MEDSURG Test Bank

Situation 1: Rica, a Pediatric Cardiovascular Nurse is assigned to take care of 3 children in her unit. She just admitted a
12-year-old female patient suffering from Rheumatic Fever (RF)

1. When doing an assessment, which ONE of the following conditions is NOT present based on the Jones Criteria?
A. Erythema marginatum
B. Subcutaneous nodules
C. Chorea
D. Bronchopneumonia

2. In Rheumatic fever, the factor contributory to the development of this disease process is brought about by:
A. auto-immune reaction to streptococcal infection
B. auto-immune reaction to collagen diseases
C. parents had rheumatic heart disease
D. exposure to colds and droplet infection

3. Leny, 6 years old, is receiving digitalis for having Patent Ductus Arteriosus with heart failure. Prior to the
administration of the medicines, which of the following nursing actions should be done by nurse Rica?
A. Take the carotid pulse rate for one full minute.
B. Take the heart rate for one full minute.
C. Take the respiratory rate.
D. Take the blood pressure.

4. While nurse Rica was doing her regular rounds, one of the mothers approached her saying that her child who has a
Tetralogy of Fallot preferred to squat on bed rather than assuming a supine position. The BEST action of the nurse is:
A. let the mother continue the position of her child if she feels comfortable with it
B. divert the child's attention by letting her join the nurses’ rounds
C. put her on bed and start to administer oxygen inhalation
D. discourage the child and let her lie on bed with 2 pillows instead

5. Another patient in the Unit is Letty, 8 years old, waiting to be scheduled for surgery because of a Coarctation of the
Aorta. With this disorder, Letty will manifest which one of the following symptoms?
A. Murmur and bruit of the lungs.
B. Central and peripheral edema.
C. Hypertension and diminished pulses in the extremities.
D. Hepatomegaly and shortness of breath.

Situation 2: Mr. Joe is 55-year-old, married, a car dealer has consulted the ER because of fever, indigestion, weight loss,
right abdominal pain, body malaise, and itchiness of the skin. Based on the health history the patient has been a chain
smoker and drinks alcoholic beverages almost every day especially when he has clients to entertain. His physical
examination showed he has a suspected liver cirrhosis. He was advised for admission for further work-up and treatment.

6. In your observational data, what additional EARLY SIGN of liver cirrhosis do you expect patient to manifest?
A. Gonadal atrophy
B. Hypotension
C. Splenomegaly
D. Ankle edema

7. You are the nurse on duty when Mr. Joe was admitted in the pay floor. In which of the following statements is TRUE of
liver cirrhosis?
1. Nutritional deficiency with decreased protein intake contributes to liver damage
2. cirrhosis can happen to people with alcohol intake.
3. Women are at greater risk for the development of alcohol-induced liver disease.
4. Most patients affected by liver cirrhosis are between 40 to 60 years of age.
A. 1, 2, 3 & 4
B. 1 & 2
C. 1, 2& 3
D. 2&3

8. During Mr. Joe's confinement he developed further itchiness of the skin and jaundice. Which of the following nursing
actions is NOT recommended as this will induce skin breakdown?
A. Add baking soda when bathing the patient.
B. Massage the skin with emollients every 2 hours.
C. Use of commercial soaps and alcohol-based 1otions.
D. Rub the itchy skin with knuckles instead of using the nails.
9. At early stage of Mr. Joe's disease process, the physician ordered this SPECIFIC diet for Mr. Joe. You emphasized to
the dietitian that he should be served foods that is
A. high carbohydrate and low sodium
B. high calorie and high carbohydrate
C. low protein and high fat
D. high protein and high fat

10. Mr. Joe started to develop ascites and complained of heaviness of the lower extremities to the physician. An order of
Spironolactone (Aldactone) 25 mg./day What adverse effect of the drug should you monitor?
A. Irregular pulse rate
B. Hypokalemia
C. Hyperkalemia
D. Palpitation

Situation 3 Mr. Perez is a surgical nurse in a medical center and he had been practicing for almost five years in this unit.
The staff go on shift rotation. For that shift, he had two patients for operation. One is for Lobectomy and another is for
Nephrectomy.

