1. The physician orders oropharyngeal suctioning as needed for a client in a coma.

The
nurse prepares to suction when assessment reveals:*
0/1

a. Drainage of mucus and saliva from the mouth

b. The presence of gurgling sounds with each breath

c. Development of cyanosis in the nailbed of the fingers
d. The presence of a dry cough at increasingly frequent intervals

2. When assessing a client with varicose veins, the nurse should expect:*
1/1
a. Distorted toenails
b. Complaints of leg fatigue

c. Localized heat in the calves

d. Reddened areas on the legs

3. In response to a question about varicose veins, the nurse relates that they tend to
develop as a result of:*
0/1

a. Repeated venous inflammatory episodes

b. Increased hydrostatic pressure in the veins

c. Valve obstructing the flow of blood to the heart
d. Hereditary weakness in the surrounding leg muscles

4. Preoperative teaching for a client who is to have cataract surgery should include the
importance of:*
1/1

a. Remaining flat for 3 hours

b. Breathing and coughing deeply
c. Eating a soft diet for 2 days
d. Avoiding bending from the waist

5. A client receiving hemodialysis has AV fistula for circulatory access. An important

nursing consideration in caring for this client is:*
1/1

a. Preventing infection
b. Observing aseptic technique
c. Checking weight daily
d. Observing arm precaution

6. When a client develops a hemolytic transfusion reaction because of incompatible

blood, the nurse should assess the client for: *
0/1

a. Dyspnea

b. Backache
c. Cyanosis
d. Bradycardia

7. As a result of transfusion reaction, a client suffers kidney damage. When determining

kidney damage, the most significant clinical response that the nurse should assess is:*
1/1

a. Polyuria
b. Decreased urinary output

c. Hematuria
d. Acute pain over the kidney area

8. A client with acute renal failure complains of nausea, pain in the abdomen, diarrhea,
and muscular weakness. The nurse notes an irregularity in pulse and signs of
pulmonary edema. These are probably manifestations of:*
1/1

a. Calcium excess
b. Sodium deficiency
c. Potassium excess

d. Calcium deficiency

9. When caring for a client who is receiving peritoneal dialysis, the nurse should:*
···/1
a. Position the client from side to side if fluid is not draining properly

b. Notify the physician if there is a deficit of 200 ml in the drainage fluid

c. Maintain the client in a flat, supine position during the entire procedure
d. Remove the cannula at the end of procedure and apply a dry, sterile dressing

10. The physician orders oxygen therapy via nasal cannula (nasal prongs) at two liters
per minute for an elderly client with heart failure. A priority nursing action would be to:*
0/1

a. Always maintain the client on bed rest

b. Investigate if the client has COPD
c. Determine if the client is a mouth breather
d. Obtain the oxygen saturation measurements

11. A client with a history of acute myocardial infarction complains about the lack of salt
in the food. The nurse should explain that the salt must be limited to:*
0/1

a. Prevent any rise in blood pressure from the tissue edema

b. Produce a diuretic effect and reduce the circulating blood volume

c. Reduce the amount of edema present, which interferes with the heart action
d. Prevent the further accumulation of fluid and increasing workload of the heart

12. A client has a diagnosis of acute cholecystitis with biliary colic. In addition to pain in
the right upper quadrant, the nurse should expect the client to have:*
1/1

a. Melena and diarrhea

b. Vomiting of coffee–ground emesis
c. An intolerance to foods high in lipids

d. Gnawing pain when the stomach is empty

13. Following a cholecystectomy, Mrs. Santillan should be assessed for signs of

bleeding or hemorrhage. These observations are made because:*
0/1
a. Prostaglandins are released at the surgical site
b. The inflammatory process interferes with platelet formation
c. Diaphragmatic excursion places pressure on the suture line

d. Blood clotting may be hindered by lack of vitamin K absorption

14. A client has a T-tube in place following a cholecystectomy and a choledochostomy.

Care of the patient post-operatively should primarily focus on:*
1/1

a. Ensuring low-fat diet

b. Promoting lung expansion thru DBE

c. Prevent abscess formation at the surgical site

d. Encourage early ambulation

15. When caring for a client 8 hours following the surgical creation of a colostomy, the
observation that would be considered normal is:*
0/1

a. The presence of hyperactive bowel sounds.

