This is a 40-item examination which can help you improve, review and challenge your knowledge about the topic of: Burns. If you are taking the board examination or nurse licensure examination or even the NCLEX, then this practice exam is for you.

1. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

2. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?

A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness

3. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?

A. The medication will be effective more quickly than if given intramuscularly.
B. It is less likely to interfere with the client’s breathing and oxygenation.
C. The danger of an overdose during fluid remobilization is reduced.
D. The client delayed gastric emptying.

4. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

5. Which client factors should alert the nurse to potential increased complications with a burn injury?

A. The client is a 26-year-old male.
B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client’s clothing.

6. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response?

A. “To increase the urine output and prevent kidney damage.”
B. “To stimulate intestinal movement and prevent abdominal bloating.”
C. “To decrease hydrochloric acid production in the stomach and prevent ulcers.”
D. “To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock.”

7. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?

A. Immediately following the injury
B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase

8. What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

A. Pulse oximetry reading of 80%
B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum

9. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?

A. The burn is full thickness rather than partial thickness.
B. The client is unable to fully pronate and supinate the extremity.
C. Capillary refill is slow in the digits and the distal pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the extremity.

10. What additional laboratory test should be performed on any African American client who sustains a serious burn injury?

A. Total protein
B. Tissue type antigens
C. Prostate specific antigen
D. Hemoglobin S electrophoresis

11. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?

A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells

12. The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action?

A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.

13. The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?

A. Raise the head of the bed.
B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.

14. Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action?

A. Notify the emergency team.
B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer’s lactate.

15. On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?

A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning

16. Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?

A. Reposition the client onto the right side.
B. Document the finding as the only action.
C. Notify the emergency team.
D. Increase the IV flow rate.

17. Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?

A. Increased urine output, decreased urine specific gravity
B. Increased peripheral edema, decreased blood pressure
C. Decreased peripheral pulses, slow capillary refill
D. Decreased serum sodium level, increased hematocrit

18. What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm?

A. Risk for Ineffective Breathing Pattern
B. Decreased Tissue Perfusion
C. Risk for Disuse Syndrome
D. Disturbed Body Image

19. All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?

A. Serum sodium elevated to 131 mmol/L (mEq/L)
B. Serum potassium 7.5 mmol/L (mEq/L)
C. Arterial pH is 7.32
D. Hematocrit is 52%

20. The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission?

A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities

21. In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?

A. “Are you a smoker?”
B. “When was your last chest x-ray?”
C. “Have you ever had asthma or any other lung problem?”
D. “In what exact place or space were you when you were burned?”

22. Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited

23. Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

A. The client is able to talk.
B. The client is alert and oriented.
C. The client’s oxygen saturation is 97%.
D. The client’s chest movements are uninhibited

24. The burned client’s family ask at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?

A. “When fluid remobilization has started.”
B. “When the burn wounds are closed.”
C. “When IV fluids are discontinued.”
D. “When body weight is normal.”

25. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month

26. The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?

A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.

27. Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?

A. Handwashing on entering the client’s room
B. Encouraging the client to cough and deep breathe
C. Administering the prescribed tetanus toxoid vaccine
D. Changing gloves between cleansing different burn areas

28. In reviewing the burned client’s laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis?

A. The total white blood cell count is 9000/mm3.
B. The lymphocytes outnumber the basophils.
C. The “bands” outnumber the “segs.”
D. The monocyte count is 1,800/mm3.

29. The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?

A. Place a towel roll under the client’s neck or shoulder.
B. Keep the client in a supine position without the use of pillows.
C. Have the client turn the head from side to side 90 degrees every hour while awake.
D. Keep the client in a semi-Fowler’s position and actively raise the arms above the head every hour while awake.

30. The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint?

A. Hip maintained in 30-degree flexion, no knee flexion
B. Hip flexed 90 degrees and knee flexed 90 degrees
C. Hip, knee, and ankle all at maximum flexion
D. Hip at zero flexion with leg flat

31. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds
C. Decreased white blood cell count
D. Increased serum creatinine level

32. The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action?

A. Nothing, because the findings are normal for clients during the acute phase of recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client’s airway and oxygen saturation.
D. Notify the burn emergency team.

33. Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

A. Changing gloves between wound care on different parts of the client’s body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.

34. When should ambulation be initiated in the client who has sustained a major burn?

A. When all full-thickness areas have been closed with skin grafts
B. When the client’s temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after resolution of the fluid shift

35. What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?

A. “For the first few days after surgery, the donor sites will be painful.”
B. “Because the graft is my own skin, there is no chance it won’t ‘take’.”
C. “I will have some scarring in the area when the skin is removed for grafting.”
D. “Once all grafting is completed, my risk for infection is the same as it was before I was burned.”

36. Which statement by the client indicates correct understanding of rehabilitation after burn injury?

A. “I will never be fully recovered from the burn.”
B. “I am considered fully recovered when all the wounds are closed.”
C. “I will be fully recovered when I am able to perform all the activities I did before my injury.”
D. “I will be fully recovered when I achieve the highest possible level of functioning that I can.”

37. Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment?

A. “After this treatment, my ears will not stick out.”
B. “The mask will help protect my skin from sun damage.”
C. “Using this mask will prevent scars from being permanent.”
D. “My facial scars should be less severe with the use of this mask.”

38. What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?

A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements

39. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:

a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules

40. Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should:

a. Maintain room humidity below 40%
b. Place top sheet on the client
c. Limit the occurrence of drafts
d. Keep room temperature at 80 degrees

Medical-Surgical Nursing Exam 13: Burns (40 Items) Original source at: Nurseslabs

This is a 25-item examination which can help you improve, review and challenge your knowledge about the topic of: Pain Management. If you are taking the board examination or nurse licensure examination or even the NCLEX, then this practice exam is for you.

1. A chronic pain client reports to you, the charge nurse, that the nurse have not been responding to requests for pain medication. What is your initial action?

a. Check the MARs and nurses’ notes for the past several days.
b. Ask the nurse educator to give an in-service about pain management.
c. Perform a complete pain assessment and history on the client.
d. Have a conference with the nurses responsible for the care of this client

2. Family members are encouraging your client to “tough it out” rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family’s wishes. Priority nursing interventions for this client should target which dimension of pain?

a. Sensory
b. Affective
c. Sociocultural
d. Behavioral
e. Cognitive

3. A client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is not responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of pain?

a. Amitriptyline (Elavil)
b. Corticosteroids
c. Methylphenidate (Ritalin)
d. Lorazepam (Ativan)

4. Which client is most likely to receive opioids for extended periods of time?

a. A client with fibrolyalgia
b. A client with phantom limb pain
c. A client with progressive pancreatic cancer
d. A client with trigeminal neuralgia

5. As the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. What action should you take first?

a. Make a note in the nurse’s file and continue to observe clinical performance
b. Refer the new nurse to the in-service education department.
c. Quiz the nurse about knowledge of pain management
d. Give praise for the correct dose and time and discuss the deficits in charting.

6. In caring for a young child with pain, which assessment tool is the most useful?

a. Simple description pain intensity scale
b. 0-10 numeric pain scale
c. Faces pain-rating scale
d. McGill-Melzack pain questionnaire

7. In applying the principles of pain treatment, what is the first consideration?

a. Treatment is based on client goals.
b. A multidisciplinary approach is needed.
c. The client must be believed about perceptions of own pain.
d. Drug side effects must be prevented and managed.

8. Which route of administration is preferred if immediate analgesia and rapid titration are necessary?

a. Intraspinal
b. Patient-controlled analgesia (PCA)
c. Intravenous (IV)
d. Sublingual

9. When titrating an analgesic to manage pain, what is the priority goal?

a. Administer smallest dose that provides relief with the fewest side effects.
b. Titrate upward until the client is pain free.
c. Titrate downwards to prevent toxicity.
d. Ensure that the drug is adequate to meet the client’s subjective needs.

10.In educating clients about non-pharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function under your continued support and supervision?

a. Therapeutic touch
b. Use of heat and cold applications
c. Meditation
d. Transcutaneous electrical nerve stimulation (TENS)

11.Place the examples of drugs in the order of usage according to the World Health Organization (WHO) analgesic ladder.

a. Morphine, hydromorphone, acetaminophen and lorazepam
b. NSAIDs and corticosteroids
c. Codeine, oxycodone and diphenhydramine
_____, _____, _____

12.Which client is at greater risk for respiratory depression while receiving opioids for analgesia?

a. An elderly chronic pain client with a hip fracture
b. A client with a heroin addiction and back pain
c. A young female client with advanced multiple myeloma
d. A child with an arm fracture and cystic fibrosis

13.A client appears upset and tearful, but denies pain and refuses pain medication, because “my sibling is a drug addict and has ruined out lives.” What is the priority intervention for this client?

a. Encourage expression of fears on past experiences
b. Provide accurate information about use of pain medication
c. Explain that addiction is unlikely among acute care clients.
d. Seek family assistance in resolving this problem.

14.A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal?

a. Fever
b. Nausea
c. Diaphoresis
d. Abdominal cramps

15.In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant?

a. Assist the client with preparation of a sitz bath.
b. Monitor the client for signs of discomfort while ambulating
c. Coach the client to deep breathe during painful procedures
d. Evaluate relief after applying a cold application.

16.The physician has ordered a placebo for a chronic pain client. You are newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take?

a. Prepare the medication and hand it to the physician
b. Check the hospital policy regarding use of the placebo.
c. Follow a personal code of ethics and refuse to give it.
d. Contact the charge nurse for advice.

17.For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take?

a. Closely assess for nonverbal signs such as grimacing or rocking.
b. Obtain baseline behavioral indicators from family members.
c. Look at the MAR and chart, to note the time of the last dose and response.
d. Give the maximum PRS dose within the minimum time frame for relief.

18.Which route of administration is preferable for administration of daily analgesics (if all body systems are functional)?

a. IV
b. IM or subcutaneous
c. Oral
d. Transdermal
e. PCA

19.A first day post-operative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take?

a. Deliver the bolus dose per standing order.
b. Contact the physician to increase the dose.
c. Try non-pharmacological comfort measures.
d. Assess the pain for location, quality, and intensity.

20.Which non-pharmacological measure is particularly useful for a client with acute pancreatitis?

a. Diversional therapy, such as playing cards or board games
b. Massage of back and neck with warmed lotion
c. Side-lying position with knees to chest and pillow against abdomen
d. Transcutaneous electrical nerve stimulation (TENS)

21.What is the best way to schedule medication for a client with constant pain?

a. PRN at the client’s request
b. Prior to painful procedures
c. IV bolus after pain assessment
d. Around-the-clock

22.Which client(s) are appropriate to assign to the LPN/LVN, who will function under the supervision of the RN or team leader? (Choose all that apply.)

a. A client who needs pre-op teaching for use of a PCA pump
b. A client with a leg cast who needs neurologic checks and PRN hydrocodone
c. A client post-op toe amputation with diabetic neuropathic pain
d. A client with terminal cancer and severe pain who is refusing medication

23.For a client who is taking aspirin, which laboratory value should be reported to the physician?

a. Potassium 3.6 mEq/L
b. Hematocrit 41%
c. PT 14 seconds
d. BUN 20 mg/dL

24.Which client(s) would be appropriate to assign to a newly graduated RN, who has recently completed orientation? (Choose all that apply.)

a. An anxious, chronic pain client who frequently uses the call button
b. A client second day post-op who needs pain medication prior to dressing changes
c. A client with HIV who reports headache and abdominal and pleuritic chest pain
d. A client who is being discharged with a surgically implanted catheter

25.A family member asks you, “Why can’t you give more medicine? He is still having a lot of pain.” What is your best response?

a. “The doctor ordered the medicine to be given every 4 hours.”
b. “If the medication is given too frequently he could suffer ill effects.”
c. “Please tell him that I will be right there to check of him.”
d. “Let’s wait about 30-40 minutes. If there is no relief I’ll call the doctor.”

Medical-Surgical Nursing Exam 12: Pain Management (25 Items) Original source at: Nurseslabs

This is a 60-item examination which can help you improve, review and challenge your knowledge about the topic of: Musculoskeletal Disorders & Care. If you are taking the board examination or nurse licensure examination or even the NCLEX, then this practice exam is for you.

1. A client is 1 day postoperative after a total hip replacement. The client should be placed in which of the following position?

a. Supine
b. Semi Fowler’s
c. Orthopneic
d. Trendelenburg

2. A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make?

a. Observe the color of the fingers
b. Palpate the radial pulse under the cast
c. Check the cast for odor and drainage
d. Evaluate the response to analgesics

3. After a computer tomography scan with intravenous contrast medium, a client returns to the unit complaining of shortness of breath and itching. The nurse should be prepared to treat the client for:

a. An anaphylactic reaction to the dye
b. Inflammation from the extravasation of fluid during injection.
c. Fluid overload from the volume of the infusions
d. A normal reaction to the stress of the diagnostic procedure.

4. While caring for a client with a newly applied plaster of Paris cast, the nurse makes note of all the following conditions. Which assessment finding requires immedite notification of the physician?

a. Moderate pain, as reported by the client
b. Report, by client, the heat is being felt under the cast
c. Presence of slight edema of the toes of the casted foot
d. Onset of paralysis in the toes of the casted foot

5. Which of these nursing actions will best promote independence for the client in skeletal traction?

a. Instruct the client to call for an analgesic before pain becomes severe.
b. Provide an overhead trapeze for client use
c. Encourage leg exercise within the limits of traction
d. Provide skin care to prevent skin breakdown.

6. A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis.

a. The client reports pain in the affected leg
b. A large hematoma is visible in the affected extremity
c. The affected extremity is shortenend, adducted, and extremely rotated
d. The affected extremity is edematous.

7. The nurse is caring for a client with compound fracture of the tibia and fibula. Skeletal traction is applied. Which of these priorities should the nurse include in the care plan?

a. Order a trapeze to increase the client’s ambulation
b. Maintain the client in a flat, supine position at all times.
c. Provide pin care at least every hour
d. Remove traction weights for 20 minutes every two hours.

8. To prevent foot drop in a client with Buck’s traction, the nurse should:

a. Place pillows under the client’s heels.
b. Tuck the sheets into the foot of the bed
c. Teach the client isometric exercises
d. Ensure proper body positioning.

9. Which nursing intervention is appropriate for a client with skeletal traction?

a. Pin care
b. Prone positioning
c. Intermittent weights
d. 5lb weight limit

10. In order for Buck’s traction applied to the right leg to be effective, the client should be placed in which position?

a. Supine
b. Prone
c. Sim’s
d. Lithotomy

11. An elderly client has sustained intertrochanteric fracture of the hip and has just returned from surgery where a nail plate was inserted for internal fixation. The client has been instructed that she should not flex her hip. The best explanation of why this movement would be harmful is:

a. It will be very painful for the client
b. The soft tissue around the site will be damaged
c. Displacement can occur with flexion
d. It will pull the hip out of alignment

12. When the client is lying supine, the nurse will prevent external rotation of the lower extremity by using a:

a. Trochanter roll by the knee
b. Sandbag to the lateral calf
c. Trochanter roll to the thigh
d. Footboard

13. A client has just returned from surgery after having his left leg amputated below the knee. Physician’s orders include elevation of the foot of the bed for 24 hours. The nurse observes that the nursing assistant has placed a pillow under the client’s amputated limb. The nursing action is to:

a. Leave the pillow as his stump is elevated
b. Remove the pillow and elevate the foot of the bed
c. Leave the pillow and elevate the foot of the bed
d. Check with the physician and clarify the orders

14. A client has sustained a fracture of the femur and balanced skeletal traction with a Thomas splint has been applied. To prevent pressure points from occurring around the top of the splint, the most important intervention
is to:

a. Protect the skin with lotion
b. Keep the client pulled up in bed
c. Pad the top of the splint with washcloths
d. Provide a footplate in the bed

15. The major rationale for the use of acetylsalicylic acid (aspirin) in the treatment of rheumatoid arthritis is to:

a. Reduce fever
b. Reduce the inflammation of the joints
c. Assist the client’s range of motion activities without pain
d. Prevent extension of the disease process

16. Following an amputation, the advantage to the client for an immediate prosthesis fitting is:

a. Ability to ambulate sooner
b. Less change of phantom limb sensation
c. Dressing changes are not necessary
d. Better fit of the prosthesis

17. One method of assessing for sign of circulatory impairment in a client with a fractured femur is to ask the client to:

a. Cough and deep breathe
b. Turn himself in bed
c. Perform biceps exercise
d. Wiggle his toes

18. The morning of the second postoperative day following hip surgery for a fractured right hip, the nurse will ambulate the client. The first intervention is
to:

a. Get the client up in a chair after dangling at the bedside.
b. Use a walker for balance when getting the client out of bed
c. Have the client put minimal weight on the affected side when getting up
d. Practice getting the client out of bed by having her slightly flex her hips

19. A young client is in the hospital with his left leg in Buck’s traction. The team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to:

a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot

20. When evaluating all forms of traction, the nurse knows the direction of pull is controlled by the:

a. Client’s position
b. Rope/pulley system
c. Amount of weight
d. Point of friction

21. When a client has cervical halter traction to immobilize the cervical spine counteraction is provided by:

a. Elevating the foot of the bed
b. Elevating the head of the bed
c. Application of the pelvic girdle
d. Lowering the head of the bed

22. After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client’s toes for:

a. Increase in the temperature
b. Change in color
c. Edema
d. Movement

23. A 23 year old female client was in an automobile accident and is now a paraplegic. She is on an intermittent urinary catheterization program and diet as tolerated. The nurse’s priority assessment should be to observe for:

a. Urinary retention
b. Bladder distention
c. Weight gain
d. Bower evacuation

24. A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the last two years. The most important assessment question for the nurse to ask related to the client’s drug therapy is whether she has

a. Headaches
b. Tarry stools
c. Blurred vision
d. Decreased appetite

25. A 7 year old boy with a fractured leg tells the nurse that he is bored. An appropriate intervention would be to

a. Read a story and act out the part
b. Watch a puppet show
c. Watch television
d. Listen to the radio

26. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. Which of the following would be the nurse most likely to asses:

a. Limited motion of joints
b. Deformed joints of the hands
c. Early morning stiffness
d. Rheumatoid nodules

27. After teaching the client about risk factors for rheumatoid arthritis, which of the following, if stated by the client as a risk factor, would indicate to the
nurse that the client needs additional teaching?

a. History of Epstein-Barr virus infection
b. Female gender
c. Adults between the ages 60 to 75 years
d. Positive testing for human leukocyte antigen (HLA) DR4 allele

28. When developing the teaching plan for the client with rheumatoid arthritis to promote rest, which of the following would the nurse expect to instruct the client to avoid during the rest periods?

a. Proper body alignment
b. Elevating the part
c. Prone lying positions
d. Positions of flexion

29. After teaching the client with severe rheumatoid arthritis about the newly prescribed medication methothrexate (Rheumatrex 0), which of the following statements indicates the need for further teaching?

a. “I will take my vitamins while I am on this drug”
b. “I must not drink any alcohol while I’m taking this drug”
c. I should brush my teeth after every meal”
d. “I will continue taking my birth control pills”

