PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
. Following surgery, Mario complains of mild incisional pain
while performing deep- breathing and coughing exercises. The
nurse’s best response would be:
A. “Pain will become less each day.”
B. “This is a normal reaction after surgery.”
C. “With a pillow, apply pressure against the incision.”
D. “I will give you the pain medication the physician ordered.”
Answer: (C) “With a pillow, apply pressure against the incision.”
Applying pressure against the incision with a pillow will help
lessen the intra-abdominal pressure created by coughing which
causes tension on the incision that leads to pain.
2. The nurse needs to carefully assess the complaint of pain of
the elderly because older people
A. are expected to experience chronic pain
B. have a decreased pain threshold
C. experience reduced sensory perception
D. have altered mental function
Answer: (C) experience reduced sensory perception
Degenerative changes occur in the elderly. The response to
pain in the elderly maybe lessened because of reduced acuity
of touch, alterations in neural pathways and diminished
processing of sensory data.
3. Mary received AtropineSO4 as a pre-medication 30 minutes
ago and is now complaining of dry mouth and her PR is higher,
than before the medication was administered. The nurse’s best
A. The patient is having an allergic reaction to the drug.
B. The patient needs a higher dose of this drug
C. This is normal side-effect of AtSO4
D. The patient is anxious about upcoming surgery
Answer: (C) This is normal side-effect of AtSO4
Atropine sulfate is a vagolytic drug that decreases
oropharyngeal secretions and increases the heart rate.
4. Ana’s postoperative vital signs are a blood pressure of 80/50
mm Hg, a pulse of 140, and respirations of 32. Suspecting
shock, which of the following orders would the nurse question?
A. Put the client in modified Trendelenberg's position.
B. Administer oxygen at 100%.
C. Monitor urine output every hour.
D. Administer Demerol 50mg IM q4h
Answer: (D) Administer Demerol 50mg IM q4h
Administering Demerol, which is a narcotic analgesic, can
depress respiratory and cardiac function and thus not given to a
patient in shock. What is needed is promotion for adequate
oxygenation and perfusion. All the other interventions can be
expected to be done by the nurse.
5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a
cystectomy with the creation of an ileal conduit in the morning.
He is wringing his hands and pacing the floor when the nurse
enters his room. What is the best approach?
A. "Good evening, Mr. Pablo. Wasn't it a pleasant day, today?"
B. "Mr, Pablo, you must be so worried, I'll leave you alone with
your thoughts.
C. “Mr. Pablo, you'll wear out the hospital floors and yourself at
this rate."
D. "Mr. Pablo, you appear anxious to me. How are you feeling
about tomorrow's surgery?"
Answer: (D) "Mr. Pablo, you appear anxious to me. How are
you feeling about tomorrow's surgery?"
The client is showing signs of anxiety reaction to a stressful
event. Recognizing the client’s anxiety conveys acceptance of
his behavior and will allow for verbalization of feelings and
concerns.
6. After surgery, Gina returns from the Post-anesthesia Care
Unit (Recovery Room) with a nasogastric tube in place
following a gall bladder surgery. She continues to complain of
nausea. Which action would the nurse take?
A. Call the physician immediately.
B. Administer the prescribed antiemetic.
C. Check the patency of the nasogastric tube for any
obstruction.
D. Change the patient’s position.
Answer: (C) Check the patency of the nasogastric tube for any
obstruction.
Nausea is one of the common complaints of a patient after
receiving general anesthesia. But this complaint could be
aggravated by gastric distention especially in a patient who has
undergone abdominal surgery. Insertion of the NGT helps
relieve the problem. Checking on the patency of the NGT for
any obstruction will help the nurse determine the cause of the
problem and institute the necessary intervention.
7. Mr. Perez is in continuous pain from cancer that has
metastasized to the bone. Pain medication provides little relief
and he refuses to move. The nurse should plan to:
A. Reassure him that the nurses will not hurt him
B. Let him perform his own activities of daily living
C. Handle him gently when assisting with required care
D. Complete A.M. care quickly as possible when necessary
Answer: (C) Handle him gently when assisting with required
care
Patients with cancer and bone metastasis experience severe
pain especially when moving. Bone tumors weaken the bone to
appoint at which normal activities and even position changes
can lead to fracture. During nursing care, the patient needs to
be supported and handled gently.
8. A client returns from the recovery room at 9AM alert and
oriented, with an IV infusing. His pulse is 82, blood pressure is
120/80, respirations are 20, and all are within normal range. At
10 am and at 11 am, his vital signs are stable. At noon,
however, his pulse rate is 94, blood pressure is 116/74, and
respirations are 24. What nursing action is most appropriate?
A. Notify his physician.
B. Take his vital signs again in 15 minutes.
C. Take his vital signs again in an hour.
D. Place the patient in shock position.
Answer: (B) Take his vital signs again in 15 minutes.
Monitoring the client’s vital signs following surgery gives the
nurse a sound information about the client’s condition.
Complications can occur during this period as a result of the
surgery or the anesthesia or both. Keeping close track of
changes in the VS and validating them will help the nurse
initiate interventions to prevent complications from occurring.
9. A 56 year old construction worker is brought to the hospital
unconscious after falling from a 2-story building. When
assessing the client, the nurse would be most concerned if the
assessment revealed:
A. Reactive pupils
B. A depressed fontanel
C. Bleeding from ears
D. An elevated temperature
Answer: (C) Bleeding from ears
The nurse needs to perform a thorough assessment that could
indicate alterations in cerebral function, increased intracranial
pressures, fractures and bleeding. Bleeding from the ears
occurs only with basal skull fractures that can easily contribute
to increased intracranial pressure and brain herniation
10. Which of the ff. statements by the client to the nurse
indicates a risk factor for CAD?
A. “I exercise every other day.”
B. “My father died of Myasthenia Gravis.”
C. “My cholesterol is 180.”
D. “I smoke 1 1/2 packs of cigarettes per day.”
Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.”
Smoking has been considered as one of the major modifiable
risk factors for coronary artery disease. Exercise and
maintaining normal serum cholesterol levels help in its
prevention.
11. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor
knowledge regarding this drug?
A. It has positive inotropic and negative chronotropic effects
B. The positive inotropic effect will decrease urine output
C. Toxixity can occur more easily in the presence of
hypokalemia, liver and renal problems
D. Do not give the drug if the apical rate is less than 60 beats
per minute.
Answer: (B) The positive inotropic effect will decrease urine
output
Inotropic effect of drugs on the heart causes increase force of
its contraction. This increases cardiac output that improves
renal perfusion resulting in an improved urine output.
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
12. Valsalva maneuver can result in bradycardia. Which of the
following activities will not stimulate Valsalva's maneuver?
A. Use of stool softeners.
B. Enema administration
C. Gagging while toothbrushing.
D. Lifting heavy objects
Answer: (A) Use of stool softeners.
Straining or bearing down activities can cause vagal stimulation
that leads to bradycardia. Use of stool softeners promote easy
bowel evacuation that prevents straining or the valsalva
maneuver.
13. The nurse is teaching the patient regarding his permanent
artificial pacemaker. Which information
given by the nurse shows her knowledge deficit about the
artificial cardiac pacemaker?
A. take the pulse rate once a day, in the morning upon
awakening
B. may be allowed to use electrical appliances
C. have regular follow up care
D. may engage in contact sports
Answer: (D) may engage in contact sports
The client should be advised by the nurse to avoid contact
sports. This will prevent trauma to the area of the pacemaker
generator.
14. A patient with angina pectoris is being discharged home
with nitroglycerine tablets. Which of the
following instructions does the nurse include in the teaching?
A. “When your chest pain begins, lie down, and place one
tablet under your tongue. If the pain continues, take another
tablet in 5 minutes.”
B. “Place one tablet under your tongue. If the pain is not
relieved in 15 minutes, go to the hospital.”
C. “Continue your activity, and if the pain does not go away in
10 minutes, begin taking the nitro tablets one every 5 minutes
for 15 minutes, then go lie down.”
D. “Place one Nitroglycerine tablet under the tongue every five
minutes for three doses. Go to the hospital if the pain is
unrelieved.
Answer: (D) “Place one Nitroglycerine tablet under the tongue
every five minutes for three doses. Go to the hospital if the pain
is unrelieved.
Angina pectoris is caused by myocardial ischemia related to
decreased coronary blood supply. Giving nitroglycerine will
produce coronary vasodilation that improves the coronary blood
flow in 3 – 5 mins. If the chest pain is unrelieved, after three
tablets, there is a possibility of acute coronary occlusion that
requires immediate medical attention.
15. A client with chronic heart failure has been placed on a diet
restricted to 2000mg. of sodium per day. The client
demonstrates adequate knowledge if behaviors are evident
such as not salting food and avoidance of which food?
A. Whole milk
B. Canned sardines
C. Plain nuts
D. Eggs
Answer: (B) Canned sardines
Canned foods are generally rich in sodium content as salt is
used as the main preservative.
16. A student nurse is assigned to a client who has a diagnosis
of thrombophlebitis. Which action by this team member is most
appropriate?
A. Apply a heating pad to the involved site.
B. Elevate the client's legs 90 degrees.
C. Instruct the client about the need for bed rest.
D. Provide active range-of-motion exercises to both legs at
least twice every shift.
Answer: (C) Instruct the client about the need for bed rest.
In a client with thrombophlebitis, bedrest will prevent the
dislodgment of the clot in the extremity which can lead to
pulmonary embolism.
17. A client receiving heparin sodium asks the nurse how the
drug works. Which of the following points would the nurse
include in the explanation to the client?
A. It dissolves existing thrombi.
B. It prevents conversion of factors that are needed in the
formation of clots.
C. It inactivates thrombin that forms and dissolves existing
thrombi.
D. It interferes with vitamin K absorption.
Answer: (B) It prevents conversion of factors that are needed in
the formation of clots.
Heparin is an anticoagulant. It prevents the conversion of
prothrombin to thrombin. It does not dissolve a clot.
18. The nurse is conducting an education session for a group of
smokers in a “stop smoking” class.
Which finding would the nurse state as a common symptom of
lung cancer? :
A. Dyspnea on exertion
B. Foamy, blood-tinged sputum
C. Wheezing sound on inspiration
D. Cough or change in a chronic cough
Answer: (D) Cough or change in a chronic cough
Cigarette smoke is a carcinogen that irritates and damages the
respiratory epithelium. The irritation causes the cough which
initially maybe dry, persistent and unproductive. As the tumor
enlarges, obstruction of the airways occurs and the cough may
become productive due to infection.
19. Which is the most relevant knowledge about oxygen
administration to a client with COPD?
A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus
for breathing.
B. Hypoxia stimulates the central chemoreceptors in the
medulla that makes the client breath.
C. Oxygen is administered best using a non-rebreathing mask
D. Blood gases are monitored using a pulse oximeter.
Answer: (A) Oxygen at 1-2L/min is given to maintain the
hypoxic stimulus for breathing.
