MEDICAL SURGICAL NURSING (Quiz bowl 2)
Situation 1. A 74-year-old man with a 3-day history
of worsening Chronic Obstructive Pulmonary
Disease is hospitalized. His breathing is labored;
breath sounds are congested with rhonchi
throughout; and his SaO2 (as measured by pulse
oximetry) is 88%.
1. When attempting to improve the client's blood gas
values through improved ventilation and oxygen
therapy, which is the client's primary stimulus for
breathing?
a. Low PO2 c. High PO2
b. High PCO2 d. Normal HCO3-
Answer: A
Rationale: A chronically elevated PCO2 level (above
50 mmHg) is associated with inadequate response of
the respiratory center to plasma carbon dioxide. The
major stimulus to breathing now becomes hypoxia (low
PO2).
2. Why is it important for supplemental oxygen to be
carefully monitored in this patient?
a. High oxygen levels will promote microbial growth in
the patient's lungs
b. Increased PaO2 levels can elevate the drive to
breathe in patients with COPD
c. Increasing PaO2 beyond what is needed will lead to
oxygen toxicity
d. Increased PaO2 levels can depress the drive to
breathe in patients with COPD
Answer: C
Rationale: Increased PaO2 levels can depress the
drive to breathe, which is largely driven by hypoxemia.
3. The client is placed on a 35% aerosol mask, and
blood is drawn for arterial blood gas analysis. The
results are pH 7.33; PaO 2 68 mmHg; PaCO2 53
mmHg, and bicarbonate 18 mEq/L. Which acid-base
imbalance does the patient most likely have?
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis
Answer: A
Rationale: When a patient’s PaCO2 is elevated,
carbonic acid is retained leading to acidosis. Because
the acidosis is respiratory in origin, the patient most
likely has respiratory acidosis.
4. Why should the nurse who is caring for a client with
COPD encourage the client to quit smoking?
a. Smoking decreases the amount of mucus production
b. Smoking damages the ciliary cleaning mechanism
c. Smoking shrinks the alveoli in the lungs
d. Smoking allows hemoglobin to become highly
oxygenated
Answer: B
Rationale: Smoking damages the ciliary action in the
respiratory tract, which is a protective
mechanism.
5. The client is complaining of increased dyspnea.
Upon assessment, the client's respiratory rate is 24
breaths per minute. The appropriate nursing action is
to:
a. Call a code
b. Reassure he client that there is no need to worry
c. Determine the need to increase the oxygen
d. Conduct further assessment of the client's
respiratory status
Answer: D
Rationale: Obtaining further assessment data is the
appropriate nursing action.
• (Option A). Calling a code is a premature action.
• Reassuring the client that there is “no need.
(Option B) “worry” is inappropriate
• (Option C) Oxygen is not increased without
approval of the physician, especially because
the client with COPD can retain CO2.
Situation 2. For 5 years, a 55-year-old man has had
episodes of paroxysmal supraventricular
tachycardia one or two times a month, usually
following heavy exercise or caffeine intake. About
2 months ago, the episodes increased to every 1 to
2 days, with symptoms including palpitations,
difficulty breathing, and dizziness.
6. Bradycardia may result from, except:
a. Fear, anger or pain
b. Vomiting or suctioning
c. Vagal stimulation
d. Stress, pain or vomiting
Answer: A
Rationale: Tachycardia may occur as a result of fear,
anger or pain.
• Options B, C and D are incorrect because
vomiting and suctioning may stimulate the
vagus nerve, which can cause bradycardia.
7. The doctor orders preliminary tests to help assess
the client's condition. The diagnostic test that depicts a
graphical representation of the heart's electrical activity
is called:
a. A cardiac catheterization
b. A holter monitor
c. An electrocardiogram
d. An echocardiogram
Answer: C
Rationale: An Electrocardiogram (ECG) is a non-
invasive test that depicts a graphical representation of
the heart's electrical activity and detects the normal
and abnormal heart rhythms.
• Option A is incorrect because cardiac
catheterization is a fluoroscopic examination
of intracardiac structures.
• Option B is incorrect because a holter monitor
continuously records the heart's electrical
activity for 24 hours.
• Option D is incorrect because an
echocardiogram is a test that uses echoes
from sound waves to visualize intracardiac
structures
8. Diltiazem is ordered to control the client's
paroxysmal supraventricular tachycardia. This drug is
classified as:
a. An inotropic agent
b. An ACE inhibitor
c. A calcium channel blocker
d. A beta-adrenergic blocker
Answer: C
Rationale: Diltiazem is a calcium channel blocker that
inhibits calcium ion influx across cardiac and smooth-
muscle cell membranes. When given to the client with
PSVT, it blocks electrical impulses at the SA node,
thereby decreasing heart rate, myocardial contractility
and oxygen demand.
9. What is the expected outcome of this medication's
administration?
a. Increased heart rate
b. Reduced heart rate
c. Decreased blood pressure
d. Improved strength of myocardial contractility
Answer: B
Rationale: Diltiazem is a calcium channel blocker that
inhibits calcium ion influx across cardiac and smooth-
muscle cell membranes. When given to the client with
PSVT, it blocks electrical impulses at the SA node,
thereby decreasing heart rate, myocardial contractility
and oxygen demand.
10. The client shows no improvement with the drug
therapy, so radio frequency catheter ablation is
performed. Discharge instructions should include:
a. Calling the doctor if his heart rate increases with
exercise
b. Resuming anti-arrhythmic drug therapy after
discharge
c. Returning for a daily follow-up ECG for 2 months
d. Telling the client that he may feel palpitations and it
will subside after 2 to 3 weeks
Answer: D
Rationale: In radio frequency catheter ablation, radio
frequency energy is delivered through an intracardiac
electrode catheter that selectively destroys or modifies
cardiac tissue. Beats that triggered the PVST will no
longer do so because the reentrant circuit has been
destroyed. The palpitations will subside after 2 to 3
weeks.
• Option A is incorrect because this is a normal
response to exercise.
• Option B is incorrect because anti-arrhythmic
drugs will no longer be needed following radio
frequency ablation.
• Option C is incorrect because a follow-up
ECG is usually done in 1 to 3 months.
Situation 3. A 40 years old client is anxious about
acquiring breast cancer, since both her mother and
sister died from breast cancer. She visits the clinic
for routine check-up, and for some inquiries.
11. The nurse is teaching the client about
mammography. The nurse tells the client that:
a. There is no discomfort associated with the procedure
b. Mammography takes about 1 hour
c. She should not use deodorants on the day of the test
d. She should remain on NPO 12 hours before the
procedure
Answer: C
Rationale: The woman should not use underarm
deodorant or powder on the day of examination to
avoid having confusing
shadows on the film.
• (Option A) Women may experience fleeting
discomfort because maximum compression is
necessary for proper visualization.
• (Option B) Mammography takes about 15
minutes, but the woman may be asked to wait
while the images are checked to make sure
they're readable.
• (Option D) There is no need for the client to be
on NPO before the procedure.
12. In performing the breast-self-examination, the
nurse should explain that the purpose of performing the
examination is to discover:
a. Changes from previous self-examinations
b. Fibrocystic masses
c. Thickness and fullness
d. Malignant or benign lumps
Answer: A.
Rationale: Routine breast-self-examination will help
women become familiar with their “normal
abnormalities”. If a change occurs, they should seek
medical attention.
13. The client tells the nurse that she has found a
painless lump in her right breast during her monthly
BSE. Which assessment finding would strongly
suggest that the client's lump is cancerous?
a. Presence of orange peel skin
b. Soft and mobile
c. non-capsulated mass
d. Fixed, non-tender, irregular and hard
Answer: D.
