Download MCQ for Nursing Students 16

MCQs for Nursing Students 16
Medical Surgical Nursing
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1. Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid
colostomy when the stool is:
a. Green liquid
b. Solid formed
c. Loose, bloody
d. Semiformed
1. Answer: (C) Loose, bloody
Normal bowel function and soft-formed stool usually do not occur until around the
seventh day following surgery. The stool consistency is related to how much water is
being absorbed.
2. Where would nurse Kristine place the call light for a male patient with a right-sided brain
attack and left homonymous hemianopsia?
a. On the patient’s right side
b. On the patient’s left side
c. Directly in front of the patient
d. Where the patient like
2. Answer: (A) On the patient’s right side
The patient has left visual field blindness. The patient will see only from the right side.
3. A male patient is admitted to the emergency department following an accident. What are the
first nursing actions of the nurse?
a. Check respiration, circulation, neurological response.
b. Align the spine, check pupils, and check for hemorrhage.
c. Check respirations, stabilize spine, and check circulation.
d. Assess level of consciousness and circulation.
3. Answer: (C) Check respirations, stabilize spine, and check circulation
Checking the airway would be priority, and a neck injury should be suspected.
4. In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces preload and
relieves angina by:
a. Increasing contractility and slowing heart rate.
b. Increasing AV conduction and heart rate.
c. Decreasing contractility and oxygen consumption.
d. Decreasing venous return through vasodilation.
4. Answer: (D) Decreasing venous return through vasodilation.
The significant effect of nitroglycerin is vasodilation and decreased venous return, so
the heart does not have to work hard.
5. Nurse Patricia finds a female patient who is post-myocardial infarction (MI) slumped on the
side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?
a. Call for help and note the time.
b. Clear the airway
c. Give two sharp thumps to the precordium, and check the pulse.
d. Administer two quick blows.
5. Answer: (A) Call for help and note the time.
Having established, by stimulating the patient, that the patient is unconscious rather
than sleep, the nurse should immediately call for help. This may be done by dialing the
operator from the patient’s phone and giving the hospital code for cardiac arrest and the
patient’s room number to the operator, of if the phone is not available, by pulling the
emergency call button. Noting the time is important baseline information for cardiac
arrest procedure.
6. Nurse Monett is caring for a patient recovering from gastrointestinal bleeding. The nurse
should:
a. Plan care so the patient can receive 8 hours of uninterrupted sleep each night.
b. Monitor vital signs every 2 hours.
c. Make sure that the patient takes food and medications at prescribed intervals.
d. Provide milk every 2 to 3 hours.
6. Answer: (C) Make sure that the patient takes food and medications at prescribed
intervals.
Food and drug therapy will prevent the accumulation of hydrochloric acid, or will
neutralize and buffer the acid that does accumulate.
7. A male patient was on warfarin (Coumadin) before admission, and has been receiving heparin
I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do?
a. Stop the I.V. infusion of heparin and notify the physician.
b. Continue treatment as ordered.
c. Expect the warfarin to increase the PTT.
d. Increase the dosage, because the level is lower than normal.
7. Answer: (B) Continue treatment as ordered.
The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the
therapeutic level is 1.5 to 2 times the normal level.
8. A patient underwent ileostomy, when should the drainage appliance be applied to the stoma?
a. 24 hours later, when edema has subsided.
b. In the operating room.
c. After the ileostomy begin to function.
d. When the patient is able to begin self-care procedures.
8. Answer: (B) In the operating room.
The stoma drainage bag is applied in the operating room. Drainage from the ileostomy
contains secretions that are rich in digestive enzymes and highly irritating to the skin.
Protection of the skin from the effects of these enzymes is begun at once. Skin exposed
to these enzymes even for a short time becomes reddened, painful, and excoriated.
9. A patient undergone spinal anesthetic, it will be important that the nurse immediately position
the patient in:
a. On the side, to prevent obstruction of airway by tongue.
b. Flat on back.
c. On the back, with knees flexed 15 degrees.
d. Flat on the stomach, with the head turned to the side.
9. Answer: (B) Flat on back.
To avoid the complication of a painful spinal headache that can last for several days, the
patient is kept in flat in a supine position for approximately 4 to 12 hours
postoperatively. Headaches are believed to be caused by the seepage of cerebrospinal
fluid from the puncture site. By keeping the patient flat, cerebral spinal fluid pressures
are equalized, which avoids trauma to the neurons.
10. While monitoring a male patient several hours after a motor vehicle accident, which
assessment data suggest increasing intracranial pressure?
a. Blood pressure is decreased from 160/90 to 110/70.
b. Pulse is increased from 87 to 95, with an occasional skipped beat.
c. The patient is oriented when aroused from sleep, and goes back to sleep
immediately.
d. The patient refuses dinner because of anorexia.
10. Answer: (C) The patient is oriented when aroused from sleep, and goes back to sleep
immediately.
This finding suggest that the level of consciousness is decreasing.
11. Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may
appear first?
a. Altered mental status and dehydration
b. Fever and chills
c. Hemoptysis and Dyspnea
d. Pleuritic chest pain and cough
11. Answer: (A) Altered mental status and dehydration
Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are the common
symptoms of pneumonia, but elderly patients may first appear with only an altered
lentil status and dehydration due to a blunted immune response.
12. A male patient has active tuberculosis (TB). Which of the following symptoms will be exhibit?
a. Chest and lower back pain
b. Chills, fever, night sweats, and hemoptysis
c. Fever of more than 104°F (40°C) and nausea
d. Headache and photophobia
12. Answer: (B) Chills, fever, night sweats, and hemoptysis
Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain
may be present from coughing, but isn’t usual. patients with TB typically have lowgrade fevers, not higher than 102°F (38.9°C). Nausea, headache, and photophobia aren’t
usual TB symptoms.
13. Mark, a 7-year-old patient is brought to the emergency department. He’s tachypneic and
afebrile and has a respiratory rate of 36 breaths/minute and has a nonproductive cough. He
recently had a cold. Form this history; the patient may have which of the following conditions?
a. Acute asthma
b. Bronchial pneumonia
c. Chronic obstructive pulmonary disease (COPD)
d. Emphysema
13. Answer: (A) Acute asthma
Based on the patient’s history and symptoms, acute asthma is the most likely diagnosis.
He’s unlikely to have bronchial pneumonia without a productive cough and fever and
he’s too young to have developed (COPD) and emphysema.
14. Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4
breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?
a. Asthma attack
b. Respiratory arrest
c. Seizure
d. Wake up on his own
14. Answer: (B) Respiratory arrest
Narcotics can cause respiratory arrest if given in large quantities. It’s unlikely the patient
will have asthma attack or a seizure or wake up on his own.
