TESTMANSHIP – MEDICAL SURGICAL NURSING

TEST TAKING STRATEGY-BASED

JUNE 2009 NURSING LICENSURE EXAMINATION
SITUATION: A nurse is assigned in the medical-surgical ward. Nurse Jay is assigned to several post-surgery clients.

1. A client who just underwent a tonsillectomy is becoming slightly restless, has an increased pulse rate, and exhibits slight pallor.
The nurse notes that the client is swallowing frequently. Which of the following interpretation most appropriately describes the
cause of the manifestation noted by the Nurse Jay?
a. the client needs pain medication
b. the client may have postoperative bleeding or hemorrhage
c. this is an expected postoperative finding
d. the client has some mild post operative edema
TTS: KEY WORD ASSOCIATION
ANSWER: B- Signs of postoperative hemorrhage include pallor, restlessness, frequent swallowing, large amounts of bloody drainage
or vomitus, increasing pulse rate, and a falling blood pressure.

2. Four hours post – operatively, a client complains of guarding and rigidity of the abdomen. Nurse Jay’s initial intervention is:
a. Assess for signs of peritonitis
b. Call the physician
c. Administer pain medication
d. Ignore the client
TTS: NURSING PROCESS
ANSWER: A. Assess for signs of peritonitis. Assessment precedes intervention. Symptoms presented are signs of peritonitis.
Assessment will provide you the data for prompt intervention.

3. The client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. Nurse Jay assesses the site and
determines that the client has developed phlebitis. Nurse Jay avoids which action in the care of this client?
a. Notifies the physician
b. Applies warm moist packs to the site
c. Discontinues the IV catheter at that site
d. Starts a new IV line in a proximal portion of the same vein
TTS: KEY WORD-NEGATIVE ANSWER
ANSWER: D – The nurse should restart the IV in a vein other than the one that has developed phlebitis.
The nurse should discontinue the IV at the phlebitis site and apply warm moist compresses to the area to speed resolution of the
inflammation. Because phlebitis has occurred, the nurse also notifies the physician about the IV complication.

4. Another client complains of severe abdominal pain. The client had a subtotal gastrectomy three days ago. The nurse palpates the
client’s abdomen and notes rigidity. The nurse should first:
a. Assist the client to ambulate
b. Assess the client’s vital signs
c. Administer the prescribed analgesic
d. Encourage the use of the spirometer
TTS: PRIORITY- NURSING PROCESS
ANSWER: B. Rigidity and pain are hallmarks of bleeding from the suture line and/or of peritonitis; vital signs provide supporting
data.

5. A client has impaired verbal communication as a result of temporary tracheostomy following a laryngectomy. In planning for
communication with this client, Nurse Jay would avoid which of the following methods because it would be least helpful for this
particular client.
a. Use of hand or finger signals
b. Nodding and shaking of head to say yes or no
c. Use of picture board
d. Use of pencil and paper
TTS: NEGATIVE ANSWER
ANSWER: B- Following laryngectomy, the client should not be asked to nod or shake the head because it is painful for the client. The
use of eye blink or hand or finger signals is acceptable. Other helpful methods include the use of a pencil and paper, word or picture
board, flash cards, or a magic slate.

6. Salim had abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to
10 (worst pain). Which of the following would be the nurse’s first action?
a. Obtain an order for a stronger pain medication because the client’s pain has increased
b. Assess the client to rule out possible complications secondary to surgery
c. Check the client’s chart to determine when pain medication was last administered
d. Explain to the client that the pain should not be this severe 3 days postoperatively
TTS: PRIORITY- NURSING PROCESS
ANSWER: B – Assessment should be done first so that the source of the pain could be identified.
7. After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively,
how should the nurse position the client?
a. With the affected hip flexed acutely
b. With the leg on the affected side abducted
c. With the leg on the affected side adducted
d. With the affected hip rotated externally
TTS: CONTRASTING
ANSWER: B – The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental
dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client
not to cross the legs.
A, C, D – The nurse should avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively),
adducting the leg on the affected side (such as by moving it toward the midline), or externally rotating the affected hip (such as by
removing support along the outer side of the leg) because these positions may cause dislocation of the injured hip joint.
8. Four hours post – operatively, Mr. Castro complains of guarding and rigidity of the abdomen. Nurse Maria’s initial intervention is:
a. Assess for signs of peritonitis
b. Call the physician
c. Administer pain medication
d. Ignore the client
TTS: NURSING PROCESS
ANSWER: A- Assessment precedes intervention. Symptoms presented are abdominal pain and distention, rebound tenderness and
fever. Assessment will provide you the data for prompt intervention. B, C- can be done after assessment. D-always address feelings of
pain.

9. Following an abdominal surgery a client complains of pain. The first action by the nurse should be to:
a. Reposition the client
b. Monitor vital signs
c. Administer the ordered analgesic
d. Determine the characteristic of pain
TTS: NURSING PROCESS
ANSWER: D - The exact nature of the pain must be determined to distinguish whether this is pain caused by the surgery or is from
some other cause.
A and B-this could be done later.
C-prescribed analgesics would be given after determining the exact nature of illness
10. The nurse is caring for a client who recently underwent a total hip replacement. The nurse should:
1. Ease the client onto low toilet seat.
2. Caution client not to cross the legs at the knees when out of bed.
3. Use firm chairs when the client is sitting out of bed.
4. Limit client hip flexion when sitting.
a. 1, 3
b. 1, 2, 4
c. 2, 4
d. 2, 3, 4
TTS: SELECT THAT ALL APPLY
ANSWER: D
1 – Should be high toilet seat
2, 3, 4 – Correct statement

11. While being prepared for surgery for a ruptured spleen, a client complains of feeling of lightheaded. The client’s color is pale and
the pulse is very rapid. The nurse assesses that the client may be:
a. hyperventilating
b. going into shock
c. extremely anxious
d. developing an infection
TTS: KEY WORD ASSOCIATION
ANSWER: -B-lightheadedness, pale appearance and a rapid pulse are signs of impending shock

12. Lymphedema is the most common postoperative complication following axillary lymph node resection. The following actions
would minimize this problem, except:
a. elevate arm pillow with arm support
b. keep the arm abducted
c. reinforce the arm excercises
d. take the BP from the arm on the affected side
TTS: KEY WORD ASSOCIATION, NEGATIVE ANSWER
ANSWER: D-this will put excess pressure to the blood vessels and lymph nodes inhibiting circulation

13. During a blood transfusion a client develops chills and headache. The nurse’s best action is to:
a. lightly cover the client
b. notify the physician stat
c. stop the transfusion immediately
d. slow the blood flow to keep the vein open
TTS: PRIORITY QUESTION
ANSWER: C-because the patient is having acute hemolytic reaction

SITUATION: Maria diagnosed with cancer of her thyroid gland underwent surgery
14. Maria is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to
keep at the client's bedside?
a. Indwelling urinary catheter kit
b. Tracheostomy set
c. Cardiac monitor
d. Humidifier
TTS: PRIORITY- ABC
ANSWER: B- After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the
nurse should keep a tracheostomy set at the client's bedside in case of a respiratory emergency.