Rationale: A malignant breast tumor is usually non-
tender, irregular in shape, firm and hard, and fixed to
skin or underlying tissues.
• (Option A). The orange peel appearance of
the breast is caused by interference with
lymphatic drainage. This is a classic sign of
advanced breast cancer.
• (Option B.) Soft and mobile lumps are usually
benign breast lumps, such as cysts.
14. In the Philippines, which of the following methods
is strongly suggested and recommended to decrease
mortality due to breast cancer?
a. Mammography c. BMA
b. BSE d. TSE
Answer: B.
Rationale: In the Philippines, BSE (Breast Self-Exam)
is used for early detection of breast cancer. It is the
cheapest and most affordable screening procedure.
• (Option A). If a mass is detected,
mammography is used to confirm it. Baseline
mammography is suggested for all women
between ages 35-39, and yearly
mammography after age 40. If with family
history of breast care, mammography should
be started at age 30.
15. The client's tumor is said to be ERP+. You know
that estrogen receptor-positive tumor:
a. An indicator that the client might respond to
tamoxifen
b. A good indicator of the possibility of breast
reconstruction
c. An indicator that metastasis has already occurred
d. A good indicator for giving an estrogen replacement
therapy to decrease the tumor size
Answer: A.
Rationale: Estrogen receptor-positive tumors signify
that the tumors have receptor sites for estrogen and
are dependent on estrogen for growth. Tamoxifen, a
selective estrogen receptor modulator, has an
estrogen-blocking effect and prevents estrogen from
binding to the receptor sites, thus preventing tumor
growth.
• (Option C). Giving estrogen replacement
therapy will enhance tumor growth.
Situation 4. A 53-year-old man has a six-year
history of hepatic cirrhosis. He was brought to the
emergency room because he began vomiting large
amounts of dark-red blood. The physician
suspects bleeding esophageal varices.
16. A Sengstaken-Blakemore tube was inserted to
tamponade the bleeding esophageal varices. While the
balloon tamponade is in place, The nurse who is caring
for the client gives the highest priority to:
a. Auscultating breath sounds
b. Assessing the client's stools for occult blood
c. Evaluating capillary refill in extremities
d. Performing frequent mouth care
Answer: A
Rationale: Airway obstruction and aspiration of gastric
contents are potential serious complications of balloon
tamponade. Frequent assessment of the client's
respiratory status is the priority.
• Option B is incorrect because stools positive
for occult blood may indicate slow leaking
varices. Important, but not the priority
intervention.
• In option C, although tissue oxygenation
assessment is important, it is not the priority
assessment.
• In option D, frequent mouth care should be
performed, but it is not the priority
intervention.
17. The nurse is caring for a client, who has a
Sengstaken-Blakemore tube in place to stop the
bleeding. Which of the following actions should the
nurse take first if the client suddenly experiences
difficulty breathing?
a. Elevate the head of the bed
b. Cut and remove the tube
c. Apply oxygen with a nasal cannula
d. Listen to the client's lungs
Answer: B
Rationale: Scissors should be kept at the bedside of
all clients with an esophagogastric tube (Sengstaken-
Blakemore tube) and the tube should be cut if the client
experiences respiratory compromise. Maintaining the
client's airway is the first priority of care.
18. Which rationale supports explaining the placement
of an esophageal tamponade tube in the client, who is
hemorrhaging?
a. Maintaining the client's level of anxiety and alertness
b. Reducing fear and obtaining cooperation
c. Beginning teaching for home care
d. Allowing the client to help insert the tube
Answer: B
Rationale: An esophageal tamponade tube
(Sengstaken-Blakemore tube) would be inserted in
critical situations. Typically, the client is fearful and
highly anxious. The nurse therefore explains about the
placement to help obtain the client's cooperation and
reduce his fear.
• Option A is incorrect because a client's
anxiety should be decreased, not maintained,
and depending on the degree of hemorrhage,
the client may not be alert.
• Option C is incorrect because this type of tube
is used only short term and is not indicated for
home use.
• Option D is incorrect because the tube is large
and uncomfortable. The client would not be
helping to insert the tube.
19. When caring for the client, with esophageal varices,
the nurse knows that bleeding in this disorder usually
stems from:
a. Duodenal ulcers
b. Pulmonary hypertension
c. Perforation of the esophagus
d. Increase pressure within the portal veins
Answer: D
Rationale: Increased pressure within the portal veins
(portal hypertension) causes these veins to bulge,
leading to rupture and bleeding into the lower
esophagus.
• Options A, B and C are incorrect because
bleeding associated with esophageal varices
doesn't stem from esophageal perforation,
pulmonary hypertension, and peptic ulcers.
20. Mr. Estrada is receiving a vasopressin infusion.
Which of these findings would indicate a complication
of this therapy?
a. Polyuria c. Flushed skin
b. Tinnitus d. Angina
Answer: D
Rationale: Vasopressin causes vasoconstriction,
which helps in controlling the bleeding of the
esophageal varices. However, vasopressin may
precipitate an acute anginal attack or myocardial
infarction, especially in those with known
cardiovascular disease.
• Options A, B and C are incorrect because
these complications are unrelated to the
question.
Situation 5. A client, who suffered major burn
injuries, is rushed to hospital. The patient is a 160-
lb male and is estimated at having 70% of his total
body surface area burned.
21. During the fluid accumulation phase of a major burn
injury, fluid shifts from the:
a. Interstitial space to intravascular space
b. Intravascular space to intracellular space
c. Intravascular space to the interstitial space
d. Intracellular space to interstitial space
Answer: C
Rationale: During the fluid accumulation phase, which
occurs within the first 24 to 36 hours after a burn injury,
fluid shifts from the intravascular space to the interstitial
space (third-space shift).
22. During the fluid remobilization phase, the nurse
would expect to see signs of which electrolyte
imbalance?
a. Hyperkalemia c. Hypernatremia
b. Hypokalemia d. Hypovolemia
Answer: B
Rationale: Hypokalemia occurs in the fluid
remobilization phase as potassium shifts from the
extracellular fluid back into the cells.
23. You insert an IV line and begin fluid resuscitation.
The doctor wants you to use the Parkland formula.
What amount of Lactated Ringer’s solution should you
administer over the first 8 hours?
a. 5,110 mL c. 10,080 mL
b. 10,220 mL d. 5,040 mL
Answer: C
Rationale: The formula is 4 mL x TBSA x weight in kg.
So, 4 mL x 70% x 72 kg = 20,160 mL of Lactated
Ringer’s solution in the first 24 hours. Therefore, you
would give 10,080 mL (or half) in the first 8 hours.
24. 48 hours after the burn injury, what physiologic
changes can be expected?
a. Decrease urination
b. Increase diuresis
c. Increased blood volume
d. Decreased hemoglobin level
Answer: B
Rationale: During remobilization phase, which starts
about 48 hours after the initial injury, fluid shifts back to
the vascular compartment. Edema to the burn site
decreases and blood flow to kidneys increases, which
increases diuresis.
25. Burn wound sepsis develops and mafenide acetate
10% (Sulfamylon) is ordered BID. While applying
Sulfamylon to the wound, it is important for the nurse
to prepare the client for expected responses to the
topical application which include
a. Possible severe metabolic alkalosis with continued
use
b. Severe burning pain for a few minutes following
application
c. Chilling due to evaporation of solution from the
moistened dressings
d. Black discoloration of everything that comes in
contact with this drug
Answer: B
Rationale: Mafenide acetate 10% (Sulfamylon)
causes burning on application. An analgesic may be
required before the ointment is applied.
