R.A.

SIBALA TUTORIAL SERVICES

COMPREHENSIVE EXAM TEST 1
MEDICAL-SURGICAL NURSING

1. An elderly patient may have sustained a basilar skull Iracture

aIter slipping and Ialling on a slippery sidewalk. The nurse
knows that basilar skull Iractures:
a.are the least signiIicant type oI skull Iractures
b.may cause cerebrospinal Iluid leaks Irom the nose or ears
c.have no characteristic Iinding
d.are always surgically repaired
2. The nurse is teaching Iamily members oI a patient with a
concussion about the early signs oI increase intracranial pressure
(ICP). Which oI the II would she cite as an early sign oI
increased ICP?
a.Decreased systolic blood pressure
b.Headache and vomiting
c.Inability to wake the patient with noxious stimuli
d.Dilated pupils that don`t react to light
3.Gary V. is diagnosed with retinal detachment. Which
intervention is the most important Ior this patient?
a.Admitting him to the hospital on strict bed rest
b.Patching both his eyes
c.ReIerring him to an ophthalmologist
d.Preparing him Ior surgery
4.Dr. Harry Marson, a chemist, sustained a chemical burn to one
eye. Which intervention takes priority Ior a patient with a
chemical burn oI the eye?
a.Patch the aIIected eye and call the ophthalmologist
b.Administer a cyclopegic agent to reduce ciliary spasm
c.Immediately instill a topical anesthetic, then irrigate the eye
with saline solution
d.Administer antibiotics to reduce the risk oI inIection
5.The nurse is assessing a patient and notes Brudzinski`s sign and
Kernig`s sign. These are two classic signs oI which oI the II
disorders?
a.Cerebrovascular Accident c. Seizure disorder
b. Meningitis d. Parkinson`s Disease
6.The nurse should instruct the patient with Parkinson`s disease to
avoid which oI the II?
a.Walking in an indoor shopping mall
b.Sitting on the deck on a cool summer evening
c.Walking to the car on a cold morning
d.Sitting on the beach in the sun on a summer day
7.Jasmine suIIered a cerebrovascular accident that leIt her unable to
comprehend speech and unable to speak. This type oI aphasia is
known as:
a.Receptive b. Expressive c. Global d. Conduction
8.Cynthia complains that her headaches are occurring more
Irequently despite taking medications. Patients with a history oI
headaches should be taught to avoid:
a.Freshly prepared meats c. Skim milk
b.Citrus Iruits d. Chocolate
9.Immediately Iollowing cerebral aneurysm rupture, the patient
usually complains oI:
a.Photophobia c. Seizures
b.Explosive headaches d. Hemiparesis
10. JenniIer suIIered a cervical Iracture requiring immobilization
with halo traction. When caring Ior the patient in halo traction,
the nurse must:
a.Keep a wrench taped to the halo vest Ior quick removal iI
cardiopulmonary resuscitation is necessary
b.Remove the brace once a day to allow the patient to rest
c.Encourage the patient to use a pillow under the ring
d.Remove the brace so that the patient can shower
Situation (11-15). Sheila is admitted to the hospital with a serum
glucose level of 618 mg/dL. Shes awake and oriented, with hot, dry
skin, a temperature of 38.1C, a heart rate of 166 beats/min., a BP
of 108/70mmHg.
11. Based on Sheila`s assessment Iindings, which nursing diagnosis
takes highest priority?
a.Fluid volume deIicit related to osmotic diuresis
b.Decrease cardiac output related to elevated heart rate
c.Altered nutrition: less than body requirements related to
insulin deIiciency
d.IneIIective thermoregulation related to dehydration
12. The nurse should include which instruction when teaching
Sheila about insulin administration?
a.'Administer insulin aIter the Iirst meal oI the day.
b. 'Administer insulin at a 45-degree angle into the deltoid
muscle.
c. 'Shake the vial oI insulin vigorously beIore witdrawing the
medication.
d.'Draw up clear insulin Iirst when mixing two types oI insulin
in one syringe.
