FINALS EXAM B.

Encouraging slow, deep breaths

Fluid, Electrolyte and Acid-Base Imbalances C. Preparing to administer sodium bicarbonate

1. A patient with tented skin turgor, dry mucous
membranes, and decreased urinary output is
under nurse Mark’s care. Which nursing
intervention should be included the care plan of
Mark for his patient?
A. Administering I.V. and oral fluids
B. Clustering necessary activities throughout the
day
D. Administer low-flow oxygen therapy
4. Marie Joy’s lab test revealed that her serum
calcium is 2.5 mEq/L. Which assessment data
does the nurse document when a client
diagnosed with hypocalcemia develops a
carpopedal spasm after the blood-pressure cuff
is inflated?

C. Assessing color, odor, and amount of sputum A. Positive Trousseau’s sign

D. Monitoring serum albumin and total protein B. Positive Chvostek’s sign

levels
C. Tetany

D. Paresthesia
2. Marriane is admitted in the hospital due to
having lower than normal potassium level in her
bloodstream. Her medical history reveals 5. Lab tests revealed that patient Z’s [Na+] is
vomiting and diarrhea prior to hospitalization. 170 mEq/L. Which clinical manifestation would
Which foods should the nurse instruct the client nurse Natty expect to assess?
to increase?
A. Tented skin turgor and thirst
A. Whole grains and nuts
B. Muscle twitching and tetany
B. Milk products and green, leafy vegetables
C. Fruity breath and Kussmaul’s respirations
C. Pork products and canned vegetables
D. Muscle weakness and paresthesia
D. Orange juice and bananas

3. Mary Jean, a first year nursing student, was

rushed to the clinic department due to
hyperventilation. Which nursing intervention is
the most appropriate for the client who is
subsequently developing respiratory alkalosis?

A. Administering sodium chloride I.V.

6. Dino has a history of chronic obstructive
pulmonary disease and has the following
arterial blood gas results: partial pressure of
oxygen (PO2), 55 mm Hg, and partial pressure
of carbon dioxide (PCO2), 60 mm Hg. When
attempting to improve the client’s blood gas
values through improved ventilation and oxygen
therapy, which is the client’s primary stimulus
for breathing?
D. 18-year-old Albert who has renal disease
9. Genevieve is diagnosed with
hypomagnesemia, which nursing intervention
would be appropriate?
A. Instituting seizure precaution to prevent
injury

A. High PCO2 B. Instructing the client on the importance of

preventing infection
B. Low PO2
C. Avoiding the use of tight tourniquet when
C. Normal pH drawing blood
D. Normal bicarbonate (HCO3) D. Teaching the client the importance of early
ambulation

7. A client with very dry mouth, skin and

mucous membranes is diagnosed of having 10. Which electrolyte would the nurse identify
dehydration. Which intervention should the as the major electrolyte responsible for
nurse perform when caring for a client determining the concentration of the
diagnosed with fluid volume deficit? extracellular fluid?
A. Assessing urinary intake and output A. Potassium
B. Obtaining the client’s weight weekly at B. Phosphate
different times of the day
C. Chloride
C. Monitoring arterial blood gas (ABG) results
D. Sodium
D. Maintaining I.V. therapy at the keep-vein-
open rate

11. Jon has a potassium level of 6.5 mEq/L,

which medication would nurse Wilma
8. Which client situation requires the nurse to anticipate?
discuss the importance of avoiding foods high in
potassium? A. Potassium supplements

A. 14-year-old Elena who is taking diuretics B. Kayexalate

B. 16-year-old John Joseph with ileostomy C. Calcium gluconate

C. 16-year-old Gabriel with metabolic acidosis D. Sodium tablets

12. Which clinical manifestation would lead the 15. Etiologies associated with hypocalcemia
nurse to suspect that a client is experiencing may include all of the following except:
hypermagnesemia?
A. renal failure
A. Muscle pain and acute rhabdomyolysis
B. inadequate intake calcium
B. Hot, flushed skin and diaphoresis
C. metastatic bone lesions
C. Soft-tissue calcification and hyperreflexia
D. vitamin D deficiency
D. Increased respiratory rate and depth

16. Which of the following findings would the

13. Mr. Salcedo has the following arterial blood nurse expect to asses in hypercalcemia?
gas (ABG) values: pH of 7.34, partial pressure of
A. prolonged QRS complex
arterial oxygen of 80 mm Hg, partial pressure of
arterial carbon dioxide of 49 mm Hg, and a B. tetany
bicarbonate level of 24 mEq/L. Based on these
results, which intervention should the nurse C. petechiae
implement?
D. urinary calculi
A. Instructing the client to breathe slowly into a
paper bag
17. Which of the following is not an appropriate
B. Administering low-flow oxygen
nursing intervention for a patient with
C. Encouraging the client to cough and deep hypercalcemia?
breathe
A. administering calcitonin
D. Nothing, because these ABG values are
B. administering calcium gluconate
within normal limits.
C. administering loop diuretics