15. A 77-year-old male patient is admitted for elective knee surgery. Physical examination reveals
shallow respirations but no sign of respiratory distress. Which of the following is a normal
physiologic change related to aging?
a. Increased elastic recoil of the lungs
b. Increased number of functional capillaries in the alveoli
c. Decreased residual volume
d. Decreased vital capacity
15. Answer: (D) Decreased vital capacity
Reduction in vital capacity is a normal physiologic changes include decreased elastic
recoil of the lungs, fewer functional capillaries in the alveoli, and an increased in
residual volume.
16. Nurse John is caring for a male patient receiving lidocaine I.V. Which factor is the most
relevant to administration of this medication?
a. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse
oximeter.
b. Increase in systemic blood pressure.
c. Presence of premature ventricular contractions (PVCs) on a cardiac monitor.
d. Increase in intracranial pressure (ICP).
16. Answer: (C) Presence of premature ventricular contractions (PVCs) on a cardiac
monitor.
Lidocaine drips are commonly used to treat patients whose arrhythmias haven’t been
controlled with oral medication and who are having PVCs that are visible on the cardiac
monitor. SaO2, blood pressure, and ICP are important factors but aren’t as significant as
PVCs in the situation.
17. Nurse Ron is caring for a male patient taking an anticoagulant. The nurse should teach the
patient to:
a. Report incidents of diarrhea.
b. Avoid foods high in vitamin K
c. Use a straight razor when shaving.
d. Take aspirin to pain relief.
17. Answer: (B) Avoid foods high in vitamin K
The patient should avoid consuming large amounts of vitamin K because vitamin K can
interfere with anticoagulation. The patient may need to report diarrhea, but isn’t effect
of taking an anticoagulant. An electric razor-not a straight razor-should be used to
prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding;
acetaminophen should be used to pain relief.
18. Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse should treat
excess hair at the site by:
a. Leaving the hair intact
b. Shaving the area
c. Clipping the hair in the area
d. Removing the hair with a depilatory.
18. Answer: (C) Clipping the hair in the area
Hair can be a source of infection and should be removed by clipping. Shaving the area
can cause skin abrasions and depilatories can irritate the skin.
19. Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the patient,
the nurse should include information about which major complication:
a. Bone fracture
b. Loss of estrogen
c. Negative calcium balance
d. Dowager’s hump
19. Answer: (A) Bone fracture
Bone fracture is a major complication of osteoporosis that results when loss of calcium
and phosphate increased the fragility of bones. Estrogen deficiencies result
from menopause and not osteoporosis. Calcium and vitamin D supplements may be
used to support normal bone metabolism, But a negative calcium balance isn’t a
complication of osteoporosis. Dowager’s hump results from bone fractures. It develops
when repeated vertebral fractures increase spinal curvature.
20. Nurse Len is teaching a group of women to perform BSE. The nurse should explain that the
purpose of performing the examination is to discover:
a. Cancerous lumps
b. Areas of thickness or fullness
c. Changes from previous examinations.
d. Fibrocystic masses
20. Answer: (C) Changes from previous examinations.
Women are instructed to examine themselves to discover changes that have occurred in
the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness
or fullness that signal the presence of a malignancy, or masses that are fibrocystic as
opposed to malignant.
21. When caring for a female patient who is being treated for hyperthyroidism, it is important to:
a. Provide extra blankets and clothing to keep the patient warm.
b. Monitor the patient for signs of restlessness, sweating, and excessive weight loss
during thyroid replacement therapy.
c. Balance the patient’s periods of activity and rest.
d. Encourage the patient to be active to prevent constipation.
21. Answer: (C) Balance the patient’s periods of activity and rest.
A patient with hyperthyroidism needs to be encouraged to balance periods of activity
and rest. Many patients with hyperthyroidism are hyperactive and complain of feeling
very warm.
22. Nurse Kris is teaching a patient with history of atherosclerosis. To decrease the risk of
atherosclerosis, the nurse should encourage the patient to:
.
a. Avoid focusing on his weight.
b. Increase his activity level.
c. Follow a regular diet.
d. Continue leading a high-stress lifestyle
22. Answer: (B) Increase his activity level.
The patient should be encouraged to increase his activity level. Maintaining an ideal
weight; following a low-cholesterol, low sodium diet; and avoiding stress are all
important factors in decreasing the risk of atherosclerosis.
23. Nurse Greta is working on a surgical floor. Nurse Greta must logroll a patient following a:
a. Laminectomy
b. Thoracotomy
c. Hemorrhoidectomy
d. Cystectomy.
23. Answer: (A) Laminectomy
The patient who has had spinal surgery, such as laminectomy, must be log rolled to
keep the spinal column straight when turning. Thoracotomy and cystectomy may turn
themselves or may be assisted into a comfortable position. Under normal circumstances,
hemorrhoidectomy is an outpatient procedure, and the patient may resume normal
activities immediately after surgery.
24. A 55-year old patient underwent cataract removal with intraocular lens implant. Nurse Oliver is giving
the patient discharge instructions. These instructions should include which of the following?
a. Avoid lifting objects weighing more than 5 lb (2.25 kg).
b. Lie on your abdomen when in bed
c. Keep rooms brightly lit.
d. Avoiding straining during bowel movement or bending at the waist.
24. Answer: (D) Avoiding straining during bowel movement or bending at the waist.
The patient should avoid straining, lifting heavy objects, and coughing harshly because
these activities increase intraocular pressure. Typically, the patient is instructed to avoid
lifting objects weighing more than 15 lb (7kg) – not 5lb. instruct the patient when lying
in bed to lie on either the side or back. The patient should avoid bright light by wearing
sunglasses.
25. George should be taught about testicular examinations during:
.
a. when sexual activity starts
b. After age 69
c. After age 40
d. Before age 20
25. Answer: (D) Before age 20.
Testicular cancer commonly occurs in men between ages 20 and 30. A male patient
should be taught how to perform testicular self examination before age 20, preferably
when he enters his teens.
26. A male patient undergone a colon resection. While turning him, wound dehiscence with
evisceration occurs. Nurse Trish first response is to:
a. Call the physician
b. Place a saline-soaked sterile dressing on the wound.
c. Take a blood pressure and pulse.
d. Pull the dehiscence closed.
26. Answer: (B) Place a saline-soaked sterile dressing on the wound.
The nurse should first place saline-soaked sterile dressings on the open wound to
prevent tissue drying and possible infection. Then the nurse should call the physician
and take the patient’s vital signs. The dehiscence needs to be surgically closed, so the
nurse should never try to close it.
27. Nurse Audrey is caring for a patient who has suffered a severe cerebrovascular accident. During routine
assessment, the nurse notices Cheyne- Stokes respirations. Cheyne-stokes respirations are:
.
a. A progressively deeper breaths followed by shallower breaths with apneic periods.
b. Rapid, deep breathing with abrupt pauses between each breath.
c. Rapid, deep breathing and irregular breathing without pauses.
d. Shallow breathing with an increased respiratory rate
27. Answer: (A) A progressively deeper breaths followed by shallower breaths with
apneic periods.