b. The absence of drainage from the colostomy.
c. A dusky-colored edematous appearance

d. Bright bloody drainage from the colostomy

16. A client with adrenal insufficiency complains of weakness and dizziness on arising
from bed in the morning. The nurse realizes that this is most probably caused by:*
0/1

a. A lack of potassium
b. Postural hypertension

c. A hypoglycemic reaction
d. Increased extracellular fluid volume

17. When observing a client for cortisone overdose, the nurse should be particularly
alert for:*
1/1
17. When observing a client for cortisone overdose, the nurse should be particularly alert for:
a. Hypoglycemia
b. Anaphylactic shock
c. Severe anorexia
d. Behavioral changes

18. A client is admitted to the post-anesthesia care unit after an exploratory laparotomy
and toal colectomy. The observation that should be reported to the physician
immediately is:*
1/1

a. An apical pulse of 90
b. A decreased urinary output

c. Increased drainage from the nasogastric tube

d. Serosanguinous drainage on the perineal pad

19. Fluid shifts are a great danger to the client with partial-and full-thickness burns. The
nurse should initially expect to observe:*
0/1

a. A rise in blood volume

b. Decreased capillary permeability

c. A loss of sodium and an increase in blood potassium

d. Increased fluid shift and irreversible shock after 2 hours

20. IV fluid replacement therapy is important for the client with severe burns. An
expected intake and output in the first 24 hours per estimation would be:*
0/1

a. Intake, 8000 ml; output, 480 ml

b. Intake, 3000 ml; output, 2400 ml

c. Intake, 6000 ml; output, 1200 ml

d. Intake, 12000 ml, output, 4500ml

21. Considering the purpose, operation and complications associated with mechanical
ventilators, the nurse should:*
1/1

a. Regulate PEEP according to the rate and depth of the client’s respirations
b. Deflate the cuff on the endotracheal tube for 5 to 10 minutes every 1 to 2 hours
c. Assess the need for suctioning when the high pressure alarm of the ventilator is activated

d. Adjust the temperature of fluid in the humidification chamber depending on the volume of
gas delivered

22. After the chest catheters are attached to a closed drainage system, the nurse
should:*
1/1

a. Check that the fluid in the water seal compartment rises with expiration
b. Ensure the security of the connection from the client to the drainage unit

c. Ensure that there is vigorous bubbling in the suction control compartment

d. Empty the drainage container, measure and record the amount, and send a sample for
analysis every 24 hours

23. An elderly individual is hospitalized for weight loss and dehydration because of
nutritional deficits. The nurse recognizes that among elderly:*
0/1
a. Daily fluid intake must be markedly increased

b. Financial resources are usually unrelated to nutritional status

c. Except for decreased caloric needs, the nutritional needs are unchanged
d. The individual’s diet should be high in carbohydrates and low in protein

24. The nurse explains to a client with arthritis that the prescribed steroid medication
should be taken with food because:*
1/1

a. It will decrease gastric irritation

b. It will serve as a reminder to take the drug

c. The presence of food will enhance absorption
d. The medication is ineffective in an acid medium

25. A client is admitted with a diagnosis of chronic adrenal insufficiency. Because of this
condition, it would be unwise to place this client in a room:*
1/1
a. With an elderly client who has a CVA
b. With middle–aged client who has pneumonia

c. Next to a 17-year-old client with a fractured leg

d. That is private and away from nurse’s station

26. Parenteral preparations of potassium are administered slowly and continuously to

prevent:*
1/1

a. Acidosis
b. Psychotic-like reactions
c. Cardiac arrest

d. Edema of the extremities

27. Management of dumping syndrome post partial gastrectomy is best accomplished

by planning to maintain the client on a:*
0/1

a. Low-residue, bland diet.

b. Fluid intake below 500 ml.

c. Small frequent feedings schedule.
d. Low protein, high carbohydrate diet.

28. Care of a client on the evening of surgery following a craniotomy should include:*
1/1

a. Applying a binder on the neck for support.

b. Monitoring neuro-VS.

c. Ambulating the client in the room.

d. Assisting the client out of bed to a chair.

29. A major objective of nursing care for clients with acute lymphocytic leukemia on
chemotherapeutic protocols is to:*
1/1

a. Check their vital signs every 2 hours.

b. Prevent their engaging in physical activity.
c. Have them avoid contact with infected persons.

d. Reduce unnecessary stimuli in their environment.

