75 Items Practice Exam

1.
Among the following signs and symptoms, which would most likely be present in a client with mitral
regurgitation?
A. Altered level of consciousness
B. Exertional Dyspnea
C. Increase creatine phosphokinase concentration
D. Chest pain
Correct Answer: B. Exertional Dyspnea
Mitral regurgitation (MR) is defined as an abnormal reversal of blood flow from the left ventricle (LV) to
the left atrium (LA). Weight gain due to retention of fluids and worsening heart failure causes exertional
dyspnea in clients with mitral regurgitation. The patient will usually complain of significant dyspnea at
rest, exacerbated in the supine position, as well as cough with clear or pink, frothy sputum.
2. Kris with a history of chronic infection of the urinary system complains of urinary frequency and
burning sensation. To figure out whether the current problem is of renal origin, the nurse should assess
whether the client has discomfort or pain in the:
A. Urinary meatus
B. Pain in the labium
C. Suprapubic area
D. Right or left costovertebral angle
Correct Answer: D. Right or left costovertebral angle
Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the
affected side. Flank or costovertebral angle (CVA) tenderness is most commonly unilateral over the
involved kidney, although bilateral discomfort may be present. Discomfort varies from absent to severe.
This finding is usually not subtle and may be elicited with mild or moderately firm palpation.
3. Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and
characteristics, Nurse Perry assesses which signs as the best indicator of renal function.
A. Blood pressure
B. Consciousness
C. Distension of the bladder
D. Pulse rate
Correct Answer: A. Blood pressure
Perfusion can be best estimated by blood pressure, which is an indirect reflection of the adequacy of
cardiac output. Over time, uncontrolled high blood pressure can cause arteries around the kidneys to
narrow, weaken or harden. These damaged arteries are not able to deliver enough blood to the kidney
tissue. Damaged kidney arteries do not filter blood well. Kidneys have small, finger-like nephrons that
filter the blood.
4. John suddenly experiences a seizure, and Nurse Gina notices that John exhibits uncontrollable jerking
movements. Nurse Gina documents that John experienced which type of seizure?
A. Tonic seizure
B. Absence seizure
C. Myoclonic seizure
D. Clonic seizure
Correct Answer: C. Myoclonic seizure
Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple

muscle group. Myoclonus is defined as rapid, brief, jerky, or shock-like movements involving muscle or
group of muscles. Among all hyperkinetic movement disorders, Myoclonus is considered to be the most
rapid and brief. When caused by sudden muscle contraction, it is known as “positive myoclonus,” while a
brief loss of muscular tone results in “negative myoclonus” as in asterixis.
5. Smoking cessation is a critical strategy for the client with Buerger’s disease, Nurse Jasmin anticipates
that the male client will go home with a prescription for which medication?
A. Paracetamol
B. Ibuprofen
C. Nitroglycerin
D. Nicotine (Nicotrol)
Correct Answer: D. Nicotine (Nicotrol)
Nicotine (Nicotrol) is given in controlled and decreasing doses for the management of nicotine
withdrawal syndrome. Nicotine replacement therapy (NRT) is for those who want to quit smoking, as
abruptly quitting can cause withdrawals and cravings. Nicotine withdrawal occurs after smoking
cigarettes discontinued suddenly. Using NRT helps one to reduce the motivation of smoking cigarettes
because the body still gets nicotine from another safer method.
6. Nurse Lilly has been assigned to a client with Raynaud’s disease. Nurse Lilly realizes that the etiology
of the disease is unknown but it is characterized by:
A. Episodic vasospastic disorder of capillaries
B. Episodic vasospastic disorder of small veins
C. Episodic vasospastic disorder of the aorta
D. Episodic vasospastic disorder of the small arteries
Correct Answer: D. Episodic vasospastic disorder of the small arteries
Raynaud’s disease is characterized by vasospasms of the small cutaneous arteries that involve fingers
and toes. In Raynaud phenomenon, blood-flow restriction occurs during cold temperatures and
emotional stress. Specifically, in Raynaud phenomenon, there is vasoconstriction of the digital arteries
and cutaneous arterioles.
7. Nurse Jamie should explain to a male client with diabetes that self-monitoring of blood glucose is
preferred to urine glucose testing because:
A. More accurate
B. Can be done by the client
C. It is easy to perform
D. It is not influenced by drugs
Correct Answer: A. More accurate
Urine testing provides an indirect measure that may be influenced by kidney function while blood
glucose testing is a more direct and accurate measure. Accurate measurement of blood glucose is
superior to the capillary blood glucose test. However, this is dependent on the laboratory meeting
established industry standards.
8. Jessie weighed 210 pounds on admission to the hospital. After 2 days of diuretic therapy, Jessie weighs
205.5 pounds. The nurse could estimate the amount of fluid Jessie has lost:
A. 0.3 L
B. 1.5 L
C. 2.0 L
D. 3.5 L
Correct Answer: C. 2.0 L
One liter of fluid approximately weighs 2.2 pounds. A 4.5-pound weight loss equals to approximately 2L.
Diuresis is necessary for a variety of non-edematous and edematous conditions, which require clearing
out excess water when the body abnormally sequesters fluid in third space in the form of edema.
9. Question
Category: Physiological Adaptation

Nurse Donna is aware that the shift of body fluids associated with Intravenous administration of albumin
occurs in the process of:
A. Osmosis
B. Diffusion
C. Active transport
D. Filtration
Correct Answer: A. Osmosis
Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute
concentration. In physiology, osmosis (Greek for push) is the net movement of water across a
semipermeable membrane. Across this membrane, water will tend to move from an area of high
concentration to an area of low concentration. It is important to emphasize that ideal osmosis requires
only the movement of pure water across the membrane without any movement of solute particles
across the semipermeable membrane
10. Question
Category: Reduction of Risk Potential
Myrna, a 52-year-old client with a fractured left tibia, has a long leg cast and she is using crutches to
ambulate. Nurse Joy assesses for which sign and symptom that indicates complication associated with
crutch walking?
A. Left leg discomfort
B. Weak biceps brachii
C. Triceps muscle spasm
D. Forearm weakness
Correct Answer: D. Forearm weakness
Forearm muscle weakness is a probable sign of radial nerve injury caused by crutch pressure on the
axillae. Crutch palsy is observable in axilla crutch users who rest their weight on the shoulder rest. The
pressure on the brachial plexus can result in palsy to the radial and ulnar nerves. Extra padding on the
shoulder rest can aid in preventing crutch palsy.
11. Question
Category: Health Promotion and Maintenance
Which of the following statements should the nurse teach the neutropenic client and his family to avoid?
A. Performing oral hygiene after every meal
B. Using suppositories or enemas
C. Performing perineal hygiene after each bowel movement
D. Using a filter mask
Correct Answer: B. Using suppositories or enemas
Neutropenic clients are at risk for infection especially bacterial infection of the gastrointestinal and
respiratory tract. An incorrectly administered enema can damage tissue in your rectum/colon, cause
bowel perforation and, if the device is not sterile, infections.
12. Question
A female client is experiencing a painful and rigid abdomen and is diagnosed with a perforated peptic
ulcer. A surgery has been scheduled and a nasogastric tube is inserted. The nurse should place the client
before surgery in
A. Sims position
B. Supine position
C. Semi-fowlers position
D. Dorsal recumbent position
Correct Answer: C. Semi-fowlers position

