MEDICAL-SURGICAL NURSING D.

Values oxygen and carbon dioxide are both

RESPIRATORY DISORDERS pertinent data to consider a respiratory ABG
imbalance
Situation: The student nurse assigned in the medical 9. The normal respiratory rate of a newborn is:
ward where most cases are related to problems on A. >20cpm C. >60cpm
oxygenation, review the anatomy and physiology of B. >40cpm D. >80cpm
the respiratory system. 10. The respiratory center is located to what region
of the central nervous system?
1. Which among the following is true about voice A. Diencephalon C. Limbic system
production? B. Brain stem D. Cerebrum
A. The pharynx is the main organ of voice production
B. The larynx contains the short cord that produces Situation: Nurse Burakday review different diagnostic
low pitch sound procedure for patients with problems to gas
C. Long cords of the larynx produces high pitch sound exchange. The following questions are applied.
D. The larynx is the major organ for phonation
2. Respiratory system is a pipe system where gas 11. Arnaldo is confined with possible diagnosis of
passes through. The correct order of respiratory bronchocarcinoma (lung cancer). Nurse Ivy review
organs is: the patient's chart and the doctor's order reads
A. Nose-oropharynx-trachea-larynx-lungs "bronchoscopy by 7am tommorrow." The nurse
B. Nostrils-orophraynx-nasopharyx-larynx-lungs correctly prepare the patient for the procedure by
C. Nares-laryngopharynx-larynx-trachea-lungs initially:
D. Nares-orophraynx-trache-larynx-alveoli A. Obtain signature for informed consent
3. What mechanism of action is involoved in gas B. Ensure the patient's understanding of the
exchanges? procedure
A. Osmosis from higher to lower solute C. Question the physician for the appropriateness of
concentration the procedure
B. Diffusion from an area of higher to lower oxygen D. Suggest that the patient should disagree with the
concentration physician
C. Osmosis from lower to higher solute concentration 12. With the same situation above, to avoid
B. Diffusion from area of lower to higher oxygen complication during bronchoscopy, the Nurse Ivy
concentration advise the patient to:
4. Which of the following is true about right and left A. Increased fluids before the procedure
lobes of the lungs? B. Start nothing by mouth by 9pm tonight
A. Left lung is consist 2 lobes while the right is 1 lobe C. Increased fiber in the diet
lesser D. Advise the patient not to introduce anyting by
B. Right lung is comprised of one lobe higher than mouth starting midnight
the left 13. After bronchoscopy the nurse should advise the
C. Right lung is composed of 3 lobes whileleft lung is patient to expect the following discomforts, except:
1 lobe A. Blood-tinged sputum C. Hemoptysis
D. Both right and left lungs contains 3 lobes C. Return of gag reflex D. Occasional coughing
5. The type I cells of the alveoli will make the: 14.
A. Walls C. Surfactant 15. To prevent possible complications after
B. Bronchioles D. Hilum bronchoscopy, the nurse should assess return of gag
6. The type II cells of the alveoli will make the: reflex by:
A. Walls C. Surfactant A. Placing tongue blade at the posterior aspect of the
B. Bronchioles D. Hilum tongue
7. The bronchial tree starts at the primary bronchus B. Touching the uvula
then divided into two by what anatomical structure? C. Place the tongue blade at the posterior palate
A. Base of the lung C. Bronchioles D. Both B@C are correct
B. Secondary bronchi D. Hilum 16. The nurse understands that the insertion of a
8. Lungs are responsible for maintaining the acid- fine-long needle to the pleural cavity to remove air,
base balance. Which principle with regards to this fluids or blood is termed as:
function is incorrect? A. Thoracotomy C. Amniocentesis
A. High level of carbon dioxide will result to acidosis B. PleurEvac D. Thoracentesis
B. Low level of carbon dioxide will lead to alkalosis 17. Which among the following may not be routinely
C. When pH level is below normal the carbon dioxide done when a patient is about to receive
level rises ChestPhysioTherapy (CPT)?