13. When teaching Sheila about insulin therapy, the nurse should
instruct her to avoid which over-the-counter preparation that
can interact with insulin?
a.Antacids c. Vitamins with iron
b.Acetaminophen d/ Salicylates
14. Sheila`s Iamily should be taught to recognize which signs &
symptoms oI hypoglycemia?
a.Polyuria, headache, Iatigue
b.Polyphagia, Ilushed Iace, dry skin
c.Polydipsia, pallor, irritability
d.Nervousness, diaphoresis and conIusion
15. She is taught to prevent one oI the complications oI DM which
is hyperosmolar hyperglycemic non-ketotic syndrome. Which
statement by the patient indicates that she understands this
complication and the preventive measure to control it?
a.'I can avoid getting sick by not becoming dehydrated and by
paying attention to my need to urinate, drink, or eat more
than usual.
b.'II I experience trembling, weakness and headache, I should
drink a glass oI soda that contains sugar.
c.'I`ll have to monitor my blood glucose level closely and
notiIy the doctor iI it`s constantly elevated.
d.'II I begin to Ieel especially hungry and thirsty, I`ll eat a
snack high in carbohydrates.
Situation (16-18). Barbara was admitted to the hospital to have a
pituitary tumor removed. After surgery, she developed diabetes
insipidus, a common complication of this surgery.
16. The nurse should expect to administer which drug to treat
Barbara`s diabetes insipidus?
a.Vasopressin c. Regular Insulin
b.Furosemide (Lasix) d. Dextrose 10 in water
17. Which outcome indicates that treatment Ior Barbara`s diabetes
insipidus has been eIIective?
a.Fluid intake oI less than 2,500 ml in 24 hours
b.Urine output oI more than 200ml/hour
c.Blood pressure oI 90/50 mmHg
d.Pulse rate oI 126beats/minute
18. A nursing diagnosis oI risk Ior Iluid volume excess related to
aggressive Iluid resuscitation is appropriate Ior Barbara because
she requires water replacement. When the nurse evaluates her
response Ior water replacement, which signs and symptoms
would indicate water intoxication?
a.ConIusion and seizures
b.Sunken eyeballs and spasticity
c.Flaccidity and thirst
d.Tetany and increase BUN levels
Situation (19-21). Ruth, a 68yo patient who has been complaining
of sleeping more and having anorexia, weakness, irritability,
depression, bone pain and increased urination. Because of her
pain, she rarely goes outdoors.
19. Based o these signs and symptoms, Ruth most likely has:
a.Diabetes mellitus c. Hypoparathyroidism
b.Diabetes insipidus d. Hyperparathyroidism
20. Ruth`s laboratory Iindings would include which Iinding?
a.Hypocalcemia c. Hyperphosphatemia
b.Hypercalcemia d. Hypophosphatemia
21. When instructing Ruth about her diet, the nurse should stress
the importance oI:
a.Restricting Iluids c. Forcing Iluids
b.Restricting sodium d. Restricting potassium
Situation (22-24). Jeanette, age 35 is admitted to the medical-
surgical floor with fatigue, malaise, pallor, and oliguria. She has a
10yr history of systemic lupus erythematosus for which she receives
Prednisone.
22. Because Jeanette is receiving prednisone, she should be
assessed Ior:
a.Hypotension c. Hypocalcemia
b.Polyuria d. Hyperglycemia
23. The nurse enters the room and Iinds Jeanette crying. She states,
'My Iace is Iat and ugly. I can`t stand it anymore. The nurse`s
best response would be:
a.'You`ve been sick a long time. It must be very diIIicult.
b.'You can`t stop taking prednisone abruptly because you`ll
become quite ill.
c.'Obviously, you`re experiencing an adverse eIIect oI
prednisone, it will go away soon.
d.'II you`d like your privacy now, I`ll leave.
24. Which oI the II could trigger an exacerbation oI Jeanette`s
systemic lupus erythematosus?
a.sun exposure c. dietary salt intake
b.change in body temperature d. exercise
Situation (25-29). James, a 32yo is admitted in vaso-occlusive
sickle cell crisis. He complains of chest pain, shortness of breath,
severe myalgia, and arthalgia.
