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Ramon Carlo T. Almirañez, RN, RM, USRN

Fluids and Electrolytes

1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic,
and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid
volume is present?
a. Weight loss and dry skin
b. Flat neck and hand veins and decreased urinary output
c. An increase in blood pressure and increased respirations
d. Weakness and decreased central venous pressure (CVP)

2. The nurse is reading a health care provider’s (HCP’s) progress notes in the client’s record and reads that the HCP has documented
“insensible fluid loss of approximately 800 mL daily.” The nurse makes a notation that insensible fluid loss occurs through which type of
a. Urinary output
b. Wound drainage
c. Integumentary output
d. The gastrointestinal tract

3. The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which
patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.
1. U waves
2. Absent P waves
3. Inverted T waves
4. Depressed ST segment
5. Widened QRS complex
a. 1,2,3 b. 1,3,4 c. 2,4,5 d. 2,3,5

4. Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for
preparation and administration of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Prepare the medication for bolus administration.
4. Monitor the IV site for signs of infiltration or phlebitis.
5. Ensure that the medication is diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.
a. 1,2,3,4,5 b. 1,2,4,5,6 c. 2,3,4,5,6 d. 1,3,4,5,6

5. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the
client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What
additional signs would the nurse expect to note in a client with hyponatremia?
a. Muscle twitches
b. Decreased urinary output
c. Hyperactive bowel sounds
d. Increased specific gravity of the urine

6. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?
a. The client with colitis
b. The client with Cushing’s syndrome
c. The client who has been overusing laxatives
d. The client who has sustained a traumatic burn

7. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to
note in the client?
1. Twitching
2. Hypoactive bowel sounds
3. Negative Trousseau’s sign
4. Hypoactive deep tendon reflexes

8. The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the
electrocardiogram as a result of the laboratory value?
a. U waves
b. Prolonged QT interval
c. Prolonged ST segment
d. Shortened QT interval

9. The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which
patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.
1. ST depression
2. Prominent U wave
3. Tall peaked T waves
4. Prolonged ST segment
5. Widened QRS complexes
a. 1,2,3 b. 3,5 c. 2,5 d. 2,4,5

10. Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
a. The client who is taking diuretics
b. The client with hyperaldosteronism
c. The client with Cushing’s syndrome
d. The client who is taking corticosteroids


Because of the serious consequences of severe burns, management requires a multidisciplinary approach. You have important
responsibilities as a nurse.

11. While Sergio was lighting a barbecue grill with a lighter fluid his shirt burst into flames. The most effective way to extinguish the
flames with as little further damage as possible is to:
a. Log roll on the grass / ground
b. Slap the flames with his hands
c. Remove the burning clothes
d. Pour cold liquid over the flames

12. Once the flames are extinguished, it is most important to:

a. Cover Sergio with a warm blanket
b. Give him sips of water
c. Calculate the extent of his burns
d. Assess the Sergio’s breathing

13. Sergio is brought to the ER after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial
partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that means. Your most
accurate response would be:
a. Structures beneath the skin are damaged
b. Dermis is partially damaged
c. Epidermis and dermis are both damaged
d. Epidermis is damaged

14. During the first 24 hours after thermal injury, you should assess Sergio for:
a. Hypokalemia and hypernatremia
b. Hypokalemia and hyponatremia
c. Hyperkalemia and hyponatremia
d. Hyperkalemia and hypernatremia

15. Teddy, who sustained deep partial thickness and full thickness burns of the face, whole anterior chest and both upper extremities 2
days ago, begins to exhibit extreme restlessness. You recognize that this most likely indicates that Teddy is developing:
a. Cerebral hypoxia b. Metabolic acidosis c. Hypervolemia d. Renal failure

Severe burn is one of the most devastating kinds of injury one can experience. It can affect any group. You have been ready to
provide holistic care for patients with severe burns.