A. Incentive spirometry C. Vibration

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B. Postural drainage D. Percussion A. The drainage chamber should be at the level of
18. Which is the correct order of the steps in the heart
performing CPT? B. The drainage chamber is always placed on the far
1. Percussion 3. Incentive spirometry side of the bed
2. Vibration 4. Postural drainage C. The drainage chamber should be placed always
A. 1,2,3,4 C. 3,1,2,4 below the heart
B. 1,3,2,4 D. 3,2,1,4 D. The drainage chamver could be placed anywhere
19. Thoracentesis was performed to patient with beside the patient
hemothorax, the nurse's initial assessment should 26. Malia observed bubbling on the suction chamber.
focus on: The nurse should interpret this situation as:
A. Assess patient for the return of gag reflex A. A life threatening condition
B. Assess the patient for potential complication such B. A condition that needs to be referred to AP
as hemoptysis C. Criteria considered to replace the tubing
C. Evaluate the patient's knowledge about the D. Normal and document as it is
procedure 27. Chest tube drainage system is also known as:
D. Assess patient for potential shock such as A. Sengstaken blakemore tube C. Jackson-Pratt
hypotension B. Levine tube D. PleurEvac
20. Respiratory measurement that refers to the 28. A patient's watcher runs to the nurse's station
volume of air after the patient had a normal cycle of and complaints of tube disconnection. The nurse
inspiration and expiration is termed: should respond appropriately by:
A. Vital capacity C. Force expired volume A. Attempting to reconnect the tube immediately
B. Tidal volume D. Residual volume B. Dipping the tip of the tube to a glass full of water
21. When the patient's air volume is assessed during C. Covering the wound with a sterile gauze soaked in
a maximum or forced inspiration and expiration, the a normal saline
nurse obtains the: D. Covering the wound with dry occlusive sterile
A. Inspiratory reserved volume gauze
B. Expiratory reserved volume 29. Chest tube insertion primarily aims to:
C. Vital capacity A. Remove fluids and blood from the pleural cavity
D. Tidal volume B. Correct the mediastinal shifting
22. The amount of air that remains in the lungs after C. Allow the lungs to reexpand independently
a maximum expiration is also known as: D. Removes positive pressure to bring back negative
A. Residual volume C. Vital capacity intrathoracic pressure
B. Tidal volume D. Leftover volume 30. Nurse Burakingkang obsrerve that there is
23. Which among the following is an expected constant bubling in the water-seal chamber. This is
deterioration of the respiratory function among indicative of:
geriatric patients? A. Lung perforation C. Dysfunctioning
A. Increase tidal volume B. Air leaks D. All of the above
B. Altered tissue perfusion 31. The nurse should observe that the water in the
C Decreased residual volume water-seal chamber normally:
D. Increased residual volume A. Rises and falls C. Oscillates
24. The most precise and accurate diagnostic test B. Fluctuates D. All of the above
that will monitor patient's respiratory function is: 32. Another patient with chest trauma 2 weeks ago
A. Sputum culture C. CT scan has been treated with chest-tube. The singlemost
B. Chest X-ray D. Pulmonary function test criteria that the nurse will assess to evaluate that the
25. Computed tomography (CT) scan and magnetic chest-tube is ready to be removed is:
resonance imaging (MRI) are usually done if the A. Bubbling in the water-seal chamber
patient is suspected for what respiratory B. Tidaling is observed in the eater seal chamber
disturbance? C. Fluctuations in the water chamber is no longer
A. Lung cancer C. Pleural effusion observed
B. Pneumothorax D Fractured ribs D. Patient's verbalizations of relief of S/S
33. Which among the following drug classifications
Situation: Nurse Malia is assigned in the medical will affect the respiratory rate?
ward where chest tubes are attached to varoous ĺ A. H-2 receptor antagonist C. Anticholinergics
B. Beta-adrenergic blockers D. Narcotics
26. When Malia reviewed the chart of patient Q with 34. A drug which is an example in the classification
chest tube, she understands that the principle referred to #33 is:
underlying to maintain drainage of blood is: A. Theophylline C. Epinephrine
B. Ranitidine D. Morphine

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35. The nurse should anticipate administration of this 41. The client diagnosed with influenza A is being
antidote drug when there is narcotic overdose? discharged from the emergency department with a
A. Vitamin k C. Protamine sulfate prescription for antibiotics. Which statement by the
B. Naloxone HCl D. Flumazenil HCl client indicates an understanding of this
prescription?
36. The home health-care nurse is talking on the A. “These pills will make me feel better fast and I can
telephone to a male client diagnosed with return to work.”
hypertension and hears the client sneezing. The B. “The antibiotics will help prevent me from
client tells the nurse that he has been blowing his developing a bacterial pneumonia.”
nose frequently. Which question should the nurse C. “If I had gotten this prescription sooner I could
ask the client? have prevented this illness.”
A. “Have you had the flu shot in the last two (2) D. “I need to take these pills until I feel better; then I
weeks?” can stop taking the rest.”