25. Which oI the II may have triggered James` vaso-occlusive
crisis?
a.aspirin use c. jaundice
b.recent chest cold d. spicy Ioods
26. During vaso-occlusive crisis, the nurse should encourage James
to:
a.Change his position Irequently
b.Restrict his Iluid intake
c.Decrease his protein intake
d.Drink 3-5 liters oI Iluids each day
27. Unrelieved abdominal pain that occurs during vaso-occlusive
crisis may indicate:
a.Iecal impaction c. attention-seeking behavior
b.mesenteric inIarction d. pancreatitis
28. James complains oI chest pain. The nurse should:
a.NotiIy the doctor c. Massage the aIIected area
b.OIIer emotional support d. Distract the patient
29. James complains oI priapism during vaso-occlusive crisis. The
nurse suggests that:
a.Taking a warm bath may alleviate the problem
b.Taking Iolic acid supplement can prevent priapism
c.He should stop thinking sexually-arousing thoughts
d.He should stand to void
Situation (30-33). Gary is admitted to the hospital with shaking
chills and fever. His red blood cell count is abnormally low, causing
the doctor to suspect aplastic anemia.
30. Gary is at greater risk Ior inIections with aplastic anemia
because:
a.A large amount oI immature RBCs are produced
b.Granulocyte production is depressed
c.An excessive amount oI thrombocytes are present
d.Vit. B12 isn`t being absorbed by the stomach
31. Which oI the II should be included in Gary`s plan oI care?
a.Avoiding IM injections
b.Maintaining strict bed rest
c.Measuring and recording hourly intake & output
d.Checking pedal pulses every 4 hours
32. Which oI the II drugs that Gary has taken may be responsible
Ior causing aplastic anemia?
a.IbuproIen c. Levothyroxine
b.Bactrim d. Heparin
33. Gary has severe granulocytopenia. The nurse should teach him
to:
a.Avoid raw Iruits and vegetables
b.Take Vitamin C to ward oII common cold
c.Observe Ior polydipsia and polyuria
d.Restrict sodium in the diet
Situation (34-37). William is admitted to the hospital with shortness
of breath, chest pain, and numbness and tingling in his hands. His
hemoglobin level is 6.4mg/dl and his hematocrit 19.2. A Schilling
test is ordered to rule out the diagnosis of pernicious anemia.
34. When teaching William about a Schilling test, the nurse
explains that:
a.This test studies Vit. B
12
absorption Irom the stomach
b.AIter an iron injection, he`ll need to produce a urine sample
c.His urine will be collected Ior 24 hours to determine the Iolic
acid content
d.A blood sample will be taken Irom his arm, and his RBC
distribution width will be measured
35. The nurse begins the 24-hour urine collection Ior the Schilling
test at 7am. William is instructed:
a.To collect all oI his urine Irom 7am today until 7am
tomorrow
b.To discard the Iirst voided specimen at 7am today and save
all urine, including that Irom 7am the next day
c.To discard the Iirst voided specimen today and tomorrow but
save all urine in between
d.That an indwelling urinary catheter will be inserted to ensure
no urine is lost during the 24-hr period
36. William states, 'The doctor says iI I have pernicious anemia,
I`ll need shots the rest oI my liIe. Why can`t I just take a pill?
A nurse`s best response would be, 'When you have pernicious
anemia:
a.Vit. B
12
can`t be absorbed in your stomach because you lack
the intrinsic Iactor needed Ior absorption
b.The B vitamins are destroyed by the gastric mucosa beIore
absorption.
c.An overproduction oI erythropoietin inactivates Vit. B
12
in
your stomach
d.Your bone marrow is incapable oI producing RBCs
37. Anemia that results Irom Vit. B
12
deIiciency diIIers Irom other
anemia because:
a.Death Irom sepsis is likely with Vit B
12
deIiciency
b.Neurologic dysIunction may result Irom Vit B
12
deIiciency
c.Bruising, bleeding, and ecchymosis are common with Vit B
12
deIiciency
d.Shortness oI breath and tachycardia result Irom Vit B
12

deIiciency
Situation (38-39). Mary, age 72 came to the clinic at the request of
her daughter. She has a history of type 2 DM and her BP is
172/94mmHg.
38. Diagnosis oI Mary`s hypertension is based on:
a.Symptoms such as headache and visual changes
b.Serial elevation oI diastolic blood pressure
c.A Iamily history oI atherosclerosis
d.A history oI renal disease
39. Mary is prescribed Captopril (Capoten) to treat her
hypertension. This drug is classiIied as:
a.An ACE inhibitor
b.A beta-adrenergic blocker
c.A calcium-channel blocker
d.A vasodilator
Situation (40-41). Robert, age 65, is standing at the bus stop with
his daughter when he suddenly groans and collapses.