15. The nurse is caring for Marie who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do first?
a. Give calcium supplements as soon as possible
b. Observe for swelling of the neck, tracheal deviation, and severe pain.
c. Evaluate the quality of the client's voice postoperatively, noting any drastic changes.
d. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes
TTS: PRIORITY- NURSING PROCESS
ANSWER: D- Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous
system due to hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany
and neurologic alterations are primary indications of hypocalcemia.

16. For the first 72 hours after thyroidectomy surgery, a nurse would assess a client for Chvostek’s and Trousseau’s signs because
they indicate:
a. Hypocalcemia
b. Hypercalcemia
c. Hypokalemia
d. Hyperkalemia
TTS: CONTRASTING
ANSWER: A - Due to accidental of removal or damage to the parathyroid gland, the client with hypocalcemia will exhibit a positive
Chvostek’s indicated by facial spasms and Trouseau’s sign indicated by carpal spasms when a BP cuff is inflated on the upper arm.

SITUATION: Nurse Lita is caring for patients with endocrine disorders in the medical ward

17. Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would
experience:
i. heat intolerance
ii. systolic hypertension
iii. weight gain
iv. tremors
a. 1, 2,4
b. 2, 3,
c. 2, 3, 4,
d. 3, 4,
TTS: SELECT THAT ALL APPLY
ANSWER: A- All options with weight gain are incorrect.

18. Which nursing diagnosis takes highest priority for a 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
TTS: PRIORITY QUESTION
ANSWER: D- In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased
nutrient metabolism. These conditions may result in increased protein synthesis and breakdown and depletion, making Imbalanced
nutrition: Less than body requirements the most important nursing diagnosis.

19. The nurse is planning care for a 52-year-old male client in acute Addisonian crisis. Which nursing diagnosis should receive the
highest priority?
a. Risk for infection
b. Decreased cardiac output
c. Impaired physical mobility
d. Imbalanced nutrition: Less than body requirements
TTS: PRIORITY QUESTION
ANSWER: B- Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia.

20. The adrenal cortex is responsible for producing which substances?

i. Glucocorticoids
ii. Androgens
iii. Catecholamines
iv. Epinephrine
v. Mineralocoritoids
a. 2, 3, 5
b. 1, 2, 5
c. 3, 4, 2
d. 3, 4
TTS: SELECT THAT ALL APPLY
ANSWER: The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. Options with 3, and 4
are wrong

21. Which of the following would the nurse expect to find in a client diagnosed with hyperparathyroidism?
a. Hypocalcemia
b. Hypercalcemia
c. Hyperphosphatemia
d. Hyperphosphaturia
TTS: PRIORITY- CONTRASTING
ANSWER: B- Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low
(hyperphosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased.

22. The nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?
1. weight loss
2. nervousness
3. cold intolerance
4. diaphoresis
5. constipation
a. 1,2,3,5
b. 1,2
c. 1,2,4
d. 3,4,5
TTS: SELECT THAT ALL APPLY
ANSWER: C-Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include
exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, decreased sweating, and cold intolerance are signs
of hypothyroidism.

23. A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these
medications are only effective if the client:
a. Prefers to take insulin orally.
b. Has type 2 diabetes.
c. Has type 1 diabetes.
d. Is pregnant and has type 2 diabetes.
TTS: CONTRASTING
ANSWER: B- Oral antidiabetic agents are only effective in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective
in type 1 diabetes. Pregnant and lactating women aren't prescribed oral antidiabetic agents because of the possible effect on the fetus.

24. The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is
modifiable?
1. Age
2. Lifestyle
3. Obesity
4. Poor control of blood glucose
a. 1,2,3,4
b. 1,2,3
c. 2, 3, 4
d. 1,3,4
TTS: SELECT THAT ALL APPLY
ANSWER: C- Nonmodifiable risk factors are ones that the client doesn't have the ability to change. Therefore, all options with age is
incorrect.

25. Even when the diagnosis is still unknown, care of the patient is still very important. What chemical imbalance could the nurse
anticipate when the patient is vomiting excessively?
a. Metabolic Alkalosis
b. Decreased ATP synthesis
c. Metabolic Acidosis
d. Decreased Filtration and Osmosis
TTS: CONTRASTING
ANSWER: A – upon vomiting, HCl is expelled, leaving large amount of bicarbonate in the stomach leading to alkalosis.

26. The following are the hormones released by the anterior pituitary gland:
i. ACTH
ii. Growth Hormone
iii. Melanocyte Stimulating Hormone
iv. Oxytocin
v. Prolactin
vi. Growth Hormone
a. i, ii, iii, iv, v, vi
b. i, ii, iv, v, vi
c. i, iii, iv, v, vi
d. i, ii, iii, v, vi
TTS: SELECT THAT ALL APPLY
ANSWER: D- A,B,C-all options containing IV. Oxytocin are all incorrect since it is secreted by the posterior pituitary.

SITUATION: Nurse Sarah is an ER nurse and had the following patient during his shift
 27. Lee was brought to the ER because he developed manifestations of mysthenia gravis. To diagnose the presence of MG the
physician orders Tensilon Test (Endrophonium). What is true about tensilon test?
a. Increased in muscle strength indicates positive to MG
b. Increased in muscle strength indicates negative to MG
c. muscle weakness indicates positive to MG
d. no change
TTS: CONTRASTING
Correct ANSWER: A-choose among the two opposing options. An increase in strength after giving tensilon shows positive for MG.

28. Sarah in the triage area of an emergency department should assign the highest priority to:
a. 4-year old with asthma who has diminished wheezing, is pale, and is very irritable
b. 1-year old who has had vomiting and diarrhea for 2 days and has a slightly depressed anterior fontanel
c. 6-year old who fell off her bicycle and has several lower extremity lacerations that require suturing
d. 7-month old who rolled off a chair onto a carpeted floor, hitting his head but not losing consciousness
TTS: PRIORITY QUESTION- ABC
ANSWER: A. a patient with a problem on the airway is still a priority, especially so that the wheezing has diminished, which can
mean that no more air enters the airway.

29. A patient named Rodel was rush to the ER because he/she experienced a cerebrovascular accident (CVA). Which of the following
is most priority nursing diagnosis?
a. Impaired breathing pattern
b. Impaired physical mobility
c. Imbalanced nutrition: More than body requirements
d. Anxiety related to actual threat to health status.
TTS: PRIORITY QUESTION- ABC
ANSWER: A – if alteration in breathing is noted, priority measures are directed toward resolving the impairment.