D. encouraging ambulation
14. A client is diagnosed with metabolic
acidosis, which would the nurse expect the
health care provider to order?
18. A patient in which of the following disorders
A. Potassium is at high risk to develop hypermagnesemia?
B. Sodium bicarbonate A. insulin shock
C. Serum sodium level B. hyperadrenalism
D. Bronchodilator
C. nausea and vomiting 22. Aldosterone secretion in response to fluid
loss will result in which one of the following
D. renal failure electrolyte imbalances?

A. hypokalemia
19. Nursing interventions for a patient with B. hyperkalemia
hypermagnesemia include administering
calcium gluconate to: C. hyponatremia

A. increase calcium levels D. hypernatremia

B. antagonize the cardiac effects of magnesium

sulfate
23. When assessing a patient for signs of fluid
C. lower calcium levels overload, the nurse would expect to observe:

D. lower magnesium levels A. bounding pulse

B. flat neck veins

20. Which of the following is the most C. poor skin turgor

important physical assessment parameter the
nurse would consider when assessing fluid and D. bronchovesicular breath sounds
electrolyte imbalance?

A. skin turgor 24. Respiratory regulation of acids and bases

involves:
B. intake and output

C. osmotic pressure A. hydrogen

B. hydroxide
D. cardiac rate and rhythm
C. oxygen

D. carbon dioxide

21. Insensible fluid losses include:

25. Which of the following conditions is an
A. urine
equal decrease of extracellular fluid (ECF) solute
B. gastric drainage and water volume?

C. bleeding A. hypotonic FVD

D. perspiration B. isotonic FVD

C. hypertonic FVD
D. isotonic FVE
26. When assessing a patient for electrolyte
balance, the nurse is aware that etiologies for
hyponatremia include:
A. water gain
B. diuretic therapy
C. diaphoresis
D. all of the following
27. Nursing interventions for a patient with
hyponatremia include:
A. administering hypotonic IV fluids
B. encouraging water intake
C. restricting fluid intake
D. restricting sodium intake
28. When assessing a patient’s total body water
percentage, the nurse is aware that all of the
following factors influence this except:
A. age
B. fat tissue
C. muscle mass
D. gender
29. Orly Khan is suffering from fluid volume
deficit (FVD), which of the following symptoms
would the nurse expect to assess in the patient?
A. rales
B. bounding pulse
C. tachycardia
D. bulging neck veins
30. Mr. Wenceslao is scheduled to receive an
isotonic solution; which one of the following is
an example of such solution?
A. D10% W
B. 0.45% saline
C. 0.9% saline
D. 3% normal saline
31. Which of the following arterial blood gas
(ABG) values indicates uncompensated
metabolic alkalosis?
A. pH 7.48, PaCO2 42, HCO3 30
B. pH 7.48, PaCO2 46, HCO3 30
C. pH 7.48, PaCO2 34, HCO3 20
D. pH 7.48, PaCO2 34, HCO3 26
32. The process of endocrine regulation of
electrolytes involves:
A. sodium reabsorption and chloride excretion
B. chloride reabsorption and sodium excretion
C. potassium reabsorption and sodium
excretion
D. sodium reabsorption and potassium
excretion
33. The major cation in the ICF is: 37. The lungs participate in acid-base balance
by:
A. potassium
A. reabsorbing bicarbonate
B. sodium
B. splitting carbonic acid in two
C. phosphorus
C. using CO2 to regulate hydrogen ions
D. magnesium
D. sending hydrogen ions to the renal tubules

34. A patient with which of the following

disorders is at high risk for developing 38. The respiratory system regulates acid-base
hyperphosphatemia? balance by:

A. hyperkalemia A. increasing mucus production

B. hyponatremia B. changing the rate and depth of respirations

C. hypocalcemia C. forming bicarbonate

D. hyperglycemia D. reabsorbing bicarbonate

35. Calcium is absorbed in the GI tract under the

influence of:
39. Which of the following is a gas component
A. vitamin D of the ABG measurement?

B. glucose A. carbon dioxide

C. HCl B. bicarbonate

D. vitamin C C. hydrogen

D. pH

36. When serum calcium levels rise, which of

the following hormones is secreted?
40. Jonas is admitted with 1,000 ml of diarrhea
A. aldosterone per day for the last 3 days. An IV of 0.45% NaCl
mixed with 5% dextrose is infusing. Which of
B. renin the following nursing interventions is the most
C. parathyroid hormone appropriate?