• (Option A). Mafenide acetate 10%
(sulfamylon) is a strong carbonic anhydrase
inhibitor that affects the renal tubular system,
resulting in metabolic acidosis.
• (Option C). Mafenide acetate 10%
(sulfamylon) is an ointment that is applied
directly to the wound. It has the ability to
diffuse rapidly though the eschar. The wound
may be left open or dry dressing may be
applied. Silver nitrate solution is applied by
soaking the wound dressings and keeping
them constantly wet, which may cause chilling
and hypotension.
• (Option D). Mafenide acetate 10%
(Sulfamylon) does not cause discoloration.
Silver nitrate solution, another topical
antibiotic used to treat burn sepsis, has the
disadvantage of tuning everything it touches
black.
Situation 6. A 46-year-old female client is admitted
to the medical unit with complaints of weight loss,
loss of appetite, abnormal stools and abdominal
distention. A diagnosis of malabsorption
syndrome is made.
26. When planning dietary teaching for the client, with
malabsorption syndrome, the nurse should include the
need to avoid:
a. Oatmeal c. Sardines
b. Cheese d. Corn
Answer: A
Rationale: Gluten is found in barley, rye, oats and
wheat and should be avoided because it is irritating to
the GI mucosa.
• Options B, C and D are incorrect because
gluten is not found in these products and do
not have to be avoided.
27. To meet the client's needs, the nurse should:
a. Encourage consumption of meats at mealtime and
high-protein snacks
b. Allow the client to eat food preferences
c. Institute IV therapy to improve hydration
d. Maintain NPO status, because food precipitates
diarrhea
Answer: A
Rationale: The diet should be high in protein and
calories, low in fat and gluten-free for individuals with
malabsorption syndrome. Protein is needed for tissue
rebuilding.
• Option B is incorrect because the client may
prefer foods high in gluten, which would
potentiate malabsorption.
• Option C is incorrect because IV therapy is a
dependent function and does not provide all
the necessary nutrients.
• Option D is incorrect because diarrhea is
caused by malabsorption, which accounts for
the depressed nutritional status; once the
diarrhea is corrected, it is essential to
compensate by providing a nutritious diet.
28. Nurse Mar should assess the stool of the client for
the classic sign of:
a. Melena c. Frank blood
b. Fat globules d. Currant jelly consistency
Answer: B
Rationale: Undigested fat in the feces (steatorrhea) is
associated with diseases of the intestinal mucosa (e.g.,
celiac sprue) or pancreatic enzyme deficiency.
• Option A is incorrect because darkening of
feces by blood pigments (melena) is related
to upper GI bleeding.
• Option C is incorrect because bright red blood
or frank blood in the stool is related to lower
GI bleeding (e.g., hemorrhoids).
• Option D is incorrect because stools
containing blood and mucus (currant jelly
stools) are associated with intussusception.
29. Foods that can be served to the client would
include:
a. Veal cutlet with parmesan
b. Cheese omelet with chopped spinach
c. Chicken noodle soup with crackers
d. Roast beef sandwich with pickles
Answer: B
Rationale: Neither of these foods contains gluten, and
they are permitted on a diet for a client with
malabsorption syndrome.
• Option A is incorrect because the breading on
the veal cutlet contains gluten and cannot be
eaten by this client.
• Option C is incorrect because noodles and
crackers contain gluten.
• Option D is incorrect because the bread for
the sandwich contains gluten.
30. The nurse knows that striking clinical improvement
should be noted to the client after administration of:
a. Vitamin B12 c. A gluten-free diet
b. Folic acid d. Corticotropin
Answer: C
Rationale: Gluten, a cereal protein, appears to be
responsible for morphologic changes of the intestinal
mucosa with no tropical sprue (adult celiac disease).
• In option A, vitamin B12 may be administered
if macrocytic anemia or achlorhydria
develops; however, it does not correct the
major pathology.
• Option B is incorrect because folic acid, along
with antimicrobial agents, is used to treat
tropical sprue; it causes dramatic
improvement.
• In option D, the use of corticosteroids may be
advantageous with either form of sprue;
however, this does not produce the dramatic
effect achieved by an approach in another
option.
Situation 7. A client is admitted to the hospital with
chief complaint of seizures. Client reported weight
gain and reduced urine output. He is diagnosed
with Syndrome of Inappropriate Diuretic Hormone.
31. Which nursing diagnosis is most appropriate for the
client who has hyponatremia?
a. Fluid volume excess related to increased thyrotropin
secretion
b. Impaired gas exchange related to pulmonary edema
c. Risk for injury related to seizure activity
d. Impaired skin integrity related to peripheral edema
Answer: C
Rationale: Patients with hyponatremia are at high risk
for seizures. Nursing interventions should be aimed at
safety and protection, including using padded siderails,
administering supplemental oxygen, and keeping an
oral airway readily available.
• (Option A). Thyrotropin is a hormone
produced by the anterior PG. It has no role in
SIADH.
• (Option B). Pulmonary edema is a
complication of hypernatremia and is not
commonly seen in SIADH or hyponatremia.
• (Option D). Peripheral edema is not
associated with SIADH.
32. Which of the following laboratory findings would the
nurse expect to find?
a. Serum osmolality level of 250 mOsm/kg
b. Urine specific gravity of 1.001
c. Serum sodium level of 145 mEq/L
d. BUN level of 45 mg/dL
Answer: A
Rationale: Serum osmolality level will be decreased in
SIADH secretion due to fluid retention.
• (Option B). Urine specific gravity will be high
due to decreased urine output.
• (Option C). Serum sodium level will also be
decreased due to fluid retention and excretion
of large volumes of sodium by the kidney.
• (Option D). BUN level is not affected.
33. The client’s treatment plan should include which of
the following to combat fluid imbalances with SIADH
secretion?
a. Colloids
b. Forced Fluid
c. Hypotonic saline solution
d. Hypertonic saline solution
Answer: D
Rationale: SIADH secretion is characterized by
excessive amounts of antidiuretic hormone secreted
from the posterior pituitary. Key features of antidiuretic
hormone excess include water retention,
hyponatremia, and low osmolality level. Treatment
includes fluid restriction, and administration of
hypertonic saline solution.
34. The client is thirsty and frequently asks the nurse
for water. The most appropriate response would be to:
a. Give him extra fluids with his medications
b. Keep adequate water at his bedside
c. Prepare an IV infusion of hypotonic saline
d. Explain that his fluid intake must be restricted to 27
to 34 oz (800 to 1,000 ml) per day
Answer: D
Rationale: Along with meticulous intake and output,
fluid restriction is an important nursing intervention in
syndrome of inappropriate antidiuretic hormone
(SIADH) to prevent further dilutional hyponatremia. Ice
chips may be offered for severe thirst.
• (Option C). Hypotonic saline infusion would
cause further fluid retention. If IV fluids are
given because of severe hyponatremia,
hypertonic (3% or 5%) saline is used.
35. Which sign suggests that a patient with SIADH has
developed complications?
a. Weight gain
b. Polyuria
c. Tetanic complications
d. Neck vein depression
Answer: A
Rationale: SIADH is associated with weight gain due
to oliguria.
• (Option B is incorrect)
• (Option C). Tetanic contraction is not a sign of
this disorder.
• (Option D). SIADH causes fluid retention,
which can lead to vascular fluid overload
signaled by neck vein distention.
Situation 8. A 43-year-old female client is admitted
to the medical-surgical unit with complaints of loss
of appetite, nausea, vomiting, increased bronze
pigmentation of the skin and fatigue. A diagnosis
of Addison's disease is made.
