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Practice Nursing test with answers and a.

Eat a three balanced meal


rationale everyday

1. When assessing a client with chest b. Stop taking the drug when the
pain, the nurse obtains a thorough symptoms subside
history. Which statement of the
patient is most suggestive of anginal c. Avoid aspirin and products that
pectoris? contain aspirin

a. The pain lasted for about 45 d. Increase the intake of fluids


minutes containing caffeine

b. The pain resolved after I ate 5. The nurse is assessing a client with
sandwich Cushing’s disease. Which observation
should be reported to the physician
c. The pain worsened when I took a immediately.
deep breath
a. Pitting edema of the legs
d. The pain occurred while I was
mowing the loan b. Irregular apical pulse

2. After experiencing a transient c. Dry mucous membrane


ischaemic attack (TIA), a client is d. Frequent urination
prescribed aspirin 80 mg p.o daily. The
nurse should teach the client that this 6. A client with myasthenia gravis is
medication has been prescribed to receiving continuous mechanical
ventilation. When the high pressure
a. Control headache pain alarm on the ventilator sounds, what
b. Enhance immune response should the nurse do?

c. Prevent intracranial bleeding a. Check the presence of the apical


pulse
d. Decrease platelet coagulation
b. Suction the patient’s artificial
3. The physician prescribes several drugs airway
for a client with hemorrhagic stroke .
which drug order should the nurse c. Increase the oxygen percentage
question. d. Ventilate using a manual
a. Heparin sodiim (heplock) resuscitation bag

b. Dexamethasone ( decadron) 7. Which of the following takes the


highest priority for parkinson’s crisis?
c. Methyldopa (aldomet)
a. Altered nutrition: less than body
d. Phentoin (dilantin) requirements

4. A client with peptic ulcer is about to b. Ineffective airway clearance


begin a therapeutic regimen that
includes a bland diet,antacids and c. Altered urinary elimination
ranitindine hcl (zantac). Which d. Risk for injury
instructions should the nurse provide
before this client is discharged.
8. Which nursing diagnosis is most a. Fluid intake of less than 2500 ml in
appropriate for a client with Addison’s 24 hours
disease?
b. Urine output of more than 200
a. Risk for infection ml/hr

b. Fluid volume excess c. Blood p ressure of 90/50

c. Urinary retrention d. Pulse rate of 126 beats/min

d. Hypothermia 13.Which action should the nurse include


in the plan of care for a client with a
9. Which of these signs suggest that a fiberglass cast on the right hand?
client with Symptom if Inappropriate
Antidiuretic Hormone(SIADH) has a. Keep the casted arm with a light
developed complications? blanket

a. Titanic contractions b. Avoid handling the cast for 24 hrs


or until dry
b. Neck vein distention
c. Assess pedal and tibial pulses
c. Weight loss every 24 hrs
d. Polyuria d. Assess movement and sensation in
10.Which of these findings best the fingers of the right hand.
correlates with a diagnosis of 14.A client is admitted with a serum
osteoarthritis? glucose level of 618 mg/dl. The client
a. Joint stiffness that decreases with is awake and oriented, with hot, dry
activity skin, a temperature of 100.6 F(38.1
C)PR of 116 bpm, and BP of 108/70
b. Eythema and edema over the affected mmhg. Based on these findings, which
joints nursing diagnosis receive the highest
priority?
c. Anorexia and weight loss
a. Fluid volume deficit r/t osmotic
d. Fever and malaise diuresis
11.When communicating with a client b. Decreased cardiac output r/t
with (sensory) receptive aphasia, the increased HR
nurse should?
c. Altered nutrition : less than body
a. Allow time for the client to respond requirements r/t to insulin
deficiency
b. Speak loudly and articulate clearly
d. Ineffective thermoregulation r/t to
c. Give the client a writing pad
dehydration.
d. Use short, simple sentences
15.Which nursing action should take the
12.Which outcome indicates that highest priority when caring for a
treatment for diabetes insipidus is client with hemiparesis caused by
effective? cerebrovascular accident?
a. Perform passive range of motion mEq/L. which disorder these ABG
exercise values suggests?

b. Place the client on the affected a. Respiratory alkalosis


side
b. Respiratory acidosis
c. Use handrolls or pillows to support
c. Metabolic alkalosis
d. Apply antiembolic stockings
d. Metabolic acidosis
16.Then nurse should include which
instruction when teaching a client 20.A client is admitted to the ER with
about insulin administration? suspected overdose of unknown drug.
The client ABG values indicates
a. Administer insulin after the first respiratory acidosis, what should the
meal of the day nurse do first?

b. Administer insulin at a 45 degree a. Prepare to assist with ventilation


angle into the deltoid muscle
b. Monitor the client’s heart rhythm
c. Shake the vial of the insulin
vigorously before withdrawing the c. Prepare to begin gastric lavage
medication d. Obtain urine for drug screening
d. Draw up clear insulin when mixing 21.A client is being returned to the room
two types of insulin in one syringe. after subtotal thyroidectomy. Which
17.The nurse should expect a client with piece of equipment is important to the
hypothyroidism to report which of nurse to bring to the client’s bedside?
these health concerns? a. Indwelling folley catherer kit
a. Increased appetite and weight loss b. Tracheostomy set
b. Puffiness of the face and hands c. Cardiac monitor
c. Nervousness and tremors d. Humidifier
d. Increasing exophthalmos 22.Which of these findings is an early
18.A client with hypothyroidism is sign of bladder cancer?
receiving levothyroxine a. Painless hematuria
sodium(synthroid), 50 mcg. P.O daily.
Which of these findings should the b. Occasional polyria
nurse recognize as an adverse effect?
c. Nocturia
a. Dysuria
d. Dysuria
b. Leg cramps
23.Which statement from a client who
c. Tachycardia takes Nitroglycerin ( Nitrostat) as
needed for angina pain indicates that
d. Blurred vision further teaching is necessary?
19.A client ABG values are pH=7.12, a. I store the tablets in a dark bottle
PaCO2= 40 mmHg, and HCO3= 15
b. I take the tablet in a full glass of which laboratory test when caring for
water this patient?