D. calcitonin A. Get an infusion controller from central

supply.
B. Mix all antibiotics in 0.45% NaCl with 5% B. tachycardia
dextrose.
C. hyperactive deep-tendon reflex
C. Check the patient’s potassium level and
D. cardiac arrhythmias
contact the doctor for IV additive orders.

D. Assess the patient for signs of hyperkalemia.

44. Daniel who is a marathon runner is at high
risk for fluid volume deficit. Which one of the
41. When teaching a patient about foods high in following is a related factor?
magnesium, the nurse would include:
A. decreased diuresis
A. green vegetables
B. disease-related process
B. butter
C. decreased breathing and perspiration
C. cheese
D. increased breathing and perspiration
D. tomatoes

45. Jomarick is diagnosed with FVD; which of

42. Maria, an 85-year-old patient with a feeding
tube, has been experiencing severe watery
stool. The patient is lethargic and has poor skin
turgor, a pulse of 120, and hyperactive reflexes.
Nursing interventions would include:
A. measuring and recording intake and output
and daily weights
B. administering salt tablets and monitoring
hypertonic parenteral solutions
the following nursing diagnoses might apply to
his condition?
A. altered urinary elimination
B. decreased cardiac output
C. increased cardiac output
D. vomiting

C. administering sedatives 46. Body fluids perform which of the following

functions?
D. applying wrist restraints to avoid
displacement of the feeding tube A. transport nutrients

B. transport electrical charges

43. Christoff is diagnosed with C. cushion the organs

hypermagnesemia. Symptoms of her condition
D. facilitate fat metabolism
may include:

A. hypertension
47. Alexander has hypotonic FVE; which of the
following findings would the nurse expect to
assess in the patient?
A. poor skin turgor and increased thirst
B. weight gain and thirst
C. interstitial edema and hypertension
D. hypotension and pitting edema
48. The interstitial space holds approximately
how many liters?
A. 3 L
B. 6 L
C. 9 L
D. 12 L
49. Sodium balance is important for which of
the following functions?
A. transmitting impulses in nerve and muscle
fibers via the calcium-potassium pump
B. exchanging for magnesium and attracting
chloride
C. combining with hydrogen and chloride for
acid-base balance
D. exchanging for potassium and attracting
chloride
50. In renal regulation of water balance, the
functions of angiotensin II include:
A. blood clotting within the nephron
B. increasing progesterone secretion into the
renal tubules
C. catalyzing calcium-rich nutrients
D. selectively constricting portions of the
arteriole in the nephron
51. Which of the following nursing diagnoses
might not apply to a patient with FVE?
A. ineffective airway clearance
B. potential for decreased cardiac output
C. ineffective breathing pattern
D. potential for increased cardiac output
52. The majority of the body’s water is
contained in which of the following fluid
compartments?
A. intracellular
B. interstitial
C. intravascular
D. extracellular
53. The danger of fluid sequestered in the third
space is that the fluid:
A. is hypertonic and can cause hypervolemia
B. is hypotonic and can cause water intoxication
C. is not available for circulation
D. contains large amounts of acids
54. Which of the following clinical conditions 58. Interpret the ABG result: pH: 7.33, pCO2:
promotes electrolyte excretion? 31 , HCO3: 19

A. nasogastric feedings

B. use of surgical drains A. Respiratory Acidosis

C. immobility from fractures B. Respiratory Alkalosis

D. chronic water drinking C. Metabolic Acidosis

D. Metabolic Alkalosis

55. Which of the following are lost as a result of 59. Interpret the ABG result: pH: 7.48, pCO2: 29,
vomiting? HCO3: 21

A. bicarbonate and calcium A. Respiratory Acidosis

B. sodium and hydrogen B. Respiratory Alkalosis

C. sodium and potassium C. Metabolic Acidosis

D. hydrogen and potassium D. Metabolic Alkalosis

60.Interpret: pH: 7.39, pCO2: 38, HCO3: 24

56. Interpret the ABG result: pH: 7.31, pCO2: 47, A. Fully Compensated
HCO3: 28
B. Partially Compensated
A. Respiratory Acidosis
C. Uncompensated
B. Respiratory Alkalosis
D. Normal
C. Metabolic Acidosis