30. When completing the history and physical examination of a client diagnosed with osteoarthritis, which of the following would the nurse assess?

a. Anemia
b. Osteoporosis
c. Weight loss
d. Local joint pain

31. At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?

a. At bedtime
b. On arising
c. Immediately after meal
d. On an empty stomach

32. When preparing a teaching plan for the client with osteoarthritis who is taking celecoxib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren), is that the celecoxib is likely to produce which of the following?

a. Hepatotoxicity
b. Renal toxicity
c. Gastrointestinal bleeding
d. Nausea and vomiting

33. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating which of the following?

a. A developing infection
b. Bleeding in the operative site
c. Joint dislocation
d. Glue seepage into soft tissue

34. Which of the following would the nurse assess in a client with an intracapsular hip fracture?

a. Internal rotation
b. Muscle flaccidity
c. Shortening of the affected leg
d. Absence of pain the fracture area

35. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a rupture disc?

a. Informing the client that the procedure is painless
b. Taking a thorough history of past surgeries
c. Checking for previous complaints of claustrophobia
d. Starting an intravenous line at keep-open rate

36. Which of the following actions would be a priority for a client who has been in the postanesthesia care unit (PACU) for 45 minutes after an above the knee amputation and develops a dime size bright red spot on the ace bondage above the amputation site?

a. Elevate the stump
b. Reinforcing the dressing
c. Calling the surgeon
d. Drawing a mark around the site

37. A client in the PACU with a left below the knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?

a. Tell the client it is impossible to feel the pain
b. Show the client that the toes are not there
c. Explain to the client that the pain is real
d. Give the client the prescribed narcotic analgesic

38. The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In which of the following exercises would the nurse instruct the client to best prepare him for using crutches?

a. Abdominal exercises
b. Isometric shoulder exercises
c. Quadriceps setting exercises
d. Triceps stretching exercises

39. The client with an above the knee amputation is to use crutches until the prosthesis is properly lifted. When teaching the client about using the crutches, the nurse instructs the client to support her weight primarily on which of the following body areas?

a. Axillae
b. Elbows
c. Upper arms
d. Hands

40. Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the ED in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. When assessing the client, the nurse would be especially alert for signs and symptoms of which of the following?

a. Hemorrhage
b. Infection
c. Deformity
d. Shock

41. The client with a fractured tibia has been taking methocarbamol (Robaxin), when teaching the client about this drug, which of the following would the nurse include as the drug’s primary effect?

a. Killing of microorganisms
b. Reduction in itching
c. Relief of muscle spasms
d. Decrease in nervousness

42. A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mmHg, a pulse rate of 115bpm, and respirations of 8 breaths/minute and shallow, the nurse interprets these finding as indicating which of the following?

a. Expected common side effects
b. Hypersensitivity reactions
c. Possible habituating effects
d. Hemorrhage from GI irritation

43. When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first?

a. The area proximal to the fracture
b. The actual fracture site
c. The area distal to the fracture
d. The opposite extremity for baseline comparison

44. A client with fracture develops compartment syndrome. When caring for the client, the nurse would be alert for which of the following signs of possible organ failure?

a. Rales
b. Jaundice
c. Generalized edema
d. Dark, scanty urine

45. Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?

a. Acute respiratory distress syndrome
b. Migraine like headaches
c. Numbness in the right leg
d. Muscle spasms in the right thigh

46. The client who had an open femoral fracture was discharged to her home, where she developed, fever, night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets these finding as indicating which of the following?

a. Pulmonary emboli
b. Osteomyelitis
c. Fat emboli
d. Urinary tract infection

47. When antibiotics are not producing the desired outcome for a client with osteomyelitis, the nurse interprets this as suggesting the occurrence of which of the following as most likely?

a. Formation of scar tissue interfering with absorption
b. Development of pus leading to ischemia
c. Production of bacterial growth by avascular tissue
d. Antibiotics not being instilled directly into the bone

48. Which of the following would the nurse use as the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury?

a. Homan’s sign
b. Pain
c. Tenderness
d. Leg girth

49. The nurse is caring for the client who is going to have an arthogram using a contrast medium. Which of the following assessments by the nurse are of highest priority?

a. Allergy to iodine or shellfish
b. Ability of the client to remain still during the procedure
c. Whether the client has any remaining questions about the procedure
d. Whether the client wishes to void before the procedure

50. The client immobilized skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the following nursing diagnoses for this client?

a. Divertional activity deficit
b. Powerlessness
c. Self care deficit
d. Impaired physical mobility

51. The nurse is teaching the client who is to have a gallium scan about the procedure. The nurse includes which of the following items as part of the instructions?

a. The gallium will be injected intravenously 2 to 3 hours before the procedure
b. The procedure takes about 15 minutes to perform
c. The client must stand erect during the filming
d. The client should remain on bed rest for the remainder of the day after the scan

52. The nurse is assessing the casted extremity of a client. The nurse assesses for which of the following signs and symptoms indicative of infection?

a. Coolness and pallor of the extremity
b. Presence of a “hot spot” on the cast
c. Diminished distal pulse
d. Dependent edema

53. The client has Buck’s extension applied to the right leg. The nurse plans which of the following interventions to prevent complications of the device?

a. Massage the skin of the right leg with lotion every 8 hours
b. Give pin care once a shift
c. Inspect the skin on the right leg at least once every 8 hours
d. Release the weights on the right leg for range of motion exercises daily

54. The nurse is giving the client with a left cast crutch walking instructions using the three point gait. The client is allowed touchdown of the affected leg. The nurse tells the client to advance the:

a. Left leg and right crutch then right leg and left crutch
b. Crutches and then both legs simultaneously
c. Crutches and the right leg then advance the left leg
d. Crutches and the left leg then advance the right leg

55. The client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:

a. Left hand and placing the cane in front of the left foot
b. Right hand and placing the cane in front of the right foot
c. Left hand and 6 inches lateral to the left foot
d. Right hand and 6 inches lateral to the left foot

56. The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse uses a:

a. Pillow to keep the right leg abducted during turning
b. Pillow to keep the right leg adducted during turning
c. Trochanter roll to prevent external rotation while turning
d. Trochanter roll to prevent abduction while turning

57. The nurse has an order to get the client out of bed to a chair on the first postoperative day after a total knee replacement. The nurse plans to do which of the following to protect the knee joint:

a. Apply a knee immobilizer before getting the client up and elevate the client’s surgical leg while sitting
b. Apply an Ace wrap around the dressing and put ice on the knee while sitting
c. Lift the client to the bedside change leaving the CPM machine in place
d. Obtain a walker to minimize weight bearing by the client on the affected leg

58. The nurse is caring for the client who had an above the knee amputation 2days ago. The residual limb was wrapped with an elastic compression bandage which has come off. The nurse immediately:

a. Calls the physician
b. Rewrap the stump with an elastic compression bandage
c. Applies ice to the site
d. Applies a dry sterile dressing and elevates it on a pillow

59. The nurse has taught the client with a below the knee amputation about prosthesis and stump care. The nurse evaluates that the client states to:

a. Wear a clean nylon stump sock daily
b. Toughen the skin of the stump by rubbing it with alcohol
c. Prevent cracking of the skin of the stump by applying lotion daily
d. Using a mirror to inspect all areas of the stump each day

60. The nurse is caring for a client with a gout. Which of the following laboratory values does the nurse expect to note in the client?

a. Uric acid level of 8 mg/dl
b. Calcium level of 9 mg/dl
c. Phosphorus level of 3 mg/dl
d. Uric acid level of 5 mg/dl

Medical-Surgical Nursing Exam 11: Musculoskeletal Care (60 Items) Original source at: Nurseslabs

1. Katherine is a young Unit Manager of the Pediatric Ward. Most of her staff nurses are senior to her, very articulate, confident and sometimes aggressive. Katherine feels uncomfortable believing that she is the scapegoat of everything that goes wrong in her department. Which of the following is the best action that she must take?

A. Identify the source of the conflict and understand the points of friction
B. Disregard what she feels and continue to work independently
C. Seek help from the Director of Nursing
D. Quit her job and look for another employment.

2. As a young manager, she knows that conflict occurs in any organization. Which of the following statements regarding conflict is NOT true?

A. Can be destructive if the level is too high
B. Is not beneficial; hence it should be prevented at all times
C. May result in poor performance
D. May create leaders

3. Katherine tells one of the staff, “I don’t have time to discuss the matter with you now. See me in my office later” when the latter asks if they can talk about an issue. Which of the following conflict resolution strategies did she use?

A. Smoothing
B. Compromise
C. Avoidance
D. Restriction

4. Kathleen knows that one of her staff is experiencing burnout. Which of the following is the best thing for her to do?

A. Advise her staff to go on vacation.
B. Ignore her observations; it will be resolved even without intervention
C. Remind her to show loyalty to the institution.
D. Let the staff ventilate her feelings and ask how she can be of help.

5. She knows that performance appraisal consists of all the following activities EXCEPT:

A. Setting specific standards and activities for individual performance.
B. Using agency standards as a guide.
C. Determine areas of strength and weaknesses
D. Focusing activity on the correction of identified behavior.

6. Which of the following statements is NOT true about performance appraisal?

A. Informing the staff about the specific impressions of their work help improve their performance.
B. A verbal appraisal is an acceptable substitute for a written report
C. Patients are the best source of information regarding personnel appraisal.
D. The outcome of performance appraisal rests primarily with the staff.

7. There are times when Katherine evaluates her staff as she makes her daily rounds. Which of the following is NOT a benefit of conducting an informal appraisal?

A. The staff member is observed in natural setting.
B. Incidental confrontation and collaboration is allowed.
C. The evaluation is focused on objective data systematically.
D. The evaluation may provide valid information for compilation of a formal report.

8. She conducts a 6-month performance review session with a staff member. Which of the following actions is appropriate?

A. She asks another nurse to attest the session as a witness.
B. She informs the staff that she may ask another nurse to read the appraisal before the session is over.
C. She tells the staff that the session is manager-centered.
D. The session is private between the two members.

9. Alexandra is tasked to organize the new wing of the hospital. She was given the authority to do as she deems fit. She is aware that the director of nursing has substantial trust and confidence in her capabilities, communicates through downward and upward channels and usually uses the ideas and opinions of her staff. Which of the following is her style of management?

A. Benevolent –authoritative
B. Consultative
C. Exploitive-authoritative
D. Participative

10. She decides to illustrate the organizational structure. Which of the following elements is NOT included?

A. Level of authority
B. Lines of communication
C. Span of control
D. Unity of direction

11. She plans of assigning competent people to fill the roles designed in the hierarchy. Which process refers to this?

A. Staffing
B. Scheduling
C. Recruitment
D. Induction

12. She checks the documentary requirements for the applicants for staff nurse position. Which one is NOT necessary?

A. Certificate of previous employment
B. Record of related learning experience (RLE)
C. Membership to accredited professional organization
D. Professional identification card

13. Which phase of the employment process includes getting on the payroll and completing documentary requirements?

A. Orientation
B. Induction
C. Selection
D. Recruitment

14. She tries to design an organizational structure that allows communication to flow in all directions and involve workers in decision making. Which form of organizational structure is this?

A. Centralized
B. Decentralized
C. Matrix
D. Informal

15. In a horizontal chart, the lowest level worker is located at the

A. Left most box
B. Middle
C. Right most box
D. Bottom

16. She decides to have a decentralized staffing system. Which of the following is an advantage of this system of staffing?

A. greater control of activities
B. Conserves time
C. Compatible with computerization
D. Promotes better interpersonal relationship

17. Aubrey thinks about primary nursing as a system to deliver care. Which of the following activities is NOT done by a primary nurse?

A. Collaborates with the physician
B. Provides care to a group of patients together with a group of nurses
C. Provides care for 5-6 patients during their hospital stay.
D. Performs comprehensive initial assessment

18. Which pattern of nursing care involves the care given by a group of paraprofessional workers led by a professional nurse who take care of patients with the same disease conditions and are located geographically near each other?

A. Case method
B. Modular nursing
C. Nursing case management
D. Team nursing

19. St. Raphael Medical Center just opened its new Performance Improvement Department. Ms. Valencia is appointed as the Quality Control Officer. She commits herself to her new role and plans her strategies to realize the goals and objectives of the department. Which of the following is a primary task that they should perform to have an effective control system?

A. Make an interpretation about strengths and weaknesses
B. Identify the values of the department
C. Identify structure, process, outcome standards & criteria
D. Measure actual performances

20. Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard?

A. The patients verbalized satisfaction of the nursing care received
B. Rotation of duty will be done every four weeks for all patient care personnel.
C. All patients shall have their weights taken recorded
D. Patients shall answer the evaluation form before discharge

21. When she presents the nursing procedures to be followed, she refers to what type of standards?

A. Process
B. Outcome
C. Structure
D. Criteria

22. The following are basic steps in the controlling process of the department. Which of the following is NOT included?

A. Measure actual performance
B. Set nursing standards and criteria
C. Compare results of performance to standards and objectives
D. Identify possible courses of action

23. Which of the following statements refers to criteria?

A. Agreed on level of nursing care
B. Characteristics used to measure the level of nursing care
C. Step-by-step guidelines
D. Statement which guide the group in decision making and problem solving

24. She wants to ensure that every task is carried out as planned. Which of the following tasks is NOT included in the controlling process?

A. Instructing the members of the standards committee to prepare policies
B. Reviewing the existing policies of the hospital
C. Evaluating the credentials of all nursing staff
D. Checking if activities conform to schedule

25. Ms. Valencia prepares the process standards. Which of the following is NOT a process standard?

A. Initial assessment shall be done to all patients within twenty four hours upon admission.
B. Informed consent shall be secured prior to any invasive procedure
C. Patients’ reports 95% satisfaction rate prior to discharge from the hospital.
D. Patient education about their illness and treatment shall be provided for all patients and their families.

26. Which of the following is evidence that the controlling process is effective?

A. The things that were planned are done
B. Physicians do not complain.
C. Employees are contended
D. There is an increase in customer satisfaction rate.

27. Ms. Valencia is responsible to the number of personnel reporting to her. This principle refers to:

A. Span of control
B. Unity of command
C. Carrot and stick principle
D. Esprit d’ corps

28. She notes that there is an increasing unrest of the staff due to fatigue brought about by shortage of staff. Which action is a priority?

A. Evaluate the overall result of the unrest
B. Initiate a group interaction
C. Develop a plan and implement it
D. Identify external and internal forces.

29. Kevin is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following is an extraneous variable of the study?

A. Date of admission
B. Length of stay
C. Age of patients
D. Absence of complications

30. He thinks of an appropriate theoretical framework. Whose theory addresses the four modes of adaptation?

A. Martha Rogers
B. Sr. Callista Roy
C. Florence Nightingale
D. Jean Watson

31. He opts to use a self-report method. Which of the following is NOT TRUE about this method?

A. Most direct means of gathering information
B. Versatile in terms of content coverage
C. Most accurate and valid method of data gathering
D. Yields information that would be difficult to gather by another method

32. Which of the following articles would Kevin least consider for his review of literature?

A. “Story-Telling and Anxiety Reduction Among Pediatric Patients”
B. “Turnaround Time in Emergency Rooms”
C. “Outcome Standards in Tertiary Health Care Institutions”
D. “Environmental Manipulation and Client Outcomes”

33. Which of the following variables will he likely EXCLUDE in his study?

A. Competence of nurses
B. Caring attitude of nurses
C. Salary of nurses
D. Responsiveness of staff

34. He plans to use a Likert Scale to determine

A. degree of agreement and disagreement
B. compliance to expected standards
C. level of satisfaction
D. degree of acceptance

35. He checks if his instruments meet the criteria for evaluation. Which of the following criteria refers to the consistency or the ability to yield the same response upon its repeated administration?

A. Validity
B. Reliability
C. Sensitivity
D. Objectivity

36. Which criteria refer to the ability of the instrument to detect fine differences among the subjects being studied?

A. Sensitivity
B. Reliability
C. Validity
D. Objectivity

37. Which of the following terms refer to the degree to which an instrument measures what it is supposed to be measure?

A. Validity
B. Reliability
C. Meaningfulness
D. Sensitivity

38. He plans for his sampling method. Which sampling method gives equal chance to all units in the population to get picked?

A. Random
B. Accidental
C. Quota
D. Judgment

39. Raphael is interested to learn more about transcultural nursing because he is assigned at the family suites where most patients come from different cultures and countries. Which of the following designs is appropriate for this study?

A. Grounded theory
B. Ethnography
C. Case study
D. Phenomenology

40. The nursing theorist who developed transcultural nursing theory is

A. Dorothea Orem
B. Madeleine Leininger
C. Betty Newman
D. Sr. Callista Roy

Nursing Leadership & Management Exam 2 (40 Items) Original source at: Nurseslabs

1. Ms. Castro is newly-promoted to a patient care manager position. She updates her knowledge on the theories in management and leadership in order to become effective in her new role. She learns that some managers have low concern for services and high concern for staff. Which style of management refers to this?

a. Organization Man
b. Impoverished Management
c. Country Club Management
d. Team Management

2. Her former manager demonstrated passion for serving her staff rather than being served. She takes time to listen, prefers to be a teacher first before being a leader, which is characteristic of

a. Transformational leader
b. Transactional leader
c. Servant leader
d. Charismatic leader

3. On the other hand, Ms. Castro notices that the Chief Nurse Executive has charismatic leadership style. Which of the following behaviors best describes this style?

a. Possesses inspirational quality that makes followers gets attracted of him and regards him with reverence
b. Acts as he does because he expects that his behavior will yield positive results
c. Uses visioning as the core of his leadership
d. Matches his leadership style to the situation at hand.

4. Which of the following conclusions of Ms. Castro about leadership characteristics is TRUE?

a. There is a high correlation between the communication skills of a leader and the ability to get the job done.
b. A manager is effective when he has the ability to plan well.
c. Assessment of personal traits is a reliable tool for predicting a manager’s potential.
d. There is good evidence that certain personal qualities favor success in managerial role.

5. She reads about Path Goal theory. Which of the following behaviors is manifested by the leader who uses this theory?

a. Recognizes staff for going beyond expectations by giving them citations
b. Challenges the staff to take individual accountability for their own practice
c. Admonishes staff for being laggards.
d. Reminds staff about the sanctions for non performance.

6. One leadership theory states that “leaders are born and not made,” which refers to which of the following theories?

a. Trait
b. Charismatic
c. Great Man
d. Situational

7. She came across a theory which states that the leadership style is effective dependent on the situation. Which of the following styles best fits a situation when the followers are self-directed, experts and are matured individuals?

a. Democratic
b. Authoritarian
c. Laissez faire
d. Bureaucratic

8. She surfs the internet for more information about leadership styles. She reads about shared leadership as a practice in some magnet hospitals. Which of the following describes this style of leadership?

a. Leadership behavior is generally determined by the relationship between the leader’s personality and the specific situation
b. Leaders believe that people are basically good and need not be closely controlled
c. Leaders rely heavily on visioning and inspire members to achieve results
d. Leadership is shared at the point of care.

