1. A patient is admitted to the medical surgical unit following surgery.

Four days after

surgery, the patient spikes a 38.9 degrees C oral temperature and exhibits a wet,
productive cough. The nurse assesses the patient with understanding that an infection
that is acquired during hospitalization is known as:
A. a community acquired infection
B. an iatrogenic infection
C. a nosocomial infection
D. an opportunistic infection
2. A client with anemia has a hemoglobin of 6.5 g/dL. The client is experiencing
symptoms of cerebral tissue hypoxia. Which of the following nursing interventions
would be most important in providing care?
A. Providing rest periods throughout the day
B. Instituting energy conservation techniques
C. Assisting in ambulation to the bathroom
D. Checking temperature of water prior to bathing
3. A client was involved in a motor vehicular accident in which the seat belt was not
worn. The client is exhibiting crepitus, decrease breath sounds on the left, complains
of shortness of breath, and has a respiratory rate of 34 breaths per minute. Which of
the following assessment findings would concern the nurse most?
A. Temperature of 102 degrees F and productive cough
B. ABG with PaO2 of 92 and PaCO2 of 40 mmHg
C. Trachea deviating to the right
D. Barrel-chested appearance
4. The proper way to open an envelop-wrapped sterile package after removing the
outer package or tape is to open the first position of the wrapper:
A. away from the body
B. to the left of the body
C. to the right of the body
D. toward the body
5. Assessment of a client with possible thrombophlebitis to the left leg and a deep vein
thrombosis is done by pulling up on the toes while gently holding down on the knee.
The client complains of extreme pain in the calf. This should be documented as:
A. positive tourniquet test
B. positive homan’s sign
C. negative homan’s sign
D. negative tourniquet test
6. Thomas Elison is a 79 year old man who is admitted with diagnosis of dementia.
The doctor orders a series of laboratory tests to determine whether Mr. Elison’s
dementia is treatable. The nurse understands that the most common cause of dementia
in this population is:
A. AIDS
 B. Alzheimer’s disease
C. Brain tumors
D. Vascular disease
7. Which of the following nursing interventions is contraindicated in the care of a
client with acute osteomyelitis?
A. Apply heat compress to the affected area
B. Immobilize the affected area
C. Administer narcotic analgesics for pain
D. Administer OTC analgesics for pain
8. A client with congestive heart failure has digoxin (Lanoxin) ordered everyday.
Prior to giving the medication, the nurse checks the digoxin level which is therapeutic
and ausculates an apical pulse. The apical pulse is 63 bpm for 1 full minute. The nurse
should:
A. Hold the Lanoxin
B. Give the half dose now, wait an hour and give the other half
C. Call the physician
D. Give the Lanoxin as ordered
9. Nurse Marian is caring for a client with haital hernia, which of the following should
be included in her teaching plan regarding causes:
A. To avoid heavy lifting
B. A dietary plan based on soft foods
C. Its prevalence in young adults
D. Its prevalence in fair-skinned individuals
10. Joseph has been diagnosed with hepatic encephalopathy. The nurse observes
flapping tremors. The nurse understands that flapping tremors associated with hepatic
encephalopathy are also known as:
A. aphasia
B. ascites
C. astacia
D. asterixis
11. Hyperkalemia can be treated with administration of 50% dextrose and insulin. The
50% dextrose:
A. causes potassium to be excreted
B. causes potassium to move into the cell
C. causes potassium to move into the serum
D. counteracts the effects of insulin
12. Which of the following findings would strongly indicate the possibility of
cirrhosis?
A. dry skin
B. hepatomegaly
C. peripheral edema
 D. pruritus
13. Aling Puring has just been diagnosed with close-angle (narrow-angle) glaucoma.
The nurse assesses the client for which of the following common presenting
symptoms of the disorder?
A. halo vision
B. dull eye pain
C. severe eye and face pain
D. impaired night vision
14. Chvostek’s sign is associated with which electrolyte impabalnce?
A. hypoclacemia
B. hypokalemia
C. hyponatremia
D. hypophosphatenia
15. What laboratory test is a common measure of the renal function?
A. CBC
B. BUN/Crea
C. Glucose
D. Alanine amino transferase (ALT)
16. Nurse Edward is performing discharge teaching for a newly diagnosed diabetic
patient scheduled for a fasting blood glucose test. The nurse explains to the patient
that hyperglycemia is defined as a blood glucose level above:
A. 100 mg/dl
B. 120 mg/dl
C. 130 mg/dl
D. 150 mg/dl
17. Mang Edison is on bed rest has developed an ulcer that is full thickness and is
penetrating the subcutaneous tissue. The nurse documents that this ulcer is in which of
the following stages?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
18. A 24 year old male patient comes to the clinic after contracting genital herpes.
Which of the following intervention would be most appropriate?
