A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY

NURSING PRACTICE III

SITUATION: In the recall of the fluids and electrolytes, the nurse should be able to understand the
calculations and other conditions related to loss or retention.
1. When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of
fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs
would not be likely to occur?
a. moist gurgling respirations
b. Weak, slow pulse

c. Distended neck veins

d. Dyspnea and coughing

2. The dietary practice that will help a client reduce the dietary intake of sodium is

a. Increasing the use of dairy products

b. Using an artificial sweetener in coffee
c. Avoiding the use of carbonated beverages

d. Using catsup for cooking and flavoring

foods

3. . When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate
tissue perfusion to vital organ is;
a. Urinary output of 30 ml in an hour
b. Central venous pressure reading of 2 cm H20
c. Pulse rates of 120 and 110 in a 15- minute period
d. Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes
4.

When monitoring for hypernatremia, the nurse should assess the client for:

a. Dry skin
b. Confusion

c. Tachycardia
d. Pale coloring

5. Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this
treatment will be a decrease in:

a. Urinary output
b. Abdominal girth

6.

c. Serum ammonia level

d. Hepatic encephalopathy

A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration.
The nurse should anticipate that the physician will order;
a. A glass of water every hour until hydrated
b. Small frequent intake of juices, broth, or milk
c. Short-term NG replacement of fluids and nutrients
d. A rapid IV infusion of an electrolyte and glucose solution

7. The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following fullthickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained
from recording

a. Weights every day .

b. Urinary output every hour

c. Blood pressure every 15 minutes

d. Extent of peripheral edema every 4 hours

8.

A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the
procedure it is most important for the nurse to observe for:

a. A rapid, thready pulse

b. Decreased peristalsis .

9.

c. Respiratory congestion
d. An increased in temperature

The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin
occurs by the process of:

a. Filtration
b. Diffusion

c. Osmosis
d. Active Transport

10. A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop
factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;

a. 13 gtt/min
b. 16 gtt/min

c. 29 gtt/min
d. 32 gtt/min

SITUATION 3: Perioperative Nursing is a special field of nursing that includes a wide variety of nursing
functions associated with the patients surgical experience during the perioperative period.
Perioperative nursing addresses the nursing roles relevant to the three phases of the surgical
experience: preoperative, intraoperative, and postoperative.
11. The best time to provide preoperative teaching on deep breathing, coughing and turning exercises is:
a.
b.
c.
d.

Before administration of preoperative medications

The afternoon or evening prior to surgery
Several days prior to surgery
Upon admission of the client in the recovery room

12. The following are the appropriate nursing actions before administration of preoperative medications EXCEPT:
a. Ascertain the consent has been
signed

b. Ensure that NPO has been maintained

c. Instruct patient to empty his bladder
d. Shave the skin at the site of surgery

e.
13. The patient has been observed pacing along the hallway goes to the bathroom frequently and
asks questions repeatedly during preoperative assessment. The most likely cause of the behavior is:
a.
b.
c.
d.

She is anxious about the surgical procedure

She is worried about separation from the family
She has urinary tract infection
She has an underlying emotional problem

14. Which of the following nursing actions would help the patient decrease anxiety during the preoperative period?
a.
b.
c.
d.

Explaining all procedures thoroughly in chronological order

Spending time listening to the patient and answering questions
Encouraging sleep and limiting interruptions
Reassuring the patient that the surgical staff are competent professional

15. Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery?

a. To prevent malnutrition
b. B.To prevent electrolyte imbalance

c. To prevent aspiration pneumonia

d. To prevent intestinal obstruction

16. Pre-op instructions to the client would include the following EXCEPT:
a.
b.
c.
d.

Deep breathing and coughing exercise

Turning to sides
C.Foot and leg exercises
reassuring her that narcotics will be given every 4 hours round the clock until she is discharged

17. The client gave her consent for the surgery. To ensure the legality of the consent, the following conditions must be met EXCEPT:
a.
b.
c.
d.