30. Understanding the side effect of implanted radiotherapy, the nurse plans to
implement:*
0/1
a. A diet low in fat with regular fluids.
b. Careful skin care to minimize breakdown and skin irritation.

c. Daily exercise and decreased fluid intake.

d. Avoid vigorous activities to prevent dislodgement of the implant.

31. A client is receiving neostigmine bromide (Prostigmin) for control of myasthenia

gravis. In the middle of the night the nurse finds the client weak, unable to move, barely
breathing. Signs that would identify the problems as being related to neostigmine
bromide excess are:*
0/1

a. Distention of the bladder.

b. High-pitched, gurgling bowel sounds.

c. Fine tremors of the fingers and eyelids.
d. Rapid pulse with occasional ectopic beats.

32. During the day, a nurse puts side rails up on the bed of 73-years-old client who has
had surgery for a fractured hip specifically:*
1/1

a. As a safety measure because of the client’s age.

b. Because all client over 65 years of age should use side rails.
c. To be used as handholds and to facilitate the client’s mobility in bed.
d. Because elderly are often disoriented for several days after anesthesia.

33. The nurse should explain to the client that sodium restriction is an effective
therapeutic tool in the treatment of heart failure because its restriction:*
1/1
a. Allows excess tissue fluid to be excreted.

b. Helps to control food intake and thus weight.

c. Aids the weakened heart muscle to contract and improves cardiac output.
d. Helps to prevent the potassium accumulation that occurs when sodium intake is higher.

34. When teaching a patient about proper diet to avoid gout all are included EXCEPT:*
1/1

a. cabbage.
b. carrots.
c. bananas.
d. Organ meats.

35. When caring for a client with spinal cord injury, during the initial post injury period
the initial responsibility of the nurse is to:*
1/1

a. Prevent urinary tract infection.

b. Prevent contractures and atrophy.
c. Avoid flexion or hyperextension of spine.

d. Prepare the client for vocational rehabilitation.

36. After emergency surgery a client requires a blood transfusion. If an allergic reaction
to transfusion occurs, the nurse’s first intervention should be to:*
1/1

a. Call the physician immediately.

b. Stop the blood and infuse saline.

c. Slow the rate of blood transfusion.

d. Relieve the symptoms with an ordered antihistamine

37. When assessing a client with hyperthyroidism the nurse would expect:*
1/1

a. Constipation, dry skin, and weight gain.

b. Lethargy, weight gain, and forgetfulness.
c. Weight loss, exophthalmos, and restlessness.
d. Weight loss, protruding eyeballs, and lethargy.

38. The most important nursing action after a cardiac catheterization like in coronary
angiography for a client with IHD would be to:*
1/1

a. Provide a bed cradle

b. Elevate the head of the bed
c. Check for a pulse deficit
d. Assess the groin for bleeding

39. A client with a heart failure is on a drug regimen of lanoxin (Digoxin) and furosemide
(Lasix). The client dislikes oranges and bananas. Therefore, the nurse should
encourage the intake of:*
0/1
a. Banana
b. Cassava
c. Cantaloupe
d. Cranberries

40. A test that might be performed by a client to help confirm the diagnosis of
myasthenia gravis involves the use of the drug:*
1/1

a. Prednisolone
b. Disodium EDTA
c. Phenytoin (Dilantin)
d. Edrophonium (Tensilon)

41. After an open reduction and internal fixation of a fractured hip, assessment of the
affected leg should include:*
1/1

a. Condition of the pin and site.

b. Mobility of the knee and ankle.
c. Pedal pulse and mobility of toes.
d. Femoral pulse and body temperature.

42. A client with myxedema is scheduled for surgery. When administering narcotics the
nurse should know that:*
0/1

a. Tolerance to the drug develops more readily.

b. Narcotics may interfere with the thyroid hormone.

c. Sedation will have a paradoxical effect causing hyperactivity.

d. One-third to one-half the usual dose of the narcotics should be prescribed.

43. When caring for a client following a left pneumonectomy for cancer, the nurse
should palpate the client’s trachea at least once a day because:*
1/1
a. The position may indicate mediastinal shift.

b. Nodular lesions may demonstrate metastasis.

c. Tracheal edema may lead to an obstructed airway.
d. The cuff of the endotracheal tube may be overinflated.

