Medical Surgical Nursing

Situation 1. Electrolytes, charged ions capable of conducting electricity, are present in all body fluids and fluid
compartments. Just as maintaining the fluid balance is vital to normal body function, so is maintaining electrolyte balance.
1. After extensive, prolonged surgery it is most important that the nurse observe the client for the depletion of the electrolyte:
a. Calcium c. Potassium
b. Sodium d. Chloride

Answer: C
Rationale: Release of adrenocortical steroids (cortisol) by the stress of surgery causes renal retention of sodium and excretion
of potassium.
In option B, although sodium may be depleted by nasogastric suction, retention by the kidneys generally balances this loss.
Options A and D are incorrect because this is not depleted by surgery or urinary excretion. (Mosby, 18th Edition)

2. The most important electrolyte of extracellular fluid is:

a. Calcium c. Potassium
b. Sodium d. Chloride

Answer: B
Rationale: Sodium is the most abundant cation of the extracellular compartment.
Option A is incorrect because calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones.
Option C is incorrect because the concentration of potassium is greater inside the cell and is important in establishing a membrane
potential, a critical factor in the cell's ability to function.
Option D is incorrect because chloride is an extracellular anion. (Mosby, 18th Edition)

3. A client is admitted with diarrhea, anorexia, weight loss and abdominal cramps. A diagnosis of colitis is made. The symptoms of
fluid and electrolyte imbalance caused by this condition that the nurse should report immediately are:
a. Tachycardia and extreme muscle weakness
b. Diplopia, skin rash and diarrhea
c. Leg and stomach cramps, nausea and vomiting
d. Development of tetany with muscle spasms
Answer: A
Rationale: Potassium, the major intracellular cation, functions with sodium and calcium to regulate neuromuscular activity and
contraction of muscle fibers, particularly the heart muscle. In hypokalemia these symptoms develop.
Option B is incorrect because these symptoms do not indicate an electrolyte imbalance.
In option C, nausea and vomiting might occur with prolonged potassium deficit; however, this is not an early sign; leg and
abdominal cramps occur with potassium excess, not deficit.
In option D, these symptoms would indicate hypocalcemia, which does not generally occur in colitis. (Mosby, 18th Edition)

4. A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest
priority?
a. Cardiac c. Neuromuscular
b. Renal d. Gastrointestinal

Answer: C
Rationale: The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity. Calcium
is vital in regulating muscle contraction and relaxation,
neuromuscular function and cardiac function. (
Kozier & Erb's Fundamentals of Nursing, 8th edition)

5. A client is receiving digoxin (Lanoxin) and furosemide (Lasix). The client should be observed for symptoms of electrolyte depletion
caused by;
a. Sodium restriction
b. Continuous dyspnea
c. Inadequate oral intake
d. Diuretic therapy
Answer: D
Rationale: Diuretic therapy that affects the loop of Henle generally involves the use of drugs that directly or indirectly increase
urinary sodium, chloride and potassium excretion.
Option A is incorrect because sodium restriction does not necessarily accompany administration of furosemide (Lasix).
Option B is incorrect because dyspnea does not directly result in a depletion of electrolytes.
Option C is incorrect because unless otherwise ordered, oral intake is unaffected. (Mosby, 18th Edition)

Situation 2. A client, found lying unconscious in an enclosed parking space, is rushed to the emergency room. Carbon
monoxide poisoning is suspected.
6. The client suffering from carbon monoxide poisoning:
a. Will always present with a cherry red skin coloring
b. Appears intoxicated
c. Appears hyperactive
d. Presents with severe hypertension
Rationale:
B. A person suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms
include headache, muscular weakness, palpitation, dizziness, and mental confusion.
A. The skin coloring in the patient with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale,
and is not a reliable diagnostic sign.

7. The nurse expects the physician to prescribe which of the following to confirm the diagnosis?
a. Pulse oximetry
b. CT scan of the head
c. Carboxyhemoglobin
d. Complete blood cell count
Rationale:
C. The diagnosis of carbon monoxide poisoning is confirmed by the measurement of carboxyhemoglobin levels in the client's
blood.
A. Pulse oximetry readings are unreliable because of the detection of CO-hemoglobin as oxyhemoglobin.
B. The neurological system may not be affected by carbon monoxide poisoning, but this will be detected by assessment of clinical
manifestations. A CT scan will not confirm the diagnosis or provide any useful information unless a structural defect of injury in
the head is a concern.
D. A CBC may provide useful information but will not confirm the diagnosis. (Silvestri, Saunders Comprehensive Review for the
NCLEX-RN Examination, 4th Edition)

8. A nurse is monitoring the results of serial arterial blood gases of the client who is asking for the oxygen mask to be removed.
The nurse determines that the oxygen may be safely removed once the carboxyhemoglobin level decreases to less than:
a. 25% b. 15% c. 10% d. 5%

Rationale:
D. Oxygen may be removed safely from the client with carbon monoxide poisoning once carboxyhemoglobin levels are less than
5%.
(Silvestri, Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition)

9. A nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse would document that the treatment
was effective when the:
a. Carboxyhemoglobin levels are less than 5%
b. Client is awake and talking
c. Client is sleeping soundly
d. Heart monitor shows sinus tachycardia
Rationale:
A. Normal carboxyhemoglobin levels are less than 5% for an adult (0.05 to 2.5 % for a non-smoker and 5 to 10% for a heavy
smoker).
B. Client can be awake and talking with abnormally high levels.
D. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and CNS depression.
(Silvestri, Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition)

10. A nurse is setting up oxygen for the client. The client is to receive oxygen at 10 L per non-rebreather mask. It is important for the
nurse to do the following, except:
 a. Adjust the flow rate to keep the reservoir bag inflated greater than 2/3 full during inspiration
b. Remind the client and his wife of the smoking policy
c. Monitor the patient carefully for risk of aspiration
d. Make sure the valves and rubber flaps are patent, functional, and not stuck

Rationale:
C. This is appropriate for a client with a face mask because the face mask limits the client’s ability to clear the mouth if vomiting
occurs.
A. Before a non-rebreather mask is placed on the patient, the reservoir bag is inflated to greater than two-thirds full of oxygen,
at a rate of 15 liters per minute.
B. Oxygen supports combustion. Smoking is not permitted in the room while O2 is set up or being administered.
D. Exhaled air is directed through a one-way valve in the mask. The valve should open during expiration and close during
inspiration. This prevents the inhalation of room air and the re-inhalation of exhaled air. The valve, along with a sufficient seal
around the patient's nose and mouth, allows for the administration of high concentrations of oxygen, 60–90% O2. (NSNA NCLEX-
RN Review, 4th Edition)

Situation 3. A nurse is caring for a client who arrives at the emergency room with the emergency medical services team
following a burn injury from an explosion. The client has sustained thoracic burns and smoke inhalation.
11. A nurse assesses the carbon monoxide level of a client following a burn injury and notes that the level is 14%. Based on this
level, which finding would the nurse expect to note during the assessment of the client?
a. Tachycardia c. Headache
b. Nausea d. Impaired visual acuity

Rationale:
C. Clinical manifestations of carbon monoxide poisoning are related to the levels of carbon monoxide saturation:
5 to 10% impaired visual acuity
11 to 20% flushing and headache
21 to 30% nausea and impaired dexterity
31 to 40% vomiting, dizziness, and syncope
41 to 50% tachypnea and tachycardia
>50% coma and death
(Saunders Comprehensive Review for the NCLEX-RN Examination, 3rd Edition)

12. The nurse avoids which action in caring for a client who sustained smoke inhalation and is at risk for impaired gas exchange?
a. Suctioning the airway as needed
b. Repositioning the client from side to side every 2 hours
c. Providing humidified oxygen as prescribed
d. Maintaining the client in a supine position with the head of the bed elevated

Rationale:
D. The nurse should avoid maintaining the client in one position. This will ultimately lead to atelectasis and possible pneumonia
A, B and C. Aggressive pulmonary measures are used to prevent respiratory complications in the client who has impaired gas
exchange as a result of a burn injury. These include turning and repositioning, positioning for comfort, using humidified oxygen,
providing incentive spirometry, and suctioning the client on an as needed basis. (Saunders Comprehensive Review for the
NCLEX-RN Examination, 3rd Edition)

13. Which initial finding would indicate the presence of inhalation injury?
a. The presence of sputum tinged with carbon and singed nasal hair
b. Tachycardia
c. Expectoration of sputum tinged with blood
d. Absent breath sounds in the lower lobes bilaterally