Cheyne-Stokes respirations are breaths that become progressively deeper followed by
shallower respirations with apneas periods. Biot’s respirations are rapid, deep breathing
with abrupt pauses between each breath, and equal depth between each breath.
Kussmaul’s respirations are rapid, deep breathing without pauses. Tachypnea is shallow
breathing with increased respiratory rate.
28. Nurse Bea is assessing a male patient with heart failure. The breath sounds commonly
auscultated in patients with heart failure are:
a. Tracheal
b. Fine crackles
c. Coarse crackles
d. Friction rubs
28. Answer: (B) Fine crackles
Fine crackles are caused by fluid in the alveoli and commonly occur in patients
with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse
crackles are caused by secretion accumulation in the airways. Friction rubs occur with
pleural inflammation.
29. The nurse is caring for Kenneth experiencing an acute asthma attack. The patient stops
wheezing and breath sounds aren’t audible. The reason for this change is that:
a. The attack is over.
b. The airways are so swollen that no air cannot get through.
c. The swelling has decreased.
d. Crackles have replaced wheezes.
29. Answer: (B) The airways are so swollen that no air cannot get through
During an acute attack, wheezing may stop and breath sounds become inaudible
because the airways are so swollen that air can’t get through. If the attack is over and
swelling has decreased, there would be no more wheezing and less emergent concern.
Crackles do not replace wheezes during an acute asthma attack.
30. Mike with epilepsy is having a seizure. During the active seizure phase, the nurse should:
a. Place the patient on his back remove dangerous objects, and insert a bite block.
b. Place the patient on his side, remove dangerous objects, and insert a bite block.
c. Place the patient o his back, remove dangerous objects, and hold down his arms.
d. Place the patient on his side, remove dangerous objects, and protect his head.
30. Answer: (D) Place the patient on his side, remove dangerous objects, and protect his
head.
During the active seizure phase, initiate precautions by placing the patient on his side,
removing dangerous objects, and protecting his head from injury. A bite block should
never be inserted during the active seizure phase. Insertion can break the teeth and lead
to aspiration.
31. After insertion of a chest tube for a pneumothorax, a patient becomes hypotensive with neck vein
distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension
pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?
a. Infection of the lung.
b. Kinked or obstructed chest tube
c. Excessive water in the water-seal chamber
d. Excessive chest tube drainage
31. Answer: (B) Kinked or obstructed chest tube
Rationales: Kinking and blockage of the chest tube is a common cause of a tension
pneumothorax. Infection and excessive drainage won’t cause a tension pneumothorax.
Excessive water won’t affect the chest tube drainage.
32. Nurse Maureen is talking to a male patient, the patient begins choking on his lunch. He’s
coughing forcefully. The nurse should:
.
a. Stand him up and perform the abdominal thrust maneuver from behind.
b. Lay him down, straddle him, and perform the abdominal thrust maneuver.
c. Leave him to get assistance
d. Stay with him but not intervene at this time
32. Answer: (D) Stay with him but not intervene at this time.
If the patient is coughing, he should be able to dislodge the object or cause a complete
obstruction. If complete obstruction occurs, the nurse should perform the abdominal
thrust maneuver with the patient standing. If the patient is unconscious, she should lay
him down. A nurse should never leave a choking patient alone.
33. Nurse Ron is taking a health history of an 84 year old patient. Which information will be most
useful to the nurse for planning care?
.
a. General health for the last 10 years.
b. Current health promotion activities.
c. Family history of diseases.
d. Marital status
33. Answer: (B) Current health promotion activities
Recognizing an individual’s positive health measures is very useful. General health in
the previous 10 years is important, however, the current activities of an 84 year old
patient are most significant in planning care. Family history of disease for a patient in
later years is of minor significance. Marital status information may be important for
discharge planning but is not as significant for addressing the immediate medical
problem.
34. When performing oral care on a comatose patient, Nurse Krina should:
a. Apply lemon glycerin to the patient’s lips at least every 2 hours.
b. Brush the teeth with patient lying supine.
c. Place the patient in a side lying position, with the head of the bed lowered.
d. Clean the patient’s mouth with hydrogen peroxide
34. Answer: (C) Place the patient in a side lying position, with the head of the bed
lowered.
The patient should be positioned in a side-lying position with the head of the bed
lowered to prevent aspiration. A small amount of toothpaste should be used and the
mouth swabbed or suctioned to remove pooled secretions. Lemon glycerin can be
drying if used for extended periods. Brushing the teeth with the patient lying supine
may lead to aspiration. Hydrogen peroxide is caustic to tissues and should not be used.
35. A 77-year-old male patient is admitted with a diagnosis of dehydration and change in mental status. He’s
being hydrated with L.V. fluids. When the nurse takes his vital signs, she notes he has a fever of 103°F
(39.4°C) a cough producing yellow sputum and pleuritic chest pain. The nurse suspects this patient may
have which of the following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Myocardial infarction (MI)
c. Pneumonia
d. Tuberculosis
35. Answer: (C) Pneumonia
Fever productive cough and pleuritic chest pain are common signs and symptoms
of pneumonia. The patient with ARDS has dyspnea and hypoxia with worsening
hypoxia over time, if not treated aggressively. Pleuritic chest pain varies with
respiration, unlike the constant chest pain during an MI; so this patient most likely isn’t
having an MI. the patient with TB typically has a cough producing blood-tinged
sputum. A sputum culture should be obtained to confirm the nurse’s suspicions.
36. Nurse Oliver is working in a out patient clinic. He has been alerted that there is an outbreak of
tuberculosis (TB). Which of the following patients entering the clinic today most likely to have TB?
a. A 16-year-old female high school student
b. A 33-year-old daycare worker
c. A 43-year-old homeless man with a history of alcoholism
d. A 54-year-old businessman
36. Answer: (C) A 43-year-old homeless man with a history of alcoholism
patients who are economically disadvantaged, malnourished, and have reduced
immunity, such as a patient with a history of alcoholism, are at extremely high risk for
developing TB. A high school student, daycare worker, and businessman probably have
a much low risk of contracting TB.
37. Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware
that which of the following reasons this is done?
a. To confirm the diagnosis
b. To determine if a repeat skin test is needed
c. To determine the extent of lesions
d. To determine if this is a primary or secondary infection
37. Answer: (C ) To determine the extent of lesions
If the lesions are large enough, the chest X-ray will show their presence in the lungs.
Sputum culture confirms the diagnosis. There can be false-positive and false-negative
skin test results. A chest X-ray can’t determine if this is a primary or secondary infection.
38. Kennedy with acute asthma showing inspiratory and expiratory wheezes and a decreased forced
expiratory volume should be treated with which of the following classes of medication right away?
a. Beta-adrenergic blockers
b. Bronchodilators
c. Inhaled steroids
d. Oral steroids
38. Answer: (B) Bronchodilators
Bronchodilators are the first line of treatment for asthma because broncho-constriction is
the cause of reduced airflow. Beta adrenergic blockers aren’t used to treat asthma and
can cause bronchoconstriction. Inhaled oral steroids may be given to reduce the
inflammation but aren’t used for emergency relief.