40. The nurse is walking down the street when she hears Robert`s
daughter screaming Ior help. How should the nurse intervene?
a.She should determine iI the victim is unresponsive, summon
emergency medical services (EMS), and initiate
cardiopulmonary resuscitation in the interim
b.She should provide rescue eIIort Ior 1 minute, then activate
the EMS system
c.She should assess the victim`s pulse and breathing, open his
airway and activate EMS
d.She should open the victim`s airway, assess his breathing,
provide rescue breathing, assess his pulse, then activate EMS
41. Which oI the II statements is true concerning endotracheal
intubation Iollowing cardiac arrest?
a.It shouldn`t be delayed so that ventilation can be delivered by
another device.
b.It increases the risk oI gastric content aspiration.
c.It should only be perIormed by persons proIicient at the
procedure.
d.It should precede deIibrillation in patients with ventricular
deIibrillation or pulseless ventricular tachycardia.
Situation (42-45). Bill, a 74yo smoker with advanced coronary
artery disease is scheduled for surgical revasculari:ation of the
coronary arteries to bypass plaque obstructions.
42. Revascularization oI the coronary arteries is also known as:
a.Percutaneous transluminal coronary angioplasty
b.Coronary artery bypass graIt
c.Percutaneous transluminal valvuloplasty
d.Valvular annuloplasty
43. When giving discharge instructions to Bill Iollowing his
coronary artery bypass graIt surgery, the nurse should include
inIormation about all oI the II symptoms, the most common oI
which is:
a.ConIusion c. Ankle edema
b.Syncope d. Depression
44. Which oI the II would be the most appropriate nursing
diagnosis Ior a patient with coronary artery disease?
a.IneIIective thermoregulation
b.Impaired gas exchange
c.Risk Ior injury
d.Decreased cardiac output
45. Which oI the II would be the best expected outcome Ior a
patient with decreased cardiac output?
a.The patient will exhibit no evidence oI conIusion
b.The patient will have normal blood urea nitrogen and
creatinine level
c.The patient`s BP and pulse will be within normal limits
d.The patient will exhibit no evidence oI skin breakdown
Situation (46-49). Bill, age 54 comes to the emergency department
complaining of sharp, substernal chest pain that increases with
deep inspiration. He had a myocardial infarction 2 months prior to
admission.
46. Bill says the pain radiates to his neck, shoulders, back and arms
& it decreases when he sits up and leans Iorward. Based on this
assessment, you suspect that he has:
a.Developed another MI c. Pericarditis
b.Endocarditis d. Myocarditis
47. When auscultating Bill`s heart sounds, the nurse would expect
to hear:
a.A grating sound c. A loud snap
b.A murmur d. A click
48. Bill begins showing signs oI heart Iailure (dyspnea, orthopnea
and tachycardia) and complains oI generalized substernal chest
pain and Iullness oI his chest. He`s at risk Ior developing which
oI the II complications oI pericarditis?
a.Neoplasms c. InIiltrates
b.Cardiac Tamponade d. Myalgia
49. The nurse should prepare Bill Ior which oI the Iollowing
emergency treatments Ior cardiac tamponade?
a.Pericardiorrhaphy c. Pericardectomy
b.Pericardiolysis d. Pericardiocentesis
Situation (50-54). David, age 24, is admitted to the hospital
following a motor vehicle accident. He wasnt wearing a seat belt.
His BP is 82/46mmHg, his HR is 118beats/min., and RR is
32breaths/min.
50. David is restless and cyanotic. Based on this Iinding, the nurse
should Iirst:
a.PerIorm nasotracheal suctioning
b.Inspect the patient`s back Ior lacerations
c.Observe the patient`s chest Ior symmetry
d.Palpate the patient`s abdomen Ior tenderness
51. While inspecting the patient`s chest, the nurse notes that the
chest wall contracts on inspiration and bulge on expiration.