Rationale:
A. Inhalation injuries are most common when a fire occurs in a closed space. The findings are facial burns, singed nasal hairs,
and sputum tinged with carbon.
B. Tachycardia is not a specific manifestation of a burn inhalation injury.
D. Auscultation of wheezing and rales suggests an inhalation injury. (Saunders Comprehensive Review for the NCLEX-RN
Examination, 3rd Edition)

14. After the initial assessment has been performed by the physician and life-threatening dysfunctions have been addressed, the
nurse reviews the physician’s orders anticipating that which pain medication will be prescribed?
a. Acetaminophen (Tylenol) with codeine sulfate
b. Morphine sulfate by the subcutaneous route
c. Intravenous (IV) morphine sulfate
d. Aspirin with oxycodone (Percodan) via nasogastric tube

Rationale:
C. Once the initial assessment has been made and life-threatening dysfunctions have been addressed, pain medication can be
administered. Narcotics administered IV are the initial medications of choice because absorption from the musculature is erratic
at this time, and an ileus can be present in the burn client. The initial medication of choice is morphine sulfate, although other
medications such as methadone, codeine, or hydromorphone may be used also. Narcotics are given by the IV route until fluid
resuscitation is complete and gastric motility is restored. (Saunders Comprehensive Review for the NCLEX-RN Examination,
3rd Edition)
15. A nurse assesses the client’s burn injury and determines that the client sustained a partial-thickness superficial burn. Based on
this determination, which finding did the nurse note?
a. Absence of wound sensation
b. Charring at the wound site
c. A dry wound surface
d. A wet, shiny, weeping wound

Rationale:
D. Partial-thickness superficial burn appears wet, shiny, and weeping, or may contain blisters. The wound blanches with pressure,
is painful, and very sensitive to touch or air currents.
A. Decreased or absence of wound sensation would occur in full-thickness or deep full-thickness burns.
B. Charring would occur in a deep full-thickness burn. (Saunders Comprehensive Review for the NCLEX-RN Examination, 3rd
Edition)

Situation 4. A female client has had a history of renal insufficiency. Her renal function has worsened and she's admitted to
the hospital for treatment of chronic renal failure.
16. The nurse knows that chronic renal failure increases the client's risk for:
a. Metabolic alkalosis secondary to retention of hydrogen ions
b. An increased serum calcium level secondary to kidney failure
c. A decreased serum phosphate level secondary to kidney failure
d. Water and sodium retention secondary to a severe decrease in the glomerular filtration rate

Answer: D
Rationale: A client with CRF is at risk for fluid imbalance such as dehydration if the kidneys fail to compensate urine, or fluid
retention if the kidneys fail to produce urine.
Option A is incorrect because CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to the kidney's inability to
excrete hydrogen ions.
In options B and C, electrolyte imbalances associated with CRF result from the kidney's inability to excrete phosphorus; such
imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. (Gingrich, Medical-Surgical Nursing, 2nd Edition)
17. The physician creates an arteriovenous fistula in the client's left arm for dialysis. Which nursing measure is necessary to maintain
the fistula?
a. Avoiding blood pressure measurements in the left arm
b. Observing for cannula separation at the connection site
c. Instructing the client not to exercise her arm
d. Applying a dry, sterile dressing daily

Answer: A
Rationale: The nurse shouldn't take blood pressure measurements in the left arm because this may compromise circulation to
the fistula, clot formation may occur, reducing the fistula's patency or rendering it useless.
Option B is incorrect because the fistula is internal, the nurse wouldn't be able to observe any separation of the cannula at the
connection site.
Option C is incorrect because the client should exercise the arm to promote circulation through the fistula.
Option D is incorrect because applying a dry, sterile dressing is unnecessary once the incision is healed. (Gingrich, Medical-
Surgical Nursing, 2nd Edition)

18. The client's serum calcium level is low. Low serum calcium levels in renal failure may be caused by:
a. Decreased amount of parathyroid hormone
b. Demineralization of bone
c. Decreased activation of vitamin D
d. Decreased levels of phosphorus

Answer: C
Rationale: Decreased activation of vitamin D in renal failure reduces GI absorption of calcium.
In option B, although demineralization of bone can occur with renal failure, the condition is due to repeated episodes of
hypocalcemia.
Option D is incorrect because clients with renal failure have elevated phosphate levels with correspondingly low calcium levels.
(Gingrich, Medical-Surgical Nursing, 2nd Edition)

19. Which observation involving the client's fistula would require the nurse to notify the doctor?
a. Blood flow detected while palpating the fistula site
b. Absence of an audible bruit while auscultating the graft
c. Blood flow observed through the cannula
d. Straw-colored blood flow observed through the cannula

Answer: B
Rationale: The nurse should hear turbulent blood flow through the vessels using the bell of the stethoscope; absent bruit
indicates a non-patent fistula, requiring the nurse to notify the doctor.
In option A, blood flow detected while palpating the fistula site indicates that the fistula is patent; notifying the doctor wouldn't be
necessary.
Option C and D are incorrect because an AV fistula doesn't require an external cannula, blood flow, regardless of color, wouldn't
be visible. (Gingrich, Medical-Surgical Nursing, 2nd Edition)

20. In chronic renal failure, symptoms may not become apparent until later stages of the disease because:
a. The kidneys have great functional reserve
 b. Liver hormones mask the symptoms
c. The adrenal glands compensate for the kidney's decreased function
d. Other body systems take over some of the kidney's functions
Answer: A
Rationale: Because of the great functional reserve of the kidneys, chronic renal failure develops more slowly than acute renal
failure and signs and symptoms don't appear until later stages of the disease.
Option B is incorrect because liver hormones don't mask symptoms of renal failure.
Options C and D are incorrect because other body systems don't compensate for the kidney's decreased function. (Gingrich,
Medical-Surgical Nursing, 2nd Edition)

Situation 5. An 18 years old male client, is admitted to the medical-surgical unit with history of abdominal cramps, loss of
appetite, nausea and passage of bloody, purulent, mucoid and watery stools. He was diagnosed of having ulcerative colitis.
21. To decrease GI irritability, the nurse should teach the client to minimize the use of:
a. Amino acids c. Sugar products
b. Cola drinks d. Rice products

Answer: B
Rationale: Milk and caffeine in cola are chemically irritating to the intestinal mucosa. They also promote secretion of gastric
juice.
Option A is incorrect because these are absorbed slowly and are not irritating.
Option C is too general; except for those that contain lactose sugars, products containing sugar generally are not irritating to the
mucosa; protein also is not irritating.
Option D is incorrect because these foods do not irritate the bowel and need not be restricted. (Mosby, 18th Edition)

22. When teaching the client about diet, the nurse recognizes that dietary teaching has been effective when the client states, “I can
eat/drink:
a. Scrambled eggs.”
b. Orange juice.”
c. Creamed potato soup.”
d. Vanilla milk shakes.”

Answer: A
Rationale: This is low residue and is less irritating to the colon than the other choices.
Option B is incorrect because this contains cellulose, which is not absorbed and irritates the colon.
Options C and D are incorrect because milk contains lactose, which is irritating to the colon. (Mosby, 18th Edition)

23. Vitamins are administered parenterally for clients with an inflamed intestine because:
a. Intestinal absorption may be inadequate
b. More rapid action results
c. They are ineffective orally
d. They decrease colon irritability

Answer: A
Rationale: Because the mucosa of the intestinal tract is damaged, its ability to absorb vitamins taken orally is greatly impaired.
In option B, although this is true, the risks associated with IV administration will outweigh the benefits.
Option C is incorrect because vitamins are effective orally unless disease of the GI tract hampers absorption.
Option D is incorrect because IV vitamins do not decrease colonic irritability. (Mosby, 18th Edition)

24. The physician orders daily stool examinations for the client. These stool examinations are ordered to determine:
a. Occult blood and organisms
b. Ova and parasites
c. Fat and undigested food
d. Culture and sensitivity

Answer: A
Rationale: Occult blood in the stool could indicate active bleeding; the stool should also be examined for microorganisms to
detect early infections that could easily become systemic by spread through the damaged intestinal mucosa.
Option B is incorrect because there is no indication that parasites are present; the situation does not warrant this examination.
Option C is incorrect because the situation does not warrant these examinations.
Option D is incorrect because the situation does not warrant culturing. (Mosby, 18th Edition)