11. When is the BEST time for the operative consent be signed by his patients?
A. As soon as the surgical procedure is explained to the patient.
B. On admission when the relatives are around.
C. A day before the surgery
D. Before any pre-op medications are administered.

12. Which of the following nursing goals are achieved when early ambulation is done by post-surgery patients?
1. improved circulation
2. improved respiratory functions
3. prevent venous stasis
4. prevent emboli formation
A. 3 and 4
В. 1, 2, 3, 4
C. 1, 3, 4
D. 1 and 2

13. Which of the following patients is MOST at risk during the induction of anesthesia?
A. 6-year-old with history of allergy
B. 65 year old diabetic woman
C. 35 year old TB case
D. 25 year old Polio Case

14. As a circulating nurse, which of the following is your PRIORITY nursing action to promote safety of your patient?
A. Prevent peri-operative position injury
B. Provide adequate lighting during the procedure.
C. Optimize surgeon's access to surgical site
D. Maintain surgical aseptic technique during the procedure.

15. Being the nurse in the Post-Anesthesia Care Unit, which of the following is your PRIORITY Concern after surgery?
A. monitor vital signs
B. observe surgical site for bleeding
C. validate doctor's orders
D. check level of consciousness

Situation 4 - Lydia is a staff-nurse working in medical unit with several patients suffering from cardiovascular and
peripheral disorders

16. There are several factors contributory to the development of these conditions. which of the following are the
PRIORITY causative factors that should be emphasized by Nurse Lydia in her health teaching?
A. Cigarette smoking and hyperlipidemia.
B. Aging process and alcohol intake
C. Stress and over-acidity
D. Sedentary life and obesity

17. Mr. Jacob is admitted due to congestive heart failure. Nurse Lydia would expect that if the failure is on the right side
of the heart, the patient will manifest which of the following?
A. Jugular vein distention.
B. Crackles on auscultation.
C. Dry productive cough.
D. Orthopnea

18. The patient has been receiving Digoxin 0.25 mg per day to regulate his heart rate. Which of the following outcomes
would indicate that this medication is achieving its desired effect?
A. Improved appetite.
B. Increased pedal edema.
C. Increased urine elimination.
D. Improved bowel elimination.

19. The other patient of Ms. Lydia is suffering from Buerger's disease. He has been complaining of intermittent
claudication of the lower extremities which has been giving him so much discomfort. What is the BEST nursing action
she should perform to address the patient's complaint?
A. Allow the patient to lie flat on bed
B. Teach him foot care and leg exercises.
C. Place affected extremities in a dependent position.
D. Apply hot water bag to the affected extremities.

20. Which of the following information is NOT True of Buerger's disease?

A. Small and medium arteries and veins are mostly affected.
B. Smoking is a major cause of Buerger's disease.
C. Incidence of Buerger's disease is high in men than women.
D. A strong relationship exists between diabetes and Buerger’s disease

Situation - Melanie, 58-year-old, beautician has undergone bowel obstruction surgery. During her first day post-op, she
vomited clear liquids about three times during your shift. Her vital signs include: temp- 37.9 degrees C, BP- 138/84, PR-
78/min and RR- 26/min. Her surgical incision is intact, slight bleeding, swelling and tenderness with slight pain.

21. Which of the following manifestations would indicate the development of wound infection?
A. Presence of elevated red blood cells count.
B. Profuse and increasing perspiration.
C. Increased blood pressure, respiratory rate and pulse rate.
D. Increasing pain on the surgical incision.

22. If the wound drainage is serosanguineous, it means the secretion is colored

A. yellow-tinged
B. pinkish-red
C. green-tinged
D. bright red

23. Later during the day, Melanie became confused, started to pull out her IV fluids as well as her wound dressings.
Complained of severe pain over the wound area. The PRIORITY action of the Nurse is to
A. apply sterile dressings over the surgical wound
B. call the surgeon at once for the health status of the
patient
C. administer the pain medication at once
D. restrain the hands of the patient

24. The drug of choice of pain relief to patient Melanie considering the Score of 8 which was assessed by the nurse based
on the rating scale of 0-10 (0-1owest, 10 is the highest) is
A. morphine S04
B. ibuprofen
C. demerol
D. paracetamol

25. When a patient is receiving opioid medication, the nurse should observe complications from the side effects by:
A. checking for the presence of loose bowel movement
B. observing signs and symptoms of addiction
C. assessing changes of circulatory status
D. assessing wakefulness of the patient at least every 2 hours

Situation 6 Nurse Aida is assigned in the Surgical Ward of a Tertiary Medical Center with several patients who are for
diagnostic tests and for surgery.