D. Metabolic Alkalosis

57.Interpret the ABG result: pH: 7.47, pCO2: 47,

HCO3: 29

A. Respiratory Acidosis

B. Respiratory Alkalosis

C. Metabolic Acidosis

D. Metabolic Alkalosis

The nurse is preparing a client for surgery. What
is the most effective method for obtaining an
accurate blood pressure reading from the
client?
A. Obtain a cuff that covers the upper one third
of the client’s arm
B. Position the cuff approximately 4 inches
above the antecubital arm
C. Use a cuff that is wide enough to cover the
upper two thirds of the client’s arm
D. Identify the Korotkoff sounds, and take a
systolic reading at 10 mmHg after the first
sound
Which of the following items on a client’s pre
surgery laboratory results would indicate a need
to contact the surgeon?
A. Platelet count of 250,000/cu.mm
B. Total cholesterol of 325 mg/dl
C. Blood urea nitrogen (BUN)) 17 mg/dl
D. Hemoglobin 9.5 mg/dl
To prevent complications of immobility, which
activities would the nurse plan for the first
postoperative day after a colon resection?
A. Turn, cough, and deep breathe every 30
minutes around the clock
B. Get the client out of bed and ambulate to a
bedside chair
C. Provide passive range of motion three times
a day
D. It is not necessary to worry about
complications of immobility on the first
postoperative day
In the recovery room, the postoperative client
suddenly becomes cyanotic. What is the most
appropriate nursing action?
A. Start administration of oxygen through a
nasal cannula
B. Call for assistance
C. Reposition the head and determine patency
of airway
D. Insert an oral airway and suction the
nasopharynx
A client is scheduled for surgery in the morning.
Preoperative orders have been written. What is
most important to do before surgery?
A. Remove all jewelries or tape wedding ring
B. Verify that all laboratory work is complete
C. Inform family or next of kin
D. Have all consent forms signed
The nurse is caring for a first day postoperative
surgical client. Prioritize the patient’s desired
dietary progression. Arrange in sequence the
dietary progression from 1 to 4: 1. Full liquid; 2.
NPO; 3. Clear liquid; 4. Soft
A. 1, 2, 3, 4
B. 2, 3, 1, 4
C. 2, 1, 4, 3
D. 4, 3, 2, 1
7. A postoperative client receives a dinner tray
with gelatin, pudding, and vanilla ice cream.
Based on the foods on the client’s tray, what
would the nurse anticipate the client’s current
diet order to be:
A. Bland diet
B. Soft diet
C. Full liquid diet
D. Regular diet
The nurse is preparing the preoperative client
for surgery. The following statements that
indicate the client is knowledgeable about his
impending surgery, except:
A. “After surgery, I will need to wear the
pneumatic compression device while sitting in
the chair”
B. “The skin prep area is going to be longer and
wider than the anticipated incision”
C. “I cannot have anything to drink or eat after
midnight on the night before the surgery”
D. “To ensure my safety, a ‘time out’ will be
conducted in the operating room”
Which of the following is the primary purpose
of maintaining NPO for 6 to 8 hours before
surgery?
A. To prevent malnutrition
B. To prevent electrolyte imbalance
C. To prevent aspiration pneumonia
D. To prevent intestinal obstruction
The nurse will provide preoperative teaching on
deep breathing, coughing and turning exercises.
When is the best time to provide the
preoperative teachings
A. Before administration of preoperative
medications
B. The afternoon or evening prior to surgery
C. Several days prior to surgery
D. Upon admission of the client in the recovery
room
Which of the following factors ensure validity of
informed written consent, except:
A. The patient is of legal age with proper mental
disposition
B. If the patient is a child, secure consent from
the parents or legal guardian
C. The consent is secured before administration
of preoperative medications
D. If the patient is unable to write, the nurse
signs the consent for the patient
Which of the following drugs is administered to
minimize respiratory secretions preoperatively?
A. Valium (diazepam)
B. Phenergan (promethazine)
C. Atropine sulfate
D. Demerol (Meperidine)
Which of the following is experienced by the
patient who is under general anesthesia?
A. The patient is unconscious
B. The patient is awake
C. The patient experiences slight pain
D. The patient experiences loss of sensation in
the lower half of the body
Which of the following is most dangerous
complication during induction of spinal
anesthesia?
A. Cardiac arrest
B. Hypotension
C. Hyperthermia
D. Respiratory paralysis
Which of the following postoperative patients is
at risk for respiratory complications?
A. The obese patient with long history of
smoking who had undergone upper abdominal
surgery
B. The patient with normal pulmonary function
who had undergone upper abdominal surgery
C. An adolescent patient with diabetes mellitus
who had undergone cholecystectomy
D. A football player who had undergone knee
replacement surgery
The patient had undergone spinal anesthesia
for appendectomy. To prevent spinal headache,
the nurse should place the patient in which of
the following positions?
A. Semi-Fowler’s
B. Flat on bed for 6 to 8 hours
C. Prone position
D. Modified Trendelenburg position
The nurse is admitting a patient to the operating
room. Which of the following nursing actions
should be given highest priority by the nurse?
A. Assessing the patient’s level of consciousness
B. Checking the patient’s vital signs
C. Checking the patient’s identification and
correct operative permit
D. Positioning and performing skin preparation
to the patient
Which of the following assessment data is most
important to determine when caring for a
patient who has received spinal anesthesia?
A. The time of return of motion and sensation
in the patient’s legs and toes
B. The character if the patient’s respiration B. Fast, thready pulse, bradypnea