25. After many years of coping with ulcerative colitis, the client makes the decision to have a colectomy as advice by the physician.
A significant factor in this decision may have been the knowledge that:
a. It would be temporary until the colon heals
b. Surgical treatment cures ulcerative colitis
c. Ulcerative colitis can progress to Crohn's disease
d. Without surgery the client would be unable to eat table foods

Answer: B
Rationale: When the diseased bowel is removed, the client's symptoms cease.
Option A is incorrect because surgical removal of a body part is not temporary, but permanent.
Option C is incorrect because ulcerative colitis does not progress to Crohn's disease; clients with ulcerative colitis have an
 increased risk for colorectal cancer.
Option D is not a true statement. (Mosby, 18th Edition)

Situation 6. A 45 years old client presents to the emergency department with nausea, and steady epigastric pain centered
near the navel that radiates to the back. Blood studies reveal elevated amylase, lipase, and white blood cell count levels.
The client is diagnosed with acute pancreatitis.
26. The most common cause of acute pancreatitis is:
a. Gallstones c. Alcohol
b. Eating low-fat foods d. Pregnancy

Rationale:
A. Gallstones are the most common cause of acute pancreatitis.
C. Alcohol consumption is the second most common cause. (Lippincott’s Fluids and Electrolytes Made Incredibly Easy)

27. Which of these imbalances typically occur in acute pancreatitis?

a. Hypercalcemia c. Hypernatremia
b. Hypovolemia d. Hypermagnesemia

Rationale:
B. In acute pancreatitis, fluid shifting from the intravascular space into the interstitial spaces and retroperitoneum causes
hypovolemia.
(Lippincott’s Fluids and Electrolytes Made Incredibly Easy)

28. The pancreas functions as both an exocrine and endocrine gland. Which of these is an example of its exocrine function?
a. The pancreas produces hydrochloric acid
b. Insulin is produced into islets of Langerhans
c. Amylase is produced in the acinar cells
d. The pancreas secretes its enzymes into the stomach

Rationale:
C. The production of amylase in the acinar cells is an example of exocrine function.
A, B and D are endocrine functions.
(Lippincott’s Fluids and Electrolytes Made Incredibly Easy)

29. Patients recovering from acute pancreatitis should eat foods that are:
a. High in carbohydrates, and low in fats and proteins
b. Low in carbohydrates, proteins, and fats
c. Low in carbohydrates, and high in fats and proteins
d. High in carbohydrates and fats, and low in proteins

Rationale:
A. The patient recovering from acute pancreatitis should eat foods that are high in carbohydrates and low in fats and proteins.
(Lippincott’s Fluids and Electrolytes Made Incredibly Easy)

30. The patient with acute pancreatitis may report that his pain decreases:
a. When he lies on his stomach
b. When he lies on his side with his knees drawn toward his chest
c. After eating a large meal
d. After vomiting

Rationale:
B. Pain caused by acute pancreatitis is commonly relieved when the patient lies on his side with his knees drawn toward his
chest. (Lippincott’s Fluids and Electrolytes Made Incredibly Easy)

Situation 7. A preschool child with leukemia is admitted to the hospital with complaints of fever, chills, fatigue, and pallor.
31. In writing a nursing care plan for a child with leukemia, the nurse should include all of the following goals. Which goal is most
important?
a. Prevent injury
b. Meet developmental needs
c. Promote adequate nutrition
d. Maintain infection-free state

Rationale:
D. The leading cause of morbidity and mortality in children with leukemia is infection. Therefore, preventing infection is the most
important.
A, B and C are less important goals for the child with leukemia. (Davis, NCLEX-RN Success, 2nd Edition)

32. Labs are drawn and the results reported. Which lab data will provide the most likely explanation for the fatigue and pallor?
a. Hemoglobin 6.0 g/dL
b. Magnesium 2.0 mEq/L
c. Creatinine 2.5 mg/dL
d. WBC 12.6 x 103/ L

Rationale:
 A. The hemoglobin content for children is normally 11-13 g/dL. A patient with a hemoglobin content of 6.0 g/dL has severe
anemia. RBCs contain hemoglobin, which transports oxygen to the cells. Because of the decreased levels of hemoglobin and
an associated decrease in oxygen-carrying capacity, the patient would be expected to exhibit the clinical manifestation of fatigue
and pallor. (Chernecky, NCLEX-RN Review Guide)

33. The child is receiving chemotherapy with vincristine. The nurse should observe this child closely for the side effect of:
a. Diarrhea
b. Paresthesia and footdrop
c. Diplopia
d. Hemorrhagic cystitis

Rationale:
B. Vincristine is an antineoplastic Vinca alkaloid, which causes numbness, tingling, footdrop, and paresthesia.
A. Vincristine may cause constipation, not diarrhea.
C. Vincristine does not cause visual changes.
D. Hemorrhagic cystitis may be caused by cyclophosphamide (Cytoxan), not vincristine. (Davis, NCLEX-RN Success, 2nd Edition)

34. The parents of a preschool child with leukemia tell the nurse that their daughter frequently has nightmares, and they wonder how
to handle this. The nurse would be most correct in advising them to:
a. Comfort her, by bringing her into her bed
b. Comfort her, but leave her in her own bed
c. Encourage the child to draw a picture of her dreams and discuss them with her primary nurse during hospitalization
d. Consult a child psychologist to determine why she has recurring sleep disturbances

Rationale:
B. Most psychologists would recommend that a child be referred comfort in the form of a hug, kiss, and cuddle.
A. The child should be left in his/her own bed to avoid overdependence on the parents.
C. It could be difficult for this preschool child to draw a picture of her dreams.
D. For the preschool child, nightmares are a common occurrence and can be accepted as a normal part of growth and
development. Therefore, no professional intervention is necessary at this time. (Davis, NCLEX-RN Success, 2nd Edition)

35. The child develops oral ulcer. Which of the following interventions is inappropriate?
a. Offer the child a bland, moist, soft diet
b. Use a soft toothbrush
c. Encourage the child to use viscous lidocaine before meals
d. Provide frequent normal saline mouth rinses

Rationale:
C. Viscous lidocaine is never recommended for children with mucosal ulcerations secondary to chemotherapy, because of the
risk of depressed gag reflex and aspiration. (Davis, NCLEX-RN Success, 2nd Edition)

Situation 8. Care of the clients with tracheostomy is often a challenge to a beginning nurse. The following questions will
test your knowledge on Tracheostomy and its related care.

36. In contrary to tracheostomy tubes, sizes of chest tubes are expressed in terms of:
a. Gauge c. m2
b. French d. Diameter

Rationale:
B. French pertains to the size/diameter of chest tubes. The larger French signify larger diameter of the tube.
A. Gauge pertains to the diameter of the needle shaft. It varies from #18 to #28. The larger gauge number signify smaller diameter
of the shaft.
(Kozier & Erb's Fundamentals of Nursing, 8th Edition)

37. The nurse knows that in Tracheotomy creation, 1% Lidocaine and 1:100,000 Epinephrine is injected at the incision site. The
purpose of Lidocaine is mainly to provide anesthetic effect, while the Epinephrine is needed to:
a. Relax the bronchus and dilate the airway for easier insertion
b. Promote hemostasis
c. Promote faster healing
d. Prevent the vasovagal reflex that might cause bradycardia

Rationale:
B. Epinephrine produces vasoconstriction, thus aiding in the control of bleeding, and preventing rapid absorption of the anesthetic
agent thereby prolonging its local action. (Fairchild, Perioperative Nursing Principles and Practice)

38. In cleaning the inner cannula or other parts of the tracheostomy tube, the best cleansing mediums are:
a. Alcohol and sterile saline
b. Povidone iodine and sterile saline
c. Hydrogen peroxide and Sterile saline
d. Alcohol and hydrogen peroxide

Rationale:
 C. The inner cannula is soaked in hydrogen peroxide (effective in loosening crusted secretions from the inner lumen of the
tracheostomy tube) or sterile saline, per manufacturer's instructions; and rinsed with saline solution. (Brunner and Suddarth's
Textbook of Medical-Surgical Nursing, 11th Edition)

39. A client has impaired verbal communication as a result of temporary tracheostomy following a laryngectomy. In planning for
communication with this client, the nurse would avoid which of the following methods because it would be least helpful for this
particular client?
a. Nodding and shaking the head for yes or no
b. Use of a pencil and paper
c. Use of hand or finger signals
d. Use of a picture board