26. Mr. Rustom, 38 years old, is scheduled for Laparoscopic Cholecystectomy in the morning the next day. He verbalizes
to you and says, "Dr. Alex will open me up to remove my gallstone?" Which of the following is your BEST response?
A. Let us discuss with the surgeon your operation before you go to the OR.
B. "I know the surgeon will remove your stones with a new technique.
C. "Let me call the OR supervisor to discuss the procedure with you.
D. "I will call the anesthesiologist to explain more the
procedure.

27. A critical component before Mr. Rustom goes for surgery is the nurse preoperative teaching. Which of the following is
NOT advisable prior to surgery?
A. Teach him deep breathing exercises.
B. Fast at midnight, but can drink water if he becomes thirsty.
C. Instruct him to void before going to the operating room
D. Teach him leg and coughing exercises

28. After 5 days, Mr. Rustom is ready to go home. His discharge instruction includes observations of the fo1lowing
complications, EXCEPT:
A. Palpitation
B. Loss of appetite
C. Increased body temperature
D. Bleeding

Situation 8 Mr Bang, 62 year old, an Executive of a shoe company was brought to the hospital after having vomited bright
red blood immediately after supper. He claimed he had drinking session with his former
classmates in college. He was already advised by their family physician not to drink alcohol due to a suspected fatty liver.
You are the nurse-on -duty when he was admitted.

29. Based on your assessment and history taking for Mr Bang which PRIORITY findings should you document and report
to the physician?
A. Use of anti-inflammatory drugs.
B. Vital signs BP-140/90, PR-88/min.RR- 24 / min.
C. abdominal pain 3 in a scale of 10).
D. Tense, rigid abdomen.

30. You have formulated your Nursing Diagnosis for the patient and wrote in
the nursing care plan Which ONE of the following?
A. Deficient Fluid Volume R/T Vomiting of blood and gastric secretion.
B. Non-compliance R/T alcohol and medication intake.
C. Fear of death R/T unknown cause of bleeding.
D. Risk for Aspiration R/T active bleeding.

Situation - Mr. Alba, 62 yr. old, an executive of a construction firm was admitted in a nearby tertiary hospital because of
sudden severe abdominal pain. After completing the physical examination he was
advised to be admitted for a suspected abdominal aneurysm.

31. When a patient is suffering from abdominal aortic aneurysm, the clinical manifestations likely to be present are the
following EXCEPT
A. severe mid-abdominal and lumbar back pain
B. pulsating abdominal mass
C. ischemic pain not relieved by rest
D. cool cyanotic extremities in the iliac arteries

32. In order to confirm the diagnosis, an abdominal ultrasonography was ordered which revealed rupture of the blood
vessels. To decrease the amount of gas in the bowel, the patient has to fast for how long PRIOR to the procedure?
A. 5-7 hours
B. 13 -24
C. 4-6 hours
D. 8-12 hours

33. The anesthesiologist visited the patient and informed him that a moderate sedation will be used during surgery. Which
of the following are the responsibilities of the health team with this type of anesthesia? Continual assessment of

1. vital signs
2. level of consciousness
3. cardiac function
4. respiratory function
A. 1& 2
B. 2 & 3
C. 1, 2,3 & 4
D. 1, 2 & 3

34. Immediately after surgery, the PRIORITY complication that has to be watched by the nurse is
A. renal failure
B. impotence
C. infection
D. hemorrhage

Situation 9 – Nurse Norma is assigned on a 3-11 shift in the female medical Ward of a Tertiary Hospital. Patient Alma has
been complaining of excruciating abdominal pain and was asking for pain medication. She was referred to the physician
on duty (POD) for an immediate relief of pain.