COPD causes a chronic CO2 retention that renders the medulla
insensitive to the CO2 stimulation for breathing. The hypoxic
state of the client then becomes the stimulus for breathing.
Giving the clientoxygen in low concentrations will maintain the
client’s hypoxic drive.
20. When suctioning mucus from a client's lungs, which nursing
action would be least appropriate?
A. Lubricate the catheter tip with sterile saline before insertion.
B. Use sterile technique with a two-gloved approach
C. Suction until the client indicates to stop or no longer than 20
second
D. Hyperoxygenate the client before and after suctioning
Answer: (C) Suction until the client indicates to stop or no
longer than 20 second
One hazard encountered when suctioning a client is the
development of hypoxia. Suctioning sucks not only the
secretions but also the gases found in the airways. This can be
prevented by suctioning the client for an average time of 5-10
seconds and not more than 15 seconds and hyperoxygenating
the client before and after suctioning.
21. Dr. Santos prescribes oral rifampin (Rimactane) and
isoniazid (INH) for a client with a positive Tuberculin skin test.
When informing the client of this decision, the nurse knows that
the purpose of this choice of treatment is to
A. Cause less irritation to the gastrointestinal tract
B. Destroy resistant organisms and promote proper blood levels
of the drugs
C. Gain a more rapid systemic effect
D. Delay resistance and increase the tuberculostatic effect
Answer: (D) Delay resistance and increase the tuberculostatic
effect
Pulmonary TB is treated primarily with chemotherapeutic
agents for 6-12 mons. A prolonged treatment duration is
necessary to ensure eradication of the organisms and to
prevent relapse. The increasing prevalence of drug resistance
points to the need to begin the treatment with drugs in
combination. Using drugs in combination can delay the drug
resistance.
22. Mario undergoes a left thoracotomy and a partial
pneumonectomy. Chest tubes are inserted, and one-bottle
water-seal drainage is instituted in the operating room. In the
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
postanesthesia care unit Mario is placed in Fowler's position on
either his right
side or on his back to
A. Reduce incisional pain.
B. Facilitate ventilation of the left lung.
C. Equalize pressure in the pleural space.
D. Increase venous return
Answer: (B) Facilitate ventilation of the left lung.
Since only a partial pneumonectomy is done, there is a need to
promote expansion of this remaining Left lung by positioning
the client on the opposite unoperated side.
23. A client with COPD is being prepared for discharge. The
following are relevant instructions to the client regarding the
use of an oral inhaler EXCEPT
A. Breath in and out as fully as possible before placing the
mouthpiece inside the mouth.
B. Inhale slowly through the mouth as the canister is pressed
down
C. Hold his breath for about 10 seconds before exhaling
D. Slowly breath out through the mouth with pursed lips after
inhaling the drug.
Answer: (D) Slowly breath out through the mouth with pursed
lips after inhaling the drug.
If the client breathes out through the mouth with pursed lips,
this can easily force the just inhaled drug out of the respiratory
tract that will lessen its effectiveness.
24. A client is scheduled for a bronchoscopy. When teaching
the client what to expect afterward, the nurse's highest priority
of information would be
A. Food and fluids will be withheld for at least 2 hours.
B. Warm saline gargles will be done q 2h.
C. Coughing and deep-breathing exercises will be done q2h.
D. Only ice chips and cold liquids will be allowed initially.
Answer: (A) Food and fluids will be withheld for at least 2 hours.
Prior to bronchoscopy, the doctors sprays the back of the throat
with anesthetic to minimize the gag reflex and thus facilitate the
insertion of the bronchoscope. Giving the client food and drink
after the procedure without checking on the return of the gag
reflex can cause the client to aspirate. The gag reflex usually
returns after two hours.
25. The nurse enters the room of a client with chronic
obstructive pulmonary disease. The client's nasal cannula
oxygen is running at a rate of 6 L per minute, the skin color is
pink, and the respirations are 9 per minute and shallow. What is
the nurse’s best initial action?
A. Take heart rate and blood pressure.
B. Call the physician.
C. Lower the oxygen rate.
D. Position the client in a Fowler's position.
Answer: (C) Lower the oxygen rate.
The client with COPD is suffering from chronic CO2 retention.
The hypoxic drive is his chief stimulus for breathing. Giving O2
inhalation at a rate that is more than 2-3L/min can make the
client lose his hypoxic drive which can be assessed as
decreasing RR.
26. The nurse is preparing her plan of care for her patient
diagnosed with pneumonia. Which is the most appropriate
nursing diagnosis for this patient?
A. Fluid volume deficit
B. Decreased tissue perfusion.
C. Impaired gas exchange.
D. Risk for infection
Answer: (C) Impaired gas exchange.
Pneumonia, which is an infection, causes lobar consolidation
thus impairing gas exchange between the alveoli and the blood.
Because the patient would require adequate hydration, this
makes him prone to fluid volume excess.
27. A nurse at the weight loss clinic assesses a client who has a
large abdomen and a rounded face. Which additional
assessment finding would lead the nurse to suspect that the
client has Cushing’s syndrome rather than obesity?
A. large thighs and upper arms
B. pendulous abdomen and large hips
C. abdominal striae and ankle enlargement
D. posterior neck fat pad and thin extremities
Answer: (D) posterior neck fat pad and thin extremities
“Buffalo hump” is the accumulation of fat pads over the upper
back and neck. Fat may also accumulate on the face. There is
truncal obesity but the extremities are thin. All these are noted
in a client with Cushing’s syndrome.
28. Which statement by the client indicates understanding of
the possible side effects of Prednisone therapy?
A. “I should limit my potassium intake because hyperkalemia is
a side-effect of this drug.”
B. “I must take this medicine exactly as my doctor ordered it. I
shouldn’t skip doses.”
C. “This medicine will protect me from getting any colds or
infection.”
D. “My incision will heal much faster because of this drug.”
Answer: (B) “I must take this medicine exactly as my doctor
ordered it. I shouldn’t skip doses.”
The possible side effects of steroid administration are
hypokalemia, increase tendency to infection and poor wound
healing. Clients on the drug must follow strictly the doctor’s
order since skipping the drug can lower the drug level in the
blood that can trigger acute adrenal insufficiency or Addisonian
Crisis
29. A client, who is suspected of having Pheochromocytoma,
complains of sweating, palpitation and headache. Which
assessment is essential for the nurse to make first?
A. Pupil reaction
B. Hand grips
C. Blood pressure
D. Blood glucose
Answer: (C) Blood pressure
Pheochromocytoma is a tumor of the adrenal medulla that
causes an increase secretion of catecholamines that can
elevate the blood pressure.
30. The nurse is attending a bridal shower for a friend when
another guest, who happens to be a diabetic, starts to tremble
and complains of dizziness. The next best action for the nurse
to take is to:
A. Encourage the guest to eat some baked macaroni
B. Call the guest’s personal physician
C. Offer the guest a cup of coffee
D. Give the guest a glass of orange juice
Answer: (D) Give the guest a glass of orange juice
In diabetic patients, the nurse should watch out for signs of
hypoglycemia manifested by dizziness, tremors, weakness,
pallor diaphoresis and tachycardia. When this occurs in a
conscious client, he should be given immediately carbohydrates
in the form of fruit juice, hard candy, honey or, if unconscious,
glucagons or dextrose per IV.
31. An adult, who is newly diagnosed with Graves disease,
asks the nurse, “Why do I need to take
Propanolol (Inderal)?” Based on the nurse’s understanding of
the medication and Grave’s
disease, the best response would be:
A. “The medication will limit thyroid hormone secretion.”
B. “The medication limit synthesis of the thyroid hormones.”
C. “The medication will block the cardiovascular symptoms of
Grave’s disease.”
D. “The medication will increase the synthesis of thyroid
hormones.”
Answer: (C) “The medication will block the cardiovascular
symptoms of Grave’s disease.”
Propranolol (Inderal) is a beta-adrenergic blocker that controls
the cardiovascular manifestations brought about by increased
secretion of the thyroid hormone in Grave’s disease.
32. During the first 24 hours after thyroid surgery, the nurse
should include in her care:
A. Checking the back and sides of the operative dressing
B. Supporting the head during mild range of motion exercise
C. Encouraging the client to ventilate her feelings about the
surgery
D. Advising the client that she can resume her normal activities
immediately
Answer: (A) Checking the back and sides of the operative
dressing
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
Following surgery of the thyroid gland, bleeding is a potential
complication. This can best be assessed by checking the back
and the sides of the operative dressing as the blood may flow
towards the side and back leaving the front dry and clear of
drainage.
33. On discharge, the nurse teaches the patient to observe for
signs of surgically induced hypothyroidism. The nurse would
know that the patient understands the teaching when she
states she should notify the MD if she develops:
A. Intolerance to heat
B. Dry skin and fatigue
C. Progressive weight gain
D. Insomnia and excitability
Answer: (C) Progressive weight gain
Hypothyroidism, a decrease in thyroid hormone production, is
characterized by hypometabolism that manifests itself with
weight gain.
34. What is the best reason for the nurse in instructing the
client to rotate injection sites for insulin?
A. Lipodystrophy can result and is extremely painful
B. Poor rotation technique can cause superficial hemorrhaging
C. Lipodystrophic areas can result, causing erratic insulin
absorption rates from these
D. Injection sites can never be reused
Answer: (C) Lipodystrophic areas can result, causing erratic
insulin absorption rates from these
Lipodystrophy is the development of fibrofatty masses at the
injection site caused by repeated use of an injection site.
Injecting insulin into these scarred areas can cause the insulin
to be poorly absorbed and lead to erratic reactions.
35. Which of the following would be inappropriate to include in
a diabetic teaching plan?
A. Change position hourly to increase circulation
B. Inspect feet and legs daily for any changes
C. Keep legs elevated on 2 pillows while sleeping
D. Keep the insulin not in use in the refrigerator
Answer: (C) Keep legs elevated on 2 pillows while sleeping
The client with DM has decreased peripheral circulation caused
by microangiopathy. Keeping the legs elevated during sleep will
further cause circulatory impairment.
36. Included in the plan of care for the immediate post-
gastroscopy period will be:
A. Maintain NGT to intermittent suction
B. Assess gag reflex prior to administration of fluids
C. Assess for pain and medicate as ordered
D. Measure abdominal girth every 4 hours
Answer: (B) Assess gag reflex prior to administration of fluids
The client, after gastroscopy, has temporary impairment of the
gag reflex due to the anesthetic that has been sprayed into his
throat prior to the procedure. Giving fluids and food at this time
can lead to aspiration.
36. Included in the plan of care for the immediate post-
gastroscopy period will be:
A. Maintain NGT to intermittent suction
B. Assess gag reflex prior to administration of fluids
C. Assess for pain and medicate as ordered
D. Measure abdominal girth every 4 hours
Answer: (B) Assess gag reflex prior to administration of fluids
The client, after gastroscopy, has temporary impairment of the
gag reflex due to the anesthetic that has been sprayed into his
throat prior to the procedure. Giving fluids and food at this time
can lead to aspiration.