From this assessment, she suspects:
a.Hemothorax c. Pneumothorax
b.Flail Chest d. Tension Pneumothorax
52. David`s arterial blood gas (ABG) analysis reveals a pH oI 7.20,
a PaCO2 oI 65mmHg, a PaO2 oI 45mmHg, and HCo3 oI 22
mEq/L. These laboratory values indicate:
a.Respiratory Acidosis c. Respiratory Alkalosis
b.Metabolic Acidosis d. MetabolicAlkalosis
53. David`s respiratory status continues to deteriorate. The nurse
should prepare to assist with:
a.Chest decompression c. Pulmonary Iunction tests
b.Chest tube insertion d. Endotracheal intubation
Situation (54-56). Tomas, is a 19yo roofer who fell from a scaffold
20 feet to the ground. He was admitted to the emergency
department with multiple abrasions, complaining of shortness of
breath.
54. Tomas` chest Xray reveals a right pneunothorax. With this in
mind, the nurse should Iirst:
a.Help the patient turn, cough, and deep-breathe
b.Prepare a chest drainage system
c.Prepare the patient Ior CT scan oI the chest
d.Administer a sedative.
55. As the nurse helps Tomas out oI bed, his chest tube becomes
dislodged and Ialls to the Iloor. Which oI the II must be done
Iirst:
a.Positioning the patient on the side where the chest tube was
placed
b.Reinserting the chest tube
c.Sealing oII the insertion site
d.Having the patient perIorm valsalva maneuver
56. Assessment oI Tomas aIter chest tube insertion should include:
a.Noting bubbling within the drainage chamber
b.Measuring chest drainage every 24 hours
c.Auscultating breath sounds every 4 hours as needed
d.Percussing Ior subcutaneous emphysema every 8 hours
Situation 57-60. Britney is admitted to the medical-surgical floor
with a 2-week history of hemoptysis. The doctor suspects lung
cancer and has ordered the appropriate diagnostic tests.
57. While preparing Britney Ior a diagnostic test, the nurse
explains, 'The doctor will insert a tube down your throat to
visualize your trachea and lung passages. The nurse has
explained which oI the II diagnostic tests?
a.Bronchoscopy c. Pulmonary Angiography
b.Ventilation & PerIusion Scan d. Oral Endoscopy
58. The nurse is caring Ior Britney immediately Iollowing her
bronchoscopy. Which oI the II nursing diagnoses should
receive priority?
a.Pain related to throat irritation
b.Risk Ior aspiration related to gag reIlex suppression
c.Risk Ior injury related to restraint use during the procedure
d.Anxiety related to possible diagnosis
59. Britney undergoes a right pneumonectomy Ior lung cancer.
Which oI the II positions should not be used when
repositioning her immediately Iollowing the procedure?
a.Semi-Iowler`s c. Right-side lying
b.LeIt-side lying d. High-Iowler`s
60. Britney should be assessed closely Ior which oI the II
complications oI a pneumonectomy?
a.Pulmonary edema c. Pleurisy
b.Transposition oI the great vessels d. Pericarditis
Situation (61-66). The ff questions pertain to the GI system.
61. When caring Ior a patient with esophageal varices, the nurse
knows that bleeding in this disorder usually stems Irom:
a.Esophageal perIoration
b.Pulmonary hypertension
c.Portal Hypertension
d.Peptic Ulcers
62. Jean is diagnosed with Hepatitis A. What special precautions
should the nurse take when caring Ior this patient?
a.Put on a mask and gown beIore entering the patient`s room
b.Wear gloves and a gown when removing the patient`s bedpan
c.Prevent the droplet spread oI the organism
d.Use caution when bringing Iood to the patient
63. Discharge instructions Ior a patient who has been operated on
Ior colorectal cancer include irrigating colostomy. The nurse
knows her teaching is eIIective when the patient states he`ll
contact the doctor iI:
a.He experiences abdominal cramping while the irrigant is
inIusing
b.He has diIIiculty inserting the irrigation tube into the stoma
c.He expels Ilatus while the return is running out
d.He`s unable to complete the procedure in 1 hour
64. The nurse explains to the patient who has had an abdominal
perineal resection that an indwelling urinary catheter must be
kept in place Ior several days aIterward because:
a.It prevents urinary tract inIection Iollowing surgery
b.It prevents urine retention and resulting pressure on the
perineal wound
c.It minimizes the risk oI wound contamination by the urine
d.It determines whether the surgery caused bladder trauma
65. The Iirst day aIter surgery the nurse Iinds no measurable Iecal
drainage Irom a patient`s colostomy stoma. What is the most
appropriate nursing interventions?