30. The nurse is caring for a client with chest trauma. Which nursing diagnosis takes highest priority?
a. Impaired gas exchange
b. Anxiety
c. Decreased cardiac output
d. Ineffective cardiopulmonary tissue perfusion
TTS: PRIORITY
ANSWER: A- For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is
essential for survival. Although the other options are possible nursing diagnoses for this client, they take lower priority.
performed but is not the priority.

31. An unresponsive and pulse less client is brought into the emergency room after being in a car accident, and a neck injury
is suspected. The nurse opens the client’s airway by which method?
a. Head tilt/chin lift
b. Lift the head up and place the head on two pillows and attempt to ventilate.
c. Jaw-thrust maneuver
d. Keeping the client flat and grasping the tongue
TTS: PRIORITY-DO NO FURTHER HARM
ANSWER: C – In suspected neck injuries, the appropriate way to open the airway is the Jaw-thrust maneuver. If a neck
injury is present, this maneuver will prevent further injury. Option a, b and d are incorrect.

32. A client arrives at the emergency department with upper gastrointestinal bleeding and is in moderate distress. The priority nursing
action is to?
a. Ask the client about the precipitating events
b. Insert a nasogastric tube and hematest the emesis
c. Complete an abdominal physical examination
d. Obtain vital signs
TTS: NURSING PROCESS
ANSWER: D- The priority action is to obtain vital signs to determine whether the client is in shock from blood loss and to obtain a
baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical
needs are met. Insertion of an NG tube may be prescribed but is not the priority action. A complete abdominal physical examination needs
to be

33. A nurse in the emergency room admits a client who is bleeding freely from a scalp laceration obtained during a fall from a step-
ladder when the client was doing outdoor home repair. The nurse takes which of the following actions first in the care of this
wound?
a. Ask the client about timing of the last tetanus vaccination
b. Cleanses the wound with sterile normal saline
c. Prepares for suturing the area
d. Administers prophylactic antibiotic
TTS: NURSING PROCESS- ASSESSMENT
ANSWER. B – This removes the dirt or foreign matter in the wound and allows visualization of the size of the wound, direct pressure
is also applied to control the bleeding. If suturing is necessary the surrounding hair maybe shave. Prophylactic antibiotics are often
prescribes. The date of the clients last tetanus shot is determined and prophylactics is given.

34. When developing a plan of care for a patient recovering from a serious thermal burn, the nurse knows that the most important
immediate goal of therapy is:
a. Planning for the patient’s rehabilitation and discharge
 b. Providing emotional support to the patient and family
c. Maintaining the patient’s fluid, electrolyte, and acid-base balance
d. Preserving full range of motion in all affected joints
TTS: PRIORITY, KEY WORD
ANSWER: C – The most important immediate goal therapy for a patient with a serious thermal burn is maintain fluid, electrolytes and
acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation,
respiratory failure, cardiac failure, and acute tubular necrosis. The other options are important aspects of care but do not take
precedence over maintaining the patient’s fluid, electrolyte, and acid-base balance.

35. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the
nurse should take is
a. Start a peripheral IV
b. Initiate closed-chest massage
c. Establish an airway
d. Obtain the crash cart
TTS: PRIORITY-ABC
ANSWER: C- Establish an airway
Establishing an airway is always the primary objective in a cardiopulmonary arrest.

36. The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after hearing the report?
a. The client with asthma who is now ready for discharge
b. The client with a peptic ulcer who has been vomiting all night
c. The client with chronic renal failure returning from dialysis
d. The client with pancreatitis who was admitted yesterday
TTS: PRIORITY- UNSTABLE PATIENT FIRST
ANSWER: B- The client with a peptic ulcer who has been vomiting all night A perforated peptic ulcer could cause nausea, vomiting
and abdominal distention, and may be a life threatening situation. The client should be assessed immediately and findings reported to
the health care provider

37. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send
back to be seen first?
a. A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying
b. A teenager who got a singed beard while camping
c. An elderly client with complaints of frequent liquid brown colored stools
d. A middle aged client with intermittent pain behind the right scapula
TTS: PRIORITY-AIRWAY
ANSWER: B- A teenager who got singed a singed beard while camping
This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat
or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve
fibers so the client will not be aware of swelling.

38. Which of these clients would the triage nurse request for the health care provider to examine immediately?
a. A 5 month-old infant who has audible wheezing and grunting
b. An adolescent who has soot over the face and shirt
c. A middle-aged man with second degree burns over the right hand
d. A toddler with singed ends of long hair that extends to the waist
TTS: PRIORITY- ABC
ANSWER: A- A 5 month-old infant who has audible wheezing and grunting
The age and the findings puts this client at immediate risk for respiratory complications.

39. A client was admitted 24 hours ago following pulmonary trauma. The nurse monitors for which earliest clinical manifestation of
ARDS?
a. Increase in respiratory rate
b. Blood tinged frothy sputum
c. Bronchial breath sounds
d. Diffuse pulmonary infiltrates on chest x-ray
TTS: PRIORITY- ABC
ANSWER: A – ARDS usually develops within 24-48 hours after an initiating event such as pulmonary trauma. In most cases, dyspnea
and tachypnea are the earliest clinical manifestations.
B - Blood tinged frothy sputum would present later.
C – Breath sounds in early stages of ADRS are usually clear but then may progress to bronchial breath sounds when pulmonary edema
occurs.
D – Chest x-ray may be normal during the early stages but will show infiltrates in the later stage.
SOURCE: SAUNDERS Q and A REVIEW 3rd Ed. P 43.

40. A client is brought to the emergency room by the police after having seriously lacerated both wrists. The initial action that the
nurse will take is to:
a. Assess and treat the wound sites
b. Secure and record a detailed history
c. Encourage and assist the client to ventilate feelings
d. Administer an antianxiety agent
TTS: NURSING PROCESS- ASSESSMENT
ANSWER: A – The initial action when a client has attempted suicide is to assess and treat any injuries. Although options B, C and D
may be appropriate at some point, the initial action would be to treat the wounds.
41. A client admitted to the nursing unit from the emergency department has a Cervical spinal cord injury. Which assessment should
the nurse perform first when admitting the client to the nursing unit?
a. Take the client’s temperature
b. Assess extremity muscle strength
c. Observe for dyskinesias
d. Listen to breath sounds
TTS: PRIORITY- ABC
ANSWER: D – Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the
highest priority. Assessment of temperature and strength can be done after adequate oxygenation is assured. Dyskinesias occur in
cerebellar disorders, so they are not as important in cord-injured clients, unless head injury is suspected.

42. The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:
a. Establish unresponsiveness
b. Call for help
c. Open the airway
d. Assess the client for a carotid pulse
TTS: PRIORITY- FIRST ACTION
ANSWER A: The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client
for breathing while opening the airway, deliver two breaths, and check for a carotid pulse.