39. Mr. Vasquez 56-year-old patient with a 40-year history of smoking one to two packs of cigarettes per day
has a chronic cough producing thick sputum, peripheral edema and cyanotic nail beds. Based on this
information, he most likely has which of the following conditions?
a. Adult respiratory distress syndrome (ARDS)
b. Asthma
c. Chronic obstructive bronchitis
d. Emphysema
39. Answer: (C) Chronic obstructive bronchitis
Because of this extensive smoking history and symptoms the patient most likely has
chronic obstructive bronchitis. patient with ARDS have acute symptoms of hypoxia and
typically need large amounts of oxygen. patients with asthma and emphysema tend not
to have chronic cough or peripheral edema.
Situation: Francis, age 46 is admitted to the hospital with diagnosis of Chronic Lymphocytic Leukemia.
40. The treatment for patients with leukemia is bone marrow transplantation. Which statement about bone
marrow transplantation is not correct?
.
a. The patient is under local anesthesia during the procedure
b. The aspirated bone marrow is mixed with heparin.
c. The aspiration site is the posterior or anterior iliac crest.
d. The recipient receives cyclophosphamide (Cytoxan) for 4 consecutive days before
the procedure
40. Answer: (A) The patient is under local anesthesia during the procedure
Before the procedure, the patient is administered with drugs that would help to prevent
infection and rejection of the transplanted cells such as antibiotics, cytotoxic, and
corticosteroids. During the transplant, the patient is placed under general anesthesia.
41. After several days of admission, Francis becomes disoriented and complains of frequent
headaches. The nurse in-charge first action would be:
a. Call the physician
b. Document the patient’s status in his charts.
c. Prepare oxygen treatment
d. Raise the side rails
41. Answer: (D) Raise the side rails
A patient who is disoriented is at risk of falling out of bed. The initial action of the nurse
should be raising the side rails to ensure patients safety.
42. During routine care, Francis asks the nurse, “How can I be anemic if this disease causes increased my
white blood cell production?” The nurse in-charge best response would be that the increased number of
white blood cells (WBC) is:
.
a. Crowded red blood cells
b. Are not responsible for the anemia.
c. Uses nutrients from other cells
d. Have an abnormally short life span of cells
42. Answer: (A) Crowd red blood cells
The excessive production of white blood cells crowd out red blood cells production
which causes anemia to occur.
43. Diagnostic assessment of Francis would probably not reveal:
a. Predominance of lymhoblasts
b. Leukocytosis
c. Abnormal blast cells in the bone marrow
d. Elevated thrombocyte counts
43. Answer: (B) Leukocytosis
Chronic Lymphocytic leukemia (CLL) is characterized by increased production of
leukocytes and lymphocytes resulting in leukocytosis, and proliferation of these cells
within the bone marrow, spleen and liver.
44. Robert, a 57-year-old patient with acute arterial occlusion of the left leg undergoes an emergency
embolectomy. Six hours later, the nurse isn’t able to obtain pulses in his left foot using Doppler ultrasound.
The nurse immediately notifies the physician, and asks her to prepare the patient for surgery. As the nurse
enters the patient’s room to prepare him, he states that he won’t have any more surgery. Which of the
following is the best initial response by the nurse?
a. Explain the risks of not having the surgery
b. Notifying the physician immediately
c. Notifying the nursing supervisor
d. Recording the patient’s refusal in the nurses’ notes
44. Answer: (A) Explain the risks of not having the surgery
The best initial response is to explain the risks of not having the surgery. If the patient
understands the risks but still refuses the nurse should notify the physician and the
nurse supervisor and then record the patient’s refusal in the nurses’ notes.
45. During the endorsement, which of the following patients should the on-duty nurse assess
first?
a. The 58-year-old patient who was admitted 2 days ago with heart failure, blood
pressure of 126/76 mm Hg, and a respiratory rate of 22 breaths/minute.
b. The 89-year-old patient with end-stage right-sided heart failure, blood pressure of
78/50 mm Hg, and a “do not resuscitate” order
c. The 62-year-old patient who was admitted 1 day ago with thrombophlebitis and is
receiving L.V. heparin
d. The 75-year-old patient who was admitted 1 hour ago with new-onset atrial
fibrillation and is receiving L.V. dilitiazem (Cardizem)
45. Answer: (D) The 75-year-old patient who was admitted 1 hour ago with new-onset atrial
fibrillation and is receiving L.V. diltiazem (Cardizem)
The patient with atrial fibrillation has the greatest potential to become unstable and is on L.V.
medication that requires close monitoring. After assessing this patient, the nurse should
assess the patient with thrombophlebitis who is receiving a heparin infusion, and then the
58- year-old patient admitted 2 days ago with heart failure (his signs and symptoms are
resolving and don’t require immediate attention). The lowest priority is the 89-year-old with
end stage right-sided heart failure, who requires time-consuming supportive measures.
46. Honey, a 23-year old patient complains of substernal chest pain and states that her heart feels like “it’s
racing out of the chest”. She reports no history of cardiac disorders. The nurse attaches her to a cardiac
monitor and notes sinus tachycardia with a rate of 136beats/minutes. Breath sounds are clear and the
respiratory rate is 26 breaths/minutes. Which of the following drugs should the nurse question the patient
about using?
a. Barbiturates
b. Opioids
c. Cocaine
d. Benzodiazepines
46. Answer: (C) Cocaine
Because of the patient’s age and negative medical history, the nurse should question her
about cocaine use. Cocaine increases myocardial oxygen consumption and can cause
coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial
ischemia, and myocardial infarction. Barbiturate overdose may trigger respiratory
depression and slow pulse. Opioids can cause marked respiratory depression,
while benzodiazepines can cause drowsiness and confusion.
47. A 51-year-old female patient tells the nurse in-charge that she has found a painless lump in her right
breast during her monthly self-examination. Which assessment finding would strongly suggest that this
patient’s lump is cancerous?
a. Eversion of the right nipple and mobile mass
b. Nonmobile mass with irregular edges
c. Mobile mass that is soft and easily delineated
d. Nonpalpable right axillary lymph nodes
47. Answer: (B) Nonmobile mass with irregular edges
Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A
mobile mass that is soft and easily delineated is most often a fluid-filled benign cyst.
Axillary lymph nodes may or may not be palpable on initial detection of a cancerous
mass. Nipple retraction — not eversion — may be a sign of cancer.
48. A 35-year-old patient with vaginal cancer asks the nurse, “What is the usual treatment for this
type of cancer?” Which treatment should the nurse name?
a. Surgery
b. Chemotherapy
c. Radiation
d. Immunotherapy
48. Answer: (C) Radiation
The usual treatment for vaginal cancer is external or intravaginal radiation therapy. Less
often, surgery is performed. Chemotherapy typically is prescribed only if vaginal cancer
is diagnosed in an early stage, which is rare. Immunotherapy isn’t used to treat vaginal
cancer.
49. Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to
the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
a. No evidence of primary tumor, no abnormal regional lymph nodes, and no
evidence of distant metastasis
b. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant
metastasis
c. Can’t assess tumor or regional lymph nodes and no evidence of metastasis
d. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and
ascending degrees of distant metastasis
49. Answer: (B) Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of
distant metastasis
TIS, N0, M0 denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence
of distant metastasis. No evidence of primary tumor, no abnormal regional lymph nodes,
and no evidence of distant metastasis is classified as T0, N0, M0. If the tumor and regional
lymph nodes can’t be assessed and no evidence of metastasis exists, the lesion is classified as
TX, NX, M0. A progressive increase in tumor size, no demonstrable metastases of the
regional lymph nodes, and ascending degrees of distant metastasis is classified as T1, T2, T3,
or T4; N0; and M1, M2, or M3.
50. Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the patient how to
care for the neck stoma, the nurse should include which instruction?
a. “Keep the stoma uncovered.”
b. “Keep the stoma dry.”
c. “Have a family member perform stoma care initially until you get used to the
procedure.”
d. “Keep the stoma moist.”
50. Answer: (D) “Keep the stoma moist.”
The nurse should instruct the patient to keep the stoma moist, such as by applying a
thin layer of petroleum jelly around the edges, because a dry stoma may become
irritated. The nurse should recommend placing a stoma bib over the stoma to filter and
warm air before it enters the stoma. The patient should begin performing stoma care
without assistance as soon as possible to gain independence in self-care activities.
51. A 37-year-old patient with uterine cancer asks the nurse, “Which is the most common type of cancer in
women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?
a. Breast cancer
b. Lung cancer
c. Brain cancer
d. Colon and rectal cancer
51. Answer: (B) Lung cancer
Lung cancer is the most deadly type of cancer in both women and men. Breast cancer
ranks second in women, followed (in descending order) by colon and rectal cancer,
pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer,
brain cancer, stomach cancer, and multiple myeloma.
52. Antonio with lung cancer develops Horner’s syndrome when the tumor invades the ribs and affects the
sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should
note:
.
a. miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
b. chest pain, dyspnea, cough, weight loss, and fever.
c. arm and shoulder pain and atrophy of arm and hand muscles, both on the affected
side.
d. hoarseness and dysphagia
52. Answer: (A) miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face.
Horner’s syndrome, which occurs when a lung tumor invades the ribs and affects the
sympathetic nerve ganglia, is characterized by miosis, partial eyelid ptosis, and anhidrosis
on the affected side of the face. Chest pain, dyspnea, cough, weight loss, and fever are
associated with pleural tumors. Arm and shoulder pain and atrophy of the arm and hand
muscles on the affected side suggest Pancoast’s tumor, a lung tumor involving the first
thoracic and eighth cervical nerves within the brachial plexus. Hoarseness in a patient with
lung cancer suggests that the tumor has extended to the recurrent laryngeal nerve;
dysphagia suggests that the lung tumor is compressing the esophagus.
53. Vic asks the nurse what PSA is. The nurse should reply that it stands for:
a. prostate-specific antigen, which is used to screen for prostate cancer.
b. protein serum antigen, which is used to determine protein levels.
c. pneumococcal strep antigen, which is a bacteria that causes pneumonia.
d. Papanicolaou-specific antigen, which is used to screen for cervical cancer.
53. Answer: (A) prostate-specific antigen, which is used to screen for prostate cancer.
PSA stands for prostate-specific antigen, which is used to screen for prostate cancer. The
other answers are incorrect.
54. What is the most important postoperative instruction that nurse Kate must give a patient who
has just returned from the operating room after receiving a subarachnoid block?
a. “Avoid drinking liquids until the gag reflex returns.”
b. “Avoid eating milk products for 24 hours.”
c. “Notify a nurse if you experience blood in your urine.”
d. “Remain supine for the time specified by the physician.”
54. Answer: (D) “Remain supine for the time specified by the physician.”
The nurse should instruct the patient to remain supine for the time specified by the
physician. Local anesthetics used in a subarachnoid block don’t alter the gag reflex. No
interactions between local anesthetics and food occur. Local anesthetics don’t cause
hematuria.
55. A male patient suspected of having colorectal cancer will require which diagnostic study to
confirm the diagnosis?
a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT) scan
55. Answer: (C) Sigmoidoscopy
Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the
detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a
sign of colorectal cancer; however, the test doesn’t confirm the diagnosis. CEA may be
elevated in colorectal cancer but isn’t considered a confirming test. An abdominal CT
scan is used to stage the presence of colorectal cancer.
56. During a breast examination, which finding most strongly suggests that the Luz has breast
cancer?
a. Slight asymmetry of the breasts.
b. A fixed nodular mass with dimpling of the overlying skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable masses that change with the menstrual cycle
56. Answer: (B) A fixed nodular mass with dimpling of the overlying skin
A fixed nodular mass with dimpling of the overlying skin is common during late stages
of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple
discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round,
freely movable masses that change with the menstrual cycle indicate fibrocystic breasts,
a benign condition.
57. A female patient with cancer is being evaluated for possible metastasis. Which of the
following is one of the most common metastasis sites for cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
57. Answer: (A) Liver
The liver is one of the five most common cancer metastasis sites. The others are the
lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are
occasional metastasis sites.
58. Nurse Mandy is preparing a patient for magnetic resonance imaging (MRI) to confirm or rule out a
spinal cord lesion. During the MRI scan, which of the following would pose a threat to the patient?
a. The patient lies still.
b. The patient asks questions.
c. The patient hears thumping sounds.
d. The patient wears a watch and wedding band.
58. Answer: (D) The patient wears a watch and wedding band.
During an MRI, the patient should wear no metal objects, such as jewelry, because the
strong magnetic field can pull on them, causing injury to the patient and (if they fly off)
to others. The patient must lie still during the MRI but can talk to those performing the
test by way of the microphone inside the scanner tunnel. The patient should hear
thumping sounds, which are caused by the sound waves thumping on the magnetic
field.
59. Nurse Cecile is teaching a female patient about preventing osteoporosis. Which of the
following teaching points is correct?
a. Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss.
b. To avoid fractures, the patient should avoid strenuous exercise.
c. The recommended daily allowance of calcium may be found in a wide variety of
foods.
d. Obtaining the recommended daily allowance of calcium requires taking a calcium
supplement.
59. Answer: (C) The recommended daily allowance of calcium may be found in a wide
variety of foods.
Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women
require 1,500 mg per day. It’s often, though not always, possible to get the recommended
daily requirement in the foods we eat. Supplements are available but not always necessary.
