r Tony returns from surgery with permanent colostomy.

During the first 24 hours

the colostomy does not drain. The nurse should be aware that:
a. Proper functioning of nasogastric suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery

Immediately after liver biopsy, the client is placed on the right side, the nurse is
aware that that this position should be maintained because it will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary ducts
c. Position with greatest comfort
d. Promote circulating blood volume

 Tony has diagnosed with hepatitis A. The information from the health history that
is most likely linked to hepatitis A is:
a. Exposed with arsenic compounds at work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants

 Nurse Trish is aware that the laboratory test result that most likely would indicate
acute pancreatitis is an elevated:
a. Serum bilirubin level
b. Serum amylase level
c. Potassium level
d. Sodium level
Ä A client is suspected to develop tetany after a subtotal thyroidectomy. Which of
the following symptoms might indicate tetany?
a. Tingling in the fingers
b. Pain in hands and feet
c. Tension on the suture lines
d. Bleeding on the back of the dressing

 A client has been diagnosed with glomerulonephritis complains of thirst. The

nurse should offer:
a. Juice
b. Ginger ale
c. Milk shake
d. Hard candy

 The nurse is assessing a client with pleural effusion. The nurse expect to find:
a. Deviation of the trachea towards the involved side
b. Reduced or absent of breath sounds at the base of the lung
c. Moist crackles at the posterior of the lungs
d. Increased resonance with percussion of the involved area

 A client admitted with newly diagnosed with Hodgkin¶s disease. Which of the
following would the nurse expect the client to report?
a. Lymph node pain
b. Weight gain
c. Night sweats
d. Headache
 È A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid
(CSF) for analysis. Which of the following values should be negative if the CSF is
normal?
a. Red blood cells
b. White blood cells
c. Insulin
d. Protein

r Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge

teaching should include

A.telling him to avoid heavy lifting for 4 to 6 weeks
B. instructing him to have a soft bland diet for two weeks
C. telling him to resume his previous daily activities without limitations
D. recommending him to drink eight glasses of water daily

11. If a client has severe bums on the upper torso, which item would be a primary
concern?

A. Debriding and covering the wounds

B. Administering antibiotics
C. Frequently observing for hoarseness, stridor, and dyspnea
D. Establishing a patent IV line for fluid replacement

12. Maria refuses to acknowledge that her breast was removed. She believes that her
breast is intact under the dressing. The nurse should

A. call the MD to change the dressing so Kathy can see the incision
B. recognize that Kathy is experiencing denial, a normal stage of the grieving
process
C. reinforce Kathy¶s belief for several days until her body can adjust to stress of
surgery.
 D. remind Kathy that she needs to accept her diagnosis so that she can begin
rehabilitation exercises.

13. Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and
replaced with a graft. When she arrives in the RR she is still in shock. The nurse¶s
priority should be

A. placing her in a trendeleburg position

B. putting several warm blankets on her
C. monitoring her hourly urine output
D. assessing her VS especially her RR

14. A major goal for the client during the first 48 hours after a severe bum is to prevent
hypovolemic shock. The best indicator of adequate fluid balance during this period is
A. Elevated hematocrit levels.
B. Urine output of 30 to 50 ml/hr.
C. Change in level of consciousness.
D. Estimate of fluid loss through the burn eschar.

15. John, 16 years old, is brought to the ER after a vehicular accident. He is

pronounced dead on arrival. When his parents arrive at the hospital, the nurse should:

A. ask them to stay in the waiting area until she can spend time alone with them
B. speak to both parents together and encourage them to support each other and
express their emotions freely
C. Speak to one parent at a time so that each can ventilate feelings of loss
without upsetting the other
D. ask the MD to medicate the parents so they can stay calm to deal with their
son¶s death.
16. A nurse is performing CPR on an adult patient. When performing chest
compressions, the nurse understands the correct hand placement is located over the

A. upper half of the sternum

B. upper third of the sternum
C. lower half of the sternum
D. lower third of the sternum

17. Which of the following activities is not encouraged in a patient after an eye surgery?

A. sneezing, coughing and blowing the nose

B. straining to have a bowel movement
C. wearing tight shirt collars
D. sexual intercourse

18. Which nursing diagnosis is of the highest priority when caring for a client with
myasthenia gravis?

A. Pain
B. High risk for injury related to muscle weakness
C. Ineffective coping related to illness
D. Ineffective airway clearance related to muscle weakness

19. A client jokes about his leukemia even though he is becoming sicker and weaker.
The nurse¶s most therapeutic response would be:

A. ³Your laugher is a cover for your fear.´

B. ³He who laughs on the outside, cries on the inside.´
C. ³Why are you always laughing?´
D. ³Does it help you to joke about your illness?´
20. Jose, who had a myocardial infarction 2 days earlier, has been complaining to the
nurse about issues related to his hospital stay. The best initial nursing response would
be to:

A. Allow him to release his feelings and then leave him alone to allow him to
regain his composure
B. Refocus the conversation on his fears, frustrations and anger about his
condition
C. Explain how his being upset dangerously disturbs his need for rest
D. Attempt to explain the purpose of different hospital routines