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MEDICAL SURGICAL NURSING

Nursing Practice 3 (Set A)
Prepared By: Prof. Josie Q. Udan
Philippine Nursing Licensure Examination
NAME:
1. Which of the following intravenous solutions is hypotonic?
a) NaCl 0.9%
b) D5LR
c) D10 W
d) NaCl 0.45%

2. The most accurate indicator of fluid deficit is:

a) Poor skin turgor.
b) A change in body weight.
c) An elevation of body temperature.
d) A decrease in blood pressure.

3. The acid – base imbalance that may occur with severe vomiting is:
a) Respiratory acidosis
b) Respiratory alkalosis
c) Metabolic acidosis
d) Metabolic alkalosis

4. A client took 8 ounces of orange juice, 6 ounces of milk tea and 6 ounces of milk. What is the
calculated intake of the client?
a) 400 ml
b) 500 ml.
c) 600 ml.
d) 700 ml.

5. The client is on low sodium diet. Which of the following foods may be allowed in the client’s diet?
a) Celery
b) Carrot cake
c) Tomato juice
d) Orange juice

6. The client’s serum magnesium is 4.5 mEq/L. Which of the following antidotes does the nurse
prepare to administer?
a) Calcium gluconate
b) Magnesium sulfate
c) Aluminum hydroxide
d) Sodium bicarbonate

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 7. The client who is very anxious and is experiencing deep, rapid respiration is admitted in the
emergency department. Which of the following acid – base imbalances may occur?
a) Metabolic alkalosis
b) Metabolic acidosis
c) Respiratory alkalosis
d) Respiratory acidosis

8. A patient is receiving Aldactone, a potassium-sparing diuretic. The nurse should be alert for which
of the following symptoms?
a) Carpopedal spasms
b) Excitement, agitation
c) Poor muscle tone and leg cramps
d) Irregular pulse and diarrhea

9. A client has the following arterial blood gas results: pH 7.52, PaCo2 30 mmHg, HCO3 24 mEq/L. The
nurse determines that these results indicate
a) Metabolic acidosis
b) Metabolic alkalosis
c) Respiratory acidosis
d) Respiratory alkalosis

10. An elderly woman was admitted to the medical unit with dehydration. The following are clinical
indications of this problem EXCEPT
a) weight loss
b) weak thready pulse
c) poor skin turgor
d) oliguria, concentrated urine

Care of Patients with Eye and Ear Disorders

11. The following statements are true about Snellen’s test EXCEPT
a. Right eye is tested first, then the left eye, then both eyes.
b. The client should be 30 feet away from the chart.
c. It can assess nearsightedness and farsightedness.
d. A result of 20/200 indicates legal blindness.

12. The client had undergone cataract extraction. Iridectomy is done for which of the following
reasons?
a. To prevent secondary glaucoma.
b. To prevent color blindness.
c. To prevent retinal detachment.
d. To prevent color blindness.

13. The client had undergone retinal detachment repair. Which of the following should concern the
nurse most?
a. The client complains of thirst.
b. The client complains of nausea.
c. The client complains of severe pain in the eye.
d. The client complains of fatigue.

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14. The following statements are true statements about glaucoma. Select all that apply.
1. It is characterized by initially loss of central vision.
2. IOP is 25mmHg and above.
3. It leads to irreversible blindness
4. It requires lifelong miotic eye drops.
5. It can be cured by surgery
a. 1,2,3,4,5 b. 1,2,3,4 c. 2,3,4 d. 1,2,4,5

15. The following medications are indicated in a client with glaucoma EXCEPT
a. Pilocarpine
b. Carbachol
c. Atropine
d. Timolol maleate

16. Which of the following assessment findings indicate presbycussis?

a. The client has difficulty hearing in quiet environment.
b. The client has difficulty understanding women’s voice.
c. The client’s Weber’s test indicates that vibration of tuning fork is perceived better in the
poor ear.
d. The client hears and understands telephone conversation well.

17. The client has been diagnosed to have Meniere’s disease. The client should avoid which of the
following to prevent acute attack of the disease?
a. High sodium foods
b. Fruit juices
c. Steamed fish
d. Green salad

18. The client is experiencing vertigo due to Meniere’s disease. Which of the following is the priority
nursing diagnosis?
a. High risk for injury related to vertigo.
b. Alteration in comfort related to tinnitus.
c. Altered body image related to hearing loss.
d. Altered nutrition related to nausea and vomiting.

