College of Nursing

FINAL EXAM
NCM 41118L
First Semester, SY 2021-2022

Name: __________________________________ Date: _______________________

Section: _________________________________ Score: ______________________

General Directions:
 Read and understand each statement carefully.
 Write the letter of your chosen answer in a sheet of paper.

Stem-Option. Choose the letter of the best/correct answer.

Situation: John is an 18 year old college student who suffered an injury to his cervical spine in a
football game.

1. In directing emergency care until ambulance arrives, it is important that the school nurse
a. Place a makeshift pillow under his head
b. Check to see if he can move all of his extremities
c. Keep him flat and immobilized in a neutral position
d. Cover him with a blanket
2. A primary goal of nursing care when John is brought into the emergency room will be:
a. Prevention of spinal shock c. maintenance of orientation
b. Maintenance of respirations d. provision of pain relief
3. John has a tracheostomy performed and is on assisted ventilation. The alarm on the ventilator
sounds. The initial response by the nurse should be to quickly:
a. Notify the physician to come immediately
b. Check all connections from the respirator
c. Notify the respiratory therapist to come immediately
d. Adjust the pressure controls
4. When suctioning John, the nurse should:
a. Ensure that he is able to take a breath between insertions of the catheter
b. Suction him for at least 30 seconds with each catheter insertion
c. Apply suction and gently rotate the catheter while inserting it into the bronchial
bifurcation
d. Use clean technique during the suction procedure
5. As part of health education in the community, Cancer awareness should be discussed.
The warning signs of Cancer should be mention except for which of the following :
a. Change in bowel and bladder habits and sore that does not heal
b. Unusual bleeding or discharge and unexplained weight loss
c. Unexplained anemia and thickening or lump
d. Nagging cough, colds, fever and high pitch voice
6. To verify the difference of Benign and Malignant neoplasm, the nurse should emphasize
except for which of the following?
a. Benign is localized while malignant is infiltrating surrounding tissues
b. Benign is not encapsulated and malignant is capsulated
c. Malignant occurs metastasis while benign never occurs metastasis
d. Malignant is poorly differentiated and benign is well differentiated mature cells
7. Nita, 33 years old, diagnosed of breast cancer. She requested for different therapeutic
modalities of cancer management. Which of the following should be included?
 a. Chemotherapy, radiation therapy, surgical interventions and Immunotherapy
b. Chemotherapy, bone marrow transplant, radiation therapy and surgical interventions
c. Surgical interventions and chemotherapy
d. Radiation therapy and Chemotherapy
8. Nita would like to know more about chemotherapy. Chemotherapy was emphasized by
the attending physician as requested. The discussion about chemotherapy should
emphasize except for which of the following?
a. Chemotherapy destroy all malignant tumor cells without excessive destruction of
normal cells
b. Chemotherapy is contraindicated to patient with recent surgery, impaired renal and
hepatic functions and pregnancy
c. All of the above
d. None of the above
9. Nita started chemotherapy sessions and nursing interventions for chemotherapy side
effects are the priority of staff nurse. Which of the following is not a side effect of
chemotherapy?
a. Nausea, vomiting, diarrhea and constipation
b. Stomatitis, alopecia, skin pigmentation and nail changes
c. Menorrhagia, hemorrhagic cystitis and increase hemoglobin
d. Menopausal or amenorrhea, urine color changes and anemia
10. Nausea and vomiting was main concern of Nita after session of chemotherapy. Which of
the following medication should be requested for antiemetic?
a. Metoclopramide c. Dexamethasone
b. Lactulose d. Milk of Magnesia
11. Dianne was diagnosed of breast CA and the biopsy result stated Stage III. The nurse was
requested to document the result and as the nurse recalls the stage III breast Ca is
characterized by which of the following?
a. Tumor size up to 2 cm
b. Tumor size is up to 5cm with axillary node involvement
c. Tumor size is more than 5cm with axillary and neck lymph nodes involvement
d. Metastasis to distant organs (liver, lungs, bone and brain)
12. The client whose father and uncle died of colorectal cancer asks the nurse how to modify
a diet to reduce the risk of this cancer. The nurse can suggest:
a. Decreasing unrefined whole-grain products
b. Decreasing consumption of alcohol
c. Increasing consumption of vitamin A
d. Increasing consumption of organ meats
13. The nurse assesses that the client most at risk for breast cancer is the:
a. 26 year-old multipara whose father died from lung cancer
b. 38 year-old primapara who had menarche at age 9
c. 42 year-old multipara who had menarche at age 14
d. 68 year-old nullipara receiving treatment for osteoporosis
14. When explaining the treatment to a client who is receiving interleukin-2 (IL-2) as part
of the therapeutic plan for the management of a malignant melanoma, the nurse would
emphasize the ability of this agent to:
a. increase oxygenation to cells that are not malignant.
b. physically dissolve the tumor mass.
c. strengthen immune response.
d. replace damaged and diseased cells from bone marrow
15. A client is receiving furosemide (Lasix) 40 mg by mouth twice a day. In the plan of care,
the nurse should emphasize teaching the client about the importance of consuming:
a. Fresh, green vegetables c. low-fat milk
b. Bananas & oranges d. creamed corn