Semi-fowlers position will localize the spilled stomach contents in the lower part of the abdominal cavity.
Initiation of fluid resuscitation should start as soon as the diagnosis is made. Insertion of a nasogastric
tube to decompress the stomach and a Foley catheter to monitor urine output are essential steps.
13. Question
Which nursing intervention ensures adequate ventilating exchange after surgery?
A. Remove the airway only when the client is fully conscious
B. Assess for hypoventilation by auscultating the lungs
C. Position client laterally with the neck extended
D. Maintain humidified oxygen via nasal cannula
Correct Answer: C. Position client laterally with the neck extended
Positioning the client laterally with the neck extended does not obstruct the airway so that drainage of
secretions and oxygen and carbon dioxide exchange can occur. This position promotes oxygenation via
maximum chest expansion and is implemented during events of respiratory distress. Do not let the client
slide down; this causes the abdomen to compress the diaphragm, which could cause respiratory change.
14. Question
George, who has undergone thoracic surgery has a chest tube connected to a water-seal drainage
system attached to suction. Presence of excessive bubbling is identified in the water-seal chamber, the
nurse should:
A. “Strip” the chest tube catheter
B. Check the system for air leaks
C. Recognize the system is functioning correctly
D. Decrease the amount of suction pressure

Correct Answer: B. Check the system for air leaks
Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion. Know the
location of air leak (patient- or system-centered) by clamping thoracic catheter just distal to exit from the
chest. If bubbling stops when the catheter is clamped at the insertion site, leak is patient-centered (at
insertion site or within the patient).
15. Question
A client who has been diagnosed with hypertension is being taught to restrict intake of sodium. The
nurse would know that the teachings are effective if the client states that:
A. I can eat celery sticks and carrots
B. I can eat broiled scallops
C. I can eat shredded wheat cereal
D. I can eat spaghetti on rye bread
Correct Answer: C. I can eat shredded wheat cereal
Wheat cereal has a low sodium content. Sodium controls fluid balance in the body and maintains blood
volume and blood pressure. Eating too much sodium may raise blood pressure and cause fluid retention,
which could lead to swelling of the legs and feet or other health issues.
16. Question
A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulting from
ascites. The nurse should be aware that the ascites is most likely the result of increased:
A. Pressure in the portal vein
B. Production of serum albumin

C. Secretion of bile salts
D. Interstitial osmotic pressure
Correct Answer: A. Pressure in the portal vein
Enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting in
ascites. Portal pressure increases above a critical threshold and circulating nitric oxide levels increase,
leading to vasodilation. As the state of vasodilatation becomes worse, the plasma levels of
vasoconstrictor sodium-retentive hormones elevate, renal function declines, and ascitic fluid forms,
resulting in hepatic decompensation.
17. Question
Category: Management of Care
A newly admitted client diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node
biopsy under local anesthesia. What does the nurse assess first after the procedure?
A. Vital signs
B. Incision site
C. Airway
D. Level of consciousness
Correct Answer: C. Airway
Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have
affected the swallowing reflex or the inflammation may have closed in on the airway leading to
ineffective air exchange. When the numbness wears off, the throat may feel scratchy for several days.
After the test, the cough reflex will return in 1 to 2 hours. Then the client may eat and drink normally.
18. Question
A client has 15% blood loss. Which of the following nursing assessment findings indicates hypovolemic
shock?
A. Systolic blood pressure less than 90mm Hg
B. Pupils unequally dilated
C. Respiratory rate of 4 breath/min
D. Pulse rate less than 60 bpm
Correct Answer: A. Systolic blood pressure less than 90mm Hg
Typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg.
The first changes in vital signs seen in hypovolemic shock include an increase in diastolic blood pressure
with narrowed pulse pressure. As volume status continues to decrease, systolic blood pressure drops. As
a result, oxygen delivery to vital organs is unable to meet oxygen demand.
19. Question
Nurse Lucy is planning to give preoperative teaching to a client who will be undergoing rhinoplasty.
Which of the following should be included?
A. Results of the surgery will be immediately noticeable postoperatively
B. Normal saline nose drops will need to be administered preoperatively
C. After surgery, nasal packing will be in place 8 to 10 days
D. Aspirin-containing medications should not be taken 14 days before surgery
Correct Answer: D. Aspirin-containing medications should not be taken 14 days before surgery
Aspirin-containing medications should not be taken 14 days before surgery to decrease the risk of
bleeding. Impaired coagulation may cause postoperative complications. Patients should be asked about a
history of excessive bruising or bleeding, consumption of drugs, supplements, or vitamins that alter
coagulation cascade or history of thrombotic events in the past. Any drug, vitamins, or supplement that
impairs coagulation might have to be suspended preoperatively.
20. Question
Paul is admitted to the hospital due to metabolic acidosis caused by Diabetic ketoacidosis (DKA). The
nurse prepares which of the following medications as an initial treatment for this problem?
A. Regular insulin
B. Potassium
C. Sodium bicarbonate
D. Calcium gluconate
Correct Answer: A. Regular insulin
Metabolic acidosis is anaerobic metabolism caused by lack of ability of the body to use circulating
glucose. Administration of insulin corrects this problem. The discovery of insulin, along with the
antibiotics, has led to a drastic decrease in mortality with DKA, down to 1%. Intravenous insulin by
continuous infusion is the standard of care. Previous treatment protocols have recommended the
administration of an initial bolus of 0.1 U/kg, followed by the infusion of 0.1 U/kg/h.
21. Question
Dr. Marquez tells a client that an increased intake of foods that are rich in Vitamin E and beta-carotene
are important for healthier skin. The nurse teaches the client that excellent food sources of both of these
substances are:
A. Fish and fruit jam
B. Oranges and grapefruit
C. Carrots and potatoes
D. Spinach and mangoes
Correct Answer: D. Spinach and mangoes
Beta-carotene and Vitamin E are antioxidants which help to inhibit oxidation. Vitamin E is found in the
following foods: wheat germ, corn, nuts, seeds, olives, spinach, asparagus and other green leafy
vegetables. Food sources of beta-carotene include dark green vegetables, carrots, mangoes and
tomatoes.
22. Question
A client has Gastroesophageal Reflux Disease (GERD). The nurse should teach the client that after every
meal, the client should:
A. Rest in a sitting position
B. Take a short walk
C. Drink plenty of water
D. Lie down at least 30 minutes
Correct Answer: A. Rest in a sitting position
Gravity speeds up digestion and prevents reflux of stomach contents into the esophagus. Instruct to
remain in an upright position at least 2 hours after meals; avoiding eating 3 hours before bedtime. Helps
control reflux and causes less irritation from reflux action into the esophagus.
23. Question
After gastroscopy, an adaptation that indicates major complication would be:
A. Nausea and vomiting
B. Abdominal distention
C. Increased GI motility
D. Difficulty in swallowing
Correct Answer: B. Abdominal distention