19. The nurse is to administer ear irrigation as prescribed by the physician. Which of the following is
appropriate nursing action?
a. Direct the flow of solution to the ear drum.
b. Use cold water.
c. Warm solution at 98 degree Fahrenheit.
d. Position the client with the ear to be irrigated facing upward.

Care of Patients with Burns

20. The client has second degree burns from scalding from boiling water. Which of the following are
characteristics of second degree burns?
a. Destruction of the epidermis.
b. The area appears moist with blisters.
c. The area is painless.
d. The area appears pearly white.
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 21. During the emergent phase of burns, the nurse expects the following assessment findings
EXCEPT
a. Hypovolemia, increased hematocrit.
b. Diuresis, decreased hematocrit.
c. Hyperkalemia, hyponatremia.
d. Oliguria, fall of BP

22. Dehydration occurs during the first 48 hours of burns. Which of the following is the primary
cause of dehydration?
a. Increased fluid loss by evaporation from the areas of burns.
b. Actual fluid destruction by the burning process.
c. Shifting of plasma into the interstitial compartment.
d. Fluid loss through blister formation.

23. Hyponatremia occurs in burns because sodium is trapped in the edema fluids. Which of the
following acid – base imbalances more likely will occur?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

24. The client was rescued from a fire in his home. He was observed to have nasal singed hair.
Which of the following should be given highest priority when caring for this client?
a. Initiation of fluid replacement.
b. Securing an airway.
c. Relief of pain.
d. Prevention of infection.

25. In case of fire, what is the priority action by the nurse?

a. Activate the fire alarm.
b. Close the door where the fire is discovered.
c. Remove the client from the area of fire.
d. Go get the fire extinguisher.

26. The client has extensive body burns. Which of the following nursing actions is most
appropriate when applying antimicrobials in the area?
a. Use cotton swabs.
b. Use 4” by 4” gauze.
c. Use sterile gloves.
d. Use tongue blade.

27. A client had burns of the right hand from boiling water. The following nursing actions are
appropriate when caring for this client EXCEPT
a. Remove jewelries
b. Apply dressings on the fingers separately.
c. Apply splint with the fingers curbed.
d. Apply dressings with the fingers together.

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 Care of Patients with Musculoskeletal Disorders
28. A client was diagnosed to have rheumatoid arthritis. The following would most likely be assessed
by the Nurse. Select all that apply.
1. Limited motion of joint.
2. Deformed fingers of the hands.
3. Early morning stiffness.
4. Excessive dryness of the eyes
a. 1,2,3,4 b. 2,3,4 c. 1,2,3 d. 1,3,4

29. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin),
prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?
a. At bed time.
b. On arising.
c. Immediately after the meal.
d. On an empty stomach.

30. Which of the following would be appropriate to include when preparing a client for magnetic
resonance imaging (MRI) to evaluate a ruptured disc?
a. Informing the client that the procedure is painless.
b. Taking a thorough history of past surgeries.
c. Checking for previous complaints of claustrophobia.
d. Starting an intravenous line at keep – open rate.

31. After a bilateral lumbar laminectomy at L5-S1, which of the following is a priority nursing
diagnosis for the client in immediate postoperative phase?
a. Impaired physical mobility related to back pain.
b. Imbalanced Nutrition: Less Than Body Requirement related to postoperative status.
c. Bowel incontinence related to decreased physical activity.
d. Disturbed body image related to fear of disfiguring surgical scars.

32. After a laminectomy, the client states, “The doctor said that I can do anything I want to.” Which
of the following activities, if stated by the client indicates the need for further teaching?
a. Drying the dishes.
b. Cooking meals.
c. Folding clothes.
d. Sweeping the front porch.

33. The nurse determines that the client who has had a lumbar laminectomy with a spinal fusion
understands his postoperative instruction when he places himself in which of the following
positions when sitting in a chair?
a. With the feet flat on the floor.
b. On a low footstool.
c. In any comfortable position with legs uncrossed.
d. On a high footstool so the feet are level with the chair.