43. A nurse is performing a respiratory assessment on a client being treated for asthma attack. The nurse determines that the client’s
respiratory status is worsening if which of the following occurs?
a. Loud wheezing
b. Wheezing during inspiration and expiration
c. Wheezing on expiration
d. Noticeably diminished breath sounds
TTS: LOOK FOR CLUES IN OPTIONS
ANSWER: D – Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Noticeably diminished breath
sounds are an indication of severe obstruction and impending respiratory failure.
A - Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with
severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be
able to move sufficient air to produce breath sounds.
B and C -Wheezing usually occurs first on expiration. As the asthma attack progresses, the client may wheeze during both inspiration
and expiration.

44. A nurse is caring for a client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in
the client?
a. Pallor
b. Low arterial PaO2
c. Elevated arterial PaO2
d. Decreased respiratory rate
TTS: CONTRASTING
ANSWER: B – Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mmHg.
D - The earliest sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client
may exhibit air hunger, retractions, and cyanosis.

45. A client admitted to the nursing unit from the emergency department has a C-4 spinal cold injury. Which assessment
should the perform first when admitting the client to the nursing unit?
a. Take the client’s temperature
b. Assess extremity muscle strength
c. Observe for dyskinesias
d. Listen to breath sound
TTS: PRIORITY- ABC
ANSWER: D – Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment
is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is assured.
Dyskinesias occur in cerebellar disorders, so they are not as important in cord-injured clients, unless head injury is suspected.

SITUATION: Nurse Anne is caring for patients diagnosed with AIDS

46. The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of
the following as a priority in the plan of care?
a. Providing emotional support to decrease fear
b. Protecting the client from infection
c. Encouraging discussion about lifestyle changes
d. Identifying factors that decrease the immune function
TTS: PRIORITY QUESTION- SAFETY OF CLIENT
ANSWER: B – Inadequate immune bodies is at risk for infection

47. The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome. After administering the
medication, the nurse disposes of the used needle by
a. Placing it in a puncture resistant container
b. Laying the needle and syringe on the bedside table and carefully recapping the needle
c. Asking the client to recap the needle
d. Recapping the needle before placing it in a puncture resistant container
TTS: SAFETY
ANSWER: A- B, C, D – are all similar about recapping, although the handled technique is allowed it is done only when there is a need
to recap

48. The nurse is caring for a client with acquired immunodeficiency syndrome who is experiencing night fever and night sweats.
Which nursing interventions would be the least helpful in managing this symptom?
a. Keep a change of bed linens nearby in case they are needed
b. Maintain adequate ventilation
c. Cover patient with more blankets
d. Keep liquids at the bed side
TTS: NEGATIVE
ANSWER: C – this will make the client warmer due to the warm effect of blankets

SITUATION: Lawrence playing basketball accidentally slips and injured himself

49. Which nursing diagnosis takes highest priority for Lawrence with a compound fracture?
a. Imbalanced nutrition: Less than body requirements related to immobility
b. Impaired physical mobility related to trauma
c. Risk for infection related to effects of trauma
d. Activity intolerance related to weight-bearing limitations
TTS- PRIORITY
ANSWER: C – A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of
defense against infection, any skin opening places the client at risk for infection.
A – Imbalanced nutrition: Less than body requirements is rarely associated with fractures. B, D – Although Impaired physical
mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they
aren't as life-threatening as infection.

50. The nurse is caring for Lawrence placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?
a. Assessing the extremity for neurovascular integrity
b. Keeping the client from sliding to the foot of the bed
c. Keeping the ropes over the center of the pulley
d. Ensuring that the weights hang free at all times
TTS: PRIORITY- ASSESSMENT FIRST
ANSWER: A – Although all measures are correct, assessing neurovascular integrity takes priority.
B – The pull of the traction must be continuous to keep the client from sliding.
C – Sufficient counter traction must be maintained at all times by keeping the ropes over the center of the pulley.
D – The line of pull is maintained by allowing the weights to hang free.

51. Lawrence also has fractured his right arm and a fiberglass cast was applied. Which action should the nurse include in the plan of
care?
a. Keeping the casted arm warm by covering it with a light blanket
b. Avoiding handling the cast for 24 hours or until it is dry
c. Evaluating pedal and posterior tibial pulses every 2 hours
d. Assessing movement and sensation in the fingers of the right arm.
TTS: NURSING PROCESS
ANSWER: D – The nurse should assess a casted arm every 2 hours for finger movement and sensation to make sure the cast isn't
restricting circulation.
A – To reduce the risk of skin breakdown, the nurse should leave a casted arm uncovered, which allows air to circulate through the
cast pores to the skin below.
B – Unlike a plaster cast, a Fiberglas cast dries quickly and can be handled without damage soon after application.
C – The nurse should assess the brachial and radial pulses distal to the cast — not the pedal and posterior tibial pulses, which are
found in the legs.

52. A nurse is preparing Lawrence a how to ambulate with a cane. Before teaching cane-assisted ambulation, the priority
nursing assessment is to determine:
a. That the client has full range of motion ability
b. The client’s balance, strength and confidence
c. If the client is self conscious of using a cane
d. That the client has high level of stamina
TTS: UMBRELLA
ANSWER: B – Assessing the client’s balance, strength and confidence helps determines if the appropriate assistive device
has been chosen. Full range of motion and high level of stamina are not needed for waking with a cane. Although body image
(self-consciousness) is a component of the assessment, it is not the priority.

SITUATION: Jamal, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old
woman fell at the railway. Jamal rushed at the scene.

53. As a registered nurse, Jamal knew that the first thing that he will do at the scene is?
a. Stay with the person, encourage her to remain still and immobilize the leg while waiting for the ambulance.
b. Leave the person for a few moments to call for help.
c. Reduce the fracture manually.
d. Move the person to a safer place.
TTS: SAFETY
ANSWER: D- The old woman is in the middle of a train railway. It is very unsafe to immobilize here legs and remain still at the
middle of a railway considering that a train might come anytime while waiting for an ambulance. Safety is the utmost importance at
this point. If letter D is not among the choices and the situation is a little less dangerous, the ANSWER will be A. Remember that in
all cases of emergencies, removing the victim from the scene to a much safer place is a priority.

54. Marie the patient who Jamal rescued was now Immobilized and brought to the emergency room. The X-ray shows a fractured
femur and pelvis. The ER Nurse would carefully monitor Marie for which of the following sign and symptoms?
a. Tachycardia and hypotension
b. Fever and bradycardia
c. Bradycardia and hypertension
d. Fever and hypertension
TTS: CONTRASTING OPTIONS
ANSWER: A- hemorrhage results in severing of the vascular supply of the bone of the femur and the pelvis due to the fracture leading
to bleeding causing the s/s of tachycardia and hypotension.

SITUATION: In the ICU, Nurse San Pedro was caring for patients with neurologic disorders

55. A client in the intensive care unit is on a volume –cycled mechanical ventilator. The high-pressure alarm (PAP) begins to sound
repeatedly. The client is sleeping quietly. What is the most appropriate initial response by the nurse?
a. Call the respiratory therapist to check the ventilator.
b. Turn the client to stimulate coughing.
c. Obtain arterial blood for blood gas analysis.
d. Check the ventilator tubing.
TTS: PRIORITY- NURSING PROCESS
ANSWER: D- unless the client is coughing, has decreased airway compliance, or has an airway obstruction, a high pressure alarm
usually indicates water collection in or kinking or ventilator tubing. The tubing should be checked first.