9. Ms. Castro learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader?

a. Focuses on management tasks
b. Is a caretaker
c. Uses trade-offs to meet goals
d. Inspires others with vision

10. She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely?

a. Have condescending trust and confidence in their subordinates
b. Gives economic or ego awards
c. Communicates downward to the staff
d. Allows decision making among subordinates

11. Harry is a Unit Manager I the Medical Unit. He is not satisfied with the way things are going in his unit. Patient satisfaction rate is 60% for two consecutive months and staff morale is at its lowest. He decides to plan and initiate changes that will push for a turnaround in the condition of the unit. Which of the following actions is a priority for Harry?

a. Call for a staff meeting and take this up in the agenda.
b. Seek help from her manager.
c. Develop a strategic action on how to deal with these concerns.
d. Ignore the issues since these will be resolved naturally.

12. She knows that there are external forces that influence changes in his unit. Which of the following is NOT an external force?

a. Memo from the CEO to cut down on electrical consumption
b. Demands of the labor sector to increase wages
c. Low morale of staff in her unit
d. Exacting regulatory and accreditation standards

13. After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to this?

a. Collaboration
b. Majority rule
c. Dominance
d. Compromise

14. One staff suggests that they review the pattern of nursing care that they are using, which is described as a:

a. job description
b. system used to deliver care
c. manual of procedure
d. rules to be followed

15. Which of the following is TRUE about functional nursing?

a. Concentrates on tasks and activities
b. Emphasizes use of group collaboration
c. One-to-one nurse-patient ratio
d. Provides continuous, coordinated and comprehensive nursing services

16. Functional nursing has some advantages, which one is an EXCEPTION?

a. Psychological and sociological needs are emphasized.
b. Great control of work activities.
c. Most economical way of delivering nursing services.
d. Workers feel secure in dependent role

17. He raised the issue on giving priority to patient needs. Which of the following offers the best way for setting priority?

a. Assessing nursing needs and problems
b. Giving instructions on how nursing care needs are to be met
c. Controlling and evaluating the delivery of nursing care
d. Assigning safe nurse: patient ratio

18. Which of the following is the best guarantee that the patient’s priority needs are met?

a. Checking with the relative of the patient
b. Preparing a nursing care plan in collaboration with the patient
c. Consulting with the physician
d. Coordinating with other members of the team

19. When Harry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority?

a. Each patient as listed on the worksheet
b. Patients who needs least care
c. Medications and treatments required for all patients
d. Patients who need the most care

20. She is hopeful that her unit will make a big turnaround in the succeeding months. Which of the following actions of Harry demonstrates that he has reached the third stage of change?

a. Wonders why things are not what it used to be
b. Finds solutions to the problems
c. Integrate the solutions to his day-to-day activities
d. Selects the best change strategy

21. Julius is a newly-appointed nurse manager of The Good Shepherd Medical Center, a tertiary hospital located within the heart of the metropolis. He thinks of scheduling planning workshop with his staff in order to ensure an effective and efficient management of the department. Should he decide to conduct a strategic planningworkshop, which of the following is NOT a characteristic of this activity?

a. Long-term goal-setting
b. Extends to 3-5 years in the future
c. Focuses on routine tasks
d. Determines directions of the organization

22. Which of the following statements refer to the vision of the hospital?

a. The Good Shepherd Medical Center is a trendsetter in tertiary health care in the Philippines in the next five years Goal
b. The officers and staff of The Good Shepherd Medical Center believe in the unique nature of the human person
c. All the nurses shall undergo continuing competency training program.
d. The Good Shepherd Medical Center aims to provide a patient-centered care in a total healing environment.

23. The statement, “The Good Shepherd Medical Center aims to provide patient-centered care in a total healing environment” refers to which of the following?

a. Vision
b. Goal
c. Philosophy
d. Mission

24. Julius plans to revisit the organizational chart of the department. He plans to create a new position of a Patient Educator who has a coordinating relationship with the head nurse in the unit. Which of the following will likely depict this organizational relationship?

a. Box
b. Solid line
c. Broken line
d. Dotted line

25. He likewise stresses the need for all the employees to follow orders and instructions from him and not from anyone else. Which of the following principles does he refer to?

a. Scalar chain
b. Discipline
c. Unity of command
d. Order

26. Julius orients his staff on the patterns of reporting relationship throughout the organization. Which of the following principles refer to this?

a. Span of control
b. Hierarchy
c. Esprit d’ corps
d. Unity of direction

27. He emphasizes to the team that they need to put their efforts together towards the attainment of the goals of the program. Which of the following principles refers to this?

a. Span of control
b. Unity of direction
c. Unity of command
d. Command responsibility

28. Julius stresses the importance of promoting ‘esprit d corps’ among the members of the unit. Which of the following remarks of the staff indicates that they understand what he pointed out?

a. “Let’s work together in harmony; we need to be supportive of one another”
b. “In order that we achieve the same results; we must all follow the directives of Julius and not from other managers.”
c. “We will ensure that all the resources we need are available when needed.”
d. “We need to put our efforts together in order to raise the bar of excellence in the care we provide to all our patients.”

29. He discusses the goal of the department. Which of the following statements is a goal?

a. Increase the patient satisfaction rate
b. Eliminate the incidence of delayed administration of medications
c. Establish rapport with patients.
d. Reduce response time to two minutes.

30. He wants to influence the customary way of thinking and behaving that is shared by the members of the department. Which of the following terms refer to this?

a. Organizational chart
b. Cultural network
c. Organizational structure
d. Organizational culture

31. He asserts the importance of promoting a positive organizational culture in their unit. Which of the following behaviors indicate that this is attained by the group?

a. Proactive and caring with one another
b. Competitive and perfectionist
c. Powerful and oppositional
d. Obedient and uncomplaining

32. Stephanie is a new Staff Educator of a private tertiary hospital. She conducts orientation among new staff nurses in her department. Joseph, one of the new staff nurses, wants to understand the channel of communication, span of control and lines of communication. Which of the following will provide this information?

a. Organizational structure
b. Policy
c. Job description
d. Manual of procedures

33. Stephanie is often seen interacting with the medical intern during coffee breaks and after duty hours. What type of organizational structure is this?

a. Formal
b. Informal
c. Staff
d. Line

34. She takes pride in saying that the hospital has a decentralized structure. Which of the following is NOT compatible with this type of model?

a. Flat organization
b. Participatory approach
c. Shared governance
d. Tall organization

35. Centralized organizations have some advantages. Which of the following statements are TRUE?

1. Highly cost-effective
2. Makes management easier
3. Reflects the interest of the worker
4. Allows quick decisions or actions.

a. 1 & 2
b. 2 & 4
c. 2, 3& 4
d. 1, 2, & 4

36. Stephanie delegates effectively if she has authority to act, which is BEST defined as:

a. having responsibility to direct others
b. being accountable to the organization
c. having legitimate right to act
d. telling others what to do

37. Regardless of the size of a work group, enough staff must be available at all times to accomplish certain purposes. Which of these purposes is NOT included?

a. Meet the needs of patients
b. Provide a pair of hands to other units as needed
c. Cover all time periods adequately.
d. Allow for growth and development of nursing staff.

38. Which of the following guidelines should be least considered in formulating objectives for nursing care?

a. Written nursing care plan
b. Holistic approach
c. Prescribed standards
d. Staff preferences

39. Stephanie considers shifting to transformational leadership. Which of the following statements best describes this type of leadership?

a. Uses visioning as the essence of leadership.
b. Serves the followers rather than being served.
c. Maintains full trust and confidence in the subordinates
d. Possesses innate charisma that makes others feel good in his presence.

40. As a manager, she focuses her energy on both the quality of services rendered to the patients as well as the welfare of the staff of her unit. Which of the following management styles does she adopt?

a. Country club management
b. Organization man management
c. Team management
d. Authority-obedience management

Nursing Leadership & Management Exam 1 (40 Items) Original source at: Nurseslabs

Guidelines

• This is a 100-item examination about Medical-Surgical Nursing.
• Rationales and answers are given below.
• You are given 1 minute and 20 seconds each question. A total of 2 hours for this 100-item exam.

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

1. As a registered nurse, Arthur 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 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.

2. Arthur suspects a hip fracture when he noticed that the old woman’s leg is

A. Lengthened, Abducted and Internally Rotated.
B. Shortened, Abducted and Externally Rotated.
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally Rotated.

3. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to

A. Infection
B. Thrombophlebitis
C. Inflammation
D. Degenerative disease

4. The old woman told John that she has osteoporosis; Arthur knew that all of the following factors would contribute to osteoporosis except

A. Hypothyroidism
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin.

5. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms?

A. Tachycardia and Hypotension
B. Fever and Bradycardia
C. Bradycardia and Hypertension
D. Fever and Hypertension

SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.

6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane

A. On his left hand, because his right side is weak.
B. On his left hand, because of reciprocal motion.
C. On his right hand, to support the right leg.
D. On his right hand, because only his right leg is weak.

7. You also told Mr. Rojas to hold the cane

A. 1 Inches in front of the foot.
B. 3 Inches at the lateral side of the foot.
c. 6 Inches at the lateral side of the foot.
D. 12 Inches at the lateral side of the foot.

8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him

A. Moves the cane when the right leg is moved.
B. Leans on the cane when the right leg swings through.
C. keeps the cane 6 Inches out to the side of the right foot.
D. Holds the cane on the right side.

SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood

9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as

A. PPD
B. PDP
C. PDD
D. DPP

10. The nurse would inject the solution in what route?

A. IM
B. IV
C. ID
D. SC

11. The nurse notes that a positive result for Alfred is

A. 5 mm wheal
B. 5 mm Induration
C. 10 mm Wheal
D. 10 mm Induration

12. The nurse told Alfred to come back after

A. a week
B. 48 hours
C. 1 day
D. 4 days

13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action?

A. Call the Physician
B. Notify the radiology dept. for CXR evaluation
C. Isolate the patient
D. Order for a sputum exam

14. Why is Mantoux test not routinely done in the Philippines?

A. It requires a highly skilled nurse to perform a Mantoux test
B. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions
D. Almost all Filipinos will test positive for Mantoux Test

15. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?

A. I
B. II
C. III
D. IV

16. How long is the duration of the maintenance phase of his treatment?

A. 2 months
B. 3 months
C. 4 months
D. 5 months

17. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase?

A. Rifampicin
B. Isoniazid
C. Ethambutol
D. Pyridoxine

18. According to the DOH, the most hazardous period for development of clinical disease is during the first

A. 6-12 months after
B. 3-6 months after
C. 1-2 months after
D. 2-4 weeks after

19. This is the name of the program of the DOH to control TB in the country

A. DOTS
B. National Tuberculosis Control Program
C. Short Coursed Chemotherapy
D. Expanded Program for Immunization

20. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except

A. 23 Year old athlete with diabetes insipidus
B. 23 Year old athlete taking long term Decadron therapy and anabolic steroids
C. 23 Year old athlete taking illegal drugs and abusing substances
D. Undernourished and Underweight individual who undergone gastrectomy

21. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention?

A. Primary
B. Secondary
C. Tertiary
D. Quarterly

SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.

22. Michiel 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

23. The nurse plans to teach Michiel 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

24. The nurse should insert the colostomy tube for irrigation at approximately

A. 1-2 inches
B. 3-4 inches
C. 6-8 inches
D. 12-18 inches

25. The maximum height of irrigation solution for colostomy is

A. 5 inches
B. 12 inches
C. 18 inches
D. 24 inches

26. 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. Agrees to look at the colostomy
D. States that colostomy care is the function of the nurse while he is in the hospital

27. While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would

A. Stop the irrigation by clamping the tube
B. Slow down the irrigation
C. Tell the client that cramping will subside and is normal
D. Notify the physician

28. The next day, the nurse will assess Michiel’s 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

29. Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be

A. Eat eggs
B. Eat cucumbers
C. Eat beet greens and parsley
D. Eat broccoli and spinach

30. The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?

A. Use 500 ml to 1,000 ml NSS
B. Suspend the irrigant 45 cm above the stoma
C. Insert the cone 4 cm in the stoma
D. If cramping occurs, slow the irrigation

31. The nurse knew that the normal color of Michiel’s stoma should be

A. Brick Red
B. Gray
C. Blue
D. Pale Pink

SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.

32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?

A. Hyperventilating James with 100% oxygen before and after suctioning
B. Instilling 3 to 5 ml normal saline to loosen up secretion
C. Applying suction during catheter withdrawal
D. Suction the client every hour

33. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?

A. Fr. 5
B. Fr. 10
C. Fr. 12
D. Fr. 18

34. Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?

A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 20-25 mmHg

35. If a Wall unit is used, What should be the suctioning pressure required by James?

A. 50-95 mmHg
B. 95-110 mmHg
C. 100-120 mmHg
D. 155-175 mmHg

36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?

A. New set of tracheostomy tubes and Oxygen tank
B. Theophylline and Epinephrine
C. Obturator and Kelly clamp
D. Sterile saline dressing

37. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?

A. Wilma places 2 fingers between the tie and neck
B. The tracheotomy can be pulled slightly away from the neck
C. James’ neck veins are not engorged
D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.

38. Wilma knew that James have an adequate respiratory condition if she notices that

A. James’ respiratory rate is 18
B. James’ Oxygen saturation is 91%
C. There are frank blood suction from the tube
D. There are moderate amount of tracheobronchial secretions

39. Wilma knew that the maximum time when suctioning James is

A. 10 seconds
B. 20 seconds
C. 30 seconds
D. 45 seconds

SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.

40. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma?

A. Loss of peripheral vision
B. Irreversible vision loss
C. There is an increase in IOP
D. Pain

41. Nurse jet knew that Acute close angle glaucoma is caused by

A. Sudden blockage of the anterior angle by the base of the iris
B. Obstruction in trabecular meshwork
C. Gradual increase of IOP
D. An abrupt rise in IOP from 8 to 15 mmHg

42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures

A. It measures the peripheral vision remaining on the client
B. Measures the Intra Ocular Pressure
C. Measures the Client’s Visual Acuity
D. Determines the Tone of the eye in response to the sudden increase in IOP.

43. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change?

A. IRIS
B. PUPIL
C. RODS [RETINA]
D. CONES [RETINA]

44. Nurse Jet knows that Aqueous Humor is produce where?

A. In the sub arachnoid space of the meninges
B. In the Lateral ventricles
C. In the Choroids
D. In the Ciliary Body

45. Nurse Jet knows that the normal IOP is

A. 8-21 mmHg
B. 2-7 mmHg
c. 31-35 mmHg
D. 15-30 mmHg

46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would Nurse Jet implement to measure CN II’s Acuity?

A. Slit lamp
B. Snellen’s Chart
C. Wood’s light
D. Gonioscopy

47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to

A. Contract the Ciliary muscle
B. Relax the Ciliary muscle
C. Dilate the pupils
D. Decrease production of Aqueous Humor

48. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is

A. Reduce production of CSF
B. Reduce production of Aquesous Humor
C. Constrict the pupil
D. Relaxes the Ciliary muscle

49. When caring for Mr. Batumbakal, Jet teaches the client to avoid

A. Watching large screen TVs
B. Bending at the waist
C. Reading books
D. Going out in the sun

50. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure?

A. Reading newsprint
B. Lying down
C. Watching TV
D. Listening to the music

51. If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in any case systemic toxicity occurs?

A. Atropine Sulfate
B. Pindolol [Visken]
C. Naloxone Hydrochloride [Narcan]
D. Mesoridazine Besylate [Serentil]

SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a nurse assess and analyze changes in the adult client’s health.

52. Nurse Anna is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Anna noticed a rotary nystagmus towards the irrigated ear. What does this means?

A. Indicates a CN VIII Dysfunction
B. Abnormal
C. Normal
D. Inconclusive

53. Ear drops are prescribed to an infant, The most appropriate method to administer the ear drops is

A. Pull the pinna up and back and direct the solution towards the eardrum
B. Pull the pinna down and back and direct the solution onto the wall of the canal
C. Pull the pinna down and back and direct the solution towards the eardrum
D. Pull the pinna up and back and direct the solution onto the wall of the canal

54. Nurse Jenny is developing a plan of care for a patient with Menieres disease. What is the priority nursing intervention in the plan of care for this particular patient?

A. Air, Breathing, Circulation
B. Love and Belongingness
C. Food, Diet and Nutrition
D. Safety

55. After mastoidectomy, Nurse John should be aware that the cranial nerve that is usually damage after this procedure is

A. CN I
B. CN II
C. CN VII
D. CN VI

56. The physician orders the following for the client with Menieres disease. Which of the following should the nurse question?

A. Dipenhydramine [Benadryl]
B. Atropine sulfate
C. Out of bed activities and ambulation
D. Diazepam [Valium]

57. Nurse Anna is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful?

A. I will try to eat foods that are low in sodium and limit my fluid intake
B. I must drink atleast 3,000 ml of fluids per day
C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
D. I will not eat turnips, red meat and raddish

58. Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Joemar assessed peachy and found out It was an insect. What should be the first thing that Nurse Joemar should try to remove the insect out from peachy’s ear?

A. Use a flashlight to coax the insect out of peachy’s ear
B. Instill an antibiotic ear drops
C. Irrigate the ear
D. Pick out the insect using a sterile clean forceps

59. Following an ear surgery, which statement if heard by Nurse Oca from the patient indicates a correct understanding of the post operative instructions?

A. Activities are resumed within 5 days
B. I will make sure that I will clean my hair and face to prevent infection
C. I will use straw for drinking
D. I should avoid air travel for a while

60. Nurse Oca will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates?

A. Indicating a Cranial Nerve VIII Dysfunction
B. The test should be repeated again because the result is vague
C. This is Grossly abnormal and should be reported to the neurosurgeon
D. This indicates an intact and working vestibular branch of CN VIII

61. A client with Cataract is about to undergo surgery. Nurse Oca is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?

A. Anxiety R/T to the operation and its outcome
B. Sensory perceptual alteration R/T Lens extraction and replacement
C. Knowledge deficit R/T the pre operative and post operative self care
D. Body Image disturbance R/T the eye packing after surgery

62. Nurse Joseph is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Josph to make?

A. He might have a sensory hearing loss in the left ear
B. Conductive hearing loss is possible in the right ear
C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
D. He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.

63. Aling myrna has Menieres disease. What typical dietary prescription would nurse Oca expect the doctor to prescribe?

A. A low sodium , high fluid intake
B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake
D. low sodium and restricted fluid intake

SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.
Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.

64. Which of the following is the appropriate nursing diagnosis?

A. Fluid volume deficit R/T furrow tongue
B. Fluid volume deficit R/T uncontrolled vomiting
C. Dehydration R/T subnormal body temperature
D. Dehydration R/T incessant vomiting

65. Approximately how much fluid is lost in acute weight loss of .5kg?

A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml

66. Postural Hypotension is

A. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
C. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting

67. Which of the following measures will not help correct the patient’s condition

A. Offer large amount of oral fluid intake to replace fluid lost
B. Give enteral or parenteral fluid
C. Frequent oral care
D. Give small volumes of fluid at frequent interval

68. After nursing intervention, you will expect the patient to have

1. Maintain body temperature at 36.5 C
2. Exhibit return of BP and Pulse to normal
3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed

A. 1,3
B. 2,4
C. 1,3,4
D. 2,3,4

SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.