44. The physician orders cimetidine (Tagamet) for a client with dyspepsia. The nurse
should teach that this drug acts by:*
0/1

a. Lowering the stress level.

b. Neutralizing gastric acidity.
c. Decreasing gastric motor activity.

d. Diminishing gastric secretion in the stomach.

45. A client with severe gastritis vomits a large amount of blood and a lavage is
performed. A room temperature irrigating solution is used to produce:*
1/1

a. Coagulation of blood
b. Constriction of blood vessels

c. Neutralization of acids
d. Stimulation of vagus nerve
46. Buck’s extension is often ordered initially for clients with fracture of the femur
primarily to:*
1/1

a. Prevent soft tissue edema.

b. Reduce the need for cast application.
c. Prevent damage to the surrounding nerves.
d. Reduce the muscle spasms around the fracture site.

47. The client has a total hip arthroplasty. After surgery the nurse should:*
0/1

a. Log roll client when turning.

b. Elevate the affected limb on a pillow.
c. Keep an abduction pillow between the legs at all times.
d. Place a trochanter roll along the entire extremity.

48. Following the surgery for a colostomy, the most effective way of helping a client
accept the colostomy would be to:*
1/1

a. Begin to teach self-care of the colostomy immediately.

b. Provide literature containing factual data about colostomies.
c. Contact a member of a support group to come and speak with the client.

d. Point out the number of important people who have had colostomies.

49. The nurse administers beclomethasone (Vanceril) by inhalation to a client with

asthma. The purpose of this therapy is to:*
1/1

a. Promote rest and relaxation.

b. Diminish respiratory bacteria.
c. Stimulate smooth muscle relaxation.
d. Reduce inflammatory cell responses.
50. A client has a history of myxedema. When performing a physical assessment the
nurse would expect the client’s skin to be:*
1/1

a. Dry and flaky.

b. Warm and moist

c. Flushed and dry.
d. Smooth and silky

51. The purpose of the water in the water seal chamber of a chest tube drainage system
is to:*
1/1
a. Prevent entrance of air into the pleural cavity.

b. Foster removal of chest secretions by capillarity.

c. Decrease the danger of sudden change in pressure in the tube.
d. Facilitate emptying bloody drainage from the chest.

52. When a client sustains a deep partial-thickness burns because of a severe sunburn,
the best first-aid measure to use is:*
1/1

a. Cool, moist towels.

b. Analgesics, sunburn spray

c. Dry, sterile dressings.
d. D. Vitamin A and D ointment

53. A person sustains deep partial-thickness burns but refuses to seek medical
attention. This person should be advised to go to hospital or a physician if:*
0/1

a. Blisters appear
b. A low-grade fever develops

c. Edema and redness occur

d. The urinary output decreases
54. A transurethral resection of the prostate is performed. After surgery, the client’s
nursing care should include:*
1/1

a. Changing the abdominal dressing.

b. Maintaining patency of the cystostomy tube.
c. Observing for hemorrhage and wound infection.
d. Maintaining patency of a three-way Foley catheter.

55. The most important test used to determine if a transplanted kidney is working is:*
0/1
a. Renal scan
b. White blood cell count
c. Serum creatinine
d. Twenty-four hour urine output

56. To assess the neurovascular status of an extremity casted from the ankle to the
thigh, the nurse should:*
1/1

a. Palpate the femoral artery of the affected leg.

b. Assess the affected leg for positive Homan’s sign.
c. Compress and release the toenails of the affected foot.

d. Instruct the client to flex and extend the knee of the affected leg.

57. On the first postoperative day after the left modified radical mastectomy, the nursing
care plan of the client should include which of the following?*
0/1

a. Encouraging the client to wear a breast prosthesis.

b. Keeping the left arm and shoulder immobile.

c. Placing the client in semi-Fowler’s position with left arm and hand elevated.
d. Changing the pressure dressing as necessary.

58. Mr. Tomas, a type I diabetic client is on insulin therapy. To avoid lipodystrophy, the
nurse should teach the client to do which of the following? 1. Exercise
regularly. 2. Massage the injection site. 3. Inject insulin at room
temperature. 4. Rotate injection sites.*
1/1

a. 1,2 only
b. 3,4 only

c. 1,3,4
d. 2,3,4

59. The client with bronchial asthma is experiencing difficulty of breathing. This is due
to:*
1/1
a. Hyperventilation caused by anxiety.
b. Bronchospasm, which causes carbon dioxide retention.

c. A decrease in residual volume.

d. Loss of elasticity of alveolar walls.