c. I check for my tongue to tingle a. RBC count


when I take a tablet
b. Serum uric acid
d. I’ll go to the hospital if 3 tablets, 5
minutes apart don’t relieve the c. Serum potassium
pain 28.A client has been diagnosed with type
24.The nurse is assessing the puncture 1 insulin dependent DM. which client’s
site of a client who has received a comment correlates best with this
purified protein derivative test. Which disorder?
finding indicates a need for further a. I was thirsty all the time. I just
evaluation? couldn’t get enough to drink
a. 15 mm induration b. It seemed like I had no appetite. I
b. Reddened area had to get myself eat

c. 10 mm bruise c. I had cough and cold that jjust


didn’t seem to go away
d. Blister
d. I noticed a pain when I went to the
25.A client must take streptomycin bathromm
sulfate for TB. Before the therapy
begins, the nurse should inform the 29.A client is receing chemotherapy for
client to inform the physician if which breast cancer. Which assessment
of the following symptoms occur? finding indicates chemotherapy
induced fluid and electrolyte
a. Decreased color discrimination imbalance?

b. Increased urinary frequency a. Urine output of 400 ml in 8 hrs

c. Decreased hearing acuity b. Serum potassium level of 3.6


mEq/L
d. Increased appetite.
c. BP of 120/64 to 130/72 mmHg
26.During a late stage of AIDS, a client
demonstrates signs of AIDS related d. Dry oral mucous membrane and
dementia. The nurse should give cracked lips
highest nursing prioroity to which of
the following nursing diagnosis? 30.After chemotherapy, a client develops
N/V . for this client, the nurse should
a. Bathing or hygiene self care deficit give the highest priority to which
action in the plan of care?
b. Impaired cerebral perfusion
a. Serve small portions of bland food
c. Dysfunctional grieving
b. Encourage rhythmic breathing
d. Risk for injury exercise
27.A client with gout is receiving c. Administer metoclopromide and
Probenecid. The nurse should monitor dexamethasone as prescribed
d. Withould fluid for the the first 4-6 c. Consuming a high protein , high
hrs fiber diet

31.A client is receiving Zidovdine d. Taking only enteric medications


(Retrovir) to treat AIDS, for this client,
the nurse should monitor the value of 35.To prevent esophageal reflux in a
which laboratory test? client with hiatus hernia, the nurse
should provide which discharge
a. RBC count instructions?

b. Fasting blood glucose a. Lie down after meals to promote


digestion
c. Serum calcium
b. Avoid coffee and alcoholic
d. Platelet count beverages
32.A client seeks care for low back pain of c. Consuming low protein, high fiber
2 weeks duration. Which assessment diet
finding suggests a herniated
intervertebral disk? d. Limit fluids with meals

a. Pain that radiates down the posterior 36.A client with increasing difficulty
thigh swallowing , weight loss and fatigue
just received a diagnosis of
b. Back pain when the knees are flexed esophageal cancer. Because this client
c. Atrophy of the lower legs has difficulty swallowing, the nurse
should give the highest priority to
d. Positive Homan’s sign which action.

33.For a client with hepatitis b, the nurse a. Helping the client cope with body
should monitor closely for the onset image disturbance
development of which clinical
manifestation? b. Ensuring adequate nutrition

a. Jaundice c. Maintaining a patent airway

b. Arm and leg pruritus d. Preventing injury

c. Fatigue during ambulation 37.The nurse is caring for a client with


cirrhosis. Which manifestations
d. Irritability and drowsiness indicate deficient Vit. K absorption
caused by this liver disease?
34.A client is recovering from ileostomy
that was performed to treat a. Dyspnea and fatigue
inflammatory bowel disease. During
the teaching discharge, the nurse b. Ascites and orthopnea
should stress: c. Purpura nd petechaie
a. Increasing fluid intake to prevent d. Gynecosmastia and testicular
dehydration hypertrophy
b. Wearing appliance pouch only at 38.Two days ago, the client underwent an
bedtime autograft for secof and third degree
burns on the arms. Now the nurse a. Encourage oral feedings as soon as
finds the client doing arm ecxercise. possible
Te nurse knows that exercise should
be avoided because it may. b. Develop an alternative
communication method
a. Dislodge the autograft
c. Keep the tracheostomy cuff fully
b. Increase the edema in the arms inflated

c. Increase the amount of scarring d. Keep the client flat in bed

d. Decrease circulation of the fingers 42.After a left pneumonectomy, a client


has a chest tube for drainage. For this
39.A client with UTI receives a client, the nurse must
prescription for cotrimoxazole (Septra)
2 tablets P.O daily for 10 days. Which a. Monitor fluctuations in the water
observation best demonstrates that seal chamber
the client followed the prescribed
regimen? b. Clamp the chest tube once every
shift
a. Increase urine output to 2L in 24
hrs c. Encourage coughing and deep
breathing
b. Decreased flank and abdominal
discomfort d. Milk the chest tube every 2 hrs

c. Absence of bacteria on urine 43.A client reports sharp chest pain in the
culture right side of the chest and difficulty of
breathing and has respiratory rate of
d. Normal RBC count 40 bpm. Which goal should the nurse
consider as the top priority?
40.A client has undergone laryngectomy
and tracheostomy formation. Which a. Maintainance of adequate
instruction should the nurse give to circulatory volume
the client and family about the
operation? b. Maintainance of effective
respiration
a. The tracheostomy tube should be
cleaned with alcohol and water. c. Anxiety reduction

b. Family members should conitinue d. Pain reduction


to converse with the client 44.A client develops brigh red urine while
c. Oral intake should be limited to 1 receiveing heparin for pulmonary
week only embolus. What should the nurse do
first?
d. The amount of protein in the diet
should be limited a. Decrease the heparin infusion rate

41.When caring for a client who has just b. Prepare to administer protamine
had a total laryngectomy,the nurse sulfate
should plan to c. Monitor the paritial thromboplastin
time(PTT)
d. Stop the infusion for 2 hrs and start b. Notify the physician immediately
it at a lower dose as prescribed
c. Assess the irrigation catheter for
45.In a client is chronic bronchitis, which patency and drainage
sign should lead the nurse to suspect
right heart failure (cor pulmonale) d. Asminsiter meperidine 50 mg IM as
prescribe
a. Circumoral cyanosis
49.A client with arterial insuffieciency has
b. Bilateral crackels just undergone below knee
amputation of the right leg. Which
c. Productive cough action should the nurse include in the
d. Leg edema post op[ care plan?