69. Which of the following is a characteristic of a patient with advanced Parkinson’s disease?

A. Disturbed vision
B. Forgetfulness
C. Mask like facial expression
D. Muscle atrophy

70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by

A. Injurious chemical substances
B. Hereditary factors
C. Death of brain cells due to old age
D. Impairment of dopamine producing cells in the brain

71. The patient was prescribed with levodopa. What is the action of this drug?

A. Increase dopamine availability
B. Activates dopaminergic receptors in the basal ganglia
C. Decrease acetylcholine availability
D. Release dopamine and other catecholamine from neurological storage sites

72. You are discussing with the dietician what food to avoid with patients taking levodopa?

A. Vitamin C rich food
B. Vitamin E rich food
C. Thiamine rich food
D. Vitamin B6 rich food

73. One day, the patient complained of difficulty in walking. Your response would be

A. You will need a cane for support
B. Walk erect with eyes on horizon
C. I’ll get you a wheelchair
D. Don’t force yourself to walk

SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.

74. The nurse will assess a loss of ability in which of the following areas?

A. Balance
B. Judgment
C. Speech
D. Endurance

75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:

A. Insomnia
B. Aphraxia
C. Agnosia
D. Aphasia

76. The nurse is aware that in communicating with an elderly client, the nurse will

A. Lean and shout at the ear of the client
B. Open mouth wide while talking to the client
C. Use a low-pitched voice
D. Use a medium-pitched voice

77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?

A. I know the hallucinations are parts of the disease
B. I told her she is wrong and I explained to her what is right
C. I help her do some tasks he cannot do for himself
D. Ill turn off the TV when we go to another room

78. Which of the following is most important discharge teaching for Mr. Dela Isla

A. Emergency Numbers
B. Drug Compliance
C. Relaxation technique
D. Dietary prescription

SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.

79. What is the action of this drug?

A. Increases glandular secretion for clients affected with cystic fibrosis
B. Dissolve blockage of the urinary tract due to obstruction of cystine stones
C. Reduces secretion of the glandular organ of the body
D. Stimulate peristalsis for treatment of constipation and obstruction

80. What should the nurse caution the client when using this medication

A. Avoid hazardous activities like driving, operating machineries etc.
B. Take the drug on empty stomach
C. Take with a full glass of water in treatment of Ulcerative colitis
D. I must take double dose if I missed the previous dose

81. Which of the following drugs are not compatible when taking Probanthine?

A. Caffeine
B. NSAID
C. Acetaminophen
D. Alcohol

82. What should the nurse tell clients when taking Probanthine?

A. Avoid hot weathers to prevent heat strokes
B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a day
D. Avoid cold weathers to prevent hypothermia

83. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder?

A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
D. Glaucoma

SITUATION : Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.

84. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?

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

85. Considering Mr. Franco’s conditions, 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

86. What is the rationale for giving Mr. Franco frequent mouth care?

A. He will be thirsty considering that he is doesn’t drink enough fluids
B. To remove dried blood when tongue is bitten during a seizure
C. The tactile stimulation during mouth care will hasten return to consciousness
D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.

87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?

A. Massage reddened areas with lotion or oils
B. Turn frequently every 2 hours
C. Use special water mattress
D. Keep skin clean and dry

88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?

A. Expressive aphasia is prominent on clients with right sided weakness
B. The affected lobe in the patient is the Right lobe
C. The client will have problems in judging distance and proprioception
D. Clients orientation to time and space will be much affected

SITUATION : a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.

89. Which result of the lab test will be significant to the diagnosis?

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

90. 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

91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :

A. Allay anxiety and apprehension
B. Reduce pain
C. Prevent vomiting
D. Relax abdominal muscle

92. Common anesthesia for appendectomy is

A. Spinal
B. General
C. Caudal
D. Hypnosis

93. Post op care for appendectomy include the following except

A. Early ambulation
B. Diet as tolerated after fully conscious
C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise

94. Peritonitis 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

95. If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication?

A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon

96. NGT was connected to suction. In caring for the patient with NGT, the nurse must

A. Irrigate the tube with saline as ordered
B. Use sterile technique in irrigating the tube
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips

97. When do you think the NGT tube be removed?

A. When patient requests for it
B. Abdomen is soft and patient asks for water
C. Abdomen is soft and flatus has been expelled
D. B and C only

Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.

98. What do you call a STROKE that manifests a bizarre behavior?

A. Inorganic Stroke
B. Inorganic Psychoses
C. Organic Stroke
D. Organic Psychoses

99. The main difference between chronic and organic brain syndrome is that the former

A. Occurs suddenly and reversible
B. Is progressive and reversible
C. tends to be progressive and irreversible
D. Occurs suddenly and irreversible

100. Which behavior results from organic psychoses?

A. Memory deficit
B. Disorientation
C. Impaired Judgement
D. Inappropriate affect

Medical-Surgical Nursing Comprehensive Exam 3 (100 Items) Original source at: Nurseslabs

Guidelines

• This is a 100-item examination about Medical-Surgical Nursing.
• Rationales and answers are given below.
• You are given 1 minute and 20 seconds each question. A total of 2 hours for this 100-item exam.

1. After a cerebrovascular accident, a 75 yr old client is admitted to the health care facility. The client has left-sided weakness and an absent gag reflex. He’s incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g/dl. Which of the following is a priority for this client?

a. checking stools for occult blood
b. performing range-of-motion exercises to the left side
c. keeping skin clean and dry
d. elevating the head of the bed to 30 degrees

2. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:

a. destroys the odor-proof seal
b. wont affect the colostomy system
c. is appropriate for relieving the gas in a colostomy system
d. destroys the moisture barrier seal

3. When assessing the client with celiac disease, the nurse can expect to find which of the following?

a. steatorrhea
b. jaundiced sclerae
c. clay-colored stools
d. widened pulse pressure

4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium because:

a. reducing sodium promotes urea nitrogen excretion
b. reducing sodium improves her glomerular filtration rate
c. reducing sodium increases potassium absorption
d. reducing sodium decreases edema

5. The nurse is caring for a client with a cerebral injury that impaired his speech and hearing. Most likely, the client has experienced damage to the:

a. frontal lobe
b. parietal lobe
c. occipital lobe
d. temporal lobe

6. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the 2nd hour. The nurse should suspect:

a. Cushing’s syndrome
b. Diabetes mellitus
c. Adrenal crisis
d. Diabetes insipidus

7. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

a. limit oral fluid intake for 1 to 2 weeks
b. report the presence of fine, sandlike particles through the nephrostomy tube.
c. Notify the physician about cloudy or foul smelling urine
d. Report bright pink urine within 24 hours after the procedure

8. 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 of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority?

a. deficient fluid volume related to osmotic diuresis
b. decreased cardiac output related to elevated heart rate
c. imbalanced nutrition: Less than body requirements related to insulin deficiency
d. ineffective thermoregulation related to dehydration

9. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The
nurse should expect the dose’s:

a. onset to be at 2 p.m. and its peak at 3 p.m.
b. onset to be at 2:15 p.m. and its peak at 3 p.m.
c. onset to be at 2:30 p.m. and its peak at 4 p.m.
d. onset to be at 4 p.m. and its peak at 6 p.m.

10. A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:

a. 52 mm Hg
b. 88 mm Hg
c. 48 mm Hg
d. 68 mm Hg

11. A 52 yr-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 client’s lump is cancerous?

a. eversion of the right nipple and a mobile mass
b. nonmobile mass with irregular edges
c. mobile mass that is oft and easily delineated
d. nonpalpable right axillary lymph nodes

12. A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?

a. Social worker
b. registered dietician
c. occupational therapist
d. enterostomal nurse therapist

13. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture?

a. basilar
b. temporal
c. occipital
d. parietal

14. A male client should be taught about testicular examinations:

a. when sexual activity starts
b. after age 60
c. after age 40
d. before age 20

15. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?

A. fluid intake for the last 24 hours
B. baseline arterial blood gas (ABG) levels
C. prior outcomes of weaning
D. electrocardiogram (ECG) results

16. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women:

A. perform breast self-examination annually
B. have a mammogram annually
C. have a hormonal receptor assay annually
D. have a physician conduct a clinical evaluation every 2 years

17. When caring for a client with esophageal varices, the nurse knows that bleeding in this disorder usually stems from:

A. esophageal perforation
B. pulmonary hypertension
C. portal hypertension
D. peptic ulcers

18. A 49-yer-old client was admitted for surgical repair of a Colles’ fracture. An external fixator was placed during surgery. The surgeon explains that this method of repair:

A. has very low complication rate
B. maintains reduction and overall hand function
C. is less bothersome than a cast
D. is best for older people

19. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction?

A. “Be sure to eat meat at every meal.”
B. “Monitor your fruit intake and eat plenty of bananas.”
C. “Restrict your salt intake.”
D. “Drink plenty of fluids.”

20. The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has tow children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support
her coping?

A. Tell the client’s spouse or partner to be supportive while she recovers.
B. Encourage the client to proceed with the next phase of treatment.
C. Recommend that the client remain cheerful for the sake of her children.
D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.

21. A 21 year-old male has been seen in the clinic for a thickening in his right testicle. The physician ordered a human chorionic gonadotropin (HCG) level. The nurse’s explanation to the client should include the fact that:

A. The test will evaluate prostatic function.
B. The test was ordered to identify the site of a possible infection.
C. The test was ordered because clients who have testicular cancer has elevated levels of HCG.
D. The test was ordered to evaluate the testosterone level.

22. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:

A. A skin rash.
B. Peripheral edema.
C. A dry cough.
D. Postural hypotension.

23. Which assessment finding indicates dehydration?

A. Tenting of chest skin when pinched.
B. Rapid filling of hand veins.
C. A pulse that isn’t easily obliterated.
D. Neck vein distention

24. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to:

A. Avoid focusing on his weight.
B. Increase his activity level.
C. Follow a regular diet.
D. Continue leading a high-stress lifestyle.

25. For a client newly diagnosed with radiationinduced thrombocytopenia, the nurse should include which intervention in the plan of care?

A. Administer aspirin if the temperature exceeds 38.8º C.
B. Inspect the skin for petechiae once every shift.
C. Provide for frequent periods of rest.
D. Place the client in strict isolation.

26. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation (SaO2) 96% or better. The client most likely has:

A. poor peripheral perfusion
B. a possible Hematologic problem
C. a psychosomatic disorder
D. left-sided heart failure

27. For a client in addisonian crisis, it would be very risky for a nurse to administer:

A. potassium chloride
B. normal saline solution
C. hydrocortisone
D. fludrocortisone

28. The nurse is reviewing the laboratory report of a client who underwent a bone marrow biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the existence of a large number of immature:

A. lymphocytes
B. thrombocytes
C. reticulocytes
D. leukocytes

29. The nurse is performing wound care on a foot ulcer in a client with type 1 diabetes mellitus. Which technique demonstrates surgical asepsis?

A. Putting on sterile gloves then opening a container of sterile saline.
B. Cleaning the wound with a circular motion, moving from outer circles toward the center.
C. Changing the sterile field after sterile water is spilled on it.
D. Placing a sterile dressing ½” (1.3 cm) from the edge of the sterile field.

30. A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?

A. high volumes of fluid intake
B. aerobic exercise programs
C. caffeine-containing products
D. foods rich in protein

31. A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which organ?

A. adrenal cortex
B. pancreas
C. adrenal medulla
D. parathyroid

32. A client has a medical history of rheumatic fever, type 1 (insulin dependent) diabetes mellitus, hypertension, pernicious anemia, and appendectomy. She’s admitted to the hospital and undergoes mitral valve replacement surgery. After discharge, the client is scheduled for a tooth extraction. Which history finding is a major risk factor for infective endocarditis?

A. appendectomy
B. pernicious anemia
C. diabetes mellitus
D. valve replacement

33. A 62 yr-old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past two years. She’s fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Test reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl, and potassium level 3.8 mEq/L. which of the following nursing diagnoses is most appropriate for this client?

A. Deficient fluid volume related to inability to conserve water
B. Imbalanced nutrition: less than body requirements related to hypermetabolic state
C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
D. Imbalanced nutrition: less than body requirements related to catabolic effects of insulin deficiency

34. A 20 yr-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb (4.5 kg) and has cramps and occasional diarrhea. The nurse should include which of the following when doing a nutritional assessment?

A. Let the client eat as desired during the hospitalization.
B. Weight the client daily.
C. Ask the client to list what she eats during a typical day.
D. Place the client on I & O status and draw blood for electrolyte levels.

35. When instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave’s disease?

A. Keep an accurate record of intake and output.
B. Use nasal desmopressin acetate DDAVP).
C. Be sure to get regulate follow-up care.
D. Be sure to exercise to improve cardiovascular fitness.

36. A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit. Which nursing diagnosis is appropriate at this time?

A. Deficient knowledge related to interventions used to treat acute illness
B. Impaired physical mobility related to complete bed rest
C. Social isolation related to restricted visiting hours in the intensive care unit
D. Anxiety related to the threat of death

37. A client is admitted to the health care facility with active tuberculosis. The nurse should include which intervention in the plan of care?

A. Putting on a mask when entering the client’s room.
B. Instructing the client to wear a mask at all times
C. Wearing a gown and gloves when providing direct care
D. Keeping the door to the client’s room open to observe the client

38. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should:

A. Apply suction to the NG tube every hour.
B. Clamp the NG tube if the client complains of nausea.
C. Irrigate the NG tube gently with normal saline solution.
D. Reposition the NG tube if pulled out.

39. Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?

A. administer 2 to 3 L of IV fluid rapidly
B. administer 6 L of IV fluid over the first 24 hours
C. administer a dextrose solution containing normal saline solution
D. administer IV fluid slowly to prevent circulatory overload and collapse

40. Which of the following is an adverse reaction to glipizide (Glucotrol)?

A. headache
B. constipation
C. hypotension
D. photosensitivity

41. The nurse is caring for four clients on a stepdown intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one who:

A. has a respiratory infection
B. is intubated and on a ventilator
C. has pleural chest tubes
D. is receiving feedings through a jejunostomy tube

42. The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

A. Make inhalation longer than exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.

43. A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn’t answered immediately. The most appropriate response to her would be:

A. “You seem angry. Would you like to talk about it?”
B. “Calm down. You know that stress will make your symptoms worse.”
C. “Would you like to talk about the problem with the nursing supervisor?”
D. “I can see you’re angry. I’ll come back when you’ve calmed down.”

44. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relive symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?

A. Taking daily walks.
B. Engaging in anaerobic exercise.
C. Reducing daily fat intake to less than 45% of total calories
D. Avoiding foods that increase levels of highdensity lipoproteins (HDLs)

45. A physician orders gastric decompression for a client with small bowel obstruction. The nurse should plan for the suction to be:

A. low pressure and intermittent
B. low pressure and continuous
C. high pressure and continuous
D. high pressure and intermittent

46. Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?

A. Risk for injury
B. Impaired urinary elimination
C. Ineffective breathing pattern
D. Imbalanced nutrition: less than body requirements

47. Parathyroid hormone (PTH) has which effects on the kidney?

A. Stimulation of calcium reabsorption and phosphate excretion
B. Stimulation of phosphate reabsorption and calcium excretion
C. Increased absorption of vit D and excretion of vit E
D. Increased absorption of vit E and excretion of Vit D

48. A visiting nurse is performing home assessment for a 59-yr old man recently discharged after hip replacement surgery. Which home assessment finding warrants health promotion teaching from the nurse?

A. A bathroom with grab bars for the tub and toilet
B. Items stored in the kitchen so that reaching up and bending down aren’t necessary
C. Many small, unsecured area rugs
D. Sufficient stairwell lighting, with switches to the top and bottom of the stairs

49. A client with autoimmune thrombocytopenia and a platelet count of 800/uL develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, “I don’t need surgery—this will go away on its own.” In considering her response to the client, the nurse must depend on the ethical principle of:

A. beneficence
B. autonomy
C. advocacy
D. justice

50. Which of the following is t he most critical intervention needed for a client with myxedema coma?

A. Administering and oral dose of levothyroxine (Synthroid)
B. Warming the client with a warming blanket
C. Measuring and recording accurate intake and output
D. Maintaining a patent airway

51. Because diet and exercise have failed to control a 63 yr-old client’s blood glucose level, the client is prescribed glipizide (Glucotrol). After oral administration, the onset of action is:

A. 15 to 30 minutes
B. 30 to 60 minutes
C. 1 to 1 ½ hours
D. 2 to 3 hours

52. A client with pneumonia is receiving supplemental oxygen, 2 L/min via nasal cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which complication may arise if the client receives a high oxygen concentration?

A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis

53. A client with type 1 diabetes mellitus has been on a regimen of multiple daily injection therapy. He’s being converted to continuous subcutaneous insulin therapy. While teaching the client bout continuous subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use of:

A. intermediate and long-acting insulins
B. short and long-acting insulins
C. short-acting only
D. short and intermediate-acting insulins

54. a client who recently had a cerebrovascular accident requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to:

A. prevent leaning
B. distribute weight away from the involved side
C. maintain stride length
D. prevent edema

55. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac stepdown unit (CSU). While giving report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should be especially observant for:

A. hypertension
B. high urine output
C. dry mucous membranes
D. pulmonary crackles

56. The nurse is caring for a client with a fractures hip. The client is combative, confused, and trying to get out of bed. The nurse should:

A. leave the client and get help
B. obtain a physician’s order to restrain the client
C. read the facility’s policy on restraints
D. order soft restraints from the storeroom

57. For the first 72 hours after thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate which of the following?

A. hypocalcemia
B. hypercalcemia
C. hypokalemia
D. Hyperkalemia

58. In a client with enteritis and frequent diarrhea, the nurse should anticipate an acidbase imbalance of:

A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis

59. When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

A. position the client in a supine position
B. elevate the head of the bed 90 degrees during meals
C. encourage the client to remove dentures
D. encourage thin liquids for dietary intake

60. A nurse is caring for a client who has a tracheostomy and temperature of 39º C. which intervention will most likely lower the client’s arterial blood oxygen saturation?

A. Endotracheal suctioning
B. Encouragement of coughing
C. Use of cooling blanket
D. Incentive spirometry

61. A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:

A. fluid resuscitation
B. infection
C. body image
D. pain management

62. Which statement is true about crackles?

A. They’re grating sounds.
B. They’re high-pitched, musical squeaks.
C. They’re low-pitched noises that sound like snoring.
D. They may be fine, medium, or course.

63. A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter. Management of her care would include:

A. scheduling her for annual tuberculin skin testing
B. placing her in quarantine until sputum cultures are negative
C. gathering a list of persons with whom she has had recent contact
D. advising her to begin prophylactic therapy with isoniazid (INH)

64. The nurse is caring for a client who ahs had an above the knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells the nurse that he doesn’t wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the client’s problem is:

A. Hopelessness
B. Powerlessness
C. Disturbed body image
D. Fear

65. A client with three children who is still I the child bearing years is admitted for surgical repair of a prolapsed bladder. The nurse would find that the client understood the surgeon’s preoperative teaching when the client states:

A. “If I should become pregnant again, the child would be delivered by cesarean delivery.”
B. “If I have another child, the procedure may need to be repeated.”
C. “This surgery may render me incapable of conceiving another child.”
D. “This procedure is accomplished in two separate surgeries.”