She gave her consent freely

She must understand the nature of the surgery
The consent must be signed by a witness
Signing should be done after the administration of pre-anesthesia meds

18. .How frequent should the nurse monitor the VS of the patient in the recovery room?
a. Every 15 minutes
b. Every 30 mins

c. Every 45 mins
d. Every 60 mins

19. Which of the following drugs is given to relieve nausea and vomiting?
a. Mepivacaine
b. Aquamephyton

c. Nubain
d. Plasil

20. The most important factor in the prevention of post-op infection is:
a. Proper administration of antibiotics
b. Fluid intake of 2-3L/day

c. Practice of strict aseptic techniques

d. Frequent change of wound dressings

e. SITUATION 4: Subtotal gastrectomy is a procedure that is use to manage clients who are
suffering from peptic ulcer disease. This procedure may be done with Bilroth I or Bilroth II
anastomosis.
21. A client is scheduled for a subtotal gastrectomy. In anticipation of clarifying information for client education, the nurse
knows that vagotomy is done as part of the surgical treatment for peptic ulcers in order to
a.
b.
c.
d.

Decrease secretion of hydrochloric acid

Improve the tone of the GI muscles
Increase blood supply to the jejunum
Prevent the transmission of pain impulses

22. Which of the following facts best explains why the duodenum is not removed during a subtotal gastrectomy?
a.
b.
c.
d.

The head of the pancreas is adherent to the duodenal wall

The common bile duct empties into the duodenal lumen
The wall of the jejunum contains no intestinal villi
The jejunum receives its blood supply through the duodenum

23. During the immediate postoperative period following gastric surgery, why must the nurse be particularly
conscientious about encouraging a client to cough and deep-breathe at regular intervals?
a.
b.
c.
d.

Marked changes in intrathoracic pressure will stimulate gastric drainage

The high abdominal incision will lead to shallow breathing to avoid pain
The phrenic nerve will have been permanently damaged during the surgical procedure
Deep-breathing will prevent post op vomiting and intestinal distention

24. Prior to having a subtotal gastrectomy, a client is told about the dumping syndrome. The nurse explains that it is:
a.
b.
c.
d.

The bodys absorption of toxins produced by liquefaction of dead tissue

Formation of an ulcer at the margin of the gastrojejunal anastomosis
Obstruction of venous flow from the stomach into the portal system
Rapid emptying of food and fluid from the stomach into the jejunum

25. Which of the following statements by a client recovering from a subtotal gastrectomy would indicate a need
for additional teaching about the diet protocol for dumping syndrome?
a.
b.
c.
d.

I plan to eat a diet low in carbohydrates and high in protein and fat
I plan to eat a diet high in CHO and low in CHON and fat
I will eat slowly and avoid drinking fluids during meals
I will try to assume a recumbent position after meals for 30 mins to 1 hour to enhance digestion and relieve
symptoms

26.
27.
28.
29.
30. SITUATION: Surgery, whether elective or emergent, is a stressful, complex event. Today, as a result
of advances in surgical techniques and instrumentation as well as in anesthesia, many surgical
procedures that were once performed in an inpatient setting now take place in an ambulatory or
outpatient setting. Competent care of ambulatory or same-day surgical patients requires a sound
knowledge of all aspects of perioperative and perianesthesia nursing practice.
31. The client who is scheduled to have surgery cannot read or write. The surgeon obtaining the consent wants
to have the client's spouse sign the consent instead. What is the nurse's best action?
A. Nothing; a signed informed consent statement does not need to be obtained from this client.
B. Locate the spouse, because the informed consent statement must be signed by the client's
closest relative.
C. Inform the surgeon that the client may sign the informed consent statement with an X in front of
two witnesses.
D. Notify the administration because the court must appoint a legal guardian to represent the client's
best interests and give consent for all surgical procedures.
32. Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed),
the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart
seems to be beating faster than normal. What is the nurse's best first action?
A. Document the findings as the only action.
B. Check the client's pulse and blood pressure.
C. Prepare to administer epinephrine and diphenhydramine (Benadryl).
D. Explain to the client that these symptoms are normal responses to the medication.
33. 28. Which nursing action or statement is most likely to reduce anxiety in a client being brought to the
surgical suite?
A. Asking the client if he or she has talked with the hospital chaplain
B. Asking the client what specific surgery he or she is having done today
C. Asking the client if he or she wants family members to be with them in the holding area
D. Explaining to the client that the surgical area is the most technologically advanced in the city
34. 29. Who is responsible for accompanying the surgical client to the postanesthesia recovery area after
surgery and for giving a report of the client's intraoperative experience to the PACU nurse?
35.

a.
b.