34. A client who had an above-the-knee amputation is to use crutches until the prosthesis is properly
fitted. When teaching the client about using the crutches the nurse instructs the client to support
her weight primarily on which of the following body areas?
a. Axillae
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 b. Elbows
c. Upper arms
d. Hands

35. When preparing the teaching plan for a client about crutch walking using a swing- to- gait
pattern, which of the following would the nurse include?
a. Advance the crutch on one side and then advance the opposite foot, repeat on the
opposite side.
b. Advance the crutch on one side and simultaneously advance and bear weight on the
opposite foot, repeat on the opposite side.
c. Advance both crutches together and then follow by lifting both lower extremities to the
level of crutches.
d. Advance both crutches together and then follow by lifting both lower extremities past the
level of crutches.

36. Osteoporosis is a systemic skeletal disease characterized by low bone mass, leading to enhanced
bone fragility and a consequent increase in fracture risk. The following are risk factors to
osteoporosis. Select all that apply.
1) Obesity
2) Low physical activity
3) Tobacco use and Alcohol drinking
4) Menopause
5) Low calcium intake
a. 1,2,3,4,5 b. 2,3,4,5 c. 1,2,3,5 d. 2,3,4

37. The clinical manifestations of osteoporosis include the following EXCEPT

a. Decreasing height (10 to 15 cm) due to collapsing vertebrae.
b. Back pain (T5 to L5).
c. Dowager’s hump (curved upper back).
d. Crepitus.

38.The most commonly used bone mineral density (BMD) screening is:
a. Dual – energy X – ray Absorptiometry (DXA).
b. Bone X- Ray
c. Ultrasound
d. MRI

39. The nurse provides the following appropriate health teachings to a patient with osteoporosis.
Select all that apply.
1. Include foods rich in calcium in the diet such as milk and dairy products, tofu, green leafy
vegetables, seafoods.
2. Fosamax, a calcium metabolism modifier is best taken with full glass of water after rising
in the morning and remain upright for 30 minutes after taking the medication.
3. Take calcium, vitamin D supplements as prescribed.
4. Exercise at least 30 minutes, 5 days a week, then work up to 60 minutes.
5. Avoid use of tobacco products and alcohol.
a. 1,3,4 b. 1,2,3,4,5 c. 1, 3, 5 d. 1,3,4

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 Care of Patients with Hepato – Biliary and Pancreatic Disorders
40. If a gallstone becomes lodged in the common bile duct, the nurse should anticipate that the client’s
stools would most likely become what color?
a. Green
b. Black, tarry
c. Brown
d. Clay- colored

41. When the client’s common bile duct is obstructed, the nurse should evaluate the client for signs of
which of the following complications?
A. Respiratory distress.
B. Circulatory overload.
C. Urinary tract infection.
D. Prolonged bleeding time.

42. A client undergoes a traditional cholecystectomy and choledochotomy and returns from surgery with
a T-tube. To evaluate the effectiveness of the T-tube, the nurse should understand that the primary
reason for the T-tube is to accomplish which of the following goals?
a. Promote wound drainage.
b. Provide a way to irrigate the tract.
c. Minimize the passage of bile into the duodenum.
d. Prevent the bile into the duodenum.

43. After a cholecystectomy it is recommended that the client follows a low-fat diet at home to prevent
which of the following problems?
a. Constipation
b. Pruritus
c. Diarrhea
d. Jaundice

44. A client undergoes a laparoscopic cholecystectomy. Which of the following are normally
experienced within 24 hours after surgery?
a. Bloatedness, abdominal pain that radiates to the shoulders.
b. Jaundice, pruritus, tea- colored urine
c. Anorexia, flatulence
d. Nausea, frequent belching

45. The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching
and jerking. How should the nurse interpret the significance of these symptoms?
a. The client maybe developing hypocalcemia.
b. The client is experiencing a reaction to Meperidine (Demerol).
c. The client has a nutritional imbalance.
d. The client needs a muscle relaxant to help him rest.

46. The location of pain in a patient with acute pancreatitis is:

a. Right upper quadrant
b. Midepigastrium or left upper quadrant
c. Mc Burney’s point
d. Left anterior lumbar area
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 47. The client with liver cirrhosis has developed ascites. The nurse should recognize that the
pathologic basis for the development of ascites in clients with cirrhosis is portal hypertension and
a. An excess serum sodium level.
b. An increased metabolism of aldosterone.
c. A decreased flow of hepatic lymph.
d. A decreased serum albumin level.

