.
77. A client with psoriasis visits the dermatology
clinic. When inspecting the affected areas, the
nurse expects to see which type of secondary
lesion?
A. scale
B. crust
C. ulcer
D. scar
ANS: A
A scale is the characteristic secondary lesion
occurring in psoriasis. Although crusts, ulcers,
and scars also are secondary lesions in skin
disorders, they don’t accompany psoriasis.
78. The nurse is caring for a bedridden, elderly
adult. To prevent pressure ulcers, which
intervention should the nurse include in the plan
of care?
A. Turn and reposition the client a minimum of
every 8 hours.
B. Vigorously massage lotion into bony
prominences.
C. Post a turning schedule at the client’s
bedside.
D. Slide the client, rather than lifting when
turning.
ANS: C
A turning schedule with a signing sheet will help
ensure that the client gets turned and thus, help
prevent pressure ulcers. Turning should occur
every 1-2 hours—not every 8 hours—for clients
who are in bed for prolonged periods. The nurse
should apply lotion to keep the skin moist but
should avoid vigorous massage, which could
damage capillaries. When moving the client, the
nurse should lift rather than slide the client to
void shearing.
79. Following a full-thickeness (3rd degree) burn
of his left arm, a client is treated with artificial
skin. The client understands postoperative care
of the artificial skin when he states that during
the first 7 days after the procedure, he’ll restrict:
A. range of motion
B. protein intake
C. going outdoors
D. fluid ingestion
ANS: A
To prevent disruption of the artificial skin’s
adherence to the wound bed, the client should
restrict range of motion of the involved limb.
Protein intake and fluid intake are important for
healing and regeneration and shouldn’t be
restricted. Going outdoors is acceptable as long
as the left arm is protected from direct sunlight.
80. A client received burns to his entire back and
left arm. Using the Rule of Nines, the nurse can
calculate that he has sustained burns on what
percentage of his body?
A. 9%
B. 18%
C. 27%
D. 36%
ANS: C
According to the Rule of Nines, the posterior and
anterior trunk, and legs each make up 18% of
the total body surface. The head, neck, and
arms each make up 9% of total body durface,
and the perineum makes up 1%. In this case,
the client received burns to his back (18%) and
one arm (9%), totaling 27%.
81. The nurse is providing care for a client who
has a sacral pressure ulcer with wet-to-dry
dressing. Which guideline is appropriate for a
wet-to-dry dressing?
A. The wound should remain moist form the
dressing.
B. The wet-to-dry dressing should be tightly
packed into the wound.
C. The dressing should be allowed to dry out
before removal.
D. A plastic sheet-type dressing should cover the
wet dressing.
ANS: A
A wet-to-dry saline dressing should always keep
the wound moist. Tight packing or dry packing
can cause tissue damage and pain. A dry gauze
—not a plastic-sheet-type dressing—should
cover the wet dressing.
82. While in skilled nursing facility, a client
contracted scabies, which is diagnosed the day
after discharge. The client is living at her
daughter’s home with six other persons. During
her visit to the clinic, she asks a staff nurse,
“What should my family do?” the most accurate
response from the nurse is:
A. “All family members will need to be treated.”
B. “If someone develops symptoms, tell him to
see a physician right away.”
C. “Just be careful not to share linens and
towels with family members.”
D. “After you’re treated, family members won’t
be at risk for contracting scabies.”
ANS: A
When someone in a group of persons sharing a
home contracts scabies, each individual in the
same home needs prompt treatment whether
he’s symptomatic or not. Towels and linens
should be washed in hot water. Scabies can be
transmitted from one person to another before
symptoms develop
83. In an industrial accident, client who weighs
155 lb (70.3 kg) sustained full-thickness burns
over 40% of his body. He’s in the burn unit
receiving fluid resuscitation. Which observation
shows that the fluid resuscitation is benefiting
the client?
A. A urine output consistently above 100
ml/hour.
