Professional Documents
Culture Documents
Practice Exam in Nursing Set F
Practice Exam in Nursing Set F
Practice Exam in Nursing Set F
Randy has undergone kidney transplant, what assessment would prompt Nurse Katrina to
suspect organ rejection?
b. Polyuria
c. Hypertension
d. Shock
2. The immediate objective of nursing care for an overweight, mildly hypertensive male
client with ureteral colic and hematuria is to decrease:
a. Pain
b. Weight
c. Hematuria
d. Hypertension
4. Ricardo, was diagnosed with type I diabetes. The nurse is aware that acute hypoglycemia
also can develop in the client who is diagnosed with:
a. Liver disease
b. Hypertension
c. Type 2 diabetes
d. Hyperthyroidism
b. Nystagmus
c. Leukopenia
d. Polycythemia
6. Norma, with recent colostomy expresses concern about the inability to control the
passage of gas. Nurse Oliver should suggest that the client plan to:
7. Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse
would evaluate that the instructions were understood when the client states, “I should:
b. Keep the irrigating container less than 18 inches above the stoma.”
d. Insert the irrigating catheter deeper into the stoma if cramping occurs during the procedure.”
8. Patrick is in the oliguric phase of acute tubular necrosis and is experiencing fluid and
electrolyte imbalances. The client is somewhat confused and complains of nausea and
muscle weakness. As part of the prescribed therapy to correct this electrolyte imbalance,
the nurse would expect to:
a. Administer Kayexalate
a. 18 gtt/min
b. 28 gtt/min
c. 32 gtt/min
d. 36 gtt/min
10. Terence suffered from burn injury. Using the rule of nines, which has the largest percent
of burns?
d. Upper trunk
11. Herbert, a 45 year old construction engineer is brought to the hospital unconscious after
falling from a 2-story building. When assessing the client, the nurse would be most
concerned if the assessment revealed:
a. Reactive pupils
b. A depressed fontanel
d. An elevated temperature
12. Nurse Sherry is teaching male client regarding his permanent artificial pacemaker.
Which information given by the nurse shows her knowledge deficit about the artificial
cardiac pacemaker?
a. take the pulse rate once a day, in the morning upon awakening
13. The nurse is ware that the most relevant knowledge about oxygen administration to a
male client with COPD is
b. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath.
14. Tonny has undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are
inserted, and one-bottle water-seal drainage is instituted in the operating room. In the
postanesthesia care unit Tonny is placed in Fowler’s position on either his right side or on
his back. The nurse is aware that this position:
15. Kristine is scheduled for a bronchoscopy. When teaching Kristine what to expect
afterward, the nurse’s highest priority of information would be:
16. Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect
hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
a. hypernatremia.
b. hypokalemia.
c. hyperkalemia.
d. hypercalcemia.
17. Ms. X has just been diagnosed with condylomata acuminata (genital warts). What
information is appropriate to tell this client?
a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a
Papanicolaou (Pap) smear annually.
b. The most common treatment is metronidazole (Flagyl), which should eradicate the problem
within 7 to 10 days.
c. The potential for transmission to her sexual partner will be eliminated if condoms are used
every time they have sexual intercourse.
d. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted
during oral sex.
18. Maritess was recently diagnosed with a genitourinary problem and is being examined in
the emergency department. When palpating the her kidneys, the nurse should keep which
anatomical fact in mind?
a. The left kidney usually is slightly higher than the right one.
c. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾” to 1-1/8″) wide.
d. The kidneys lie between the 10th and 12th thoracic vertebrae.
19. Jestoni with chronic renal failure (CRF) is admitted to the urology unit. The nurse is
aware that the diagnostic test are consistent with CRF if the result is:
c. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/ dl.
d. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%.
20. Katrina has an abnormal result on a Papanicolaou test. After admitting that she read her
chart while the nurse was out of the room, Katrina asks what dysplasia means. Which
definition should the nurse provide?
a. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of
their origin.
c. Replacement of one type of fully differentiated cell by another in tissues where the second type
normally isn’t found.