B. “Are there any small children in the home?” 42. The nurse is developing a plan of care for a client
C. “Are you taking over-the counter-medicine for diagnosed with laryngitis and identifies the client
these symptoms?” problem “altered communication.” Which
D. “Do you have any cold sores associated with your intervention should the nurse implement?
sneezing?” A. Instruct the client to drink a mixture of brandy and
37. The school nurse is presenting a class to students honey several times a day.
at a primary school on how to prevent the B. Encourage the client to whisper instead of trying
transmission of the common cold virus. Which to speak at a normal level.
information should the nurse discuss? C. Provide the client with a blank note pad for writing
A. Instruct the children to always keep a tissue or any communication.
handkerchief with them. D. Explain that the client’s aphonia may become a
B Explain that children current with immunizations permanent condition.
will not get a cold. 43. Which nursing task could be delegated to an
C. Tell the children that they should go to the doctor unlicensed nursing assistant?
if they get a cold. A. Feed a client who is postoperative tonsillectomy
D. Include a demonstration of how to wash hands the first meal of clear liquids.
correctly. B. Encourage the client diagnosed with a cold to
38. The client has been diagnosed with chronic drink a glass of orange juice.
sinusitis. Which signs and symptoms would alert the C. Obtain a throat culture on a client diagnosed with
nurse to a potentially life-threatening complication? bacterial pharyngitis.
A. Muscle weakness c. Nuchal rigidity. D. Escort the client diagnosed with laryngitis outside
B. Purulent sputum d. Intermittent loss of to smoke a cigarette.
muscle control. 44. The nurse is caring for a client diagnosed with a
39. The client diagnosed with tonsillitis is scheduled cold. Which is an example of an alternative therapy?
to have surgery in the morning. Which assessment A. Vitamin C, 2000 mg daily.
data should the nurse notify the surgeon about prior B. Strict bed rest.
to surgery? C. Humidification of the air.
A. The client has a hemoglobin of 12.2 g/dL and D. Decongestant therapy.
hematocrit of 36.5%. 45. The nurse is assessing a 79-year-old client
B. The client has an oral temperature of 100.2°F and diagnosed with pneumonia. Which signs and
a dry cough. symptoms would the nurse expect to find when
C. There are one (1) to two (2) white blood cells in assessing the client?
the urinalysis. A. Confusion and lethargy.
D. The client’s current International Normalized Ratio B. High fever and chills.
(INR) is 1.0. C. Frothy sputum and edema.
40. The influenza vaccine is in short supply. Which D. Bradypnea and jugular vein distention.
group of clients would the public health nurse 46. The nurse is planning the care of a client
consider priority when administering the vaccine? diagnosed with pneumonia and writes a problem of
A. Elderly and chronically ill clients. “impaired gas exchange.” Which would be an
B. Child-care workers and children younger than age expected outcome for this problem?
four (4) years. A. Performs chest physiotherapy three (3) times a
C. Hospital chaplains and health-care workers. day.
D. LSchoolteachers and students living in a B. Able to complete activities of daily living.
dormitory. C. Ambulates in the hall and back several times
during each shift.

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D. Alert and oriented to person, place, time, and 52. The day shift charge nurse on a medical unit is
events. making rounds after report. Which client should be
47. The client diagnosed with a community-acquired seen first?
pneumonia is being admitted to the medical unit. A. The 65-year-old client diagnosed with tuberculosis
Which nursing intervention has the highest priority? who has a sputum specimen to be sent to the lab.
A. Administer the oral antibiotic stat. B. The 76-year-old client diagnosed with aspiration
B. Order the meal tray to be delivered as soon as pneumonia who has a clogged feeding tube.
possible. C. The 45-year-old client diagnosed with pneumonia
C. Obtain a sputum specimen for culture and who has a pulse oximetry reading of 92%.
sensitivity. D. The 39-year-old client diagnosed with bronchitis
D. Have the unlicensed nursing assistant weigh the who has an arterial oxygenation level of 89%.
client. 53. The client is admitted with a diagnosis of rule out
48. The 56-year-old client diagnosed with tuberculosis. Which type of isolation procedures
tuberculosis (TB) is being discharged. Which should the nurse implement?
statement made by the client indicates an A. Standard Precautions C. Droplet Precautions.
understanding of the discharge instructions? B. Contact Precautions D. Airborne
A. “I will take my medication for the full three (3) Precautions.
weeks prescribed.” 54. The nurse observes the unlicensed nursing
B. “I must stay on the medication for months if I am assistant (NA) entering an airborne isolation room
to get well.” and leaving the door open. Which action would be
C. “I can be around my friends because I have started the nurse’s best response?
taking antibiotics.” A. Close the door and discuss the NA’s action when
D. P“I should get a TB skin test every three (3) the NA comes out of the room.
months to determine if I am well.” B. Make the NA come back outside the room and
49. The company nurse is administering tuberculin then reenter closing the door.
skin testing to employees who have possibly been C. Say nothing to the NA but report the incident to
exposed to a client with active tuberculosis. Which the nursing supervisor.
statement indicates the need for radiological D. Enter the client’s room and discuss the matter
evaluation instead of skin testing? with the NA immediately.