16. A burn that is white, painless, and leathery in texture describes a:

a. Second degree burn
b. Third degree burn or full thickness burn
c. Deep partial thickness burn
d. First degree or superficial burn

17. Critically ill patients are at high risk for the following complication during the emergent phase:
a. Myocardial infarction c. Burn shock
b. Neurogenic shock d. Contractures

18. The most effective method of delivering pain medication during the emergent phase is:
a. Intramuscularly c. Orally
b. Subcutaneously d. Intravenously

19. Edema presents a significant problem in burn wounds because:

a. Loss of protein prevents tissue repair
b. Edema impedes tissue perfusion / oxygenation
c. Edema provides a milieu for bacterial proliferation
d. Edema can produce a tourniquet effect

20. Which of the following can be a fatal complication of upper airway burns?
a. Stress ulcers
b. Hemorrhage
c. Shock
d. Laryngeal spasms and swelling

Musculoskeletal Disorders

21. A nurse notices a client lying on the floor at the bottom of the stairs. He’s alert and oriented and states that he fell down several
stairs. He denies pain other than in his arm, which s swollen and appears deformed. After calling for help, what should the nurse do?
a. Place the client in a sitting position.
b. Immobilize the client’s arm.
c. Help the client walk to the nearest nurses’ station.
d. Raise the client’s arm above his heart.

22. A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase, The nurse should tell the
client to transfer body weight to the unaffected leg, and then:
a. advance both legs.
b. advance the unaffected leg.
c. advance the affected leg.
d. advance both crutches.
RATIONALE: The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the
crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.

23. A nurse is giving instructions to a client who’s going home with a cast on his leg. Which teaching point is most critical?
a. Using crutches properly
b. Exercising joints above and below the cast, as ordered
c. Avoiding walking on a leg cast without the physician’s permission
d. Reporting signs of impaired circulation
RATIONALE: Although all of these points are important, reporting signs of impaired circulation is the most critical. Signs of impaired
circulation must be reported to the physician immediately to prevent permanent damage. The other options reflect more long-term
concerns. The client should learn to use his crutches properly to avoid nerve damage. The client may exercise above and below the
cast, as the physician orders. The client should be told not to walk on the cast without the physician’s permission.

24. Which of the following would the nurse assess when completing the history and physical examination
of a client diagnosed with osteoarthritis?
a. Anemia.
b. Osteoporosis.
c. Weight loss.
d. Local joint pain.

25. A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
a. “OA is a non-inflammatory joint disease. RA is characterized by inflamed, swollen joints.”
b. “OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints.”
c. “OA affects joints on both sides of the body. RA is usually unilateral.”
d. “OA is more common in women. RA is more common in men.”

26. A client has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment?
a. Joint pain, crepitus, Heberden’s nodes
b. Hot, inflamed joint; crepitus; joint pain
c. Tophj, enlarged jolts, Bouchard’s nodes
d. Swelling, jolt pail, and tenderness on palpation

27. A nurse is caring for a client with a cast on his left arm after sustaining a fracture. Which assessment finding is most significant for
this client?
a. Fingers on the left hand are swollen and cool
b. Presence of a normal popliteal pulse
c. Cast edges are rough, with skin irritation present
d. Minimal pain in the left arm

28. A client is in the emergency department with a suspected fracture of the right hip. Which assessment findings should the nurse
1. The right leg is longer than the left leg.
2.The right leg shorter than the left leg.
3.The right leg is abducted.
4.The right leg is adducted.
5.The right leg is externally rotated.
6.The right leg is internally rotated.
a. 1,2,4 b. 1,2,3 c. 2,3,4 d. 2,4,5

29. After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24
to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis?
a. Compartment syndrome
b. Fat embolism
c. Infection
d. Volkmann’s ischemic contracture
30. X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and
allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?
a. “Place both crutches on the first step and swing both legs upward to this step.”
b. “Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together.”
c. “Place the crutches and injured leg on the first step, followed by the unaffected leg.”
d. “Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side
RATIONALE: When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg
moving together. Any other method is incorrect and could increase the client’s risk of falling.

Cancer Nursing

Situation 10 - Radiation therapy is another modality of cancer management. With the emphasis on multidisciplinary management, you
have important responsibilities when caring for patient receiving radiation therapy.
31. Thrombocytopenia often results from bone marrow depression. As a nurse, you should observe the following symptoms:
a. Headache, dizziness, blurred vision
b. Severe sore throat, bacteremia, hepatomegaly
c. Petechiae, ecchymosis, epistaxis
d. Weakness, easy fatigability, pallor

32. When caring for Albert who has thrombocytopenia, which of the following intervention should you include in your plan?
a. Provide rest in between activities
b. Place Albert on strict isolation precaution
c. Inspect his skin for petechiae, bruising, GI bleeding regularly
d. Administer antipyretics if his temperature exceeds 380C

33. Mandy is receiving external radiation therapy and he complains of fatigue and malaise. Which of the following nursing interventions
would be MOST helpful for Mandy?
a. Refer him to physician
b. Help him plan his activities and rest period
c. Reassure him that these feelings are normal
d. Tell him that sometimes these feelings can be psychogenic