Osteoporosis doesn’t show up on ordinary X-rays until 30% of the bone loss has occurred.
Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended
routinely for women over 35 who are at risk. Strenuous exercise won’t cause fractures.
60. Before Jacob undergoes arthroscopy, the nurse reviews the assessment findings for
contraindications for this procedure. Which finding is a contraindication?
a. Joint pain
b. Joint deformity
c. Joint flexion of less than 50%
d. Joint stiffness
60. Answer: (C) Joint flexion of less than 50%
Arthroscopy is contraindicated in patients with joint flexion of less than 50% because of
technical problems in inserting the instrument into the joint to see it clearly. Other
contraindications for this procedure include skin and wound infections. Joint pain may
be an indication, not a contraindication, for arthroscopy. Joint deformity and joint
stiffness aren’t contraindications for this procedure.
61. Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is characterized by
urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men over age 30?
a. Septic arthritis
b. Traumatic arthritis
c. Intermittent arthritis
d. Gouty arthritis
61. Answer: (D) Gouty arthritis
Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in the
joints, especially those in the feet and legs. Urate deposits don’t occur in septic or
traumatic arthritis. Septic arthritis results from bacterial invasion of a joint and leads to
inflammation of the synovial lining. Traumatic arthritis results from blunt trauma to a
joint or ligament. Intermittent arthritis is a rare, benign condition marked by regular,
recurrent joint effusions, especially in the knees.
62. A heparin infusion at 1,500 unit/hour is ordered for a 64-year-old patient with stroke in evolution. The
infusion contains 25,000 units of heparin in 500 ml of saline solution. How many milliliters per hour should
be given?
a. 15 ml/hour
b. 30 ml/hour
c. 45 ml/hour
d. 50 ml/hour
62. Answer: (B) 30 ml/hour
An infusion prepared with 25,000 units of heparin in 500 ml of saline solution yields 50
units of heparin per milliliter of solution. The equation is set up as 50 units times X (the
unknown quantity) equals 1,500 units/hour, X equals 30 ml/hour.
63. A 76-year-old male patient had a thromboembolic right stroke; his left arm is swollen. Which
of the following conditions may cause swelling after a stroke?
a. Elbow contracture secondary to spasticity
b. Loss of muscle contraction decreasing venous return
c. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side
d. Hypoalbuminemia due to protein escaping from an inflamed glomerulus
63. Answer: (B) Loss of muscle contraction decreasing venous return
In patients with hemiplegia or hemiparesis loss of muscle contraction decreases venous
return and may cause swelling of the affected extremity. Contractures, or bony
calcifications may occur with a stroke, but don’t appear with swelling. DVT may
develop in patients with a stroke but is more likely to occur in the lower extremities.
A stroke isn’t linked to protein loss.
64. Heberden’s nodes are a common sign of osteoarthritis. Which of the following statement is
correct about this deformity?
a. It appears only in men
b. It appears on the distal interphalangeal joint
c. It appears on the proximal interphalangeal joint
d. It appears on the dorsolateral aspect of the interphalangeal joint.
64. Answer: (B) It appears on the distal interphalangeal joint
Heberden’s nodes appear on the distal interphalangeal joint on both men and women.
Bouchard’s node appears on the dorsolateral aspect of the proximal interphalangeal
joint.
65. Which of the following statements explains the main difference between rheumatoid arthritis
and osteoarthritis?
a. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t
b. Osteoarthritis is a localized disease rheumatoid arthritis is systemic
c. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized
d. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn’t
65. Answer: (B) Osteoarthritis is a localized disease rheumatoid arthritis is systemic
Osteoarthritis is a localized disease, rheumatoid arthritis is systemic. Osteoarthritis isn’t
gender-specific, but rheumatoid arthritis is. patients have dislocations and subluxations
in both disorders.
66. Mrs. Cruz uses a cane for assistance in walking. Which of the following statements is true
about a cane or other assistive devices?
a. A walker is a better choice than a cane.
b. The cane should be used on the affected side
c. The cane should be used on the unaffected side
d. A patient with osteoarthritis should be encouraged to ambulate without the cane
66. Answer: (C) The cane should be used on the unaffected side
A cane should be used on the unaffected side. A patient with osteoarthritis should be
encouraged to ambulate with a cane, walker, or other assistive device as needed; their
use takes weight and stress off joints.
67. A male patient with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no
70/30 insulin available. As a substitution, the nurse may give the patient:
a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
b. 21 U regular insulin and 9 U NPH.
c. 10 U regular insulin and 20 U NPH.
d. 20 U regular insulin and 10 U NPH.
67. Answer: (A) a. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct
substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices
are incorrect dosages for the prescribed insulin.
68. Nurse Len should expect to administer which medication to a patient with gout?
a. aspirin
b. furosemide (Lasix)
c. colchicines
d. calcium gluconate (Kalcinate)
68. Answer: (C) colchicines
A disease characterized by joint inflammation (especially in the great toe), gout is
caused by urate crystal deposits in the joints. The physician prescribes colchicine to
reduce these deposits and thus ease joint inflammation. Although aspirin is used to
reduce joint inflammation and pain in patients with osteoarthritis and rheumatoid
arthritis, it isn’t indicated for gout because it has no effect on urate crystal
formation. Furosemide, a diuretic, doesn’t relieve gout. Calcium gluconate is used to
reverse a negative calcium balance and relieve muscle cramps, not to treat gout.
69. Mr. Domingo with a history of hypertension is diagnosed with primary hyperaldosteronism. This
diagnosis indicates that the patient’s hypertension is caused by excessive hormone secretion from which of
the following glands?
a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid
69. Answer: (A) Adrenal cortex
Excessive secretion of aldosterone in the adrenal cortex is responsible for the
patient’s hypertension. This hormone acts on the renal tubule, where it promotes
reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas
mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes
the catecholamines — epinephrine and norepinephrine. The parathyroids secrete
parathyroid hormone.
70. For a diabetic male patient with a foot ulcer, the doctor orders bed rest, a wetto- dry dressing change
every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for
this patient?
a. They contain exudate and provide a moist wound environment.
b. They protect the wound from mechanical trauma and promote healing.
c. They debride the wound and promote healing by secondary intention.
d. They prevent the entrance of microorganisms and minimize wound discomfort.
70. Answer: (C) They debride the wound and promote healing by secondary intention
For this patient, wet-to-dry dressings are most appropriate because they clean the foot
ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary
intention. Moist, transparent dressings contain exudate and provide a moist wound
environment. Hydrocolloid dressings prevent the entrance of microorganisms and
minimize wound discomfort. Dry sterile dressings protect the wound from mechanical
trauma and promote healing.
71. Nurse Zeny is caring for a patient in acute addisonian crisis. Which laboratory data would the
nurse expect to find?
a. Hyperkalemia
b. Reduced blood urea nitrogen (BUN)
c. Hypernatremia
d. Hyperglycemia
71. Answer: (A) Hyperkalemia
In adrenal insufficiency, the patient has hyperkalemia due to reduced aldosterone
secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is
caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired
gluconeogenesis and a reduction of glycogen in the liver and muscle, causing
hypoglycemia.