Abdominal distension may be associated with pain, may indicate perforation, a complication that could
lead to peritonitis. Bowel perforation occurs in less than 0.3 % of cases, and infection is rarely reported.
Complications typically are identified in the first 24 hours after the procedure. Perforation is identified
due to fever, tachycardia, abdominal pain or discomfort.
24. Question
A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions
that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood
when the client tells a family member that:
A. “Most people need to eat a high protein diet for 12 months after surgery”
B. “I should not eat those foods that upset me before the surgery”
C. “I should avoid fatty foods as long as I live”
D. “Most people can tolerate regular diet after this type of surgery”
Correct Answer: D. “Most people can tolerate regular diet after this type of surgery”
It may take 4 to 6 months to eat anything, but most people can eat anything they want. Start with clear
liquids after the surgery to prevent nausea, vomiting, and constipation, (soup, Jell-O, juices, popsicles,
and carbonated beverages.) then advance to a regular low-fat diet. Eat smaller meals more often instead
of fewer larger meals.
24. Question
A client who has undergone a cholecystectomy asks the nurse whether there are any dietary restrictions
that must be followed. Nurse Hilary would recognize that the dietary teaching was well understood
when the client tells a family member that:
A. “Most people need to eat a high protein diet for 12 months after surgery”
B. “I should not eat those foods that upset me before the surgery”
C. “I should avoid fatty foods as long as I live”

D. “Most people can tolerate regular diet after this type of surgery”
Correct Answer: D. “Most people can tolerate regular diet after this type of surgery”
It may take 4 to 6 months to eat anything, but most people can eat anything they want. Start with clear
liquids after the surgery to prevent nausea, vomiting, and constipation, (soup, Jell-O, juices, popsicles,
and carbonated beverages.) then advance to a regular low-fat diet. Eat smaller meals more often instead
of fewer larger meals.
25. Question
Nurse Rachel teaches a client who has been recently diagnosed with hepatitis A about untoward signs
and symptoms related to Hepatitis that may develop. The one that should be reported immediately to
the physician is:
A. Restlessness
B. Yellow urine
C. Nausea
D. Clay-colored stools
Correct Answer: D. Clay-colored stools
Clay-colored stools are indicative of hepatic obstruction. Acute HAV infection is typically a self-limited
illness characterized by nausea, vomiting, right upper quadrant abdominal discomfort, malaise, anorexia,
myalgia, fatigue, and fever. Patients may develop dark urine and pale stools within a week, followed by
jaundice, icteric (yellow-tinted) sclera, and pruritus.
26. Question
Category: Pharmacological and Parenteral Therapies
Which of the following antituberculosis drugs can damage the 8th cranial nerve?
A. Isoniazid (INH)
B. Para Aminosalicylic acid (PAS)
C. Ethambutol hydrochloride (Myambutol)
D. Streptomycin
Correct Answer: D. Streptomycin
Streptomycin is an aminoglycoside and damage to the 8th cranial nerve (ototoxicity) is a common side
effect of aminoglycosides. Ototoxicity and vestibular impairment are often thought to be the hallmark of
streptomycin toxicity. In extreme cases, deafness may occur due to ototoxicity, thus caution must be
exercised when combining streptomycin with other potentially ototoxic drugs. Vestibular impairment
usually manifests during the course of treatment and is typically permanent.
28. Question
Ryan has undergone a subtotal gastrectomy. The nurse should expect that nasogastric tube drainage will
be what color for about 12 to 24 hours after surgery?
A. Bile green
B. Bright red
C. Cloudy white
D. Dark brown
Correct Answer: D. Dark brown
12 to 24 hours after subtotal gastrectomy gastric drainage is normally brown, which indicates digested
food. Assess color, amount, and odor of gastric drainage, noting any changes in these parameters or the
presence of clots or bright bleeding. Initial drainage is bright red. It becomes dark, then clear or
greenish-yellow over the first 2 to 3 days. A change in the color, amount, or odor may indicate a
complication such as hemorrhage, intestinal obstruction, or infection.
29. Question

Nurse Joan is assigned to come for a client who has just undergone eye surgery. Nurse Joan plans to
teach the client activities that are permitted during the postoperative period. Which of the following is
best recommended for the client?
A. Watching circus
B. Bending over
C. Watching TV
D. Lifting objects
Correct Answer: C. Watching TV
Watching TV is permissible because the eye does not need to move rapidly with this activity, and it does
not increase intraocular pressure. Once the patient gets home, it is recommended that they rest their
eyes and nap. Several hours post-surgery, most people are able to watch some television or look at a
computer screen for a short period of time. Because cataract surgery is only performed on one eye at a
time, the patient may notice an imbalance in the vision until the second eye is operated on (usually 1–4
weeks later).
30. Question
A client suffered from a lower leg injury and seeks treatment in the emergency room. There is a
prominent deformity to the lower aspect of the leg, and the injured leg appears shorter than the other
leg. The affected leg is painful, swollen and beginning to become ecchymotic. The nurse interprets that
the client is experiencing:
A. Fracture
B. Strain
C. Sprain
D. Contusion
Correct Answer: A. Fracture