16. Small air bubbles adhering to the interior surface of the syringe might have which effect
with parenteral administration?
a. Altered onset of action c. altered drug absorption
b. Altered duration d. altered drug dose
17. The physician prescribes a loop diuretic for a client. When administering this drug, the
nurse anticipates that the client may develop which electrolyte imbalance?
a. Hypervolemia c. hyperkalemia
b. Hypokalemia d. hypernatremia
18. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a
serum sodium level of 128 mEq/L, the least beneficial type of IV fluid would be:
a. Dextrose 5% in half-normal saline solution
b. Normal saline solution
c. Dextrose 5% in water (D5 W)
d. Lactated ringer’s solution
19. A drug must enter the bloodstream before it can act within the body. Which parenteral
administration route places a drug directly into the circulation, requiring no absorption?
a. IM c. intradermal
b. Subcutaneous d. IV
20. The physician prescribes an infusion of 2,400 ml of IV fluid over 24 hours, with half this
amount to be infused over the first 10 hours. During the first 10 hours, the client should
receive how many milliliters of IV fluid per hour?
a. 50 ml/hour c. 120 ml/hour
b. 100ml/hour d. 240ml/hour
21. A client with a fluid volume deficit is receiving an IV infusion of dextrose 5% in water
and LR solution at 125 ml/hour. Which assessment finding indicates the need for
additional IV fluids?
a. Serum sodium level of 135 mEq/L c. neck vein distention
b. 37.6˚C d. dark amber urine
22. The nurse notes that a client’s IV insertion site is red, swollen, & warm to the touch.
Which action should the nurse take first?
a. Discontinue the IV infusion
b. Apply a warm, moist compress to the IV site
c. Check the IV infusion for patency
d. Apply an ice pack to the IV site
23. The nurse regularly inspects a client’s IV site to ensure patency & prevent extravasation
during dopamine (Intropin) therapy. What is the treatment for dopamine extravasation?
a. Elevating the affected limb, applying warm compresses, & administering
phentolamine (Regitine) as prescribed
b. Elevating the affected limb, applying cold compress, and administering
hyaluronidase as prescribed
c. Maintaining the limb in a dependent position & massaging it every 15 minutes
d. Asking the physician to make an incision & allowing the affected area to drain
24. Which type of solution raises serum osmolarity & pulls fluid from the intracellular &
interstitial compartments into the intravascular compartment?
a. Isotonic c. electrotonic
b. Hypertonic d. hypotonic
25. Before administering packed red blood cells, the nurse must flush the client’s IV line.
Which solution should the nurse use to flush the line?
a. Normal saline solution c. dextrose 5% in water
b. Lactated ringer’s solution d. dextrose 5% in normal saline solution
26. While performing rounds, a nurse finds that a client is receiving the wrong IV solution.
The nurse’s initial response should be to:
a. Remove the IV catheter & call the physician
b. Write up an incident report describing the mistake
c. Slow the iv flow rate & hang the appropriate solution
d. Wait until the next bottle is due & then change to the proper solution
27. The physician orders an IV bolus injection of lidocaine (Xylocaine) for a client with a
ventriculr arrhythmia. What should the nurse do before administering a direct IV bolus?
a. Gently aspirate the syringe for a blood return
b. Insert an IV line into the opposite arm
c. Warm the IV medication to room temperature
d. Place a tourniquet on the arm to be used for injection
28. When assessing a client’s IV insertion site, the nurse notes normal color & temperature at
the site & no swelling. However, the IV solutions haven’t infused at the ordered rate; the
flow rate is slow even with the roller clamp wide open. When the nurse lowers the IV
fluid bag, no blood returns to the tubing. What should the nurse do first?
a. Discontinue the IV infusion at that site & restart it in the other arm
b. Irrigate the IV tubing with 1 ml of normal saline solution
c. Check the tubing for kinks & reposition the client’s wrist & elbow
d. Elevate the IV fluid bag
29. The nurse discovers that an IV site in a client’s hand has infiltrated, causing localized
pain & swelling. Which intervention would relieve the client’s discomfort most
effectively?
a. Elevating the hand & wrapping it in a warm towel
b. Placing an ice pack on the hand
c. Administering an as-needed analgesic
d. Wrapping the arm in an elastic bandage from wrist to elbow
30. Which of the following types of solutions when administered IV would cause a shift of
fluid from body tissues to the bloodstream?
a. Hypotonic c. sodium chloride
b. Isotonic d. hypertonic
31. Which of the following solutions should the nurse anticipate for fluid replacement in the
male patient?
a. Lactated ringer’s solution c. type O negative blood
b. Hypertonic solution d. D5% of water
32. Induction of vomiting is indicated for accidental poisoning patient who has ingested:
a. Rust remover c. aspirin
b. Gasoline d. toilet bowl cleaner
33. Which of the following terms refers to a process by which an individual receives
education about recognition of stress reactions and management strategies for handling
stress?
a. Defusing c. follow-up
b. Debriefing d. critical incident stress management