66. A client experiences problems in body temperature regulation associated with a skin impairment. Which gland is most likely involved?

A. Eccrine
B. Sebaceous
C. Apocrine
D. Endocrine

67. A school cafeteria worker comes to the physician’s office complaining of severe scalp itching. On inspection, the nurse finds nail marks on the scalp and small light-colored round specks attached to the hair shafts close to the scalp. These findings suggest that the client suffers from:

A. scabies
B. head lice
C. tinea capitis
D. impetigo

68. Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:

A. erythema
B. leukocytosis
C. pressure-like pain
D. swelling

69. A 28 yr-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially suspected. The diagnosis is confirmed if the rash appears:

A. erythematous with raised papules
B. dry and scaly with flaking skin
C. inflamed with weeping and crusting lesions
D. excoriated with multiple fissures

70. When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately?

A. Complaints of intense thirst
B. Moderate to severe pain
C. Urine output of 70 ml the 1st hour
D. Hoarseness of the voice

71. A client is admitted to the hospital following a burn injury to the left hand and arm. The client’s burn is described as white and leathery with no blisters. Which degree of severity is this burn?

A. first-degree burn
B. second-degree burn
C. third-degree burn
D. fourth-degree burn

72. The nurse is caring for client with a new donor site that was harvested to treat a new burn. The nurse position the client to:

A. allow ventilation of the site
B. make the site dependent
C. avoid pressure on the site
D. keep the site fully covered

73. a 45-yr-old auto mechanic comes to the physician’s office because an exacerbation of his psoriasis is making it difficult to work. He tells the nurse that his finger joints are stiff and sore in the morning. The nurse should respond by:

A. Inquiring further about this problem because psoriatic arthritis can accompany psoriasis vulgaris
B. Suggesting he take aspirin for relief because it’s probably early rheumatoid arthritis
C. Validating his complaint but assuming it’s an adverse effect of his vocation
D. Asking him if he has been diagnosed or treated for carpal tunnel syndrome

74. The nurse is providing home care instructions to a client who has recently had a skin graft. Which instruction is most important for the client to remember?

A. Use cosmetic camouflage techniques.
B. Protect the graft from direct sunlight.
C. Continue physical therapy.
D. Apply lubricating lotion to the graft site.

75. a 28 yr-old female nurse is seen in the employee health department for mild itching and rash of both hands. Which of the following could be causing this reaction?

A. possible medication allergies
B. current life stressors she may be experiencing
C. chemicals she may be using and use of latex gloves
D. recent changes made in laundry detergent or bath soap.

76. The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for:

A. hives
B. a toxin
C. a tubercle
D. a virus

77. A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

A. scale
B. crust
C. ulcer
D. scar

78. The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?

A. Turn and reposition the client a minimum of every 8 hours.
B. Vigorously massage lotion into bony prominences.
C. Post a turning schedule at the client’s bedside.
D. Slide the client, rather than lifting when turning.

79. Following a full-thickeness (3rd degree) burn of his left arm, a client is treated with artificial skin. The client understands postoperative care of the artificial skin when he states that during the first 7 days after the procedure, he’ll restrict:

A. range of motion
B. protein intake
C. going outdoors
D. fluid ingestion

80. A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

A. 9%
B. 18%
C. 27%
D. 36%

81. The nurse is providing care for a client who has a sacral pressure ulcer with wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?

A. The wound should remain moist form the dressing.
B. The wet-to-dry dressing should be tightly packed into the wound.
C. The dressing should be allowed to dry out before removal.
D. A plastic sheet-type dressing should cover the wet dressing.

82. While in skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter’s home with six other persons. During her visit to the clinic, she asks a staff nurse, “What should my family do?” the most accurate response from the nurse is:

A. “All family members will need to be treated.”
B. “If someone develops symptoms, tell him to see a physician right away.”
C. “Just be careful not to share linens and towels with family members.”
D. “After you’re treated, family members won’t be at risk for contracting scabies.”

83. In an industrial accident, client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?

A. A urine output consistently above 100 ml/hour.
B. A weight gain of 4 lb (1.8 kg) in 24 hours.
C. Body temperature readings all within normal limits
D. An electrocardiogram (ECG) showing no arrhythmias.

84. The nurse is reviewing the laboratory results of a client with rheumatoid arthritis. Which of the following laboratory results should the nurse expect to find?

A. Increased platelet count
B. Elevated erythrocyte sedimentation rate (ESR)
C. Electrolyte imbalance
D. Altered blood urea nitrogen (BUN) and creatinine levels

85. Which nursing diagnosis takes the highest priority for a client with Parkinson’s crisis?

A. Imbalanced nutrition: less than body requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury

86. A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

A. Increase the frequency of the catheterizations.
B. Insert an indwelling urinary catheter
C. Place the client on fluid restrictions
D. Use a condom catheter instead of an invasive one.

87.The nurse is caring for a client who is to undergo a lumbar puncture to assess for the presence of blood in the cerebrospinal fluid (CSF) and to measure CSF pressure. Which result would indicate n abnormality?

A. The presence of glucose in the CSF.
B. A pressure of 70 to 200 mm H2O
C. The presence of red blood cells (RBCs) in the first specimen tube
D. A pressure of 00 to 250 mmH2O

88. The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:

A. conjunctival sac
B. pupil
C. sclera
D. vitreous humor

89. A 52 yr-old married man with two adolescent children is beginning rehabilitation following a cerebrovascular accident. As the nurse is planning the client’s care, the nurse should recognize that his condition will affect:

A. only himself
B. only his wife and children
C. him and his entire family
D. no one, if he has complete recovery

90. Which action should take the highest priority when caring for a client with hemiparesis caused by a cerebrovascular accident (CVA)?

A. Perform passive range-of-motion (ROM) exercises.
B. Place the client on the affected side.
C. Use hand rolls or pillows for support.
D. Apply antiembolism stockings

91. The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic attack (TIA). Which fact should the nurse include in the teaching plan?

A. TIA symptoms may last 24 to 48 hours.
B. Most clients have residual effects after having a TIA.
C. TIA may be a warning that the client may have cerebrovascular accident (CVA)
D. The most common symptom of TIA is the inability to speak.

92. The nurse has just completed teaching about postoperative activity to a client who is going to have a cataract surgery. The nurse knows the teaching has been effective if the client:

A. coughs and deep breathes postoperatively
B. ties his own shoes
C. asks his wife to pick up his shirt from the floor after he drops it.
D. States that he doesn’t need to wear an eyepatch or guard to bed

93. The least serious form of brain trauma, characterized by a brief loss of consciousness and period of confusion, is called:

A. contusion
B. concussion
C. coup
D. contrecoup

94. When the nurse performs a neurologic assessment on Anne Jones, her pupils are dilated and don’t respond to light.

A. glaucoma
B. damage to the third cranial nerve
C. damage to the lumbar spine
D. Bell’s palsy

95. A 70 yr-old client with a diagnosis of leftsided cerebrovascular accident is admitted to the facility. To prevent the development of diffuse osteoporosis, which of the following objectives is most appropriate?

A. Maintaining protein levels.
B. Maintaining vitamin levels.
C. Promoting weight-bearing exercises
D. Promoting range-of-motion (ROM) exercises

96. A client is admitted with a diagnosis of meningitis caused by Neisseria meningitides. The nurse should institute which type of isolation precautions?

A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions

97. A young man was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, “He was unconscious briefly and then became alert and behaved as though nothing had happened.” Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client’s intracranial pressure (ICP) is increasing, the nurse would expect to observe which of the
following signs first?

A. pupillary asymmetry
B. irregular breathing pattern
C. involuntary posturing
D. declining level of consciousness

98. Emergency medical technicians transport a 28 yr-old iron worker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.” Which intervention by the nurse has the
highest priority?

A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in Trendelenburg’s position
D. Assessing the level of consciousness

99. Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial infarction. Which nursing intervention should appear on this client’s plan of care?

A. Perform activities of daily living for the client to decease frustration.
B. Provide a stimulating environment.
C. Establish and maintain a routine.
D. Try to reason with the client as much as possible.

100. For a client with a head injury whose neck has been stabilized, the preferred bed position is:

A. Trendelenburg’s
B. 30-degree head elevation
C. flat
D. side-lying

Medical-Surgical Nursing Comprehensive Exam 2 (100 Items) Original source at: Nurseslabs

Guidelines

• This is a 100-item examination about Medical-Surgical Nursing.
• Rationales and answers are given below.
• You are given 1 minute and 20 seconds each question. A total of 2 hours for this 100-item exam.

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

1. As a registered nurse, Dervid 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
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.

2. Dervid suspects a hip fracture when he noticed that the old woman’s leg is

A. Lengthened, Abducted and Internally Rotated.
B. Shortened, Abducted and Externally Rotated.
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally Rotated.

3. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to

A. Infection
C. Thrombophlebitis
B. Inflammation
D. Degenerative disease

4. The old woman told John that she has osteoporosis; Dervid knew that all of the following factors would contribute to osteoporosis except

A. Hypothyroidism
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin.

5. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms?

A. Tachycardia and Hypotension
B. Fever and Bradycardia
C. Bradycardia and Hypertension
D. Fever and Hypertension

SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.

6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold the cane

A. On his left hand, because his right side is weak.
B. On his left hand, because of reciprocal motion.
C. On his right hand, to support the right leg.
D. On his right hand, because only his right leg is weak.

7. You also told Mr. Rojas to hold the cane

A. 1 Inches in front of the foot.
B. 3 Inches at the lateral side of the foot.
c. 6 Inches at the lateral side of the foot.
D. 12 Inches at the lateral side of the foot.

8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him

A. Moves the cane when the right leg is moved.
B. Leans on the cane when the right leg swings through.
C. keeps the cane 6 Inches out to the side of the right foot.
D. Holds the cane on the right side.

SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood

9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as

A. PPD
B. PDP
C. PDD
D. DPP

10. The nurse would inject the solution in what route?

A. IM
B. IV
C. ID
D. SC

11. The nurse notes that a positive result for Alfred is

A. 5 mm wheal
B. 5 mm Induration
C. 10 mm Wheal
D. 10 mm Induration

12. The nurse told Alfred to come back after

A. a week
B. 48 hours
C. 1 day
D. 4 days

13. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action?

A. Call the Physician
B. Notify the radiology dept. for CXR evaluation
C. Isolate the patient
D. Order for a sputum exam

14. Why is Mantoux test not routinely done in the Philippines?

A. It requires a highly skilled nurse to perform a Mantoux test
B. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions
C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions
D. Almost all Filipinos will test positive for Mantoux Test

15. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH?

A. I
B. II
C. III
D. IV

16. How long is the duration of the maintenance phase of his treatment?

A. 2 months
B. 3 months
C. 4 months
D. 5 months

17. Which of the following drugs is UNLIKELY given to Mang Alfred during the maintenance phase?

A. Rifampicin
B. Isoniazid
C. Ethambutol
D. Pyridoxine

18. According to the DOH, the most hazardous period for development of clinical disease is during the first

A. 6-12 months after
B. 3-6 months after
C. 1-2 months after
D. 2-4 weeks after

19. This is the name of the program of the DOH to control TB in the country

A. DOTS
B. National Tuberculosis Control Program
C. Short Coursed Chemotherapy
D. Expanded Program for Immunization

20. Susceptibility for the disease [ TB ] is increased markedly in those with the following condition except

A. 23 Year old athlete with diabetes insipidus
B. 23 Year old athlete taking long term Decadron therapy and anabolic steroids
C. 23 Year old athlete taking illegal drugs and abusing substances
D. Undernourished and Underweight individual who undergone gastrectomy

21. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention?

A. Primary
B. Secondary
C. Tertiary
D. Quarterly

SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.

22. Michiel 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

23. The nurse plans to teach Michiel 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

24. The nurse should insert the colostomy tube for irrigation at approximately

A. 1-2 inches
B. 3-4 inches
C. 6-8 inches
D. 12-18 inches

25. The maximum height of irrigation solution for colostomy is

A. 5 inches
B. 12 inches
C. 18 inches
D. 24 inches

26. 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. Agrees to look at the colostomy
D. States that colostomy care is the function of the nurse while he is in the hospital

27. While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would

A. Stop the irrigation by clamping the tube
B. Slow down the irrigation
C. Tell the client that cramping will subside and is normal
D. Notify the physician

28. The next day, the nurse will assess Michiel’s 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

29. Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be

A. Eat eggs
B. Eat cucumbers
C. Eat beet greens and parsley
D. Eat broccoli and spinach

30. The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?

A. Use 500 ml to 1,000 ml NSS
B. Suspend the irrigant 45 cm above the stoma
C. Insert the cone 4 cm in the stoma
D. If cramping occurs, slow the irrigation

31. The nurse knew that the normal color of Michiel’s stoma should be

A. Brick Red
B. Gray
C. Blue
D. Pale Pink

SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.

32. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?

A. Hyperventilating James with 100% oxygen before and after suctioning
B. Instilling 3 to 5 ml normal saline to loosen up secretion
C. Applying suction during catheter withdrawal
D. Suction the client every hour

33. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?

A. Fr. 5
B. Fr. 10
C. Fr. 12
D. Fr. 18

34. Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?

A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 20-25 mmHg

35. If a Wall unit is used, What should be the suctioning pressure required by James?

A. 50-95 mmHg
B. 95-110 mmHg
C. 100-120 mmHg
D. 155-175 mmHg

36. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation?

A. New set of tracheostomy tubes and Oxygen tank
B. Theophylline and Epinephrine
C. Obturator and Kelly clamp
D. Sterile saline dressing

37. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?

A. Wilma places 2 fingers between the tie and neck
B. The tracheotomy can be pulled slightly away from the neck
C. James’ neck veins are not engorged
D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.

38. Wilma knew that James have an adequate respiratory condition if she notices that

A. James’ respiratory rate is 18
B. James’ Oxygen saturation is 91%
C. There are frank blood suction from the tube
D. There are moderate amount of tracheobronchial secretions

39. Wilma knew that the maximum time when suctioning James is

A. 10 seconds
B. 20 seconds
C. 30 seconds
D. 45 seconds

SITUATION : Juan Miguel Lopez Zobel Ayala de Batumbakal was diagnosed with Acute Close Angle Glaucoma. He is being seen by Nurse Jet.

40. What specific manifestation would nurse Jet see in Acute close angle glaucoma that she would not see in an open angle glaucoma?

A. Loss of peripheral vision
B. Irreversible vision loss
C. There is an increase in IOP
D. Pain

41. Nurse jet knew that Acute close angle glaucoma is caused by

A. Sudden blockage of the anterior angle by the base of the iris
B. Obstruction in trabecular meshwork
C. Gradual increase of IOP
D. An abrupt rise in IOP from 8 to 15 mmHg

42. Nurse jet performed a TONOMETRY test to Mr. Batumbakal. What does this test measures

A. It measures the peripheral vision remaining on the client
B. Measures the Intra Ocular Pressure
C. Measures the Client’s Visual Acuity
D. Determines the Tone of the eye in response to the sudden increase in IOP.

43. The Nurse notices that Mr. Batumbakal cannot anymore determine RED from BLUE. The nurse knew that which part of the eye is affected by this change?

A. IRIS
B. PUPIL
c. RODS [RETINA]
D. CONES [RETINA]

44. Nurse Jet knows that Aqueous Humor is produce where?

A. In the sub arachnoid space of the meninges
B. In the Lateral ventricles
C. In the Choroids
D. In the Ciliary Body

45. Nurse Jet knows that the normal IOP is

A. 8-21 mmHg
B. 2-7 mmHg
c. 31-35 mmHg
D. 15-30 mmHg

46. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would Nurse Jet implement to measure CN II’s Acuity?

A. Slit lamp
B. Snellen’s Chart
C. Wood’s light
D. Gonioscopy

47. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to

A. Contract the Ciliary muscle
B. Relax the Ciliary muscle
C. Dilate the pupils
D. Decrease production of Aqueous Humor

48. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is

A. Reduce production of CSF
B. Reduce production of Aquesous Humor
C. Constrict the pupil
D. Relaxes the Ciliary muscle

49. When caring for Mr. Batumbakal, Jet teaches the client to avoid

A. Watching large screen TVs
B. Bending at the waist
C. Reading books
D. Going out in the sun

50. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure?

A. Reading newsprint
B. Lying down
C. Watching TV
D. Listening to the music

51. If Mr. Batumbakal is receiving pilocarpine, what drug should always be available in any case systemic toxicity occurs?

A. Atropine Sulfate
B. Pindolol [Visken]
C. Naloxone Hydrochloride [Narcan]
D. Mesoridazine Besylate [Serentil]

SITUATION : Wide knowledge about the human ear, it’s parts and it’s functions will help a nurse assess and analyze changes in the adult client’s health.

52. Nurse Budek is doing a caloric testing to his patient, Aida, a 55 year old university professor who recently went into coma after being mauled by her disgruntled 3rd year nursing students whom she gave a failing mark. After instilling a warm water in the ear, Budek noticed a rotary nystagmus towards the irrigated ear. What does this means?

A. Indicates a CN VIII Dysfunction
B. Abnormal
C. Normal
D. Inconclusive
53. Ear drops are prescribed to an infant, The most appropriate method to administer the ear drops is

A. Pull the pinna up and back and direct the solution towards the eardrum
B. Pull the pinna down and back and direct the solution onto the wall of the canal
C. Pull the pinna down and back and direct the solution towards the eardrum
D. Pull the pinna up and back and direct the solution onto the wall of the canal

54. Nurse Budek is developing a plan of care for a patient with Menieres disease. What is the priority nursing intervention in the plan of care for this particular patient?

A. Air, Breathing, Circulation
B. Love and Belongingness
C. Food, Diet and Nutrition
D. Safety

55. After mastoidectomy, Nurse Budek should be aware that the cranial nerve that is usually damage after this procedure is

A. CN I
B. CN II
C. CN VII
D. CN VI

56. The physician orders the following for the client with Menieres disease. Which of the following should the nurse question?

A. Dipenhydramine [Benadryl]
B. Atropine sulfate
C. Out of bed activities and ambulation
D. Diazepam [Valium]

57. Nurse Budek is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful?

A. I will try to eat foods that are low in sodium and limit my fluid intake
B. I must drink atleast 3,000 ml of fluids per day
C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet
D. I will not eat turnips, red meat and raddish

58. Peachy was rushed by his father, Steven into the hospital admission. Peachy is complaining of something buzzing into her ears. Nurse Budek assessed peachy and found out It was an insect. What should be the first thing that Nurse Budek should try to remove the insect out from peachy’s ear?

A. Use a flashlight to coax the insect out of peachy’s ear
B. Instill an antibiotic ear drops
C. Irrigate the ear
D. Pick out the insect using a sterile clean forceps

59. Following an ear surgery, which statement if heard by Nurse Budek from the patient indicates a correct understanding of the post operative instructions?