A. The client’s first skin test indicates a purple flat 55.The client is admitted to a medical unit with a
area at the site of injection. diagnosis of pneumonia. Which signs and symptoms
B. The client’s second skin test indicates a red area would the nurse look for when assessing the client?
measuring four (4) mm. A. Pleuritic chest discomfort and anxiety.
C. The client’s previous skin test was read as positive. B. Asymmetrical chest expansion and pallor.
D. The client has never shown a reaction to the C. Leukopenia and CRT 3 seconds.
tuberculin medication. D Substernal chest pain and diaphoresis.
50. The nurse is caring for the client diagnosed with 56. When assessing the client with COPD, which
pneumonia. Which information should the nurse health promotion information would be most
include in the teaching plan? Select all that apply. important for the nurse to obtain?
1. Place the client on oxygen by nasal cannula. A. Number of years the client has smoked.
2. Plan for periods of rest during activities of daily B. Risk factors for complications.
living. C. Ability to administer inhaled medication.
3. Place the client on a fluid restriction of 1000 mL D. Possibility for lifestyle changes.
per day. 57. The client diagnosed with an exacerbation of
4. Restrict the client’s smoking to two (2) to three (3) COPD is in respiratory distress. Which intervention
cigarettes per day. should the nurse implement first?
5. Monitor the client’s pulse oximetry readings every A. Assist the client into a sitting position at 90
four (4) hours. degrees.
A. 1-2-3 b. 2-3-4 c. 3-4-5 d. 1-2- B. Give oxygen at six (6) LPM via nasal cannula.
5 C. Monitor vital signs with the client sitting upright.
51. While feeding the client diagnosed with D. Notify the doctorr about the client’s status.
aspiration pneumonia, the client becomes dyspneic, 58. When assessing the client with the diagnosis of
begins to cough, and is turning blue. Which nursing COPD, which data would require the nurse to take
intervention would the nurse implement first? immediate action?
A. Suction the client’s nares. A. Large amounts of thick white sputum.
B. Turn the client to the side. B. Oxygen flow meter set on eight (8) liters.
C. Place the client in the Trendelenburg position. C. Use of accessory muscles during inspiration.
D. Notify the doctor. D Presence of a barrel chest and dyspnea.

4
59. While the nurse is caring for the client diagnosed D. Discuss the NA’s action with the charge nurse so
with COPD, which outcome would require a revision that appropriate action can be taken.
in the plan of care? 65. When assessing the client recently diagnosed
A. The client has no signs of respiratory distress. with COPD, which sign and symptom should the
B. The client shows an improved respiratory pattern. nurse expect?
C. The client demonstrates intolerance to activity. A. Clubbing of the client’s fingers.
D. The client participates in establishing goals. B. Infrequent respiratory infections.
60. The nurse is caring for the client diagnosed with C. Chronic sputum production.
end-stage COPD. Which data would warrant D. Non-productive hacking cough.
immediate intervention by the nurse? 66. What statement made by the client would
A. The client’s pulse oximeter reading is 92%. indicate that the nurse’s discharge teaching was
B. The client’s arterial blood gas level is 74. effective for the client diagnosed with COPD?
C. The client has SOB when walking to the bathroom. A. “I need to get an influenza vaccine each year, even
D. The client’s sputum is rusty colored. when there is a shortage.”
61. What statement made by the client diagnosed B. “I need to get a vaccine for pneumonia each year
with chronic bronchitis indicates to the nurse that with my flu shot.”
more teaching is needed? C. “If I reduce my cigarette smoking to six (6) a day, I
A. “I should contact my doctor if my sputum changes won’t have difficulty breathing.”
color or amount.” D. “I need to restrict my drinking liquids to keep from
B. “I will take my bronchodilator regularly to prevent having so much phlegm.”
having bronchospasms.” 67. The nurse is completing the admission
C. “This metered dose inhaler gives a precise amount assessment on a 13-year-old client diagnosed with
of medication with each dose.” asthma. Which signs and symptoms would the nurse
D. “I need to return to the doctor to have my blood expect to find?
drawn with my annual physical.” A. Fever and crepitus C. Dyspnea and wheezing.