Rationale:
A. Following laryngectomy, the client should not be asked to nod or shake the head because it is painful for the client. The use
of eye blink or hand or finger signals is acceptable. Other helpful methods includes the use of a pencil and paper, word or picture
board, flash cards, or a magic slate. (Silvestri, Saunders’ Q&A Review for the NCLEX-RN Examination, 3rd Edition)

40. For which of the following reasons will a surgeon select a cuffed tube over a non-cuffed tracheostomy tube?
a. To prevent coughing
b. For efficient securing
c. For mechanical ventilation
d. For excellent attachment

Rationale:
C. The cuff is an inflatable attachment to the tracheostomy tube that is designed to occlude the space between the tracheal walls
and the tube, to permit effective mechanical ventilation and to minimize the risk of aspiration.
A. It does not prevent coughing.
B and D. The tracheostomy tube is secured in place by tapes fastened around the patient's neck. (Brunner and Suddarth's
Textbook of Medical-Surgical Nursing, 11th Edition)

Situation 9. The client is admitted to the emergency department with diagnosis of hypovolemic shock secondary to a 30%
blood volume loss resulting from a motorcycle accident.
41. With a diagnosis of hypovolemic shock, the nurse expects to assess all of the following, except:
a. An elevated central venous pressure reading
b. A decreased and concentrated urinary output
c. Tachycardia and a thready pulse
d. Hypotension with a small pulse pressure

Rationale:
A. A decreased CVP reading is present with hypovolemic shock.
B. During the compensatory stage of shock, the body shunts blood from organs (such as the kidneys) to the brain ad heart to
ensure adequate blood supply to these vital organs. As a result, urine output decreases in response to the release of aldosterone
and ADH.
C. Tachycardia and thready pulse result from stimulation of the sympathetic nervous system and subsequent release of
cathecholamines.
D. A client in shock experiences a drop in pulse pressure, which indicates a decreasing stroke volume. During the progressive
stage of shock, the mechanisms that regulate BP can no longer compensate, and systolic BP drops. (Smeltzer, Brunner and
Suddarth's Textbook of Medical-Surgical Nursing, 11th Edition)

42. The nurse takes blood pressure readings every 5 minutes. She knows that shock is well advanced when the systolic pressure
drops to less than:
a. 100 mmHg c. 110 mmHg
b. 90 mmHg d. 120 mmHg

Rationale:
B. The progressive stage of shock is characterized by hypotension, or systolic BP of less than 90 mmHg or a decrease in systolic
BP of 40mmHg.
(Smeltzer, Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 11th Edition)

43. The physician prescribes crystalloid solution to be administered to restore blood volume. The nurse knows that a crystalloid
solution is:
a. Lactated ringer's solution
b. Plasma or plasma substitute
c. A blood transfusion
d. Serum albumin

Rationale:
A. Common IV crystalloids (electrolyte solutions that move freely between intravascular and interstitial compartment) used for
resuscitation in hypovolemic shock include Lactated Ringer’s solution and normal saline.
B and C. Blood products, which are crystalloid solutions, may need to be administered, particularly if the cause of the hypovolemic
shock is hemorrhage.
D. Albumin is a colloidal solution (large-molecule IV solutions) commonly used to treat hypovolemic shock. It expands
intravascular blood volume by exerting oncotic pressure, thereby pulling fluid into the intravascular space. (Smeltzer, Brunner
and Suddarth's Textbook of Medical-Surgical Nursing, 11th Edition)
44. A urinary catheter is inserted to measure hourly output. The nurse knows that inadequate volume replacement is reflected by
an output of less than:
a. 100 cc/hour c. 80 cc/hour
b. 50 cc/hour d. 30 cc/hour

Rationale:
D. Normal urine output is 30-60 cc/hour. (Smeltzer, Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 11th Edition)

45. Emergency treatment for hypovolemic shock includes:

a. Administration of IV fluid
b. Administration of antibiotics
c. Administration of vasodilators
d. Relief of pain

Rationale:
A. Emergency treatment relies on prompt and adequate fluid and blood replacement to restore intravascular volume and to raise
systolic blood pressure and maintain it above 90 mmHg. (Lippincott’s cardiovascular Care Made Incredibly Easy)

Situation 10. A 33-year-old client was diagnosed with systemic lupus erythematosus. The doctor prescribes prednisone to
be taken every other day.
46. Which clinical manifestations would the nurse expect to see on a patient with systemic lupus erythematosus?
a. Red, burning, tearing eyes
b. Morning stiffness and joint tenderness
c. Night sweats and fever
d. Chest tightness with wheezing on expiration

Rationale:
B. Clinical features of SLE involve multiple body systems. When the musculoskeletal system is involved, the client exhibits joint
tenderness, edema and morning stiffness.
A. These are associated with allergic rhinitis.
C. These are associated with AIDS.
D. These are associated with allergic asthma. (Lippincott's Review Series: Medical-Surgical Nursing, 4th Edition)

47. The nurse should instruct the client to take her prednisone:
a. With food before 8 am
b. At bedtime
c. 1 hour before any meal
d. After lunch

Rationale:
A. Taking prednisone (or glucocorticoid) in the early morning rather than at bedtime helps the patient maintain the normal pattern
of cortisol production by the adrenal glands. This production peaks during the early morning; because cortisol production depends
on the body’s cortisol level, taking prednisone in the early morning suppresses the patient’s endogenous cortisol production.
Taking prednisone with food reduces gastric irritation; taking the drug before or after a meal or snack would be less effective.
(Gingrich, Medical-Surgical Nursing, 2nd Edition)

48. Which statement made by the client would indicate a need for further teaching regarding minimizing exacerbations and
complication associated with SLE?
a. “I need to maximize my time outdoors and maintain a suntan.”
b. “I should not skip taking my prednisone pill.”
c. “Taking hydrochloroquine (Plaquenil) will help my arthritis.”
d. “I should wear a medic alert bracelet.”

Rationale:
A. A client with SLE should avoid extended exposure to the sun, as it might lead to exacerbation of SLE. (Chernecky, NCLEX-
RN Review Guide)

49. The client develops hyperkalemia. The doctor prescribes sodium polysterene sulfonate (Kayexalate) to reduce the patient's
serum potassium level. This drug works by:
a. Forcing potassium into the cells
b. Pulling potassium into the bowel for excretion
c. Promoting renal excretion of potassium
d. Pulling potassium out of the bowel for excretion

Rationale:
B. Sodium polysterene sulfonate is a cation exchange resin that causes potassium to move out of the blood into the intestines.
It's then excreted in the stool. (Lippincott's Review Series: Medical-Surgical Nursing)

50. The client owns a pool in her backyard. Which instruction should the nurse give her?
a. “There are no restrictions on your activities, but plan rest periods.”
b. “Remember to keep your medication with you at all times.”
c. “Wear a sunscreen and avoid exposure to sunlight.”
d. “Get some sun, but limit your exposure because sunburn can occur quickly.”
 Rationale:
C. Because exposure to UV light can activate SLE, the patient should avoid direct exposure to sunlight and wear sunscreen and
protective clothing to filter out reflected rays.
A and D. Giving the patient no restrictions or telling her she can sunbathe for a limited time may lead to dangerous exposure to
UV light.
B. The patient should not keep her medication outside near the pool; it could get wet. (Gingrich, Medical-Surgical Nursing, 2nd
Edition)

Situation 11. Effective communication is a basic skill in providing health care to clients.
51. The hospice nurse visits a client dying of ovarian cancer. During the visit, the client expresses that “If I can just live long enough
to attend my daughter’s graduation, I’ll be ready to die.” Which phase of coping is this client experiencing?
a. Anger c. Denial
b. Depression d. Bargaining

Rationale:
D. Bargaining identifies a behavior in which the individual is wiling to do anything to avoid loss of change prognosis or fate.
A. Anger also may be a first response to upsetting news and the predominant theme is “why me?” or the blaming of others.
B. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn.
C. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. (Silvestri, Saunders Comprehensive
Review for the NCLEX-RN Examination, 4th Edition)

52. A client brought to the emergency room is dead on arrival (DOA). The family of the client tells the physician that the client had a
terminal cancer. The emergency room physician examines the client and asks the nurse to contact the medical examiner
regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which of the following
responses to the family is appropriate?
a. “I will contact the medical examiner regarding your request.”
b. “It is required by the law. Why don't we talk about it and why don't you tell me why you don't want an autopsy done?”
c. “An autopsy is mandatory for any client who is DOA.”
d. “The decision is made by the medical examiner.”