36. The nurse should observe the client closely for
signs of infectious complications because there is a
disturbance in:
a. Electrolyte balances
b. Metabolic processes
c. Stress response
d. Respiratory function
Answer: C
Rationale: Because of diminished glucocorticoid
production, there is a decreased response to stress.
• In option A, there is hyponatremia and
hyperkalemia in this disorder; however, these
do not alter the defense against infection.
• In option B, glucocorticoids are involved with
metabolism; however, this does not directly
affect susceptibility to infection.
• Option D is incorrect because the respiratory
system is not affected.
37. Therapy for Mrs. Perez is aimed chiefly at:
a. Restoring electrolyte balance
b. Decreasing eosinophils
c. Increasing lymphoid tissue
d. Improving carbohydrate metabolism
Answer: A
Rationale: Lack of mineralocorticoids causes
hyponatremia, hypovolemia, and hyperkalemia.
Dietary modification and administration of cortical
hormones is aimed at correcting these electrolyte
imbalances.
• Option B is incorrect because there is no
disturbance in the eosinophil count.
• Option C is incorrect because lymphoid tissue
does not change.
• In option D, although glucocorticoids are
involved in metabolic activities, including
carbohydrate metabolism, the primary aim of
therapy is to restore electrolyte imbalance.
Lack of electrolyte balance is life-threatening.
38. An important nursing intervention specific for the
client is:
a. Encouraging exercise
b. Protecting from emotional exertion
c. Monitoring for hypernatremia
d. Restricting fluid intake
Answer: B
Rationale: Exertion, either physical or emotional,
places additional stress on the adrenal glands, which
may precipitate an Addisonian crisis.
• Option A is incorrect because low levels of
adrenocortical hormones will cause fatigue,
and exercise may result in crisis because of
increased metabolic demands.
• Option D is incorrect because restricting fluid
intake is contraindicated because of the risk
for hypovolemia.
• Option C is incorrect because the nurse
should assess for hyponatremia, not
hypernatremia, and hyperkalemia.
39. The client is receiving cortisone therapy. In the
event that the client neglects to continue the cortisone
therapy, an acute adrenocortical insufficiency may
occur. The predominant sign the client should be
advised to report is the following, except:
a. Dysphagia
b. Pallor
c. Increased respiratory rate
d. Decreased blood pressure
Answer: A
Rationale: Inadequate circulating glucocorticoids and
mineralocorticoids lead to hypotension, pallor,
weakness, tachycardia, and tachypnea.
• In option A, dysphagia does not occur in an
Addisonian crisis.
40. Before the discharge of the client, the physician
prescribes hydrocortisone and fludrocortisones. The
nurse expects hydrocortisone to:
a. Control excessive loss of potassium salts
b. Prevent hypoglycemia and permit the client to
respond to stress
c. Increase amounts of angiotensin II to raise the
client's blood pressure
d. Decrease cardiac dysrhythmias and dyspnea
Answer: B
Rationale: Hydrocortisone is a glucocorticoid that has
anti-inflammatory action and aids in metabolism of
carbohydrate, fat, and protein, causing elevation of
blood glucose. Thus, it enables the body to adapt to
stress.
• Option A is incorrect because potassium salts
are retained in Addison's disease.
• Option C is incorrect because lack of
angiotensin II is not the cause of hypotension
in this disorder.
 • Option D is incorrect because cardiac
dysrhythmias are caused by electrolyte
imbalances, and dyspnea is caused by
hypovolemia and decreased oxygen supply;
neither is affected by hydrocortisone.
Situation 9. A 35-year-old female actress
complains of frequent bruising, facial hair, absent
of menstruation, weight gain and acne. A diagnosis
of Cushing's syndrome is made.
41. When assessing the client, the nurse should expect
the client to demonstrate:
a. A decrease in the growth of hair
b. Emotional lability and euphoria
c. An increased resistance to bruising
d. Ectomorphism with a moon face
Answer: B
Rationale: Excess adrenocorticoids cause emotional
lability, euphoria, and psychosis.
• Option A is incorrect because increased
secretion of androgens results in hirsutism.
• In option D, although a moon face is
associated with corticosteroid therapy,
ectomorphism is a term for a tall, thin,
genetically determined body type and is
unrelated to Cushing's syndrome.
• Option C is incorrect because capillary
fragility results in multiple ecchymotic areas.
42. Which of the following laboratory results confirm the
diagnosis of the client's Cushing's syndrome?
a. High cortisol levels and low corticotropin levels
b. High cortisol levels and high corticotropin levels
c. Low cortisol levels and high corticotropin levels
d. Low cortisol levels and low corticotropin levels
Answer: B
Rationale: A corticotropin-secreting pituitary tumor
would cause high corticotropin and high cortisol levels.
• Options A and D are incorrect because high
corticotropin level with a low cortisol level and
a low corticotropin with a low cortisol level
would be associated with hypercortisolism.
• Option C is incorrect because low
corticotropin levels and high cortisol levels
would be seen if there was a primary defect in
the adrenal glands.
43. The client's Cushing's syndrome was most likely
caused by:
a. An inborn error of metabolism
b. A corticotropin-secreting pituitary adenoma
c. Adrenal carcinoma
d. An ectopic corticotropin-secreting tumor
Answer: B
Rationale: A corticotropin-secreting pituitary adenoma
is the most common cause of Cushing's syndrome in
women between ages 20 and 40. The client's diagnosis
is Cushing's syndrome, because Cushing's syndrome
refers to excess cortisol secretion, resulting from
neoplasms of the adrenal cortex or prolonged and
excessive intake of glucocorticoids. Cushing's disease
is Cushing's syndrome secondary to excessive
corticotropin secretion with or without a pituitary
adenoma.
• Option A is incorrect because a female with
an inborn error of metabolism wouldn't be
menstruating.
• Option C is incorrect because adrenal
carcinoma usually isn't accompanied by
hirsutism.
• Option D is incorrect because ectopic
corticotropin-secreting tumors are more
common in older men and generally
associated with weight loss.
44. The client will undergo a transsphenoidal
hypophysectomy. Preoperatively, the nurse should
assess the client for potential complications by:
a. Performing capillary glucose testing every 4 hours
b. Checking the patient's temperature every 4 hours
c. Testing the patient's urine specific gravity
d. Testing for ketones in the patient's urine
Answer: A
Rationale: The nurse should perform capillary glucose
testing every 4 hours because excess cortisol may
cause insulin resistance, placing the client at risk for
hyperglycemia.
• In option B, although temperature regulation
may be affected by excess cortisol; it doesn't
accurately indicate infection.
• Option C is incorrect because urine specific
gravity isn't indicated because, although fluid
balance may be compromised, it usually isn't
dangerously imbalanced.
• Option D is incorrect because urine ketone
testing isn't indicated because the client does
secrete insulin and therefore isn't at risk for
ketosis.
45. In the immediate postoperative period following
transsphenoidal hypophysectomy, Nurse Harry should
carefully assess Mrs. Potter for:
a. Hypercalcemia c. Hyperglycemia
b. Hypocortisolism d. Hypoglycemia
Answer: B
Rationale: The nurse should assess the client for
hypocortisolism. Abrupt withdrawal of endogenous
cortisol may lead to severe adrenal insufficiency.
Corticosteroids are given during surgery to prevent
hypocortisolism from occurring. Signs and symptoms
of hypocortisolism are vomiting, increased weakness,
dehydration, and hypotension.
• Option A is incorrect because calcium
imbalance shouldn't occur in this situation.
• Option C is incorrect because once the
corticotropin-secreting tumor is removed, the
client shouldn't be at risk for hyperglycemia.