34. During a disaster, the nurse sees a victim in a green triage tag. The nurse knows that the
person has:
a. Injuries that are significant & require medical care but can wait hours without
threat to life or limb.
b. Injuries that are life threatening but survivable with minimal intervention
c. Injuries that are minor & treatment can be delayed hours to days
d. Indicates injuries that are extensive & chances of survival are unlikely even with
definitive care.
35. Which of the following statements reflects the nursing management of pulmonary
anthrax (B. anthraxis)?
a. Airborne person-to-person transmission occurs
b. Diagnosis is by pulmonary function testing & chest x-ray
c. Prophylaxis with fluoroquinone is suggested after exposure
d. Pulmonary effects include respiratory failure, shock, & death within four to 7
days after exposure
36. The first step in decontamination is:
a. To immediately apply personal protective equipment
b. A thorough soap & water wash and rinse of the patient
c. Removal of the patient’s clothing & jewelry and then rinsing the patient with
water
d. To immediately apply a chemical decontamination foam to the area of
contamination
37. The term given to the category of triage that refers to life threatening or potentially life-
threatening injury or illness requiring immediate treatment is:
a. Non-acute c. immediate
b. Emergent d. urgent
38. Which of the following statements refer to a management tool for organizing personnel,
facilities, equipment, & communication for any emergency situation.
a. Office of emergency management c. the hospital emergency preparedness plan
b. National disaster medical system d. the incident command system
39. Treatment of an acetaminophen overdose includes the administration of:
 a. Naloxone (narcan) c. N-acetylcysteine (mucomyst)
b. Flumazenil (Romazicon) d. Diazepam (valium)
40. When the patient has been field triaged & categorized as blue, the nurse recognize that
the patient requires:
a. Urgent care c. fast-track or psychological support
b. Emergent care d. immediate care
41. In triage in disaster, open fracture is an example of:
a. Immediate c. delayed
b. Minimal d. expectant
42. Which of the following triage have the highest priority?
a. Emergent c. non-urgent
b. Urgent d. emergency
43. It is an emergency management system which employs a logical management structure,
defined responsibilities, clear reporting channels, and a common nomenclature to help
unify hospitals with other emergency responders.
a. The Hospital Emergency Incident Command System (HEICS)
b. Disaster management & risk reduction system
c. Natural disaster management group
d. Hospital emergency department
44. It refers to a deliberate act of murder and destruction which disrupts infrastructure and is
directed towards civilians with the aim of meeting political ends.
a. Suicide bombing c. terrorism
b. Blast injuries d. natural disaster
45. The sorting of and allocation of treatment to patients and especially battle and disaster
victims according to a system of priorities designed to maximize the number of survivors.
a. Decontamination c. prioritization
b. Disaster management d. triage
46. It gives priority to the persons who have life threatening injuries even if they will take up
a lot of resources.
a. Military triage c. hospital triage
b. Civilian triage d. triage in disaster
Situation: A nurse is called to a neighbor’s home after a 56 years old man collapses. After
quickly assessing the victim, the nurse determines that CPR is necessary. The nurse instructs the
man’s wife to call the rescue squad.
47. The victim is lying in an upholstered reclining chair when the nurse arrives. Where
should the nurse position him for CPR?
a. On the sofa c. on the tipped-back reclining
b. On the floor d. on a mattress pulled onto the floor
48. The victim’s teenage son tells the nurse that he knows CPR and can help. The nurse
initiates external cardiac compressions while the son administers artificial ventilations.
The nurse should administer cardiac compressions at which rate?
a. 40 to 60 per minute c. 60 to 80 per minute
b. 50 to 70 per minute d. 80 to 100 per minute
49. The victim is transported by ambulance to the hospital’s emergency room, where the
admitting nurse quickly assesses his condition. Of the following observations, the one
most often recommended for determining the effectiveness of CPR is noting whether:
a. Pulse rate is normal
b. Pupils are reacting to light
c. Mucous membranes are pink
d. Systolic blood pressure is at least 80 mm Hg
50. The client receives epinephrine (Adrenalin) in the ER. This drug is administered
primarily because of its ability to:
a. Dilate bronchioles c. free glycogen from the liver
b. Constrict arterioles d. enhance myocardial contractility
51. The client regains consciousness and is breathing spontaneously. He is confused and very
anxious. Which of the following courses of action would likely give this client the most
support while life-saving measures are being performed?
a. Occasionally hold his hand firmly
b. Ask him if he knows why he is afraid
c. Remind him that his wife is in the waiting room
d. Tell him that he can help most by trying to relax
Situation: Mr. Cortez, age 47, is admitted from the ER with severe substernal chest pain. A
diagnosis of acute myocardial infarction is made. He is in severe pain and is cold, clammy, &
dyspneic.