60. A client with bronchial asthma is allergic to dust. The nurse should include which of
the following in the teaching plan for the client?*
1/1

a. Seek assistance for housework.

b. The house must be free from decorations to maintain dust-free environment.
c. Use damp cloth when wiping surfaces in the house at all times to limit dust particles in the
house.

d. The condition must be accepted because dust cannot be avoided.

61. After head and neck surgery, the nurse should include which of the following in the
nursing care plan of the client?*
1/1

a. Logroll the client using the draw sheet.

b. Encourage the client to cough frequently.
c. Keep the client’s head of bed elevated at 30-45 degree angle and monitor for respiratory
difficulty

d. Provide range-of-motion exercises early during the postoperative period.

62. A client with COPD was admitted in the hospital. The nurse should assess for:*
1/1

a. Bladder distention
b. Increased pulse rate
c. Drop in blood pressure
d. Adventitious breath sounds

63. The client was diagnosed with liver cirrhosis, which of the following is your most
important nursing care for this patient:*
1/1

a. Monitor his neuro-VS and maintain present liver function.

b. Restrict fluid intake.

c. Maintain patient flat on bed
d. Perform muscle exercises

64. The following instruments are considered as critical and should sterilized prior to
use: 1. retractors, mayo curve and straight 2. endoscopes and
thermometers 3. surgical needles and sutures 4. mosquito forcep, deaver
and army navy*
0/1
a. 1,2,3
b. 1,3,4
c. 2,3,4
d. 1,2,3,4

65. Which of the following is the priority of the nurse when receiving the patient in the
OR?*
1/1

a. Baseline VS
b. Check if nail polish has been removed
c. Check if patient is started on NPO
d. Check patient’s identity and consent
66. The nurse would expect a client who has had a cerebrovascular accident involving
the right cerebral cortex and cranial nerves and resulting in left hemiplegia to
demonstrate paralysis on the left:*
0/1

a. Lower extremities and lower jaw

b. Arm, left leg, left side of the face

c. Arm, left leg, right side of the face

d. Upper extremity and left side of the face

67. Following ESWL it is best that the patient with urolithiasis to?*
1/1
a. Discontinue oral hygiene temporarily.
b. Ensure hot or cold fluids to drink.
c. Keep HOB elevated after meals frequently.
d. Instruct to strain all voided urine

68. As part of the planning of care for a client with expressive aphasia, the nurse should
include the following: 1. Help the client associate words with physical objects 2.
Anticipate needs of the client at all times to be the same 3. Help the client accept
this disability as permanent 4. Allow the client to verbalize needs.*
1/1
a. 1 only

b. 2, 4 only
c. 1, 2, 4
d. 1, 2, 3

69. Myasthenia gravis is primarily due to:*

0/1

a. A genetic defect in the production of acetylcholine.

b. Decreased number of functioning acetylcholine receptors.

c. An increase in the production of cholinesterase.
d. A reduced amount of neurotransmitter acetylcholine.
70. The client with Parkinson’s disease would most likely manifest which of the
following?*
0/1

a. Intellectual impairment.
b. Flattened affect
c. Tonic-clonic seizure.

d. Changes in sensation

71. The nurse gathered a nursing history of a client with basal cell carcinoma. Which of
the following questions should be included by the nurse?*
1/1
a. “Has anybody in your family had been afflicted with this condition?”
b. “Are you frequently exposed to sunlight between 11:00 A.M. and 3:00 P.M.?”

c. “Do you smoke cigarettes?”

d. “What kind of food do you usually eat?”

72. The client had experienced cerebrovascular accident. He remains unresponsive to

sensory stimulations such as heat, cold, pain, and touch. Which lobe of his brain is
involved?*
0/1
a. Frontal lobe.

b. Occipital lobe.
c. Parietal lobe.
d. Temporal lobe.