37. Which description of pain would be most characteristic of a
duodenal ulcer?
A. Gnawing, dull, aching, hungerlike pain in the epigastric area
that is relieved by food intake
B. RUQ pain that increases after meal
C. Sharp pain in the epigastric area that radiates to the right
shoulder
D. A sensation of painful pressure in the midsternal area
Answer: (A) Gnawing, dull, aching, hungerlike pain in the
epigastric area that is relieved by food intake
Duodenal ulcer is related to an increase in the secretion of HCl.
This can be buffered by food intake thus the relief of the pain
that is brought about by food intake.
38. The client underwent Billroth surgery for gastric ulcer. Post-
operatively, the drainage from his NGT is thick and the volume
of secretions has dramatically reduced in the last 2 hours and
the client feels like vomiting. The most appropriate nursing
action is to:
A. Reposition the NGT by advancing it gently NSS
B. Notify the MD of your findings
C. Irrigate the NGT with 50 cc of sterile
D. Discontinue the low-intermittent suction
Answer: (B) Notify the MD of your findings
The client’s feeling of vomiting and the reduction in the volume
of NGT drainage that is thick are signs of possible abdominal
distention caused by obstruction of the NGT. This should be
reported immediately to the MD to prevent tension and rupture
on the site of anastomosis caused by gastric distention.
39. After Billroth II Surgery, the client developed dumping
syndrome. Which of the following should
the nurse exclude in the plan of care?
A. Sit upright for at least 30 minutes after meals
B. Take only sips of H2O between bites of solid food
C. Eat small meals every 2-3 hours
D. Reduce the amount of simple carbohydrate in the diet
Answer: (A) Sit upright for at least 30 minutes after meals
The dumping syndrome occurs within 30 mins after a meal due
to rapid gastric emptying, causing distention of the duodenum
or jejunum produced by a bolus of food. To delay the emptying,
the client has to lie down after meals. Sitting up after meals will
promote the dumping syndrome.
40. The laboratory of a male patient with Peptic ulcer revealed
an elevated titer of Helicobacter pylori.
Which of the following statements indicate an understanding of
this data?
A. Treatment will include Ranitidine and Antibiotics
B. No treatment is necessary at this time
C. This result indicates gastric cancer caused by the organism
D. Surgical treatment is necessary
Answer: (A) Treatment will include Ranitidine and Antibiotics
One of the causes of peptic ulcer is H. Pylori infection. It
releases toxin that destroys the gastric and duodenal mucosa
which decreases the gastric epithelium’s resistance to acid
digestion. Giving antibiotics will control the infection and
Ranitidine, which is a histamine-2 blocker, will reduce acid
secretion that can lead to ulcer.
41. What instructions should the client be given before
undergoing a paracentesis?
A. NPO 12 hours before procedure
B. Empty bladder before procedure
C. Strict bed rest following procedure
D. Empty bowel before procedure
Answer: (B) Empty bladder before procedure
Paracentesis involves the removal of ascitic fluid from the
peritoneal cavity through a puncture made below the umbilicus.
The client needs to void before the procedure to prevent
accidental puncture of a distended bladder during the
procedure.
42. The husband of a client asks the nurse about the protein-
restricted diet ordered because of advanced liver disease.
What statement by the nurse would best explain the purpose of
the diet?
A. “The liver cannot rid the body of ammonia that is made by
the breakdown of protein in the digestive system.”
B. “The liver heals better with a high carbohydrates diet rather
than protein.”
C. “Most people have too much protein in their diets. The
amount of this diet is better for liver healing.”
D. “Because of portal hyperemesis, the blood flows around the
liver and ammonia made from protein collects in the brain
causing hallucinations.”
Answer: (A) “The liver cannot rid the body of ammonia that is
made by the breakdown of protein in the digestive system.”
The largest source of ammonia is the enzymatic and bacterial
digestion of dietary and blood proteins in the GI tract. A protein-
restricted diet will therefore decrease ammonia production.
43. Which of the drug of choice for pain controls the patient with
acute pancreatitis?
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
A. Morphine
B. NSAIDS
C. Meperidine
D. Codeine
Answer: (C) Meperidine
Pain in acute pancreatitis is caused by irritation and edema of
the inflamed pancreas as well as spasm due to obstruction of
the pancreatic ducts. Demerol is the drug of choice because it
is less likely to cause spasm of the Sphincter of Oddi unlike
Morphine which is spasmogenic.
44. Immediately after cholecystectomy, the nursing action that
should assume the highest priority is:
A. encouraging the client to take adequate deep breaths by
mouth
B. encouraging the client to cough and deep breathe
C. changing the dressing at least BID
D. irrigate the T-tube frequently
Answer: (B) encouraging the client to cough and deep breathe
Cholecystectomy requires a subcostal incision. To minimize
pain, clients have a tendency to take shallow breaths which can
lead to respiratory complications like pneumonia and
atelectasis. Deep breathing and coughing exercises can help
prevent such complications.
45. A Sengstaken-Blakemore tube is inserted in the effort to
stop the bleeding esophageal varices in a patient with
complicated liver cirrhosis. Upon insertion of the tube, the client
complains of difficulty of breathing. The first action of the nurse
is to:
A. Deflate the esophageal balloon
B. Monitor VS
C. Encourage him to take deep breaths
D. Notify the MD
Answer: (A) Deflate the esophageal balloon
When a client with a Sengstaken-Blakemore tube develops
difficulty of breathing, it means the tube is displaced and the
inflated balloon is in the oropharynx causing airway obstruction
46. The client presents with severe rectal bleeding, 16 diarrheal
stools a day, severe abdominal pain, tenesmus and
dehydration. Because of these symptoms the nurse should be
alert for other problems associated with what disease?
A. Chrons disease
B. Ulcerative colitis
C. Diverticulitis
D. Peritonitis
Answer: (B) Ulcerative colitis
Ulcerative colitis is a chronic inflammatory condition producing
edema and ulceration affecting the entire colon. Ulcerations
lead to sloughing that causes stools as many as 10-20 times a
day that is filled with blood, pus and mucus. The other
symptoms mentioned accompany the problem.
47. A client is being evaluated for cancer of the colon. In
preparing the client for barium enema, the nurse should:
A. Give laxative the night before and a cleansing enema in the
morning before the test
B. Render an oil retention enema and give laxative the night
before
C. Instruct the client to swallow 6 radiopaque tablets the
evening before the study
D. Place the client on CBR a day before the study
Answer: (A) Give laxative the night before and a cleansing
enema in the morning before the test
Barium enema is the radiologic visualization of the colon using
a die. To obtain accurate results in this procedure, the bowels
must be emptied of fecal material thus the need for laxative and
enema.
48. The client has a good understanding of the means to
reduce the chances of colon cancer when
he states:
A. “I will exercise daily.”
B. “I will include more red meat in my diet.”
C. “I will have an annual chest x-ray.”
D. “I will include more fresh fruits and vegetables in my diet.”
Answer: (D) “I will include more fresh fruits and vegetables in
my diet.”
Numerous aspects of diet and nutrition may contribute to the
development of cancer. A low-fiber diet, such as when fresh
fruits and vegetables are minimal or lacking in the diet, slows
transport of materials through the gut which has been linked to
colorectal cancer.
49. Days after abdominal surgery, the client’s wound dehisces.
The safest nursing intervention when
this occurs is to
A. Cover the wound with sterile, moist saline dressing
B. Approximate the wound edges with tapes
C. Irrigate the wound with sterile saline
D. Hold the abdominal contents in place with a sterile gloved
hand
Answer: (A) Cover the wound with sterile, moist saline dressing
Dehiscence is the partial or complete separation of the surgical
wound edges. When this occurs, the client is placed in low
Fowler’s position and instructed to lie quietly. The wound should
be covered to protect it from exposure and the dressing must
be sterile to protect it from infection and moist to prevent the
dressing from sticking to the wound which can disturb the
healing process.
50. An intravenous pyelogram reveals that Paulo, age 35, has a
renal calculus. He is believed to have a small stone that will
pass spontaneously. To increase the chance of the stone
passing, the nurse would instruct the client to force fluids and to
A. Strain all urine.
B. Ambulate.
C. Remain on bed rest.
D. Ask for medications to relax him.
Answer: (B) Ambulate.
Free unattached stones in the urinary tract can be passed out
with the urine by ambulation which can mobilize the stone and
by increased fluid intake which will flush out the stone during
urination.
51. A female client is admitted with a diagnosis of acute renal
failure. She is awake, alert, oriented, and complaining of severe
back pain, nausea and vomiting and abdominal cramps. Her
vital signs are blood pressure 100/70 mm Hg, pulse 110,
respirations 30, and oral temperature 100.4°F (38°C). Her
electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her
urinary output for the first 8 hours is 50 ml. The client is
displaying signs of which electrolyte imbalance?
A. Hyponatremia
B. Hyperkalemia
C. Hyperphosphatemia
D. Hypercalcemia
Answer: (A) Hyponatremia
The normal serum sodium level is 135 – 145 mEq/L. The
client’s serum sodium is below normal. Hyponatremia also
manifests itself with abdominal cramps and nausea and
vomiting
52. Assessing the laboratory findings, which result would the
nurse most likely expect to find in a
client with chronic renal failure?
A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to
1.5 mg/dl
B. Decreased serum calcium, blood pH 7.2, potassium 6.5
mEq/L
C. BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl
D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35,
decreased serum calcium
Answer: (B) Decreased serum calcium, blood pH 7.2,
potassium 6.5 mEq/L
Chronic renal failure is usually the end result of gradual tissue
destruction and loss of renal function. With the loss of renal
function, the kidneys ability to regulate fluid and electrolyte and
acid base balance results. The serum Ca decreases as the
kidneys fail to excrete phosphate, potassium and hydrogen ions
are retained.
53. Treatment with hemodialysis is ordered for a client and an
external shunt is created. Which nursing action would be of
highest priority with regard to the external shunt?
A. Heparinize it daily.
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
B. Avoid taking blood pressure measurements or blood
samples from the affected arm.
C. Change the Silastic tube daily.
D. Instruct the client not to use the affected arm.
Answer: (B) Avoid taking blood pressure measurements or
blood samples from the affected arm.
In the client with an external shunt, don’t use the arm with the
vascular access site to take blood pressure readings, draw
blood, insert IV lines, or give injections because these
procedures may rupture the shunt or occlude blood flow
causing damage and obstructions in the shunt.
54. Romeo Diaz, age 78, is admitted to the hospital with the
diagnosis of benign prostatic hyperplasia (BPH). He is
scheduled for a transurethral resection of the prostate (TURP).
It would be inappropriate to include which of the following
points in the preoperative teaching?