C. The patient’s level of consciousness C. Apprehension and restlessness

D. The amount of wound drainage D. Faintness, pallor

The nurse is transferring the patient from the The diabetic patient who had undergone
postanesthesia care unit to the surgical unit. abdominal surgery experiences wound
Which of the following is the primary reason for evisceration. Which of the following is the most
gradual change of position of the patient? appropriate immediate nursing action?

A. To prevent muscle injury A. Cover the wound with sterile gauze

moistened with sterile normal saline
B. To prevent sudden drop of blood pressure
B. Cover the wound with sterile dry gauze
C. To prevent respiratory distress
C. Cover the wound with water-soaked gauze
D. To promote comfort
D. Leave the wound uncovered and pull the skin
edges together
The nurse is caring for a patient who had
undergone exploratory laparotomy. Which of
the following postop findings should the nurse The patient had undergone a total hip
report to the physician? replacement. He complains of pain in the
operative site. Which of the following is the
A. The patient pushes out the oral airway with appropriate initial nursing action?
his tongue
A. Administer the ordered analgesic
B. The patient’s urine output is 20 ml/hr for
the past 2 hours B. Instruct the patient to do deep breathing and
coughing exercises
C. The patient’s vital signs are as follows: BP =
100/70 mmHg; PR = 95 bpm; RR = 9 minute; T = C. Assess the patient’s pain level and vital signs
36.8°C
D. Change the patient’s position
D. The patient’s wound drainage

Which of the following are not members of the

The patient had undergone thyroidectomy. sterile team in the operating room, except:
Which of the following are the earliest signs of
poor tissue perfusion and poor respiratory A. Surgeon
function? B. Scrub nurse
A. Cyanosis, lethargy
C. Radiology technician
D. Circulating nurse
The best position for kidney, chest, or hip
surgery is:
A. Supine
B. Trendelenburg
C. Lithotomy
D. Lateral
The preoperative phase of surgery begins with...
A. decision to proceed with surgical
intervention
B patient being admitted to the pre-admission
testing unit
C. patient being transferred to the OR suite
D. patient signing admission paperwork
Which of the following surgeries would be
classified as emergent?
A. the decision to proceed with surgical
intervention Kidney stones
B. the patient being admitted to the pre-
admission testing unit Urethral stones
C. the patient being transferred to the OR suite
Fractured skull
D. the patient signing admission paperwork
Which of the following conditions is commonly
associated with obese patients and of primary
concern when scheduled for surgery? Select all
that apply
A. Wound infection
B. Sleep apnea
C. Wound dehiscence
D. the patient signing admission paperwork
Which health care provider informs the patient
of the benefits and risks of surgery prior to
going to surgery?
A. Registered Nurse
B. Surgeon
C. OR administrator
D. the patient signing admission paperwork
Which of the following items is included in a
valid informed consent? Select all that apply
A .Patient must be 16 years of age or older
B. Patient must be 18 years of age or older
C. Consent must be freely given
D. the patient signing admission paperwork
ASA (aspirin) should be discontinued...
A. 7-10 days before surgery
B. 1-3 days after surgery
C. At least 30 days before surgery
D. At least 60 days after surgery
Which of the following statements is the correct
way for patients to splint incisions when they
cough?
A. Put the palms of the fingers together and
interlace the fingers snugly and place hands
across incision
B. Hold one hand gently directly over the
incision and breathe deeply before coughing
C. .Hold both hands on top of each other
strongly exerting pressure over the incision
D. Have the patient deep breathe while they
provide medium pressure over the incision
Which one of the following would be included
in your teaching for the pre-operative patient?
A. Take a deep breath and hold for 5 seconds,
repeat 15 times twice daily
B. Take a deep breath and hold for 10 seconds
C. Take a deep breath and hold for 3 seconds,
repeat 15 times twice daily
D. Take a deep breath and hold for 5 seconds,
repeat 5 times twice daily
Healthy patients are allowed clear liquids up
to...
A. 4 hours before an elective surgical procedure
B. 3 hours before an elective procedure
C. 2 hours before an elective procedure
D.8 hours before an elective procedure
The patient who is considered at risk for surgical
complications is...
A. A patient with arthritis
B. A patient with HTN (hypertension)
C. A patient who smokes
D. A patient who smokes
The nurse has just reassessed the condition of a
postoperative client who was admitted 1 hour
ago to the surgical unit. The nurse plans to
monitor which parameter most carefully during
the next hour?
A. Urine output of 20ml/hour
B. Temperature of 37.6 C
C. Blood pressure of 114/70
D. Serous drainage on the surgical dressing
A postoperative client asks the nurse why it is
so important to deep-breathe and cough after
surgery. When formulating a response, the
nurse incorporates the understanding that
retained pulmonary secretions in a
postoperative client can lead to which
condition?
A. Pneumonia
B. Hypoxemia
C. Fluid imbalance
D. Pulmonary embolism