56. Which of the following is the most important assessment during the acute stage of an unconscious patient?
a. Level of awareness and response to pain
b. Papillary reflexes and response to sensory stimuli
c. Coherence and sense of hearing
d. Patency of airway and adequacy of respiration
TTS: PRIORITY QUSTION- ABC
ANSWER: D- Airway is always a priority in an unconscious client. Refer to maslows hierarchy of needs for prioritization. Although
this is not absolute, knowledge with pathophysiology will best lead you to the correct option

57. Considering Mr. Franco’s who was diagnosed with CVA, which of the following is most important to include in preparing
Franco’s bedside equipment?
a. Hand bell and extra bed linen
b. Sandbag and trochanter rolls
c. Footboard and splint
d. Suction machine and gloves
TTS: PRIORITY QUESTION- ABC
ANSWER: D -CVA patients has impaired swallowing ability and if not absent, depressed gag reflex. Client is at the highest risk for
aspiration when eating or drinking that is why NGT is initiated early in the hospitalization. B- Prevent EXTERNAL ROTATION in
hip or leg fracture. Footboards and splint prevents FOOTDROP seen in clients that has a severed peroneal nerve or prolonged
immobilization usually due to fractures that eventually puts pressure on the peroneal nerve. A is not specific to clients with CVA.

58. Which intervention is most critical for a client with myxedema coma?
a. Administering an oral dose of levothyroxine
b. Warming the client with a warming blanket
c. Measuring and recording accurate intake and output
d. Maintaining a patent airway
TTS: PRIORITY- AIRWAY
ANSWER: D - Because respirations are depressed in myxedema coma, maintaining a patent airway is the priority. Ventilatory
support is usually needed. Thyroid replacement will be administered IV though myxedema coma is associated with severe
hypothermia, a warming blanket shouldn’t be used because it may cause vasodilation and shock. Gradual warming with blankets
would be appropriate. Intake and output are very important but aren’t critical intervention at this time.

59. The nurse hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and notes that the client is in
ventricular tachycardia. The nurse rushes to the client’s room. Upon reaching the clients bedside, the nurse would take which
action first?
a. Prepare for cardioversion
b. Prepare to defibrillate the client
c. Call a code
d. Check the clients level of consciousness
TTS: PRIORITY- NURSING PROCESS
ANSWER: D - When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for
unresponsiveness ensures whether the client is affected by the decreased cardiac output. If the client is unconscious, then the
ABCDs—airway, breathing, circulation, defibrillation—of cardiopulmonary resuscitation or basic life support are initiated.

60. The nurse is assessing a geriatric client with senile dementia. Which neurotransmitter condition is most likely to contribute to this
client's cognitive changes?
a. Decreased acetylcholine level
b. Increased acetylcholine level
c. Increased epinephrine level
d. Decreased norepinephrine level
TTS: CONTRASTING
ANSWER: A. A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy geriatric clients and in
the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in
clients with dementia.
B. Incorrect option it should be decreased
D. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli,
such as the increased heart and respiratory rates caused by panic.

61. A client becomes restless and agitated and complains of shortness of breath and palpitations. The nurse identifies on the cardiac
monitor that the client is experiencing an atrial fibrillation with a rapid ventricular response. Which nursing diagnosis is the most
important at this time?
a. Decreased cardiac output
b. Ineffective breathing pattern
c. Anxiety
d. Impaired gas exchange
TTS: PRIORITY- ABC
ANSWER: A- In atrial fibrillation with rapid ventricular response, the atrial chambers quiver, do not contract normally, and fill the
ventricles with blood during the last part of diastole. This results in the loss of an important atrial contribution to cardiac output, called
the “atrial kick.” Loss of the atrial kick and the rapid ventricular rate causes a reduction of cardiac output by as much as 25%. Options
2, 3, and 4 are not associated with the data in the question.

62. The nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has
developed hyperglycemia?
a. Cheyne stroke respirations
b. Increased urine output
c. Decreased urine output
d. Diaphoresis
TTS: CONTRASTING
ANSWER: B- Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose
metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an
increased urine output. Chyne stroke respirations suggest increased ICP. A decreased appetite and diaphoresis suggest hypoglycemia.

63. A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the
most important?
a. Immediately stop the transfusion, infuse dextrose 5% in water (D 5W), and call the physician.
b. Slow the transfusion and monitor the client closely
c. Stop the transfusion, notify the blood bank, and administer antihistamines.
d. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.
TTS: PRIORITY- ADDRESS IMMEDIATE PROBLEM
ANSWER: D – When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be
infused to maintain venous access, and the blood bank and physician should be notified immediately. Other nursing actions include
saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs,
obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock.
Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines may be
administered for a mild allergic reaction.

64. A nurse is caring for a client who is going to have an arteriogram with contrast medium. Which of the following actions by the
nurse is a priority?
a. Determine the presence of allergy
b. Tell the client that the shoulder will be moved around during the procedure
c. Ask the client for last minute questions about the procedure
d. Tell the client to move bowels before the procedure
TTS: PRIORITY- NURSING PROCESS
ANSWER: A- because of the risk of allergy to contrast media the nurse places the highest priority on allergy assessment.

65. The client experienced an open pneumothorax and has a sucking chest wound, which has been covered with occlusive dressing.
The client suddenly begins to experience severe dyspnea, and the nurse notes tracheal deviation to the unaffected side. The nurse
should immediately?
a. Remove the dressing
b. Reinforce the dressing
c. Check apical heart rate
d. Measure oxygen saturation by oximetry
TTS: PRIORITY- ASSESSMENT
ANSWER: A-Assessment of the effect to the heart by the tension of air should be done first.

SITUATION: Nurse Jessica is in the orthopedic ward and cares for the following clients:

66. A client is treated in a physician’s office for a sprained ankle after a fall. Radiographic examination has ruled out a
fracture. Before sending the client home, the nurse plans to teach the client to avoid which of the following in the next 24
hours?
a. Resting the foot
b. Applying a heating pad
c. Applying an elastic compression bandage
d. Elevating the ankle on a pillow while sitting or lying down
TTS: KEY WORD-NEGATIVE
ANSWER: B – Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression and elevation) for the first 24
hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours
because it could increase venous congestion, which would increase edema and pain.

67. A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when the client will be able
to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg:
a. In 48 hours
b. In 24 hours
c. In about 8 hours
d. Within 20 to 30 minutes of application
TTS: KEY WORD- LOOK FOR CLUES IN OPTIONS
ANSWER: D – A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes
and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30
minutes.
TTS STRATEGY: Use the process of elimination. Use the strategic word NONPLASTER. Option a and b should be
eliminated first because these time frames are similar to the drying times for plaster casts. Recalling that the nonplaster type
of cast is lighter and dries quickly may help you choose the 20 to 30 minutes time frame as correct.