A. Activities are resumed within 5 days
B. I will make sure that I will clean my hair and face to prevent infection
C. I will use straw for drinking
D. I should avoid air travel for a while

60. Nurse Budek will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates?

A. Indicating a Cranial Nerve VIII Dysfunction
B. The test should be repeated again because the result is vague
C. This is Grossly abnormal and should be reported to the neurosurgeon
D. This indicates an intact and working vestibular branch of CN VIII

61. A client with Cataract is about to undergo surgery. Nurse Budek is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient?

A. Anxiety R/T to the operation and its outcome
B. Sensory perceptual alteration R/T Lens extraction and replacement
C. Knowledge deficit R/T the pre operative and post operative self care
D. Body Image disturbance R/T the eye packing after surgery

62. Nurse Budek is performing a WEBERS TEST. He placed the tuning fork in the patients forehead after tapping it onto his knee. The client states that the fork is louder in the LEFT EAR. Which of the following is a correct conclusion for nurse Budek to make?

A. He might have a sensory hearing loss in the left ear
B. Conductive hearing loss is possible in the right ear
C. He might have a sensory hearing loss in the right hear, and/or a conductive hearing loss in the left ear.
D. He might have a conductive hearing loss in the right ear, and/or a sensory hearing loss in the left ear.

63. Aling myrna has Menieres disease. What typical dietary prescription would nurse Budek expect the doctor to prescribe?

A. A low sodium , high fluid intake
B. A high calorie, high protein dietary intake
C. low fat, low sodium and high calorie intake
D. low sodium and restricted fluid intake

SITUATION : [ From DEC 1991 NLE ] A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch.

Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.

64. Which of the following is the appropriate nursing diagnosis?

A. Fluid volume deficit R/T furrow tongue
B. Fluid volume deficit R/T uncontrolled vomiting
C. Dehydration R/T subnormal body temperature
D. Dehydration R/T incessant vomiting

65. Approximately how much fluid is lost in acute weight loss of .5kg?

A. 50 ml
B. 750 ml
C. 500 ml
D. 75 ml

66. Postural Hypotension is

A. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting.
B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting
C. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting
D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting

67. Which of the following measures will not help correct the patient’s condition

A. Offer large amount of oral fluid intake to replace fluid lost
B. Give enteral or parenteral fluid
C. Frequent oral care
D. Give small volumes of fluid at frequent interval

68. After nursing intervention, you will expect the patient to have

1. Maintain body temperature at 36.5 C
2. Exhibit return of BP and Pulse to normal
3. Manifest normal skin turgor of skin and tongue
4. Drinks fluids as prescribed

A. 1,3
B. 2,4
C. 1,3,4
D. 2,3,4

SITUATION: [ From JUN 2005 NLE ] A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.

69. Which of the following is a characteristic of a patient with advanced Parkinson’s disease?

A. Disturbed vision
B. Forgetfulness
C. Mask like facial expression
D. Muscle atrophy

70. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by

A. Injurious chemical substances
B. Hereditary factors
C. Death of brain cells due to old age
D. Impairment of dopamine producing cells in the brain

71. The patient was prescribed with levodopa. What is the action of this drug?

A. Increase dopamine availability
B. Activates dopaminergic receptors in the basal ganglia
C. Decrease acetylcholine availability
D. Release dopamine and other catecholamine from neurological storage sites

72. You are discussing with the dietician what food to avoid with patients taking levodopa?

A. Vitamin C rich food
B. Vitamin E rich food
C. Thiamine rich food
D. Vitamin B6 rich food

73. One day, the patient complained of difficulty in walking. Your response would be

A. You will need a cane for support
B. Walk erect with eyes on horizon
C. I’ll get you a wheelchair
D. Don’t force yourself to walk

SITUATION: [ From JUN 2005 NLE ] Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.

74. The nurse will assess a loss of ability in which of the following areas?

A. Balance
B. Judgment
C. Speech
D. Endurance

75. Mr. Dela Isla said he cannot comprehend what the nurse was saying. He suffers from:

A. Insomnia
B. Aphraxia
C. Agnosia
D. Aphasia

76. The nurse is aware that in communicating with an elderly client, the nurse will

A. Lean and shout at the ear of the client
B. Open mouth wide while talking to the client
C. Use a low-pitched voice
D. Use a medium-pitched voice

77. As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?

A. I know the hallucinations are parts of the disease
B. I told her she is wrong and I explained to her what is right
C. I help her do some tasks he cannot do for himself
D. Ill turn off the TV when we go to another room

78. Which of the following is most important discharge teaching for Mr. Dela Isla

A. Emergency Numbers
B. Drug Compliance
C. Relaxation technique
D. Dietary prescription

SITUATION : Knowledge of the drug PROPANTHELINE BROMIDE [Probanthine] Is necessary in treatment of various disorders.

79. What is the action of this drug?

A. Increases glandular secretion for clients affected with cystic fibrosis
B. Dissolve blockage of the urinary tract due to obstruction of cystine stones
C. Reduces secretion of the glandular organ of the body
D. Stimulate peristalsis for treatment of constipation and obstruction

80. What should the nurse caution the client when using this medication

A. Avoid hazardous activities like driving, operating machineries etc.
B. Take the drug on empty stomach
C. Take with a full glass of water in treatment of Ulcerative colitis
D. I must take double dose if I missed the previous dose

81. Which of the following drugs are not compatible when taking Probanthine?

A. Caffeine
B. NSAID
C. Acetaminophen
D. Alcohol

82. What should the nurse tell clients when taking Probanthine?

A. Avoid hot weathers to prevent heat strokes
B. Never swim on a chlorinated pool
C. Make sure you limit your fluid intake to 1L a day
D. Avoid cold weathers to prevent hypothermia

83. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder?

A. Urinary retention
B. Peptic Ulcer Disease
C. Ulcerative Colitis
D. Glaucoma

SITUATION : [ From DEC 2000 NLE ] Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.

84. Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?

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

85. Considering Mr. Franco’s conditions, 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

86. What is the rationale for giving Mr. Franco frequent mouth care?

A. He will be thirsty considering that he is doesn’t drink enough fluids
B. To remove dried blood when tongue is bitten during a seizure
C. The tactile stimulation during mouth care will hasten return to consciousness
D. Mouth breathing is used by comatose patient and it’ll cause oral mucosa dying and cracking.

87. One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?

A. Massage reddened areas with lotion or oils
B. Turn frequently every 2 hours
C. Use special water mattress
D. Keep skin clean and dry

88. If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?

A. Expressive aphasia is prominent on clients with right sided weakness
B. The affected lobe in the patient is the Right lobe
C. The client will have problems in judging distance and proprioception
D. Clients orientation to time and space will be much affected

SITUATION : [ From JUN 1988 NLE ] a 20 year old college student was rushed to the ER of PGH after he fainted during their ROTC drill. Complained of severe right iliac pain. Upon palpation of his abdomen, Ernie jerks even on slight pressure. Blood test was ordered. Diagnosis is acute appendicitis.

89. Which result of the lab test will be significant to the diagnosis?

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

90. 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

91. Pre-anesthetic med of Demerol and atrophine sulfate were ordered to :

A. Allay anxiety and apprehension
B. Reduce pain
C. Prevent vomiting
D. Relax abdominal muscle

92. Common anesthesia for appendectomy is

A. Spinal
B. General
C. Caudal
D. Hypnosis

93. Post op care for appendectomy include the following except

A. Early ambulation
B. Diet as tolerated after fully conscious
C. Nasogastric tube connect to suction
D. Deep breathing and leg exercise

94. Peritonitis 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

95. If after surgery the patient’s abdomen becomes distended and no bowel sounds appreciated, what would be the most suspected complication?

A. Intussusception
B. Paralytic Ileus
C. Hemorrhage
D. Ruptured colon

96. NGT was connected to suction. In caring for the patient with NGT, the nurse must

A. Irrigate the tube with saline as ordered
B. Use sterile technique in irrigating the tube
C. advance the tube every hour to avoid kinks
D. Offer some ice chips to wet lips

97. When do you think the NGT tube be removed?

A. When patient requests for it
B. Abdomen is soft and patient asks for water
C. Abdomen is soft and flatus has been expelled
D. B and C only

Situation: Amanda is suffering from chronic arteriosclerosis Brain syndrome she fell while getting out of the bed one morning and was brought to the hospital, and she was diagnosed to have cerebrovascular thrombosis thus transferred to a nursing home.

98. What do you call a STROKE that manifests a bizarre behavior?

A. Inorganic Stroke
B. Inorganic Psychoses
C. Organic Stroke
D. Organic Psychoses

99. The main difference between chronic and organic brain syndrome is that the former

A. Occurs suddenly and reversible
B. Is progressive and reversible
C. tends to be progressive and irreversible
D. Occurs suddenly and irreversible

100. Which behavior results from organic psychoses?

A. Memory deficit
B. Disorientation
C. Impaired Judgement
D. Inappropriate affect

Medical-Surgical Nursing Comprehensive Exam 1 (100 Item) Original source at: Nurseslabs

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance.

Situation : Mrs. Andres brought his son, Juanito, age 3 to the Pediatric clinic. She noticed that her son is not speaking and tend to repeat everything she says. The mother also told the nurse that Juanito prefers to be alone, will cry when someone will come near him and tend to rock himself from morning till he will fell asleep.

1. An essential clinical feature of autistic disorder is:

A. Inability to concentrate in any task
B. Easily Distracted
C. Stereotyped motor behaviors
D. Poor motor skills

2. Headbanging is a common manifestation of an autistic child. A relevant nursing diagnosis would be:

A. Activity intolerance C. Risk for Injury
B. Impaired physical mobility D. Impaired skin integrity

3. According to freud, Juanity is at what psychosexual stage?

A. Anal B. Oral C. Phallic D. Latency

4. Typically, if there is a change in the environment, the child will manifest which of the following?

A. Clinging behavior C. Suicide
B. Temper tantrums D. Talks incoherently

5. The best treatment approach for autistic children is encouraging their desired behavior through positive reinforcement. This is:

A. Milieu Therapy B. Psychoanalysis C. Play Therapy D. Behavior Therapy

6. There is no definite cause identified for autism, but a strong link has been found on:

A. Environmental factors C. Upbringing
B. Genetic factors D. MMR vaccination

7. Which of the following is true about Autism?

A. Autism is common among boys than girls
B. Autism is common among girls than boys
C. MMR vaccination has been strongly linked in the development of Autism
D. Autistic children usually develops normal social skills

8. The mother of Juanito asked the nurse, When is autism diagnose? The nurse will respond:

A. Autism is diagnosed after 3 years old
B. Autism is diagnosed after 6 years old
C. At 4 years old, Autism is diagnosed
D. Autism is diagnosed before 3 years old

9. If a child with autism develops destructive behavior, The drug of choice that the nurse will expect that the physician will give to control self injury is:

A. Chlorpromazine [Thorazine] C. Time-out
B. Methylphenidate [Ritalin] D. Valium, Librium or other Anxiolytic

10. Chlorpromazine was given to the child. Which is true with regards to this medication?

A. Expect that the child will be unusually alert and hyperactive during the therapeutic period
B. The mother should decrease the fluid intake of the child as this drug causes fluid retention
C. That the drug is given in order to decrease the child’s hyperactivity
D. The mother should avoid overexposing the child to sunlight for the child might develop rashes due to photosensitivity

Situation : Mastery of Psychotropic medications is necessary for the therapeutic improvement in the health of the psychiatric clients.

11. Lithium is only given:

A. P.O B. IM C. IV D. SQ

12. The nurse should expect that a client who cheeks the medication is a non-complaint patient. Knowing the non compliance is the single most important factor for exacerbation and rehospitalisation, the doctor ordered Prolixin [Fluphenazine Decanoate]. The nurse knows that is it given:

A. Orally B. Sublingually C. IV D. IM

13. Which of the following is an antidepressant?

A. Serenace (Haloperidol)
B. Valium (Diazepam)
C. Tofranil (Imipramine HCl)
D. Trilaton (Pherpenazine)

14. The nurse knows that the relationship between sodium and lithium is that:

A. When lithium increases, sodium also increases
B. When sodium increases, lithium also increases
C. They are inversely proportional
D. They are directly proportional

15. Which of the following class of antidepressant is the least sedating?

A. SSRI B. MAOI C. TCA D. Neuroleptics

Situation : Mang Cardo, Age 72, is a widower with moderate Alzheimer’s disease. Was brought to the home for the Aged by his married daughter. On admission, she says to the nurse, “I never thought this would happen to us. I really feel guilty about bringing him here, I can’t bear to part with him.”

16. The nurse’s therapeutic response to Mang Carlos’ daughter is:

A. “You have indeed made a sound decision, Your father needs professional care which you cannot provide at home.”
B. “Why are you feeling guilty bringing him here?”
C. “I know that his has been a difficult time for you. You seemed troubled about bringing him here.”
D. “You have done well everything for your father, Do not be upset. We will take care of him.”

17. Initially, the nursing diagnosis would be:

A. Impaired communication C. Altered thought process
B. Impaired social interaction D. Altered family process

18. To guide the nurse in planning activities for Mang Carlos, The nurse should prioritize soliciting which information?

A. Support system from the significant others
B. Coping mechanism
C. Routine activities at home
D. The extent of memory impairment

19. Cardo appears to be awake and restless throughout the night, Which of the following is the medication you are expecting to be given?

A. Diazepam [Valium] C. Imipramine [Tofranil]
B. Chlorpromazine [Thorazine] D. Lithium [Lithane]

20. One morning, Mang Cardo has difficulty putting his pyjamas. In Alzheimer’s disease, this is known as:

A. Aphasia B. Agnosia C. Apraxia D. Anomia

21. Which of the following is the cause of Dementia of the Alzheimer’s type?

A. Unknown C. Increasing Age
B. Decreased Acetylcholine D. Senile plaques deposition

22. The initial sign of Dementia is:

A. Aphasia C. Confusion
B. Forgetfullness D. Restlessness

23. Mang Cardo has been talking about how he got his scratch on his left arm, he told you that it was caused by a shard of glass that touches his skin accidentally. The next day, he told you that the scratch was caused by a knife he did not see that it fell from the table towards his arms. The next day, he said it was bitten by an ant and he scratched it because it was itchy. This is a symptom seen in Dementia known as:

A. Confusion B. Altercation C. Aphasia D. Confabulation

24. Tacrine was given to the client and the nurse knows that which of the following enzyme is periodically checked?

A. ALT B. Creatinine C. AST D. BUN

25. A client with Alzheimer’s disease mumbles incoherently and rambles in a confused manner. To help redirect the client’s attention, the nurse should encourage the client to:

A. fold towels and pillowcases. C. play cards with another client.
B. participate in a game of charades. D. perform an aerobic exercise.

Situation : A nurse is working with an aggressive client in the psychiatric unit.

26. All of the following concepts are true EXCEPT:
A. Hostility is destructive
B. Frustration develops in response to unmet needs, wants and desire
C. Anger is always incompatible with love
D. Aggression can be expressed in a constructive as well as a destructive manner.

27. Carlo is acting out hostile and aggressive feeling by kicking the chairs in the room. the MOST effective way to deal with Carlo’s behavior is initially to:

A. Set limits on the behavior by verbal command
B. Administer PRN tranquilizer
C. Remove the chairs from the room
D. Restrain the patient and place him in the “Isolation Room”

28. Mrs. Dizon was visiting her son at the Psychiatry Ward. Which of the following items will the nurse not allow to be brought inside the ward?

A. String rosary bracelet C. Bottle of coke
B. Box of cake D. Rubber shoes

29. Which of the following will probably be most therapeutic for a patient on a behavioral modification ward?

A. If the client is agitated, discuss the feelings especially anger
B. Insist to stop obscene language by verbal reprimand
C. Give client support and positive feedback for controlling use of obscene language
D. Provide a punching bag as an alternative to express upset emotions

30. Which of the following must be considered while planning activities for the depressed patient?

A. Activities which require exertion of energy
B. Challenging activities to get him out of his depression
C. Structured activities that the client can participate
D. Variety of unstructured activities

31. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual, the nurse should:

A. keep an eye contact while staring at the client
B. keep his/her hands behind his/her back or in one’s pockets
C. fold his/her arms across his/her chest
D. keep an “open” posture, e.g. Hands by sides but palms turned outwards

32. A patient in the ward suddenly slapped you in the face and spitted on your face and is obviously agitated and violent. Which of the following is the best nursing action?

A. Tell the client: “Because of that, you are not going to eat your lunch, dinner and breakfast anymore.”
B. Slap the client back and say “I am your nurse, you are a patient and you have no right to hurt me.”
C. Prepare a 5 member team to restraint the client
D. Respond by saying “You are losing control of yourself, you slapped me and you spitted on me and you are way out of control”

33. Which of the following is an accurate way of reporting and recording an incident?

A. “When asked about his relationship with his father, client became anxious.”
B. “When asked about his relationship with his father, client clenched his jaw/teeth, made a fist and turned away from the nurse.”
C. “When asked about his relationship with his father, client was resistant to respond”
D. “When asked about his relationship with his father, his anger was suppressed”

34. To encourage thought, which of the following approaches is NOT therapeutic?

A. “Why do you feel angry?”
B. “When do you usually feel angry?”
C. “How do you usually express anger?”
D. What situations provoke you to be angry?”

35. A patient grabs and about to throw it. The nurse best responds saying.

A. “Stop! Put that chair down.”
B. “Don’t be silly.”
C. “Stop! The security will be here in a minute.”
D. “Calm down.”

Situation: In your professional nursing role, it is essential to establish a meaningful nurse-patient relationship.

36. A helping nurse patient relationship is characterized by which of the following?

A. Recovery promoting C. Mutual interaction
B. Growth facilitating D. Health enhancing

37. Demonstrating a helping relationship enables you to establish in the patient:

A. Compliance to treatment
B. Positive response to illness
C. Gratitude to your services
D. Some sense of trust in you

38. Therapeutic communication begins with:

A. Knowing the patient C. Interacting with the patient
B. Trust D. Knowing yourself

39. Which of the following approaches will most likely make your patient accept your help?

A. Attending to all his needs C. Demonstrating a relaxed and attending attitude
B. Calling him by first name D. Asking personal questions for health information

40. The client said “I am troubled that my Son is starting to use drugs.” The nurse replied, “It’s troubling and painful for you, I feel sorry about this.” The nurse’s reply is an example of:

A. Empathy B. Sympathy C. Telepathy D. Self awareness

41. Preparation for termination of the nurse-patient relationship begins during the:

A. Termination phase C. Pre-orientation phase
B. Working phase D. Orientation phase

42. The client’s past reactions to ending relationships is withdrawal. The nurse assists her to practice better ways of coping termination by providing opportunities to:

A. Test new patterns of behavior C. Conceptualize her problem
B. Plan for alternatives D. Value and find meaning in experience

9. A male nurse reminds the client that is already time for group activities, The client responded by yelling to the nurse “You are always telling me what to do! Just like my father!” This is an example of:
A. Symbolization C.Reaction Formation
B. Transference D. Counter Transference

44. The longest and the most productive phase of the NPR is:

A. Termination phase C. Pre-orientation phase
B. Working phase D. Orientation phase

45. The objection of the nurse-patient relationship is to provide an opportunity of the patient to:

A. Clarify problems C. Have a corrective emotional experience
B. Develop insights D. Develop interpersonal relationship

Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning.