Situation 10. You are the nurse assigned to care for 49. Which of the following would be an expected
a client diagnosed with Peptic Ulcer Disease. outcome for a client with peptic ulcer disease?

46. A client with peptic ulcer disease tells you that he
has black stools, which he has not reported to his
physician. Based on this information which nursing
diagnosis would be appropriate for this client?
a. Imbalanced Nutrition: Less than Body Requirements
related to gastric bleeding
b. Ineffective Coping related to fear of diagnosis of
chronic illness
c. Constipation related to decreased gastric motility
d. Deficient Knowledge related to unfamiliarity with
significant signs and symptoms
Answer: D
Rationale: Black, tarry stools are an important
warming sign of bleeding in peptic ulcer disease.
Digested blood
in the stool causes it to be black. The odor of the stool
is very offensive. Clients with peptic ulcer disease
should be instructed to report to incidence of black
stools promptly to their primary healthcare provider.
47. You are preparing to teach a client with a peptic
ulcer about the diet that should be followed after
discharge. You should explain that the diet will most
likely consist of which of the following?
a. Large amounts of milk
b. Bland foods
c. High-protein foods
d. Any foods that are tolerated
Answer: D
Rationale: The client can eat three regular meals a
day. Specific dietary restrictions vary from client to
client.
• (Option A.) Avoid a diet rich in milk and
creams, which are acid stimulants.
48. Which instruction would be included in the teaching
plan for the client taking antacids?
a. “Avoid taking other medications within 2 hours of this
one.”
b. “Take the antacid with 8 oz of water.”
c. “Weigh yourself daily when taking this medication.”
d. “Continue taking antacids even when pain
subsides.”
Answer: A
Rationale: Antacids neutralize gastric acid and
decrease the absorption of other medications. The
client should be instructed to avoid taking other
medications within 2 hours of the antacid.
• (Option B). Water, which dilutes the antacid,
should not be taken with antacid.
• (Option C). Daily weights are indicated if the
client is taking a diuretic, not an antacid.
• (Option D). A histamine receptor antagonist
should be taken when pain subsides.
a. The client ill explains the rationale for eliminating
alcohol from the diet
b. The client will demonstrate appropriate use of
analgesics t control pain
c. The client will eliminate contact sports from his or her
lifestyle
d. The client will verbalize the importance of monitoring
hemoglobin and hematocrit every 3 months
Answer: A
Rationale: Alcohol is a gastric irritant that should be
eliminated from the intake of the client with peptic ulcer
disease.
• (Option B). Analgesics are not used to control
ulcer pain; many analgesics are gastric
irritants.
• (Option C). The client can maintain an active
lifestyle and does not need to eliminate
contact sports as long as they are not stress-
inducing.
• (Option D). The client’s hemoglobin and
hematocrit typically do not need to be
monitored every 3 months, unless
gastrointestinal bleeding is suspected.
50. The client asks the nurse what causes a peptic
ulcer. You appropriately respond that recent research
indicates that many peptic ulcers are the result of which
of the following?
a. A genetic defects in the gastric mucosa
b. Work-related stress
c. Diets high in fat
d. Helicobacter pylori infection
Answer: D
Rationale: Most peptic ulcers are caused by
Helicobacter pylori, which release toxins that destroy
the gastric and duodenal mucosa.
Situation 11. The communication process is
essential to the leader or manager in supervising
client care.
51. The nurse who effectively analyzes the
communication process recognizes that messages
are:
a. Verbal and non-verbal
b. Connotative and denotative
c. Learned and unlearned
d. Native as well as foreign
Answer: A
52. Basically, communication is part and parcel of
planning to manage client care. Which of the following
skills should be included? Select all that apply.
1. Focusing 4. Clarifying
2. Observing 5. Responding
3. Attending 6. Teaching

a. 3, 4, 5 ,6 c. 1, 3, 4, 5
b. 1, 2, 3, 4 d. 2, 3, 4 ,5

Answer: A
53. The most controversial way of communicating
doctor’s orders is by phone. It becomes valid and legal
only when:
a. Countersigned by the medical doctor
b. Countersigned by the receiving Registered Nurse
c. Signed by the physician who gave the order
d. Signed by the resident physician on duty
Answer: C
54. To facilitate effective communication between an
immediate post-op client and the nurse, he/she should:
a. Assist the client to a comfortable and safe position
while he/she explains what measures are being done
b. Maintain calm attitude and just care for the client as
needed
c. Observe non-verbal cues
d. Encourage the client to discuss feeling/pain of
discomfort openly
Answer: B
55. The nurse instructs the nursing attendant to
perform cleansing enema until the return flow is clear.
The nursing attendant understood the instruction when
she says “I will…”
a. “Need 1 liter of tap water to have a clear return flow.”
b. “Stop the enema only if the return flow is without
formed fecal material.”
c. “Call you when the return flow is clear.”
d. “Put the client in left Sims’s position to achieve the
desired return flow.”
Answer: D
Situation 12. The implementation of efficient
surgical interventions requires team work by all
members of the surgical team.
56. Following a preoperative visit, the perioperative
nurse creates a nursing diagnosis to:
a. Alert the OR team of specific instrument needed for
the case
b. Follow a specific surgeon’s orders
c. Document the level and progress of nursing care
d. Identify the patient’s needs and to define actions to
meet those needs
Answer: D.
Rationale: Nursing diagnoses provide the basis for
selecting nursing interventions that will achieve
outcomes for which the nurse is accountable.
57. Traffic flow in and out of a procedure room should
be kept to a minimum to:
1. Maintain positive pressure within the room
2. Reduce noise level
3. Increase team concentration
4. Decrease microbial count
a. 1 and 2 c. 1, 3 and 4
b. 3 and 4 d. All of the above
Answer: D.
Rationale:
• Traffic flow must be regulated in order to
make sure that the doors to procedure rooms
remains closed to maintain the positive
pressure inside the procedure room. Each
procedure room should be maintained with
positive pressure, which forces the old air out
of the room and prevents the air from
surrounding areas from entering into the
procedure room.
• 2 and 3. Traffic flow must be regulated in
order to control the noise and allow the OR
team to concentrate with the procedure.
• 4. Traffic flow within the surgical suite should
be unidirectional (from entry to exit, and from
clean to dirty) to prevent cross-contamination
from one area to another.
58. When preparing a procedure room for the first case
of the day, the perioperative nurse notices the room
humidity level to be 70%. The first action should be to:
a. Notify plant engineering of the problem before
opening the sterile supplies
b. Open the sterile supplies and call plant engineering
to report the humidity level
c. Do nothing since the reading is within acceptable
limits
d. Adjust the thermostat to make the room colder
Answer: A
Rationale: The temperature in a procedure room
should be maintained between 68o F and 75o F, with
humidity levels kept between 50 and 55% at all times.
Controlling the internal temperature and humidity at
this constant level greatly reduces the chance of
growth of microorganism or the production of static
electricity, thus providing a safe environment for both
the patient and staff.
59. The instrument (back table) becomes
contaminated with solution as the surgeon is closing
the peritoneum. The first course of action as a scrub
person would be to:
a. Red rape the instrument table before proceeding
with the procedure
b. Use the Mayo stand only
c. Cover the contaminated area with a sterile towel and
proceed with the procedure
d. Avoid that part of the table which is contaminated
Answer: C
Rationale: If the drapes become permeated or moist,
they must be considered contaminated, and must be
covered with a sterile towel before proceeding with the
procedure.