48. It is a course tremor characterized by rapid, nonrhythmic extension and flexion on the wrist and
fingers. This results from neurologic function impairment due to elevated serum ammonia levels in
patients with liver cirrhosis.
a. Jacksonian seizure
b. Asterixis
c. Trousseau’s sign
d. Tinel’s sign

49. A client with cirrhosis vomits bright red blood and the physician decides to insert a Sengstaken –
Blakemore tube. Which of the following is most important equipment for the nurse to prepare at
the bedside?
a. Suction apparatus
b. Forceps
c. Scissors
d. Tracheostomy set

50. The physician orders oral neomycin and neomycin enema for the client with cirrhosis. The nurse
understands that the purpose of this therapy is to:
a. Reduce abdominal pressure.
b. Prevent straining during defecation.
c. Block ammonia formation.
d. Reduce bleeding within the intestine.

51. A client’s serum ammonia level is elevated and the physician orders 30 ml. of lactulose (Cephulac).
Which of the following side – effects of this drug would the nurse expect to see?
a. Increased urine output.
b. Improved level of consciousness.
c. Increased bowel movements.
d. Nausea and vomiting.

52. The nurse is providing discharge instructions for the client with cirrhosis. Which of the following
statements best indicates that the client has understood the teaching?
a. “I should avoid constipation to decrease chances of bleeding.”
b. “I should eat a high protein, high – carbohydrate diet to provide energy.”
c. “If I get enough rest and follow my diet it is possible for my cirrhosis to be cured.”
d. “It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin.”

53. The serum potassium (K+) level of the client with liver cirrhosis is 3.0 mEq/L. Which of the following
diuretic is expected by the nurse to be ordered by the physician to relieve his ascites?
a. Lasix b. Diuril c. Bumex d. Aldactone

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54. The nurse is reviewing discharge plans with a client who has been hospitalized with hepatitis A. The
nurse would recognize that the client understood preventive measures that should be used to
reduce the risk of spreading the disease when the client states, “I should:
1. Wash my hands frequently.
2. Dispose of my tissues properly.
3. Launder my clothes separately.
4. Use a separate bathroom from my family.

Care of Patients with Gastrointestinal Disorders

55. A client is taking Sucralfate, a cytoprotective drug for treatment of peptic ulcer disease. Which of
the following statements best indicates that the client understands how to correctly take the
medication?
a. “I should take Sucralfate 30 minutes to 1 hour before I take my meal.”
b. “It is best for me to take Sucralfate 1 to 2 hours after meals.”
c. “I need to decrease my intake of fluids so that I don’t dilute the effect of my
Sucralfate.”
d. “My Sucralfate will be most effective if I take it whenever I experience stomach pains.”

56. As a result of gastric resection, the client is at risk for development of dumping syndrome. The
nurse would prepare a plan of care for this client that includes the following. Select all that apply.
1.The client should eat in lying position.
2. Place the client in left side – lying position after meal.
3. The client should be given small, frequent feedings.
4. Provide high carbohydrate diet.
5. Instruct client to take fluids with meals.
a. 1,2,3 b. 1,2,3,4 c. 1,3,4,5 d. 1,2,3,4,5

57. Which goal for the client’s care should take priority during the first day of hospitalization for an
exacerbation of ulcerative colitis?
A. Promoting self – care and independence.
B. Managing diarrhea.
C. Maintaining adequate nutrition.
D. Promoting rest and comfort.

58. In a client with acute appendicitis the nurse should anticipate which of the following treatments?
A. Administration of enemas to cleanse the bowel.
B. Insertion of a nasogastric tube.
C. Placement of client on NPO status.
D. Administration of heat to the abdomen.

59. The characteristic clinical manifestations of Crohn’s disease are as follows, EXCEPT
A. Diarrhea (5 to 6 soft stools per day).
B. Transmural inflammation (the entire wall of the intestine is affected).
C. The ileum and ascending colon are commonly affected. Inflammation is discontinuous
(regional).
D. Stool is with blood, pus and mucus.