46.When caring for a client with a. Elevate the stump fot the first 24
endotracheal tube, the nurse should hrs
consider which action to be the most b. Maintain the client on complete
important? bed rest
a. Auscultate the lungs for bilateral c. Appy heat to the stump as the
breath sounds client desires
b. Turning the client from side to side d. Remove the pressure dressing
every 2 hrs after the first 8 hrs
c. Monitor serial blood gas every 4 hrs 50.Which of these laboratory test is the
d. Provide frequent oral hygiene most accurate indicator of renal
function
47.The nurse administer albuterol
(Proventil) as prescribed to a client a. BUN
with emphysema. Which findings b. Creatinine clearance
indicate that the drug is producing a
therapeutic effect? c. Serum creatinine

a. RR of 22 bpm d. Urinalysis

b. Dialted and reactive pupils 51.Which nursing intervention is the most


important when caring for a client with
c. Urine output of 40 ml/hr acute pyelonphritis?
d. PR of 100 bpm a. Administer sitz bath twice a day
48.After transurethral resection of the b. Increase fluid intake to 3 L a day
prostate for benign prostatic
hypertrophy, a client returns to the c. Use an indwelling (folley) catheter
room with continous bladder irrigation. to measure urine output accurately
On the first day after surgery, the
client reports bladder pain, what d. Encourage the client to drink
should the nurse do first? cranberry juice to acidify the urine

a. Increase the IV flow rate


52.Which nursing intervention is the most c. Maintain bed rest for 72 hrs postop
important during the acute oliguric
phase of acuter renal failure? d. Turn the patient from side to side
using the log rolling technique
a. Encouraging coughing and deep
breathing exercise

b. Promoting carbohydrate intake 56.The nurse must total parenteral


nutrition(TPN) through a triple lumen
c. Limiting fluid intake catheter line. What can the nurse do
to prevent complications?
d. Controlling pain
a. Cover the catheter insertion site
53.A client with renal failure is with an occlusive dressing
undergoing continous ambulatory
peritoneal dialysis (CAPD). Which b. Use clean technique when
nursing diagnosis is most apporopriate changing the dressing
for this client?
c. Insert an indwelling urinary
a. Altered urinary elimination catheter

b. Toileting self care deficit d. Keep the client on complete bed


rest.
c. Sensory or perceptual alterations
57.The nurse assesses a client shortly
d. Dressing or grooming self care after kidney transplant surgery. Which
deficit postoperative finding should the nurse
54.A client is admitted with a cervical report to the physician immediately?
spine injury caused by a diving a. Serum potassium of 4.9 mEq/L
accident. When planning this client’s
care,the nurse should give which b. Serum sodium of 135 mEq/L
nursing diagnosis the highest priority?
c. Temperature of 99.2 F (37.3)
a. Impaired physical mobility
d. Urine output of 400 ml in 24 hrs
b. Ineffective breathing pattern
58.A cient is admitted with a gunshot
c. Sensory or perceptual alteration wound to the abdomen. After an
exploratory laparatomy, the client ,
d. Activity intolerance the client is transferred to the ICU.
55.The nurse is developing a plan of care Which assessment finding suggests
for a patient who has undergone a that the client now is developing acute
laminectomy to repair a herniated renal failure?
intervertebral disk. Which action a. BUN level of 22 mg/dl
should the nurse include?
b. Serum creatinine level of 1.2 mg/dl
a. Keep the pillow under the knees at
all time c. Temperature of 1.2 F

b. Place the client in a semi fowler’s d. Urine output of 400 ml in 24 hrs


position
59.A client seeks care for severe pain in a. Spironolactone (alsdactone)
the right upper quadrant of the
abdomen, which is accompanied by b. Phytonadione( mephyton)
nausea and vomiting. The physician c. Furosimide (Lasix)
makes a diagnosis of acute
cholecystitis and cholelithiasis. For this d. Warfarin (Coumadin)
client, which nursing diagnosis should
receive the highest priority? 63.The physician prescribes
spironolactone(Aldactone) 50 mg P.O
a. Pain r/t biliary spasm four times daily for a client with fluid
retention due to liver cirrhosis, which
b. Knowledge deficit r/t prevention of finding indicates that the drug is
recurrence producing a therapeutic effect?
c. Anxiety r/t unknown outcome of a. Serum K level of 3.5 mEq/L
hospitalization
b. Weight loss of 2 lb in 24 hrs
d. Altered nutrition: less than body
requirements r/t to biliary c. Serum Na level of 135 mEq/L
inflammatioin
d. Blood pH of 7.25
60.For a client with advanced liver
cirrhosis, which assessment finding 64.While preparing a client with for
best indicates deterioration of liver cholecystectomy, the nurse explains
function? that incentive spirometry will be used
after surgery. The nurse also should
a. Fatigue and muscke weakness tell the client the primary purplose of
incentive spirometry is:
b. ‘difficulty in arousal
a. Increases respiratory effectiveness
c. Nausea and anorexia
b. Preclude the need for nasogastric
d. Weight gain intubation
61.A client is admitted with increased c. Improve nutritional status during
ascites associated with cirrhosis. the recovery period
Which nursing diagnosis should
receive the highest priority? d. Decrease the amount of respiratory
anesthesia
a. Fatigue
65.A client is transferred to ICU after
b. Fluid volume excess evacuation of a subdural hematoma.
c. Ineffective breathing pattern To reduce the risk of increasing
intracranial pressure , the nurse
d. Altered nutrition: less than body should:
requirements
a. Encourage oral fluid intake
62.A client with advanced cirrhosis has a
prothrombin time of 15 seconds b. Suction the client once per shift
compared to a control time of 11 sec. c. Elevate the head of the bed to high
which drug should the nurse expect to fowlers
administer?
d. Administer a stool softener as a. Remove the weight once every
prescribed shift