68. A nurse has given a client with a leg cast instructions on a cast care at home. The nurse would evaluate that the client
needs further instruction if the client makes which of the following statements?
a. “I should avoid walking on wet, slippery floors.”
b. “I’m not supposed to scratch the skin underneath the cast.”
c. “It’s okay to wipe dirt off the top of the cast with a damp cloth.”
d. “If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting.”
TTS: NEGATIVE ANSWER
ANSWER: D – Clients instructions should include avoiding walking on wet slippery floors to prevent falls. Surface soil on a
cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent
skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never
scratch under a cast because of the risk of skin breakdown and ulcer formation.
TTS STRATEGY: Use the process of elimination: note the strategic words NEEDS FURTHER TEACHING. These words
indicate a negative event query and ask you to select an option that is incorrect. Remember never to use a hair dryer on a cast
or on the skin under a cast with the dryer set at the warmest setting; only cool setting are used to prevent burns.

69. A client has Buck’s extension traction on applied to the right leg. The nurse would plan which of the following
interventions to prevent complications of the device?
a. Give pin care once a shift.
b. Massage the skin of the right leg with lotion every 8 hours.
c. Inspect the skin on the right leg at least once every 8 hours.
d. Release the weights on the right leg for daily range-of-motion exercises.
TTS: ELIMINATION, NURSING PROCESS
ANSWER: C – Buck’s extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least
once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases
the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction.
TTS STRATEGY: Use the process of elimination and the steps of nursing process. Option c is the only option that relates to
assessment.

70. A nurse has given a client instruction about crutch safety. The nurse determines that the client needs reinforcement of
information if the client states:
a. That he or she will not use someone else’s crutches.
b. That crutch tips will not slip even when wet.
c. The need to have spare crutches and tips available.
d. That crutch tips should be inspected periodically for wear.
TTS: PRIORITY- SAFETY
ANSWER: B – Crutch tips should remain dry. Water could cause the client to slip by decreasing the surface friction of the
rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use
only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if
needed.
TTS STRATEGY: Use the process of elimination. Note the strategic word NEEDS REINFORCEMENT OF
INFORMATION. These words indicate a negative event query and ask you to select an option that is incorrect. Remember
that crutch tips can slip when they get wet and spare crutches and tips should be available if needed.

71. A nurse has conducted teaching with a client in an arm cast about signs and symptoms of compartment syndrome. The
nurse determines that the client understands the information if the client states that he or she should report which of the
following early symptoms of compartment syndrome?
a. Cold, bluish-colored fingers
b. Numbness and tingling in the fingers
c. Pain that increases when the arm is dependent.
d. Pain relieved only by oxycodone and aspirin (Percodan).
TTS: KEY WORD
ANSWER: B – The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other
symptoms include pain unrelieved by narcotics, pain that increases with limb elevation, and pallor and coolness to the distal
limb. Cyanosis is a late sign.
TTS STRATEGY: Use the process of elimination, note the keyword early. Knowing that compartment syndrome is
characterized by insufficient circulation and ischemis caused by pressure will direct you to option B.
72. A child is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which
assessment is most important in the immediate postoperative period?
a. Capillary refill, sensation, and motion in all extremities.
b. Pain level
c. Ability to turn using the logroll technique.
d. Ability to flex and extend the feet.
TTS: PRIORITY- ABC
ANSWER: A - When the spinal column is manipulated during surgery, altered neurovascular status is a possible
complication; therefore, neurovascular checks including circulation, sensation, and motion should be checked at least every 2
hours. B - Level of pain is an important postoperative assessment, but circulatory status is most important. C - Logrolling is
performed by nurses. D - Assessment of flexion and extension of the lower extremities is a component of option a, which
includes checking motion. A is umbrella option also.
TTS STRATEGY: Use the ABC’s and the process of elimination. Option a addresses circulatory status.

73. A child has just returned from surgery and has a hip spica cast. A priority nursing action at this time is to:
a. Elevate the head of bed
b. Abduct the hips using pillows
c. Assess circulatory status
d. Turn the child on the right side
TTS: NURSING PROCESS
ANSWER: C – During the first few hours after a cast is applied, the chief concern is swelling that may cause the cast to act
as a tourniquet and obstruct circulation. Therefore, circulatory assessment is the priority. A - Elevating the head of the bed of
a child in a hip spica cast would cause discomfort. B - Using pillows to abduct the hips is not necessary because a hip spica
cast immobilizes the hip and knee. D - Turning the child side to side at least every 2 hours is important because it allows the
body cast to dry evenly and prevents complications related to immobility; however, it is not a higher priority than checking
circulation.

74. A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, the nurse
implements which priority intervention?
a. Ensures that oxygen is being delivered.
b. Maintains an intravenous access
c. Administers sedation to prevent claustrophobia
d. Provides emotional support to the client’s family
TTS: PRIORITY-PHYSIOLOGIC
ANSWER: A – Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric
pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high level of oxygen
promotes the action of phagocytes and promotes healing of the wound. Because the client is placed in a closed chamber, the
administration of oxygen is of primary importance. Although options B, C and D may be appropriate interventions, option A
is the priority.

75. A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse prepares to provide which type
of wound care to the fasciotomy site?
a. Dry sterile dressings
b. Wet sterile saline dressings
c. Hydrocolloid dressings
d. One-half strength betadine dressings
TTS: CONTRASTING OPTIONS
ANSWER: B – the fasciotomy site is not sutured, but is left open to relieve pressure and edema. The site is covered with
wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and
closed. A Hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there
should be no reason to require betadine. Additionally betadine can be irritating to normal tissues.

SITUATION: Nurse Les is a new nurse in the medical-surgical ward with the following clients:

76. On a medical-surgical floor, the nurse is caring for a cluster of clients who have been diagnosed with diabetes mellitus. Which
client should the nurse assess first?
a. An 80-year old client with a blood glucose level of 350 mg/dl
b. A 20-year old client with a blood glucose level of 70 mg/dl
c. A 60-year old client experiencing nausea and vomiting
d. A 55 year old client complaining of chest pressure
TTS: PRIORITY- LOOK FOR MOST LIFE THREATENING
ANSWER: D - The nurse should assess the client with chest pressure first because he might be experiencing a myocardial infarction.
Chest pressure may indicate tissue ischemia that is brought about lactic acid build up causing the pressure or discomfort. The blood
glucose levels in A and B are abnormal, but not life threatening: therefore, those clients don’t require immediate attention. After
assessing the client with chest pressure, the nurse should assess the client experiencing nausea and vomiting because this may cause an
electrolyte imbalance.