A. TURP is the most common operation for BPH.
B. Explain the purpose and function of a two-way irrigation
system.
C. Expect bloody urine, which will clear as healing takes place.
D. He will be pain free.
Answer: (D) He will be pain free.
Surgical interventions involve an experience of pain for the
client which can come in varying degrees. Telling the pain that
he will be pain free is giving him false reassurance.
55. Roxy is admitted to the hospital with a possible diagnosis of
appendicitis. On physical examination, the nurse should be
looking for tenderness on palpation at McBurney’s point, which
is located in the
A. left lower quadrant
B. left upper quadrant
C. right lower quadrant
D. right upper quadrant
Answer: (C) right lower quadrant
To be exact, the appendix is anatomically located at the Mc
Burney’s point at the right iliac area of the right lower quadrant.
56. Mr. Valdez has undergone surgical repair of his inguinal
hernia. Discharge teaching should include
A. telling him to avoid heavy lifting for 4 to 6 weeks
B. instructing him to have a soft bland diet for two weeks
C. telling him to resume his previous daily activities without
limitations
D. recommending him to drink eight glasses of water daily
Answer: (A) telling him to avoid heavy lifting for 4 to 6 weeks
The client should avoid lifting heavy objects and any strenuous
activity for 4-6 weeks after surgery to prevent stress on the
inguinal area. There is no special diet required. The fluid intake
of eight glasses a day is good advice but is not a priority in this
case.
57. A 30-year-old homemaker fell asleep while smoking a
cigarette. She sustained severe burns of the face,neck, anterior
chest, and both arms and hands. Using the rule of nines, which
is the best estimate of total body-surface area burned?
A. 18%
B. 22%
C. 31%
D. 40%
Answer: (C) 31%
Using the Rule of Nine in the estimation of total body surface
burned, we allot the following: 9% - head; 9% - each upper
extremity; 18%- front chest and abdomen; 18% - entire back;
18% - each lower extremity and 1% - perineum.
58. Nursing care planning is based on the knowledge that the
first 24-48 hours post-burn are characterized by:
A. An increase in the total volume of intracranial plasma
B. Excessive renal perfusion with diuresis
C. Fluid shift from interstitial space
D. Fluid shift from intravascular space to the interstitial space
Answer: (D) Fluid shift from intravascular space to the
interstitial space
This period is the burn shock stage or the hypovolemic phase.
Tissue injury causes vasodilation that results in increase
capillary permeability making fluids shift from the intravascular
to the interstitial space. This can lead to a decrease in
circulating blood volume or hypovolemia which decreases renal
perfusion and urine output.
59. If a client has severe bums on the upper torso, which item
would be a primary concern?
A. Debriding and covering the wounds
B. Administering antibiotics
C. Frequently observing for hoarseness, stridor, and dyspnea
D. Establishing a patent IV line for fluid replacement
Answer: (C) Frequently observing for hoarseness, stridor, and
dyspnea
Burns located in the upper torso, especially resulting from
thermal injury related to fires can lead to inhalation burns. This
causes swelling of the respiratory mucosa and blistering which
can lead to airway obstruction manifested by hoarseness, noisy
and difficult breathing. Maintaining a patent airway is a primary
concern.
60. Contractures are among the most serious long-term
complications of severe burns. If a burn is located on the upper
torso, which nursing measure would be least effective to help
prevent contractures?
A. Changing the location of the bed or the TV set, or both, daily
B. Encouraging the client to chew gum and blow up balloons
C. Avoiding the use of a pillow for sleep, or placing the head in
a position of hyperextension
D. Helping the client to rest in the position of maximal comfort
Answer: (D) Helping the client to rest in the position of maximal
comfort
Mobility and placing the burned areas in their functional position
can help prevent contracture deformities related to burns. Pain
can immobilize a client as he seeks the position where he finds
less pain and provides maximal comfort. But this approach can
lead to contracture deformities and other complications.
61. An adult is receiving Total Parenteral Nutrition (TPN). Which
of the following assessment is essential?
A. evaluation of the peripheral IV site
B. confirmation that the tube is in the stomach
C. assess the bowel sound
D. fluid and electrolyte monitoring
Answer: (D) fluid and electrolyte monitoring
Total parenteral nutrition is a method of providing nutrients to
the body by an IV route. The admixture is made up of proteins,
carbohydrates, fats, electrolytes, vitamins, trace minerals and
sterile water based on individual client needs. It is intended to
improve the clients nutritional status. Because of its
composition, it is important to monitor the clients fluid intake
and output including electrolytes, blood glucose and weight.
62. Which drug would be least effective in lowering a client's
serum potassium level?
A. Glucose and insulin
B. Polystyrene sulfonate (Kayexalate)
C. Calcium glucomite
D. Aluminum hydroxide
Answer: (D) Aluminum hydroxide
Aluminum hydroxide binds dietary phosphorus in the GI tract
and helps treat hyperphosphatemia. All the other medications
mentioned help treat hyperkalemia and its effects.
63. A nurse is directed to administer a hypotonic intravenous
solution. Looking at the following labeled solutions, she should
choose
A. 0.45% NaCl
B. 0.9% NaCl
C. D5W
D. D5NSS
Answer: (A) 0.45% NaCl
Hypotonic solutions like 0.45% NaCl has a lower tonicity that
the blood; 0.9% NaCl and D5W are isotonic solutions with
same tonicity as the blood; and D5NSS is hypertonic with a
higher tonicity thab the blood.
64. A patient is hemorrhaging from multiple trauma sites. The
nurse expects that compensatory mechanisms associated with
hypovolemia would cause all of the following symptoms
EXCEPT
A. hypertension
B. oliguria
C. tachycardia
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
D. tachypnea
Answer: (A) hypertension
In hypovolemia, one of the compenasatory mechanisms is
activation of the sympathetic nervous system that increases the
RR & PR and helps restore the BP to maintain tissue perfusion
but not cause a hypertension. The SNS stimulation constricts
renal arterioles that increases release of aldosterone,
decreases glomerular filtration and increases sodium & water
reabsorption that leads to oliguria.
65. Maria Sison, 40 years old, single, was admitted to the
hospital with a diagnosis of Breast Cancer. She was scheduled
for radical mastectomy. Nursing care during the preoperative
period should consist of
A. assuring Maria that she will be cured of cancer
B. assessing Maria's expectations and doubts
C. maintaining a cheerful and optimistic environment
D. keeping Maria's visitors to a minimum so she can have time
for herself
Answer: (B) assessing Maria's expectations and doubts
Assessing the client’s expectations and doubts will help lessen
her fears and anxieties. The nurse needs to encourage the
client to verbalize and to listen and correctly provide
explanations when needed.
66. Maria refuses to acknowledge that her breast was removed.
She believes that her breast is intact under the dressing. The
nurse should
A. call the MD to change the dressing so Kathy can see the
incision
B. recognize that Kathy is experiencing denial, a normal stage
of the grieving process
C. reinforce Kathy’s belief for several days until her body can
adjust to stress of surgery.
D. remind Kathy that she needs to accept her diagnosis so that
she can begin rehabilitation exercises.
Answer: (B) recognize that Kathy is experiencing denial, a
normal stage of the grieving process
A person grieves to a loss of a significant object. The initial
stage in the grieving process is denial, then anger, followed by
bargaining, depression and last acceptance. The nurse should
show acceptance of the patient’s feelings and encourage
verbalization.
67. A chemotherapeutic agent 5FU is ordered as an adjunct
measure to surgery. Which of the ff. statements about
chemotherapy is true?
A. it is a local treatment affecting only tumor cells
B. it affects both normal and tumor cells
C. it has been proven as a complete cure for cancer
D. it is often used as a palliative measure.
Answer: (B) it affects both normal and tumor cells
Chemotherapeutic agents are given to destroy the actively
proliferating cancer cells. But these agents cannot differentiate
the abnormal actively proliferating cancer cells from those that
are actively proliferating normal cells like the cells of the bone
marrow, thus the effect of bone marrow depression.
68. Which is an incorrect statement pertaining to the following
procedures for cancer diagnostics?
A. Biopsy is the removal of suspicious tissue and the only
definitive method to diagnose cancer
B. Ultrasonography detects tissue density changes difficult to
observe by X-ray via sound waves.
C. CT scanning uses magnetic fields and radio frequencies to
provide cross-sectional view of tumor
D. Endoscopy provides direct view of a body cavity to detect
abnormality.
Answer: (C) CT scanning uses magnetic fields and radio
frequencies to provide cross-sectional view of tumor
CT scan uses narrow beam x-ray to provide cross-sectional
view. MRI uses magnetic fields and radio frequencies to detect
tumors.
69. A post-operative complication of mastectomy is
lymphedema. This can be prevented by
A. ensuring patency of wound drainage tube
B. placing the arm on the affected side in a dependent position
C. restricting movement of the affected arm
D. frequently elevating the arm of the affected side above the
level of the heart.
Answer: (D) frequently elevating the arm of the affected side
above the level of the heart.
Elevating the arm above the level of the heart promotes good
venous return to the heart and good lymphatic drainage thus
preventing swelling.
70. Which statement by the client indicates to the nurse that the
patient understands precautions necessary during internal
radiation therapy for cancer of the cervix?
A. “I should get out of bed and walk around in my room.”
B. “My 7 year old twins should not come to visit me while I’m
receiving treatment.”
C. “I will try not to cough, because the force might make me
expel the application.”
D. “I know that my primary nurse has to wear one of those
badges like the people in the x-ray department, but they are not
necessary for anyone else who comes in here.”
Answer: (B) “My 7 year old twins should not come to visit me
while I’m receiving treatment.”
Children have cells that are normally actively dividing in the
process of growth. Radiation acts not only against the
abnormally actively dividing cells of cancer but also on the
normally dividing cells thus affecting the growth and
development of the child and even causing cancer itself.
71. High uric acid levels may develop in clients who are
receiving chemotherapy. This is caused by:
A. The inability of the kidneys to excrete the drug metabolites
B. Rapid cell catabolism
C. Toxic effect of the antibiotic that are given concurrently
D. The altered blood ph from the acid medium of the drugs
Answer: (B) Rapid cell catabolism
One of the oncologic emergencies, the tumor lysis syndrome, is
caused by the rapid destruction of large number of tumor
cells. . Intracellular contents are released, including potassium
and purines, into the bloodstream faster than the body can
eliminate them. The purines are converted in the liver to uric
acid and released into the blood causing hyperuricemia. They
can precipitate in the kidneys and block the tubules causing
acute renal failure.
72. Which of the following interventions would be included in
the care of plan in a client with cervical
implant?
A. Frequent ambulation
B. Unlimited visitors
C. Low residue diet
D. Vaginal irrigation every shift
Answer: (C) Low residue diet
It is important for the nurse to remember that the implant be
kept intact in the cervix during therapy. Mobility and vaginal
irrigations are not done. A low residue diet will prevent bowel
movement that could lead to dislodgement of the implant.