66.Two days after repairing a client’s b. Maintain the bed in knee gatch
ruptured cerebral aneurysm, the position
physician orders mannitol (osmitro)
1.5 g/kg, to be infused over 60 c. Keep the client is a semi fowler’s
minutes. If the client weighs 175 lbs, position
how many grams of mannitol should d. Maintain traction in correct body
be administered? allignment
a. 263 g 70.A client who has just received a
b. 119 g diagnosis of early glaucoma is being
prepared for discharge. Which
c. 75g information should the nurse provide
during this client’s discharge teaching
d. 60 g session?
67.A client is receiving a n I.V infusion of a. Instructions for eye patching
mannitol after undergoing intracranial
pressure surgery for removal of a b. Discharge assessment of visual
brain tumor. To determine if this drug acuity
is producing its therapeutic effect, the
nurse should consider which as the c. Demonstration of eye drop
most significant instillation

a. Decrease level of consciousness d. Instructions on intraocular lens


cleaning
b. Elevated BP
71.A client was admitted to a coronary
c. Increased urine output care unit with acute myocardial
infarction (MI). Now the client report
d. Decreased heart rate midsternal pain radiating down the left
68.A client is hospitalized for open arm, appears restless and is slightly
reducrion of a fractured femur. During diaphoretic. The nurse obtains the
postoperative assessments, the nurse following assessment findings: T= 00.
monitors for signs of fat embolism, 6 F (37.5 C); PR = 102 bpm,
which include: regular;slightly labored respiration of
26 bpm, and BP of 150/90 mmHg.
a. Pallor and coolness of the affected When planning the client’s care, the
leg nurse should give the highest priority
to which nursing diagnosis?
b. Nausea and vomiting after eating
a. Risk for altered body temperature
c. Hypothermia and bradycardia
b. Decreased cardiac output
d. Restlessness and petechiae
c. Anxiety
69.A client is in Buck’s skin traction for
right hip fracture. The nurse should d. Pain
include which action in this client’s
plan of care.
72.A client with cirrhosis of the liver is b. Use aspirin for joint pain
increaslingly confused and combative.
Which of the following diets would the c. Plan to take iron for 6 months
nurse expect to be ordered for this d. Avoid taking iron with tea or
client? calcium supplements
a. Low fat, low sodium 76.A client with exacerbation of COPD
b. High carbohydrate, low protein and pneumonia has the following ABG
results: pH 7.30, PaC02 60 mmHg,
c. Low potassium ,low phosphorus PaO2 75 mmHg and HCO3 is 24 Meq/L.
The nurse anticipates wich
d. Gluten and wheat free. intervention?
73.Which of the following should the a. Increase oxygen via face mask
nurse teach a client using recombinant
epoetin alpha (Epogen) for chronic b. Encourage coughing and deep
renal failure? breathing

a. This drug will help with the c. Admister sodium bicarbonate


bleeding problems associated with
kidney damage d. No intervention is neede. ABG
values are normal
b. Epoetin alpha should reduce
fatigue and improve energy level 77.A client with cerebrovascular accident
has a nursing diagnosis of ineffective
c. Taking this medication may reduce airway clearance. The goal for this
the need for dialysis client is to mobilize pulmonary
secretions. Which action should the
d. Once a good blood level is nurse plan to take to meet this goal?
established, the injectable form will
be changed to an oral form a. Reposition the client every 2 hrs

74.An appropriate plan of care for a client b. Restrict fluids to 1000 ml in 24 hrs
admitted with renal colic would
include which of the following? c. Asminister O2 by nasal canula as
ordered
a. Inserting an indwelling urinary
catheter d. Keep the head of the bed at a 30
degrees angle
b. Straining all urine
78.A client is admitted to the hospital
c. Maintaining T tube patency with a productive cough, night sweats
and fever. Which of these actions is
d. Limiting fluid intake most important in the client’s initial
75.Which statement would not be plan of care?
included in discharge teaching for a a. assess the client’s temperature
client with a history of rheumatoid every 8 hrs
arthritis who was treated with severe
anemia secondary to GI hemorrhage? b. place the client in respiratory
isolation
a. Take your iron supplement with
orange juice
c. monitor the client’f fluidintake and 82.A client with history of atrial fibrillation
output presents to the outpatient clinic with
nausea, vomiting, HR of 55 bpm, and
d. wear gloves during all client visual disturbances. The nurse would
contact further assess the client for which of
79.a client with heart failure has been the following conditions?
receiving an IV infusion at 125 ml/hr. a. Digitalis glycoside toxicity
Now the client is short of breath and
the nurse notes of bilateral crackles, b. Angina
neck vein distention and tachycardia.
What should the nurse do first? c. Heart failure

a. Notify the physician d. Depression

b. Discontinue the IV access device 83.A client’s ABG values are pH of 7.29,
PaO2 48 mmHg, PaCO2 76 mmHg,
c. Administer the prescribed diuretic HCO3 of 36 mEq/l. the plan of care for
this client with these values would
d. Slow the infusion and notify the include close monitoring for which of
physician the following s/sx?
80.After bronchoscopy, the client must a. Cyanosis and restlessness
receive NPO until the gag reflex
returns. What is the best way to b. Flushed skin and lethargy
assess the gag reflex?
c. Weakness and irritability
a. Instruct the client to cough
d. Anxiety and fever
b. Ask the client to extend the tongue
84.During postural drainage, movement
c. Tickle the uvula with a tongue of secretions from the lower
blade respiratory tract to the upper
respiratory tract occurs due to:
d. Observe while the client swallows
sips of water. a. Friction between the cilia

81.A client with shock due to hemorrhage b. Force of gravity


has these V/S: T= 97.6 F(36.4C), PR=
140 bpm, BP of 60/30 mmHG. For this c. Increased insulin use
client, the nurse should question d. Increased red blood cell production
which physician’s order?
85.Clients with COPD may be bedridden
a. Monitor urine output every hr at home and get little exercise. Which
b. Infuse IV fluids at 83 ml/hr of the following is a normal physiologic
reaction to prolonged period of bed
c. Admister oxygen by nasal canula at rest and inactivity?
3 L/min
a. Increased sodium retention
d. Draw specimens for hemoglobin
and hematocrit every 6 hrs b. Increased calcium excretion

c. Increased insulin use


d. Increased red blood cell production b. Elevated creatinine phosphokinase
(CPK) value
86.For a client with COPD who has trouble
raising respiratory secretions, which of c. Agrees to participating in cardiac
the following nursing measures would rehabilitation program
help reduce the tenacity of secretions?
d. Can perform personal self care
a. Ensuring that the client’s diet is low activities without pain.
in Na
90.Which of the following is expected for
b. Ensuring that the client’s oxygen a client on the day of hospitalization
therapy is continous after an MI? the client:

c. Helping the client maintain a high a. Has minimal chest pain


fluid intake
b. Can identify risk factors for MI
d. Keeping the client in sitting
position as much as possible c. Agrees to participating in cardiac
rehabilitation program
87.The nurse teaches the client with
COPD to assess for signs and d. Can perform personal self care
symptoms of right sided heart failure activities without pain
which include: 91.Nursing measures for the client who
a. Clubbing of nail beds has had an MI include helping the
client to avoid activity that results in
b. Hypertension valsalva maneuver. Which of the
following actions would help prevent
c. Ankle edema valsalva maneuver? Have the client:
d. Increased appetite a. Take fewer deep breaths
88.While caring for a client who has b. Clench teeth while moving in bed
sustained an MI, the nurse notes eight
premature ventricular contractions in c. Drinks fluids through a straw
1 minute on the cardiac monitor. The
client is receiving an IV infusion of 5% d. Avoid holding breath during activity
dextrose in water and 2 L/minte of 92.A basic principle of any rehabilitation
oxygen. The nurse’s first course of program , including cardiac
action would be to: rehabilitation begins:
a. Increase the IV infusion rate a. On discharge from hospital
b. Notify the physician promptly b. On discharge from cardiac care
c. Increase the oxygen concentration unit

d. Administer a prescribed analgesic c. On admission to the hospital

89.Whichof the following findings is an d. Four weeks after the onset of


indicative of MI? disease

a. Elevated serum cholesterol level 93.The client has a history of heart failure
and the nurse is preparing the client to
go home. The nurse should instruct c. Reduce fluid volume
the client to:
d. Improve myocardial contractility
a. Monitor urine output daily
97.The most effective measure the nurse
b. Maintain bed rest for at least one can use to prevent the wound
week infection when changing a client’s
dressing after coronary artery bypass
c. Monitor daily potassium intake surgery is to:
d. Weigh daily a. Observe careful handwashing
94.Digoxin is administred IV to clients procedures
with CHF primarily because the drugs b. Cleanse the incisional area with
acts to : antiseptic
a. Dilate coronary artery c. Use prepacked sterile dressing to
b. Increase myocardial contractility cover the wound

c. Decrease cardiac dysrhytmias d. Place soiled dressings in a


waterproof bag before disposing
d. Decrease electrical conductivity in them
the heart
98.Which information obtained by the
95.The client ask the nurse about the nurse when assessing a patient
reason for taking enalapril maleate. admitted with mitral valve stenosis
The nurse based her response on the should be communicated to the health
fact that enalapril is prescribed for care provider immediately?
people with heart failure to:
a. The pt has a loud diastolic murmur
a. Lower blood pressure by increasing all across the precordium
peripheral resistance
b. The pt has crackles audible to the
b. Lower the heart rate by slowing the lung apices
conduction sytem
99.When caring for a pt with infective
c. Block the conversion of angiotensin endocarditis of the tricuspid valve, the
1 to angiotesin 11 nurse will plan to monitor the pt for:

d. Increase cardiac contractility a. Flank pain


thereby improving cardiac output
b. Hemiparesis
96.Metoprolol tartrate a Beta adrenergic
antagonsist may be administered to a c. Dyspnea
client with heart failure because it acts d. splenomegaly
to:
100. the nurse is taking a history from a 24
a. Reduce peripheral vascular y/o pt with hypertrophic cardiomyopathy.
resistance Which information obtained by the nurse is
b. Increase peripheral vascular the most important?
reistance a. the pt reports using cocaine once
at 16 y/o
b. the patient has a history of upper highly flavored foods, aspirin may
respiratory infection cause ulcer and bleeding and should
be avoided.
c. the pt’s 29 year old brother has had
a sudden cardiac arrest 5. C. cushing’s disease is an excessive
production of
d. the pt has a family history of CAD mineralocorticoids( aldosterone- for
Answers to part 1 sodium and water reabsorption),
glucocorticoids( cortisol- breakdown of
1. D. precipitating factors of angina fats and protein and gluconeogenesis)
include exertion during physical and androgens (masculine hormone.
activities,colds, after heavy meals , Although a pitting edema is a
emotional stress wherein there’s an characteristic symptom of cushing
increase oxygen demand but less disease because of excessive water
supply d/t of obstruction of blood flow. and sodium reabsorption, it is not an
It may also occur during rest as a emergency condition. Irregular apical
result of coronary spasm. Pain usually pulse is the primary concern and
last for 3-5 minutes or 15-20 min should be reported immediately.
especially after a heavy meal or
anger. 6. B. the ventilator will alarm to let the
caregiver know there is a problem.
2. D. TIA is caused by temporary Some of the most common alarms are
decreased in blood flow , could be high pressure, low pressure and
caused by atherosclerosis,emboli or battery. If the high pressure alarm
thrombi. Anticoagulants such as sounds, it means that air is having a
aspirin is given to dissolve the clot or hard time getting into the lungs, it
prevent platelet aggregation that usually means suctioning is needed to
could lead to emboli or thrombi. get extra secretions out of the airway.
Low pressure means that there might
3. A. hemorrhagic stroke can lead to be an airleak or a disconnected tube.
seizures. Thus antiseizures such as
phentoin is prescribed. One often 7. B. Parkinson’s crisis is also referred as
cause is hypertension causing small acute akinesia present in advanced
vessels in the brain to rupture and state of the disease. The rigidity of the
bleed thus antihypertensive such as intercoastal muscle makes the patient
methyldopa is included. The bleeding unable to cough out accumulated
also cause edema or inflammation to sputum/secretions .thus, patients with
the surrounding tissues so anti- parkinson’s disease are prone to
inflammatory such as dexamethason repiratory infections.
is given to reduce the edema. Heparin
is an anticoagulant that may cause 8. A. Addison’s disease is also known as
further bleeding and should be Adrenal insufficiency. There’s
questioned. insufficient adrenocorticotropic
hormone (ACTH) production which
4. C. teaching should include small includes epinephrine and
frequent feeding to avoid too much norepinephrine that are helpful in the
HCl acid secretion, completing the flight and fight response. If the body is
prescribed medications even the unable to fight off stressors, this will
patient seems to feel better, avoiding lead to body exhaustion and increase
gastric irritants such as caffeine, susceptibility to illnesses and
infections. Another adrenal hormone is 13.D. It is unnecessary to keep the cast
aldosterone which is responsible for warm, it should be exposed to cool air.
water and sodium reabsorption. Fiberglass is dried up within 10-15
Insufficient amount of this leads to minutes, there’s no need to assess the
increased loss of sodium and water, pedal and tibial pulses since it’s not
not urine retention and fluid excess. the one casted. The casted part is the
Excessive loss of sodium and water right arm so it is important to check
can lead to dehydration and increase distal circulation and sensation. Assess
temperature. brachial and ulnar pulse.