A. The surgeon and scrub nurse

B. The surgeon and circulating nurse
C. The anesthesiologist and scrub nurse
D. The anesthesiologist and circulating nurse
36.
30. The nurse has admitted a client to the unit following a modified radical mastectomy for treatment of
breast cancer. The nurse plans to place the right arm in which of the following positions?
a. elevated above shoulder level
c. level with the right atrium
b. elevated on a pillow
d. dependent to the right atrium
e. 31. Harry underwent lobectomy. Which of following is the purpose of harrys closed chest drainage post
lobectomy:
a. expansion of the remaining lung
c. prevention of mediastinal shift
b. facilitation of coughing
d. promotion of wound healing
e. Situation: Nurse Fiona is assisting a client with Eyes and Ears disorders. She is using her
proper judgment in taking care of her patients and sees to it that they are comfortable and
recovers in the disease process without complications.
f. 32. Melrose is having a difficulty in her hearing and balance. Upon assessment, nurse Fiona would most
likely pay particular attention to the functioning of what cranial nerve?
a. CN 4
c. CN 8
b. CN 5
d. CN 10
e. 33. Tonometry is performed on the client with suspected diagnosis of glaucoma. The nurse Fiona is aware
that the normal intraocular pressure is:
a. 10-20 mmHg
c. 22- 30 mmHg
b. 2-7 mmHg
d. 31-35 mmHg
e. 34. A client is being discharged after cataract removal and the nurse reinforces instruction regarding home
care. Which of the following , if stated by the client indicates understanding of the instruction?
I will not lift anything if it weighs more than 10 lbs
I will take aspirin if I have any discomfort

c.
d.

I will wear my eye shield at night and my glasses during the day
I will wear an eye patch to prevent my affected eye from bleeding
f. 35. A nurse assigned to care for client hospitalized with Menieres disease the nurse expects that which of
the following would be most likely be prescribed for the client?
a.
low cholesterol diet
c.
low carbohydrate diet
b.
low sodium diet
d.
low fat diet
e.
f. 36. A client with Menieres disease is experiencing severe vertigo. The nurse instructs the client to do which
of the following to assist in controlling the vertigo.
g.
a. Increased fluid intake to 3000 mL/day
h.
b. avoid sudden head movements
i.
c. lie still and listen to rock music
j.
d. increase sodium in the diet
k.
l. 37. A client with an acute myocardial infarction is receiving nitroglycerin (Tridil) by continuous IV infusion.
Which statement by the client indicates that this drug is producing its therapeutic effect?
m. a. I have a bad headache.
n. b. My chest pain is decreasing.
o. c. I feel a tingling sensation around my mouth.
p. d. My blood pressure must be up because my vision is blurred.
q. 38. A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has
fatigue and mild ankle swelling which is most pronounced at the end of the day. The nurse suspects a
cardiovascular disorder. When exploring the chief complaint the nurse should find out if the client has
any other common cardiovascular symptoms such as:
r. a. Shortness of breath
t. c. Irritability
s. b. Insomnia
u. d. Lower substernal abdominal pain
v.
39. A client is admitted for treatment of Prinzmetals angina. When developing the plan of care the nurse
keeps in mind that this type of angina is triggered by:
w. a. Activities that increase myocardial demand
x. b. Are unpredictable amount of activity
y. c. Coronary artery spasm
z. d. The same type of activity that caused previous angina episodes
aa. 40. Before discharge, which instruction should the nurse give to a client receiving digoxin (Lanoxin)?
ab.
a. Take an extra dose of digoxin if you miss one dose.
ac.
b. Call the physician if you have a rapid heart rate.
ad.
c. Call the physician if your pulse drops below 80 beats/minute.
ae.
d. Take digoxin with meals
af. SITUATION: Cystic Fibrosis is a disease caused by mutations in the CF transmembrane
conductance regulator protein, which is a chloride channel found in all exocrine tissues.
ag. 41. A "sweat test" or newborn screening may be used to detect:
a. Cystic fibrosis

c.