60. Collaborative management for Crohn’s disease are as follows:

1. Low fiber diet.
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 2. Steroid.
3. Azulfidine (Sulfisoxazole).
4. Surgery is ileostomy.
a. 1,2,3 b. 1,2,3,4 c. 1,2 d. 3,4

61. The following are true statements about ileostomy EXCEPT

A. Ileostomy stoma is found in the right lower quadrant of the abdomen.
B. Ileostomy has continuous watery fecal drainage.
C. Ileostomy requires irrigation.
D. Effluent from the ileostomy contains enzymes that may irritate peristomal skin.

62. The following are true statements about typhoid fever. Select all that apply.
1. It is caused by dangerous bacteria called Salmonella typhi.
2. It can be spread to others through the fecal-oral route.
3. Even after antibiotic treatment, a small number of people who recover from typhoid fever
continue to harbor the bacteria (chronic carriers).
4. Most people become infected by drinking contaminated water, eating contaminated food or
close contact with an infected person.
5. Children and those in developing countries are at greatest risk of getting the disease.
a. 1,2,3 b. 1,2,3,4 c. 1,2,3,4,5 d. 1,2,4,5

63. The following are characteristic manifestations of typhoid fever. Select all that apply.
1. Fever that starts low and increases daily, possibly reaching as high as 104.9 F (40.5 C)
2. Headache, Weakness and fatigue, Muscle aches
3. Sweating, Dry cough
4. Loss of appetite and weight loss
5. Diarrhea or constipation
a. 1,2,3,4,5 b. 1,2,4,5 c. 1,2,3 d. 1,2,4

64. Because the vaccine won't provide complete protection from typhoid fever, these health teachings
are to be given to clients when traveling to high-risk areas:
1. Wash hands before eating or preparing food and after using the toilet. Carry an alcohol-
based hand sanitizer for times when water isn't available.
2. Avoid drinking untreated water. Drink only bottled water or canned or bottled carbonated
beverages. Ask for drinks without ice. Use bottled water to brush your teeth, and try not to
swallow water in the shower.
3. Avoid raw fruits and vegetables. Because raw produce may have been washed in
contaminated water, avoid fruits and vegetables that you can't peel, especially lettuce.
4. Choose hot foods. It's best to avoid food from street vendors — it's more likely to be
infected.
5. Know where the doctors are. Find out in advance about medical care in the areas you'll
visit, and carry a list of the names, addresses and phone numbers of recommended
doctors.
a.1,2,3 b. 1,2,3,4 c. 1,2,3,4,5 d. 1,2,3,5

Care of Patients with Blood Disorders

65. The following statements are true about ALL ( Acute Lymphocytic Leukemia). Select all that apply:
1. It is the most common type of leukemia among children, age 2 to 9 years old.
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 2. The primary problem in leukemia is proliferation of immature WBCs.
3. ALL when detected early is curable with chemotherapy.
4. Decreased production of platelets causes abnormal bleeding like nose bleeding, rectal
bleeding, bruising, ecchymosis, visual changes (retinal bleeding).
5. Decreased production of RBCs causes signs and symptoms like pallor, fatigue,
weakness, palpitations, faintness, weight loss, shortness of breath.
a. 1,2,3,4 b.1,2,4,5 c.1,2,3,5 d. 1,2,3,4,5

66. Nursing interventions for a client with ALL, to prevent infection should include the following. Select
all that apply.
1. Avoid exposure to all sources of stagnant water (e.g. flower vases, denture cups, water
pitchers, humidifiers and plants).
2. Encourage or assist with personal hygiene – mouth care, perirectal care, daily shower or bath
with mild soap.
3. Monitor vital signs every 4 hours, especially body temperature. Report fever of 101°F or 38°C
and above.
4. Assess for changes in mental status like restlessness, irritability, confusion, headache or
changes in level of consciousness. These changes are often the first subtle signs of sepsis.
5. Avoid crowds; avoid raw or undercooked foods.
a. 1,2,3 b. 1,2,3,4 c. 1,2,3,4,5 d. 1,2,5

67. Preventing and managing bleeding in a client with ALL should include the following. Select all that
apply.
1. Provide soft toothbrush for mouth care.
2. Keep fingernails and toenails short and smooth.
3. Monitor pad count during menstruation.
4. Avoid use of ASA and NSAIDs.
5. Teach avoidance of constipation with increased fluid and fiber.
a. 1,2,3,4,5 b. 1,3,4 c. 1,2,3,4 d. 1,3, 4, 5

68. The client had been diagnosed to have aplastic anemia. Which of the following statements of the
client indicates the need for further teaching?
A. “I will brush my teeth with soft – bristled toothbrush.”
B. “I will avoid eating raw fruits and vegetables.”
C. “I am allowed to go and watch basketball games.”
D. “I have to avoid people with cough and colds.”