9. B. antidiuretic hormone(ADH) prevents 14.A. hyperglycemia could lead to


diuresis or urination. Excessive ADH osmotic dieresis leading to fluid
leads to excess Na and H2O retention volume deficit as manifested by dry
thereby gaining weight. Increased skin. Decreased cardiac output can’t
amount of fluid in the blood vessels be related to increasese HR, it is d/t
causes increased venous return and dehydration and increased heart rate
fluid overload. Chronic condition may is a compensatory mechanism .
lead to congestive heart failure in there’s no data for insulin deficiency ,
which distended neck vein is one of there might be enough insulin but the
the sign cells are resistant to use it.

10.A. osteoarthritis is not an 15.Ewan ko pa


inflammatory disease thereby doesn’t
produce inflammatory and systemic 16.D. Insulin is usually administered
sign and symptoms. It ‘s a wear and before meal to anticipate the increase
tear degenerative disease. Pain can of blood sugar after eating. Never
occur after repetitive use of the joint . administer a subcutaneous insulin
pain and stiffness can also occur after deltoid because you might give it IM.
a long period of inactivity such as Deltoid is muscular so it is only used
when you go to bed at night and suffer for IM insulin route. Don’t shake the
a pain and stiffness when you wake up bottle to mix, just roll gently between
in the morning. hands or by turning the bottle up and
down slowly.
11.Receptive aphasia is characterized by
fluent but meaningless speech with 17.B. thyroid hormones are responsible
severe impairment of the ability for many metabolic processes. Options
understanding spoken and written A,C,D are result of hyperthyroidism d/t
words. Short and simple sentences increased metabolism and
should be used. neuromuscular hyperactivity. One
function of thyroid hormone is protein
12.A. DI is characterized by inadequate synthesis which maintain osmotic
antidiuretic hormone leading to pressure in the blood vessels . if
excessive loss of Na and H20 followed protein concentration in the vessels is
by hypotension and tachycardia. decreased,there’s a fluid shift into the
Tachycardia is a compensatory extracellular space leading to edema.
mechanism in an effort to pump more
blood d/t the decreasing circulating 18.C. synthroid adverse effects typically
fluid. It is important to increase the resulted from overdose and include
fluid intake to prevent hypovolemic the signs and symptoms of
shock.
hyperthyroidism which includes After 48-72 hours, an induration of 10
tachycardia. mm or more is a positive test and
indicates that you might be positive
19.D. pH is below normal which suggest for PTB, a further evaluation and
an acidosis. PaCO2 is for respiratory testing is needed to confirm the
index while HCO3 is for metabolic. The presence of PTB.
pH follows HCO3, thereby it is
metabolic acidosis 25.C. Streptomycin is an antibiotic
belonging to the aminoglycosides
20.A. always follow the principle of ABC family. Aminoglycosides work by
prioritization, Airway, breathing, inhibiting the bacterial protein
circulation. Respiratory acidosis is synthesis. Streptomycin frequently
typically the result of accumulation of affects the vestibular branch of the
CO2 in the body tissues due to auditory nerve causing nausea,
hypoventilation. First priority is to vomiting, vertigo. Symptoms subside
assist with the prescribed therapy and recovery occur following
which includes means to improve discontinuation of the drug. In long
ventilation. term therapy however, ototoxic effect
21.B. Bleeding / hematoma is a life causes hearing loss when extensive is
threatening complication that usually permanent.
obstructs airway postthyroidectomy. 26.A. the main problem mention is
Tracheostomy set should be at the dementia. People with dementia may
bedside to establish airway not be able to think well enough to do
immediately if respiratory distress normal activities of daily living such as
occurs. getting dressed and eating.
22.A. In an early stage of cancer, it 27.A. Probenecid works by decreasing
usually starts as a tumor , as tumor uric acid in the blood by promoting its
invades vascularized tumor, it may kidney exctetion.
cause bleeding.
In overdosage and intoxication, it
23.B. Nitroglycerin is an unstable causes various hematologic side
substance and easily denatured when effects.
exposed to heat and light. The dark
bottle protect the drug from the light. 28.A. DM type 1 is a decreased in insulin
If the drug doesn’t tingle under the production leading to increasing
tongue, it could be that it’s not amount of glucose in the blood.
working anymore, it could be expired Hyperglycemia causes osmotic
or denatured. You should not take diuresis that leads to frequent
more than 3 tablets , if the pain is not urination and leads to dehydration.
relieve in 15 minutes, you should
consult the doctor because this is not 29.D. A,B,C are normal findings. S/E iof
an angina pain anymore, it could be a chemotherapy includes nausea and
myocardial infarction. vomiting, prolonged N/V caused
dehydration.
24.A. mantoux test or tuberculin test is a
screening test for pulmonary 30.C. it is more logical and appropriate to
tuberculosis. It is done by introducing administer prescribed antiemtic first
a protein derivative of the causative before feeding the patient. This is to
bacteria in the dermis of the skin. avoid vomiting after a meal.
31.A. the most serious S/E of zidovudine adequate nutrition in relation to this
is anemia, myopathy and neutripenia problem.