Common signs and symptoms of fracture include pain, deformity, shortening of the extremity, crepitus
and swelling. These injuries are associated with symptoms of pain, deformity, swelling, and a wound that
may be bleeding. It should be noted that the wound may not lie directly over the fracture site. The
movement and neurovascular status of all involved limbs should be assessed to ascertain whether or not
there is a possible nerve or vascular injury associated with the fracture.
31. Question
Nurse Jenny is instilling an otic solution into an adult male client’s left ear. Nurse Jenny avoids doing
which of the following as part of the procedure
A. Pulling the auricle backward and upward.
B. Warming the solution to room temperature.
C. Pacing the tip of the dropper on the edge of the ear canal.
D. Placing the client in a side lying position.
Correct Answer: C. Placing the tip of the dropper on the edge of the ear canal.
The dropper should not touch any object or any part of the client’s ear. Don’t allow the dropper tip to
touch the ear, fingers, or any other surface. It could pick up bacteria or other germs that can lead to an
ear infection.
32. Question
Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following
symptoms?
A. Absence of drainage from the ileostomy for 6 or more hours
B. Passage of liquid stool in the stoma
C. Occasional presence of undigested food
D. A temperature of 37.6 °C
Correct Answer: A. Absence of drainage from the ileostomy for 6 or more hours
Sudden decrease in drainage or onset of severe abdominal pain should be reported immediately to the
physician because it could mean that obstruction has been developed. Sometimes the ileostomy does
not function for short periods of time after surgery. This is not usually a problem, but if the stoma is not
active for more than 6 hours and the patient experiences cramps or nausea, he may have an obstruction.
33. Question
Jerry has been diagnosed with appendicitis. He develops a fever, hypotension, and tachycardia. The
nurse suspects which of the following complications?
A. Intestinal obstruction
B. Peritonitis
C. Bowel ischemia
D. Deficient fluid volume
Correct Answer: B. Peritonitis
Complications of acute appendicitis are peritonitis, perforation and abscess development. Diffuse
peritonitis and sepsis can also develop, which may progress to significant morbidity and possible death.
Postoperative abscesses, hematomas, and wound complications are all complications that can be seen
after appendectomies. If the wound does get infected, one may grow Bacteroides. “Recurrent”
appendicitis can occur if too much of the appendiceal stump is left after an appendectomy.
34. Question
Which of the following complications should the nurse carefully monitor a client with acute pancreatitis?
A. Myocardial Infarction
B. Cirrhosis
C. Peptic ulcer
D. Pneumonia
Correct Answer: D. Pneumonia
A client with acute pancreatitis is prone to complications associated with the respiratory system. The
relationship between Mycoplasma pneumoniae infection and acute pancreatitis has been debated in the
literature. In 1973, Mardh et al. reported four adult cases of acute pancreatitis following pneumonia due
to MP; in three of the patients, the pancreatitis occurred in the 3rd week after the onset of cough, by
which time the respiratory tract symptoms had almost disappeared.
35. Question
Which of the following symptoms during the icteric phase of viral hepatitis should the nurse expect the
client to inhibit?
A. Watery stool
B. Yellow sclera
C. Tarry stool
D. Shortness of breath
Correct Answer: B. Yellow sclera
Liver inflammation and obstruction block the normal flow of bile. Excess bilirubin turns the skin and
sclera yellow and the urine dark and frothy. After 3 to 10 days, the urine darkens, followed by jaundice.
Systemic symptoms often regress, and patients feel better despite worsening jaundice. The liver is
usually enlarged and tender, but the edge of the liver remains soft and smooth. Mild splenomegaly
occurs in 15 to 20% of patients. Jaundice usually peaks within 1 to 2 weeks.
36. Question
Marco, who was diagnosed with a brain tumor, was scheduled for craniotomy. In preventing the
development of cerebral edema after surgery, the nurse should expect the use of:
A. Diuretics
B. Antihypertensive
C. Steroids
D. Anticonvulsants
Correct Answer: C. Steroids
Glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development
of edema. Corticosteroids produce their effect through multiple pathways. In general, they produce anti-
inflammatory and immunosuppressive effects, protein and carbohydrate metabolic effects, water and
electrolyte effects, central nervous system effects, and blood cell effects.
37. Question
Halfway through the administration of blood, the female client complains of lumbar pain. After stopping
the infusion Nurse Hazel should:
A. Increase the flow of normal saline
B. Assess the pain further
C. Notify the blood bank
D. Obtain vital signs.
Correct Answer: A. Increase the flow of normal saline
The blood must be stopped at once, and then normal saline should be infused to keep the line patent
and maintain blood volume. Treatment is to stop the transfusion, leave the IV in place, intravenous fluids
with normal saline, keeping urine output greater than 100 mL/hour, diuretics may also be needed and
cardiorespiratory support as appropriate. A hemolytic workup should also be performed which includes
sending the donor blood and tubing as well as post-transfusion labs (see below for list) from the
recipient to the blood bank.
38. Question
Nurse Maureen knows that the positive diagnosis of HIV infection is made based on which of the
following:
A. A history of high-risk sexual behaviors.
B. Positive ELISA and western blot tests
C. Identification of an associated opportunistic infection
D. Evidence of extreme weight loss and high fever
Correct Answer: B. Positive ELISA and western blot tests
These tests confirm the presence of HIV antibodies that occur in response to the presence of the human
immunodeficiency virus (HIV). When there is a possibility of acute or early HIV infection, the most
sensitive screening immunoassay available (ideally, a combination antigen/antibody immunoassay) in
addition to an HIV virologic (viral load) test is performed. RT-PCR based viral load test is favored. A
positive HIV virologic test generally indicates HIV infection.
39. Question
Nurse Maureen is aware that a client who has been diagnosed with chronic renal failure recognizes an
adequate amount of high-biological-value protein when the food the client selected from the menu was:
A. Raw carrots
B. Apple juice
C. Whole wheat bread
D. Cottage cheese
Correct Answer: D. Cottage cheese