Patient is also strictly isolated to protect other people from the
radiation emissions
73. Which nursing measure would avoid constriction on the
affected arm immediately after mastectomy?
A. Avoid BP measurement and constricting clothing on the
affected arm
B. Active range of motion exercises of the arms once a day.
C. Discourage feeding, washing or combing with the affected
arm
D. Place the affected arm in a dependent position, below the
level of the heart
Answer: (A) Avoid BP measurement and constricting clothing
on the affected arm
A BP cuff constricts the blood vessels where it is applied. BP
measurements should be done on the unaffected arm to ensure
adequate circulation and venous and lymph drainage in the
affected arm
74. A client suffering from acute renal failure has an unexpected
increase in urinary output to 150ml/hr. The nurse assesses that
the client has entered the second phase of acute renal failure.
Nursing actions throughout this phase include observation for
signs and symptoms of
A. Hypervolemia, hypokalemia, and hypernatremia.
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
B. Hypervolemia, hyperkalemia, and hypernatremia.
C. Hypovolemia, wide fluctuations in serum sodium and
potassium levels.
D. Hypovolemia, no fluctuation in serum sodium and potassium
levels.
Answer: (C) Hypovolemia, wide fluctuations in serum sodium
and potassium levels.
The second phase of ARF is the diuretic phase or high output
phase. The diuresis can result in an output of up to 10L/day of
dilute urine. Loss of fluids and electrolytes occur.
75. An adult has just been brought in by ambulance after a
motor vehicle accident. When assessing the client, the nurse
would expect which of the following manifestations could have
resulted from sympathetic nervous system stimulation?
A. A rapid pulse and increased RR
B. Decreased physiologic functioning
C. Rigid posture and altered perceptual focus
D. Increased awareness and attention
Answer: (A) A rapid pulse and increased RR
The fight or flight reaction of the sympathetic nervous system
occurs during stress like in a motor vehicular accident. This is
manifested by increased in cardiovascular function and RR to
provide the immediate needs of the body for survival.
76. Ms. Sy undergoes surgery and the abdominal aortic
aneurysm is resected and replaced with a graft. When she
arrives in the RR she is still in shock. The nurse's priority should
be
A. placing her in a trendeleburg position
B. putting several warm blankets on her
C. monitoring her hourly urine output
D. assessing her VS especially her RR
Answer: (D) assessing her VS especially her RR
Shock is characterized by reduced tissue and organ perfusion
and eventual organ dysfunction and failure. Checking on the
VS especially the RR, which detects need for oxygenation, is a
priority to help detect its progress and provide for prompt
management before the occurrence of complications.
77. A major goal for the client during the first 48 hours after a
severe bum is to prevent hypovolemic shock. The best indicator
of adequate fluid balance during this period is
A. Elevated hematocrit levels.
B. Urine output of 30 to 50 ml/hr.
C. Change in level of consciousness.
D. Estimate of fluid loss through the burn eschar.
Answer: (B) Urine output of 30 to 50 ml/hr.
Hypovolemia is a decreased in circulatory volume. This causes
a decrease in tissue perfusion to the different organs of the
body. Measuring the hourly urine output is the most quantifiable
way of measuring tissue perfusion to the organs. Normal renal
perfusion should produce 1ml/kg of BW/min. An output of 30-50
ml/hr is considered adequate and indicates good fluid balance.
78. A thoracentesis is performed on a chest-injured client, and
no fluid or air is found. Blood and fluids is administered
intravenously (IV), but the client's vital signs do not improve. A
central venous pressure line is inserted, and the initial reading
is 20 cm H^O. The most likely cause of these findings is which
of the following?
A. Spontaneous pneumothorax
B. Ruptured diaphragm
C. Hemothorax
D. Pericardial tamponade
Answer: (D) Pericardial tamponade
Pericardial tamponade occurs when there is presence of fluid
accumulation in the pericardial space that compresses on the
ventricles causing a decrease in ventricular filling and stretching
during diastole with a decrease in cardiac output. . This leads to
right atrial and venous congestion manifested by a CVP reading
above normal.
79. Intervention for a pt. who has swallowed a Muriatic Acid
includes all of the following except
A. administering an irritant that will stimulate vomiting
B. aspirating secretions from the pharynx if respirations are
affected
C. neutralizing the chemical
D. washing the esophagus with large volumes of water via
gastric lavage
Answer: (A) administering an irritant that will stimulate vomiting
Swallowing of corrosive substances causes severe irritation
and tissue destruction of the mucous membrane of the GI tract.
Measures are taken to immediately remove the toxin or reduce
its absorption. For corrosive poison ingestion, such as in
muriatic acid where burn or perforation of the mucosa may
occur, gastric emptying procedure is immediately instituted,
This includes gastric lavage and the administration of activated
charcoal to absorb the poison. Administering an irritant with the
concomitant vomiting to remove the swallowed poison will
further cause irritation and damage to the mucosal lining of the
digestive tract. Vomiting is only indicated when non-corrosive
poison is swallowed.
80. Which initial nursing assessment finding would best indicate
that a client has been successfully resuscitated after a cardio-
respiratory arrest?
A. Skin warm and dry
B. Pupils equal and react to light
C. Palpable carotid pulse
D. Positive Babinski's reflex
Answer: (C) Palpable carotid pulse
Presence of a palpable carotid pulse indicates the return of
cardiac function which, together with the return of breathing, is
the primary goal of CPR. Pulsations in arteries indicates blood
flowing in the blood vessels with each cardiac contraction.
Signs of effective tissue perfusion will be noted after.
81. Chemical burn of the eye are treated with
A. local anesthetics and antibacterial drops for 24 – 36 hrs.
B. hot compresses applied at 15-minute intervals
C. Flushing of the lids, conjunctiva and cornea with tap or
preferably sterile water
D. cleansing the conjunctiva with a small cotton-tipped
applicator
Answer: (C) Flushing of the lids, conjunctiva and cornea with
tap or preferably sterile water
Prompt treatment of ocular chemical burns is important to
prevent further damage. Immediate tap-water eye irrigation
should be started on site even before transporting the patient to
the nearest hospital facility. In the hospital, copious irrigation
with normal saline, instillation of local anesthetic and antibiotic
is done.
82. The Heimlich maneuver (abdominal thrust), for acute airway
obstruction, attempts to:
A. Force air out of the lungs
B. Increase systemic circulation
C. Induce emptying of the stomach
D. Put pressure on the apex of the heart
Answer: (A) Force air out of the lungs
The Heimlich maneuver is used to assist a person choking on a
foreign object. The pressure from the thrusts lifts the
diaphragm, forces air out of the lungs and creates an artificial
cough that expels the aspirated material.
83. John, 16 years old, is brought to the ER after a vehicular
accident. He is pronounced dead on arrival. When his parents
arrive at the hospital, the nurse should:
A. ask them to stay in the waiting area until she can spend time
alone with them
B. speak to both parents together and encourage them to
support each other and express their emotions freely
C. Speak to one parent at a time so that each can ventilate
feelings of loss without upsetting the other
D. ask the MD to medicate the parents so they can stay calm to
deal with their son’s death.
Answer: (B) speak to both parents together and encourage
them to support each other and express their emotions freely
Sudden death of a family member creates a state of shock on
the family. They go into a stage of denial and anger in their
grieving. Assisting them with information they need to know,
answering their questions and listening to them will provide the
needed support for them to move on and be of support to one
another.
84. An emergency treatment for an acute asthmatic attack is
Adrenaline 1:1000 given hypodermically. This is given to:
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
A. increase BP
B. decrease mucosal swelling
C. relax the bronchial smooth muscle
D. decrease bronchial secretions
Answer: (C) relax the bronchial smooth muscle
Acute asthmatic attack is characterized by severe
bronchospasm which can be relieved by the immediate
administration of bronchodilators. Adrenaline or Epinephrine is
an adrenergic agent that causes bronchial dilation by relaxing
the bronchial smooth muscles.
85. A nurse is performing CPR on an adult patient. When
performing chest compressions, the nurse understands the
correct hand placement is located over the
A. upper half of the sternum
B. upper third of the sternum
C. lower half of the sternum
D. lower third of the sternum
Answer: (C) lower half of the sternum
The exact and safe location to do cardiac compression is the
lower half of the sternum. Doing it at the lower third of the
sternum may cause gastric compression which can lead to a
possible aspiration.
86. The nurse is performing an eye examination on an elderly
client. The client states ‘My vision is blurred, and I don’t easily
see clearly when I get into a dark room.” The nurse best
response is:
A. “You should be grateful you are not blind.”
B. “As one ages, visual changes are noted as part of
degenerative changes. This is normal.”
C. “You should rest your eyes frequently.”
D. “You maybe able to improve you vision if you move slowly.”
Answer: (B) “As one ages, visual changes are noted as part of
degenerative changes. This is normal.”
Aging causes less elasticity of the lens affecting
accommodation leading to blurred vision. The muscles of the
iris increase in stiffness and the pupils dilate slowly and less
completely so that it takes the older person to adjust when
going to and from light and dark environment and needs
brighter light for close vision.
87. Which of the following activities is not encouraged in a
patient after an eye surgery?
A. sneezing, coughing and blowing the nose
B. straining to have a bowel movement
C. wearing tight shirt collars
D. sexual intercourse
Answer: (D) sexual intercourse
To reduce increases in IOP, teach the client and family about
activity restrictions. Sexual intercourse can cause a sudden rise
in IOP.
88. Which of the following indicates poor practice in
communicating with a hearing-impaired client?
A. Use appropriate hand motions
B. Keep hands and other objects away from your mouth when
talking to the client
C. Speak clearly in a loud voice or shout to be heard
D. Converse in a quiet room with minimal distractions
Answer: (C) Speak clearly in a loud voice or shout to be heard
Shouting raises the frequency of the sound and often makes
understanding the spoken words difficult. It is enough for the
nurse to speak clearly and slowly.
89. A client is to undergo lumbar puncture. Which is least
important information about LP?
A. Specimens obtained should be labeled in their proper
sequence.
B. It may be used to inject air, dye or drugs into the spinal
canal.
C. Assess movements and sensation in the lower extremities
after the
D. Force fluids before and after the procedure.
Answer: (D) Force fluids before and after the procedure.
LP involves the removal of some amount of spinal fluid. To
facilitate CSF production, the client is instructed to increase
fluid intake to 3L, unless contraindicated, for 24 to 48 hrs after
the procedure.
90. A client diagnosed with cerebral thrombosis is scheduled for
cerebral angiography. Nursing care of the client includes the
following EXCEPT
A. Inform the client that a warm, flushed feeling and a salty
taste may be
B. Maintain pressure dressing over the site of puncture and
check for
C. Check pulse, color and temperature of the extremity distal to
the site of
D. Kept the extremity used as puncture site flexed to prevent
bleeding.