35. In addition to the identification bracelet worn by the patient, how can the nurse on duty (NOD) verify the identity of
her patient when administering the drugs?
A. Ask the question, "Are you Ms. Alma?"
B. Read the patient's name at the foot of the bed.
C. Ask the patient's name from the watcher.
D. Ask the patient's husband's name

36. The physician orders a PRN pain medication to patient Alma. When will Nurse Norma administer a PRN drug?
A. A standing order is carried out as discontinued for another order.
B. When the physician writes the sheet specified until
drug as needed in the order
C. A single dose of the drug carried out by the nurse at a time specified by the physician
D. An order written by the physician that has to be carried out immediately.

37. When a patient is in pain, what PRIORITY consideration should Nurse Norma observe?
A. Goal of treatment of the health professionals.
B. Perception of pain of the individual.
C. Harmful effects of the drugs.
D. Cost of the pain medication.

38. Prior to the administration of pain medication, Nurse Alma assesses the degree of the pain of patient before and after
the drug administration. Using the numeric scale of 0-10 (0 is the lowest and 10 is the highest) on pain, when the patient
has rated her pain as 7 it means it is
A. severe
B. tolerated
C. slight
D. moderate

Situation 10 Communication is a basic component of person to person relationship. In the clinical setting nurses are
evaluated by patients to be efficient in carrying out activities of daily living but sometimes limited in employing routine
bedside care.

39. Nurse Helen is taking care of an older person and has been waiting for almost two hours for her son to arrive. She is
ready for discharge. Which of the following statements is an example of a therapeutic communication?
A. "I can call your son by cellphone to remind him that you are waiting."
B. "Your son must be in a traffic jam right now."
C. "I'1l stay with you until your son arrives."
D. "Would you want to watch the television while waiting.

40. You are teaching 66-year-old male diabetic client about the effects of insulin. He is ready for discharge the next week.
Which of the following is a statement of a helping relationship with the patient?
A. "In a few days I'l1 review what you have learned about actions and effects of your insulin."
B. "You keep on forgetting what I said but I will try to repeat some of them.
C. "I already mentioned those actions and effects of Insulin, I think you forgot some of them."
D. "Would you like me to discuss the information to your wife? She can assist you?

Situation 11 Len, a 35 year old dressmaker has been experiencing recurrent episodes of abdominal pain, nausea and
vomiting and feels her stomach is bloated. She has been taking contraceptive pills in the past. She is married with three
children. She consulted the OPD and was advised by the physician to be admitted for suspected Pancreatitis

41. Nurse Gladys started her admission care to Ms. Len. Which of the following laboratory examinations do you expect
the physician to order for the patient?
A. Serum lipase and Amylase
B. Creatinine & Phosphate
C. Serum Transaminase
D. Urea Nitrogen Substance

42. As a Nurse, which of the following assessment data you will MOST likely NOT to find on patient Len?
A. Abdominal and back pain with tenderness
B. Cramping pains before intake of heavy meals.
C. Pain unrelieved by intake of antacids
D. Mid-epigastric pain acute in onset after heavy meals

43. The MOST useful diagnostic test to validate whether Ms. Len is suffering from Pancreatitis is for her to undergo
A. Endoscopic Retrograde Cholangio-Pancreatography
B. Endoscopic Ultrasound
C. Percutaneous Transhepatic Cholangiography
D. Cholesterol Serum level

44. When managing a patient with Acute Pancreatitis the first PRIORITY is to:
A. insert urinary catheter for adequate elimination
B. encourage oral fluids to improve elimination
C. insert nasogastric tube to decompress stomach
D. administer IV fluids to replace electrolytes lost

45. One of the SAFETY alerts that the Nurse-on-duty (NOD) will have to watch for patient with Acute Pancreatitis is
A. Diabetes Insipidus
B. Respiratory distress
C. Hypercalcemia
D. Pericarditis

Situation 12 Norilee, an accountant, 29 years old was rushed by her husband in the ER because of body weakness,
palpitation, confusion and diaphoresis. Her blood glucose is 450 mg./dl with fruity acetone
smell on her breath. She was diagnosed to be suffering from type I diabetes mellitus 6 months ago.