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B. A weight gain of 4 lb (1.8 kg) in 24 hours.
C. Body temperature readings all within normal
limits
D. An electrocardiogram (ECG) showing no
arrhythmias.
ANS: A
In a client with burns, the goal of fluid
resuscitation is to maintain a mean arterial blood
pressure that provides adequate perfusion of
vital structures. If the kidneys are adequately
perfused, they will produce an acceptable urine
output of at least 0.5 ml/kg/hour. Thus, the
expected urine output of a 155-lb client is 35
ml/hour, and a urine output consistently above
100 ml/hour is more than adequate. Weight gain
from fluid resuscitation isn’t a goal. In fact, a 4 lb
weight gain in 24 hours suggests third spacing.
Body temperature readings and ECG
interpretations may demonstrate secondary
benefits of fluid resuscitation but aren’t primary
indicators.
84. The nurse is reviewing the laboratory results
of a client with rheumatoid arthritis. Which of the
following laboratory results should the nurse
expect to find?
A. Increased platelet count
B. Elevated erythrocyte sedimentation rate
(ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN) and
creatinine levels
ANS: B
The ESR test is performed to detect
inflammatory processes in the body. It’s a
nonspecific test, so the health care professional
must view results in conjunction with physical
signs and symptoms. Platelet count,
electrolytes, BUN, and creatinine levels aren’t
usually affected by the inflammatory process.
85. Which nursing diagnosis takes the highest
priority for a client with Parkinson’s crisis?
A. Imbalanced nutrition: less than body
requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury
ANS: B
In Parkinson’s crisis, dopamine-related
symptoms are severely exacerbated, virtually
immobilizing the client. A client who is confined
to bed during a crisis is at risk for aspiration and
pneumonia. Also, excessive drooling increases
the risk of airway obstruction. Because of these
concerns, ineffective airway clearance is the
priority diagnosis for this client. Although
imbalanced nutrition:less than body
requirements, impaired urinary elimination and
risk for injury also are appropriate diagnoses for
this client, they aren’t immediately lifethreatening
and thus are less urgent.
86. A client with a spinal cord injury and
subsequent urine retention receives intermittent
catheterization every 4 hours. The average
catheterized urine volume has been 550 ml. The
nurse should plan to:
A. Increase the frequency of the
catheterizations.
B. Insert an indwelling urinary catheter
C. Place the client on fluid restrictions
D. Use a condom catheter instead of an invasive
one.
ANS: A
As a rule of practice, if intermittent
catheterization for urine retention typically yields
500 ml or more, the frequency of catheterization
should be increased. Indwelling catheterization
is less preferred because of the risk of urinary
tract infection and the loss of bladder tone. Fluid
restrictions aren’t indicated for this case; the
problem isn’t overhydration, rather it’s urine
retention. A condom catheter doesn’t help empty
the bladder of a client with urine retention.
87.The nurse is caring for a client who is to
undergo a lumbar puncture to assess for the
presence of blood in the cerebrospinal fluid
(CSF) and to measure CSF pressure. Which
result would indicate n abnormality?
A. The presence of glucose in the CSF.
B. A pressure of 70 to 200 mm H2O
C. The presence of red blood cells (RBCs) in the
first specimen tube
D. A pressure of 00 to 250 mmH2O
ANS: D
The normal pressure is 70 to 200 mm H2O are
considered abnormal. The presence of glucose
is an expected finding in CSF, and RBCs
typically occur in the first specimen tube from
the trauma caused by the procedure.
88. The nurse is administering eyedrops to a
client with glaucoma. To achieve maximum
absorption, the nurse should instill the eyedrop
into the:
A. conjunctival sac
B. pupil
C. sclera
D. vitreous humor
ANS: A
The nurse should instill the eyedrop into the
conjunctival sac where absorption can best take
place. The pupil permits light to enter the eye.
The sclera maintains the eye’s shape and size.
The vitreous humor maintains the retina’s
placement and the shape of the eye.