60. Halfway through the surgical procedure, the
surgeon, who has been standing, requests a sitting
stool. The perioperative nurse should:
a. Give the surgeon the stool since he/she requested it
b. Remind the surgeon that change of position alters
the sterile field boundaries, and then give the surgeon
the stool
c. Give the surgeon the stool and document the
incidence on the perioperative record
d. Remind the surgeon about the correlation between
changing positions and the maintenance of the sterile
field
and refuse to give him/her the stool
Answer: B
Rationale: The nurse should remind the surgeon that
a change of position alters the sterile field boundaries,
but as long as the physician is careful not to break the
sterile technique, the nurse can give the surgeon the
stool.
Situation 13. A 51-year-old male client is admitted
to the medical-surgical unit of a tertiary hospital
with complaints of gastroesophageal reflux,
regurgitation, dysphagia, and belching. The
physician suspects a hiatal hernia.
61. The client has a sliding esophageal hernia. The
physician prescribes an H2 -receptor antagonist. The
nurse explains that H2 -receptor antagonists work by:
a. Decreasing the pressure in the lower esophageal
sphincter (LES)
b. Inhibiting secretion of gastric acid by the parietal
cells
c. Neutralizing gastric acid
d. Coating the mucous membrane of the esophagus
and stomach
Answer: B
Rationale: H2 -receptor antagonists inhibit the
histamine action at the H2 -receptor sites in the gastric
parietal cells.
• Option A is incorrect because anticholinergic
drugs are used to decrease LES pressure.
• Option C is incorrect because antacids
neutralize gastric acid.
• Option D is incorrect because mucosal
protectant such as sucralfate (Carafate) acts
in coating the mucous membrane of the
esophagus and stomach.
62. The nurse prepares to administer an H2 -receptor
antagonist to the client. Which of the following drugs is
an H2 - receptor antagonist?
a. Omeprazole c. Metoclopramide
b. Cimetidine d. Sucralfate
Answer: B
Rationale: Cimetidine (Tagamet) is an H2 -receptor
antagonist. It acts by inhibiting the histamine action at
the H2 - receptor sites in the gastric parietal cells.
• Option A is incorrect because omeprazole
(Prilosec) is a proton pump inhibitor, which is
used in decreasing gastric acid concentration
in peptic ulcer and gastroesophageal reflux
disease.
• Option C is incorrect because
metoclopramide (Reglan) stimulates upper GI
tract motility.
• Option D is incorrect because sucralfate
(Carafate) is a mucosal protectant.
63. The client is scheduled for an
esophagogastroduodenoscopy (EGD) procedure. The
nurse explains that EGD:
a. Directly visualizes the esophagus with a flexible
fiber-optic endoscope
b. Examines gastric fluid that is aspirated with a flexible
tube
c. Visualizes the esophagus after a radioactive isotope
is injected intravenously
d. Is an esophageal X-ray that is taken while the client
swallows a barium solution
Answer: A
Rationale: An EGD (esophagogastroduodenoscopy)
uses a fiber-optic endoscope to directly visualize the
esophagus.
• Option B is incorrect because this is a gastric
pH analysis. It is done by aspirating fluid from
a flexible nasogastric tube.
• Option C is incorrect because this is a
computed tomography (CT) scan of the
esophagus. It visualizes the esophagus after
a radioactive isotope is injected intravenously.
• Option D is incorrect because this is a barium
swallow. It is an esophageal X-ray that is
taken while the client swallows a barium
solution.
64. After the client has had the EGD procedure, the
most important nursing action would be to:
a. Place the client in a side-lying position to prevent
aspiration
b. Assess the client's neck for cervical crepitus
c. Assess the client's vital signs frequently
d. Give the client an anesthetic lozenge for his sore
throat
Answer: C
Rationale: The nurse should assess the client's vital
signs frequently; changes in vital signs signal possible
esophageal perforation.
• Options A and D are incorrect because
positioning the client and administering
lozenges don't take priority over assessing
vital signs.
• Option B is incorrect because cervical
crepitus is seen if air from the mediastinum
moves into the soft tissues of the neck.
65. Discharge teaching for the client should include:
a. Explaining that he should elevate the head of his bed
with 6 to 8 inches (15 to 20 cm) blocks
b. Instructing the client to increase fluid intake with
meals
c. Telling the client to recline for 1 hour after eating
d. Telling the client to eat three regular meals every day
Answer: A
Rationale: The nurse should instruct the client to
elevate the head of his bed on 6 to 8 inches blocks.
The elevation will prevent the esophageal hernia from
sliding upward and causing discomfort, regurgitation,
and belching.
• Options B and D are incorrect because eating
smaller meals and not increasing fluid intake
at meals prevents the stomach from filling,
which can add to the discomfort.
• Option C is incorrect because reclining after
meals may cause the hernia to slide up and
cause the symptoms.
Situation 14. A 60-year-old male client is admitted
with a diagnosis of pneumonia. He complains of
pain when coughing.
66. Laboratory results: RBC 2,000,000; WBC 5,000;
and platelets 300,000. Considering the above findings,
which of the following clinical manifestations are the
most likely manifestations Fidel is to exhibit?
a. Decreased respiration and increased pulse
b. Increased pulse and increased respiration
c. Increased respiration and normal pulse
d. Normal respiration and increased pulse
Answer: B
Rationale: Laboratory results indicate a low RBC
count (normal RBC count is 4.5 to 5.5 millions/uL),
which may indicate presence of anemia. As a result,
the amount of oxygen delivered to body tissues is
diminished, thereby causing compensatory
tachycardia and tachypnea.
67. Because of these laboratory findings, the nurse is
aware that her most appropriate action is to prevent
which of the following?
a. Over activity that may lead to exhaustion
b. Injury that may lead to bleeding
c. Cross-contamination and infections
d. Hypercoagulation that might lead to thrombus
formation
Answer: A
Rationale: The client's RBC count is low (normal range
is 4.5 to 5.5 millions/uL), which may indicate presence
of anemia. Due to diminished oxygen supply to body
tissues, the client easily tires. The client should be
assisted to prioritize activities, and to balance activity
and rest to prevent over exhaustion.
• (Option B). The client's WBC count is within
normal range (5,000 to 10,000/uL), and is
therefore not prone to bleeding.
• (Option C & D). The client's platelet count is
within normal range (150,000 to 400,000/uL),
and is therefore not prone to infection or
hypercoagulation.
68. A sputum specimen is collected from the client for
culture and sensitivity. This study is to ascertain which
of the following facts?
a. The antibiotics that would be most helpful
b. The patient's sensitivity to antibiotics
c. The virulence of microorganism involved
d. The patient's probable reaction to the causative
microorganism
Answer: A
Rationale: A sputum culture isolates and identifies the
cause of a pulmonary infection, not the virulence of the
microorganism involved. Sensitivity testing determines
which antibiotic is most effective in treating the
infection.
69. Which of the following should the nurse do in
assisting the client in doing deep breathing and
coughing exercise?
a. Turn him to the unaffected side and ask him to cough
b. Encourage him to cough and then give the pain
medication as ordered
c. Recognize that the patient is too sick to cough at this
time
d. Splint the patient's chest while he coughs
Answer: D
Rationale: Assist the client in splinting the chest while
doing deep breathing and coughing exercises.
70. Upon discharge, the health teachings of the nurse
to the client should include the following, except:
a. Avoid drafts
b. Avoid fatigue
c. Maintain usual exercise
d. Maintain hygiene
Answer: A
Rationale: Pneumonia is either viral or bacterial.
Exposure to drafts does not cause pneumonia.
• (Option B). Fatigue and weakness may be
prolonged after pneumonia. The nurse should
emphasize adequate rest and nutrition to
prevent recurrence of pneumonia.
• (Option C). Usual exercises of deep breathing
and coughing should be continued to allow
expansion of the lungs.