Grave's disease

b. . Adrenal insufficiency

d. Hypothyroidism

e. 42. The most common causes of death in people with cystic fibrosis is:
f.
a. Dehydration
b. Opportunistic infection

c. Lung cancer
d. Respiratory failure

g. SITUATION : A client admitted to an acute care facility with pneumonia is receiving supplemental
oxygen, 2 liters/minute via nasal cannula. The client's history includes chronic obstructive
pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the
nurse closely monitors the oxygen flow and the client's respiratory status.
h. 43. Which complication may arise if the client receives a high oxygen concentration?
i.
j.
a. Apnea
l. c. Respiratory alkalosis
k. b. Anginal pain
m. d. Metabolic alkalosis
n. 44. A client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care
center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The
nurse would be especially vigilant to include information about complying with medication therapy if the
clients baseline theophylline level was:
o.

a. 10 mcg/mL
b. 12 mcg/mL

c. 15 mcg/mL
d. 18mcg/mL

p.
q. 45. A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive
pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?

A. Hypocapnia
B. A hyperinflated chest noted on the chest x-ray
C. Increase oxygen saturation with exercise
D. A widened diaphragm noted on the chest x-ray
r. SITUATION : Nurse Donna is caring for a client with deep vein thrombosis who was admitted to
the health care facility.
s. 46. Nurse Donna must be alert for complications such as pulmonary embolism. Which findings suggest
pulmonary embolism?
a. Nonproductive cough and abdominal pain
c. Bradypnea and bradycardia
b. Hypertension and lack of fever
d. Chest pain and dyspnea
e. 47. In case of pulmonary embolism, nurse Donna would anticipate an order for immediate administration
of:
a. warfarin
c. heparin
b. dexamethazone
d. protamine sulfate
e. 48. The following are warning signs of cancer. Which one is not?
f.
a. Change In bladder and bowel
c. Weight gain
habits
d. Nagging cough or hoarseness
b. Indigestion or difficulty in swallowing
g. 49. Monthly examination (BSE) can help in early detection of breast CA. When do you perform BSE?
h.
a. once a month after menstruation
b. once a month before menstruation
c. every other month after menstruation
d. every other month before menstruation
i.
j. 50. The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A
stand for?
a. Actinic
c. Arcus
b. Asymmetry
d. Assessment
e. 51. The nurse is teaching a client who suspects that she has a lump in her breast. The nurse
instructs the client that a diagnosis of breast cancer is confirmed by:
f. a. Breast self-examination
h. c. Fine needle aspiration
g. b. Mammography
i. d. Chest x-ray
j. 52. A 52-year old female tells the nurse that she has found a painless lump in her right breast during
her monthly self-examination. Which assessment finding would strongly suggest that this clients
lump is cancerous?
k. a. Eversion of the right nipple and mobile mass
l. b. Non-mobile mass with irregular edges
m. c. Mobile mass that is soft and easily delineated
n. d. Non palpable right axillary lymph nodes
o. SITUATION : Cushings syndrome results from excessive, rather than deficient,
adrenocortical activity.
p. 53. A client is transferred to a rehabilitation center after being treated in the hospital for a
cerebrovascular accident (CVA). Because the client has a history of Cushings syndrome
(hypercortisolism) and chronic obstructive pulmonary disease (COPD), the nurse formulates a
nursing diagnosis of:
q. a. Risk for imbalanced fluid volume related to excessive sodium loss
r. b. Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion
s. c. Ineffective health maintenance related to frequent hypoglycemic episodes secondary to Cushings
syndrome
t. d. Decreased cardiac output related to hypotension secondary to Cushings syndrome
u. 54. All of the following are symptoms of Cushing's syndrome except:
v. a. Severe fatigue and weakness
b. Hypertension and elevated blood
glucose

c. A protruding hump between the

shoulders
d. Hair loss

w. 55. Which of the following conditions is caused by long-term exposure to high levels of cortisol?
x.

a. Addison's disease
b.. Crohn's disease

c. Adrenal insufficiency
d. Cushing's syndrome

y. 56. The client with Cushing's syndrome is undergoing a dexamethasone suppression test. The nurse
plans to implement which steps during this test?

a. A. collect a 24-hour urine specimen to measure serum cortisol levels

b. administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning
c. draw blood samples before and after exercise to evaluate the effect of exercise on
serum cortisol level
d.

m.