One cup of cottage cheese contains approximately 225 calories, 27 g of protein, 9 g of fat, 30 mg
cholesterol, and 6 g of carbohydrate. Proteins of high biological value (HBV) contain optimal levels of
amino acids essential for life. In general, proteins from animal sources have a higher biological value than
proteins from plant sources. Animal sources of protein are meat, poultry, fish, eggs, milk, cheese and
yogurt, and they provide high biological value proteins.
40. Question
Kenneth, who was diagnosed with uremic syndrome has the potential to develop complications. Which
among the following complications should the nurse anticipates:
A. Flapping hand tremors
B. An elevated hematocrit level
C. Hypotension
D. Hypokalemia
Correct Answer: A. Flapping hand tremors
Elevation of uremic waste products causes irritation of the nerves, resulting in flapping hand tremors.
The classic description has been in hepatic diseases but other causes can commonly cause asterixis
including azotemia and respiratory disease. Asterixis is a disorder of motor control characterized by an
inability to actively maintain a position and consequent irregular myoclonic lapses of posture affecting
various parts of the body independently.
41. Question
A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant
assessment would be:
A. Flank pain radiating in the groin
B. Distention of the lower abdomen
C. Perineal edema
D. Urethral discharge
Correct Answer: B. Distention of the lower abdomen
This indicates that the bladder is distended with urine, therefore palpable. In the elective setting, the
examination should include abdominal examination (looking for a palpable bladder/loin pain) and
examination of external genitalia (meatal stenosis or phimosis). Benign prostatic hyperplasia (BPH) refers
to the nonmalignant growth or hyperplasia of prostate tissue and is a common cause of lower urinary
tract symptoms in men.
42. Question
A client has undergone a penile implant. After 24 hrs of surgery, the client’s scrotum was edematous and
painful. The nurse should:
A. Assist the client with sitz bath
B. Apply warm soaks in the scrotum
C. Elevate the scrotum using a soft support
D. Prepare for a possible incision and drainage
Correct Answer: C. Elevate the scrotum using a soft support
Elevation increases lymphatic drainage, reducing edema and pain. The penis should then be placed
upward on the lower abdomen, to limit any downward curvature of this penis postoperatively. Scrotal
support or tight mesh underwear may be used after the sterile dressing is removed.
43. Question
Nurse Hazel receives emergency laboratory results for a client with chest pain and immediately informs
the physician. An increased myoglobin level suggests which of the following?
A. Liver disease
B. Myocardial damage
C. Hypertension
D. Cancer
Correct Answer: B. Myocardial damage
Detection of myoglobin is a diagnostic tool to determine whether myocardial damage has occurred.
Myoglobin, an oxygen-carrying protein found in cardiac muscle and striated skeletal muscle, presents an
attractive alternative to CPK and LDH in the emergency department setting for identification of acute
myocardial infarction. Myoglobin levels may be elevated in the serum within one hour after myocardial
cell death with peak levels reached within four to six hours.
Nurse Maureen would expect a client with mitral stenosis would demonstrate symptoms associated with
congestion in the:
A. Right atrium
B. Superior vena cava
C. Aorta
D. Pulmonary
Correct Answer: D. Pulmonary
When mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle
because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation
is under pressure. Mitral valve areas less than 2 square centimeters causes an impediment to the blood
flow from the left atrium into the left ventricle. This creates a pressure gradient across the mitral valve.
As the gradient across the mitral valve increases, the left ventricle requires the atrial kick to fill with
blood.
45. Question

A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
A. Ineffective health maintenance
B. Impaired skin integrity
C. Deficient fluid volume
D. Pain
Correct Answer: A. Ineffective health maintenance
Managing hypertension is the priority for the client with hypertension. Clients with hypertension
frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic
nature of hypertension that makes it so difficult to treat. Monitor and record BP. Measure both arms and
thighs three times, 3–5 min apart while the patient is at rest, then sitting, then standing for initial
evaluation. Use correct cuff size and accurate technique.
46. Question
Nurse Hazel teaches the client with angina about common expected side effects of nitroglycerin
including:
A. High blood pressure
B. Stomach cramps
C. Headache
D. Shortness of breath
Correct Answer: C. Headache
Because of its widespread vasodilating effects, nitroglycerin often produces side effects such as
headache, hypotension, and dizziness. Headaches can be severe, throbbing, and persistent and may
occur immediately after use. Vasodilation and venous pooling can increase the amount of blood in the
cranial space, resulting in increased intracranial pressures; this can cause persistent, throbbing
headaches, along with confusion, fever, vertigo, nausea, vomiting, and visual disturbances.
47. Question
The following are lipid abnormalities. Which of the following is a risk factor for the development of
atherosclerosis and PVD?
A. High levels of low-density lipid (LDL) cholesterol
B. High levels of high-density lipid (HDL) cholesterol
C. Low concentration triglycerides
D. Low levels of LDL cholesterol.
Correct Answer: A. High levels of low-density lipid (LDL) cholesterol
An increase in LDL cholesterol concentration has been documented as a risk factor for the development
of atherosclerosis. LDL cholesterol is not broken down into the liver but is deposited into the wall of the
blood vessels. As the LDL particles leave the blood and enter the arterial intima, they accumulate by
being trapped by proteoglycans and are modified. While the modifications of LDL are not elucidated,
oxidative modification generating oxidized LDL appears to be an attractive candidate.
48. Question
Which of the following represents a significant risk immediately after surgery for repair of aortic
aneurysm?
A. Potential wound infection
B. Potential ineffective coping
C. Potential electrolyte imbalance
D. Potential alteration in renal perfusion
Correct Answer: D. Potential alteration in renal perfusion