73. When transporting a client on a stretcher, the nurse ensures that the client’s arms
do not hang down over the edge to prevent injury is in observance of which of the
following bioethical principles:*
1/1

a. Non-maleficence.

b. Beneficence
c. Justice.
d. Autonomy

74. The nurse assists the surgeon in obtaining which of the following blood vessels
commonly used for CABG?*
0/1

a. carotid artery
b. Saphenous vein
c. radial artery

d. internal mammary artery

75. Which of the following manifestations indicate increased intracranial

pressure? 1. Rising blood pressure, slow bounding pulse.2. Elevated body
temperature, widening pulse pressure. 3. Slow respirations,
restlessness. 4. Rapid weak pulse, intermittent fever.*
0/1
a. 1,2 only

b. 1,3 only
c. 1,2,3
d. 2,3,4

76. The client with diabetes mellitus developed diabetes ketoacidosis. Which of the
following results of laboratory tests should the nurse expect? 1. Elevated serum
glucose 2. Increased acidity 3. Low carbon dioxide 4. High
carbon dioxide*
0/1

a. 1, 3 only
b. 2, 3 only
c. 1, 2, 4

d. 1, 2, 3

77. The client with diabetes mellitus had self-injected regular insulin. She omitted her
breakfast because she was already late for work. Which of the following assessments
are indicative of hypoglycemic reaction to insulin?*
1/1

a. Pallor, diaphoresis, tremors.

b. Dry, flushed skin, excessive urination.

c. Glycosuria, abdominal pain, excessive thirst.
d. Weakness, altered level of consciousness, fruity odor of breath.

78. Immediately following thyroidectomy, a client should be monitored for: 1.

Unstable vital signs. 2. Signs of respiratory obstruction. 3. Severe
hoarseness of voice. 4. Elevated body temperature.*
0/1
a. 1, 2 only
b. 1, 2, 4
c. 2, 3, 4

d. 1, 2, 3, 4

79. Multiple Sclerosis has no identified cause, although it is associated with which of the
following factors?*
1/1

a. Impaired digestion
b. Ocular motility
c. Autoimmunity

d. Defective sebaceous gland formation.

80. The nurse expects which of the following as typical of a patient with polycythemia
vera:*
1/1

a. Cyanosis and pruritus

b. Rudy complexion, pruritus, and increased hemoglobin/hematocrit.

c. Fatigue and dizziness.

d. Tenderness and vomiting.

81. Following spinal surgery in a client with slipped disc, the client would be best placed
in which position?*
1/1

a. Supine with the knee-gatch elevated

b. Semi-fowler’s position with knees flexed
c. Supine with the legs extended

d. With the head elevated and the feet against a footboard.

82. When suctioning a client with tracheostomy, which of the following is inappropriate
action by the nurse?*
1/1

a. The nurse initiates the suction as the catheter is withdrawn.

b. The nurse inserts 3-5 inches of the catheter into the tracheostomy.
c. The nurse applies suction for 5 to 10 seconds.
d. The nurse uses a new sterile catheter with each insertion.

83. The client is for sigmoidoscopy. As part of the preparation of the client, the nurse
should:*
0/1

a. Inform the client that he will drink white, chalk-like substance

b. Administer laxative the morning of the test.

c. Withhold all fluids and foods for 24 hours before the examination.
d. Administer an enema the morning of the test.

84. After a subtotal gastrectomy, a client returned to the surgical unit. The nurse can
best prevent pulmonary complications by:*
0/1

a. keeping an oral airway in place.

b. maintaining a consistent oxygen therapy.

c. promoting frequent turning and deep breathing to mobilize secretions.

d. suctioning secretions as necessary.

85. If during a colostomy irrigation, a client complains of abdominal cramps, the nurse
should:*
1/1
a. clamp the catheter for a few minutes.

b. discontinue the irrigation.

c. lower the container of the fluid.
d. elevate the container of the fluid.

86. A client is admitted to the hospital with cancer of the breast. The client has fever
and diarrhea. The client asks the nurse, “Do you think that I’ m going to have surgery?
The best response by the nurse in the situation would be?*
0/1

a. “Are you afraid to have surgery?”

b. “Have you asked your physician about this matter?”
c. “Since you have cancer of the breast, I believe that your physician will suggest surgery.”

d. “You better discuss this matter with your physician.”

87. The nurse is caring for an 82-year-old male client. The client experiences hearing
loss caused by aging. The nurse expects which of the following in the client?*
0/1

a. Copious, moist cerumen.

b. Difficulty hearing women’s voice.
c. Red, swollen tympanic membrane.
d. Hearing better in a noisy environment.