62. Which nursing diagnoses would be appropriate B. Rales and hives D. Normal chest shape and
for the nurse to include in the plan of care for the eupnea.
client diagnosed with COPD? Select all that apply. 68. The nurse is planning the care of a client
1. Impaired gas exchange. diagnosed with asthma and has written a problem of
2. Inability to tolerate temperature extremes. “anxiety.” Which nursing intervention should be
3. Activity intolerance. implemented?
4. Inability to cope with changes in roles. A. Stay with the client.
5. Alteration in nutrition. B. Notify the health-care provider.
A. 1-2-3 b. 1-3-4 c. 1-2-3-4 C. Administer an anxiolytic medication.
d. 1-2-3-4-5 D. Encourage the client to drink fluids.
63. Which outcome would be appropriate for the 69. The case manager is arranging a care planning
client problem “ineffective gas exchange” for the meeting regarding the care of a 65year-old client
client recently diagnosed with COPD? diagnosed with adult-onset asthma. Which health-
A. The client demonstrates the correct way to purse- care disciplines should participate in the meeting?
lip breathe. Select all that apply.
B. The client lists three (3) signs/symptoms to report 1. Nursing 3. Social Work. 5. Speech therapy
to the doctor 2. Pharmacy 4. Occupational Therapy
C. The client will drink at least 2500 mL of water a. 1-2-3 b. 2-3-4 c. 3-4-5 d. 2-4-5
daily. 70. The client is diagnosed with mild intermittent
D. The client will be able to ambulate 100 feet with asthma. Which medication should the nurse discuss
dyspnea. with the client?
64. The primary nurse observes the unlicensed A. Daily inhaled corticosteroids.
nursing assistant removing the nasal cannula from B. Use of systemic steroids.
the client diagnosed with COPD while ambulating the C. Use of a “rescue inhaler.”
client to the bathroom. Which action should the D. Leukotriene agonists.
primary nurse take? 71. The nurse knows the client understands teaching
A. Praise the NA because this prevents the client regarding mast cell stabilizer medications when the
from tripping on the oxygen tubing. client makes which statement?
B. Place the oxygen back on the client while sitting in A. “I should take two (2) puffs when I begin to have
the bathroom and say nothing. an asthma attack.”
C. Explain to the NA in front of the client that the B. “I must taper off the medications and not stop
oxygen must be left in place at all times. taking them abruptly.”

5
C “These drugs will be most effective if taken at glucocorticoid inhaled medication. Which
bedtime.” information should the nurse teach regarding this
D “These drugs are not good at the time of an medication?
attack.” A. Do not abruptly stop taking this medication; it
72. The client diagnosed with asthma is admitted to must be tapered off.
the emergency department with difficulty breathing B. Immediately rinse the mouth following
and a blue color around the mouth. Which diagnostic administration of the drug.
test will be ordered to determine the status of the C. Hold the medication in the mouth for fifteen (15)
client? seconds before swallowing.
A. Complete blood count C. Allergy skin testing. D. Take the medication immediately when an attack
B. Pulmonary function test D. Drug cortisol level. starts.
73. The registered nurse and a licensed practical 77. The nurse is discussing the care of a child
nurse are caring for five (5) clients on a medical unit. diagnosed with asthma with the parent. Which
Which clients would the nurse assign to the licensed referral would be important to include?
practical nurse? Select all that apply. A. Referral to a dietitian.
1. The 32-year-old female diagnosed with exercise- B. Referral for allergy testing.
induced asthma who has a forced vital capacity of C. Referral to the developmental psychologist.
1000 mL. D. Referral to a home health nurse.
2. The 45-year-old male with adult-onset asthma 78. The nurse is discharging a client newly diagnosed
who is complaining of difficulty completing all of the with restrictive airway disease, asthma. Which
ADLs at one time. statement indicates the client understands the
3. The 92-year-old client diagnosed with respiratory discharge instructions?
difficulty who is beginning to be confused and keeps A. “I will call 911 if my medications don’t control an
climbing out of bed. attack.”
4. The 6-year-old client diagnosed with intrinsic B. “I should wash my bedding in warm water.”
asthma who is scheduled for discharge and the C “I can still eat at the Chinese restaurant when I
mother needs teaching about the medications. want.”