32.A.The protruded or herniated disk 37.C. Vit K is important in the clotting


irritates or compressed the mechanism of the body. Lack of this
surrounding nerve endings which can lead to bleeding. Purpura and
causes severe back pain radiating to petechiae are forms of bleeding
the thighs.
38.A. avoid exercise for 3-4 wks because
33.D. all options are clinical manifestation this may stretch and injure the graft.
of hepatitis B. I think the most correct
answer is D, because it needs closer 39.C. Antibacterial should work for what
monitoring and care. its designed for and that is to
eliminate the causing bacteria of a
34.A. ileostomy is bringing out the ileum disease. Even though the symptoms
which is the end of the small intestine subside, still a number of the
into an opening on the abdomen. One causative bacteria is present in the
important function of the colon is urinary tract, if the medication is
water absroption, since water is not stopped without completing the
anymore pass through the colon , prescribed duration of antimicrobial
most fluid is lost into the pouch rather therapy, they will again multiply and
than being absorb making the client cause the exacerbation of the disease.
more prone to dehydration. Pouch Therefore, it is important to complete
should be worn all the time. Low fiber the whole duration of the drug therapy
diet should be advised postoperatively to ensure elimination of all the
because surgery causes the bowel to bacteria.
swell making digestion of fiber
difficult. Once the swelling has 40.B. inner cannula is cleaned with
subsided(usually after 8 wks) the Hydrogen Peroxide and rainsed with
patient can resume a normal diet. water. The stoma is also cleaned using
a soapy wash cloth then rinsing it.
35.B. instruction to the patient should Inner surrounding of the stoma with
include avoiding acid stimulant such driep up sputum crust can be cleaned
as coffee, alcohol, fatty foods,aspirin, with a cotton tipped swab soaked in
tobacco, chocolate, peppermint,etc. hydrogen peroxide. Alcohol promotes
you should also instruct patient to dryness. There’s no indication why you
remain in upright position for atleat 30 have to limit fluid intake. Protein
min after eating and sleeping with the intake should be increased to promote
bed slightly elevated, small frequent healing. Patient can still communicate
feeding is better tolerated than 3 big with proper speech therapy and
meals. learning other means of
communication.
36.B. Esophageal CA presents many signs
and symptoms. However the question 41.B. keep the bed elevated to promote
is asking specifically on the problem ventilation of the lungs and reduces
r/t to difficulty swallowing. You should edema and swelling of the neck. The
look for a problem that is most related patient is on NGT feeding
to difficulty swallowing, that is temporarily , no food is allowed by
insufficient food intake and nutrition. mouth until the pharyngeal suture line
The nurse should then ensure is healed. The tracheostomy cuff
should not be fully inflated to avoid 46.A. the most priority is to ensure a
pressure trauma to the windpipe. patent airway, auscultating the
Usually 10 ml of air is used and the presence of breathsound is an
cuff should be deflated once in a while indication that the air way is patent.
to relieve the pressure. In total
laryngectomy, speech rehabilitation 47.A. albuterol is a bronchodilator that
training is necessary( esophageal relaxes muscle of the airway and
voice, electrolarynx) or using sign increases airflow into the lungs
language. 48.C. always assess first before you
42.A. clamp is only necessary when there intervene. Clots along the drainage
is a leak along the tubing and is used can cause urine stasis and aggravate
to locate the leak. Clamp should only pain.
be used in a limited time to prevent 49.A. this is to prevent edema.
tension pneumothorax and
mediastinal shift. Milking is only per 50.B. Creatinine clearance. Creatine is a
MD order. To ensure that the drainage byproduct of metabolism and excreted
system is intact, the nurse should by the kidney.
monitor for gently fluctuations in the
water seal chamber with each 51.B. increase fluid intake is very
inspiration and expirarion.This is important to flushes out bacteria
called tidaling. Though coughing and
52.C. in oliguric phase , it doesn’t mean
deep breathing is also an important
that there is an insufficient fluid
teaching, making sure the drainage
intake, it’s because there’s a decrease
system is intact is more important to
glomerular filtration leading to fluid
serves its purpose.
accumulation in the body and fluid
43.B. Follow the ABC overload. Emphasize Na and fluid
prioritization( 1.Airway, 2.breathing, restriction at this point.
3.circulation)
53.C. peritonitis is the most major risk in
44.C. Assess first before you intervene. peritoneal dialysis d/t to introduction
PTT is used to test how long it takes of microorganism through the
your blood to clot and check for catheter.
bleeding problems especially when the
54.B. airway and breathing is always the
patient is on blood thinning therapy
priority.
such as heparin .
55.D. Pillows under knees can be used
45.D. the question is asking specifically
but should not be kept at all time to
about sign of righ heart failure. Cor
promote venous return and prevent
pulmonale is a right ventricular
blood clot formation. Ambulation is
hypertrophy due to chronic lung
encouraged within hours after surgery
disease. Right side heart failure is
to promote lung aeration. Pt can be
usually associated with signs of the
positioned supine with a pillow under
venous system. Due to the
neck or at the sides. The patient
hyperthropy of the right ventricle,
should also change position at least
there is insufficient filling, thus blood
every 2 hrs , when turning the body
backs up to the venous system
should be moved as a unit.
causing peripheral edema.
56.A. patients with central line catheter Furosemide and Spironolactone are
are ambulatory and urinary catheter is diuretics.
not needed unless there’s some
kidney pathology that requires the use 63.B. Sprironolactone is a K sparing
of it. Sterile technique is used when diuretic . It is used to excrete extra
changing the dressing , occlusive fluid from the body , therby, lose of
dressing is used to prevent air from body weight means tha most fluid are
entering the line. being excreted out.

57.D. Normal serum potassium level is 64.A. incentive spirometry is a breathing


3.5-5 mEq/L, normal serum sodium is device that promote maximal lung
135-145 mEq/L. normal urine output is aeration and respiratory effectiveness
at least 30 ml/hr . 65.D. Elevate only to 15-30 degrees to
58.D. The first phase of acute renal promote venous return and reduce
failure is oliguric phase with urine cerebral edema. Enforce any fluid
output of 400ml or less in 24 hrs. restriction and monitor carefully input
Normal urine ourput in 24 hrs is 1500 and output. Avoid activities that
ml. normal serum creatinine is .7-1.4 increase intrathoracic or
mg/dl. BUN is not significantly intraabdominal pressure such as
increased normal bun is 10-20 mg/dl. straining during bowel movement, this
impedes blood flow from the cranium.
59.A. one principle of prioritization is to Suctioning can stimulate the vagal
look on the client’s needs on the reflex and further increase ICP,
clients perspective . pain is considered suctioning is only done if its extremely
as the 5th vital sign. The pain is severe necessary.
that needs to be addressed first
among the other options. 66.1 kg= 2. 2 lbs