21. During a routine checkup, Nurse Marianne assesses a male client with acquired
immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most
common AIDS-related cancer?
b. Multiple myeloma
c. Leukemia
d. Kaposi’s sarcoma
22. Ricardo is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal
(subarachnoid) block during surgery. In the operating room, the nurse positions the client
according to the anesthesiologist’s instructions. Why does the client require special
positioning for this type of anesthesia?
a. To prevent confusion
b. To prevent seizures
23. A male client had a nephrectomy 2 days ago and is now complaining of abdominal
pressure and nausea. The first nursing action should be to:
25. A male client with inflammatory bowel disease undergoes an ileostomy. On the first day
after surgery, Nurse Oliver notes that the client’s stoma appears dusky. How should the
nurse interpret this finding?
26. Anthony suffers burns on the legs, which nursing intervention helps prevent
contractures?
27. Nurse Ron is assessing a client admitted with second- and third-degree burns on the
face, arms, and chest. Which finding indicates a potential problem?
29. Nurse Maria plans to administer dexamethasone cream to a female client who has
dermatitis over the anterior chest. How should the nurse apply this topical agent?
c. In long, even, outward, and downward strokes in the direction of hair growth
d. In long, even, outward, and upward strokes in the direction opposite hair growth
30. Nurse Kate is aware that one of the following classes of medication protect the ischemic
myocardium by blocking catecholamines and sympathetic nerve stimulation is:
c. Narcotics
d. Nitrates
31. A male client has jugular distention. On what position should the nurse place the head of
the bed to obtain the most accurate reading of jugular vein distention?
a. High Fowler’s
b. Raised 10 degrees
c. Raised 30 degrees
d. Supine position
32. The nurse is aware that one of the following classes of medications maximizes cardiac
performance in clients with heart failure by increasing ventricular contractility?
a. Beta-adrenergic blockers
c. Diuretics
d. Inotropic agents
33. A male client has a reduced serum high-density lipoprotein (HDL) level and an elevated
low-density lipoprotein (LDL) level. Which of the following dietary modifications is not
appropriate for this client?
34. A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with
an acute myocardial infarction. Which of the following actions would breach the client
confidentiality?
a. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the
client to that unit
b. The CCU nurse notifies the on-call physician about a change in the client’s condition
c. The emergency department nurse calls up the latest electrocardiogram results to check the
client’s progress.
d. At the client’s request, the CCU nurse updates the client’s wife on his condition
a. Start an L.V. line and administer amiodarone (Cardarone), 300 mg L.V. over 10 minutes.
36. After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse Katrina
determines that mean arterial pressure (MAP) is which of the following?
a. 46 mm Hg
b. 80 mm Hg
c. 95 mm Hg
d. 90 mm Hg
37. A female client arrives at the emergency department with chest and stomach pain and a
report of black tarry stool for several months. Which of the following order should the nurse
Oliver anticipate?
b. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split product values.
c. Electrocardiogram, complete blood count, testing for occult blood, comprehensive serum
metabolic panel.
38. Macario had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the
following conditions is suspected by the nurse when a decrease in platelet count from
230,000 ul to 5,000 ul is noted?
a. Pancytopenia
39. Which of the following drugs would be ordered by the physician to improve the platelet
count in a male client with idiopathic thrombocytopenic purpura (ITP)?
c. Methotrezate
d. Vitamin K
40. A female client is scheduled to receive a heart valve replacement with a porcine valve.
Which of the following types of transplant is this?
a. Allogeneic
b. Autologous
c. Syngeneic
d. Xenogeneic
41. Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the
initial response to the injury in the extrinsic pathway?
a. Release of Calcium
42. Instructions for a client with systemic lupus erythematosus (SLE) would include
information about which of the following blood dyscrasias?
a. Dressler’s syndrome
b. Polycythemia
c. Essential thrombocytopenia
43. The nurse is aware that the following symptoms is most commonly an early indication of
stage 1 Hodgkin’s disease?
a. Pericarditis
b. Night sweat
c. Splenomegaly
d. Persistent hypothermia
44. Francis with leukemia has neutropenia. Which of the following functions must
frequently assessed?
a. Blood pressure
b. Bowel sounds
c. Heart sounds
d. Breath sounds
45. The nurse knows that neurologic complications of multiple myeloma (MM) usually
involve which of the following body system?
a. Brain
b. Muscle spasm
c. Renal dysfunction
d. Myocardial irritability
46. Nurse Patricia is aware that the average length of time from human immunodeficiency
virus (HIV) infection to the development of acquired immunodeficiency syndrome (AIDS)?
b. 5 to 7 years
c. 10 years
47. An 18-year-old male client admitted with heat stroke begins to show signs of
disseminated intravascular coagulation (DIC). Which of the following laboratory findings is
most consistent with DIC?