A. Encourage him to maintain bed rest for several days
B. Monitor temperature every 4 hours
C. Instruct him to avoid sexual contact during acute phases of illness
D. Encourage him to use antifungal agents regularly
19. An 8 year old boy is brought to the trauma unit with a chemical burn to the face.
Priority assessment would include which of the following?
A. Skin integrity
 B. BP and pulse
C. Patency of airway
D. Amount of pain
20. A client with anemia due to chemotherapy has a hemoglobin of 7.0 g/dL. Which
of the following complaints would be indicative of tissue hypoxia related to anemia?
A. dizziness
B. fatigue relieved by rest
C. skin that is warm and dry to the touch
D. apathy
21. Hazel Murray, 32 years old complains of abrupt onset of chest and back pain and
loss of radial pulses. The nurse suspects that Mrs. Murray may have:
A. Acute MI
B. CVA
C. Dissecting abdominal aorta
D. Dissecting thoracic aneurysm
22. Nurse Alexandra is establishing a plan of care for a client newly admitted with
SIADH. The priority diagnosis for this client would be which of the following?
A. Fluid volume deficit
B. Anxiety related to disease process
C. Fluid volume excess
D. Risk for injury
23. Nursing management of the client with a UTI should include:
A. Taking medication until feeling better
B. Restricting fluids
C. Decreasing caffeine drinks and alcohol
D. Douching daily
24. Felicia Gomez is 1 day postoperative from coronary artery bypass surgery. The
nurse understands that a postoperative patient who’s maintained on bed rest is at high
risk for developing:
A. angina
B. arterial bleeding
C. deep vein thrombosis (DVT)
D. dehiscence of the wound
25. Which of the following statement is true regarding the visual changes associated
with cataracts?
A. Both eyes typically cataracts at the same time
B. The loss of vision is experienced as a painless, gradual blurring
C. The patient is suddenly blind
D. The patient is typically experiences a painful, sudden blurring of vision.
Answers and Rationales
1. C. a nosocomial infection. Nosocomial, or hospital-acquired are infections
acquired during hospitalization for which the patient isn’t being primarily treated.
Community acquired or opportunistic infections may not be acquired during
hospitalization. An iatrogenic infection is caused by the doctor or by medical
therapy. And an opportunistic infection affects a compromised host.
2. C. Assisting in ambulation to the bathroom. Cerebral tissue hypoxia is commonly
associated with dizziness. The greatest potential risk to the client with dizziness is
injury, especially with changes in position. Planning for periods of rest and
conserving energy are important with someone with anemia because of his or her
fatigue level but most important is safety.
3. C. Trachea deviating to the right. A mediastinal shift is indicative of a tension
pneumothorax along with the other symptoms in the question. Since the
individual was involved in a MVA, assessment would be targeted at acute
traumatic injuries to the lungs, heart or chest wall rather than other conditions
indicated in the other answers. Option A is common with pneumonia; values in
option B are not alarming; and option D is typical of someone with COPD.
4. A. away from the body. When opening an envelop-wrapped sterile package,
reaching across the package and using the first motion to open the top cover away
from the body eliminates the need to later reach across the steri9le field while
opening the package. To remove equipment from the package, opening the first
portion of the package toward, to the left, or to the right of the body would require
reaching across a sterile field.
5. B. positive homan’s sign. Pain in the calf while pulling up on the toes is abnormal
and indicates a positive test. If the client feels nothing or just feels like the calf
muscle is stretching, it is considered negative. A tourniquet test is used to measure
for varicose veins.
6. B. Alzheimer’s disease. Alzheimer’s disease is the most common cause of
dementia in the elderly population. AIDS, brain tumors and vascular disease are
all less common causes of progressive loss of mental function in elderly patients.
7. A. Apply heat compress to the affected area. Options B, C and D are appropriate
nursing interventions when caring for a client diagnosed with osteomyelitis. The
application of heat can increase edema and pain in the affected area and spread
bacteria through vasodilation.
8. D. Give the Lanoxin as ordered. The Lanoxin should be held for a pulse of 60
bpm. Nurses cannot arbitrarily give half of a dose without a physician’s order.