69. Which of the following manifestations does the nurse most likely observe in a client with
Hodgkin’s disease?
a. Difficulty swallowing.
b. Painless, enlarged cervical lymph nodes.
c. Difficulty breathing.
d. A feeling of fullness over the liver.

70. The client with chronic myelocytic leukemia will receive blood transfusion. Which of the following is
inappropriate nursing action?
a. Check cross – matching and blood – typing before administration of blood transfusion.
b. Administer lactated ringers in dextrose 5 % as “piggy back”.
c. Use blood transfusion set with micron mesh filter.
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 d. Obtain baseline Vital Signs.

71. The client had been diagnosed to have polycythemia vera. Which of the following measures is not
included in the nursing care plan of the client?
a. Increase fluid intake.
b. Monitor the client for signs and symptoms of thromboembolism.
c. Advise the client to avoid high altitude.
d. Implement contact precaution.

72. The client who had undergone gastric surgery developed pernicious anemia. Which of the following
statements when made by the client indicates the need for further teaching?
a. “I will have to take Vitamin B12 tablets for lifetime.”
b. “I will need to have Vitamin B12 injections for lifetime.”
c. “I will need to undergo physical examination every six months.”
d. “I will have blood transfusions as necessary.”

73. The 25 – year old male client had been diagnosed to have multiple myeloma. Which of the following
is a common probable problem that the nurse may anticipate in this client?
a. Bleeding
b. Fractures
c. Edema
d. Cough and dyspnea

Care of Patients with Endocrine Disorders

74. The most common predisposing factor to Grave’s Disease is:
A. autoimmune disorders C. thyroid drugs
B. severe emotional stress D. viral infections

75. Preparation of the client for BMR (Basal Metabolic Rate) measurement includes the following
EXCEPT:
A. NPO for 10 – 12 hours.
B. night sleep for 8 – 10 hours.
C. instruct the client not to get up from the bed until the test is done.
D. inform that blood specimen will be withdrawn in the morning.

76. Which of the following is NOT a manifestation of Grave’s disease?

A. weight loss C. increased appetite to eat
B. elevated BP D. cold intolerance

77. The client with hypothyroidism will least likely exhibit which of the following signs and symptoms?
A. Sluggish reaction C. Diarrhea
B. Weight gain D. Hypercalcemia

78. The following are appropriate nursing interventions for the client with Grave’s Disease EXCEPT:
A. provide high – caloric diet
B. instill artificial tears into the eyes if exophthalmos is present
C. promote safety
D. provide warm environment

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79. Which of the following drugs is NOT administered to a client with hyperthyroidism?
A. PTU B. Tapazole C. Synthroid D. Lugol’s solution

80. The client with hyperthyroidism is given Lugol’s solution. Which of the following nursing
interventions should be done by the nurse?
A. Add fruit juice or a glass of water and ice cubes to the medication.
B. Administer the drug with antacid.
C. Administer the drug undiluted.
D. Administer the drug at bedtime.

81. The following are nursing interventions when administering Synthroid EXCEPT:
A. check BP and PR.
B. administer the medication on full stomach.
C. administer the medication in gradually increasing dose.
D. monitor the client for signs and symptoms of thyroidal disturbances.

82. The best position for the client following thyroid surgery is:
A. lateral B. supine C. semi – Fowler’s D. prone

83. The primary reason for monitoring the BP of the client post – thyroidectomy is to assess for:
A. hypovolemic shock C. thyroid crisis
B. positive Trousseau’s sign D. myxedema

84. Propylthiouracil (PTU) is prescribed for a client with Grave’s disease to decrease circulating thyroid
hormone. The nurse should teach the client to immediately report which of the following signs
and symptoms?
A. Sore throat, fever
B. Painful, excessive menstruation
C. Constipation
D. Increased urine output

85. The nurse asks the client to state her name as soon as she regains consciousness postoperatively
after a subtotal thyroidectomy and at each assessment. The nurse does this primarily to monitor
for signs of which of the following?
a. Internal hemorrhage.
b. Decreasing level of consciousness.
c. Laryngeal nerve damage.
d. Upper airway obstruction.