5. The 20-year-old client diagnosed with asthma who D. “If I get a headache I should take a nonsteroidal
has a pulse oximetry reading of 95% and wants to anti-inflammatory drug.”
sleep all the time. 79. The client is diagnosed with a pulmonary
a. 1-2-3 b. 2-3-4 c. 3-4-5 embolus and is receiving a heparin drip. The bag
d. 1-2-5 hanging is 20,000 units/500 mL of D5W infusing at 22
74. The charge nurse is making rounds. Which client mL/hr. How many units of heparin is the client
should the nurse assess first? receiving each hour?
A. The 29-year-old client diagnosed with reactive a. 880 unit b. 870 units c. 890 units d. 860 units
airway disease who is complaining that the nurse 80. Which assessment data would support that the
caring for him was rude. client has experienced a pulmonary embolus?
B. The 76-year-old client diagnosed with heart failure A. Calf pain with dorsiflexion of the foot.
who has 2edema of the lower extremities. B. Sudden onset of chest pain and dyspnea.
C. The 15-year-old client diagnosed with diabetic C. Left-sided chest pain and diaphoresis.
ketoacidosis after a bout with the flu who has a D. Bilateral crackles and low-grade fever.
blood glucose reading of 189 mg/dL. 81. The client diagnosed with a pulmonary embolus
D. The 62-year-old client diagnosed with COPD and is in the intensive care unit. Which assessment data
pneumonia who is receiving O2 by nasal cannula at would warrant immediate intervention from the
two (2) liters per minute. nurse?
75. The client diagnosed with exercise-induced A. The client’s ABGs are pH 7.36, PaO2 95, PaCO2 38,
asthma (EIA) is being discharged. Which information HCO3 24.
should the nurse include in the discharge teaching? B. The client’s telemetry exhibits occasional
A Take two (2) puffs on the rescue inhaler and wait premature ventricular contractions.
five (5) minutes before exercise. C The client’s pulse oximeter reading is 90%.
B. Warmup exercises will increase the potential for D. The client’s urinary output for the 12-hour shift is
developing the asthma attacks. 800 mL.
C Use the bronchodilator inhaler immediately prior 82. The client has just been diagnosed with a
to beginning to exercise. pulmonary embolus. Which intervention should the
D. Increase dietary intake of food high in nurse implement?
monosodium glutamate (MSG). A. Administer oral anticoagulants.
76. The client diagnosed with restrictive airway B. Assess the client’s bowel sounds.
disease, asthma, has been prescribed a C. Prepare the client for a thoracentesis.

6
D Institute and maintain bed rest. A. Low arterial oxygen when administering high
83. The nurse is preparing to administer the oral concentration of oxygen.
anticoagulant warfarin (Coumadin) to a client who B. The client has dyspnea and tachycardia and is
has a PT/PTT of 22/39 and an INR 2.8. What action feeling anxious.
should the nurse implement? C Bilateral breath sounds clear and pulse oximeter
A. Assess the client for abnormal bleeding. reading is 95%.
B. Prepare to administer vitamin K (AquaMephyton). D. The client has jugular vein distention and frothy
C. Administer the medication as ordered. sputum.
D. Notify the doctor to obtain an order to increase 90. Which assessment data would indicate the client
the dose. diagnosed with ARDS has experienced a complication
84. The nurse identified the client problem secondary to the ventilator?
“decreased cardiac output” for the client diagnosed A. The client’s urine output is 100 mL in two (2)
with a pulmonary embolus. Which intervention hours.
should be included in the plan of care? B. The pulse oximeter reading is greater than 95%.
A. Monitor the client’s arterial blood gases. C. The client has asymmetrical chest expansion.
B. Assess skin color and temperature. D. The telemetry reading shows sinus tachycardia.
C. Check the client for signs of bleeding. 91. The doctor ordered stat arterial blood gases
D. Keep the client in the Trendelenburg position. (ABGs) for the client diagnosed with ARDS. The ABG
85. Which nursing interventions should the nurse results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24.
implement for the client diagnosed with a pulmonary Which action should the nurse implement?
embolus who is undergoing thrombolytic therapy? A. Continue to monitor the client without taking any
Select all that apply. action.