48. Mario comes to the clinic complaining of fever, drenching night sweats, and unexplained
weight loss over the past 3 months. Physical examination reveals a single enlarged
supraclavicular lymph node. Which of the following is the most probable diagnosis?
a. Influenza
c. Leukemia
d. Hodgkin’s disease
49. A male client with a gunshot wound requires an emergency blood transfusion. His blood
type is AB negative. Which blood type would be the safest for him to receive?
a. AB Rh-positive
b. A Rh-positive
c. A Rh-negative
d. O Rh-positive
Situation: Stacy is diagnosed with acute lymphoid leukemia (ALL) and beginning chemotherapy.
50. Stacy is discharged from the hospital following her chemotherapy treatments. Which
statement of Stacy’s mother indicated that she understands when she will contact the
physician?
d. “Should Stacy have continued hair loss, I need to call the doctor”.
51. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best
response for the nurse is:
b. “You should not worry about her hair, just be glad that she is alive”.
c. “Yes it is upsetting. But try to cover up your feelings when you are with her or else she may be
upset”.
d. “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may be different in
texture”.
52. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse in-
charge should:
53. During the administration of chemotherapy agents, Nurse Oliver observed that the IV
site is red and swollen, when the IV is touched Stacy shouts in pain. The first nursing action
to take is:
54. The term “blue bloater” refers to a male client which of the following conditions?
b. Asthma
d. Emphysema
55. The term “pink puffer” refers to the female client with which of the following
conditions?
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
a. 15 mm Hg
b. 30 mm Hg
c. 40 mm Hg
d. 80 mm Hg
57. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2
46 mm Hg; HCO3- 24 mEq/L; Sao2 81%. This ABG result represents which of the following
conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
58. Norma has started a new drug for hypertension. Thirty minutes after she takes the drug,
she develops chest tightness and becomes short of breath and tachypneic. She has a
decreased level of consciousness. These signs indicate which of the following conditions?
a. Asthma attack
b. Pulmonary embolism
c. Respiratory failure
d. Rheumatoid arthritis
Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out
cirrhosis of the liver:
60. The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at
increased risk for excessive bleeding primarily because of:
b. Varix formation
c. Inadequate nutrition
61. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most
common with this condition?
d. Hypotension
62. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactulose p.o.
every 2 hours. Mr. Gonzales develops diarrhea. The nurse best action would be:
b. “Maybe you’re reacting to the drug; I will withhold the next dose”.
c. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
63. Which of the following groups of symptoms indicates a ruptured abdominal aortic
aneurysm?
a. Lower back pain, increased blood pressure, decreased re blood cell (RBC) count, increased
white blood (WBC) count.
b. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC
count.
c. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC
count, decreased WBC count.
d. Intermittent lower back pain, decreased blood pressure, decreased RBC count, increased WBC
count.
64. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his
buttocks. Which of the following steps should the nurse take first?
65. Which of the following treatment is a suitable surgical intervention for a client with
unstable angina?
a. Cardiac catheterization
b. Echocardiogram
c. Nitroglycerin
66. The nurse is aware that the following terms used to describe reduced cardiac output and
perfusion impairment due to ineffective pumping of the heart is:
a. Anaphylactic shock
b. Cardiogenic shock
c. Distributive shock
67. A client with hypertension ask the nurse which factors can cause blood pressure to drop
to normal levels?
a. Kidneys’ excretion to sodium only.
68. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is
administered to treat hypertension is:
69. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus
erythematosus (SLE) is:
70. Arnold, a 19-year-old client with a mild concussion is discharged from the emergency
department. Before discharge, he complains of a headache. When offered acetaminophen,
his mother tells the nurse the headache is severe and she would like her son to have
something stronger. Which of the following responses by the nurse is appropriate?
b. “Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.”
c. “Narcotics are avoided after a head injury because they may hide a worsening condition.”
d. Stronger medications may lead to vomiting, which increases the intracranial pressure (ICP).”
71. When evaluating an arterial blood gas from a male client with a subdural hematoma, the
nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the
result?
c. Normal
72. When prioritizing care, which of the following clients should the nurse Olivia assess first?
73. JP has been diagnosed with gout and wants to know why colchicine is used in the
treatment of gout. Which of the following actions of colchicines explains why it’s effective
for gout?
a. Replaces estrogen
b. Decreases infection
c. Decreases inflammation
74. Norma asks for information about osteoarthritis. Which of the following statements
about osteoarthritis is correct?
a. Exophthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema
76. Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the
nurse report to the physician immediately?
d. Frequent urination
77. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive
care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour,
leading the nurse to suspect diabetes insipidus. Which laboratory findings support the
nurse’s suspicion of diabetes insipidus?
a. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to
urinate, drink, or eat more than usual.”
b. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains
sugar.”
c. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly
elevated.”
d. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”
79. A 66-year-old client has been complaining of sleeping more, increased urination,
anorexia, weakness, irritability, depression, and bone pain that interferes with her going
outdoors. Based on these assessment findings, the nurse would suspect which of the
following disorders?
a. Diabetes mellitus
b. Diabetes insipidus
c. Hypoparathyroidism
d. Hyperparathyroidism
80. Nurse Lourdes is teaching a client recovering from addisonian crisis about the need to
take fludrocortisone acetate and hydrocortisone at home. Which statement by the client
indicates an understanding of the instructions?
b. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
c. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
81. Which of the following laboratory test results would suggest to the nurse Len that a
client has a corticotropin-secreting pituitary adenoma?
83. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed
with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according
to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he
receives 8 U of regular insulin. Nurse Mariner should expect the dose’s:
84. The physician orders laboratory tests to confirm hyperthyroidism in a female client with
classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?
a. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH
stimulation test
c. An increase in the TSH level after 30 minutes during the TSH stimulation test
d. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by
radioimmunoassay
85. Rico with diabetes mellitus must learn how to self-administer insulin. The physician has
prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH)
to be taken before breakfast. When teaching the client how to select and rotate insulin
injection sites, the nurse should provide which instruction?
a. “Inject insulin into healthy tissue with large blood vessels and nerves.”
b. “Rotate injection sites within the same anatomic region, not among different regions.”
d. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”
86. Nurse Sarah expects to note an elevated serum glucose level in a client with
hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding
should the nurse anticipate?
c. Serum alkalosis
87. For a client with Graves’ disease, which nursing intervention promotes comfort?
88. Patrick is treated in the emergency department for a Colles’ fracture sustained during a
fall. What is a Colles’ fracture?
89. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development
of this disorder?
90. Johnny a firefighter was involved in extinguishing a house fire and is being treated to
smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring
intubation and mechanical ventilation. He most likely has developed which of the following
conditions?
b. Atelectasis
c. Bronchitis
d. Pneumonia
91. A 67-year-old client develops acute shortness of breath and progressive hypoxia
requiring right femur. The hypoxia was probably caused by which of the following
conditions?
a. Asthma attack
b. Atelectasis
c. Bronchitis
d. Fat embolism
92. A client with shortness of breath has decreased to absent breath sounds on the right
side, from the apex to the base. Which of the following conditions would best explain this?
a. Acute asthma
b. Chronic bronchitis
c. Pneumonia
d. Spontaneous pneumothorax
93. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s
now in the emergency department complaining of difficulty of breathing and chest pain. On
auscultation of his lung field, no breath sounds are present in the upper lobe. This client
may have which of the following conditions?
a. Bronchitis
b. Pneumonia
c. Pneumothorax
d. Tuberculosis (TB)
94. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
d. The tissue from the other lung grows over to the other side
95. Hemoptysis may be present in the client with a pulmonary embolism because of which of
the following reasons?