administer an injection of adrenocorticotropic hormone (ACTH) 30 minutes before drawing blood to

measure serum cortisol levels

z. 57. In assessing a client with possible Cushings syndrome. In a client with Cushings syndrome, the
nurse would expect to find:
a. hypotension
b. thick, coarse skin
c. deposits of adipose tissue in the trunk and dorsocervical area
d. weight gain in arms and legs
aa. 58. Which laboratory test result best supports a diagnosis of Addisons disease?
a. Blood urea nitrogen (BUN) level of 12
c. Serum sodium level of 134 mEq/L
mg/dl
d. Serum potassium level of 5.8 mEq/L
b. Blood glucose level of 90 mg/dl
e.
f. 59. Before discharge, a client with Addisons disease should be instructed to do which of the
following when exposed to period of stress?
a. Administer hydrocortisone IM
b. Drink 8oz fluids
c. Perform capillary blood glucose monitoring four times daily
d. Continue to take his usual dose of hydrocortisone
g. 60.Select the correct disorder for these symptoms: (1) salt craving; (2) high K+; (3) hypotension; (4)
hypoglycemia; (5) collapse due to stress--h. a. diabetes, Type I;
i. b. Cushing's disease(syndrome);
j. c. diabetes insipidus;
k.
d. Addison's Disease (hypoadrenalism
l. Situation: A nurse must be aware in her actions in delivering patient care. The bioethical
principles are very helpful in helping her attain this.
61. Nurse Bea enters a pts room & finds the pt lying on the floor. Bea checks the pt & calls the nsg
supervisor & the physician to inform them of the occurrence. The nursing supervisor instructs Bea to
make an incident report w/c she did, understanding that it allows analysis of adverse pt events through:
a A method of promoting quality care & risk mgt
b Determining the effectiveness of interventions in relation to outcomes
c Appropriate method of reporting to local agencies
d Providing pts w/ necessary stabilizing treatments
n. 62. Nurse Ann observes that a pt received pain medication 1 hr ago from another nurse, but that the
pt still has severe pain. The nurse has previously observed this same occurrence. Nurse Ann plans
to do w/c of the ff.?
a Talk w/ the nurse who gave the medication
b Talk to the nsg. supervisor
c Call the physician
d Report the information to the police
o. 63. Which of the following would refer to ones duty to benefit or promote the good of others?
p.
a. Veracity
b. Beneficence
c. Nonmaleficence
d. Ethical Principles
q.
r. 64. A pt has died and a family member is asked about the funeral arrangements. The family
member refuses to discuss the issue. The nurses most appropriate action is to:
a Provide info needed for decision making
b Suggest a referral to a mental health professional
c Show acceptance of lability of feelings
d Remain w/ the family member w/o discussing funeral arrangements
s. 65. Patient Ramon arrives in the ER & is staggering, confused & verbally abusive; complains of a
headache from drinking alcohol & is asking for meds. Nurse Ann explains that the physician will
need to perform an assessment before administration of medication. When he becomes verbally
abusive, Nurse Ann threatens to place him in restraints. Which can the pt legally charge Ann as a
result of the nsg action?
a Assault
c Negligence
b Battery
d Invasion of privacy
e Situation: Research is indispensable in the practice of nursing; thus, an astute nurse must
have a comprehensive grasp of the research process to achieve quality in patient care.
f 66.
Research in nursing is primarily conducted for what purpose;
a. To improve nursing practice
c. To solve nursing problems
b. To formulate nursing theories
d. To test nursing hypothesis
e. 67. A type of research whose purpose is merely to determine the general picture of the population, to
get the over-all distribution of respondents;

a.
b.
e.

f.

g.

a. Causal
c. Descriptive
b. Relational
d. Exploratory
e. 68. When the researcher wishes to determine the association of one variable to another, the type
of research is;
a. Descriptive
c. Causal
b. Relational
d. Evaluative
e. 69. When the researcher wishes to determine the association of one variable to another, the type
of research is;
a. Descriptive
c. Causal
b. Relational
d. Evaluative
e. 70. Facts which are presumed to be true and existing and need not be tested are called?
Theory
c. Concepts.
Hypothesis
d.
Assumptions
SITUATION Hyperthyroidism is the second most prevalent endocrine disorder second to
diabetes mellitus. Treatment of hyperthyroidism is directed toward reducing thyroid hyperactivity
to relieve symptoms and remove the cause of important complications. This treatmemt
intervention may include both medical and surgical management.
71. Which nursing diagnosis takes highest priority for a female client with hyperthyroidism?
A. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone
excess
B. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing
C. Body image disturbance related to weight gain and edema
D. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
72. Nurse Ruth is assessing the client after subtotal thyroidectomy. The assessment reveals muscle
twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should
suspect which complication?

h.
i.
j.