46. Mental retardation is:

A. a delay in normal growth and development caused by an inadequate environment
B. a lack of development of sensory abilities
C. a condition of subaverage intellectual functioning that originates during the developmental period and is associated with impairment in adaptive behavior
D. a severe lag in neuromuscular development and motor abilities

47. An important principle for the nurse to follow in interacting with retarded children is:

A. seen that if the child appears contented, his needs are being met
B. provide an environment appropriate to their development task as scheduled
C. treat the child according to his chronological age
D. treat the child according to his developmental level

48. The child was classified as having an IQ of 55. This is said to be:

A. Mild Mental Retardation C. Severe Mental Retardation
B. Moderate Mental Retardation D. Profound Mental Retardation

49. Which of the following is true with regards to Mild Mental Retardation?

A. Trainable, Can reach up to 2nd grade and can reach the maturity of a 7 year old
B. Custodial and barely trainable
C. Requires total care throughout life, Mental age of a young infant
D. Educable, can reach up to grade 6 and has a maturity of a 12 year old

50. A child with an IQ of 35-49 is:

A. Barely trainable C. Educable
B. Trainable D. Requires total care

51. Which of the following is true with regards to mental retardation?

A. Mental retardation is always accompanied by physical features
B. Hereditary and perinatal factors do not result to mental retardation
C. Mental retardation is a mental illness
D. Hereditary and perinatal factors are known to result to impaired intellectual functioning

52. The onset of mental retardation is before the child reaches what particular age?

A. 17 B. 16 C. 15 D. 18

53. The possible nursing diagnosis for a mentally retarded child who is hyperactive is:

A. Impaired physical mobility
B. Potential for injury
C. Impaired social adjustment
D. Ineffective coping

54. A tranquilizing agent given in calming a hyperactive mentally retarded is:

A. Chlorpromazine [Thorazine] C. Imipramine [Tofranil]
B. Haloperidol [Haldol] D. Diazepam [Valium]

55. This form of psychotherapy allows the child to experience and express intense or troubling emotion in a safe environment with a caring individual:

A. Play therapy C. Behavior therapy
B. Milieu therapy D. Gestalt therapy

Situation : Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood.

56. Which of the following is true about manic reaction?

A. It is an expression of destructive impulse
B. A means of coping with frustrations and disappointments
C. A means of ignoring reality
D. An attempt to ward of feelings of underlying depression

57. Nursing care plan for a client with Mania like Margie should give priority to:

A. Discourage him from manipulating the staff
B. Prevent him from assaulting other patient
C. Protect him against suicidal attempts
D. Provide adequate food and fluid intake

58. During a nurse patient interaction, Margie jumps rapidly from one topic to another, This is known as:

A. Flight of Ideas C. Ideas of reference
B. Clang association D. Neologism

59. Which of the following is a suitable activity that a nurse should assign for a Manic client?

A. delivering supply of linen to other rooms
B. conducting a drama workshop
C. engaging in activity therapy and group exercises
D. painting a mural with other patients

60. The doctor ordered lithium. You know that this is indicated in patients with:

A. Depression C. Schizophrenia
B. Mania D. Anxiety disorders

61. Lithium has a narrow therapeutic range of:

A. 0.1 to 1.0 mEq/L C. 10 to 50 mEq/L
B. 0.6 to 1.2 mEq/L D. 50 to 100 mEq/L

62. Which of the following is a side effect of lithium toxicity?

A. Anuria C. Sudden burst of muscle strength
B. Oliguria D. Polyuria

63. What specimen is taken from a client when checking the lithium level of the body?

A. Blood B. Stool C. Urine D. Sweat

64. Which of the following is NOT a drug use to augment lithium toxicity?

A. Urea B. Mannitol C. Aminophylline D. Acetylcysteine

65. The nurse has a standing order of Lithium for Margie. If the lithium level is 1.5 mEq/L, the nurse knows that she should:

A. Administer the next dose and continue monitoring the client
B. Report this to the physician
C. Recheck the lithium level and validate first before doing any action
D. Withhold the next dose and notify the physician

Situation : Nursing informatics is a way of using information technology, computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977.

66. The ANA recognized nursing informatics heralding its establishment as a new field in nursing during what year?

A. 1992 B. 1994 C. 2001 D. 2004

67. When is the first certification of nursing informatics given?

A. 1992-1993 B. 1994-1995 C. 2001-2002 D. 2004-2005

68. Which of the following is the 3 integrated components of the nursing informatics?

1. Nursing science 3. Health science
2. Computer science 4. Information science

A. 1,2,3 B. 1,3,4 C. 1,2,4 D. 3,4,5

69. A textbook publisher wants to store large amount of data in a computer format that cannot be changed by other people. Which of the following would best serve this purpose?

A. CD ROM B. Floppy disk C. RAM D. Network

70. The challenge most associated with the utilization of an electronic record system is which of the following?

A. Cost B. Accuracy C. Privacy D. Curability

71. A client insists that the practitioner use a treatment method discovered on an internet data base. Which of the following response is most appropriate?

A. “The treatment must be examine to see if it is appropriate”
B. “Most website treatments have not been studied or researched”
C. “The person establishing the website is the only one who can use it on clients”
D. “Websites are like advertising, they are biased and may not be legitimate.”

72. This is a type of a computerized recording system that enables hospitals to organize various data such as admission, records, clinical laboratory, pharmacy, inventory and finance.

A. Management information system
B. Hospital information system
C. University information system
D. Government information system

73. A nurse, who is proficient in computers and information technology that uses these advantages to promote effective and secured use of computerized record is referred to as:

A. Information technician C. Nursing information technician
B. Nursing IT D. Nurse Informaticist

74. One advantage of a computerized recording system is that:

A. The nursing diagnoses for a client’s data can be accurately determined
B. Cost of confinement will be reduced
C. Information concerning the client can be easily updated
D. The number of people to take care of the client will be reduced

75. You are to research the different types of oxygen delivery system. From the nasal cannula up to the venturi mask. Using nursing informatics, you found out different sources of information. One of the question that needs to be answered in your research is “What type of oxygen delivery system is the most comfortable?” you will answer:

A. Nasal cannula, according to the American journal of nursing and medicine
B. Face masks, according to a nursing blog site
C. Venturi mask, according to Wikipedia
D. Oxygen tents, according to a personal website from yahoo search engine

Situation: Celina age 25, a ramp model, suddenly became blind after her boyfriend broke off with her. A thorough work up did not reveal any pathological findings.

76. The loss or alteration of physical functioning without organize cause bit is an expression of a psychological needs is known as:

A. Somatization C. Hypochondriasis
B. Depersonalization D. Conversion

77. Initially, the relevant nursing diagnosis the nurse includes in her care plan is:

A. Self esteem disturbance
B. Impaired adjustment
C. Ineffective individual coping
D. Ineffective denial

78. The defense mechanism commonly used by these clients is:

A. Projection C. Repression
B. Rationalization D. Sublimation

79. An appropriate nursing intervention which can help Celina is:

A. Establishing a trusting relationship
B. Encourage her to verbalize her feelings
C. Reinforce reality
D. Accept her limitation as a person

80. An effective modality of treatment for Celina would be:

A. Milieu therapy
B. Systematic desensitisation
C. Cognitive-Behavioral therapy
D. Psychopharmacology

Situation : Records and Records management is one of the core of professional nursing
practice.

81. The National Archives of the Phils. (NAP) is mandated by R.A. 9470 of 2007 to plan, formulate and implement records management and archival administration program for the efficient action, utilization, maintenance, retention, preservation, conservation and disposal of public records including the adoption of security measures and vital records protection program for the government and give technical assistance to all branches of government. Hospitals should safe keep their record and coordinate with which of the following agency for its disposal?

A. National Archives of the Philippines
B. Metropolitan Manila Development Authority
C. Record Management and Archive Office
D. Department Of Health

82. If The research team finished the research about Ana’s case and they are done disseminating data and after the report has been completed and written, Pre-processed data about Ana should be:

A. Preserved C. Stored for future use
B. Destroyed by Burning or Shredding D. Keep in a private file nobody can access

83. All of the following are purposes of the chart EXCEPT:

A. To document the quality of care
B. A vehicle for communication
C. For the prerecording of nursing actions
D. For research and education

84. What is an example of a subjective data?

A. Color of wound drainage
B. Odor of breath
C. Respiration of 14 breaths/minute
D. The patient’s statement of “I feel sick to my stomach”

85. Charting should be legible and include only standard abbreviations. Which of the
following is NOT a standard abbreviation?

A. PRN C. NNO
B. OD D. NPO

Situation: A nurse should be aware that some problems in the emergency setting are not always physiologic. Sometimes, Crisis can affect the patient in an emergency setting.

86. Which of the following statements best describes acquaintance rape?

A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so
B. When two people don’t love each other and engage in sexual activities
C. When someone on a date tricks the other person into having sexual intercourse
D. Sexual intercourse committed with force or the threat of force without a person’s consent

87. Male to male rape is also another problem that a nurse can encounter. The nurse knows that in male to male rape, The perpetrator is usually:

A. An effeminate male homosexual C. A heterosexual who believes that he is superior
B. A young, newcomer heterosexual male D. A passive homosexual male

88. An 18 year old male client was rushed to the hospital due to burns, bruises and cuts on the face and body. The teenager confessed that he was raped by 4 of his classmates, all of which are also male. Male to male rape also occurs and the nurse must know that:

A. If there is an erection, the male victim also consents to the rape itself.
B. That all male to male rape cases occurs at home, which is statutory most of the time.
C. That male rape victims are usually homosexuals. Which are very much deserving to be raped.
D. Most victims of male to male rapes never dare to report the incident.

89. One of four factors describing the experience of sexually abused children and the effect it has on their growth and development is stigmatization. Stigma will occur when:

A. A child blames him or herself for the sexual abuse and begins to withdraw and Isolate
B. Newspapers and the media don’t keep sexual abuse private and accidentally or on purpose reveal the name of the victim
C. The child has been blamed by the abuser for his or her sexual behaviors, saying that the child asked to be touched or did not make the abuser to stop
D. The child’s agony is shared by other members of the family or friends when the
sexual abuse becomes public knowledge

90. Which of the following is an example of hostile environment in terms of sexual harassment?

A. the boss assures you of a big promotion if you go out on a couple of dates with him
B. your supervisor makes masturbatory gestures every time you walk pass him
C. the personnel manager hints that the job will be yours if you cooperate sexually with him
D. your boss suggests that your “raise” is dependent upon having sex with him

Situation : You are a nurse working in the medical ward.

91. Mr. E.O. age 52 had a laryngectomy due to cancer of the larynx. Discharge instructions are given to Mr.F.O. and his family. Which response by written communication from Mr. F.O. or verbal response from the family, will be a signal to the nurse that the instructions need to be reclarified?

a. it is acceptable to take over-the-counter medications now that condition is stable
b. the suctioning at home must be a clean procedure, not sterile.
c. report swelling, pain or excessive drainage
d. cleans skin around stoma BID, use hydrogen peroxide and rinse with water, pat dry.

92. Dr. Tuazon scheduled Mrs. Poe for a right breast mass incision with frozen section and possible mastectomy on Monday, first case. As the nurse in-charge for scheduling you will collaborate with the following departments EXCEPT:

a. pathology c. anesthesia
b. dietary d. surgery

93. A mother who is pregnant and has ovarian cancer has to undergo surgery to treat the cancer. In the process the fetus died. The doctrine that justifies the death of the fetus is:

a. justice c. exception to the role
b. anatomy d. double effect

94. A nurse is waiting for a report to be sent by fax. The machine activates but instead of the report, the nurse received a sexually oriented photograph. The MOST appropriate nursing action is to:

a. call the nursing supervisor and report the incident
b. cut the photograph and throw it away.
c. call the police
d. call the unit who sent it and ask for the name of person who sent the photograph

95. Ms. F.X.. has been admitted with right upper quadrant pain and has been placed on a low fat diet. Which of the following trays would be acceptable for her?

a. liver, fried potatoes and avocado
b. whole milk, rice and pastry
c. ham, mashed potatoes, cream peas
d. skim milk, lean fish, tapioca pudding

Situation : Some equipments and materials in our hospital are color coded, this is to increase the
safety and proficiency of rendering patients care.

96. If a nurse has been ordered to prepare a spinal set gauge 16, the nurse knew that the color for that spinal set is coded at:

A. Red B. Pink C. Yellow D. Blue

97. If the anaesthesiologist asked for a 22 gauge spinal set, the nurse knew that the color of the set that she will obtain is:

A. Red B. Pink C. Yellow D. Blue

98. For pediatric patients, the spinal set is coded with color:

A. Red B. Pink C. Yellow D. Blue

99. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb, 30 year old athlete she request the circulating nurse to prepare a pink spinal set with another blue set as stand by. What gauge spinal sets will make available in the OR suite?
A. Gauge 16 and 22
B. Gauge 18 and 16
C. Gauge 16 and 20
D. Gauge 5 and 22

100. Medical gases are used a lot in the OR. Some gases are used to operate equipment and some are used to administer general anesthesia through inhalation. What is the identifying color of the tank which contains ‘laughing gas’?

A. Yellow B. Green C. Black D. Blue

Preboard Exam B — Test 5: Mental Health & Psychiatric Nursing Original source at: Nurseslabs

Guidelines

• Read the situations and each questions and choices carefully!
• Choose the best answer.
• You are given 2 hours for this 100 item test. That’s 1 minute and 20 seconds for each question.
• Answers will be given below. Check your performance.

Situation 1 : Cancer of the prostate is the leading cancer in Men other than skin cancer. The following questions will assess your knowledge and theoretical foundation in dealing with clients with prostate cancer.

1. Among the following population group, who has a higher risk in the development of prostate cancer?

A. African-American C. Asian
B. Caucasian D. Hispanics

2. Which among the following is NOT a risk factor for prostate cancer?

A. A family member with prostate cancer C. High fat and diet high in red meats
B. Advancing age D. Smoking

3. Mr. Juan Jose Rodrigo has been diagnosed with prostate cancer just a few hours ago. Which of the following sign would alert the nurse that the cancer is already advanced?

A. “I have difficulty starting my urination”
B. “My backs and hips are painful and my right leg is slightly larger than the other”
C. “My urine is bloody”
D. “My urine is bouncing”

4. At the initial sign and symptoms of prostate cancer, before diagnosis, the physician can perform a screening test to detect a characteristic “STONY HARD” prostate and nodules at the prostate area using:

A. Cytoscopy C. DRE
B. PSA D. MRI

5. To diagnose the presence of prostate cancer, the physician will perform:

A. Transrectal needle biopsy of the prostate
B. Test to identify the PSA levels
C. Transrectal ultrasound
D. Radiolabeled monoclonal antibody capromab penetide with indium-111

6. After the removal of the prostate tissue, The physician soaked the solution in formaldehyde in a sterile specimen container and asked you to send the specimen immediately. Which of the following is a correct nursing action?

A. “Dr. Ruiz, I don’t think this specimen is acceptable. Please redo the procedure and do not soak the specimen in any medium.”
B. “Dr. Ruiz, I just want you to know that you soaked the specimen in formaldehyde wherein, it should not be soaked in any medium at all.”
C. Accept the specimen because there is nothing wrong with the physician’s action
D. “Dr. Ruiz, it should be soaked in NSS not formaldehyde. I am going to report you to the board of medicine for this could lead to a false result.”

7. In any biopsy, the specimen is sent to the:

A. Radiologist B. Nearest of Kin C. Pathologist D. Medical Technologist

8. PSA is used not for the detection but to know if the cancer is responding to treatment or advancing. The nurse knows that the abbreviation PSA stands for:

A. Prostate specific antibody C. Prostate specified antibody
B. Prostate specific antigen D. Prostate specified antigen

9. In testing for the PSA, the nurse will collect which specimen?

A. Blood B. Urine C. Feces D. Prostatic fluid

10. Mr. Rodrigo said that he has difficulty voiding. Which of the following is the best nursing action to encourage voiding in any clients with voiding difficulties?

A. Encourage the client to drink plenty of fluids to promote urination
B. Bring the client to the bathroom and stay with him when the sensation to void is felt by the client
C. Catheterize the client
D. Encourage the use of bathroom or commode rather than bedpans

Situation : Care of clients with tracheotosmy is often a challenge to a beginning nurse. The following questions will test your knowledge on Tracheostomy and its related care.

11. You know that when rendering tracheotosmy care, the priority consideration is always to keep the airway patent and also to prevent infection at the site. The nurse knows the technique used in rendering Tracheostomy care is:

A. Clean B. Disinfected C. Sterile D. Medical

12. Prior to the suctioning or removal of the inner cannula, the nurse knows that the client is prepared and positioned in:

A. High fowlers B. Semi fowlers position C. Left side lying D. Sims

13. In cleaning the inner cannula or other parts of the tracheotosmy tube, The best cleansing mediums are:

A. Hydrogen peroxide and Sterile NSS
B. Providone Iodine and Sterile NSS
C. Alcohol and Sterile NSS
D. Alcohol and Hydrogen Peroxide

14. In contrary with Tracheostomy tubes, sizes of chest tubes are expressed in terms of:

A. French B. Gauge C. M2 D. Diameter

15. Which of the following is NOT true with regards to securing the Tracheostomy?

A. The cuff provides sufficient securing
B. The Tracheostomy can be sutured in place
C. The Tracheostomy can be stapled in place
D. Tie or Velcro tie are used to generally secure the Tracheostomy around the client

16. The nurse knows that in Tracheostomy creation, 1% Lidocaine and 1:100,000 Epinephrine is injected at the incision site. The purpose of Lidocaine is mainly to provide anesthetic effect while the Epinephrine is needed to:

A. Relax the bronchus and dilate the airway for easier insertion
B. To promote faster healing
C. To prevent the Vasovagal reflex that might cause bradycardia
D. For Hemostasis

17. Which of the following is not considered as a regular part of a Tracheostomy tube?

A. The outer cannula C. The obturator
B. The inner cannula D. The cuff

18. Which of the following is the reason why will a surgeon select a cuffed tube over a non cuffed Tracheostomy tube?

A. Cuffed tube offers efficient securing C. Cuff tube offers excellent attachment
B. Cuffed tube is mainly used to prevent coughing D. For mechanical ventilation

19. The size of the Tracheostomy tube is denoted in terms of:

A. French C. Units
B. Gauge D. Size / mmID

20. The function of the obturator is:

A. To direct the outer cannula to traverse the curvature of the trachea for easier insertion
B. In cases of emergency, when outer cannula accidentally dislodges
C. To facilitate dilation of the stoma for the insertion of the outer cannula
D. To prevent too much pressure on the jugular vein after the tie has been placed

Situation : Organ donation is a new form of treatment that provides multiple complication such as rejection.