The nurse is developing a plan of care for a
client scheduled for surgery. The nurse should
include which activity in the nursing care plan
for the client on the day of surgery?
A. Avoid oral hygiene and rinsing with
mouthwash
B. Verify that the client has not eaten for the
last 24 hours
C. Have the client void immediately before
going into surgery
D. Report immediately any slight increase in BP
or pulse
A client with a perforated gastric ulcer is
scheduled for surgery. The client cannot sign
the operative consent form because of sedation
from opioid analgesics that have been
administered. The nurse should take which
most appropriate action in the care of this
client?
A. Obtain a court order for the surgery.
B. Have the charge nurse sign the informed
consent immediately
C. Send the client to surgery without the
consent form being signed
D. Obtain a telephone consent from a family
member, following agency policy
A preoperative client expresses anxiety to the
nurse about upcoming surgery. Which response
by the nurse is most likely to stimulate further
discussion between the client and the nurse?
A. "If it's any help, everyone is nervous before
surgery."
B."I will be happy to explain the entire surgical
procedure with you."
C. "Can you share with me what you've been
told about your surgery?"
D. "Let me tell you about the care you'll receive
after surgery and the amount of pain you can
anticipate".
Which type of surgery is most likely to
predispose a patient to postoperative
atelectasis, pneumonia or respiratory failure?
A. Upper abdominal surgery on an obese
patient with a long history of smoking
B. Upper abdominal surgery on a patient with
normal pulmonary function
C. Lower abdominal surgery on a young patient
with diabetes mellitus
D. Surgery on the extremities of a non-smoking
football player
The circulating nurse and the scrub technician
find a discrepancy in the sponge count. Which
action should the circulating nurse take first?
A. Contact the surgical manager.
B. Re-count all sponge
C. Complete an occurrence report
D. Notify the client’s surgeon
The circulating nurse prepares the sterile field in
the operating room (OR). Fifteen minutes later,
the nurse is informed the surgery is delayed for
20 minutes because the surgeon is working at
another hospital. Which is the best action for
the nurse to take?
A. Monitor the sterile field while awaiting the
surgeon
B. Tear down the sterile field until the surgeon
arrives in the OR
C. Cover the sterile field with a sterile drape
until the surgery is about to begin
D. Close and tape the OR doors so that no one
may enter
1. Guidelines for early detection of cancer
include the following EXCEPT:
Pap smear only among sexually-active women
Monthly BSE for women 20 years of age and
above
Baseline mammogram taken for women over 40
years of age.
Guaiac stool examination on yearly basis for
adults over 50 years
2. If a client receives Pap smear report
that is Class 1, what should the nurse advise?
Refrain from sexual activity
Report to the clinic for repeat pap smear
Undergo biopsy
Return for another pap smear in 1-3 years as
directed by physician
3. The client had undergone external
radiation treatment. The most common
systematic side effects of the treatment include
the following EXCEPT?
Anorexia
Fatigue
Malaise
Dry desquamation of the skin
4. Patient teaching on skin care among
clients undergoing external radiation includes
the following?
Massage the area daily
Apply lotion to the area
Wash area with water only, no soap
Expose the area to sunlight
5. Which of the following medications
would you used to relieve nausea and vomiting
due to chemotherapy?
Metochlopramide (Reglan)
Lactulose (Duphalac)
Dexamethasone (Decadron)
Magnesium Hydroxide (Milk of Magnesia)
6. A 54-year old client is admitted to the
hospital for breast cancer. During the pre op
period, what is the most important
consideration in the client’s nursing care?
Reassure the client that surgery will cure cancer
Assess understanding of the procedure and
expectation of the bodily appearance after
surgery
Maintain a cheerful and optimistic behaviour
Keep visitors to a minimum so that she can have
time to reflect on her condition
7. A chemotherapeutic agent,
methotrexate is ordered for a client. Which of
the following statements is true about
chemotherapy?
It affects the tumor cells
It causes few side effects
It can destroy all cancer cells in one exposure
It affects both cancer cells and normal cells
8. The client receiving 5-fluorouracil
develops stomatitis. Nursing interventions for
the client include the following EXCEPT:
Normal saline gargle every 2 hours
Taking hot liquids
Soft, blind diet
Topical anesthetics before meals
9. The client with cervical cancer has a
cervical cobalt implant in place. Which of the
following nursing interventions should be
included in her care of plan?
Frequent ambulation
Low-residue diet
Vaginal irrigation every shift
Position the bed so that the client faces the
door
10. A 32- year old client had MRM
(modified radical mastectomy) the nurse