52. All of the following interventions are important. Which should be done first?
a. Administer oxygen c. institute complete bed rest
b. Place in semi-fowler’s position d. administer morphine by slow IV push
53. Mr. Cortez is started on heparin therapy. The nurse should tell Mr. Cortez he is receiving
heparin to:
a. Thin his blood c. stop his blood from clotting
b. Slow the clotting of his blood d. dissolve the clot in his heart
54. Mr. Cortez begins to have blood in his stool & has episodes of epistaxis. In view of this
development, which drug should the nurse have available?
a. Vitamin C (ascorbic acid) c. protamine sulfate
b. Vitamin K (aquamephyton) d. calcium chloride
55. Mr. Cortez suffers CHF & is given digitalis. Which of the following indicates a toxic
effect of digitalis?
a. Hypokalemia c. nausea & vomiting
b. Tachycardia d. gynecomastia
56. With left sided CHF, which of the following symptoms is most expected?
a. Nocturnal dyspnea c. oliguria
b. Sacral edema d. anorexia
57. Mr. Cortez is advised to eliminate foods high in cholesterol from his diet. This means he
should avoid eggs and:
a. Liver c. chicken
b. Yogurt d. corn oil

Situation: Allen, 23 years old, was injured in an automobile accident.

58. Of the following sequences, which would be the most appropriate in the minutes
immediately following trauma?
a. Control the hemorrhage; establish an open airway; stabilize the fractured
vertebrae; splint the fractured leg.
b. Establish an open airway; control the hemorrhage; stabilize the fractured
vertebrae; splint the fractured leg.
c. Establish an open airway; stabilize the fractured vertebrae; control the
hemorrhage; splint the fractured leg.
d. Establish an open airway; control the hemorrhage; splint the fractured leg;
stabilize the fractured vertebrae
59. Which is the most important intervention in treating hemorrhage?
a. Allay apprehension c. prevent chilling, but do not overheat
b. Give oral fluids d. restore blood volume
60. Shock causes which of the following?
a. A PO2 greater than 80 mm Hg c. A PCO2 less than 45 mm Hg
b. A pH less than 7.34 d. decrease in capillary permeability
61. If CPR were performed by two persons, which of the following ratios of cardiac
compression to pulmonary ventilation would be used?
a. 1:1 c. 15:2
b. 5:1 d. 20:2
62. Effective CPR would be best indicated by which sign?
a. Palpable carotid pulse c. easily blanched nail beds
b. Dilated pupils d. normal skin color
63. The patient is conscious & is bleeding from a compound fracture of the right leg. The
adequacy of his general tissue perfusion can be determined by the assessment of all of the
following except one. Which of the following is incorrect?
a. Urinary output c. level of consciousness
b. Blood pressure d. skin color
64. What is the primary objective of therapy for shock?
a. Maintain adequate BP c. maintain adequate vascular tone
b. Improve tissue perfusion d. improve kidney function
65. Patient’s injuries include a skull fracture. One of the goals of care for him is to observe
for increasing intracranial pressure. Increased intracranial pressure would be indicated by
which signs?
a. Increased PR & increased BP c. decreased PR & increased BP
b. Increased PR & decreased BP d. decreased PR & decreased BP
66. In addition, which of the following would best indicate increased intracranial pressure?
a. BP change from 110/80 mm Hg to 140/50 mm Hg
b. Pulse change from 78/min to 92.min
c. Respirations change from 16/min to 26/min
d. Change in LOC from stupor to drowsy & restless
67. The structure most frequently injured by blast.
a. Tympanic membrane c. lungs
b. Brain d. eyes
68. It include burns from fire or radiation, crush injury associated with structural collapse,
poisoning from carbon monoxide or other toxic products of the explosion, and inhalation
of dust or chemicals from the explosion.
a. Primary blast injury c. tertiary blast injury
b. Secondary blast injury d. quaternary blast injury