There is a potential alteration in renal perfusion manifested by decreased urine output. The altered renal
perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic cross-
clamping during the surgery. Intervention or surgical treatment risks versus benefits of repair in patients
at increased risk for open surgery should be considered, and no intervention may be appropriate in some
cases. Patients should be well informed regarding their options, risks of repair, and potential
postoperative complications.
49. Question
Category: Basic Care and Comfort
Nurse Josie should instruct the client to eat which of the following foods to obtain the best supply of
Vitamin B12?
A. Dairy products
B. Vegetables
C. Grains
D. Broccoli
Correct Answer: A. Dairy products
Good sources of vitamin B12 are dairy products and meats. Among animal products, those from
ruminants are particularly rich in vitamin B12, which is naturally synthesized by the ruminal microflora
and transferred to milk. Dairy products retain, in general, a major part of the vitamin B12 naturally
present in milk, some processing conditions may even add to the basal level by production of vitamin
B12 from propionic bacteria in Swiss-type cheeses.
50. Question
Karen has been diagnosed with aplastic anemia. The nurse monitors for changes in which of the
following physiologic functions?
A. Bowel function
B. Peripheral sensation
C. Bleeding tendencies
D. Intake and output
Correct Answer: C. Bleeding tendencies
Aplastic anemia decreases the bone marrow production of RBCs, white blood cells, and platelets. The
client is at risk for bruising and bleeding tendencies. Aplastic anemia refers to the syndrome of chronic
primary hematopoietic failure from injury leading to diminished or absent hematopoietic precursors in
the bone marrow and attendant pancytopenia.
51. Question
Lydia is scheduled for elective splenectomy. Before the client goes to surgery, the nurse in charge final
assessment would be:
A. Signed consent
B. Vital signs
C. Name band
D. Empty bladder
Correct Answer: B. Vital signs
An elective procedure is scheduled in advance so that all preparations can be completed ahead of time.
The vital signs are the final check that must be completed before the client leaves the room so that
continuity of care and assessment is provided for.
52. Question
What is the peak age range for acquiring acute lymphocytic leukemia (ALL)?
A. 4 to 12 years.
B. 20 to 30 years
C. 40 to 50 years
D. 60 to 70 years
Correct Answer: A. 4 to 12 years.
The peak incidence of Acute Lymphocytic Leukemia (ALL) is 4 years of age. It is uncommon after 15 years
of age. It is diagnosed in about 4000 people in the United States each year with the majority being under
the age of 18. It is the most common malignancy of childhood. The peak age of diagnosis is between two
and ten years of age.
53. Question
Marie with acute lymphocytic leukemia suffers from nausea and headache. These clinical manifestations
may indicate all of the following except:
A. Effects of radiation
B. Chemotherapy side effects
C. Meningeal irritation
D. Gastric distension
Correct Answer: D. Gastric distension
Acute Lymphocytic Leukemia (ALL) does not cause gastric distention. It does invade the central nervous
system, and clients experience headaches and vomiting from meningeal irritation. The primary care
provider and nurse practitioner may be responsible for follow up after treatment and report back to the
interprofessional team. These patients need close monitoring as they are prone to infections,
coagulation dyscrasias, and relapse.
54. Question
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC). Which of the following is
contraindicated with the client?
A. Administering Heparin
B. Administering Coumadin
C. Treating the underlying cause
D. Replacing depleted blood products
Correct Answer: B. Administering Coumadin
Disseminated Intravascular Coagulation (DIC) has not been found to respond to oral anticoagulants such
as Coumadin. Warfarin is contraindicated in patients with hemorrhagic tendencies (e.g., active GI
ulceration, patients bleeding from the GI, respiratory, or GU tract; a cerebral aneurysm; central nervous
system (CNS) hemorrhage; dissecting aortic aneurysm; spinal puncture and other diagnostic or
therapeutic procedures with the potential for significant bleeding).
55. Question
Which of the following findings is the best indication that fluid replacement for the client with
hypovolemic shock is adequate?
A. Urine output greater than 30ml/hr
B. Respiratory rate of 21 breaths/minute
C. Diastolic blood pressure greater than 90 mmHg
D. Systolic blood pressure greater than 110 mmHg
Correct Answer: A. Urine output greater than 30ml/hr
Urine output provides the most sensitive indication of the client’s response to therapy for hypovolemic
shock. Urine output should be consistently greater than 30 to 35 mL/hr. Renal losses of salt and fluid can
lead to hypovolemic shock. The kidneys usually excrete sodium and water in a manner that matches
intake. Diuretic therapy and osmotic diuresis from hyperglycemia can lead to excessive renal sodium and
volume loss. In addition, there are several tubular and interstitial diseases beyond the scope of this
article that cause severe salt-wasting nephropathy.
56. Question
Which of the following signs and symptoms would Nurse Maureen include in her teaching plan as an
early manifestation of laryngeal cancer?
A. Stomatitis
B. Airway obstruction
C. Hoarseness
D. Dysphagia
Correct Answer: C. Hoarseness
Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2
weeks should be evaluated because it is one of the most common warning signs. Patients are typically
male with a history of current or past tobacco smoking. Hoarseness is often an early presenting
symptom of glottic cancers due to vocal cord immobility or fixation, with pain with swallowing and
referred ear pain indicating advanced disease.
57. Question
Karina, a client with myasthenia gravis, is to receive immunosuppressive therapy. The nurse understands
that this therapy is effective because it:
A. Promotes the removal of antibodies that impair the transmission of impulses
B. Stimulates the production of acetylcholine at the neuromuscular junction.
C. Decreases the production of autoantibodies that attack the acetylcholine receptors.
D. Inhibits the breakdown of acetylcholine at the neuromuscular junction.
Correct Answer: C. Decreases the production of autoantibodies that attack the acetylcholine receptors.
Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack
the acetylcholine receptors at the neuromuscular junction. Immunotherapy is used to upregulate or
downregulate the immune system to achieve a therapeutic effect in immunological mediated disorders
including immunodeficiencies, hypersensitivity reactions, autoimmune diseases, tissue and organ
transplantations, malignancies, inflammatory disorders, infectious diseases, and any other disease,
where immunotherapy can improve the quality and life expectancy.
58. Question
A female client is receiving IV Mannitol. An assessment specific to safe administration of the said drug is:
A. Vital signs q4h
B. Weighing daily
C. Urine output hourly
D. Level of consciousness q4h
Correct Answer: C. Urine output hourly
The osmotic diuretic mannitol is contraindicated in the presence of inadequate renal function or heart
failure because it increases the intravascular volume that must be filtered and excreted by the kidney.
Urine output also requires monitoring; failure for urine output to increase after administration of
mannitol should prompt cessation of mannitol and evaluation for possible renal or genitourinary issues.
59. Question
Patricia, a 20-year-old college student with diabetes mellitus, requests additional information about the
advantages of using a pen-like insulin delivery device. The nurse explains that the advantages of these
devices over syringes include:
A. Accurate dose delivery
B. Shorter injection time
C. Lower cost with reusable insulin cartridges