46. Which of the following are the clinical characteristics of Type I diabetes mellitus EXCEPT
A. Often have islet cell antibodies
B. Ketosis prone when insulin is absent
C. Onset any age, above 30 year old, usually obese
D. Onset any age, below 30 year old, usually thin
of fruity

47. Patient Norilee upon admission has a breath characteristic acetone, this is brought about by the presence of
A. lactic acids
B. uric acid
C. nitric acid
D. ketoacids

48. Based on the presenting manifestations of patient Norilee, you expect that the physician will likely order which of the
following treatment?
A. 50% Dextrose
B. D5 Lactated ringers
C. Dextrose 10% in water
D. Normal Saline solution

49. When caring for patient Norilee, which of the following should be included in your teaching plan?
1. Signs and symptoms of hypoglycemia
2. Self-glucose monitoring
3. Administration of insulin
4. Meal planning and exercise

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

50. When formulating a Nursing diagnosis for Ms Norilee who is suffering from type I diabetes mellitus with
ketoacidosis, which of the following will be the top PRIORITY?
A. Impaired tissue integrity
B. Deficient fluid volume
C. Imbalanced nutrition
D. Risk for infection

51. The nurse teaches the client that which of the following meals would be best on her low cholesterol diet?

a. Hamburger, salad and milkshake

b. Baked liver, green beans, and coffee
c. Spaghetti with tomato sauce, salad and coffee
d. Fried chicken, green beans and skim milk

52. While caring for a client who has sustained an MI, the nurse notes eight premature ventricular contractions (PVCs) in
1 minute on the cardiac monitor. The client is receiving an intravenous infusion of 5% dextrose in water and 2 liters
/minute of oxygen. The nurse’s first course of action would be to:

a. Increase the intravenous infusion rate.

b. Notify the physician promptly
c. Increase the oxygen concentration
d. Administer a prescribed analgesic

53. Which among the following interventions should you consider as the highest priority when caring for June who has
hemiparesis secondary to stroke?
a. Place June on an upright lateral position
b. Perform range of motion exercise
c. Apply anti embolic stockings
d. Use hand rolls or pillows for support

54. Which of the following techniques does the nurse avoid when changing a client’s position in bed if the client is
hemiplegic?
a. Rolling the client onto her side.
b. Sliding the client to move her up in bed.
c. Lifting the client when moving her up in bed.
d. Having the client help lift herself off the bed using a trapeze.

55. The patient reveals a Glasgow Coma Scale of: Motor Response - 5; Verbal Response - 3; Eye Opening – 2. What is the
level of consciousness of the patient?
a. Conscious
b. Lethargy
c. Stupor
d. Coma

56. The patient reveals a Glasgow Coma Scale of: Motor Response - 6; Verbal Response - 3; Eye Opening – 3. What is the
level of consciousness of the patient?
a. Conscious
b. Lethargy
c. Stupor
d. Coma

57. Jose, 40 year old with chronic renal failure. An arteriovenous fistula was created for hemodialysis in his left arm.
What diet instructions will you need to reinforce prior to his discharge?

a. Drink plenty of water

b. Restrict your salt intake
c. Monitor fruit and vegetable intake
d. Be sure to eat meat every meal

58. A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis
for the treatment of chronic renal failure. Which finding indicates that the fistula is patent?
a. absence of bruit on auscultation of the fistula
b. palpitation of a thrill over the fistula
c. presence of a radial pulse in the left wrist
d. capillary refill less than 3 seconds in the nail beds of the finger on the left hand

59. Which nursing intervention is of primary importance in blood transfusion?

a. Identifying the client

b. Checking the flow rate
c. Monitoring the vital signs
d. Maintaining the blood temperature

60. After a car accident, a patient is anxious & dyspneic w/ severe pain. The left chest wall moves in during inspiration &
balloons out when he exhales. These are symptoms of:
a. Hemothorax
b. Pleural effusion
c. Atelectasis
d. Flail Chest

61. When caring for a client with an endotracheal tube, the nurse should consider w/c action most important?
a. Auscultate the lungs for bilateral breath sounds.
b. Turn the client from side to side every 2 hours.
c. Monitor serial blood gas values every 4 hours.
d. Provide frequent oral hygiene.