encourage her to look at the incision site before
discharged .She turns her head and cries “It is
horrible”. How should the nurse respond?
“I understand how you feel. I’d feel the same
way too.”
“It’s ok. You can look at it in the mirror when
you’re home.”
“Your feelings are normal; it’s alright to cry”
“I know this awful, but it’s not that terrible.”
11. Which of the following is the priority
nursing diagnosis after mastectomy?
Disturb in self- concept
Self-care deficit
Activity intolerance
Alteration in cardiac output
12. Lypmphedema is the most common
postoperative complication following axillary
lymph node resection. The following actions
would minimize this problem EXCEPT;
Elevate arm with pillow
Keep arm abducted
Reinforce the arm exercises
Take the BP from the arm on the affected side
13. A patient had been diagnosed to have
rheumatoid arthritis. The following are
characteristics manifestations:
Pain on use joints, tophi, crepitus
Pain on non-use of joints subcutaneous
nodules, elevated ESR
Heberdens nodes, elevated serum uric acid,
fever
Unilateral affected of joints, localized swelling,
body malaise
14. The nurse is caring for a client with an
internal radiation implant. When caring for the
client, the nurse should observe which
principle?
Limit the time with the client to 1 hour per shift
Do not allow pregnant women into the clients
room
Remove the dosimeter film badge when
entering the cleints room
Individuals younger than 16 yo may be allowed
to go in the room as long as they are 6 feet
away from the client
15. The client is hospitalized for insertion of
an internal cervical radiation implant. While
giving care, the nurse finds the radiation
implant in the bed. The initial action by the
nurse is to:
Call the physician
Reinsert the implant into the vagina
immediately
Pick up the implant with gloved hands and flush
it down the toilet
Pick up the implant with long-handled forceps
and place it in a container
16. The nurse is caring for client
experiencing neutropia as a result of
chemotherapy and develops a plan of care for
the client. The nurse plans to:
Restrict all visitor
Restrict fluid intake
Teach the client and family about the need for
hand hygiene
Insert and indwelling catheter to prevent skin
breakdown
17. The home health care nurse is caring for
a client with cancer and the client is
complaining of acute pain. The most
appropriate nursing assessment of the client
pain would include which of the following?
The clients pain rating
Nonverbal cues from the client
The nurses impression of the clients pain
Pain relief after appropriate nursing
intervention
18. During admission assessment of a client
with advanced ovarian cancer, the nurse
recognizes which symptoms as typical of the
disease?
Diarrhea
Hypermonerrhea
Abnormal bleeding
Abdominal distention
19. The nurse is instructing the client to
perform a testicular self- examination. The
nurse tells the client:
To examine the testicles while lying down
That the best time for the examination is after
a shower
To gently feel the testicle with one finger to feel
for a growth
That testicular self examination should be done
atleast every 6 months
20. The nurse is teaching a client about the
risk factors associated with colorectal cancer.
The nurse determines that further teaching
related to colorectal cancer is necessary if the
client identifies which of the following as an
associated risk factors?
Age younger than 50 yo
History of colorectal polyps
Family history of colorectal cancer
Chronic inflammatory bowel disease
21. The nurse is reviewing the history of a
client with bladder cancer. The nurse expects to
note documentation of which most common
symptom this type of cancer?
Dysuria
Hematuria
Urgency in urination
Frequency in urination
22. The community health nurse is
instructing a group of female clients about
breast self -examination. The nurse instructs the
clients to perform the examination;
At the onset of menstruation
Every month during ovulation
Weekly at the same time of the day
1 week after the menstruation begins
23. The client is diagnosed as having a
bowel tumor and several diagnostic test are
prescribed. The nurse understands that which
test will confirm the diagnosis of malignancy
Biopsy of the tumor
Abdominal ultrasound
Magnetic resonance imaging
Computed tomography scan
24. A client calls the nurse in the
emergency department and tells the nurse that
he was just stung by a bumble bee while
gardening. The client is afraid of a severe
reaction because the clients neighbour
experienced such a reaction just 1 week ago.
The appropriate nursing action is to:
Advise the client to soak the site in hydrogen
peroxide
Ask client if he ever sustained a bee sting in
the past
Tell the client to call ambulance for transport to
the emergency department
Tell the client not to worry about the sting
unless difficulty with breathing occurs
25. The community health nurse is
conducting a research and is identifying clients
in the community at risk for latex allergy. Which
client population is at risk for developing this