96. Alvin with a massive pulmonary embolism will have an arterial blood gas analysis
performed to determine the extent of hypoxia. The acid-base disorder that may be present
is?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
97. After a motor vehicle accident, Armand an 22-year-old client is admitted with a
pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system.
Bubbling soon appears in the water seal chamber. Which of the following is the most likely
cause of the bubbling?
a. Air leak
b. Adequate suction
c. Inadequate suction
98. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives
3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop
factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how
many drops per minute?
a. 18
b. 21
c. 35
d. 40
99. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive
heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin
contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to
the child?
a. 1.2 ml
b. 2.4 ml
c. 3.5 ml
d. 4.2 ml
100. Nurse Alexandra teaches a client about elastic stockings. Which of the following
statements, if made by the client, indicates to the nurse that the teaching was successful?
a. “I will wear the stockings until the physician tells me to remove them.”
c. “Every four hours I should remove the stockings for a half hour.”
d. “I should put on the stockings before getting out of bed in the morning.”
Answers and Rationale
Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection.
Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by urethral
distention and smooth muscle spasm; relief from pain is the priority.
3. Answer: (D) Decrease the size and vascularity of the thyroid gland.
Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland,
which limits the risk of hemorrhage when surgery is performed.
The client with liver disease has a decreased ability to metabolize carbohydrates because of a
decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.
7. Answer: (B) Keep the irrigating container less than 18 inches above the stoma.”
This height permits the solution to flow slowly with little force so that excessive peristalsis is not
immediately precipitated.
Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the
intestine, reducing the serum potassium level.
9. Answer:(B) 28 gtt/min
This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10)
and divide the result by the amount of time in minutes (12 hours x 60 minutes)
The percentage designated for each burned part of the body using the rule of nines: Head and
neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk
18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.
The nurse needs to perform a thorough assessment that could indicate alterations in cerebral
function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs
only with basal skull fractures that can easily contribute to increased intracranial pressure
and brain herniation.
The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the
area of the pacemaker generator.
13. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing.
COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation
for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the
client oxygen in low concentrations will maintain the client’s hypoxic drive.
Since only a partial pneumonectomy is done, there is a need to promote expansion of this
remaining Left lung by positioning the client on the opposite unoperated side.
15. Answer: (A) Food and fluids will be withheld for at least 2 hours.
Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the
gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink
after the procedure without checking on the return of the gag reflex can cause the client to
aspirate. The gag reflex usually returns after two hours.
17. Answer: (A) This condition puts her at a higher risk for cervical cancer; therefore, she
should have a Papanicolaou (Pap) smear annually.
Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap
smears are very important for early detection. Because condylomata acuminata is a virus, there is
no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won’t
protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth,
oropharynx, and larynx.
18. Answer: (A) The left kidney usually is slightly higher than the right one.
The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney.
The average kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2¼”) wide, and
2.5 cm (1″) thick. The kidneys are located retroperitoneally, in the posterior aspect of the
abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd
lumbar vertebrae.
19. Answer: (C) Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl.
The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to
1.5 mg/dl. The test results in option C are abnormally elevated, reflecting CRF and the kidneys’
decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH
and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium,
magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5
mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the
normal range of 60% to 75%.
20. Answer: (D) Alteration in the size, shape, and organization of differentiated cells
Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The
presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of
their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement
in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by
another in tissues where the second type normally isn’t found is called metaplasia.
21. Answer: (D) Kaposi’s sarcoma
Kaposi’s sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma,
multiple myeloma, and leukemia may occur in anyone and aren’t associated specifically with
AIDS.
The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and
headache and to ensure proper anesthetic distribution. Proper positioning doesn’t help prevent
confusion, seizures, or cardiac arrhythmias.
If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds.
If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these
findings must be reported to the physician. Palpation should be avoided postoperatively with
abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won’t
relieve the client’s discomfort.
24. Answer: (B) Lying on the left side with knees bent
For a colonoscopy, the nurse initially should position the client on the left side with knees bent.
Placing the client on the right side with legs straight, prone with the torso elevated, or bent over
with hands touching the floor wouldn’t allow proper visualization of the large intestine.