72. A patient is admitted for treatment of the syndrome of inappropriate antidiuretic hormone
(SIADH). Which nursing intervention is appropriate?
a. Infusing I.V. fluids rapidly as ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids as ordered
72. Answer: (C) Restricting fluids
To reduce water retention in a patient with the SIADH, the nurse should restrict fluids.
Administering fluids by any route would further increase the patient’s already
heightened fluid load.
73. A female patient tells nurse Nikki that she has been working hard for the last 3 months to control her
type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the patient’s efforts, the
nurse should check:
a. urine glucose level.
b. fasting blood glucose level.
c. serum fructosamine level.
d. glycosylated hemoglobin level.
73. Answer: (D) glycosylated hemoglobin level.
Because some of the glucose in the bloodstream attaches to some of the hemoglobin and
stays attached during the 120-day lifespan of red blood cells, glycosylated hemoglobin
levels provide information about blood glucose levels during the previous 3 months.
Fasting blood glucose and urine glucose levels only give information about glucose
levels at the point in time when they were obtained. Serum fructosamine levels provide
information about blood glucose control over the past 2 to 3 weeks.
74. Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a diabetic patient at 7 a.m. At
what time would the nurse expect the patient to be most at risk for a hypoglycemic reaction?
a. 10:00 am
b. Noon
c. 4:00 pm
d. 10:00 pm
74. Answer: (C) 4:00 pm
NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration.
Because the nurse administered NPH insulin at 7 a.m., the patient is at greatest risk for
hypoglycemia from 3 p.m. to 7 p.m.
75. The adrenal cortex is responsible for producing which substances?
a. Glucocorticoids and androgens
b. Catecholamines and epinephrine
c. Mineralocorticoids and catecholamines
d. Norepinephrine and epinephrine
75. Answer: (A) Glucocorticoids and androgens
The adrenal glands have two divisions, the cortex and medulla. The cortex produces
three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The
medulla produces catecholamines — epinephrine and norepinephrine.
76. On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability
of the nervous system. When questioned, the patient reports numbness and tingling of the mouth and
fingertips. Suspecting a life threatening electrolyte disturbance, the nurse notifies the surgeon immediately.
Which electrolyte disturbance most commonly follows thyroid surgery?
a. Hypocalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia
76. Answer: (A) Hypocalcemia
Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed
accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after
surgery. Thyroid surgery doesn’t directly cause serum sodium, potassium, or magnesium
abnormalities. Hyponatremia may occur if the patient inadvertently received too much fluid;
however, this can happen to any surgical patient receiving I.V. fluid therapy, not just one
recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are
associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.
77. Which laboratory test value is elevated in patients who smoke and can’t be used as a general
indicator of cancer?
a. Acid phosphatase level
b. Serum calcitonin level
c. Alkaline phosphatase level
d. Carcinoembryonic antigen level
77. Answer: (D) Carcinoembryonic antigen level
In patients who smoke, the level of carcinoembryonic antigen is elevated. Therefore, it
can’t be used as a general indicator of cancer. However, it is helpful in monitoring
cancer treatment because the level usually falls to normal within 1 month if treatment is
successful. An elevated acid phosphatase level may indicate prostate cancer. An
elevated alkaline phosphatase level may reflect bone metastasis. An elevated serum
calcitonin level usually signals thyroid cancer.
78. Francis with anemia has been admitted to the medical-surgical unit. Which assessment
findings are characteristic of iron-deficiency anemia?
a. Nights sweats, weight loss, and diarrhea
b. Dyspnea, tachycardia, and pallor
c. Nausea, vomiting, and anorexia
d. Itching, rash, and jaundice
78. Answer: (B) Dyspnea, tachycardia, and pallor
Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well as
fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea
may signal acquired immunodeficiency syndrome (AIDS). Nausea, vomiting, and
anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an
allergic or hemolytic reaction.
79. In teaching a female patient who is HIV-positive about pregnancy, the nurse would know
more teaching is necessary when the patient says:
a. The baby can get the virus from my placenta.”
b. “I’m planning on starting on birth control pills.”
c. “Not everyone who has the virus gives birth to a baby who has the virus.”
d. “I’ll need to have a C-section if I become pregnant and have a baby.”
79. Answer: (D) “I’ll need to have a C-section if I become pregnant and have a baby.”
The human immunodeficiency virus (HIV) is transmitted from mother to child via the
transplacental route, but a Cesarean section delivery isn’t necessary when the mother is
HIV-positive. The use of birth control will prevent the conception of a child who might
have HIV. It’s true that a mother who’s HIV positive can give birth to a baby who’s HIV
negative.
80. When preparing Judy with acquired immunodeficiency syndrome (AIDS) for discharge to the
home, the nurse should be sure to include which instruction?
a. “Put on disposable gloves before bathing.”
b. “Sterilize all plates and utensils in boiling water.”
c. “Avoid sharing such articles as toothbrushes and razors.”
d. “Avoid eating foods from serving dishes shared by other family members.”
80. Answer: (C) “Avoid sharing such articles as toothbrushes and razors.”
The human immunodeficiency virus (HIV), which causes AIDS, is most concentrated in
the blood. For this reason, the patient shouldn’t share personal articles that may be
blood-contaminated, such as toothbrushes and razors, with other family members. HIV
isn’t transmitted by bathing or by eating from plates, utensils, or serving dishes used by
a person with AIDS.
81. Nurse Marie is caring for a 32-year-old patient admitted with pernicious anemia. Which set of
findings should the nurse expect when assessing the patient?
a. Pallor, bradycardia, and reduced pulse pressure
b. Pallor, tachycardia, and a sore tongue
c. Sore tongue, dyspnea, and weight gain
d. Angina, double vision, and anorexia
81. Answer: (B) Pallor, tachycardia, and a sore tongue
Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious
anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red
tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia
of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double
vision aren’t characteristic findings in pernicious anemia.
82. After receiving a dose of penicillin, a patient develops dyspnea and hypotension. Nurse
Celestina suspects the patient is experiencing anaphylactic shock. What should the nurse do first?
a. Page an anesthesiologist immediately and prepare to intubate the patient.
b. Administer epinephrine, as prescribed, and prepare to intubate the patient if
necessary.
c. Administer the antidote for penicillin, as prescribed, and continue to monitor the
patient’s vital signs.
d. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as ordered.
82. Answer: (B) Administer epinephrine, as prescribed, and prepare to intubate the patient if
necessary.
To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent
bronchodilator as prescribed. The physician is likely to order additional medications, such as
antihistamines and corticosteroids; if these medications don’t relieve the respiratory
compromise associated with anaphylaxis, the nurse should prepare to intubate the patient.