type of allergy?
Hairdressers
The homeless
Children in day care centers
Individual living in group home
26. The home nurse is performing an
assessment on a client who has been diagnosed
with an allergy to latex. In determining the
clients risk factors associated with the allergy,
the nurse questions the client about an allergy
to which of the following food item?
Eggs
Milk
Yogurt
Bananas
27. The client with acquired
immunodefinciency syndrome diagnosed with
Kaposis Sarcoma. Based on this diagnosis, the
nurse understands that this has been confirmed
by which of the following?
Swelling in the genital area
Swelling in the lower extremities
Punch biopsy of the cutaneous lesions
Appearance of reddish-blue lesions noted on
the skin
28. As a shift leader making out -patient
assignments for the incoming shift, how would
you assign care of a patient that has had a
sealed radiation source placed?
You decide to rotate staff and assign a nurse
who has provided care for the patient
You decide to assign the same nurse who had
the patient yesterday to continue providing
quality care
None of the options are correct. Sealed
radiation therapy has no special staffing
restrictions
You decide to assign one nurse to care for all
the patients undergoing sealed radiation
therapy to provide continuum care
29. A patient who has underwent a bone
marrow transplant is at risk for what?
Bleeding and infection
Congestive heart failure
Liver failure
HIV
30. Which patient is at highest risk for
cervical cancer?
A 21yo who reports first sexual partner at the
age 14yo and that she has had at least 10
sexual partners.
A 60yo with a history of syphilis and cigarette
smoking
A 32 yo in a monogamous relationship who
declined HPV vaccine
None of the patients are at risk for cervical
cancer
31. As an oncological nurse, you know that
the finding is correct regarding breast cancer?
Masses are usually felt in the upper outer
quadrant beneath the nipple or axilla
Women who’ve had late menarche and early
menopause are at risk for breast cancer
Nipple retraction is never present
The mass is typically painful and red
32. The function of monocytes in immunity
is related to their ability to;
Stimulate the production of T and B
lymphocytes
Produce antibodies on exposure to foreign
substances
Bind antigens and stimulate natural killer cell
activation
Capture antigens by phagocytes and present
them to lymphocytes
33. The reason newborns are protected for
the first 6 months of life from bacterial infection
is because of the maternal transmission of?
IgG
IgA
IgM
IgE
34. In a type I hypersensitivity reaction the
primary immunologic disorder appears to be?
A binding of IgG to an antigen on a cell surface
Deposit of antigen-antibody complexes in small
vessels
Release of cytokines used to interact with
specific antigens
Release of chemicals mediators from IgE-
bound mast cells and basophils
35. The nurse is alerted to possible
anaphylactic shock immediately after a patient
has received intramuscular penicillin by the
development of?
Edema and itching at the injection site
Sneezing and itching of the nose and eyes
Wheal-and-flare reaction at the injection site
Chest tightness and production of thick sputum
36. Which condition would Nurse Jade
suspect when a client complaints of a runny
nose, itching and burning eyes, and sneezing
since visiting a friend who had a cat at home?
Asthma
Bronchitis
Anaphylaxis
Allergic Rhinitis
37. After the injection of an
immunotherapy program, the nurse notice a
large, red wheal on the clients arm, coughing,
and expiratory wheezing. Which intervention
should the nurse implement first?
Starting an IV line for medication administration
Beginning oxygen by way of nasal cannula
Notifying the health care provider immediately
Administering IM epinephrine per protocol
38. Mr Mc Princeton who is diagnosed with
rheumatoid arthritis complains about joints that
always hurt, saying “ I just feel like staying in
bed all day”. Which discharge instruction would
be aimed at maintaining as such function as
possible?
Apply elastic bandages to all joints to increase
the pain threshold
Refrain from exercises because it only
aggravates the disease process
Maintain a supine position most of the day to
prevent the stress of weight bearing
Promote aquatic (water) exercises or range of
motion to enhance joint mobility
39. Theon was stung by a bee now exhibits
redness and edema in the hand and forearm.
The nurses actions would be based on which
scientific rationale?
The client need regular check -ups to obtain
immunotherapy
The client should not worry; people cannot
develop an allergy to bee stings
Hypersensitivity reaction is possible; the client
may need to buy an anti-sting kit
Baking soda is the best treatment for the edema
from the bee sting
40. Nurse Mary is assisting in administering
immunization at a health center. The nurse
understands that immunization will provide:

Innate Immunity from disease

Acquired immunity from the disease

Natural immunity from the disease

Protection from all disease