69. Blast lung is characterized by the clinical triad, and these are the following, except:
a. Apnea c. tachycardia
b. bradycardia, d. hypotension.
70. Any procedure that inhibits the growth and multiplication of microorganism.
a. Sterilization c. Antiseptic
b. Bactericidal d. Disinfection
71. It is a process whereby pathogenic organisms, but not necessarily all microorganisms or
spores are destroyed.
a. Sterilization c. Antiseptic
b. Bactericidal d. disinfection
72. It is used for sterilizing disposables such as plastic syringes, catheters, or gloves before
use.
a. Ionizing radiation c. Filtration
b. Incineration d. moist heat
73. It is the state of events which pose a threat to the surrounding natural environment and
adversely affect people's health.
a. Natural disaster c. environmental hazard
b. Avalanche d. geographical hazard
74. Hazardous compound that break down slowly and can remain in the environment long
after application and in organisms long after exposure.
a. Organochlorines c. cadmium
b. Dioxins d. bisphenol A
75. These are a class of super-toxic chemicals formed as a by-product of the manufacture,
molding, or burning of organic chemicals and plastics that contain chlorine.
a. Organochlorines c. cadmium
b. Dioxins d. lead
76. A serious situation or occurrence that happens unexpectedly and demands immediate
action.
a. Emergent c. urgent
b. Emergency d. immediate
77. It refers to the deliberate release of viruses, bacteria, or other agents used to cause illness
or death in people, animals, or plants.
a. Biological warfare c. bioterrorism
b. terrorism d. epidemic
78. It refers to a deliberate act of murder and destruction which disrupts infrastructure and is
directed towards civilians with the aim of meeting political ends.
a. Biological warfare c. bioterrorism
b. Terrorism d. epidemic
79. Which of the following is not included in the other names of venipuncture?
a. Phlebotomy c. blood draw
b. Venesection d. blood letting
 80. Which of the following provides calories for energy, sparring body protein and
preventing ketosis resulting from fat breakdown?
a. D5NS c. D5W
b. .45% NaCl d. .3% NaCl
81. Which of the following Intravenous Fluids is contraindicated in severe metabolic acidosis
and/or alkalosis and liver disease?
a. Normal saline c. 5% water
b. D5 NM d. LR
82. It occurs when fluid seep out from the lumen of the vessel into the surrounding tissue.
a. Infiltration c. extravasation
b. Thrombosis d. thrombophlebitis
83. An access of fluid is disrupting homeostasis caused by infusion at a rate greater than the
patient’s system is able to accommodate.
a. Circulatory overload c. speed shock
b. Shock d. hematoma
84. The following are drugs associated to extravasation necrosis, except:
a. Calcium chloride c. dopamine
b. phenytoin d. vancomycin
85. It is defined as the adaptation of professional nursing skills in recognizing and meeting
the nursing physical and emotional needs resulting from a disaster.
a. Emergency nursing c. critical care nursing
b. Disaster nursing d. risk reduction nursing
86. Which of the following is not included in the role of the nurse at the disaster site?
a. Ensure safety c. emotional support
b. First aid d. emergency care
87. It is the body's reaction to a change that requires a physical, mental or emotional
adjustment or response.
a. Stress c. fear
b. Anxiety d. chills
88. Intervention for post-traumatic stress disorder that is normally done within 72 hours of
the incident and gives the individual or group the opportunity to talk about their
experience, how it has affected them, brainstorm coping mechanisms, identify individuals
at risk, and inform the individual or group about services available to them in their
community.
a. Defusing c. debriefing
b. Refocusing d. follow-up
89. A condition in which damaged skeletal muscle tissue breaks down rapidly and enters the
bloodstream, bringing on a potentially debilitating or life threatening illness.
a. Rhabdomyolysis c. marfan disease
b. Renal failure d. compartment syndrome