• (Option D). The client should practice good
hygiene such as frequent handwashing and
proper disposal of soiled tissues.
Situation 15. Nurses need to know and apply
ethical and legal aspects in their many different
roles. As a client advocates, nurses ensure the
client’s right to informed consent or refusal.
71. In which situation would inform consent be valid?
a. An 88-year-old male client who is alert and oriented
b. A 50-year-old client who is alert but confused
c. A 35-year-old client with a blood alcohol level of 150
mg/dl
d. A 16-year-old client who is alert and oriented and
whose family is not present
Answer: A
Rationale: Informed consent is a client’s voluntary
agreement to proceed with a procedure or treatment.
• Consent obtained from a client who is
unconscious, confused (option B),
• sedated, legally intoxicated (option C),
• a minor (option D), or mentally incompetent
would not be valid or considered a legally
binding document.
72. The family of an older adult who is aphasic
complains that the nurse failed to obtain a signed
consent before inserting an indwelling catheter to
measure hourly output. This is an example of:
a. A catheter inserted for the client’s benefit, so consent
is unnecessary
b. A treatment that does not need a separate consent
form
c. Inability to obtain consent for treatment because the
client was aphasic
d. Treatment without consent of the client, which is an
invasion of rights
Answer: B
Rationale: Inserting an indwelling catheter to measure
hourly output is considered a routine procedure to meet
basic physiologic needs and is covered by a consent
signed at the time of admission.
• Option A is incorrect because the need for
consent is not negated because the
procedure is beneficial.
• Options C and D are incorrect because this
treatment does not require special consent.
73. Which situation would not require written informed
consent for giving care?
A patient who is unable to read or write
b. An incompetent patient who has family present
c. An emergency situation
d. A provider who gives free healthcare services
Answer: C
Rationale: Voluntary consent given in writing by the
patient is required before a non-emergent surgery or
other invasive procedure can be performed. Informed
consent occurs when a patient has the full
understanding of the procedure, its risks, its potential
complications, and alternatives to care. The giving of
consent protects both the patient and the physician.
Although every effort should be made to obtain
informed consent, in a life-saving situation or
emergency, the physician may proceed without
consent. The doctrine of implied consent is applied to
emergent/life-saving situations.
74. The nurse presents an informed consent form for
insertion of a ventricular peritoneal shunt to a 40-year-
old male client. The client tells the nurse that he is
confused about what the neurosurgeon said about the
procedure. Which nursing action is appropriate?
a. Have the client sign the form so surgery is not
delayed
b. Notify the surgeon that the client has questions and
that the form is not signed
c. Have the client sign the form and tell the client that
you will call the surgeon
d. Explain the procedure to the client and have him sign
the form
Answer: B
Rationale: Obtaining informed consent is an active,
shared decision-making process between the surgeon
and the client. The surgeon must provide adequate
disclosure of the benefits and risks of the proposed
procedure. In addition, the client must have a clear
understanding and comprehension of the procedure to
be done. Lastly, the consent must be voluntary and not
forced.
75. After signing the informed consent form, the client
states, “I have changed my mind and do not want to
have the procedure done.” Which action would be most
appropriate for the nurse to take first?
a. Proceed with preparation of the client for the surgical
procedure
b. Contact the operating room and tell the personnel
there the client’s surgery has been cancelled
c. Remind the client that a signed informed consent
form is a legally binding document
d. Notify the surgeon that the client wishes to withdraw
informed consent for the procedure
Answer: D
Rationale: A client has the right to withdraw informed
consent at any time. The nurse must first inform the
surgeon of the client’s wishes to withdraw consent.
Situation 16. The behavior or actions of any
professional nurse specially while on duty are
often the reflection of their values.
76. Mrs. Y is currently enrolled in the master’s program
at the State University and is currently writing her
thesis. She applied as a chief nurse in St. Louis’s
Hospital and was accepted. Since her assumption to
office, she has been signing documents as a Master’s
graduate affixing “RN, MAN” to her name. The action
of the chief nurse constitutes a:
a. Misrepresentation
b. Malpractice
c. Personification
d. Misdemeanor
Answer: A
77. The charge nurse reported to the chief nurse that
the Demerol 50 cc vial inventory has been incorrect for
the last 24 hours. The most appropriate action of the
narcotic nurse is:
a. Review endorsement of clients who received
Demerol within the last 24 hours
b. Must log every injection of Demerol
c. Demerol inventory must be checked every
endorsement by the narcotic nurse
d. Make fraction dosage like 0.5 mL as 1 mL
Answer: A
78. A staff nurse was found charting blood glucose
result without actually doing the procedure. What is the
appropriate initial action of the senior nurse?
a. Write an incident report
b. Write and submit an explanation and reprimand as
necessary
c. Explain to the patient
d. Go on leave without pay
Answer: A
79. While making your PM shift endorsement, you saw
the nursing attendant receiving a package from a
patient’s watcher. Your appropriate action would be:
a. Review with the nursing attendant the hospital policy
b. Reprimand the nursing attendant right away
c. Endorse to the incoming shift for proper action
d. Remind the patient that gift giving to any hospital
staff is not allowed
Answer: A
80. The Code of Ethics states that the nurse’s primary
commitment is to the client whether an individual or
family, group, or community. Which nursing activity
would best demonstrate the ethical principle called
justice?
a. The nurse providing care on a “first-come-first serve”
basis
b. The nurses providing care to maximize health
according to available resources
c. The client’s preference is least considered
d. Referring the client for evaluation to the social
worker on duty regarding her socio-economic status
Answer: A
Situation 17. Records are vital tools in any
institution and should be properly maintained for
specific use and time.
81. Which of the following qualities are relevant in
documenting patients care in the patient’s record?
1. Currentness and thoroughness
2. Consciousness and accuracy
3. Orderly and systematic
4. Use of locally accepted abbreviation
5. Properly dated, legible, and signed
a. All except 4 c. All except 3
b. All of the above d. All except 5
Answer: A
Rationale: Because the client's record is a legal
document and may be used to provide evidence in the
court, many factors are considered in recording: The
health care personnel must not only maintain the
confidentiality of the client's record but also meet legal
standards in the process of recording;
• document the date and time of each recording
(5);
• follow the agency's policy about frequency of
documenting and adjust the frequency as a
client's condition indicates; all entries must be
legible and easy to read to prevent
interpretation errors (5);
• all entries on the client's record are made in
dark ink so that the record is permanent and
changes can be identified;
• each recording on the nursing notes is signed
(5) by the nurse making it; notations on
records must be accurate and correct (2);
document events in the order in which they
occur (3); record only information that
pertains to the client’s health problems and
care; recordings need to be brief as well as
complete to save time in communication
• Number 4 is incorrect because universally,
not locally, accepted abbreviations, symbols,
and terms are used.
82. Which of the following persons cannot have access
to the patient’s record?
a. The patient
b. Speech therapist
c. Physical therapist
d. Lawyer of the family
Answer: D
Rationale: The client's record is protected legally as a
private record of the client's care. Access to the record
is strictly restricted to the health professionals
• (options B and C) involved in giving care to
the client. The institution or agency is the
rightful owner of the client's record.
• This does not, however, exclude the client's
right to the same records (option A).
83. A main function of the patient’s records is to:
a. Prepare the nurse for the shift worked
b. Serve as a record of financial charges
c. Serve as a vehicle for communication
d. Ensure that the message is received
Answer: C
Rationale: The main function of the patient’s record is
to serve as the vehicle by which different health
professionals, who interacts with a client, communicate
with each other. This prevents fragmentation, repetition
and delays in client care.