D. Use of a smaller gauge needle.
Correct Answer: A. Accurate dose delivery
These devices are more accurate because they are easy to use and have improved adherence to insulin
regimens by young people because the medication can be administered discreetly. Once in use, most
insulin analog vials, cartridges, and prefilled pens must be discarded after 28 days. This means that many
patients who use a 10-ml vial end up either wasting insulin or using insulin beyond its recommended
discard date. This is rarely a problem for patients using either a 3-ml prefilled pen or a reusable pen
containing a 3-ml insulin cartridge.
60. Question
A male client’s left tibia was fractured in an automobile accident, and a cast is applied. To assess for
damage to major blood vessels from the fracture tibia, the nurse in charge should monitor the client for:
A. Swelling of the left thigh
B. Increased skin temperature of the foot
C. Prolonged reperfusion of the toes after blanching
D. Increased blood pressure
Correct Answer: C. Prolonged reperfusion of the toes after blanching
Damage to blood vessels may decrease the circulatory perfusion of the toes, this would indicate the lack
of blood supply to the extremity. If the intracompartmental pressure becomes higher than arterial
pressure, a decrease in arterial inflow will also occur. The reduction of venous outflow and arterial inflow
result in decreased oxygenation of tissues causing ischemia. If the deficit of oxygenation becomes high
enough, irreversible necrosis may occur.
61. Question
Category: Basic Care and Comfort
After a long leg cast is removed, the male client should:

A. Cleanse the leg by scrubbing with a brisk motion
B. Put leg through full range of motion twice daily
C. Report any discomfort or stiffness to the physician
D. Elevate the leg when sitting for long periods of time.
Correct Answer: D. Elevate the leg when sitting for long periods of time.
Elevation will help control the edema that usually occurs.
62. Question
While performing a physical assessment of a male client with gout of the great toe, Nurse Vivian should
assess for additional tophi (urate deposits) on the:
A. Buttocks
B. Ears
C. Face
D. Abdomen
Correct Answer: B. Ears
Uric acid has a low solubility, it tends to precipitate and form deposits at various sites where blood flow
is least active, including cartilaginous tissue such as the ears. Tophi, which are subcutaneous depositions
of urate that form nodules, can also be found in patients with persistent hyperuricemia. Tophi typically
occur in the joints, ears, finger pads, tendons, and bursae.
63. Question
Category: Safety and Infection Control

Nurse Katrina would recognize that the demonstration of crutch walking with tripod gait was understood
when the client places weight on the:
A. Palms of the hands and axillary regions
B. Palms of the hand
C. Axillary regions
D. Feet, which are set apart
Correct Answer: B. Palms of the hand
The palms should bear the client’s weight to avoid damage to the nerves in the axilla. This is the most
used technique. The left and right crutch along with the injured leg are both advanced while the
uninjured leg supports the body weight. Next, the uninjured leg is advanced. Hand grips are part of each
class of crutches. They serve as a significant connection between the crutch and the user. Hand grips
have always been adjustable in the up, down, forward and back positioning depending on the crutch.
64. Question
Mang Jose with rheumatoid arthritis states, “The only time I am without pain is when I lie in bed
perfectly still”. During the convalescent stage, the nurse in charge with Mang Jose should encourage:
A. Active joint flexion and extension
B. Continued immobility until pain subsides
C. Range of motion exercises twice daily
D. Flexion exercises three times daily
Correct Answer: A. Active joint flexion and extension
Active exercises, alternating extension, flexion, abduction, and adduction, mobilize exudates in the joints
relieves stiffness and pain. The role of exercise in promoting the joint health of a person with RA is of
great importance, especially as this is the most pronounced and invariant element of the RA disease
pathology.
65. Question
A male client has undergone spinal surgery, the nurse should:
A. Observe the client’s bowel movement and voiding patterns
B. Log-roll the client to prone position
C. Assess the client’s feet for sensation and circulation
D. Encourage client to drink plenty of fluids
Correct Answer: C. Assess the client’s feet for sensation and circulation
Alteration in sensation and circulation indicates damage to the spinal cord, if these occur, notify the
physician immediately. Assess movement and sensation of lower extremities and feet (lumbar) and
hands or arms (cervical). Although some degree of sensory impairment is usually present, deterioration
and changes may reflect development or resolution of spinal cord edema and inflammation of the
tissues secondary to damage to motor nerve roots from surgical manipulation.
66. Question
Marina with acute renal failure moves into the diuretic phase after one week of therapy. During this
phase the client must be assessed for signs of developing:
A. Hypovolemia
B. Renal failure
C. Metabolic acidosis
D. Hyperkalemia
Correct Answer: A. Hypovolemia