62. The nurse is assessing the client’s respiratory status. Which of the ff symptoms maybe an early indicator of hypoxia in
the unconscious client?
a. Cyanosis
b. Decreased respirations
c. Restlessness
d. Hypotension

63. After a left pneumonectomy, a client has a chest tube in place for drainage. For this client, the nurse must:
a. Monitor fluctuations in the water-seal chamber.
b. Clamp the chest tube once every shift.
c. Encourage coughing and deep breathing.
d. Milk the chest tube every 2 hours.

64. The nurse is aware that an oral or IV glucose tolerance test would not generally be performed on:
a. An obese person
b. A pregnant woman
c. A known diabetic
d. A cancer survivor

65. To help establish a diagnosis of acute closure glaucoma, which symptoms would the client describe?
a. Severe sudden onset of eye pain
b. Progressive loss of the ability to see “on the side”
c. Intermittent “dry eyes” with lack of tears
d. Early morning headaches

66. The nurse is caring for clients in the ER of an acute care facility. Four clients have been admitted in the last 20
minutes. Which of the admissions should the nurse take first?
a. A client complaining of chest pain unrelieved by nitroglycerine.
b. A client with third-degree burns to the face.
c. A client with a fractured left hip.
d. A client complaining of epigastric pain.

67. Maria sustained circumferential thermal burns of the left upper extremity and chest. You noted that pulse could not
be appreciated in his injured extremity. Which of the following will you do FIRST?
a. Elevate the injured extremity to increase blood flow to the heart
b. Remove dead tissues which impede circulation
c. Try to take the pulse in the uninjured extremity.
d. Notify the physician immediately

68. The extent of burns in children are normally assessed and expressed in terms of:
a. the amount of body surface that is unburned
b. percentages of total body surface area (TBSA)
c. how deep the deepest burns are
d. the severity of the burns on a 1 to 5 burn scale

69. You are in the emergency ward caring for patients with burns. What is the nursing priority for burn?
a. infection
b. airway
c. pain
d. fluids and electrolytes

70. The client w/ acute renal failure has a serum potassium level of 5.8 mEq/L. The nurse would plan w/c of the following
as a priority action?
a. increase fluid intake to dilute potassium
b. encourage increase vegetables in the diet
c. place the client on a cardiac monitor
d. check the sodium level

71. A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak & irregular,
&BP of 80/50 and is weak, mildly confused, and has a serum potassium of 3.0 mEq/L. Based on the assessment data, w/c
of the following is the priority intervention?
a. Administer prescribed potassium supplement
b. Notify the physician
c. Instruct the client on foods high in potassium
d. Withhold furosemide (Lasix)

72. A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will
teach the patient to report symptoms of adverse effects such as:
a. generalized weakness
b. facial muscle spasms
c. frequent loose stools
d. personality changes

73. A patient who has been receiving diuretic therapy is admitted to the ED with a serum potassium level of 3.1 mEq/L.
Of the following medications that the patient has been taking at home, the nurse will be most concerned about
a. metoprolol (Lopressor) 12.5 mg orally daily.
b. lantus insulin 24 units SQ every evening.
c. oral digoxin (Lanoxin) 0.25 mg daily.
d. ibuprofen (Motrin) 400 mg every 6 hours

74. The nurse working in the emergency department (ED) admits a patient with renal failure and a serum potassium level
of 8.0 mEq/L. All these orders are received from the health care provider. W/c order will the nurse implement first?
a. Place the patient on a cardiac monitor.
b. Insert a retention catheter
c. Administer Kayexalate 15 g orally.
d. Give IV furosemide (Lasix) 40 mg.

75. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by
the patient indicates that the teaching about this medication has been effective?
a. "I can have low-fat cheese."
b. "I will have apple juice instead of orange juice."
c. "I will drink at least 8 glasses of water every day."
d. "I can use a salt substitute."