25. Answer: (A) Blood supply to the stoma has been interrupted
An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin,
creating an artificial opening for waste elimination. The stoma should appear cherry red,
indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may
result from interruption of the stoma’s blood supply and may lead to tissue damage or necrosis. A
dusky stoma isn’t a normal finding. Adjusting the ostomy bag wouldn’t affect stoma color, which
depends on blood supply to the area. An intestinal obstruction also wouldn’t change stoma color.
Applying knee splints prevents leg contractures by holding the joints in a position of function.
Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the
joints in a position of function. Hyperextending a body part for an extended time is
inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises
can prevent contractures in the shoulders, but not in the legs.
A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This
client’s PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions
also are normal. The client’s rectal temperature isn’t significantly elevated and probably results
from the fluid volume deficit.
The most important intervention to prevent pressure ulcers is frequent position changes, which
relieve pressure on the skin and underlying tissues. If pressure isn’t relieved, capillaries become
occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer
formation. During passive ROM exercises, the nurse moves each joint through its range of
movement, which improves joint mobility and circulation to the affected area but doesn’t prevent
pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue
repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed
position.
29. Answer: (C) In long, even, outward, and downward strokes in the direction of hair
growth
When applying a topical agent, the nurse should begin at the midline and use long, even,
outward, and downward strokes in the direction of hair growth. This application pattern reduces
the risk of follicle irritation and skin inflammation.
Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the
response to catecholamines and sympathetic nerve stimulation. They protect the myocardium,
helping to reduce the risk of another infraction by decreasing myocardial oxygen demand.
Calcium channel blockers reduce the workload of the heart by decreasing the heart rate.
Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety.
Nitrates reduce myocardial oxygen consumption but decreases left ventricular end diastolic
pressure (preload) and systemic vascular resistance (afterload).
Inotropic agents are administered to increase the force of the heart’s contractions, thereby
increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic
blockers and calcium channel blockers decrease the heart rate and ultimately decreased
the workload of the heart. Diuretics are administered to decrease the overall vascular volume,
also decreasing the workload of the heart.
A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories
from fat. The other modifications are appropriate for this client.
34. Answer: (C) The emergency department nurse calls up the latest electrocardiogram
results to check the client’s progress
The emergency department nurse is no longer directly involved with the client’s care and thus
has no legal right to information about his present condition. Anyone directly involved in his care
(such as the telemetry nurse and the on-call physician) has the right to information about his
condition. Because the client requested that the nurse update his wife on his condition, doing so
doesn’t breach confidentiality.
ET tube placement should be confirmed as soon as the client arrives in the emergency
department. Once the airways is secured, oxygenation and ventilation should be confirmed using
an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure L.V.
access is established. If the client experiences symptomatic bradycardia, atropine is administered
as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should try to find the
cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular
tachycardia, ventricular fibrillation and atrial flutter – not symptomatic bradycardia.
MAP=286 mm HG
MAP=95 mm Hg
37. Answer: (C) Electrocardiogram, complete blood count, testing for occult blood,
comprehensive serum metabolic panel.
HATT may occur after CABG surgery due to heparin use during surgery. Although DIC and ITP
cause platelet aggregation and bleeding, neither is common in a client after revascularization
surgery. Pancytopenia is a reduction in all blood cells.
Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-
coated platelets, retaining more functioning platelets. Methotrexate can cause
thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin
overload, and ASA decreases platelet aggregation.
Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors.
Calcium is released to assist the conversion of factors X to Xa. Conversion of factors XII to XIIa and
VIII to VIII a are part of the intrinsic pathway.
In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night
sweats, malaise, and generalized pruritus. Although splenomegaly may be present in some
clients, night sweats are generally more prevalent. Pericarditis isn’t associated with Hodgkin’s
disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms.
Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease.
Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so
frequent assessment of respiratory rate and breath sounds is required. Although assessing blood
pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia.
Back pain or paresthesia in the lower extremities may indicate impending spinal cord
compression from a spinal tumor. This should be recognized and treated promptly as progression
of the tumor may result in paraplegia. The other options, which reflect parts of the nervous
system, aren’t usually affected by MM.