In the diuretic phase fluid retained during the oliguric phase is excreted and may reach 3 to 5 liters daily,
hypovolemia may occur and fluids should be replaced. The diuretic stage usually lasts for 1-2 weeks but
can persist longer. In this stage, an increase in urine output is noted and uremia begins to resolve as the
kidney continues to heal.
67. Question
Nurse Judith obtains a specimen of clear nasal drainage from a client with a head injury. Which of the
following tests differentiates mucus from cerebrospinal fluid (CSF)?
A. Protein
B. Specific gravity
C. Glucose
D. Microorganism
Correct Answer: C. Glucose
The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done
to determine whether a body fluid is a mucus or a CSF. A CSF normally contains glucose. A true normal
range cannot be given for CSF glucose. As a general rule, CSF glucose is about two thirds of the serum
glucose measured during the preceding two to four hours in a normal adult. This ratio decreases with
increasing serum glucose levels. CSF glucose levels generally do not go above 300 mg per dL (16.7 mmol
per L) regardless of serum levels.
68. Question
A 22-year-old client suffered from his first tonic-clonic seizure. Upon awakening, the client asks the nurse,
“What caused me to have a seizure? Which of the following would the nurse include in the primary
cause of tonic-clonic seizures in adults more than 20 years?
A. Electrolyte imbalance
B. Head trauma
C. Epilepsy
D. Congenital defect
Correct Answer: B. Head trauma
Trauma is one of the primary causes of brain damage and seizure activity in adults. Other common
causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular
disease. Common causes of emergency department visits after seizures are alcohol and drugs, head
injury, and epilepsy.
69. Question
What is the priority nursing assessment in the first 24 hours after admission of the client with
thrombotic CVA?
A. Pupil size and pupillary response
B. Cholesterol level
C. Echocardiogram
D. Bowel sounds
Correct Answer: A. Pupil size and papillary response
It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial
nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining
whether the brain stem is intact. Pupil size and equality is determined by balance between
parasympathetic and sympathetic innervation. Response to light reflects the combined function of the
optic (II) and oculomotor (III) cranial nerves.
70. Question
Nurse Linda is preparing a client with multiple sclerosis for discharge from the hospital to home. Which
of the following instructions is most appropriate?
A. “Practice using the mechanical aids that you will need when future disabilities arise”.
B. “Follow good health habits to change the course of the disease”.
C. “Keep active, use stress reduction strategies, and avoid fatigue”.
D. “You will need to accept the necessity for a quiet and inactive lifestyle”.
Correct Answer: C. “Keep active, use stress reduction strategies, and avoid fatigue”.
The nurse’s most positive approach is to encourage the client with multiple sclerosis to stay active, use
stress reduction techniques and avoid fatigue because it is important to support the immune system
while remaining active. Recommend participation in groups involved in fitness or exercise and/or the
Multiple Sclerosis Society. Can help the patient to stay motivated to remain active within the limits of the
disability or condition. Group activities need to be selected carefully to meet the patient’s needs and
prevent discouragement or anxiety.
71. Question
The nurse is aware the early indicator of hypoxia in the unconscious client is:
A. Cyanosis
B. Increased respirations
C. Hypertension
D. Restlessness
Correct Answer: D. Restlessness
Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in an unconscious client
who suddenly becomes restless. When oxygen delivery is severely compromised, organ function will
start to deteriorate. Neurologic manifestations include restlessness, headache, and confusion with
moderate hypoxia. In severe cases, altered mentation and coma can occur, and if not corrected quickly
may lead to death.
72. Question
A client is experiencing spinal shock. Nurse Myrna should expect the function of the bladder to be which
of the following?
A. Normal
B. Atonic
C. Spastic
D. Uncontrolled
Correct Answer: B. Atonic
In spinal shock, the bladder becomes completely atonic and will continue to fill unless the client is
catheterized. The full spinal examination should include motor, sensory reflexes including
bulbocavernosus reflex and anal wink reflex. Motor activity and strength decrease not only in the
skeletal muscles but the motor activity of internal organs like bowel and bladder. This decrease leads to
constipation and urinary retention.
73. Question
Which of the following stages is the carcinogen irreversible?
A. Progression stage
B. Initiation stage
C. Regression stage
D. Promotion stage
Correct Answer: A. Progression stage
Progression stage is the change of tumor from the preneoplastic state or low degree of malignancy to a
fast-growing tumor that cannot be reversed. Tumor progression comprises the expression of the
malignant phenotype and the tendency of malignant cells to acquire more aggressive characteristics
over time. Also, metastasis may involve the ability of tumor cells to secrete proteases that allow invasion
beyond the immediate primary tumor location. A prominent characteristic of the malignant phenotype is
the propensity for genomic instability and uncontrolled growth.
74. Question
Among the following components thorough pain assessment, which is the most significant?
A. Effect
B. Cause
C. Causing factors
D. Intensity
Correct Answer: D. Intensity
Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment.
Severity of pain may include the intensity graded by the patient or the impact pain has on function.
Intensity may be assessed with certain scales that will be reviewed below. The impact on function may
include changes with activities of daily living, activity level, and work-related duties. Pain may have an
impact on sleep, mood, appetite, or social relationships.
75. Question
A 65 year old female is experiencing a flare-up of pruritus. Which of the client’s actions could aggravate
the cause of flare-ups?
A. Sleeping in cool and humidified environment
B. Daily baths with fragrant soap
C. Using clothes made from 100% cotton
D. Increasing fluid intake
Correct Answer: B. Daily baths with fragrant soap

The use of fragrant soap is very drying to the skin hence causing pruritus. Avoid factors that may
contribute to skin dryness such as overheating, hot baths, and soaps, shower and bath products. Use
emollients for dry skin, including for washing, bathing, and showering.

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1.

A. Altered level of consciousness

C. Increase creatine phosphokinase concentration

Correct Answer: B. Exertional Dyspnea

B. Pain in the labium

D. Right or left costovertebral angle

Correct Answer: D. Right or left costovertebral angle

C. Distension of the bladder

Correct Answer: A. Blood pressure

Correct Answer: C. Myoclonic seizure

Myoclonic seizure is characterized by sudden uncontrollable jerking movements of a single or multiple

Correct Answer: D. Nicotine (Nicotrol)

A. Episodic vasospastic disorder of capillaries

B. Episodic vasospastic disorder of small veins

C. Episodic vasospastic disorder of the aorta

D. Episodic vasospastic disorder of the small arteries

Correct Answer: D. Episodic vasospastic disorder of the small arteries

B. Can be done by the client

D. It is not influenced by drugs

Correct Answer: A. More accurate

Correct Answer: C. 2.0 L

Category: Physiological Adaptation

Correct Answer: A. Osmosis

Category: Reduction of Risk Potential

A. Left leg discomfort

B. Weak biceps brachii

C. Triceps muscle spasm

Correct Answer: D. Forearm weakness

Category: Health Promotion and Maintenance

A. Performing oral hygiene after every meal

B. Using suppositories or enemas

C. Performing perineal hygiene after each bowel movement

D. Using a filter mask

Correct Answer: B. Using suppositories or enemas

Category: Physiological Adaptation

D. Dorsal recumbent position

Correct Answer: C. Semi-fowlers position

Category: Physiological Adaptation

Which nursing intervention ensures adequate ventilating exchange after surgery?

A. Remove the airway only when the client is fully conscious

B. Assess for hypoventilation by auscultating the lungs

C. Position client laterally with the neck extended

D. Maintain humidified oxygen via nasal cannula

Correct Answer: C. Position client laterally with the neck extended

Category: Reduction of Risk Potential

A. “Strip” the chest tube catheter

B. Check the system for air leaks

C. Recognize the system is functioning correctly

D. Decrease the amount of suction pressure

Category: Health Promotion and Maintenance

A. I can eat celery sticks and carrots

B. I can eat broiled scallops

C. I can eat shredded wheat cereal

D. I can eat spaghetti on rye bread

Correct Answer: C. I can eat shredded wheat cereal

Category: Physiological Adaptation

A. Pressure in the portal vein

B. Production of serum albumin