Situation: Manuel is a 52 year old laborer who is married and has no children. For the past few months,
he has complained of a generalized headache that is relieved by aspirin. Lately, he has complained of
double vision. He is admitted to the hospital with a tentative diagnosis of increase intracranial
pressure.

90. Part of the neurologic assessment for IICP includes taking vital signs. Which sign is
associated with IICP?
a. Rapid pulse rate c. varying pulse deficit
b. Widening pulse pressure d. decreased systolic pressure
91. The physician orders a CAT scan. Nursing preparation of the client for this procedure
includes:
a. Reassuring him that CAT scanning is a noninvasive procedure
b. Explaining that spinal tap will be done so that a radioactive isotope can be injected
c. Telling him that a radiopaque dye is injected into an artery in the arm
d. Explaining that the vital signs will be monitored for 2 hours after the exam
Situation: The results of the diagnostic tests indicate that Manuel has a malignant intracranial
brain tumor. He is scheduled for a supratentorial craniotomy.

92. Manuel tells the nurse he is going to die soon. Which response by the nurse would be most
therapeutic?
a. You have been getting better each day. The chemotherapy has you in remission
b. You must be very depressed. Would you like to play a game of cards?
c. I’m sure you have these feelings because of your diagnosis, but you will survive
d. Did someone say something, or did something happen to make you feel that way?
93. The doctors have told Manuel‘s wife that her husband has cancer. She asks the nurse if she
should tell her husband. The nurse replies, “Based on research of people who have cancer, a
majority report that:
a. They want to be told they have cancer even though it causes intense anxiety and
depression
b. They desire to be told they have cancer and suffer no long-term negative effects from
being told
c. They wish to avoid all discussion of their condition with anyone
d. They feel the manner in which they are told is tactless and insensitive
94. Preoperatively, the physician orders tap-water enemas until the return is clear. What is the
nurse’s best response?
a. Question the order because enemas are usually contraindicated in this situation
b. Tell the client that the enemas will be given at 6am
c. Recognize that a cleansed bowel will decrease the incidence of postoperative cerebral
edema
d. Ask the client if he would prefer to self-administer the enema
95. Manuel has a supratentorial craniotomy with removal of a malignant intracranial tumor. To
promote venous drainage postoperatively, Manuel should be positioned:
a. Flat in bed
b. In trendelenburg’s position
c. With the head of the bed elevated about 30˚- 45˚
d. In a high Fowler’s position with the knee catch elevated
96. On the day after surgery, the nurse notes that Manuel has generalized facial edema that
distorts his features. When his wife sees him, she cries, “Oh my poor husband.” What is
the most appropriate action by the nurse?
a. Recognize that the edema is a poor prognostic sign and notify the physician
b. Reassure Manuel’s wife that swelling is normal and will subside in a few days
c. Tell the wife that the edema develops when the tumor is particularly large
d. Record “observe foe renal failure” on the nursing plan