34. External-beam radiation is planned for Lucy who has endometrial cancer. You teach her that the important measure to PREVENT
complications from the effects of the radiation is to:
a. Maintain a high residue, high-fat diet
b. Perform perianal care with sitz baths and meticulous cleaning
d. Test all stools for the presence of blood
d. Inspect the mouth and throat daily for the appearance of thrush
Answer: B. External radiation or teletherapy of perianal area makes the skin sensitive and susceptible to breakdown and infection.
Discomfort brought by irradiation can be alleviated by providing sitz bath. Saunders, NCLEX comprehensive review 4th edition.

35. Brenda, a post total hysterectomy, bilateral salphingo-oophorectomy patient, had chemotherapy and radiation therapy. She is now
scheduled for brachytherapy. The nurse oriented her on the rationale and the measure to be done to prevent movement of the
radioactive source which include the following, EXCEPT:
a. Complete bed rest while source is implanted
b. Spinal anesthesia while source is implanted
c. Bowel cleansing prior to insertion of source
d. Placement of urinary foley catheter while source is implanted

The client with bladder cancer is receiving Cisplatin (Platinol) and Vincristine (Oncovin).
36. The nurse preparing to give the medication understands that the purpose of administering both of these medications is to:
a. prevent gastrointestinal side effects.
b. prevent alopecia.
c. decrease the destruction of cells.
d. increase the therapeutic response.

37. Which of the following is a priority to include in this client’s plan of care?
a. monitor the BUN and creatinine.
b. instruct the client to report tinnitus.
c. maintain IV hydration.
d. instruct the client to use a reliable method of birth control.

38. The client asks, “Why will I lose my hair from chemotherapy?” The appropriate response by the nurse is based on which of the
a. It is difficult to predict.
b. chemotherapy affects normal cell that divide often.
c. all chemotherapy causes total alopecia.
d. special shampoos can be used to prevent alopecia.

39. The nurse is aware that the classification of Cisplatin (Platinol) is:
a. Anti-neoplastic
b. Antimetabolites
c. Alkylating agent
d. Antibiotics
40. Which of the following is the priority nursing action when a client states, “My IV sites hurts!” during chemotherapy administration?
a. reposition the needle.
b. notify the physician.
c. stop the infusion.
d. apply a cold pack to the IV site.

Emergency Nursing

41. Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports
of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial
action that the nurse should direct the client to perform?
a. Removing the stinger by scraping it
b. Applying a cold compress
c. Taking an oral antihistamine
d. Call the 911

42. A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following
assessment should take the highest priority to take?
a. Irregular pulse
b. Ecchymosis in the flank area
c. A deviated trachea
d. Unequal Pupils

43. Nurse Kelly, a triage nurse encountered a client who complaints of mid-sternal chest pain, dizziness, and diaphoresis. Which of the
following nursing action should take priority?
a. Complete history taking
b. Put the client on ECG monitoring
c. Notify the physician
d. Administer oxygen therapy via nasal cannula

44. Which of the following categories of conditions should be considered first priority in a disaster?
a. Intracranial pressure and mental status
b. Lower gastrointestinal problems
c. Respiratory infection
d. Trauma

45. A guideline that is utilized in determining priorities is to assess the status of the following, EXCEPT:
a. Perfusion c. Respiration
b. Locomotion d. Mentation

46. The most important component of neurologic assessment is:

a. Pupil reactivity
b. Vital sign assessment
c. Cranial nerve assessment
d. Level of consciousness / responsiveness

47. Four clients injured in an automobile accident enter the emergency department (ED) at the same time and are immediately seen by
a triage nurse, you would assign the HIGHEST priority to the client with the:
a. Severe head injury and no blood pressure
b. Maxillofacial injury and gurgling respirations
c. Second trimester pregnancy with premature labor
d. Lumbar spinal cord injury and lower extremity paralysis

48. A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient
should be prioritized into which category?
a. Non urgent
b. Urgent
c. Emergent
d. High urgent

49. When attending a client with a head and neck trauma following a vehicular accident, the nurse's initial action is to?
a. Do oral and nasal suctioning
b. Provide oxygen therapy
c. Initiate intravenous access
d. Immobilize the cervical area

50. The term given to a category of triage that refers to life threatening or potentially life threatening injury or illness requiring
immediate treatment:
a. Immediate c. Non-acute
b. Emergent d. Urgent