86. A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48
hours after surgery. The nurse should obtain and keep at the bedside equipment to
a. begin total parenteral nutrition.
b. start a cutdown infusion.
c. administer tube feeding.
d. perform a tracheostomy.

87. Appropriate nursing diagnoses for a client with hyperthyroidism would probably include the
following EXCEPT:
a. Risk for injury (corneal abrasion) related to incomplete closure of eyelids.
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 b. Imbalanced nutrition: less than body requirements related to hypermetabolism.
c. Deficient fluid volume related to diarrhea.
d. Activity intolerance related to fatigue associated with the disorder.

88. A client with DM asks the nurse to recommend something to remove corns from his toes. The nurse
should advise him to:
a. Apply a high – quality corn plaster to the area.
b. Consult his physician or podiatrist about removing the corn.
c. Apply iodine to the corn before peeling them off.
d. Soak his feet to borax solution to peel off the corn.

89. The client with type 1 DM is taught to take Regular Insulin (Humulin R) at 6 AM each day. The client
should be instructed that the greatest risk for hypoglycemia will occur at what time?
a. 8 to 10 AM, shortly before lunch.
b. 1PM, shortly after lunch.
c. 6PM, shortly after dinner.
d. 1AM, while sleeping.

90. Which of the following monitoring activities would be a major focus when planning a nursing care
for a client who has undergone transphenoidal hypophysectomy?
a. Monitoring for cerebrospinal fluid (CSF) leak.
b. Monitoring for fluctuating blood glucose levels.
c. Monitoring for Cushing’s syndrome.
d. Monitoring for cardiac arrest.

91. Which of the following findings would be typical of Addison’s disease?

a. Hypokalemia
b. Hypernatremia
c. Hypoglycemia
d. Decreased blood urea nitrogen (BUN) level.

92. Which statement should the nurse make when teaching the client about taking oral corticorticoids?
a. “Take you medication with a full glass of water.”
b. “Take your medication on an empty stomach.”
c. “Take you medication at bedtime to increase absorption.”
d. “Take your medication with meals or with an antacid.”

93. The primary feature of pheochromocytoma’s effect on blood pressure is?

a. Systolic hypertension.
b. Diastolic hypertension.
c. Hypertension that is resistant to treatment with drugs.
d. Widening pulse pressure.

94. The client with pheochromocytoma should be instructed to avoid activities that precipitate
hypertensive crisis or paroxysms, such as:
a. Valsalva maneuver
b. Anxiety
c. Hypoglycemia

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95. The following are characteristics of NIDDM (Non – insulin dependent diabetes mellitus) EXCEPT:
a. occurs after age 40 years c. obesity
b. absolute deficiency of insulin d. ketosis resistant

96. Which of the following manifestations is least likely to be experienced by the client having
hypoglycemia?
a. Weakness, tremors c. Warm, flushed, dry skin
b. Headache, dizziness d. Slurred speech, blurred vision

97. The following are appropriate nursing interventions for the client experiencing hypoglycemia
EXCEPT:
a. provide 3 – 4 oz. of regular soft drink.
b. give a glass of fruit juice.
c. administer prescribed dose of insulin.
d. give 5 – 7 pieces of lifesavers candies.

98. The prescribed diabetic diet should consist of:

a. carbohydrates 50%, fats 30%, protein 20%
b. carbohydrates 20%, fats 30%, protein 50%
c. carbohydrates 30%, fats 20%, protein 50%
d. carbohydrates 20%, fats 50%, protein 30%

99. The following are nursing interventions when administering insulin EXCEPT:
a. administer insulin at room temperature.
b. rotate the site of injection.
c. aspirate clear insulin before cloudy insulin to combine in one syringe.
d. shake insulin vial to redistribute insulin particles.

100. The nurse notes that the insulin vial taken from the refrigerator is frozen. The expiration date is
December, 2022. Which of the following is the appropriate nursing action?
a. Discard the entire vial.
b. Thaw the insulin and use it since it has not expired yet.
c. Let the insulin vial stand for an hour, at room temperature before using it.
d. Refer the matter to the Charge nurse.

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…but those who hope in the LORD will renew their strength. They will soar on wings like
eagles; they will run and not grow weary, they will walk and not be faint. Isaiah 40:31

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