88. The client has been diagnosed to have angina pectoris. His physician prescribed
nitroglycerin sublingual tablets for chest pain. The nurse should teach the client to
suspect that the tablets have lost their potency when:*
1/1

a. Stinging sensation is experienced under the tongue.

b. The tablets are stored in clear plastic container.

c. Pain is unrelieved but facial flushing is increased.

d. Onset of relief of the chest pain is delayed.
89. When taking blood pressure of Mrs. Santos who has had thyroidectomy, the nurse
notices the client has spasms of the hand and notifies the physician. While awaiting the
physician’s order, the nurse should prepare for replacement of:*
1/1

a. Calcium

b. Magnesium
c. Bicarbonate
d. Potassium chloride

90. The nurse suspects that the client is experiencing hypokalemia when which of the
following manifestations are observed?*
1/1
a. Edema, bounding pulse, confusion
b. Apathy, weakness, abdominal distention

c. Spasms, colic, tachycardia

d. Sunken eyeballs, thirst, deep and rapid respiration.

91. After surgical clipping of a cerebral aneurysm, the client develops the syndrome of
inappropriate secretion of antidiuretic hormone. Manifestations of excessive levels of
antidiuretic hormone (ADH) are:*
1/1

a. Increased BUN and hypotension

b. Hyperkalemia and poor skin turgor
c. Hyponatremia and decreased urine output

d Polyuria and increased specific gravity of urine

92. When being admitted for a lumpectomy the client begins to cry and states, “I have
found the lump several months ago but kept putting off going to the doctor because of
what it could be.” The nurse should reply:*
0/1

a. “You must have been very frightened.”

b. “About 80% of all lumps are found to be benign.”

c. “Cry as long as you like, you need to get it out of your system.”
d. “Ninety-five percent of all lumps are discovered by the woman herself.”

93. At 4:30 PM, a client who has been receiving Humulin N insulin every morning
states, “I feel very nervous.” the nurse observes that the client’s skin is moist and cool.
The most accurate interpretation of these finding would be:*
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a. Polydipsia
b. Ketoacidosis
c. Glycogenesis
d. Hypoglycemia

94. A client with diabetes mellitus asks how exercise will affect insulin and dietary
needs. The nurse should review how exercise:*
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a. Increase the need for insulin and increase the need for carbohydrates
b. Decrease the need for insulin and decrease the need for carbohydrates

c. Increase the need for carbohydrates and decrease the need for insulin
d. Decrease the need for carbohydrates but does not affect the need for insulin

95. Lack of bile in the small intestines results in a lack of vitamin K absorption. The
nurse should realize that this will be reflected in an increase in:*
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a. Blood clotting
b. Fibrin formation
c. Prothrombin time

d. Calcium utilization

96. A male client receiving hemodialysis has surgery to create an arteriovenous fistula.
Before discharge the nurse discusses care at home with the client and his wife. The
nurse recognizes that further teaching is required when the wife says:*
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a. “I must touch the shunt several times a day to feel for the thrill.”
b. “I have to take his blood pressure every day in the arm with the fistula.”
c. “He will have to be very careful at night not to lie on the arm with the fistula.”
d. “We really should check the fistula every day for signs of redness and swelling.”

97. Following a suprapubic prostatectomy, a client complains of pain in the operative

area. The initial response of the nurse should be to:*
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a. Administer the prescribed analgesic
b. Encourage intake of fluids to dilute urine
c. Inspect the drainage tubing for occlusion

d. Measure and record the vital signs before administering an analgesic

98. When discussing diet with an obese individual with Meniere’s disease, it would be
most therapeutic if the nurse suggests that the client:*
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a. Limit intake to 900 calories a day

b. Enroll in an exercise class at the local high school
c. Get involved in diversionary activities when there is an urge to eat

d. Keep a diary of all foods eaten each day, making certain to list everything

99. A patient who received multiple cycles of high dose chemotherapy as treatment for
hodgkins lymphoma is likely to suffer from which of the following priority health issue:*
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a. alopecia and altered body image

b. sexual dysfunction
c. aplastic anemia
d. psychosis and altered coping process

100. Before discharge, a client post adomino-pelvic surgery should be informed of

activity limitations. The nurse should plan to teach that:*
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a. Most sports activities, except swimming can be resumed based on overall physical condition
b. Activities of daily living should be resumed as quickly as possible to avoid depression and
further dependency
c. With counseling and medical guidelines, a near normal lifestyle including complete sexual
function is possible
d. After surgery, changes in lifestyle must be made to accommodate the physiological changes
of the operation