1. Keep protamine sulfate readily available. B. Encourage the client to take deep breaths and
2. Avoid applying pressure to venipuncture sites. cough.
3. Assess for overt and covert signs of bleeding. C. Administer one (1) amp of sodium bicarbonate
4. Avoid invasive procedures and injections. IVP.
5. Administer stool softeners as ordered. D Notify the respiratory therapist of the ABG results.
a. 1-2-3-4 b. 1-2-3-5 c.2-3-4-5 d. 1-3-4-
5 SITUATION: Disorders of the respiratory system are
86. Which statement by the client indicates the common and are encountered by nurses in every
discharge teaching for the client diagnosed with a setting from the community to the intensive care
pulmonary embolus is effective? unit. Expert assessment skills must be developed and
A. “I am going to use a regular-bristle toothbrush.” used to provide the best care for patients with acute
B. “I will take antibiotics prior to having my teeth and chronic respiratory problem.
cleaned.” 92. A nurse understands that a safe but low level of
C “I can take enteric-coated aspirin for my oxygen saturation provides for adequate tissue
headache.” saturation but allows no reserve for situations that
D. “I will wear a medic alert band at all times.” threaten ventilation. A safe but low oxygen
87. The client diagnosed with a pulmonary embolus saturation level is:
is being discharged. Which intervention should the a. 40 mm Hg c. 80 mm Hg
nurse discuss with the client? b. 75 mm Hg d. 95 mm Hg
A. Increase fluid intake to two (2) to three (3) liters a 93. Breath sounds that originate in the smaller
day. bronchi and bronchioles and are high-pitched,
B. Eat a low-cholesterol, low-fat diet. sibilant, and musical are called:
C. Avoid being around large crowds. a. wheezes c. rales
D. Receive pneumonia and flu vaccines. b. rhonchi d. crackles
88. The client is getting out of bed and becomes very 94. Nursing directions to a patient from whom a
anxious and has a feeling of impending doom. The sputum specimen is to be obtained should include all
nurse thinks the client may be experiencing a of the following EXCEPT directing the patient to:
pulmonary embolus. Which action should the nurse A. initially clear his or her nose and throat.
implement first? b spit surface mucus and saliva into a sterile
A. Administer oxygen ten (10) L via nasal cannula. specimen container.
B. Place the client in a high Fowler’s position. C. take a few deep breaths before coughing.
C. Obtain a STAT pulse oximeter reading. d. use diaphragmatic contractions to aid in the
D. Auscultate the client’s lung sounds. expulsion of sputum.
89. The nurse suspects the client may be developing 95. A patient is admitted to the clinical area for a
ARDS. Which assessment data confirm the diagnosis thoracentesis. For this procedure, the patient is
of ARDS? assisted to any of the following positions, EXCEPT:

7
A. Lying on the unaffected side with the bed elevated Metabolic alkalosis d. Respiratory alkalosis
30 to 40 degrees
B. Lying prone with the head of the bed lowered 15
to 30 degrees FLUIDS AND ELECTROLYTES
C Sitting on the edge of the bed with her feet
supported and her arms and head on a padded Fluids and Electrolyte Imbalances
overbed table
D. Straddling a chair with her arms and head resting Situation: Nurse Amythist is dealing with patients
on the back of the chair with problems to fluids and electrolytes. For effective
intervention and management, she reviews her fluids
SITUATION :The nurse must have perfect skills, an and electrolytes homeostasis.
understanding of the wide variety of disorders that
may affect the airway, and an awareness of the 1. Which among the following is a correct principle?
impact of these alterations on patients. A. Females have higher fluid status compared to
males.
96. Airway clearance in a patient with an upper B. Majority of the newborn's fluids composition
airway infection is facilitated by all of the following, belongs to the interstitial fluid compartment.
EXCEPT: C. Higher percentage of adipose tissue will increase
A. Decreasing systemic hydration the chance of fluid maintenance.
B. Humidifying inspired room air D. The average adult fluid is approximately 60% of
C. Positional drainage of the affected area the his body weight.
D. Administering prescribed vasoconstrictive 2. The ratio of the intracellular fluid compared to
medications extracellular fluid is:
97. When oxygen therapy is being used, “No A. The ICF is inversely proportional to ECF
Smoking” signs are posted, because oxygen: B. ECF IS 10-20% higher than the ICF
A. Is combustible C. ICF is 60-70% of body weight while ECF is only 20-
B. Is explosive 30%
C Prevents the dispersion of smoke particles D. ICF and ECF contains the same amount of fluids
D Supports combustion 3. Which is true about second-fluid-shifting found in
peripheral edema and ascites?