77. A client is diagnosed with hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?
a. “I’ll eat three large meals every day without any food restrictions”
b. “I’ll lie down immediately after a meal”
c. “I’ll gradually increase the amount of heavy lifting I do”
d. “I’ll eat, small, bland meals that are high in fiber frequently”
TTS: CONTRASTING OPTIONS
ANSWER: D- In hiatal hernia, the upper portion of the stomach protrudes into the chest when intra-abdominal pressure increases. To
minimize intra-abdominal pressure and decrease gastric reflux, the client should eat small, frequent, bland meals that can pass easily
through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation.

78. A patient who has ulcerative colitis does not respond to the prescribed therapy and is admitted to the hospital for a total colectomy
and creation of an ileostomy. Which of the following measures should be given priority in the patient’s preoperative care plan?
a. Promoting the patient’s acceptance of an ileostomy
b. Monitoring the patient’s emotional state
c. Preventing the patient from developing pressure sores
d. Correcting the patient’s fluid balance
TTS: PRIORITY- PHYSIOLOGIC
ANSWER: D- Patients’ who have ulcerative colitis with severe diarrhea develop fluid and electrolyte imbalance. Therefore, it is
important to correct any imbalances prior to the procedure. A- Promoting acceptance of the ileostomy should be instituted
preoperatively. B- The patient’s emotional state can influence the outcome of the surgery and can be attended to preoperatively but
fluid and electrolyte balance is the priority. C- Since the patient with ulcerative colitis is not usually on bed rest, pressure areas are
unlikely to develop.

79. The nurse must assess the client with gastric lavage or prolonged vomiting for:
a. Acidosis
b. Alkalosis
c. Loss of oxygen from the blood
d. Loss of osmotic pressure of the blood
TTS: CONTRASTING
ANSWER. B – Excessive loss of gastric fluid results in excessive loss of hydrochloric acid and can lead to alkalosis; Hydrochloric
acid is not available to neutralize the sodium bicarbonate (NaHCO3) secreted into the duodenum by the pancreas. The intestinal tract
absorbs the excess bicarbonate and alkalosis results
A, C and D – Gastric lavage will not cause these.

80. The client with Crohn’s disease has a nursing diagnosis of pain, acute. The nurse should teach the client to avoid which action in
managing this problem?
a. Massaging the abdomen
b. Using relaxation techniques
c. Using antispasmodics medication
d. Lying supine with the legs straight
TTS: NEGATIVE
ANSWER D – Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could
aggravate inflamed intestinal tissues as the abdominal muscles are stretched.
A, B and C - Pain associated with Crohn’s disease is alleviated by the use of analgesics and antispasmodics and also by having the
client practice relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs
flexed.

81. A patient who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because
this patient has difficulty swallowing, the nurse should assign highest priority to:
a. Helping the patient cope with body image changes
b. Ensuring adequate nutrition
c. Maintaining a patent airway
d. Preventing injury
TTS: PRIORITY-AIRWAY
ANSWER. C – Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway.
Therefore, maintaining a patent airway is the highest care priority for a patient with esophageal cancer. The other options, although
appropriate for a patient with this disease, are less crucial than maintaining airway.

82. An 87 years old woman has come to the medical clinic for her annual physical examination. The nurse assessing her knows that
pulmonary function in elderly clients often shows
a. A reduced vital capacity
b. An increase in vital capacity
c. No change in functional alveoli
d. Blood gases that reflect mild acidosis
TTS: CONTRASTING
ANSWER: A. Residual volume increases with age, probably related to the loss of elastic forces in the lung. This increased residual
volume reduces the vital capacity.

83. A nurse is caring for an asthmatic patient. The nurse plans which of the following as the best time to take the client for a short
walk?
a. After the client uses a metered dose inhaler
b. Before the client uses a metered dose inhaler
c. Anytime after the client eats lunch
d. Anytime after the client has a brief nap
TTS: CONTRASTING OPTIONS
ANSWER: A- The nurse should schedule activities for the client with asthma after the client has received respiratory treatments or
medications. After the administration of bronchodilators (often administered by metered-dose inhaler), the client has the best oxygen
exchange possible and would tolerate the activity best.

84. A nurse is caring for a child with congestive heart failure provides instructions to the parents regarding the administration of
digoxin. Which of the following statements indicate a need for further instructions?
 a. if my child vomits after I give the medication I will not repeat the dose
b. I will check my Childs pulse before giving the medication
c. I will check the dose of the medication with my husband before giving the medication
d. I will mix the medication with food
TTS: NEGATIVE ANSWER
ANSWER: D- The medication should not be mixed with food or formula because this method would not ensure that the child receives
the entire dose of medication.

85. An older client is hard of hearing and has severe painful rheumatoid arthritis. The client is admitted to a nursing home after
becoming incontinent of urine. The primary consideration in the care of the client would be the need for:
a. Control of pain
b. Immobilization of joint
c. Motivation and teaching
d. Bladder control reeducation
TTS: PRIORITY
ANSWER: A. After the need to survive (air, food, water) the need for comfort and freedom from pain closely follow; care should be
given in order of the client’s basic needs.

86. Atherosclerosis impedes coronary blood flow by which of the following mechanisms?
a. Plaques obstruct the vein
b. Plaques obstruct the artery
c. Blood clots form outside the vessel wall
d. Hardened vessels dilate to allow blood to flow through
TTS: CONTRASTING
ANSWER B: Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Atherosclerosis is a direct result of
plaque formation in the artery. Hardened vessels can’t dilate properly and, therefore, constrict blood flow.

87. Patient Jaybey with pneumonia has a nursing diagnosis of activity intolerance. The nurse implements which of the following in
the patients care?
a. Keeps the environment noisy to maintain alertness
b. Encourage deep rapid breathing during activity
c. Schedule activities before giving respiratory medications or treatments
d. Observes vital signs and oxygen saturation periodically during activity
TTS: PRIORITY- NURSING PROCESS
ANSWER: D- The nurse monitors vital signs, including oxygen saturation, before, during, and after activity to gauge the client’s
response. Activities should be planned after giving the client respiratory medications or treatments to increase activity tolerance. The
client should use pursed-lip and diaphragmatic breathing to lower oxygen consumption during activity. Finally, the general
environment should be conducive to rest, since the client is easily fatigued.

88. The nurse is caring for a client admitted to the hospital with a diagnosis of angina, while the nurse is caring for the client; the
client begins to experience chest pain. The nurse should obtain which data immediately?
a. Location of intensity of pain
b. Symptoms of nausea
c. Presence of fever
d. Blood pressure
TTS: PRIORITY- LISTEN TO SUBJECTIVE COMPLAINS OF PAIN
ANSWER: A- The nurse must assess the pain by requesting a description of intensity, location, duration, and quality of the pain.
Although the nurse may check the client’s vital signs and check for symptoms of nausea, assessment of the pain is the priority.