a.Call the doctor immediately
b.Obtain an order to irrigate the stoma
c.Place the patient on bedrest and call the doctor
d.Continue the current plan oI care
66. II a patient`s GI tract is Iunctioning but he is unable to take
Ioods by mouth, the preIerred method oI Ieeding is:
a.Total parenteral nutrition
b.Peripheral parenteral nutrition
c.Enteral nutrition
d.Oral liquid supplements
Situation (67-70). Dennis has bleeding gastric ulcer. Despite
multiple blood transfusions, his hemoglobin is 7.6g/dl and
hematocrit is 28. His doctor determines that surgical intervention
is necessary.
67. Dennis goes to the operating room Ior a partial gastrectomy.
Post-operative nursing care would include:
a.Administering pain medications every 6 hours
b.Withholding Iluids by mouth until the return oI peristalsis
c.Positioning the patient in high-Iowler`s position
d.Flushing the nasogastric tube with sterile water
68. Dennis doctor perIormed a partial gastrectomy with a
vagotomy. What was the purpose oI perIorming the vagotomy?
a.To increase gastric emptying
b.To regenerate the gastric mucosa
c.To stop stress-related reactions
d.To reduce acid production
69. Post-operatively, Dennis should be assessed Ior dumping
syndrome, a complication oI partial gastrectomy. Which oI the
II are early signs and symptoms oI dumping syndrome?
a.Diaphoresis and tachycardia
b.Headache and constipation
c.Hunger and decreased bowel sound
d.Hypoglycemia and blurred vision
70. How should the nurse instruct Dennis to decrease the eIIects oI
dumping syndrome?
a.Tell the patient to drink plenty oI water with each meal
b.Instruct the patient to eat three scheduled meals each day
c.Tell the patient to sit in a semi-recumbent position during and
immediately Iollowing meals
d.Teach the patient the importance oI consuming a diet high in
carbohydrates and low in proteins
Situation (71-74). Samuel, age 64, has history of chronic renal
failure. Hes admitted to the hospital with these findings. BP
190/110mmHg, pulse 122 bpm, respirations 32breaths/min, neck
vein distention, and crackles auscultated in lung bases.
71. Which oI the II laboratory tests is the most accurate indicator oI
Samuel`s renal Iunction?
a.Blood urea nitrogen c. Serum Creatinine
b.Creatinine Clearance d. Urinalysis
72. Which nursing diagnosis should receive highest priority when
caring Ior Samuel?
a.Fear c. Fluid Volume Excess
b.Urinary Retention d. Toileting, SelI-Care DeIicit
73. Samuel develops hyperkalemia. Which Iinding indicates
hyperkalemia?
a.Crackles in the bases oI the lungs
b.Fever
c.Chvostek`s sign
d.Muscle weakness and paresthesis
74. Samuel receives hemodialysis and his condition stabilizes. The
doctor orders aluminum hydroxide (Amphojel) with each meal.
This drug is given to:
a.Remove protein wastes oI metabolism
b.Bind phosphates in the GI tract
c.Exchange sodium Ior potassium in the colon
d.Inhibit development oI a stress ulcer
Situation (75-80). Debbie returns from the operating room after a
small-bowel resection. Her vital signs are stable and her urine
output averages 30ml/hour.
75. Which nursing intervention would best prevent Debbie Irom
developing acute renal Iailure in the post-op period?
a.Having the patient deep breathe and cough every hour to
prevent lung congestion
b.Taking vital signs every 2 hours to identiIy impending
hemorrhage and shock
c.Turning the patient every 2 hours to prevent skin breakdown
d.Monitoring IV Iluids every 4 hours to prevent Iluid overload
76. The nurse is reviewing Debbie`s Iluid intake and output record.
What is the normal relationship between Iluid intake and urine
output?