97. On the second postoperative day, Manuel’s temperature is 37.8˚C. The nurse should
recognize that this:
a. Warrants use of a hypothermia blanket
b. Necessitates administration of antipyretics
c. Is a usual occurrence during this time
d. Is an early indication of meningitis

98. The nurse observes Manuel for respiratory acidosis. Which group of arterial blood
gases reflects compensated respiratory acidosis?
a. pH > 7.35; HCO3 > 26 mEq; PaCO2 < 35 mmHg
b. pH > 7.35; HCO3 <22 mEq; PaCO2 normal
c. pH < 7.35; PaCO2 >45 mmHg; HCO3 >26 mEq
d. pH < 7.35; PaCO2 >45 mmHg; HCO3 Normal
99. To control postoperative cerebral edema, the physician orders an intravenous solution of
Mannitol, 20 g in 300 ml of isotonic sodium chloride solution. Client response to the
medication is considered adequate with:
a. A central venous pressure reading of 17cm of water
b. Serum sodium of 125 mEq/liter
c. Urinary output of 45 ml/hr for 2 to 3 hours
d. Specific gravity of urine 1.001
 100. While inspecting the head dressing, the nurse notices yellow drainage on the
dressing. The nurse should:
a. Circle the area of drainage on the dressing and record on the progress note
b. Recognize that this is normal drainage of mucus
c. Notify the physician
d. Take a wound culture and send it to the laboratory

Date Prepared: Noted: Recommending Approved:

Submitted: Approval:

Oct. 9, 2015 MELANIA S. BANATICLA, RN.MAN DR. JOSIELYN P. MALIGALIG, RN MS. VIOLETA B. OCAMPO DR. ARNALDO S. DE GUZMAN
Faculty Member Dean, College of Nursing Chair, Testing and School Director
Evaluation
Department
ANSWERS:

1. ANS: C. It is most important that the client who sustains spinal cord trauma be
kept flat, aligned neutrally, and immobilized to avoid any further damage to the
spinal cord.
2. ANS: B. Cervical spinal cord injuries can interfere with respiratory function
because the fourth cervical segment contains the phrenic nerve, which
innervates the diaphragm. Therefore, maintenance of respiratory function must
be the priority of care if life is to be sustained.
3. ANS: B. If any of the connections become detached, the ventilator will not deliver
the required amount of air. Therefore, they should be quickly checked.
4. ANS: A. Because the client’s airway is temporarily blocked during suctioning and
because air is removed along with secretions, the client on a ventilator should be
reattached to the ventilator or given a breath with a self-inflating bag with
supplemental oxygen .
5. ANS: D. Nagging cough, colds, fever and high pitch voice (no colds, fever and
high pitch voice)
6. ANS: B. Benign is not encapsulated and malignant is capsulated (vise-versa)
7. ANS: A. Chemotherapy, radiation therapy, surgical interventions and
Immunotherapy
8. ANS: D. None of the above
9. ANS: C. Menorrhagia, hemorrhagic cystitis and increase hemoglobin ( should be
amenorrhea and anemia)
10. ANS: A .Metoclopramide -antiemetic
11. ANS: C. Tumor size is more than 5cm with axillary and neck lymph nodes
involvement
12. ANS:B. Alcohol consumption and a sedentary lifestyle are contributing risk
factors for colorectal cancer. Diet modification includes a high-fiber, low-fat diet and
increased intake of vitamins C and E.
13. ANS:B. Women especially at risk for breast cancer had early menarche and late
menopause, are nulliparous, and have a first-degree relative with breast cancer.
12.