SITUATION: Chronic pulmonary disorders are a A. When the plasma osmolality is higher than the
leading cause of morbidity and mortality in the interstitial osmolality edema will result
Philippines. B. When the interstitial oncotic pressure is higher
98. The pathophysiology of emphysema is directly than the plasma oncotic pressure edema will result
related to airway obstruction. The end result of C. When the interstitial osmolality is higher than the
deterioration is: plasma osmolality edema will result
A. Diminished alveolar surface area D. When the plasma oncotic pressure is higher than
B. Hypercapnia resulting from decreased carbon the interstitial oncotin pressure edema will result
dioxide 4. Which among the following principles of fluid
C. Hypoxemia secondary to impaired oxygen movement is correctly stated?
diffusion A. Osmosis is movement of water from an area of
D Respiratory acidosis due to airway obstruction low to high solutee concentration
99. The method of oxygen administration primarily B. Diffusion is movement of fluid from an area of low
used for patients with COPD is: to high molecular component
A. A nasal cannula C. Active transport is movement of subtances
B. An oropharyngeal catheter without energy utilization
C A nonrebreather mask D. Filtration is from an area of low hydrostatic
D. A venture mask pressure to high hydrostatic pressure
100. Obstruction of the airway in the patient with 5. Cations are electrolytes that carry positive
asthma is caused by all of the following, EXCEPT: charges. Which is the most abundant electrolyte in
A. Thick mucus the ECF?
B. Swelling of bronchial membranes a. Potassium c. Sodium
C. Destruction of the alveolar wall b. Magnesium d. Calcium
D. Contraction of muscles surrounding the bronchi 6. Which among the following types of intravenous
101. The nurse understands that a patient with fluid solution/s is considered to be isotonic?
status asthmaticus will likely initially evidence A. PNSS C. PLR
symptoms of: B. D5W D. AOTA
Metabolic acidosis c. Respiratory acidosis

8
7. Which among the following patients with fluid 14. The physician has advised the patient to undergo
volume deficit will the nurse monitor for the fastest grafting of the areas that incurs 3rd and 4th degrees.
improvement provided that they have been manage The type of grafting that will least likely result into
at the same time? rejection is:
A. A 40- year old with 25% TBSA is given normal A. Allograft C. Xenograft
saline solution. B. Heterograft D. Autograft
B. An infant with severe dehydration hooked with 15. When the donor tissue is obtained from a person
Ringer's Lactate solution not related to the patient, the type of grafting used
C. A middle-adult male who had an overdose of is:
diuretic managed with D5W. A. Xenograft C. Heterograft
D. A plasma expander is given to a patient with B. Autograft D. Allograft
diagnosis of diabetes insipidus
Situation: You are assigned to the medical ward with
Situation: A 25-year old male working on a factory variety of patients whose conditions are related to
was rushed to the emergency department with burn fluids and electrolytes imbalances. You are
injury. Areas of burn includes the anterior trunk, responsible for the assessment and management of
anterior aspect of the head, and anterior portion of these conditions. The following questions may be
the right upper and right lower extremities. The applied.
nurse should intervene on this situation.
8. The nurse utilizes the rule of nines for the total 16. One patient has been receiving PNSS. You have
body surface area burned. Based on this situation, noticed that the doctor's order reads the IVF shoukd
the approximate percentage of TBSA is: be given at KVO rate. The nurse assigned prior to
A. 30% C. 36‰ your shif has given 5-Liters of the solution. Which
B. 45% D. 27% laboratory finding will be expected on thia situation?
9. During the emergent phase of burn injury, the A. Hypocalcemia C. Hypercalcemia
nurse should intervene by administering intravenous B. Hyponatremia D. Hypernatremia
fluids within 24 hours. If the patient weighs 122.6lbs, 17. With the same situation in number 16, the nurse
the total amount of fluids to be given during this appropriately anticipate to administer what IVF
period is: solution?
A. 8000ml C. 8025ml A. PNSS incorporated with potassium chloride.
B. 7000ml D. 7025ml B. D5W diluted with 5% dextrose to be infused slowly
10. The nurse also assess the area burned and C. 0.45%NaCl diluted with 5%dextrose to be infused
noticedl that a large area of blister formation has rapidly
been noted. Which other manifestations are D. Any type of hypertonic solution will reverse the
consistent to this type of burn according to degree? electrolyte imbalance
A. Redness, pruritus and mild pain
B. Painful burning sensation due to dermal layer
damage
C. Mild pain including subcutaneos layer damage
D. Painless sensation, with gangrenous muscles and
bones tissue
11. Which laboratory finding can be observed to the
emergent phase of burn?
A. Hypokalemia and hypernatremia
B. Hypokalemia and hyponatremia
C. Hyperkalemia and hyponatremia
D. Hyperkalemia and hypernatremia
12. Which among the following complication/s can
be observed on a patient who is severely burned?
A. Acute tubular necrosis C. Curling's ulcer
B. Acute Renal failure D. AOTA
13. When the patient's fluid volume has been
replaced succesfully, your priority nursing diagnosis
following emergent phase is?
A. Fluid Volume Excess C. Risk for injury
B. Risk for infection D. Altered tissue
perfusion