89. A 52 yr-old married man with two adolescent
children is beginning rehabilitation following a
cerebrovascular accident. As the nurse is
planning the client’s care, the nurse should
recognize that his condition will affect:
A. only himself
B. only his wife and children
C. him and his entire family
D. no one, if he has complete recovery
ANS: CAccording to family theory, any change in
a family member, such as illness, produces role
changes in all family members and affects the
entire family, even if the client eventually
recovers completely.
90. Which action should take the highest priority
when caring for a client with hemiparesis caused
by a cerebrovascular accident (CVA)?
A. Perform passive range-of-motion (ROM)
exercises.
B. Place the client on the affected side.
C. Use hand rolls or pillows for support.
D. Apply antiembolism stockings
ANS: B
To help prevent airway obstruction and reduce
the risk of aspiration, the nurse should position a
client with hemiparesis on the affected side.
Although performing ROM exercises, providing
pillows for support, and applying antiembolism
stockings can be appropriate for a client with
CVA, the first concern is to maintain a patent
airway.
91. The nurse is formulating a teaching plan for
a client who has just experienced a transient
ischemic attack (TIA). Which fact should the
nurse include in the teaching plan?
A. TIA symptoms may last 24 to 48 hours.
B. Most clients have residual effects after having
a TIA.
C. TIA may be a warning that the client may
have cerebrovascular accident (CVA)
D. The most common symptom of TIA is the
inability to speak.
ANS: C
TIA may be a warning that the client will
experience a CVA, or stroke, in the near future.
TIA aymptoms last no longer than 24 hours and
clients usually have complete recovery after TIA.
The most common symptom of TIA is sudden,
painless loss of vision lasting up to 24 hours.
92. The nurse has just completed teaching about
postoperative activity to a client who is going to
have a cataract surgery. The nurse knows the
teaching has been effective if the client:
A. coughs and deep breathes postoperatively
B. ties his own shoes
C. asks his wife to pick up his shirt from the floor
after he drops it.
D. States that he doesn’t need to wear an
eyepatch or guard to bed
ANS: C
Bending to pick up something from the floor
would increase intraocular pressure, as would
bending to tie his shoes. The client needs to
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wear eye protection to bed to prevent accidental
injury during sleep.
93. The least serious form of brain trauma,
characterized by a brief loss of consciousness
and period of confusion, is called:
A. contusion
B. concussion
C. coup
D. contrecoup
ANS: B
Concussions are considered minor with no
structural signs of injury. A contusion is bruising
of the brain tissue with small hemorrhages in the
tissue. Coup and contrecoup are type of injuries
in which the damaged area on the brain forms
directly below that site of impact (coup) or at the
site opposite the injury (contrecoup) due to
movement of the brain within the skull.
94. When the nurse performs a neurologic
assessment on Anne Jones, her pupils are
dilated and don’t respond to light.
A. glaucoma
B. damage to the third cranial nerve
C. damage to the lumbar spine
D. Bell’s palsy
ANS: BThe third cranial nerve (oculomotor) is
responsible for pupil constriction. When there is
damage to the nerve, the pupils remain dilated
and don’t respond to light. Glaucoma, lumbar
spine injury, and Bell’s palsy won’t affect pupil
constriction.
95. A 70 yr-old client with a diagnosis of leftsided
cerebrovascular accident is admitted to
the facility. To prevent the development of diffuse
osteoporosis, which of the following objectives is
most appropriate?
A. Maintaining protein levels.
B. Maintaining vitamin levels.
C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises
ANS: C
When the mechanical stressors of weight
bearing are absent, diffuse osteoporosis can
occur. Therefore, if the client does weight-beari
ng exercises, disuse complications can be
prevented. Maintaining protein and vitamins
levels is important, but neither will prevent
osteoporosis. ROM exercises will help prevent
muscle atrophy and contractures.
96. A client is admitted with a diagnosis of
meningitis caused by Neisseria meningitides.