Rationale:
A. An autopsy is required by the law in certain circumstances, including the sudden death of a client that occurs under suspicious
circumstances. A client may have provided oral or written instructions regarding an autopsy following death. If no oral or written
instructions were provided, the law determines who has the authority to consent for an autopsy. Most often, the decision rests
with the surviving relative or next of kin.
(Silvestri, Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition)

53. The nurse recognizes that which of the following interventions is unlikely to facilitate effective communication between the dying
client and family?
a. The nurse encourages the client and family to identify and discuss feelings openly
b. The nurse makes decisions for the client and family to relieve them of unnecessary demands
c. The nurse assists the client and family in carrying out spiritually meaningful practices
d. The nurse maintains a calm attitude and acceptance when the family or client expresses anger

Rationale:
B. This describes the nurse removing the autonomy and decision making from the client and family, who are already experiencing
feelings of loss of control in that they cannot change the process of dying.
A. Maintaining effective and open communication among family members affected by death and grief is of the greatest
importance. Option A describes encouraging discussion of feelings and is likely to enhance communication.
C. The spiritual practices give meaning to life and have an impact on how people react to crisis.
D. The client and family need to know that someone will be there who is supportive and non-judgmental. (Silvestri, Saunders
Comprehensive Review for the NCLEX-RN Examination, 4th Edition)

54. A 7-year-old child has just been diagnosed with localized Hodgkin's disease and chemotherapy is planned to begin immediately.
The mother of the child asks the nurse why radiation therapy was not prescribed as part of the treatment. The appropriate and
supportive response to the mother is:
a. “The physician would prefer that you discuss treatment options with the oncologist.”
b. “I'm not sure. I'll discuss it with the physician.”
c. “It is very costly, and chemotherapy works just as well.”
d. “The child is too young to have radiation therapy.”

Rationale:
D. Radiation therapy is usually delayed until a child is 8 years old, whenever possible, to prevent retardation of bone growth and
soft tissue development. (Silvestri, Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition)

55. A 14-year-old child is diagnosed with Ewing's sarcoma of the femur. Following a course of radiation and chemotherapy, it has
been decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching
and cramping felt by the missing limb. Which nursing statement would be appropriate to assist in alleviating the child's fear?
a. “This normally occurs after the surgery and we will teach you ways to deal with it.”
b. “The pain medication that I give you will take these feelings away.”
c. “This aching and cramping is normal and temporary and will subside.”
d. “This pain is not real pain and relaxation exercises will help it go away.”
 Rationale:
D. Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of
burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition
is normal and only temporary. (Silvestri, Saunders Comprehensive Review for the NCLEX-RN Examination, 4th Edition)

Situation 12. Each member of the OR team performs his/her tasks in collaboration with the other members of the team.
56. Nurses in the PACU perform vital signs monitoring every:
a. 5 minutes c. 20 minutes
b. 15 minutes d. 30 minutes

Rationale:
B. Unless indicated more frequently, pulse, blood pressure and respirations are recorded every 15 minutes for the first hour, and
every 30 minutes for the next 2 hours. Thereafter, they are measured less frequently if they remain stable. The temperature is
monitored every 4 hours for the first 24 hours. (Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 11th Edition)

57. The OR team collaborates from the first to the last surgical procedure. Who monitors the activities of the OR suite during a
surgical procedure?
a. Circulating nurse c. Scrub nurse
b. Anesthesiologist d. Surgeon

Rationale:
A. The circulating nurse is responsible and accountable for all activities occurring during a surgical procedure, including but not
limited to, the management of personnel, equipment, supplies, and the environment during a surgical procedure, and managing
the flow of information to and from the surgical team members scrubbed at the field.
B. The anesthesiologist specializes in the administration and monitoring of anesthesia while maintaining the overall well-being
of the patient.
C. The scrub nurse is responsible for assisting the surgeon and the assistant with instrumentation, set-ups, suture presentations,
sponges, etc, while maintaining the sterility of the surgical field through aseptic techniques.
D. The surgeon serves as the primary decision-maker regarding the surgical technique during the procedure. His/her focus is
the performance of the operative procedure according to the needs ofthe patient. (Fairchild, Perioperative Nursing Principles and
Practice)

58. Another worthy study is the compliance to principles of aseptic technique among the sterile OR team. Who does not belong to
the sterile OR team?
a. Scrub nurse c. Surgeon
b. Assistant surgeon d. X-ray technician

Rationale:
D. The x-ray technician is not included in the sterile OR team.
A, B and C are members of the sterile OR team.

59. Who is responsible in daily monitoring the standards of safe nursing practice in the operating suite?
a. OR nurse supervisor
b. Surgeon
c. Perioperative nurse
d. Chief nurse

Rationale:
A. The OR nurse supervisor or the nurse manager is responsible for the day-to-day management of nursing activities in the area,
with the overall goal of rendering quality patient care during all three phases of surgical intervention. (Fairchild, Perioperative
Nursing Principles and Practice)

60. Who holds the packet flaps of sutures to open it and place it in the sterile table for use?
a. Circulating nurse c. Assistant surgeon
b. Scrub nurse d. Surgeon

Rationale:
A. Standing a safe distance from the sterile instrument table, or designated receptacle, the circulator rolls the flaps of the outer
edge backwards, and flips the inner package onto the sterile surface, being careful not the reach over the sterile field.
B, C and D are members of the sterile OR team. Holding the packet flaps of sutures results in a breaking technique. (Fairchild,
Perioperative Nursing Principles and Practice)

Situation 13. Though often overlooked, nurses must bear in mind that giving health teachings is an important part of nursing
care.
61. A nursing instructor assigns a student nurse to present a clinical conference to the student group about brain tumors on children.
The nursing student prepares for the conference and includes which of the following information in the presentation?
a. The most significant symptoms are vomiting and headaches
b. Head shaving is not required before removal of the brain tumor
c. Chemotherapy is the treatment of choice
d. Surgery is not normally performed because of the risk of functional deficits occurring as a result of the surgery

Rationale:
A. The hallmark symptoms of children with brain tumor are headaches and vomiting.
B. Before surgery, the client's head is shaved, although every effort is made to shave only as much hair as is necessary.
 C. Although chemotherapy may be needed, it is not the treatment of choice.
D. The treatment of choice is total surgical removal of the tumor without residual neurological damage. (Silvestri, Saunders’ Q&A
Review for the NCLEX-RN Examination, 3rd Edition)

62. A nurse has given instructions on site care to a hemodialysis client who had an implantation of an arteriovenous fistula in the
right arm. The nurse determines that the client needs further instructions if the client states to:
a. Sleep on the right side
b. Perform range of motion exercises routinely on the right arm
c. Avoid carrying heavy objects on the right arm
d. Report an increased temperature, redness and drainage at the site

Rationale:
A. Routine instructions to the client with an AV fistula, graft, or shunt, includes reporting signs and symptoms of infection,
performing ROM exercises to the affected extremity, avoiding sleeping with the body weight on the extremity with the access
site, and avoiding carrying heavy objects or compressing the extremity that has the access site. (Silvestri, Saunders’ Q&A Review
for the NCLEX-RN Examination, 3rd Edition)

63. A nurse has conducted a stress-management seminar for clients in an ambulatory care setting. Which statement by an attendee
would indicate that further instruction is needed?
a. “Biofeedback might be nice, but I don't like the idea of having to use equipment.”
b. “I can use guided imagery anywhere and anytime.”
c. “Using confrontation with co-workers should solve my problems at work quickly.”
d. “The progressive muscle relaxation technique should ease my tension headaches.”

Rationale:
C. Confrontation is a communication technique, not a stress management technique. It may also exacerbate stress, at least in
the short term, rather than alleviate it.
A, B and D. Biofeedback, progressive muscle relaxation, and guided imagery are techniques that the nurse can teach the client
to reduce physical impact of stress on the body and promote a feeling of self-control for the client. Biofeedback entails electronic
equipment, whereas the other requires no adjuncts, such as tapes, once the technique is learned. (Silvestri, Saunders’ Q&A
Review for the NCLEX-RN Examination, 3rd Edition)

64. A nurse provides home care instructions to a client hospitalized for transurethral resection of the prostate. Which statement by
the client indicates the need for further instructions?
a. “I can lift and push objects up to 30 pounds in weight.”
b. “I need to maintain a daily intake of 6 to 8 glasses of water daily.”
c. “I need to avoid strenuous activity for 4 to 6 weeks.”
d. “I need to include prune juice in my diet.”