Answer: (D) Kept the extremity used as puncture site flexed to
prevent bleeding.
Angiography involves the threading of a catheter through an
artery which can cause trauma to the endothelial lining of the
blood vessel. The platelets are attracted to the area causing
thrombi formation. This is further enhanced by the slowing of
blood flow caused by flexion of the affected extremity. The
affected extremity must be kept straight and immobilized during
the duration of the bedrest after the procedure. Ice bag can be
applied intermittently to the puncture site.
91. Which is considered as the earliest sign of increased ICP
that the nurse should closely observed for?
A. abnormal respiratory pattern
B. rising systolic and widening pulse pressure
C. contralateral hemiparesis and ipsilateral dilation of the pupils
D. progression from restlessness to confusion and
disorientation to lethargy
Answer: (D) progression from restlessness to confusion and
disorientation to lethargy
The first major effect of increasing ICP is a decrease in cerebral
perfusion causing hypoxia that produces a progressive
alteration in the LOC. This is initially manifested by
restlessness.
92. Which is irrelevant in the pharmacologic management of a
client with CVA?
A. Osmotic diuretics and corticosteroids are given to decrease
cerebral edema
B. Anticonvulsants are given to prevent seizures
C. Thrombolytics are most useful within three hours of an
occlusive CVA
D. Aspirin is used in the acute management of a completed
stroke.
Answer: (D) Aspirin is used in the acute management of a
completed stroke.
The primary goal in the management of CVA is to improve
cerebral tissue perfusion. Aspirin is a platelet deaggregator
used in the prevention of recurrent or embolic stroke but is not
used in the acute management of a completed stroke as it may
lead to bleeding.
93. What would be the MOST therapeutic nursing action when
a client’s expressive aphasia is severe?
A. Anticipate the client wishes so she will not need to talk
B. Communicate by means of questions that can be answered
by the client shaking the head
C. Keep us a steady flow rank to minimize silence
D. Encourage the client to speak at every possible opportunity.
Answer: (D) Encourage the client to speak at every possible
opportunity.
Expressive or motor aphasia is a result of damage in the
Broca’s area of the frontal lobe. It is amotor speech problem in
which the client generally understands what is said but is
unable to communicate verbally. The patient can best he
helped therefore by encouraging him to communicate and
reinforce this behavior positively.
94. A client with head injury is confused, drowsy and has
unequal pupils. Which of the following nursing diagnosis is most
important at this time?
A. altered level of cognitive function
B. high risk for injury
C. altered cerebral tissue perfusion
D. sensory perceptual alteration
Answer: (C) altered cerebral tissue perfusion
The observations made by the nurse clearly indicate a problem
of decrease cerebral perfusion. Restoring cerebral perfusion is
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
most important to maintain cerebral functioning and prevent
further brain damage.
95. Which nursing diagnosis is of the highest priority when
caring for a client with myasthenia gravis?
A. Pain
B. High risk for injury related to muscle weakness
C. Ineffective coping related to illness
D. Ineffective airway clearance related to muscle weakness
Answer: (D) Ineffective airway clearance related to muscle
weakness
Myasthenia gravis causes a failure in the transmission of nerve
impulses at the neuromuscular junction which may be due to a
weakening or decrease in acetylcholine receptor sites. This
leads to sporadic, progressive weakness or abnormal
fatigability of striated muscles that eventually causes loss of
function. The respiratory muscles can become weak with
decreased tidal volume and vital capacity making breathing and
clearing the airway through coughing difficult. The respiratory
muscle weakness may be severe enough to require and
emergency airway and mechanical ventilation.
96. The client has clear drainage from the nose and ears after a
head injury. How can the nurse determine if the drainage is
CSF?
A. Measure the ph of the fluid
B. Measure the specific gravity of the fluid
C. Test for glucose
D. Test for chlorides
Answer: (C) Test for glucose
The CSF contains a large amount of glucose which can be
detected by using glucostix. A positive result with the drainage
indicate CSF leakage.
97. The nurse includes the important measures for stump care
in the teaching plan for a client with an amputation. Which
measure would be excluded from the teaching plan?
A. Wash, dry, and inspect the stump daily.
B. Treat superficial abrasions and blisters promptly.
C. Apply a "shrinker" bandage with tighter arms around the
proximal end of the affected limb.
D. Toughen the stump by pushing it against a progressively
harder substance (e.g., pillow on a foot-stool).
Answer: (C) Apply a "shrinker" bandage with tighter arms
around the proximal end of the affected limb.
The “shrinker” bandage is applied to prevent swelling of the
stump. It should be applied with the distal end with the tighter
arms. Applying the tighter arms at the proximal end will impair
circulation and cause swelling by reducing venous flow.
98. A 70-year-old female comes to the clinic for a routine
checkup. She is 5 feet 4 inches tall and weighs 180 pounds.
Her major complaint is pain in her joints. She is retired and has
had to give up her volunteer work because of her discomfort.
She was told her diagnosis was osteoarthritis about 5 years
ago. Which would be excluded from the clinical pathway for this
client?
A. Decrease the calorie count of her daily diet.
B. Take warm baths when arising.
C. Slide items across the floor rather than lift them.
D. Place items so that it is necessary to bend or stretch to
reach them.
Answer: (D) Place items so that it is necessary to bend or
stretch to reach them.
Patients with osteoarthritis have decreased mobility caused by
joint pain. Over-reaching and stretching to get an object are to
be avoided as this can cause more pain and can even lead to
falls. The nurse should see to it therefore that objects are within
easy reach of the patient.
99. A client is admitted from the emergency department with
severe-pain and edema in the right foot. His diagnosis is gouty
arthritis. When developing a plan of care, which action would
have the highest priority?
A. Apply hot compresses to the affected joints.
B. Stress the importance of maintaining good posture to
prevent deformities.
C. Administer salicylates to minimize the inflammatory reaction.
D. Ensure an intake of at least 3000 ml of fluid per day.
Answer: (D) Ensure an intake of at least 3000 ml of fluid per
day.
Gouty arthritis is a metabolic disease marked by urate deposits
that cause painful arthritic joints. The patient should be urged to
increase his fluid intake to prevent the development of urinary
uric acid stones.
100. A client had a laminectomy and spinal fusion yesterday.
Which statement is to be excluded from your plan of care?
A. Before log rolling, place a pillow under the client's head and
a pillow between the client's legs.
B. Before log rolling, remove the pillow from under the client's
head and use no pillows between the client's legs.
C. Keep the knees slightly flexed while the client is lying in a
semi-Fowler's position in bed.
D. Keep a pillow under the client's head as needed for comfort.
Answer: (B) Before log rolling, remove the pillow from under the
client's head and use no pillows between the client's legs.
Following a laminectomy and spinal fusion, it is important that
the back of the patient be maintained in straight alignment and
to support the entire vertebral column to promote complete
healing.
101. The nurse is assisting in planning care for a client with a
diagnosis of immune deficiency. The nurse would incorporate
which of the ff. as a priority in the plan of care?
A. providing emotional support to decrease fear
B. protecting the client from infection
C. encouraging discussion about lifestyle changes
D. identifying factors that decreased the immune function
Answer: (B) protecting the client from infection
Immunodeficiency is an absent or depressed immune response
that increases susceptibility to infection. So it is the nurse’s
primary responsibility to protect the patient from infection.
102. Joy, an obese 32 year old, is admitted to the hospital after
an automobile accident. She has a fractured hip and is brought
to the OR for surgery.
After surgery Joy is to receive a piggy-back of Clindamycin
phosphate (Cleocin) 300 mg in 50 ml of D5W. The piggyback is
to infuse in 20 minutes. The drop factor of the IV set is 10
gtt/ml. The nurse should set the piggyback to flow at:
A. 25 gtt/min
B. 30 gtt/min
C. 35 gtt/min
D. 45 gtt/min
Answer: (A) 25 gtt/min
To get the correct flow rate: multiply the amount to be infused
(50 ml) by the drop factor (10) and divide the result by the
amount of time in minutes (20)
103. The day after her surgery Joy asks the nurse how she
might lose weight. Before answering her question, the nurse
should bear in mind that long-term weight loss best occurs
when:
A. Fats are controlled in the diet
B. Eating habits are altered
C. Carbohydrates are regulated
D. Exercise is part of the program
Answer: (B) Eating habits are altered
For weight reduction to occur and be maintained, a new dietary
program, with a balance of foods from the basic four food
groups, must be established and continued
104. The nurse teaches Joy, an obese client, the value of
aerobic exercises in her weight reduction program. The nurse
would know that this teaching was effective when Joy says that
exercise will:
A. Increase her lean body mass
B. Lower her metabolic rate
C. Decrease her appetite
D. Raise her heart rate
Answer: (A) Increase her lean body mass
Increased exercise builds skeletal muscle mass and reduces
excess fatty tissue.
105. The physician orders non-weight bearing with crutches for
Joy, who had surgery for a fractured hip. The most important
activity to facilitate walking with crutches before ambulation
begun is:
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
A. Exercising the triceps, finger flexors, and elbow extensors
B. Sitting up at the edge of the bed to help strengthen back
muscles
C. Doing isometric exercises on the unaffected leg
D. Using the trapeze frequently for pull-ups to strengthen the
biceps muscles
Answer: (A) Exercising the triceps, finger flexors, and elbow
extensors
These sets of muscles are used when walking with crutches
and therefore need strengthening prior to ambulation.
106. The nurse recognizes that a client understood the
demonstration of crutch walking when she places her weight
on:
A. The palms and axillary regions
B. Both feet placed wide apart
C. The palms of her hands
D. Her axillary regions
Answer: (C) The palms of her hands
The palms should bear the client’s weight to avoid damage to
the nerves in the axilla (brachial plexus)
107. Joey is a 46 year-old radio technician who is admitted
because of mild chest pain. He is 5 feet, 8 inches tall and
weighs 190 pounds. He is diagnosed with a myocardial infarct.
Morphine sulfate, Diazepam (Valium) and Lidocaine are
prescribed.
The physician orders 8 mg of Morphine Sulfate to be given IV.
The vial on hand is labeled 1 ml/ 10 mg. The nurse should
administer:
A. 8 minims
B. 10 minims
C. 12 minims
D. 15 minims
Answer: (C) 12 minims
Using ratio and proportion 8 mg/10 mg = X minims/15 minims
10 X= 120 X = 12 minims The nurse will administer 12 minims
intravenously equivalent to 8mg Morphine Sulfate
108. Joey asks the nurse why he is receiving the injection of
Morphine after he was hospitalized for severe anginal pain. The
nurse replies that it:
A. Will help prevent erratic heart beats
B. Relieves pain and decreases level of anxiety
C. Decreases anxiety
D. Dilates coronary blood vessels
Answer: (B) Relieves pain and decreases level of anxiety
Morphine is a specific central nervous system depressant used
to relieve the pain associated with myocardial infarction. It also
decreases anxiety and apprehension and prevents cardiogenic
shock by decreasing myocardial oxygen demand.