76. The nurse assesses a client to be experiencing muscle cramps, numbness, tingling of extremities, & twitching of the
facial muscle & eyelid when the facial nerve is tapped. The nurse reports this assessment as consistent with which of the
following?
a. hypokalemia
b. hypernatremia
c. hypocalcemia
d. hypermagnesemia

77. To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for hypocalcemia, an early sign of
hypocalcemia the nurse should assess for is:
a. weak hand grips
b. confusion
c. constipation
d. lip numbness

78. A patient with renal insufficiency develops lethargy and somnolence with a BP of 100/60, PR 62, & RR 10. The nurse
notes that the patient has been taking an aluminum hydroxide/magnesium hydroxide suspension (Maalox) for
indigestion. The nurse anticipates that management of the patient will include IV administration of:
a. magnesium sulfate
b. potassium chloride
c. calcium gluconate
d. sodium chloride
79. A patient with hypercalcemia is being cared on the medical unit. Nursing actions included on the care plan will
include:
a. maintain on bedrest to prevent pathologic fractures.
b. monitoring for Trousseau's and Chvostek's signs
c. encouraging fluid intake up to 4L every day.
d. auscultate breath sounds every 4 hours.

81. Nurse Yolan assesses the client for depression. Which of the following is a key indicator for clinical depression?
A. Anger due to pain experience.
B. Feeling of excessive guilt.
C. Anorexia and weight loss
D. Inability to care for one's physical self.

82. The client has difficulty sleeping. Which of the following interventions is LEAST helpful for Nurse Yolan to incorporate in
her care plan?
A. Instruct the client to drink herbal tea.
B. Give warm milk at bedtime
C. Perform relaxation routine such as massage, imagery or music
D. Instruct the client to drink black tea.

83. The care plan for the client includes family support. Which of the following is MOST appropriate for Nurse Yolan do for the
family to establish a relationship with the health care team?
A. Give permission to the family to take time to maintain friendship with the health care team.
B. Discuss the roles of the family members to the health care care team.
C. Explain the roles of all members of the interdisciplinary team.
D. Provide a brief explanation to the family member about the care being delivered to the client.

84. The client appears to be dehydrated. The family members are discussing whether their loved one should be given
intravenous fluid. Which of the following concepts about dehydration in terminally ill clients should guide Nurse Yolan?
A. Peripheral edema occurs because of fluid overload.
B. Thirst is an indication of dehydration.
C. Terminally ill clients are hydrated through oral and
intravenous routes.
D. All interventions for terminally ill client should be directed towards comfort and reduction of symptoms.

85. The client shows signs of imminent death. Nurse Yolan recognizes cardiovascular indicators of imminent death which are
the following EXCEPT:
A. bradycardia
B. irregular heart rate
C. tachycardia
D. lowered blood pressure

Situation - A 65-year old male is admitted for prostate cancer. On assessment, the nurse determines that the patient has
experienced incontinence. The nurse knows that incontinence is the first most common symptom of prostate cancer.

86. Based on information gathered, the nurse writes a nursing diagnosis. Which of the following diagnoses is MOST
appropriate?
A. Deficient knowledge related to self-care and risk prevention
B. Fear secondary to the diagnosis of cancer
C. Risk of urinary infection
D. Risk for impaired urinary elimination

87. To help manage incontinence, the nurse instructs the patient to do which of the following:
A. Eat foods rich in fiber
B. Increase fluid intake
C. Take in medications to manage pain
D. Perform perineal muscle exercises

88. The patient asks for treatment options for his condition. The nurse explains that treatment options are based on which of the
following:
A. gender
B. ability of the patient to implications of incontinence
C. Socio-economic status
D. grade and stage of the disease manage physical and emotional

Situation - A 34 year old female client complains of experiencing double vision and frequent headaches. The client claims to be
forgetful and has mood swings. A diagnosis of right frontal lobe lesion was made and the client was admitted for craniotomy.

89. The client claims to have a diagnostic work up in the out-patient unit before she was admitted. The admitting nurse prepares
the client for which of the procedure that wil1 MOST likely confirm the presence of brain tumor?
A. Myelogram
B. CT Scan
C. Lumbar puncture
D. Skull x-ray

90. While the client is being interviewed, she had a seizure. The initial intervention of the nurse must be directed towards:
A. Protecting the client.
B. Controlling the seizure.
C. Reducing circulation to the brain.
D. Restraining the client.