In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive
bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin
degradation products increase as fibrinolysis takes places.
Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph node enlargement.
Influenza doesn’t last for months. Clients with sickle cell anemia manifest signs and symptoms of
chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for
exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement. Leukemia
doesn’t cause lymph node enlargement.
Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-
positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a
person with Rh-negative blood receives Rh-negative blood. If Rh-positive blood is administered to
an Rh-negative person, the recipient develops anti-Rh agglutinins, and subsequent transfusions
with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood
cells.
50. Answer: (B) “I will call my doctor if Stacy has persistent vomiting and diarrhea”.
Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the
patient should stop the medication and notify the health care provider. The other manifestations
are expected side effects of chemotherapy.
51. Answer: (D) “This is only temporary; Stacy will re-grow new hair in 3-6 months, but may
be different in texture”.
This is the appropriate response. The nurse should help the mother how to cope with her own
feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows
back, it is still of the same color and texture.
Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is
leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by
pressure and the IV solution. The first action of the nurse would be to discontinue the infusion
right away to prevent further edema and other complication.
Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and
peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are
acutely short of breath and frequently need intubation for mechanical ventilation and
large amount of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and
clients with emphysema appear pink and cachectic.
Because of the large amount of energy it takes to breathe, clients with emphysema are usually
cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.” Clients
with ARDS are usually acutely short of breath. Clients with asthma don’t have any particular
characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in
appearance.
56. Answer: D 80 mm Hg
A client about to go into respiratory arrest will have inefficient ventilation and will be retaining
carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than
expected.
Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has
respiratory acidosis. The pH is less than 7.35, academic, which eliminates metabolic and
respiratory alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would have
metabolic acidosis.
58. Answer: (C) Respiratory failure
The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could
lead to eventually respiratory failure. Although the signs are also related to an asthma attack or a
pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesn’t manifest these
signs.
Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate
aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a
chronic and irreversible disease of the liver characterized by generalized inflammation and
fibrosis of the liver tissues.
Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors
resulting in impaired clotting mechanism.
Changes in behavior and level of consciousness are the first signs of hepatic encephalopathy.
Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to
convert protein metabolic product ammonia to urea. This results in accumulation of ammonia
and other toxic in the blood that damages the cells.
62. Answer: (C) “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
63. Answer: (B) Severe lower back pain, decreased blood pressure, decreased RBC count,
increased WBC count.
Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied
within the abdominal cavity. When ruptured occurs, the pain is constant because it can’t be
alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After
the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure
wouldn’t increase. For the same reason, the RBC count is decreased – not increased. The WBC
count increases as cell migrate to the site of injury.
64. Answer: (D) Apply gloves and assess the groin site
Observing standard precautions is the first priority when dealing with any blood fluid. Assessment
of the groin site is the second priority. This establishes where the blood is coming from and
determines how much blood has been lost. The goal in this situation is to stop the bleeding. The
nurse would call for help if it were warranted after the
assessment of the situation. After determining the extent of the bleeding, vital signs assessment is
important. The nurse should never move the client, in case a clot has formed. Moving can disturb
the clot and cause rebleeding.
PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a
noninvasive diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheterization
is a diagnostic tool – not a treatment.
Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results
from an allergic reaction. Distributive shock results from changes in the intravascular volume
distribution and is usually associated with increased cardiac output. MI isn’t a shock state, though
a severe MI can lead to shock.
The kidneys respond to rise in blood pressure by excreting sodium and excess water. This
response ultimately affects systolic blood pressure by regulating blood volume. Sodium or water
retention would only further increase blood pressure. Sodium and water travel together across
the membrane in the kidneys; one can’t travel without the other.
68. Answer: (D) It inhibits reabsorption of sodium and water in the loop of Henle.
Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle,
thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood
vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic
blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensin-
converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.
69. Answer: (C) Pancytopenia, elevated antinuclear antibody (ANA) titer
Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and
decreased serum complement levels. Clients may have elevated BUN and creatinine levels
from nephritis, but the increase does not indicate SLE.
70. Answer: (C) Narcotics are avoided after a head injury because they may hide a worsening
condition.