84. Which action by a nurse could jeopardize the
confidentiality of computerized medical records
available at a nurse’s station?
a. Periodically change computer access passwords
b. Prevent an unidentified healthcare worker from
viewing computer records
c. Log out and sign off all computer screens before
leaving a terminal
d. Share passwords for computer access with
colleagues who have forgotten their own password
Answer: D
Rationale: The confidentiality of computerized medical
records must be maintained. The nurse should never
share computer access passwords with other
colleagues, as another person could then use the
nurse’s personal identifier to compromise a patient’s
confidentiality.
85. The patient’s medical record is the best evidence
of the care that is given to the patient. It is the property
of:
a. The doctor owns the record
b. The healthcare team property
c. The physical property of the hospital
d. The patient owns the record
Answer: C
Rationale: The client's record is protected legally as a
private record of the client's care. Access to the record
is restricted to health professionals involved in giving
care to the client. The institution or agency (hospital) is
the rightful owner of the client's record. This does not,
however, exclude the client's rights to the same
records.
Situation 18. The practice of primary nurse in
primary nursing is preferred by many nurses
because it supports professional autonomy and
accountability of the nurses.
86. Primary nursing is most satisfying and
advantageous to the patient and nurse because of
which of the following principles?
a. Accountability is clearest since one nurse is
responsible for the overall plan and implementation of
care
b. Autonomy and authority for planning care are best
delegated to a nurse
c. Continuity of patient’s care promotes efficient
nursing care
d. The holistic approach provides for a therapeutic
relationship, continuity of care and efficient nursing
care
Answer: D
Rationale: The holistic approach, being performed in
primary nursing, provides for a therapeutic relationship,
continuity of care and efficient nursing care. It is a
method of providing comprehensive, individualized,
and consistent care. It encompasses all aspects of the
professional role, including teaching, advocacy,
decision making, and continuity of care.
87. In primary nursing, the nurse is responsible for
which of the following group of patients?
a. Big group of patients like 10 to 15 patients
b. Small group of patients like 3 to 5 patients
c. The whole ward
d. The whole unit
Answer: B
Rationale: In primary nursing, the primary nurse is
responsible for a small group of patients like 3 to 5
patients. The primary nurse can easily assess and
prioritize each patient's needs, identify nursing
diagnoses, develops a plan of care with the patient,
and evaluates the effectiveness of care with only a
small number of patients.
88. What is the function of the primary nurse in primary
nursing?
a. Acts as patient advocate and coordinate the health
care team for specific group of patients
b. Coordinates the care given to a group of patients by
support staff
c. Plans and coordinate the patient care assigned to
her from admission to discharge
d. Act as the charge nurse, organizing staff
assignments and help in solving problem in the unit
Answer: C
Rationale: The primary nurse in primary nursing plans
and coordinates the patient care assigned to her from
admission to discharge. She is responsible for
overseeing the total care of a number of clients 24
hours a day, 7 days a week, even if the primary nurse
does not deliver all the care personally. The primary
nurse remains responsible and accountable for specific
patients until they are discharged.
89. What is the role of the associate nurse in primary
nursing?
a. Coordinator of comprehensive, holistic patient care
b. Responsible for the over-all care of the patient during
off days of the primary nurse
c. Over-all manager of the unit
d. Patient advocate in the health care team
Answer: B
Rationale: The associate nurse in primary nursing is
responsible for the over-all care of the patient during off
days of the primary nurse. Associates provide some
care, but the primary nurse coordinates it and
communicates information about the patient's health to
other nurses and other health professionals.
90. The primary nurse was asked what “Pareto
Principle” is. She is correct when she answered the
following, except:
a. 20% of your production is because of your 80%
priorities
b. 20% of your priorities will give you 80% of your
production
c. Energy, time, money and personnel are on the top
20% of the immediate needs
d. It is also known as the 20/80 principle
Answer: A
Rationale: Pareto principle, also known as the 20/80
principle, states that 20% of a person's priorities will
give
80% of that person's production with energy, time,
money and personnel belonging to the top 20% of
priorities.
Situation 19. When nurses undertake to practice
their profession, they are held responsible and
accountable for the quality of performance of their
duties. The standard is a clearly defined, legal
expectation to which nurses are held accountable.
91. What is the best method for the assessment of fluid
volume increases?
a. Tissue turgor
b. Daily weight
c. Intake and output
d. Serum sodium
Answer: B
Rationale: The best method for assessment of fluid
volume increases is a daily weight measurement.
92. In which situation would the prophylactic use of
antibiotics be inappropriate?
a. Neutropenia following cancer chemotherapy
b. Emergency cesarean section
c. Fever of unknown origin in a patient with an intact
immune system
d. Following surgical debridement of an animal bite
Answer: C
Rationale: Fever is not always a clinical manifestation
of infection. The treatment of fever of unknown origin
with an antibiotic would be a potential misuse of the
drug.
• Options A, B and D are incorrect because
antibiotic can be used in these situations
prophylactically.
93. Which patient would be most appropriate to assign
to a private room?
a. Archipela Go who has been diagnosed as HIV
positive
b. Chica Go with a stage II sacral pressure ulcer
c. Bing Go who is admitted with fever of unknown origin
d. Rilla Go who is expected to die within the next 24
hours
Answer: D
Rationale: The patient who is dying should be given
the private room. A private room will allow privacy for
the patient and family. The family could stay with the
patient or come and go as needed.
94. Which actions should the nurse take to ensure the
accuracy of a telephone order, except?
a. Record the name of prescriber, the date and time of
the order, and the nurse’s signature and title
b. The co-signature of the ordering healthcare provider
must be obtained within 48 hours of the original order
c. Repeat the order back to the physician after it is
written in the medical record for confirmation
d. Limit the use of telephone orders to emergency
situations or when it is impossible for the healthcare
provider to actually write the order
Answer: B
Rationale: A telephone order is a form of verbal order.
Verbal orders are issued in an emergency or in
situations when it is impossible for a healthcare
provider to write the order (option D).
 • The order should be given to a icensed nurse
and must be repeated back to the healthcare
provider after it is written to ensure its
accuracy (option C).
• When documenting the order, the name of the
healthcare provider who issued the order, the
date and time of the order, and the signature
and title of the nurse who accepted the order
are written (option A).
• Option B is incorrect because the order
should be written on an order sheet and co-
signed by the healthcare provider within a 24-
hour, not 48-hour, period.

95. A patient has dysphagia. Which nursing action is

most appropriate for this patient?

a. Elevate the head of the bed, and observe for signs

of aspiration
b. Ensure an emesis basin is available, and plan to
administer an antiemetic if needed
c. Monitor intake and output, and encourage fluid
intake
d. Prepare for the insertion of subclavian venous
catheter for parenteral nutrition

Answer: A
Rationale: Dysphagia is the medical term for difficulty
swallowing. The head of the bed should be elevated,
and the patient observed for signs of aspiration.
• Option B is incorrect because patients with
dysphagia have difficulty swallowing, there’s
no need for an antiemetic because of
absence in emesis.
• Option C is incorrect because encouraging
the patient of fluid intake can make the patient
at risk of aspiration.
• Option D is incorrect because parenteral
nutrition is not needed.

Situation 20. Consider the following hypothesis:

“The job dissatisfaction levels and job turnover
rate of graduate nurses who have worked less than
2 years is higher than for those graduate nurses
who have worked for more than 2 years.”

96. The major reason for conducting nursing research

is to:
a. Promote the growth of the nursing profession
b. Ensure accountability of nursing practice
c. Document the cost effectiveness of nursing care
d. Improve nursing care

Answer: D
Rationale: The goal of nursing research is to improve
the