109. Oxygen 3L/min by nasal cannula is prescribed for Joey
who is admitted to the hospital for chest pain. The nurse
institutes safety precautions in the room because oxygen:
A. Converts to an alternate form of matter
B. Has unstable properties
C. Supports combustion
D. Is flammable
Answer: (C) Supports combustion
The nurse should know that Oxygen is necessary to produce
fire, thus precautionary measures are important regarding its
use.
110. Myra is ordered laboratory tests after she is admitted to
the hospital for angina. The isoenzyme test that is the most
reliable early indicator of myocardial insult is:
A. SGPT
B. LDH
C. CK-MB
D. AST
Answer: (C) CK-MB
The cardiac marker, Creatinine phosphokinase (CPK)
isoenzyme levels, especially the MB sub-unit which is cardio-
specific, begin to rise in 3-6 hours, peak in 12-18 hours and are
elevated 48 hours after the occurrence of the infarct. They are
therefore most reliable in assisting with early diagnosis. The
cardiac markers elevate as a result of myocardial tissue
damage.
111. An early finding in the EKG of a client with an infarcted
mycardium would be:
A. Disappearance of Q waves
B. Elevated ST segments
C. Absence of P wave
D. Flattened T waves
Answer: (B) Elevated ST segments
This is a typical early finding after a myocardial infarct because
of the altered contractility of the heart. The other choices are
not typical of MI.
112. Jose, who had a myocardial infarction 2 days earlier, has
been complaining to the nurse about issues related to his
hospital stay. The best initial nursing response would be to:
A. Allow him to release his feelings and then leave him alone to
allow him to regain his composure
B. Refocus the conversation on his fears, frustrations and
anger about his condition
C. Explain how his being upset dangerously disturbs his need
for rest
D. Attempt to explain the purpose of different hospital routines
Answer: (B) Refocus the conversation on his fears, frustrations
and anger about his condition
This provides the opportunity for the client to verbalize feelings
underlying behavior and helpful in relieving anxiety. Anxiety can
be a stressor which can activate the sympathoadrenal
response causing the release of catecholamines that can
increase cardiac contractility and workload that can further
increase myocardial oxygen demand.
113. Twenty four hours after admission for an Acute MI, Jose’s
temperature is noted at 39.3 C. The nurse monitors him for
other adaptations related to the pyrexia, including:
A. Shortness of breath
B. Chest pain
C. Elevated blood pressure
D. Increased pulse rate
Answer: (D) Increased pulse rate
Fever causes an increase in the body’s metabolism, which
results in an increase in oxygen consumption and demand. This
need for oxygen increases the heart rate, which is reflected in
the increased pulse rate. Increased BP, chest pain and
shortness of breath are not typically noted in fever.
114. Jose, who is admitted to the hospital for chest pain, asks
the nurse, “Is it still possible for me to have another heart attack
if I watch my diet religiously and avoid stress?” The most
appropriate initial response would be for the nurse to:
A. Suggest he discuss his feelings of vulnerability with his
physician.
B. Tell him that he certainly needs to be especially careful about
his diet and lifestyle.
C. Avoid giving him direct information and help him explore his
feelings
D. Recognize that he is frightened and suggest he talk with the
psychiatrist or counselor.
Answer: (C) Avoid giving him direct information and help him
explore his feelings
To help the patient verbalize and explore his feelings, the nurse
must reflect and analyze the feelings that are implied in the
client’s question. The focus should be on collecting data to
minister to the client’s psychosocial needs.
115. Ana, 55 years old, is admitted to the hospital to rule out
pernicious anemia. A Schilling test is ordered for Ana. The
nurse recognizes that the primary purpose of the Schilling test
is to determine the client’s ability to:
A. Store vitamin B12
B. Digest vitamin B12
C. Absorb vitamin B12
D. Produce vitamin B12
Answer: (C) Absorb vitamin B12
Pernicious anemia is caused by the inability to absorb vitamin
B12 in the stomach due to a lack of intrinsic factor in the gastric
juices. In the Schilling test, radioactive vitamin B12 is
administered and its absorption and excretion can be
ascertained through the urine.
116. Ana is diagnosed to have Pernicious anemia. The
physician orders 0.2 mg of Cyanocobalamin (Vitamin B12) IM.
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
Available is a vial of the drug labeled 1 ml= 100 mcg. The nurse
should administer:
A. 0.5 ml
B. 1.0 ml
C. 1.5 ml
D. 2.0 ml
Answer: (D) 2.0 ml
First convert milligrams to micrograms and then use ratio and
proportion (0.2 mg= 200 mcg) 200 mcg : 100 mcg= X ml : ml
100 X= 200 X = 2 ml. Inject 2 ml. to give 0.2 mg of
Cyanocobalamin.
117. Health teachings to be given to a client with Pernicious
Anemia regarding her therapeutic regimen concerning Vit. B12
will include:
A. Oral tablets of Vitamin B12 will control her symptoms
B. IM injections are required for daily control
C. IM injections once a month will maintain control
D. Weekly Z-track injections provide needed control
Answer: (C) IM injections once a month will maintain control
Deep IM injections bypass B12 absorption defect in the
stomach due to lack of intrinsic factor, the transport carrier
component of gastric juices. A monthly dose is usually sufficient
since it is stored in active body tissues such as the liver, kidney,
heart, muscles, blood and bone marrow
118. The nurse knows that a client with Pernicious Anemia
understands the teaching regarding the vitamin B12 injections
when she states that she must take it:
A. When she feels fatigued
B. During exacerbations of anemia
C. Until her symptoms subside
D. For the rest of her life
Answer: (D) For the rest of her life
Since the intrinsic factor does not return to gastric secretions
even with therapy, B12 injections will be required for the
remainder of the client’s life.
119. Arthur Cruz, a 45 year old artist, has recently had an
abdominoperineal resection and colostomy. Mr. Cruz accuses
the nurse of being uncomfortable during a dressing change,
because his “wound looks terrible.” The nurse recognizes that
the client is using the defense mechanism known as:
A. Reaction Formation
B. Sublimation
C. Intellectualization
D. Projection
Answer: (D) Projection
Projection is the attribution of unacceptable feelings and
emotions to others which may indicate the patients
nonacceptance of his condition.
120. When preparing to teach a client with colostomy how to
irrigate his colostomy, the nurse should plan to perform the
procedure:
A. When the client would have normally had a bowel movement
B. After the client accepts he had a bowel movement
C. Before breakfast and morning care
D. At least 2 hours before visitors arrive
Answer: (A) When the client would have normally had a bowel
movement
Irrigation should be performed at the time the client normally
defecated before the colostomy to maintain continuity in
lifestyle and usual bowel function/habit.
121. When observing an ostomate do a return demonstration of
the colostomy irrigation, the nurse notes that he needs more
teaching if he:
A. Stops the flow of fluid when he feels uncomfortable
B. Lubricates the tip of the catheter before inserting it into the
stoma
C. Hangs the bag on a clothes hook on the bathroom door
during fluid insertion
D. Discontinues the insertion of fluid after only 500 ml of fluid
has been instilled
Answer: (C) Hangs the bag on a clothes hook on the bathroom
door during fluid insertion
The irrigation bag should be hung 12-18 inches above the level
of the stoma; a clothes hook is too high which can create
increase pressure and sudden intestinal distention and cause
abdominal discomfort to the patient.
122. When doing colostomy irrigation at home, a client with
colostomy should be instructed to report to his physician :
A. Abdominal cramps during fluid inflow
B. Difficulty in inserting the irrigating tube
C. Passage of flatus during expulsion of feces
D. Inability to complete the procedure in half an hour
Answer: (B) Difficulty in inserting the irrigating tube
Difficulty of inserting the irrigating tube indicates stenosis of the
stoma and should be reported to the physician. Abdominal
cramps and passage of flatus can be expected during
colostomy irrigations. The procedure may take longer than half
an hour.
123. A client with colostomy refuses to allow his wife to see the
incision or stoma and ignores most of his dietary instructions.
The nurse on assessing this data, can assume that the client is
experiencing:
A. A reaction formation to his recent altered body image.
B. A difficult time accepting reality and is in a state of denial.
C. Impotency due to the surgery and needs sexual counseling
D. Suicide thoughts and should be seen by psychiatrist
Answer: (B) A difficult time accepting reality and is in a state of
denial.
As long as no one else confirms the presence of the stoma and
the client does not need to adhere to a prescribed regimen, the
client’s denial is supported
124. The nurse would know that dietary teaching had been
effective for a client with colostomy when he states that he will
eat:
A. Food low in fiber so that there is less stool
B. Everything he ate before the operation but will avoid those
foods that cause gas
C. Bland foods so that his intestines do not become irritated
D. Soft foods that are more easily digested and absorbed by
the large intestines
Answer: (B) Everything he ate before the operation but will
avoid those foods that cause gas
There is no special diets for clients with colostomy. These
clients can eat a regular diet. Only gas-forming foods that
cause distention and discomfort should be avoided.
125. Eddie, 40 years old, is brought to the emergency room
after the crash of his private plane. He has suffered multiple
crushing wounds of the chest, abdomen and legs. It is feared
his leg may have to be amputated.
When Eddie arrives in the emergency room, the assessment
that assume the greatest priority are:
A. Level of consciousness and pupil size
B. Abdominal contusions and other wounds
C. Pain, Respiratory rate and blood pressure
D. Quality of respirations and presence of pulsesQuality of
respirations and presence of pulses
Answer: (D) Quality of respirations and presence of
pulsesQuality of respirations and presence of pulses
Respiratory and cardiovascular functions are essential for
oxygenation. These are top priorities to trauma management.
Basic life functions must be maintained or reestablished
126. Eddie, a plane crash victim, undergoes endotracheal
intubation and positive pressure ventilation. The most
immediate nursing intervention for him at this time would be to:
A. Facilitate his verbal communication
B. Maintain sterility of the ventilation system
C. Assess his response to the equipment
D. Prepare him for emergency surgery
Answer: (C) Assess his response to the equipment
It is a primary nursing responsibility to evaluate effect of
interventions done to the client. Nothing is achieved if the
equipment is working and the client is not responding
127. A chest tube with water seal drainage is inserted to a client
following a multiple chest injury. A few hours later, the client’s
chest tube seems to be obstructed. The most appropriate
nursing action would be to
A. Prepare for chest tube removal
B. Milk the tube toward the collection container as ordered
C. Arrange for a stat Chest x-ray film.
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
D. Clam the tube immediately
Answer: (B) Milk the tube toward the collection container as
ordered
This assists in moving blood, fluid or air, which may be
obstructing drainage, toward the collection chamber
128. The observation that indicates a desired response to
thoracostomy drainage of a client with chest injury is:
A. Increased breath sounds
B. Constant bubbling in the drainage chamber
C. Crepitus detected on palpation of chest
D. Increased respiratory rate
Answer: (A) Increased breath sounds
The chest tube normalizes intrathoracic pressure and restores
negative intra-pleural pressure, drains fluid and air from the
pleural space, and improves pulmonary function
129. In the evaluation of a client’s response to fluid replacement
therapy, the observation that indicates adequate tissue
perfusion to vital organs is:
A. Urinary output is 30 ml in an hour
B. Central venous pressure reading of 2 cm H2O
C. Pulse rates of 120 and 110 in a 15 minute period
D. Blood pressure readings of 50/30 and 70/40 within 30
minutes
Answer: (A) Urinary output is 30 ml in an hour
A rate of 30 ml/hr is considered adequate for perfusion of
kidney, heart and brain.