14. ANS:C. Interleukins are proteins that serve as regulators of the immune system. IL-
2 is derived from T cells, augments various other T-cell activities, and enhances the
function of natural killer cells.
15.b
16. d
17. b
18. c
19. d
20. c
21. d
22. a
23. a
24. b
25. a
26. c
27. a
28. c
29. a
30. d
31. A. replacement fluids include isotonic electrolyte solutions & blood component
therapy.
32. C. overdose of aspirin should be treated with emesis or lavage, followed by ingestion
of activated charcoal to absorb the aspirin.
33. A.
34. C.
35. C
36. C
37. B
38. D
39. C
40. C
41. A
42. A
43. A
44. C
45. D
46. B
47. B
48. D
49. B. papillary reaction is the best indication of whether oxygenated blood is reaching
the client’s brain. Pupils that remain widely dilated & do not react to light likely
indicate that serious brain damage has occurred.
50. D
51. A
52. D
53. B
54. C
55. C
56. A
57. A
58. B
59. D
60. B. shock causes metabolic acidosis
61. B
62. A
63. D
64. B
65. C
66. A
67. A
68. D
69. C
70. C.
71. D
72. A
73. C
74. A
75. B
76. B
77. C
78. B
79. D
80. C
81. D
82. C
83. A
84. B
85. B
86. C
87. A
88. C
89. A
90. ANS: B. Widening pulse pressure is a sign of IICP. Other signs include
elevation of the systolic arterial pressure & decrease pulse rate. These
symptoms are caused by pressure on the medulla oblongata.
91. ANS: A. The client should be reassured that the CAT scan is a noninvasive
procedure. It is important to emphasize that he must lie very still while the
scan is being done.
92. ANS: D. The nurse needs more data. This information can be obtained by
asking the client to identify specifically what happened and encouraging
him to discuss his feelings and what is happening to him.
93. ANS: B. Research has shown that the majority of cancer clients want to be
told of their condition and suffer no long-term negative effects when they are
told.
94. ANS: A. If the client has IICP, enemas are usually not ordered preoperatively.
Enemas, especially enemas until clear, increase ICP because the client
strains to expel the contents of the enema.
95. ANS: C. The client who has had a supratentorial craniotomy should be
positioned with the head of the bed elevated 30˚-45˚. This position facilitates
venous circulation from the brain. Thus, venous drainage is promoted,
which reduces cerebral edema and decreases ICP.
96. ANS: B. The client’s family should be reassured that the facial edema is
common after supratentorial surgery. The edema occurs about 1 day after
surgery and usually subsides within a few days.
97. ANS: C. The nurse should recognize that a moderate increase in temperature
is a usual occurrence during the first 2 to 3 days postoperatively.
98. ANS: C. Respiratory acidosis can develop when the partial pressure of
carbon dioxide in arterial blood is increased. The retention of carbon
dioxide causes a decrease in the pH of arterial blood. In an effort to restore
the pH to normal or near normal limits, the kidney responds by retaining
bicarbonate ions (HCO3). This protective mechanism is termed
compensation. Clients who have had intracranial surgery are at high risk for
developing respiratory acidosis because of the associated depression of the
respiratory center in the medulla.
99. ANS: C. Mannitol is an osmotic diuretic that is used to treat IICP. It relieves
IICP by diffusing the water in the CSF back into the plasma and the
extravascular compartment. Because its effectiveness is a result of its
action as an osmotic diuretic, urinary output is a valuable aid in determining
the client’s response.
100. ANS: C. Yellowish drainage on the dressing is not a normal occurrence.
Because it could be an indication of leakage of CSF, the physician should be
notified.