Rationale:
A. The client needs to to be advised to avoid lifting items weighing greater than 20 pounds.
B. The client needs to consume a daily intake of 6 to 8 glasses of non-alcoholic fluids to minimize clot formation.
C. The client needs to to be advised to avoid strenuous activity for 4 to 6 weeks.
D. Straining during defecation is avoided to prevent bleeding. Prune juice is a satisfactory bowel stimulant. (Silvestri, Saunders’
Q&A Review for the NCLEX-RN Examination, 3rd Edition)

65. A nurse provides discharge instructions to a client with testicular cancer who had testicular surgery. The nurse tells the client:
a. To avoid driving a car for at least 8 weeks
b. To report any elevation in temperature to the physician
c. To avoid sitting for long periods for at least 6 weeks
d. Not to be fitted for prosthesis for at least 6 months

Rationale:
B. For a client who has had testicular surgery, the nurse should emphasize the importance of notifying the physician if chills,
fever drainage, redness, or discharge occurs. These symptoms may indicate presence of infection.
A. One week after testicular surgery, the client may drive.
C. Sitting needs to be avoided with prostate surgery because of the risk of hemorrhage, but this risk is not as high with testicular
surgery.
D. Often, prosthesis is inserted during surgery. (Silvestri, Saunders’ Q&A Review for the NCLEX-RN Examination, 3rd Edition)

Situation 14. A 26-year-old male client is admitted to the hospital with complaints of fatigue, loss of appetite, painful and
swollen joints that becomes stiff during the morning and after period of inactivity and temperature of 38.5ºC. The physician
diagnosed him of having Rheumatoid arthritis.
66. To prevent deformities, the nurse plans to alternate rest periods with:
a. Bracing of joints c. Passive massage
b. Active exercise d. Isometric exercises

Answer: B
Rationale: Active exercises, alternated with periods of rest, offer the best chance at avoiding the joint deformities associated
with rheumatoid arthritis because they move each involved joint through its full range of motion.
Option A is incorrect because immobilization of joints by bracing would promote the formation of contractures and deformities.
Option C is incorrect because massage affects the muscles, not the joints, and would do little to prevent deformities.
Option D is incorrect because isometric exercise will promote muscle, not joint function. (Mosby, 18th Edition)
67. The client complains of stiffness in the morning. The nurse should suggest that the patient:
a. Take a hot bath or shower each morning
b. Splint or brace the joint at all times
c. Apply ice packs for 1 hour each morning
d. Retire later at night and rise later in the morning

Answer: A
Rationale: Moist heat reduces pain and muscle spasm by relaxing muscles and increasing blood flow. Movement and exercise
will be less painful following heat applications.
Option B is incorrect because splinting joints is reserved for periods of acute inflammation or to prevent deformities and their
progression.
Option C is incorrect because ice should be applied for only 20 minutes, not 1 hour, to relieve pain by desensitizing nerve
endings. Usually reserved for acute inflammation, ice also decreases cellular activity and edema.
Option D is incorrect because rising later in the morning won't relieve the stiffness. (Gingrich, Medical-Surgical Nursing, 2nd
Edition)

68. The client takes large doses of aspirin for joint pain. He asks the nurse the difference between plain aspirin and enteric-coated
aspirin. The nurse explains that:
a. The enteric-coating prevents toxic reaction to aspirin and stomach ulcers, but plain aspirin doesn't
b. High doses of enteric-coated aspirin may lead to liver damage, but plain aspirin doesn't
c. The onset of action of enteric-coated aspirin may be slower because absorption is delayed
d. Enteric-coated aspirin may be used safely in children with chickenpox, but plain aspirin can't

Answer: C
Rationale: Enteric coating delays the absorption of the drug, delaying the onset of action.
Option A is incorrect because large doses of enteric-coated aspirin will be absorbed and may cause a toxic reaction.
Option B is incorrect because acetaminophen, not enteric-coated aspirin, in high doses may cause hepatic damage.
Option D is incorrect because aspirin must not be used in children with viral illness because of the risk of Reye's syndrome.
(Gingrich, Medical-Surgical Nursing, 2nd Edition)

69. The client's left knee becomes hot, extremely swollen and tender to touch. Arthrocentesis is planned. While teaching the patient
about the procedure, the nurse explains that it involves:
a. Removing synovial fluid under local anesthesia to evaluate fluid and relieve tissue pressure
b. Inserting a scope into the affected joint to visualize and repair damaged tissue or tendons
c. Fusing painful joints to eliminate motion and stress on the joint
d. Injecting medication into the joint to reduce inflammation and pain

Answer: A
Rationale: Arthrocentesis involves removing synovial fluid under local anesthesia to evaluate fluid and relieve pressure caused
by the fluid. (option B) Arthroscopy involves inserting a scope into the affected joint to visualize and repair damaged tissues or
tendons. (option D) An intra-articulate injection involves injecting medication into the joint to reduce pain and inflammation. (option
C) Arthrodesis involves fusing joint to eliminate motion and stress on a joint. (Gingrich, Medical-Surgical Nursing, 2nd Edition)

70. The client asks the nurse why the physician is going to inject hydrocortisone into the knee joint. The nurse explains that the most
important reason for doing this is to:
a. Reduce inflammation
b. Lubricate the joint
c. Prevent ankylosis of the joint
d. Provide physiotherapy

Answer: A
Rationale: Steroids have an anti-inflammatory effect that can reduce arthritic pannus formation.
Option B is incorrect because this will not provide lubrication.
Option C is incorrect because ankylosis refers to fusion of joints. It is only indirectly influenced by steroids, which exert their
major effect on the inflammatory process.
Option D is incorrect because injection of a drug is not physiotherapy. (Mosby, 18th Edition)

Situation 15. A nurse is assigned in the female surgical ward. While on duty, a 15-year-old client is admitted for cesarean
section. The informed consent for the operation has to be obtained.
71. The nurse recalls that which of the following is true of informed consent?
a. Nurses have the responsibility to obtain the informed consent prior to surgery
b. Because the patient is a minor, the parents should be asked to sign the consent
c. The informed consent should be signed by the patient or her 20-year-old husband if patient is unconscious
d. Legal guardian should sign the consent since the client is 15 years old

Rationale:
C. A pregnant or married minor is considered an emancipated minor, and therefore has the legal capacity to sign the informed
consent. If the patient is unconscious, a legal representative, such as the 20-year-old husband, can provide the consent.
A. The nurse is not legally responsible to obtain the consent. The nurse, however, is responsible to witness the client's signature,
verify if the client received enough information, and witness that the consent was given voluntarily.
B and D. A minor may not give legal consent. The informed consent must be signed by the parent or legal
guardian/representative. A pregnant minor client is considered an emancipated minor, and therefore has the legal capacity to
sign the informed consent. (Kozier & Erb's Fundamentals of Nursing, 8th Edition)
72. The person legally responsible for taking the informed consent is:
a. The doctor who is going to perform the procedure
b. Any doctor assigned with team
c. The OR nurse who is going to assist with the operation
d. The ward nurse where the patient stayed before the operation

Rationale:
A. Obtaining informed consent for specific medical and surgical treatment is the responsibility of the person who is going to
perform the procedure.
C and D. The nurse is not legally responsible to obtain the consent. The nurse, however, is responsible to witness the client's
signature, verify if the client received enough information, and witness that the consent was given voluntarily. (Kozier & Erb's
Fundamentals of Nursing, 8th Edition)

73. Which of the following should the nurse remember when the doctor requests to administer anesthesia?
a. Doctor's orders should always be written
b. The nurse may render medical procedure if the doctor supervises him
c. The nurse has the right to refuse it if the doctor's order is unlawful
d. The staff nurse can be accused of insubordination if she does not follow the doctor's order

Rationale:
C. A nurse is obliged to carry out a physicians order except when the nurse believes an order to be inappropriate. Administering
anesthesia is not within the scope of nursing practice. The nurse therefore should refuse to give the anesthesia.
(Saunders Comprehensive Review for the NCLEX-RN Examination, 3rd Edition)

74. After one year, the nurse rotated to the delivery room. As the DR nurse, the Obstetrician ordered her to administer spinal
anesthesia because the anesthesiologist did not arrive at the scene. The nurse would:
a. Do not follow
b. Give the anesthesia if the supervising nurse approves it
c. Give the anesthesia if the doctor writes the order
d. Give the anesthesia if the OB supervises her

Rationale:
A. Administering anesthesia is not within the scope of nursing practice. The nurse therefore should refuse to give the anesthesia.
(Saunders Comprehensive Review for the NCLEX-RN Examination, 3rd Edition)

75. The medical intern who assisted in the operation gave the post operative orders. In this case, the nurse should:
a. Clarify from the medical intern those that are ambiguous
b. Refuse to follow the order because it is not legal
c. Validate the order from the surgeon and request him to countersign
d. Follow the order as long as they are within the scope of nursing practice

Rationale:
C. A medical intern is a physician in the first postgraduate year who is learning medical practice under supervision before
beginning a residency program. The nurse has to validate the order from the surgeon, and have the surgeon countersign the
order.