130. A client with multiple injury following a vehicular accident is
transferred to the critical care unit. He begins to complain of
increased abdominal pain in the left upper quadrant. A ruptured
spleen is diagnosed and he is scheduled for emergency
splenectomy. In preparing the client for surgery, the nurse
should emphasize in his teaching plan the:
A. Complete safety of the procedure
B. Expectation of postoperative bleeding
C. Risk of the procedure with his other injuries
D. Presence of abdominal drains for several days after surgery
Answer: (D) Presence of abdominal drains for several days
after surgery
Drains are usually inserted into the splenic bed to facilitate
removal of fluid in the area that could lead to abscess
formation.
131. To promote continued improvement in the respiratory
status of a client following chest tube removal after a chest
surgery for multiple rib fracture, the nurse should:
A. Encourage bed rest with active and passive range of motion
exercises
B. Encourage frequent coughing and deep breathing
C. Turn him from side to side at least every 2 hours
D. Continue observing for dyspnea and crepitus
Answer: (B) Encourage frequent coughing and deep breathing
This nursing action prevents atelectasis and collection of
respiratory secretions and promotes adequate ventilation and
gas exchange.
132. A client undergoes below the knee amputation following a
vehicular accident. Three days postoperatively, the client is
refusing to eat, talk or perform any rehabilitative activities. The
best initial nursing approach would be to:
A. Give him explanations of why there is a need to quickly
increase his activity
B. Emphasize repeatedly that with as prosthesis, he will be able
to return to his normal lifestyle
C. Appear cheerful and non-critical regardless of his response
to attempts at intervention
D. Accept and acknowledge that his withdrawal is an initially
normal and necessary part of grieving
Answer: (D) Accept and acknowledge that his withdrawal is an
initially normal and necessary part of grieving
The withdrawal provides time for the client to assimilate what
has occurred and integrate the change in the body image.
Acceptance of the client’s behavior is an important factor in the
nurse’s intervention.
133. The key factor in accurately assessing how body image
changes will be dealt with by the client is the:
A. Extent of body change present
B. Suddenness of the change
C. Obviousness of the change
D. Client’s perception of the change
Answer: (D) Client’s perception of the change
It is not reality, but the client’s feeling about the change that is
the most important determinant of the ability to cope. The client
should be encouraged to his feelings.
134. Larry is diagnosed as having myelocytic leukemia and is
admitted to the hospital for chemotherapy. Larry discusses his
recent diagnosis of leukemia by referring to statistical facts and
figures. The nurse recognizes that Larry is using the defense
mechanism known as:
A. Reaction formation
B. Sublimation
C. Intellectualization
D. Projection
Answer: (C) Intellectualization
People use defense mechanisms to cope with stressful events.
Intellectualization is the use of reasoning and thought
processes to avoid the emotional upsets.
135. The laboratory results of the client with leukemia indicate
bone marrow depression. The nurse should encourage the
client to:
A. Increase his activity level and ambulate frequently
B. Sleep with the head of his bed slightly elevated
C. Drink citrus juices frequently for nourishment
D. Use a soft toothbrush and electric razor
Answer: (D) Use a soft toothbrush and electric razor
Suppression of red bone marrow increases bleeding
susceptibility associated with thrombocytopenia, decreased
platelets. Anemia and leucopenia are the two other problems
noted with bone marrow depression.
136. Dennis receives a blood transfusion and develops flank
pain, chills, fever and hematuria. The nurse recognizes that
Dennis is probably experiencing:
A. An anaphylactic transfusion reaction
B. An allergic transfusion reaction
C. A hemolytic transfusion reaction
D. A pyrogenic transfusion reaction
Answer: (C) A hemolytic transfusion reaction
This results from a recipient’s antibodies that are incompatible
with transfused RBC’s; also called type II hypersensitivity; these
signs result from RBC hemolysis, agglutination, and capillary
plugging that can damage renal function, thus the flank pain
and hematuria and the other manifestations.
137. A client jokes about his leukemia even though he is
becoming sicker and weaker. The nurse’s most therapeutic
response would be:
A. “Your laugher is a cover for your fear.”
B. “He who laughs on the outside, cries on the inside.”
C. “Why are you always laughing?”
D. “Does it help you to joke about your illness?”
Answer: (D) “Does it help you to joke about your illness?”
This non-judgmentally on the part of the nurse points out the
client’s behavior.
138. In dealing with a dying client who is in the denial stage of
grief, the best nursing approach is to:
A. Agree with and encourage the client’s denial
B. Reassure the client that everything will be okay
C. Allow the denial but be available to discuss death
D. Leave the client alone to discuss the loss
Answer: (C) Allow the denial but be available to discuss death
This does not take away the client’s only way of coping, and it
permits future movement through the grieving process when
the client is ready. Dying clients move through the different
stages of grieving and the nurse must be ready to intervene in
all these stages.
139. During and 8 hour shift, Mario drinks two 6 oz. cups of tea
and vomits 125 ml of fluid. During this 8 hour period, his fluid
balance would be:
A. +55 ml
B. +137 ml
C. +235 ml
D. +485 ml
Answer: (C) +235 ml
 PREVIOUS BON FILES: MEDICAL-SURGICAL NURSING
The client’s intake was 360 ml (6oz x 30 ml) and loss was 125
ml of fluid; loss is subtracted from intake
140. Mr. Ong is admitted to the hospital with a diagnosis of Left-
sided CHF. In the assessment, the nurse should expect to find:
A. Crushing chest pain
B. Dyspnea on exertion
C. Extensive peripheral edema
D. Jugular vein distention
Answer: (B) Dyspnea on exertion
Pulmonary congestion and edema occur because of fluid
extravasation from the pulmonary capillary bed, resulting in
difficult breathing. Left-sided heart failure creates a backward
effect on the pulmonary system that leads to pulmonary
congestion.
141. The physician orders on a client with CHF a cardiac
glycoside, a vasodilator, and furosemide (Lasix). The nurse
understands Lasix exerts is effects in the:
A. Distal tubule
B. Collecting duct
C. Glomerulus of the nephron
D. Ascending limb of the loop of Henle
Answer: (D) Ascending limb of the loop of Henle
This is the site of action of Lasix being a potent loop diuretic.
142. Mr. Ong weighs 210 lbs on admission to the hospital. After
2 days of diuretic therapy he weighs 205.5 lbs. The nurse could
estimate that the amount of fluid he has lost is:
A. 0.5 L
B. 1.0 L
C. 2.0 L
D. 3.5 L
Answer: (C) 2.0 L
One liter of fluid weighs approximately 2.2 lbs. Therefore a 4.5
lbs weight loss equals approximately 2 Liters.
143. Mr. Ong, a client with CHF, has been receiving a cardiac
glycoside, a diuretic, and a vasodilator drug. His apical pulse
rate is 44 and he is on bed rest. The nurse concludes that his
pulse rate is most likely the result of the:
A. Diuretic
B. Vasodilator
C. Bed-rest regimen
D. Cardiac glycoside
Answer: (D) Cardiac glycoside
A cardiac glycoside such as digitalis increases force of cardiac
contraction, decreases the conduction speed of impulses within
the myocardium and slows the heart rate.
144. The diet ordered for a client with CHF permits him to have
a 190 g of carbohydrates, 90 g of fat and 100 g of protein. The
nurse understands that this diet contains approximately:
A. 2200 calories
B. 2000 calories
C. 2800 calories
D. 1600 calories
Answer: (B) 2000 calories
There are 9 calories in each gram of fat and 4 calories in each
gram of carbohydrate and protein
145. After the acute phase of congestive heart failure, the nurse
should expect the dietary management of the client to include
the restriction of:
A. Magnesium
B. Sodium
C. Potassium
D. Calcium
Answer: (B) Sodium
Restriction of sodium reduces the amount of water retention
that reduces the cardiac workload
146. Jude develops GI bleeding and is admitted to the hospital.
An important etiologic clue for the nurse to explore while taking
his history would be:
A. The medications he has been taking
B. Any recent foreign travel
C. His usual dietary pattern
D. His working patterns
Answer: (A) The medications he has been taking
Some medications, such as aspirin and prednisone, irritate the
stomach lining and may cause bleeding with prolonged use
147. The meal pattern that would probably be most appropriate
for a client recovering from GI bleeding is:
A. Three large meals large enough to supply adequate energy.
B. Regular meals and snacks to limit gastric discomfort
C. Limited food and fluid intake when he has pain
D. A flexible plan according to his appetite
Answer: (B) Regular meals and snacks to limit gastric
discomfort
Presence of food in the stomach at regular intervals interacts
with HCl limiting acid mucosal irritation. Mucosal irritation can
lead to bleeding.
148. A client with a history of recurrent GI bleeding is admitted
to the hospital for a gastrectomy. Following surgery, the client
has a nasogastric tube to low continuous suction. He begins to
hyperventilate. The nurse should be aware that this pattern will
alter his arterial blood gases by:
A. Increasing HCO3
B. Decreasing PCO2
C. Decreasing pH
D. Decreasing PO2
Answer: (B) Decreasing PCO2
Hyperventilation results in the increased elimination of carbon
dioxide from the blood that can lead to respiratory alkalosis.
149. Routine postoperative IV fluids are designed to supply
hydration and electrolyte and only limited energy. Because 1 L
of a 5% dextrose solution contains 50 g of sugar, 3 L per day
would apply approximately:
A. 400 Kilocalories
B. 600 Kilocalories
C. 800 Kilocalories
D. 1000 Kilocalories
Answer: (B) 600 Kilocalories
Carbohydrates provide 4 kcal/ gram; therefore 3L x 50 g/L x 4
kcal/g = 600 kcal; only about a third of the basal energy need.
150. Thrombus formation is a danger for all postoperative
clients. The nurse should act independently to prevent this
complication by:
A. Encouraging adequate fluids
B. Applying elastic stockings
C. Massaging gently the legs with lotion
D. Performing active-assistive leg exercises
Answer: (D) Performing active-assistive leg exercises
Inactivity causes venous stasis, hypercoagulability, and external
pressure against the veins, all of which lead to thrombus
formation. Early ambulation or exercise of the lower extremities
reduces the occurrence of this phenomenon