60.B. All options except D are signs and 175 lb X 1 kg = 79.55 lbs
symptoms of liver cirrhosis but option 2.2 lbs
B poses the most serious
complication. Advanced liver cirrhosis 79.55 lbs X 1.5 g= 119 g
can lead to hepatic encephalopathy
which is the accumulation of toxins in
thebrain leading to decreased mental
67.C. mannitol is a diuretic that excretes
function and coma.
extra fluid out from the body.
61.C. airway and breathing is always the Increased UO is an indication that
priority. The patient has difficulty of mannitol’s desired effect is achieved
breathing because of the pressure
68.A. bone marrow is also composed of
exerted by the enlarged abdomen to
fat globules that may escapes out
the diaphragm.
during bone fracture and causes fat
62.B. The patient has prolonged clotting embolism. The fat globules can
time which predisposes the patient to impede blood flow making the
bleeding . Coaugulant such as affected leg pale and cool.
phytonadion (Vit. K)should be given to
69.D. traction should be continuous , the
counteract effect .warfarin is an
weight is never removed nor
ancticoagulant which place the patient
interrupted. The patient is in supine
in increased risk of bleeding.
with neck supported by a pillow. The therapy and or to study the stone
leg with a traction should be held composition.
straight and never flexed.
75.B. Vit C such as orange juice enhances
70.C. Glaucoma occurs due to the absorption, tea, coffee and calcium
pressure build up in the eye by reduces iron absorption. Aspirin is
increased amount of aqueous vitrous avoided because it is a blood thinner
humor. Eye drops could either work by and aggravates bleeding
promoting the flow of the aqueous
fluid or decrease the production of it. 76.B. Doctors always prescribed a low
oxygen delivery to patients with COPD
71.D. One priority in acute MI is pain usually at 2 L/min because high
control drugs such as morphine to concentration of oygen can depress
reduce catecholamine induced oxygen the respiratory drive. Besides high
demand to injured heart muscle. oxygen concentration is of no use if
the airway is obstructed with
72.A. cirrhosis may lead to malnutrition. It secretions. It is very important to
is essential to maintain a healthy , encourage the pt to cough out
nutritious diet such as increasing secretions to help clear the airway and
carbohydrate and protein intake. Low encourage deep breathing. All ABG
fat diet should be observed because values are abnoramal.
bile is needed for digestion and bile is
not sufficiently produced in cirrhotic 77.A. Fluid may be increased to liquefy
liver. Salt and Na intake should also be secretions. Oxygen administration and
minimal because patients with putting the pt in semi fowler’s do not
cirrhosis tends to retain extra fluid. help in mobilizing secretions. stroke
When liver cirrhosis is complicated by patients who are on bed rest are prone
hepatic encephalopathy, then this is to respiratory complications because
the time that protein intake should be of retention of secretions. Therefore
limited. assisted ambulation and frequent
positioning may help to mobilize
73.B. kidney produced erythropoietin secretions .
necessary for blood cell formation,
kidney damage leads to anemia. Signs 78.B. the signs and symptoms presented
and symptoms of anemia include easy are indications of PTB. It’s a safe
fatigability and body weakness. precautionary practice to place the pt
Epogen is given SQ or IV to aids in in respiratory isolation to prevent
erythropoeisis and reduces symptoms cross infection while further
of anemia assessment and evaluation is carried
out.
74.B. renal colic is a very excruciating
pain caused by the passage of stone 79.B. the nurse should suspect a
along the ureter. Indwelling catheter circulatory overload because of the
will not ease the pain. It may in fact assessment findings. Initial action is to
add more to the pain experience. T stop the IV to stop further introduction
tube is used to drain bile . Increased of fluid.
fluid intake should be encourage to
help flush the stone. It is appropriate 80.C. contraction of the back of the throat
to collect all urine and strain for stone when the uvula is tickled means that
passage to assess effectiveness of gag reflex has returned.
81.B. Iv rate should be a fast drip to is advised at least for the first couple
immediately restore the fluid volume of days at least 1-2 days. Patients are
strongly advised to participate in
82.A.Digitalis are given to patients with cardiac rehabilitation program to help
cardiac problems to strengthen heart patients to recover quickly and
contraction. Initial s/sx of Digitalis improve their overall physical, mental
toxicity is GI manifestation such as and social functioning.
N/V, loss of appetite, diarrhea. Other
symptoms include visual changes, 91.D. straining against a closed epiglottis
slow pulse , confusion etc. which includes holding breath or
forceful expiration stimulates valsalva
83.B. With the ABG values presented, the maneuver. Pts should be advised to
pt is suffering from respiratory avoid holding breaths while moving .
acidosis.
92.C. rehabilitation begins upon
84.B. In postural drainage, the patient is admission
placed on a trendelenberg position so
gravity aids in the movement of 93.D. weight gain can be a sign that you
mucus to the upper respiratory tract. the pt is retaining fluid and his heart
condition is worsening.
85.B. Immobilization causes calcium lose
from the bones into the bloodstream 94.B. Digitalis is given to increase cardiac
and cause hypercalcemia. The kidney contractility followed by decreased in
in response of hypercalcemia HR
increases its excretion.
95.C. Enalapril is an ACE inhibitor
86.C. increased fluid intake loosen up (Angiotension Converting Enzyme
secretions thus easy to expectorate inhibitor) that decreases BP.
Angiotensin II is a potent
87.C. one classical sign of right side heart vasoconstrictor.
failure is edema due to decreased
venous return. 96.A. beta adrenergic antagonist
antagonizes the action of sympathetic
88.B . Because PVC s may signal an response. It works by reducing the
impending life threatening rhythm , force of contraction of heart muscles
notify the physician if the pt has more thereby reducing peripheral resistance
than six PVCs per minute. and blood pressure .
89.B. creatine phospholinase is an 97.A. Proper handwashing has always
enzyme normally found in muscle been the single most effective
fibers. It is released in the measure to prevent cross
bloodstream when there is muscle contamination and infection.
damage. MI is the interruption of blood
supply causing heart muscle cells to 98.B. Mitral valve stenosis is the
die. narrowing and stiffening of the mitral
valve caused oftenly caused by
90.I’m not sure of the correct answer, but rheumatic fever in adults. Due to the
I guess the best option is B. Pain in MI narrowed valve, blood is not efficiently
doesn’t last until the following day. pumped into the left ventricle, over
Most patients after a heart attack are time, pressure in the atrium increases
hesitant to resume activities, bed rest and blood is backed up to the lungs
and cause pulmonary hypertension
and pulmonary edema which is
manifested by presence of lung
crackles.

99.C. Infective endocarditis is due to


bacterial or fungal infection that
affects the endocardium of the heart
especially the heart valves. Over time,
materials called vegetations
developed along the valves. These
contain bacteria, blood clots, debri
from the infection. This vegetations
prevent the valve from working
properly and will lead to cardiac
failure.

100. C. although the specific causes


of hypertrophic cardiomyopahty are
not yet fully known. The primary cause
seems to be genetic.