89. An adult receiving O2 at 3 liters per nasal cannula. His roommate lights a cigarette and tosses the match, catching the curtain on
fire. What is the priority of nurses?
a. Turn of the oxygen.
b. Sound the fire alarm.
c. Try to extinguish the flames.
d. Removed the clients from the room.
TTS: PRIORITY- IMMEDIATE, SAFETY
ANSWER: A. oxygen itself does not burn, but supports combustion, so a fire burns more readily in the presence of oxygen. If the
client is not engulfed in flames, the nurse’s priority action should be to turn off the oxygen. B, C, D. After the oxygen is discontinued,
the RACE format is followed: Rescue, Alarm, Contain or Extinguish, and Evaluate if necessary.

90. A client reports difficulty breathing and a sharp pain in the right side of the chest. The respiratory rate measures 40
breaths/minute. The nurse should assign highest priority to which goal of care?
a. Maintaining an adequate circulatory volume
b. Maintaining effective respirations
c. Reducing anxiety
d. Relieving pain
TTS: PRIORITY- ABC
ANSWER: B- As suggested by the ABCs of cardiopulmonary resuscitation — airway, breathing, and circulation — the most
important goal is to maintain a patent airway and effective respirations, regardless of the client's diagnosis or clinical presentation.
Although the other options are pertinent for this client, they're secondary to maintaining effective respirations.

91. In developing the nursing care plan, the nurse should be alerted among the alterations in a patient with acute renal failure which
include:
i. Urine output is less than .5/hr/kg
ii. Hyperkalemia
 iii. Metabolic acidosis
iv. Decreased BUN
a. iv, iii, ii, i
b. i, iv, iii
c. i, ii, iii
d. ii, iv
TTS: SELECT THAT ALL APPLY
ANSWER: C- A,B,D all options containing IV. Decreased BUN is incorrect because in renal failure, BUN is increased

92. A type 1 diabetic patient begins to complain of hunger, weakness, and speech suddenly becomes incoherent. The INITIAL
intervention of the nurse should be:
a. Assess the blood glucose level of the patient to verify hypoglycemia
b. Give 4 ounces orange juice to halt hypoglycemia
c. Prepare to administer insulin
d. Assess for signs Kussmaul’s respiration
TTS: PRIORITY- NURSING PROCESS
ANSWER: A-assessment is priority, verify the hypoglycemia

93. Antibiotic treatment is one intervention that the medical team does for a client with pyelonephritis . How should the nurse proceed
with the care plan?
a. Administer a broad-spectrum antibiotic immediately
b. Educate the client that the antibiotic regimen lasts 4-10 days
c. Obtain urine specimen for culture and sensitivity
d. Instruct the patient to stop the antibiotic if symptoms subside
TTS: PRIORITY- NURSING PROCESS
ANSWER: C – assessment of sensitive organism is priority

94. The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for
disequilibrium syndrome, the nurse assesses the client during dialysis for
1. Mental confusion
2. Twitching
3. Fever
4. Hypotension
a. 1,2
b. 2,3
c. 3,4
d. 4,1
TTS: SELECT THAT ALL APPLY
ANSWER: A – Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea,
and vomiting, twitching, and possible seizure activity.

95. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of diuretic. On assessment the nurse
notes that the client has flat neck veins, generalized muscle weakness and diminished deep tendon reflexes. The nurse suspects
hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?
1. Dry skin
2. Decreased urinary output
3. Decreased specific gravity of the urine
4. Hyperactive bowel sounds
a. 1,3
b. 2,4
c. c.1,2
d. 3,4
TTS: SELECT THAT ALL APPLY
ANSWER: D – in hyponatremia increased urinary output, decreased specific gravity and hyperactive bowel sounds would be noted.

96. If a client needed emergency surgery, thus precluding thorough preoperative teaching, which of the following would be the most
important of the nurse to review with the client?
a. Deep breathing exercises
b. Painless movement from side to side
c. Relaxation techniques
d. Use of an incentive spirometer
TTS: PRIORITY- ABC
ANSWER: A – review deep breathing exercises. Clients wait and a probable abdominal incision predispose him to postoperative
pulmonary complication. Preoperatively, a distended abdomen may prevent him from doing a return demonstration of deep breathing
exercises.

97. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented; has hot, dry skin; and has
the following vital signs: temperature 38.1 degrees Celsius, heart rate of 116 beats/min and blood pressure of 108/70 mmHg.
Based on these assessment findings, which nursing diagnosis takes highest priority?
a. Deficient fluid volume related to osmotic diuresis
b. Decreased cardiac output related to osmotic diuresis
c. Imbalanced Nutrition; less than body requirements related to insulin deficiency
d. Ineffective thermoregulation related to dehydration
TTS: PRIORITY, KEY WORD
ANSWER: A - A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume is
prioritized than from decreased cardiac output because his blood pressure is normal. Although the client’s serum glucose level is
elevated, food isn’t a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a
diagnosis of imbalanced nutrition; less than body requirements isn’t appropriate. a temperature of 38.1 isn’t life threatening,
eliminating ineffective regulation as the top priority

98. Which signs and symptoms would be seen in a client experiencing hypoglycemia?
a. Polyuria, headache, fatigue
b. Polyphagia and flushed, dry skin
c. Polydipsia and irritability
d. Nervousness, diaphoresis, and confusion
TTS: KEY WORD, LOOK FOR SIMILARITIES IN OPTIONS
ANSWER: D – Nervousness, diaphoresis, lightheadedness, confusion, paresthesia, irritability, headache, hunger, tachycardia, and
changes n speech, hearing, or vision are signs of hypoglycemia. If hypoglycemia is untreated, signs and symptoms may progress to
unconsciousness, seizures, coma, and death. The 3P’s, fatigue, and flushed, dry skin are signs of hyperglycemia.

99. Hydrocortisone given IV is the proper treatment for which of the following disease?
a. Addison’s disease
b. Cushing’s disease
c. Hyperthyroidism
d. Hypoparathyroidism
TTS: CONTRASTING
ANSWER: A – IV hydrocortisone is the proper treatment for Addison’s disease because it replaces the glucocorticoid deficiency.
Cushing’s syndrome has excessive amounts of glucocorticoids. Hyperthryroidism and hypoparathyroidism have different treatment
modalities.

100. A client presents with diaphoresis, palpitations, jitters and tachycardia, approximately 1 ½ hours after taking his regular morning
insulin. Which of the following treatment is applied for this client?
a. Check blood glucose level and administer carbohydrates.
b. Give nitroglycerin and perform an ECG.
c. Check pulse oximetry and administer oxygen therapy.
d. Restrict salt, administer diuretics and perform paracentesis
TTS: PRIORITY, KEYWORD.
ANSWER: A – The client is experiencing symptoms of hypoglycemia. Checking the blood glucose level is the most important
assessment and administering CHO will elevate blood glucose. ECG and nitroglycerine are interventions for myocardial infarction.
Administering oxygen won’t help correct the low blood glucose level. Restricting salt, administering diuretics, and performing a
paracentesis are treatment for ascites.