The nurse should institute which type of isolation
precautions?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
ANS: B
This client requires droplet precautions because
the organism can be transmitted through
airborne droplets when the client coughs,
sneezes, or doesn’t cover his mouth. Airborne
precautions would be instituted for a client
infected with tuberculosis. Standard precautions
would be instituted for a client when contact with
body substances is likely. Contact precautions
would be instituted for a client infected with an
organism that is transmitted through skin-to-skin
contact.
97. A young man was running along an ocean
pier, tripped on an elevated area of the decking,
and struck his head on the pier railing. According
to his friends, “He was unconscious briefly and
then became alert and behaved as though
nothing had happened.” Shortly afterward, he
began complaining of a headache and asked to
be taken to the emergency department. If the
client’s intracranial pressure (ICP) is increasing,
the nurse would expect to observe which of the
following signs first?
A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness
ANS: D
With a brain injury such as an epidural
hematoma (a diagnosis that is most likely based
on this client’s symptoms), the initial sign of
increasing ICP is a change in the level of
consciousness. As neurologic deterioration
progresses, manifestations involving pupillary
symmetry, breathing patterns, and posturing will
occur.
98. Emergency medical technicians transport a
28 yr-old iron worker to the emergency
department. They tell the nurse, “He fell from a
two-story building. He has a large contusion on
his left chest and a hematoma in the left parietal
area. He has compound fracture of his left femur
and he’s comatose. We intubated him and he’s
maintaining an arterial oxygen saturation of 92%
by pulse oximeter with a manual-resuscitation
bag.” Which intervention by the nurse has the
highest priority?
A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness
ANS: A
In the scenario, airway and breathing are
established so the nurse’s next priority should be
circulation. With a compound fracture of the
femur, there is a high risk of profuse bleeding;
therefore, the nurse should assess the site.
Neurologic assessment is a secondary concern
to airway, breathing and circulation. The nurse
doesn’t have enough data to warrant putting the
client in Trendelenburg’s position.
99. Alzheimer’s disease is the secondary
diagnosis of a client admitted with myocardial
infarction. Which nursing intervention should
appear on this client’s plan of care?
A. Perform activities of daily living for the client
to decease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as much as
possible.
ANS: C
Establishing and maintaining a routine is
essential to decreasing extraneous stimuli. The
client should participate in daily care as much as
possible. Attempting to reason with such clients
isn’t successful, because they can’t participate in
abstract thinking.
100. For a client with a head injury whose neck
has been stabilized, the preferred bed position
is:
A. Trendelenburg’s
B. 30-degree head elevation
C. flat
D. side-lying
ANS: B
For clients with increased intracranial pressure
(ICP), the head of the bed is elevated to
promote venous outflow. Trendelenburg’s
position is contraindicated because it can raise
ICP. Flat or neutral positioning is indicated when
elevating the head of the bed would increase the
risk of neck injury or airway obstruction. Sidelying
isn’t specifically a therapeutic treatment for
increased ICP.
101. In a comatose client, hearing is the last
sense to be lost. Therefore, the nurse should
always:
A. talk loudly in case the client can hear
B. speak softly before touching the client
C. tell others in the room not to talk to the client
D. tell family members that the client probably
can’t hear
ANS: B
Many clients have reported being able to hear
when being in a comatose state. Therefore, the
nurse should converse as if the client was alert
and oriented. Talking loudly is only appropriate if
the client is hard of hearing, and family members
should be encouraged to talk with the client
unless contraindicated.
102. When a client experiences loss of vibratory
sense on examination, this indicates:
A. injury to the cranial nerves
B. injury to the peripheral nerves
C. intact cranial nerves
D. intact peripheral nerves
ANS: B
Appropriate perception of vibration indicates
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intact dorsal column tracts and peripheral
nerves. If there’s a loss of vibratory sense, an
injury to the peripheral nerves is probable.

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