B. You can’t control or stop this. Just observe and do nursing intervention on seizure. Turn to side, protect head, not time started
& how long. Observe characteristic. Reorient.
C & D. Inappropriate

91. After surgery, it is important for the nurse to position the head of the client properly to:
A. Facilitate venous drainage.
B. Prevent hemorrhage on the suture line
C. Provide for client comfort.
D. Maintain patent airway.

92. The nurse is aware that one of the measures 1isted below is contraindicated in post-operative pulmonary toilet.
A. Suctioning
B. Deep breathing
C. Turning
D. Coughing

93. The surgeon orders glucocorticoid Dexamethasone (Decadron) to be given following craniotomy. The nurse recognizes that
this drug:
A. Creates a feeling of euphoria, which is beneficial in the early post-operative period.
B. Promotes excretion of water which aids in reducing ICP
C. Enhances venous return and thus reduce ICP.
D. Reduces cerebral edema thus reducing ICP

Situation – A nurse in the intensive care unit attends to a 20-year old female who was involved in a vehicular accident three
days prior to admission. The prognosis is very poor. No brain activity was detected after two electro encephalograms (EEGS)
were taken.

94. The family decides to wean the patient from the ventilator support. The family talks to the nurse about their decision to get
the nurses support. Which of the following actions is NOT appropriate? The nurse
A. checks the physician's orders for sedation and analgesia and make sure that the anticipated death is comfortable and
dignified
B. explains to the family what will happen at each phase of the weaning and offer support
C. tells the family that death will occur almost immediately after the patient is removed from the ventilator support
D. participates in the decision making process by offering the family information about the advantages and disadvantages of
continued ventilator support

95. Two hours after the ventilator support was discontinued, the patient dies. The nurse discusses with the family the possibility
of donating the deceased person's organs. The following are guidelines in organ or tissue donation.
1. Religious beliefs in organ donation and transplantation must be respected.
2. Donors must be free of infectious disease and cancer.
3. Consent or written orders by the physician are necessary for referral to an organ procurement organization.
4. The family of the deceased should be offered an opportunity to speak with a knowledgeable organ procurement coordinator
5. The person requesting for organ donation does not have to believe in the benefits of organ process with a positive attitude.

Which of the guidelines should the nurse observe?

A. 1,2,3,4,5
в. 1,2,4
C. 2,3,4
D. 1,3,5

96. The legal definition of death that facilitates organ donation is the cessation of
A. Function of the entire brain
B. Pulse
C. circulatory and respiratory functions
D. Respiration
97. The patient is pronounced dead by the physician. Which of the following nursing actions VIOLATES the standards of care
for a dead person?
A. Removing soiled dressing and tubes.
B. Keeping the dead person in a sitting position until the family has arrived and said their goodbyes.
C. Placing identification tags on both the shroud and the ankle
D. Preparing to transfer the body to the morgue

98. The family goes through the stages of grieving. What are the stages in the grieving process?
1. Acceptance
2. Depression
3. Denial
4. Bargaining
5. Anger

A. 3,5,1,4,2
B. 3,5,4,2,1
с. 1,5,3,4, 2
D. 1,2,5,4,3

Situation – A male teenager was wheeled in the Emergency Department (ED) with stab wound. The ED nurse suspects the
kidneys may have been injured.

99. The nurse assesses the patient for complications. Which are the MOST COMMON Complications?
1. Urinary leakage
2. Delayed bleeding from the damage
3. Abscess formation
4. Paralytic ileus
5. Renal failure

A. 2&5
B. 3&4
C. 1&2
D. 2 &3

100. The nurse knows that with renal trauma further complications may occur such as:
1. Secondary hemorrhage usually due to infection
2. Renal artery stenosis
3. Renal atrophy
4. Hypotension
5. Hydronephrosis
Which are the POSSIBLE Complications?
А. 2,3,4,5
B. 1,2,3,4,5
C. 1,2,3,5
D. 1,3,4,5