Situation 16. Nurses have a responsibility to carry out their role in compliance of the Nurse Practice Act and the Code of
Nurses.
76. To work in an emergency department, you must:
a. Have a baccalaureate degree
b. Use the nursing process in delivering nursing care
c. Have a certification in emergency nursing
d. Possess an advanced nursing degree

Rationale:
B. The professional nurse uses the nursing process to care for emergency patients. (Lippincott's Emergency Nursing Made
Incredibly Easy)

77. Certification for registered nursing practice is:

a. Offered by BON at the time a graduate writes for licensure
b. Mandatory for nurses working in specialty areas
c. Suggested by the PNA as way of validating expertise in clinical practice
d. Required in all countries after a nurse has been practicing for 5 years

Rationale:
C. The certification of registration/professional license validates knowledge and skill in a particular area. It is a demonstration of
excellence and commitment to chosen specialty area.
A. The certification of registration for the practice of nursing is issued by the BON upon passing the NLE, and paying the
prescribed fees.
B. The professional license is mandatory before one can practice nursing, not just in specialty areas. Any person practicing
without a certification of registration/professional license is punishable by law. (Smeltzer, Brunner and Suddarth's Textbook of
Medical-Surgical Nursing, 11th Edition)

78. To be responsive of the changing health care needs of our society, registered nurses will need to:
 a. Focus their care on traditional disease-oriented approach to patient care, because hospitalized patients today are more
acutely ill than they were 10 years ago
b. Learn how to delegate discharge planning to ancillary personnel so that RNs can spend their time managing the high-tech
equipment needed for patient care
c. Stress the curative aspects of illness, especially the acute, infectious disease processes
d. Place increasing emphasis on wellness, health promotion, and self-care, because majority of Filipinos suffer from chronic
debilitative illness

Rationale:
D. Due to the changing health care needs of the society, health care professionals should place emphasis on health, health
promotion, wellness, and self care.
A. As the proportion of the population reaching age 65 years has increased, and with the shift from acute illnesses to chronic
illnesses, the traditional management and care focus of the health care professionals has expanded.
C. Health care professionals must stress the preventive aspects of illness, especially of chronic illnesses. (Smeltzer, Brunner
and Suddarth's Textbook of Medical-Surgical Nursing, 11th Edition)

79. An underlying focus of nursing has evolved over time. According to the Philippine Nurses Association, registered nurses can
and should:
a. Promote optimum levels of wellness and prevent illness
b. Maintain health and assist patients with the dying process
c. Diagnose health alterations and prescribe specific nursing interventions
d. Do all of the above

Rationale:
D. The underlying focus of nursing is on health promotion; disease prevention; alleviation of suffering through diagnosis and
treatment of human response; and care of the dying. (Smeltzer, Brunner and Suddarth's Textbook of Medical-Surgical Nursing,
11th Edition)

80. Professional certification in emergency nursing allows you to:

a. Validate knowledge and skills in emergency nursing
b. Obtain a pay raise
c. Function as an advance practice nurse
d. Obtain an administrative position

Rationale:
A. The purpose of professional certification is to validate knowledge and skill in a particular area. Certification is a demonstration
of excellence and commitment to your chosen specialty area. (Lippincott's Emergency Nursing Made Incredibly Easy)

Situation 17. Incidental reports, living wills, and patients' charts are legal documents admissible in court. In working with
the client, the nurse must be knowledgeable of the legal use, implications, and accompanying responsibilities of these
documents.
81. Who owns the patient's chart?
a. The hospital
b. The patient
c. The attending physician
d. The government

Rationale:
A. The hospital/institution/agency is the rightful owner of the chart. (Kozier and Erb's Fundamentals of Nursing, 8th Edition)

82. A nurse enters the client's room and finds the client lying on the floor. Following assessment of the client, the nurse calls the
nursing supervisor and the physician to inform them of the occurrence. The nursing supervisor instructs the nurse to complete
an incident report. The nurse understands that an incident reports allow the analysis of adverse client events by:
a. Providing a method of reporting injuries to local agencies
b. Determining the effectiveness of nursing intervention in relation to outcomes
c. Evaluating quality care and the potential risks for injury to the client
d. Providing clients with necessary stabilizing treatments

Rationale:
C. Proper documentation of unusual occurrences, incidents and accidents, and nursing actions taken as a result of the
occurrence allows the nurse and administration to review the quality of care and determine any potential risks present.
A, B and D. Incident reports are not routinely filled out for interventions, nor are they used to report occurrences to other agencies.
(Silvestri, Saunders’ Q&A Review for the NCLEX-RN Examination, 3rd Edition)

83. A nurse enters a client's room and finds the client sitting on the floor. The nurse performs a thorough assessment and assists
the client back into bed. The nurse completes an incident report and notifies the physician of the incident. Which of the following
is the next appropriate nursing action regarding the incident?
a. Document a complete entry in the client's record concerning the incident
b. Make a copy of the incident report for the physician
c. Place the incident report in the client's chart
d. Document in the client's record that an incident report has been completed

Rationale:
 A. The incident report is not a substitute for a complete entry in the client's record concerning the incident.
B, C and D. The incident report is a confidential and privileged information and should not be copied, placed in the chart, or have
any reference made to it in the client's record. (Silvestri, Saunders’ Q&A Review for the NCLEX-RN Examination, 3rd Edition)

84. A nurse is performing admission assessment on a client admitted newly diagnosed with Hodgkin's disease. Which of the following
would the nurse expect the client to report?
a. Weight gain
b. Severe lymph node pain
c. Malaise, fever and night sweats
d. Headache with minor visual changes

Rationale:
C. Assessment of a client with Hodgkin's disease most often reveals enlarged painless lymph nodes, fever, malaise and night
sweats.
A. Weight loss may be present if metastatic disease occurs.
D. Headache and visual changes may occur if brain metastasis is present. (Silvestri, Saunders’ Q&A Review for the NCLEX-RN
Examination, 3rd Edition)

85. A nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will. The
client asks the nurse to act as one of the witnesses for the will. The nurse takes which action?
a. Refuses to help the client
b. Agrees to act as a witness
c. Calls the physician
d. Informs the client that a nurse caring for a client cannot serve as a witness to a living will

Rationale:
D. A living will address the withdrawal or withholding of life sustaining interventions that unnaturally prolong life. It identifies the
person who will manage care decisions if the client is unable to take action. It is witnessed and signed by two people who are
unrelated to the client. Nurse or employees of a facility in which the client is receiving care should not serve as a witness.
C. There is no reason to call the physician. (Silvestri, Saunders’ Q&A Review for the NCLEX-RN Examination, 3rd Edition)

Situation 18. Nursing as a profession utilizes a body of knowledge that includes principles of leadership and management.
86. A nurse manager of a hemodialysis unit is observing a new nurse preparing to begin hemodialysis on a client with renal failure.
The nurse manager intervenes if the new nurse planned to:
a. Wears full protective clothing such as goggles, mask, apron and gloves
b. Put on a mask and gives one to the client to wear during connection to the machine
c. Use sterile technique for needle insertion
d. Covers the connection site with a bath blanket to enhance extremity warmth

Rationale:
D. The connection site should not be covered and it should be visible so that the nurse can assess for bleeding, ischemia, and
infection at the site during hemodialysis procedure.
A, B and C. Infection is major concern with hemodialysis. The use of sterile technique and the application of a facemask for both
the nurse and the client are both extremely important. It is also imperative that standards precautions be followed, which includes
the use of goggles, mask, apron and gloves. (Silvestri, Saunders Q&A Review for NCLEX-RN Examination)

87. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant?
a. Obtaining frequent oral temperatures on a client
b. Accompanying a man being discharged to his transportation to home
c. Collecting a urine specimen from a client
d. Assisting a post-catheterization client who needs to lie fat to eat lunch

Rationale:
D. The least appropriate to assign to a nursing assistant is a post-catheterization client who needs to lie flat to eat lunch, because
this client is at risk for aspiration. (Silvestri, Saunders Q&A Review for NCLEX-RN Examination)

88. A nurse manager is planning to implement a change in the method of the documentation system in the nursing unit. Many
problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is
required. The initial step in the process of change for the nurse manager is which of the following?
a. Plan strategies to implement the change
b. Identify the inefficiency that needs improvement or correction
c. Identify potential solutions and strategies for the change process
d. Set goals and priorities regarding the change process

Rationale:
B. When beginning the change process, the nurse should identify and define the problem that needs improvement or correction.
This important first step can prevent many future problems, because if the problem is not correctly identified, a plan of change
may be aimed at the wrong problem. This is followed by goal-setting, prioritizing, and identifying potential solutions and strategies
to implement the change.
(Silvestri, Saunders Q&A Review for NCLEX-RN Examination)

89. A nursing assistant is caring for an older client with cystitis who has an indwelling catheter. The registered nurse provides
directions regarding urinary catheter care and ensures that the nursing assistant:
a. Keeps the drainage bag above the level of the bladder
 b. Lets the drainage tubing rest under the leg
c. Loops the tubing under the client’s leg
d. Uses soap and water to cleanse the perineal area

Rationale:
D. Proper care of an indwelling urinary catheter is especially important to prevent prolonged infection or reinfection on the client
with cystitis. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel
movement.
A, B and C. To prevent urine from being trapped in the bladder, the drainage bag is kept below the level of the bladder; and the
drainage tubing is not placed or looped under the client’s leg. (Silvestri, Saunders Q&A Review for NCLEX-RN Examination)

90. A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the facility.
The nurse is told that the nursing model is a primary nursing approach. The nurse understands that which of the following is a
characteristic of this type of nursing model of practice?
a. The nurse manger assigns tasks to the staff members
b. Nursing staff are led by a nurse leader in providing client care to a group of clients
c. Critical paths are used in providing client care
d. A single nurse is responsible for planning and providing individualized client care

Rationale:
D. Primary nursing is concerned with keeping the nurse the bedside actively involved in direct care while planning goal-directed,
individualized client care.
A. This identifies functional nursing.
B. This identifies team nursing.
C. This identifies a component of case management. (Silvestri, Saunders Q&A Review for NCLEX-RN Examination)

Situation 19. Your director of nursing wants to improve the quality of health care offered in the hospital. As a staff nurse in
that hospital you know that this entails quality assurance programs.
91. The use of the Standards of Nursing Practice is important in the hospital. Which of the following statements best describes what
it is?
a. These are statements that describe the maximum or highest level of acceptable performance in nursing practice
b. The Standards of Care includes the various steps of the nursing process and the standards of professional performance
c. It refers to the scope of nursing practice as defined in Republic Act 9173
d. It is a license issued by the Professional Regulation Commission to protect the public from substandard nursing practice

Answer: B
Rationale: Standards of care are the skills and learning commonly possessed by members of a profession. It includes the
various steps of the nursing process and the standards of professional performance. (Kozier and Erb's Fundamentals in Nursing,
18th Edition)

92. The following mechanisms can be utilized as part of the quality assurance program of your hospital, except:
a. Use of Nursing Interventions Classification
b. Patient satisfaction surveys
c. Review of clinical records of care of client
d. Peer review to assess care provided

Answer: A
Rationale: Quality-assurance (QA) program is an ongoing, systematic process designed to evaluate and promote excellence in
the health care provided to clients. It can be done through patient satisfaction surveys, peer review to assess care provided and
review of clinical records of care of client. Nursing Interventions Classification or NIC (option A) is incorrect because it is taxonomy
of nursing interventions. (Kozier and Erb's Fundamentals in Nursing, 18th Edition)

93. Part of standards of care has to do with the use of restraints. Which of the following statements is not true?
a. Doctor’s order for restraints should be signed within 24 hours
b. Check client’s pulse, blood pressure and circulation every 4 hours
c. Remove and reapply restraints every 2 hours
d. Offer food and toileting every 2 hours

Answer: B
Rationale: Restraints are protective devices used to limit the physical activity of the client or a part of the body. The client's chart
must contain documented evidence of frequent and regular nursing assessments of the restrained client's vital signs; circulation;
skin condition or signs of injury; and psychological status and comfort. 4 hours (option B) is too long. (Kozier and Erb's
Fundamentals in Nursing, 18th Edition)

94. To ensure client safety before starting blood transfusions the following are needed before the procedure can be done, except:
a. Take baseline vital signs
b. Have two nurses verify client identification, blood type, unit number and expiration date of blood
c. Blood should be warmed to room temperature for 30 minutes before blood transfusions is administered
d. Get consent signed for blood transfusion

Answer: C
Rationale: To ensure client safety before starting blood transfusions the following are done: take baseline vital signs; have two
nurses verify client identification, blood type, unit number and expiration date of blood; and get consent signed for blood
transfusion. When a transfusion is ordered, obtain the blood from the blood bank just before starting the transfusion. Do not store
 the blood in the refrigerator on the nursing unit; lack of temperature control mat damaged the blood. Once blood or a blood
product is removed from the refrigerator, there is limited amount of time to administer it (e.g., packed RBC should not be hand
for more than 4 hours after being removed from the refrigerator). (Kozier and Erb's Fundamentals in Nursing, 18th Edition)

95. The nurse is taking care of a critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client.
Which of the following is the appropriate action when getting DNR order over the phone?
a. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign
b. Have the registered nurse, family and doctor sign the order
c. Have 1 nurse take the order and sign it and have the doctor sign it within 24 Hours
d. Have 2 nurse validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours

Answer: D
Rationale: Only in an extreme emergency and when no other resident or intern is available should a nurse receive telephone
orders. The following are the basic standards of clinical nursing practice as regards to taking orders through the phone: have 2
nurses validate the phone order, both nurses sign the order for verification of accuracy; repeat the order aloud to the physician
and ask, “Is that correct?”; document the order on the appropriate forms, including time, date, and what prompted the call; and
secure the physician's signature on the order when the said doctor arrives at the hospital within 24 hours. (De Belen, Nursing
Law, Jurisprudence & Professional Ethics)

Situation 20: A nurse is conducting a study on the “Effect of different interventions to Cigarette Consumption.” One group
of smoker receives intensive counseling (group A). A second group is treated by a nicotine patch (group B). A third control
group receives no special treatment (group C).
96. What is the independent variable of the study?
a. Effect of interventions
b. Different interventions
c. Cigarette consumption
d. Group of smokers

Rationale:
B. The independent variable of the study (variable being manipulated) is the different interventions employed, such as counseling
and the use of nicotine patch, that brings about change in the cigarette consumption (dependent variable) of the respondents
(group of smokers)

97. What is the dependent variable of the study?

a. Effect of interventions
b. Different interventions
c. Cigarette consumption
d. Group of smokers

Rationale:
C. The manipulation of the independent variable (varied interventions) brings about change in the dependent variable, which is
the cigarette consumption of the respondents (group of smokers).

98. Which parametric procedure is most appropriate to use when differences between means of three or more groups are tested?
a. ANOVA c. Paired t-test
b. Chi-square d. Pearson R

Rationale:
A. ANOVA is used for testing the differences between means where there are three or more groups.
B. Chi-square is used to compare the differences or 2 or more variables with data that can be readily transformed into
frequencies.
C. Paired t-test is used when two measures are obtained from the same subjects.

99. The primary consideration when evaluating a research sample is its:

a. Generalizability c. Probability
b. Representativeness d. Randomization

Rationale:
B. Selecting a sample of subjects should be handled with care so that the representativeness of the selected sample as part of
the population can be achieved.

100. Nurse Jen states that there is no significant relationship between the different interventions and cigarette consumption. What
form of hypothesis is this?
a. Statistical hypothesis
b. Alternative hypothesis
c. Directional hypothesis
d. Simple hypothesis
Rationale:
A. A statistical/null hypothesis states that there is no significant relationship between the independent and dependent variables.
B. An alternative hypothesis states that there is a significant relationship between the independent and dependent variables.
D. A simple hypothesis involves only one variable.