21. Organ donation to save life was initially with the first transplant done by:

A. Dr. Christian Barnard of the Union of South Africa
B. Dr. Christian of the U.S.A.
C. Dr. Christian Barnard of Soviet Union
D. Dr. Christian Barnard of U.K.

22. In 1983, The FDA approved the first anti-rejection drug by the name of:

A. Cyclosporine B. Prednisone C. Imuran D. Azathioprine

23. You would expect that in cases of organ donation, you would expect that the immunosuppressant medications such as Cyclosporine, Prednisone and Imuran are taken:

A. For 2 years C. When rejection is not anymore viable
B. When the suture heals D. For the rest of the client’s life

24. Which of the following is a sign that the transplanted kidney is being rejected?

A. Fever and Weight Gain C. Chills, Fever, Polyuria
B. Fever and Weight Loss D. Anuria, Fever, Weight Gain and Hematuria

25. Among children candidates for organ transplant, when all selected children have appropriate tissue matches for the same donated organ, the basis for the decision as to which child gets the organ is given to the child who:

A. will receive the most benefit from the new organ
B. is most likely to die without the transplant
C. is selected by the lottery system for available organs
D. is at the top of the list and has waited the longest time

Situation: In a client with widespread colon cancer, A colectomy is the surgical procedure of choice instead of an Abdominal perineal resection.

26. Ileostomy is performed after a colectomy. The nurse will expect that the stool of the client will be:

A. Mushy B. Spicy C. Liquid D. Soft

27. When should the teaching about ileostomy care commence?

A. Immediately after the operation, when the anesthesia is wearing off
B. 72 hours after operation
C. When readiness and interest is observed
D. As soon as the patient is admitted

28. Which of the following indicates a need for further teaching in client’s with ileostomy?

A. “I am expecting a change in my diet.”
B. “I can remove the appliance during sleep.”
C. “I can still swim”
D. “I am prone to dehydration because of the ileostomy”

29. For the client’s stool to be more “formed” which of the following food are added to the client’s diet?

A. Boiled rice
B. Spaghetti and macaroni
C. Cheese
D. Bran

30. An expert nurse in the field of colostomy and ileostomy is called as a/an:

A. Enterostomal Therapy Nurse C. Nurse oncologist
B. Ostomy nurse D. Nurse Enterostomist

Situation: During surgical operation, it is inevitable to utilize sutures. The nurse should know the basic principles in suturing as well as knowledge in selecting sutures and caring for clients with sutures.

31. Steel has the highest tensile strength among sutures in the non absorbable category. When you say tensile strength, it refers to:

A. The amount of weight or force necessary to break the suture
B. The cross sectional size of the suture
C. The ability of the suture to absorb fluid
D. The force necessary to cause the knot to slip

32. In suturing the internal organs such as kidneys, liver, spleen, pancreas and stomach, the nurse knows that the type of suture material that the physician will most likely use is:

A. Steel B. Vicryl C. Cotton D. Silk

33. If the suture is removed to soon, the nurse knows that it could lead to failed healing of the wound as well as infection. If the suture is removed too late, which of the following can occur?

A. Itching B. Swelling C. Scarring D. Pain

34. The nurse noticed that there are yellow and brown crustings around the area of the suture. Which of the following is the best cleansing medium to remove such crusting?

A. Hydrogen Peroxide B. Providone Iodine C. NSS D. Alcohol

35. If the suture is performed on the client’s face. The nurse will reinforce the teaching that the client should return when for suture removal?

A. After 7 days C. After 10 days
B. After 3 to 4 Days D. The next day

36. Sizes of sutures denotes the diameter. The physician will perform a corneal transplant and will suture the eye. The nurse will prepare which of the following suture size?

A. 7 B. 5 C. 3 D. 9-0

37. Who holds the packet flaps of sutures to open it and place it in the sterile table for use?

A. Scrub nurse B. Circulating nurse C. Assistant surgeon D. Surgeon

38. Non absorbable suture material such as cotton, nylon and silk are best used in suturing which of the following abdominal layer?

A. Skin B. Peritoneum C. Fascia D. Muscle

39. When least amount of trauma is desired, or when the client is prone to keloid formation, the nurse should prepare which type of the needle?

A. Swaged B. Round C. Blunt D. Taper

40. Another alternative “suture” for skin closure is the use of ____________
A. Staple
B. Therapeutic glue
C. Absorbent dressing
D. Invisible suture

Situation: The following are questions with regards to the OPERATING ROOM.

41. The operating room is divided into three areas, The unrestricted, the semi restricted and the restricted areas. Where is the operating room?

A. Restricted B. Unrestricted C. Semi restricted D. PACU

42. What OR attires are worn in the restricted area?

A. Scrub suit, OR shoes, head cap
B. Head cap, scrub suit, mask, OR shoes
C. Mask, OR shoes, scrub suit
D. Cap, mask, gloves, shoes

43. What OR attires are worn in the semi-restricted area?

A. scrub suit only
B. scrub suit, shoe cover, mask
C. scrub suit and head cap, with or without the shoe cover
D. head cap, mask, shoe cover only

44. One of the hidden dangers in the OR is missing instruments. What is the appropriate approach to this happening?

A. correct labeling
B. “a place for everything and everything in its place”
C. install a flush sterilizer in the OR
D. increase instrument inventory

45. PACU Vital signs monitoring is performed every:

A. 5 minutes B. 10 minutes C. 15 minutes D. 30 minutes

46. Mr. T.O. has undergone surgery for lyses of adhesions. He is transferred from Post Anesthesia Care Unit (PACU) to the Surgical floor, the nurse should obtain blood pressure, pulse and respiration every:

A. 3 minutes C. 15 minutes
B. 30 minutes D. 20 minutes

47. Another worthy study is the compliance to the principles of aseptic technique among the sterile OR team. Who does NOT belong to the sterile OR team?

A. scrub nurse C. x-ray technician
B. assistant surgeon D. surgeon

48. The patient demonstrates knowledge of the psychological response to the operation and other invasive procedure when she asks about:

A. Who will be with me in the OR?
B. How is the post operative pain over the site like?
C. Will I be naked during the operation?
D. Is it cold inside the?

49. Endoscopic minimally invasive surgery has evolved from diagnostic modality to a widespread surgical technique. What department should the nurse collaborate which is unusual in conventional surgery?

A. engineering department C. blood bank services
B. x-ray department D. linen section

50. When the client is discharged from the hospital and is not capable of doing the needed care services, the following can assume the role, EXCEPT:

A. family members C. significant others
B. chaplain D. responsible caregiver

Situation: Anesthesia is used even during the Ancient times. In its evolution, modern marvels in the use of anesthesia enables the nurses to develop a more competitive approach in patient care.

51. An anesthesia delivered directly to the spinal canal is known as:

A. Epidural C. General
B. Intrathecal D. Local

52. After spinal anesthesia, 30% of the patient develops spinal headache. This is due to:

A. Severe hypotension associated with Vasodilation due to the anaesthetics.
B. Increase volume of the cerebrospinal fluid due to anesthesia induction.
C. Cerebral edema due to rapid absorption of the anaesthetics.
D. CSF leakage due to the puncture created by the spinal needle in the membrane that surrounds the spinal cord.

53. Before the induction of spinal anesthesia, the client is placed in which of the following preferred position to widen the vertebral space:

A. Quasi fetal position C. Flat on bed supine position
B. Prone position D. Sidelying position affected side

54. After spinal anesthesia, to prevent spinal headache, the client is placed on which of the following position?

A. Sitting position C. Flat on bed, supine
B. Sidelying position affected side D. Flat on bed, prone

55. Another way to prevent spinal headache is by the use of the correct needle gauge. If the client is an adult client, the anaesthesiologist might order a pink spinal set. The nurse knows that the pink spinal set has a gauge of:

A. 12 B. 16 C. 22 D. 26

Situation: The nurse utilizes the theoretical foundation basic to perioperative nursing in the various nursing scenarios:

56. In medical and nursing practice, code means a call for:

A. DNR state C. clinical case
B. call to order D. cardiopulmonary resuscitation

57. The OR team collaborates from the first to the last surgical procedure. Who monitors the activities of each OR suite?

A. scrub nurse C. circulating nurse
B. anesthesiologist D. surgeon

58. In patients with acute pancreatitis, the administration of the analgesic morphine may cause:

A. addiction C. paralytic ileus
B. urinary retention D. spasms of the sphincter of Oddi

59. Who is responsible in daily monitoring the standards of safe, nursing practice in the operating suite?

A. surgeon C. OR nurse supervisor
B. perioperative nurse D. chief nurse

60. During surgery, movement of personnel should be:

A. kept to a minimum C. monitored
B. restricted D. eliminated when possible

61. The patient has a right to information regarding the operation or other invasive procedure and potential effects. This right is achieved through:

A. Enlightened Consent C. charting
B. preoperative visit D. doctor’s rounds

62. Which statement about a person’s character is evident in the OR team?

A. it assists in the control of feelings, thoughts and emotions in the face of difficulty
B. it reflects the moral values and beliefs that are used as guides to personal behavior and actions
C. it encourages the constructive use of the pleasure of the senses
D. it refers to the quality of being righteous, correct, fair and impartial

63. You continuously evaluate the client’s adaptation to pain. Which of the following behaviors indicate appropriate adaptation?

A. The client reports pain reduction and decreased activity
B. The client denies existence of pain
C. The client can distract himself during pain episodes
D. The client reports independence from watchers

64. Pain in ortho cases may not be mainly due to the surgery. There might be other factors such as cultural or psychological that influence pain. How can you alter these factors as the nurse?

A. Explain all the possible interventions that may cause the client to worry
B. Establish trusting relationship by giving his medication on time
C. Stay with the client during pain episodes
D. Promote client’s sense of control and participation in control by listening to his concerns

65. In some hip surgeries, Fentanyl analgesia is given. What is your nursing priority care in such a case?

A. Instruct client to observe strict bed rest
B. Check for epidural catheter drainage
C. Administer analgesia through epidural catheter as prescribed
D. Assess respiratory rate carefully

Situation: Mrs. Diaz is assigned in the female surgical ward. While on duty, an 15 year old client, married, was admitted for CS. The informed consent for the operation has to be obtained.

66. The person legally responsible for taking the informed consent is:

A. The OR nurse who is going to assist with the operation
B. Any doctor assigned with the team
C. The doctor who is going to perform the procedure
D. The ward nurse where the patient stayed before the operation

67. Mr. Diaz has to remember the following with regard to the IC:

A. Because the patient is a minor, the parents should be asked to sign the consent.
B. The informed consent should be signed either by the patient or her 20 year old husband if patient is unconscious
C. Nurses has the responsibility to obtain the informed consent prior to surgery
D. Legal guardian should sign the consent since the client is 15 year old

68. The medical intern who assisted in the operation gave post operative orders. In this case, Mrs.Diaz should:

A. Validate the order from the surgeon and request him to counter sign
B. Follow the order as long as they are within the scope of nursing practice
C. Clarify from the medical intern those that are ambiguous
D. Refuse to follow the order because it is not legal

69. After one year, Mrs. Diaz was rotated to the delivery room. As a DR Nurse, the Obstetrician ordered her to administer spinal anesthesia because the anaesthesiologist did not arrive at the scene. The nurse would:

A. Give the anesthesia if the supervising nurse approves it
B. Give the anesthesia if the OB supervises her
C. Give the anesthesia if the doctor writes the order
D. Do not follow

70. Which of the following should the nurse remember when a doctor requests them to administer anesthesia?

A. The nurse has the right to refuse it, if the doctor’s order is unlawful
B. Doctor’s order should always be written
C. The nurse may render medical procedure if the doctor supervises him
D. The staff nurse can be accused of insubordination if she does not follow the doctor’s order

Situation: Miss Matias, found out that Mang Carding, newly admitted patient, has terminal cancer and that his nurse has not yet informed him of the diagnosis.

71. Initially, Miss Matias should:

A. Tell the doctor the Mang Carding hinted that he feels he has Cancer
B. Be available to listen when the patient decides to discuss his illness
C. Call in the family and the team to prepare Mang Carding about his impending death
D. Inform Mang Carding about his Diagnosis

72. On the second day, the wife of Mang Carding shows signs of grieving, The stages of Grieving identified by Elizabeth Kubler-Ross Are:

A. Numbness, Anger, Resolution and Reorganization
B. Denial, Anger, Bargaining, Disorganization, Acceptance
C. Denial, Anger, Bargaining, Depression, Resolution
D. Denial, Anger, Bargaining, Depression, Detachment

73. Which of the following will be the most helpful therapy for the Grieving family?

A. Watching the video of the dying client over and over to encourage moving on
B. A course on death and dying
C. Psychotherapy
D. Group meeting with other grieving families

74. the nurse, when dealing with the relatives of a dying patients must be sensitive to their emotional reactions. A family member who blames herself for the condition of the dying patient indicates that she:

A. Has major issues
B. is oversensitive
C. Has neurotic tendencies
D. Is potentially risk for suicide

75. In caring of a dying client during post mortem, the most important thing that the nurse should remember is:

A. Treat the body with outmost dignity
B. Close the eyes immediately before the onset of rigor mortis
C. Verify that the client is really dead by checking the ABC and double checking the death notice
D. Close the mouth, straighten the body, elbows and knees before the onset of rigor mortis

Situation : The patients chart is a legal documentation the is admissible in the court. In working with the client, The protection of the information on the chart and patient’s privacy is one of the priority. You are caring for Ana, a 12 year old grade 6 pupil from manila and is one of the daughters of Maria, A 38 year old mother of 12.

76. Who cannot access the client’s chart?

A. Maria C. Member of the health care team
B. The patient D. The nurse from the nearby hospital

77. Who owns the patient chart?

A. The patient C. The hospital
B. The doctor in charge D. The government

78. If the court issues an investigation necessitating the utilization of Ana’s chart, you know that the chart will not be admissible IF:

A. Maria refuses C. The chart is not legible
B. Ana refuses D. The chart is missing

79. The research teams from other countries are interested in investigating Ana’s case. They want to read and gather information about Ana and the manifestation of her condition. For the sake of improving knowledge and the development of a cure, the nurse knows that research is very important. Permission in this case will be taken from:

A. Ana C. The hospital management
B. Maria D. The doctor in charge

80. If Ana reaches the age of majority, 18 years of age, and Maria asks for her chart, which of the following is the best nursing action?

A. Ignore Maria’s request
B. Decline Maria’s request
C. Give the chart to the Mother of Ana
D. Tell Maria to ask permission from Ana

Situation 6 – Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care.

81. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice, after a workup he is diagnosed of having Hepatitis A. his wife asks you about gamma globulin for herself and her household help. Your most appropriate response would be:

A. “Don’t worry your husband’s type of hepatitis is no longer communicable”
B. “Gamma globulin provides passive immunity for hepatitis B”
C. “You should contact your physician immediately about getting gammaglobulin.”
D. “A vaccine has been developed for this type of hepatitis”

82. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your best response would be:

A. “You acquired the infection after you have been admitted to the hospital.”
B. “This is a highly contagious infection requiring complete isolation.”
C. “The infection you had prior to hospitalization flared up.”
D. “As a result of medical treatment, you have acquired a secondary infection.’

83. As a nurse you know that one of the complications that you have to watch out for when caring for Omar who is receiving total parenteral nutrition is:

A. stomatitis
B. hepatitis
C. dysrhythmia
D. infection

84. A solution used to treat Pseudomonas wound infection is:

A. Dakin’s solution
B. Half-strength hydrogen peroxide
C. Acetic acid
D. Betadine

85. Which of the following is the most reliable in diagnosing a wound infection?

A. Culture and sensitivity
B. Purulent drainage from a wound
C. WBC count of 20,000/μL
D. Gram stain testing

Situation : Respiration is one of the most important vital sign. This is usually the first Vital sign to be assessed more than anything for it is easily altered by the patient’s consciousness. The nurse should be aware of the different changes and alteration in respiration.

86. Another name for an abnormal breath sound is:

A. Adventurous breath sound
B. Excursion
C. Adventitious breath sound
D. Dyspnea

87. In a client with diabetic ketoacidosis, Kussmauls respiration is exhibited. This is evidence that there is the presence of:

A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis

88. If the nurse will auscultate the base of the lungs, it is expected that she will hear:

A. Bronchovesicular B. Tubular C. Vesicular D. Crackles

89. The respiratory center is found in the:

A. Pons B. Hypothalamus C. Medulla D. Lungs

90. Initially in asthma, you are expecting that the client’s acid base disturbance is:

A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis

Situation: Carbon Monoxide poisoning is said to be the 2nd leading cause of poison death. It is said to be the leading cause of inhalation poisoning. Mang edgardo was rushed to the hospital after being unconscious inside an enclosed parking lot. Carbon monoxide poisoning is suspected.

91. The pulse oximetry reading of Mang edgardo is 100%. This suggests that:

A. There is no danger of hypoxia
B. There is no carbon monoxide poisoning, it should be ruled out
C. This is not a reliable sign to rule out carbon monoxide poisoning, further assessment is required
D. That the client has an improved chance of surviving, since the client is well oxygenated

92. Which of the following is a sign the nurse will expect to see on Mang edgardo?

A. Cherry-red skin
B. Pale skin
C. Cyanotic
D. Restlessness

93. Initially, in patient with suspected inhalation poisoning, the most important intervention at the scene of poisoning is:

A. Assess the patient’s airway breathing and circulation
B. Conduct a head to toe physical assessment
C. Administer oxygen and loosen the client’s clothing
D. Carry the client on the fresh air immediately opening all windows and doors if this is enclosed

94. Which of the following laboratory result is constantly checked in clients undergoing treatment for carbon monoxide poisoning?

A. Oxygen saturation C. Skin color
B. RBC count D. Carboxyhemoglobin level

95. If a client demonstrates psychoses, visual disturbance, ataxia, amnesia and confusion even after completion of resuscitation and the return of normal oxygenation, this will indicate that:

A. The client suffered from an irreversible brain damage
B. That the client still needs to be evaluated for this is evidence that resuscitation is not yet complete
C. That the client will need a longer rehabilitation to go back to the previous functioning
D. That the client is exhibiting secondary gains

Situation: The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta.

96. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it?

A. 6 hours C. 4 hours
B. 1 hour D. 2 hours

97. What should you do FIRST before you administer blood transfusion?
A. verify client identity and blood product, serial number, blood type, cross matching results, expiration date
B. verify client identity and blood product serial number, blood type, cross matching results, expiration date with another nurse
C. check IV site and use appropriate BT set and needle
D. verify physician’s order

98. As WQ’s nurse, what will you do AFTER the transfusion has started?

A. add the total amount of blood to be transfused to the intake and output
B. discontinue the primary IV of Dextrose 5% Water
C. check the vital signs every 15 minutes
D. stay with WQ for 15 minutes to note for any possible BT reactions

99. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:

A. oliguria and jaundice C. hypertension and flushing
B. urticaria and wheezing D. headache, chills, fever

100. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention?

A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician
B. stop the blood transfusion and monitor the patient closely
C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank
D. immediately stop the BT, notify the blood bank and administer antihistamines

Preboard Exam B — Test 4: Medical-Surgical Nursing Original source at: Nurseslabs