Narcotics may mask changes in the level of consciousness that indicate increased ICP and
shouldn’t acetaminophen is strong enough ignores the mother’s question and therefore isn’t
appropriate. Aspirin is contraindicated in conditions that may have bleeding, such as trauma,
and for children or young adults with viral illnesses due to the danger of Reye’s syndrome.
Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby
masking changes in his level of consciousness.
71. Answer: (A) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure
(ICP)
72. Answer: (B) A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
77. Answer: (D) Below-normal urine osmolality level, above-normal serum osmolality level
In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine
osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that
leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus
doesn’t cause above-normal urine osmolality or below-normal serum osmolality levels.
78. Answer: (A) “I can avoid getting sick by not becoming dehydrated and by paying
attention to my need to urinate, drink, or eat more than usual.”
Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the
signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the
client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate
for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually
doesn’t need to monitor blood glucose levels. A high carbohydrate diet would exacerbate the
client’s condition, particularly if fluid intake is low.
Hyperparathyroidism is most common in older women and is characterized by bone pain and
weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercalciuria-causing
polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they
don’t have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary
frequency rather than polyuria.
80. Answer: (C) “I’ll take two-thirds of the dose when I wake up and one-third in the late
afternoon.”
A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels.
A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol
level would be associated with hypocortisolism. Low corticotropin and high cortisol levels would
be seen if there was a primary defect in the adrenal glands.
The nurse should perform capillary glucose testing every 4 hours because excess cortisol may
cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn’t
indicated because the client does secrete insulin and, therefore, isn’t at risk for ketosis. Urine
specific gravity isn’t indicated because although fluid balance can be compromised, it usually
isn’t dangerously imbalanced. Temperature regulation may be affected by excess cortisol and
isn’t an accurate indicator of infection.
83. Answer: (C) onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to
4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m.
to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.
84. Answer: (A) No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes
during the TSH stimulation test
In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A
decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3
and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also
occurs in malnutrition and liver disease and may result from administration of phenytoin and
certain other drugs.
85. Answer: (B) “Rotate injection sites within the same anatomic region, not among
different regions.”
The nurse should instruct the client to rotate injection sites within the same anatomic region.
Rotating sites among different regions may cause excessive day-to-day variations in the blood
glucose level; also, insulin absorption differs from one region to the next. Insulin should be
injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other
deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn’t
inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent
lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug
absorption, so the client shouldn’t inject insulin into sites above muscles that will be exercised
heavily.
A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs
secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An
elevated serum acetone level and serum ketone bodies are characteristic of diabetic
ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance,
diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance
and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range.
To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral
fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort.
To provide needed energy and calories, the nurse should encourage the client to eat high-
carbohydrate foods.
Colles’ fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It’s
most common in women. Colles’ fracture doesn’t refer to a fracture of the olecranon, humerus, or
carpal scaphoid.
Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed
aren’t typically associated with smoke inhalation and severe hypoxia.
Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia.
It’s unlikely the client has developed asthma or bronchitis without a previous history. He
could develop atelectasis but it typically doesn’t produce progressive hypoxia.
A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute
decreased in the amount of functional lung used in oxygenation. The sudden collapse was the
cause of his chest pain and shortness of breath. An asthma attack would show wheezing
breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath
sounds over the area of consolidation.
From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi
with bronchitis, bronchial breath sounds with TB would be heard.
94. Answer: (C) Serous fluids fills the space and consolidates the region
Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of
the heart and remaining lung. Air can’t be left in the space. There’s no gel that can be placed in
the pleural space. The tissue from the other lung can’t cross the mediastinum, although a
temporary mediastinal shift exits until the space is filled.
The infarcted area produces alveolar damage that can lead to the production of bloody sputum,
sometimes in massive amounts. Clot formation usually occurs in the legs. There’s a loss of lung
parenchyma and subsequent scar tissue formation.
Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In
pneumothorax an air leak can occur as air is pulled from the pleural space. Bubbling doesn’t
normally occur with either adequate or inadequate suction or any preexisting bubbling in the
water seal chamber.
100. Answer: (D) “I should put on the stockings before getting out of bed in the morning.