a.Fluid intake should be double the urine output
b.Fluid intake should approximately equal urine output
c.Fluid intake should be halI the urine output
d.Fluid intake should be inversely proportional to the urine
output
77. The nurse documents that Debbie is oliguric. Oliguria is
deIined as:
a.Urine output oI greater than 1500 ml in 24 hours
b.No urine output in 24 hours
c.A urine output oI less than 75ml in 24 hours
d.A urine output oI less than 500 ml in 24 hours
78. Debbie is in the oliguric phase oI acute renal Iailure. Which oI
the II actions should the nurse take when caring Ior this patient?
a.Encourage a low-carbohydrate diet
b.Observe Ior signs and symptoms oI osteoporosis
c.Help the patient maintain a Iluid restriction
d.Encourage the patient to ambulate
79. When assessing Debbie, the nurse would expect her skin to be:
a.Dry & cracked c. Pale & bruised
b.Bruised & discolored d. Pale & pruritic
80. Debbie begins peritoneal dialysis. Which outcome should the
nurse expect Irom this procedure?
a.Decreased blood urea nitrogen (BUN)
b.Stimulated urine Iormation Irom external kidney pressure
c.Increased serum glucose concentration
d.Removal oI excess serum parathyroid hormone
Situation (81-90). The following questions pertain to musculo-
skeletal system.
81. Which statement best describes the nurse`s assessment oI the
client with rheumatoid arthritis?
a.Assessment is done oI the musculoskeletal, cardiac,
pulmonary and renal systems
b.Pain is best assessed by monitoring the client`s Iacial
expressions during exam and by observing limitations in the
client`s own movement
c.Vital signs are an adequate assessment oI the acuity oI the
client`s level oI pain
d.The client`s health history is not nearly as important as the
nurse`s Iindings on physical examination
82. An adult is admitted to the medical unit with an acute
exacerbation oI rheumatoid arthritis. Which oI the II will the
nurse include on his nursing care plan?
a.Administer analgesics Ior pain when systolic blood pressure
increases 20mmHg or more or pulse increases 20 or more
b.Develop plan with client to meet selI-care needs
c.Instruct client to stop taking iron supplements that lead to
constipation
d.Schedule hygiene activities together in one block to provide
longer rest periods beIore and aIter care
83. Which statement by an adult with osteoarthritis indicates to the
nurse that she understands her therapeutic regimen?
a.I will wait until my pain is very bad beIore I take my pain
medication, or else Iurther on in my disease, the medication
won`t help at all
b.Jogging Ior short distance is better Ior my arthritis than
walking Ior longer distances
c.It would probably be a good idea Ior me to lose 30 pounds
my doctor recommended I lose
d.I should do all my house cleaning on one day, so I can rest
Ior the remainder oI the week
84. In preparing a teaching plan Ior the client with osteoarthritis,
the nurse would include which oI the II?
a.Application oI cold packs to aIIected joints to decrease
swelling
b.Client education regarding selI-administration oI medications
c.Progressively increasing activity to point muscle Iatigue to
build muscle bulk and improve rate oI metabolism
d.Teaching client that degenerative changes are progressive
and that pain is a natural sequel oI age
85. An adult has a Iractured leIt radius, which has been casted.
While perIorming an assessment oI this client, the nurse will
correctly identiIy which oI these Iindings as emergent?
a.Pain at the Iracture site
b.Swelling oI Iingers oI leIt hand
c.Diminished capillary reIill oI Iingers oI leIt hand
d.Warm, dry Iingers oI leIt hand
86. Which intervention by emergency nurse is critical in caring Ior
the client with a Iractured tibia and Iibula?