A. Tetany
B. Hemorrhage

C. Thyroid storm
D. Laryngeal nerve damage

73. After undergoing subtotal thyroidectomy, the client develops hypothyroidism. Dr. Smith prescribes
levothyroxine (Levothroid), 25 mcg P.O. daily. For which condition is levothyroxine the preferred agent?

k.

A. Primary hypothyroidism
B. Graves disease

C. Thyrotoxicosis
D. Euthyroidism

l.
m. 74. When assessing the client with pheochromocytoma, nurse April is most likely to detect:
n.

A. a blood pressure of 130/70 mm

C. bradycardia.
D. a blood pressure of 176/88 mm

Hg.
B. a blood glucose level of 130

Hg.

mg/dl.
o.
p. 75. To reverse hypertensive crisis caused by pheochromocytoma, nurse April expects to administer:
q.

A. phentolamine (Regitine)
B. methyldopa (Aldomet)
C. mannitol (Osmitrol)
D. felodipine (Plendil)

r.
s. Situation : Quality nursing care with a difference is one of the major goals of quality assurance
program or total quality management. One of the functions of nurse manager is to target and
ensure that quality nursing care is delivered. The succeeding questions pertains to maintaining
standards or quality
t. 76. Which of the following ensures quality or safe and effective nursing practice?
a. Standards
c. Targets
b. Goals
d. Philosophy
A. 77. If her patients responses conform to her plan of care the type of standard used is;
a. Outcome
c. Structure
b. Process
d. Routine
e.
78. Growth and professional development of nursing personnel should be the responsibility of:
a. The institution
c. The human resource manager
b. The personnel herself
d. The supervisors
e.
79. As a nurse manager, Miss Paloc, RN, was often asked to orient the new graduates and other nursing
personnel to the organizational structure of the hospital, the primary purpose of which is to:
a. Explain her role in the organizational structure
b. Provide information on hospitals philosophy and goals
c. Provide mechanism for equitable distribution of work load
d. Explain the staff nurses role in the organization
f.
80. Which of the following directing activities is the Chief Nurse primarily confirming?
a. Communication
b. Delegating

c. Training
d. Motivating
e. SITUATION : Margaret O'Hara, a 30-year-old known diabetic, is brought to the emergency
department by ambulance. The paramedic team reports symptoms of apparent hyperglycemia.
Stat blood glucose is 640.
f. 81. The nurse is aware that excess serum glucose acts to draw fluids osmotically with resultant polyuria.
In addition to increased urinary output, the nurse should expect to observe which of the following sets of
symptoms in Margaret?
g. a. Polydipsia, diaphoresis, bradycardia
h. b. Thirst, dry mucous membranes, hot dry skin
i.

c. Hypotension, bounding pulse, headache

j.

d. Nervousness, rapid respirations, diarrhea

k. 82. Acarbose (Precose), an alpha-glucosidase inhibitor, is prescribed to client with type 2 diabetes
mellitus. During discharge planning, nurse Pauleen would be aware of the clients need for additional
teaching when the client states:
a. If I have hypoglycemia, I should eat some sugar, not dextrose.
b. The drug makes my pancreas release more insulin.
c. I should never take insulin while Im taking this drug.
d. Its best if I take the drug with the first bite of a meal.
l. 83. Dr. Kennedy prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a male client with type 2
diabetes mellitus who has been having trouble controlling the blood glucose level through diet and
exercise. Which medication instruction should the nurse provide?
a. Be sure to take glipizide 30 minutes before meals.
b. Glipizide may cause a low serum sodium level, so make sure you have your sodium level
checked monthly.
c. You wont need to check your blood glucose level after you start taking glipizide.
d. Take glipizide after a meal to prevent heartburn.
m. 84. The male client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome
(HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide
(Tolinase).
n. Which of the following is the most important laboratory test for confirming this disorder?
a. Serum potassium level
c. Arterial blood gas (ABG) values
b. Serum sodium level
d. Serum osmolarity
e. 85. During a class on exercise for diabetic clients, a female client asks the nurse educator how often to
exercise. The nurse educator advises the clients to exercise how often to meet the goals of planned
exercise?
f.