Unless specific parameters are given concerning pulse rate, most resources
identify 60 as the reference pulse.
9. A. To avoid heavy lifting. Heavy lifting is one factor that leads to development of
a hiatal hernia. Dietary factors involve limiting fat intake, not restricting client to
 soft foods. It is more prevalent in individuals who are middle-aged or older. Fair-
skinned individuals are not prone to this condition.
10. D. asterixis. Flapping tremors associated with hepatic encephalophaty are
asterixis. Aphasia is the inability to speak. Ascites is an accumulation of fluid in
the peritoneal cavity. Astacia is the inability to stand or sit still.
11. D. counteracts the effects of insulin. The 50% dextrose is given to counteract the
effects of insulin. Insulin drives the potassium into the cell, thereby lowering the
serum potassium levels. The dextrose doesn’t directly cause potassium excretion
or any movement of potassium.
12. B. hepatomegaly. Although option D is correct, it is not a strong indicator of
cirrhosis. Pruritus can occur for many reasons. Options A and C are incorrect,
fluid accumulations is usually in the form of ascites in the abdomen.
Hepatomegaly is an enlarged liver, which is correct. The spleen may also be
enlarged.
13. C. severe eye and face pain. Narrow-angle glaucoma develops abruptly and
manifests with acute face and eye pain and is a medial emergency. Halo vision,
dull eye pain and impaired night vision are symptoms associated with open-angle
glaucoma.
14. A. hypoclacemia. Chvostek’s sign is a spasm of the facial muscles elicited by
tapping the facial nerve and is associated with hypocalcemia. Clinical signs of
hypokalemia are muscle weakness, leg cramps, fatigue, nausea and vomiting.
Muscle cramps, anorexia, nausea and vomiting are clinical signs of hyponatremia.
Clinical manifestations associated with hypophosphatemia include muscle pain,
confusion, seizures and coma.
15. B. BUN/Crea. The BUN is primarily used as indicator of kidney function because
most renal diseases interfere with its excretion and cause blood vessels to rise.
Creatinine is produced in relatively constant amounts, according to the amount of
muscle mass and is excreted entirely by the kidneys making it a good indicator of
renal function.
16. B. 120 mg/dl. Hyperglycemia is defined as a blood glucose level greater than 120
mg/dl. Blood glucose levels of 120 mg/dl, 130 mg/dl and 150 mg/dl are
considered hyperglycemic. A blood glucose of 100 mg/dl is normal.
17. C. Stage 3. A stage 3 ulcer is full thickness involving the subcutaneous tissue. A
stage 1 ulcer has a defined area of persistent redness in lightly pigmented skin. A
stage 2 ulcer involves partial thickness skin loss. Stage 4 ulcers extend through
the skin and exhibit tissue necrosis and muscle or bone involvement.
18. C. Instruct him to avoid sexual contact during acute phases of illness. Herpes is a
virus and is spread through direct contact. An antifungal would not be useful; bed
rest and temperature measurement are usually not necessary.
19. C. Patency of airway. A burn face, neck or chest may cause airway closure
because of the edema that occurs within hours. Remember the ABC’s: airway,
 breathing and circulation. Airway always comes first, even before pain. The nurse
will also assess options B and D, but these are not the highest priority
assessments.
20. A. dizziness. Central tissue hypoxia is commonly associated with dizziness.
Recognition of cerebral hypoxia is critical since the body will attempt to shunt
oxygenated blood to vital organs.
21. D. Dissecting thoracic aneurysm. A dissecting thoracic aneurysm may cause loss
of radical pulses and severe chest and back pain. An MI typically doesn’t cause
loss of radial pulses or severe back pain. CVA and dissecting abdominal
aneurysm are incorrect responses.
22. C. Fluid volume excess. SIADH results in fluid retention and hyponatremia.
Correction is aimed at restoring fluid and electrolyte balance. Anxiety and risk for
injury should be addressed following fluid volume excess.
23. C. Decreasing caffeine drinks and alcohol. Caffeine and alcohol can increase
bladder spasms and mucosal irritation, thus increase the signs and symptoms of
UTI. All antibiotics should be taken completely to prevent resistant strains of
organisms.
24. C. deep vein thrombosis (DVT). DVT, is the most probable complication for
postoperative patients on bed rest. Options A, B and D aren’t likely complications
of the post operative period.
25. B. The loss of vision is experienced as a painless, gradual blurring. Typically, a
patient with cataracts experiences painless, gradual loss of vision. Although both
eyes may develop at different rates.