a.Cutting away clothing on the injured leg
b.Palpation oI the dorsalis pedis pulses
c.Administration oI analgesic medications as ordered
d.Initiating two, large-bore IV catheters and warmed normal
saline at a Iast rate
87. A IireIighter Iell oII a rooI while Iighting a house Iire and
Iractured his Iemur. Approximately 24 hours aIter the incident,
the nurse Iinds him dyspneic, tachyneic, with scattered crackles
in his lung Iields; he is coughing up large amounts oI thick,
white sputum. The nurse correctly interpret this as:
a.Respiratory compromise related to inhalation oI smoke
b.Pneumonia related to prolonged bedrest
c.Fat embolism syndrome related to Iemur Iracture
d.Hypovolemic shock related to multiple trauma
88. An adult has a total hip replacement. The nurse understands
that his operatie hip is kept on extension and abduction because
this position
a.Reduces the risk Ior the development oI thromboemboli
b.Promotes circulation to the operative site, reducing the risk oI
avascular necrosis
c.Helps to prevent dislocation oI the hip prosthesis
d.Facilitates the drainage oI blood and Iluids oI the operative
site
89. An adult who has had a total right hip replacement asks the
nurse about 'moving around in this bed. The nurse`s best
response based on the knowledge that:
a.The client should remain supine Ior 48 hours aIter surgery,
with aIIected leg in a slightly inward-rotation position
b.Although the client must remain supine, she can cross her
legs to change position Ior comIort
c.A side-lying position is undesirable but the head oI the bed
can be elevated 60-70 to shiIt weight oII oI back and
buttocks
d.The client will be repositioned using an abductor pillow
between the legs
90. Which oI the II Iindings would alert the nurse to notiIy the
physician oI a serious complication Ior the client with a cast on
his leg?
a.Itching under the cast
b.Poor capillary reIill oI the toes
c.Ability oI client to move toes without diIIiculty
d.Pain relieved by application oI ice bag to cast
Situation (91-95). The ff questions will pertain to the Integumentary
System.
91. The nurse is caring Ior a man admitted with severe burns
sustained when his clothing caught on Iire while he was
burning leaves. During the acute burn phase, the nurse explains
to the nurse that his nursing care plan is directed toward all oI
the II except:
a.Strict aseptic technique
b.Proper alignment oI all joints
c.Maintenance oI Iluid & electrolyte balance
d.Frequent and routine administration oI narcotics
92. The nurse is planning care Ior an adult man who is admitted
with severe Ilame burns. Nursing care planning is based on the
knowledge that the Iirst 24-48 hours post-burn are
characterized by:
a.An increase in the total volume oI intravascular plasma
b.Excessive renal perIusion with dieresis
c.Fluid shiIt Irom interstitial spaces to plasma
d.Fluid shiIt Irom plasma to interstitial space
93. The nurse is caring Ior an adult who was admitted Iollowing
severe burns sustained in a house Iire. The nurse understands
that an acceptable range Ior an hourly urine output during the
Iirst 2 days post burn is:
a.20ml b. 30-50ml c. 100-150ml d. 150-200ml
94. A 23yo Iactory worker was burned severely in an industrial
accident. He has second degree burns on his right leg and arm
and on his back. He has third degree burns on his leIt arm. The
triage nurse, using the rule oI nines, estimates the extent oI the
client`s burns as:
a.36 b. 45 c. 54 d. 60
95. ReIerring to question #94, the burn patient weighs 132 lbs.;
based on this & his total body surIace area burned, compute
the amount oI Iluid resuscitation needed by the patient in the
Iirst 24 hours oI the emergent phase oI burn. Use the Parkland
Iormula:
a.11 liters b. 12 liters c. 13 liters d. 14 liters
Situation 96-100). The ff question refer to the Sense Organs.
96. A client with sensironeural hearing loss should be assessed
using which oI the Iollowing?
a. Tympanocentesis
b. Transillumination oI the sinuses
c. Electronystagmography
d. Weber and Rinne tests
97. A client reports ongoing problems with vertigo. The nurse
should question the client about which oI the Iollowing
accompanying maniIestations to determine whether the client
has developed Meniere's disease?
a. purulent discharge Irom the ear and pain
b. headache and double vision
c. nausea, vomiting, and headache
d. tinnitus, hearing loss, and a sense oI Iullness in the ear
98.A client underwent cataract removal with an intraocular lens
transplant. The nurse is giving the client discharge instructions.
Which instructions should the nurse include?
a. avoid liIting objects weighing more than 5 lb (2.2kg)
b. lie on your abdomen when in bed
c. keep rooms brightly lit
d. avoid straining during bowel movements or bending at he
waist
99. A client is blind in the right eye. From which direction should
the nursing staII approach the client?
a. Irom directly in Iront oI the client
b. Irom the right side oI the client
c. Irom the leIt side oI the client
d. Irom directly behind the client
100. BeIore cataract surgery, the nurse is to instill several types oI
eye drops into a client's right eye. The accepted abbreviation Ior
the right eye is:
a. OD b. OS c. QU d. RE