a. At least once a week

b. At least three times a week

c. At least five times a week

d. Every day

g.
h. 86. During a routine check-up, the nurse evaluates a client with rheumatoid arthritis. To assess for the most
obvious disease manifestations first, the nurse checks for:
i.
j.
a. . Muscle weakness
l. c. Painful subcutaneous nodules
k. b. Joint abnormalities
m. d. Gait disturbances
n. 87. The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction
should the nurse include in the teaching plan?
a. Exposure to sunlight will help control skin rashes.
b. There are no activity limitations between flare-ups.
c. Monitor body temperature
d. Corticosteroids may be stopped when symptoms are relieved.
o.
p. 88. A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching
the
q. client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
r.
a. Weight gain
t. c. Respiratory acidosis
s. b. Fine motor tremors
u. d. Bilateral hearing loss
v.
w. 89. A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement
indicates effective teaching about this therapy?
a. I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear.
b. I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal.
c. I will receive parenteral vitamin B12 therapy monthly for 6 months to a year.
d. I will receive parenteral vitamin B12 therapy for the rest of my life.

x. 90. A client takes prednisone (Deltasone), as prescribed, for rheumatoid arthritis. During follow-up visits, the
nurse should assess the client for common adverse reactions to this drug, such as:
y. a. Tetany and tremors
aa. c. Fluid retention and weight gain
z. b. Anorexia and weight loss
ab. d. None of the above
ac. SITUATION Arthur, 20 year old college student was rushed to the ER of St. Lukes Hospital after he
fainted during their parade for the opening of the University week celebration. Complained of severe
right iliac pain. Upon palpation of his abdomen, Arthur jerks even on slight pressure. Blood test was
ordered. Diagnosis is acute appendicitis.
91. Which of the following result of the laboratory test will be significant to the diagnosis?
ad.

A. RBC: 4.5 TO 5 Million / cu. mm.

B. Hgb: 13 to 14 gm/dl.
C. Platelets: 250,000 to 500,000

cu.mm.
D. WBC: 12,000 to 13,000/cu.mm

ae.
92. Stat appendectomy was indicated. Pre op care would include all of the following except?
A. Consent signed by the father
B. Enema STAT
C. Skin prep of the area including the pubis
D. Remove the jewelries
93. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to:
af.

A. Allay anxiety and apprehension

B. Reduce pain

C. Prevent vomiting
D. Relax abdominal muscle

ag.
94. Post op care for a client after appendectomy will include the following except:
ah.

A. Early ambulation
B. Diet as tolerated after fully
conscious

C. Nasogastric tube connect to suction

D. Deep breathing and leg exercise

ai.
95. Peritonitis may be a complication that may occur in ruptured appendix and may cause serious problems
which are
1. Hypovolemia, electrolyte imbalance
2. Elevated temperature, weakness and diaphoresis
3. Nausea and vomiting, rigidity of the abdominal wall
4. Pallor and eventually shock
A. 1 and 2
B. 2 and 3
C. 1,2,3
D. All of the above
aj. SITUATION : Matthew, a 36 year old, male patient diagnosed with colon cancer was newly put in
colostomy.
96. Mathew shows the BEST adaptation with the new colostomy if he shows which of the following?
A. Look at the ostomy site
B. Participate with the nurse in his daily ostomy care
C. Ask for leaflets and contact numbers of ostomy support groups
D. Talk about his ostomy openly to the nurse and friends
97. The nurse plans to teach Matthew about colostomy irrigation. As the nurse prepares the materials
needed, which of the following item indicates that the nurse needs further instruction?
A. Plain NSS / Normal Saline
B. K-Y Jelly
C. Tap water
D. Irrigation sleeve
98 The nurse should insert the colostomy tube for irrigation at approximately how many inches?
ak.
A. 1-2 inches
B. 12-18 inches
C. 6-8 inches
D. 3-4 inches
99. Which of the following behavior of the client indicates the best initial step in learning to care for his
colostomy?
A. Ask to defer colostomy care to another individual
B. Promises he will begin to listen the next day
C. States that colostomy care is the function of the nurse while he is in the hospital
D. Agrees to look at the colostomy
100. The next day, the nurse will assess Matthews stoma. The nurse noticed that a prolapsed stoma is
evident if she sees which of the following?
A. A sunken and hidden stoma
B. A dusky and bluish stoma
C. A narrow and flattened stoma
D. Protruding stoma with swollen appearance

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