No antidote for penicillin exists; however, the nurse should continue to monitor the patient’s
vital signs. A patient who remains hypotensive may need fluid resuscitation and fluid intake
and output monitoring; however, administering epinephrine is the first priority.
83. Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When
teaching the patient about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These
include:
a. weight gain.
b. fine motor tremors.
c. respiratory acidosis.
d. bilateral hearing loss.
83. Answer: (D) bilateral hearing loss.
Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of
30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is
discontinued. Aspirin doesn’t lead to weight gain or fine motor tremors. Large or toxic
salicylate doses may cause respiratory alkalosis, not respiratory acidosis.
84. A 23-year-old patient is diagnosed with human immunodeficiency virus (HIV). After recovering from the
initial shock of the diagnosis, the patient expresses a desire to learn as much as possible about HIV and
acquired immunodeficiency syndrome (AIDS). When teaching the patient about the immune system, the
nurse states that adaptive immunity is provided by which type of white blood cell?
a. Neutrophil
b. Basophil
c. Monocyte
d. Lymphocyte
84. Answer: (D) Lymphocyte
The lymphocyte provides adaptive immunity — recognition of a foreign antigen and
formation of memory cells against the antigen. Adaptive immunity is mediated by B
and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial
to phagocytosis. The basophil plays an important role in the release of inflammatory
mediators. The monocyte functions in phagocytosis and monokine production.
85. In an individual with Sjögren’s syndrome, nursing care should focus on:
a. moisture replacement.
b. electrolyte balance.
c. nutritional supplementation.
d. arrhythmia management.
85. Answer: (A) moisture replacement.
Sjogren’s syndrome is an autoimmune disorder leading to progressive loss of
lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the
mainstay of therapy. Though malnutrition and electrolyte imbalance may occur as a
result of Sjogren’s syndrome effect on the GI tract, it isn’t the predominant problem.
Arrhythmias aren’t a problem associated with Sjogren’s syndrome.
86. During chemotherapy for lymphocytic leukemia, Mathew develops abdominal pain, fever, and “horse
barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:
a. enzyme-linked immunosuppressant assay (ELISA) test.
b. electrolyte panel and hemogram.
c. stool for Clostridium difficile test.
d. flat plate X-ray of the abdomen.
86. Answer: (C) stool for Clostridium difficile test.
Immunosuppressed patients — for example, patients receiving chemotherapy, — are at risk
for infection with C. difficile, which causes “horse barn” smelling diarrhea. Successful
treatment begins with an accurate diagnosis, which includes a stool test. The ELISA test is
diagnostic for human immunodeficiency virus (HIV) and isn’t indicated in this case. An
electrolyte panel and hemogram may be useful in the overall evaluation of a patient but
aren’t diagnostic for specific causes of diarrhea. A flat plate of the abdomen may provide
useful information about bowel function but isn’t indicated in the case of “horse barn”
smelling diarrhea.
87. A male patient seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To
confirm that the patient has been infected with the human immunodeficiency virus (HIV), the nurse expects
the physician to order:
a. E-rosette immunofluorescence.
b. quantification of T-lymphocytes.
c. enzyme-linked immunosorbent assay (ELISA).
d. Western blot test with ELISA.
87. Answer: (D) Western blot test with ELISA.
HIV infection is detected by analyzing blood for antibodies to HIV, which form
approximately 2 to 12 weeks after exposure to HIV and denote infection. The Western blot
test — electrophoresis of antibody proteins — is more than 98% accurate in detecting HIV
antibodies when used in conjunction with the ELISA. It isn’t specific when used alone.
Erosette immunofluorescence is used to detect viruses in general; it doesn’t confirm HIV
infection. Quantification of T-lymphocytes is a useful monitoring test but isn’t diagnostic for
HIV. The ELISA test detects HIV antibody particles but may yield inaccurate results; a
positive ELISA result must be confirmed by the Western blot test.
88. A complete blood count is commonly performed before a Joe goes into surgery. What does this
test seek to identify?
a. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN)
and creatinine levels
b. Low levels of urine constituents normally excreted in the urine
c. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
d. Electrolyte imbalance that could affect the blood’s ability to coagulate properly
88. Answer: (C) Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
Low preoperative HCT and Hb levels indicate the patient may require a blood
transfusion before surgery. If the HCT and Hb levels decrease during surgery because of
blood loss, the potential need for a transfusion increases. Possible renal failure is
indicated by elevated BUN or creatinine levels. Urine constituents aren’t found in the
blood. Coagulation is determined by the presence of appropriate clotting factors, not
electrolytes.
89. While monitoring a patient for the development of disseminated intravascular coagulation
(DIC), the nurse should take note of what assessment parameters?
a. Platelet count, prothrombin time, and partial thromboplastin time
b. Platelet count, blood glucose levels, and white blood cell (WBC) count
c. Thrombin time, calcium levels, and potassium levels
d. Fibrinogen level, WBC, and platelet count
89. Answer: (A) Platelet count, prothrombin time, and partial thromboplastin time
The diagnosis of DIC is based on the results of laboratory studies of prothrombin time,
platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well
as patient history and other assessment factors. Blood glucose levels, WBC count,
calcium levels, and potassium levels aren’t used to confirm a diagnosis of DIC.
90. When taking a dietary history from a newly admitted female patient, Nurse Len should
remember that which of the following foods is a common allergen?
a. Bread
b. Carrots
c. Orange
d. Strawberries
90. Answer: (D) Strawberries
Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and
eggs. Bread, carrots, and oranges rarely cause allergic reactions.
91. Nurse John is caring for patients in the outpatient clinic. Which of the following phone calls
should the nurse return first?
.”
a. A patient with hepatitis A who states, “My arms and legs are itching.”
b. A patient with cast on the right leg who states, “I have a funny feeling in my right
leg.”
c. A patient with osteomyelitis of the spine who states, “I am so nauseous that I can’t
eat.”
d. A patient with rheumatoid arthritis who states, “I am having trouble sleeping
91. Answer: (B) A patient with cast on the right leg who states, “I have a funny feeling in
my right leg.”
It may indicate neurovascular compromise, requires immediate assessment.
92. Nurse Sarah is caring for patients on the surgical floor and has just received report from the
previous shift. Which of the following patients should the nurse see first?
a. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark
drainage noted on the dressing.
b. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid
noted in the Jackson-Pratt drain.
c. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the
previous eight hours.
d. A 62-year-old who had an abdominal-perineal resection three days ago; patient
complaints of chills.
92. Answer: (D) A 62-year-old who had an abdominal-perineal resection three days ago;
patient complaints of chills.
The patient is at risk for peritonitis; should be assessed for further symptoms and
infection.
93. Nurse Eve is caring for a patient who had a thyroidectomy 12 hours ago for treatment of
Grave’s disease. The nurse would be most concerned if which of the following was observed?
a. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.
b. The patient supports his head and neck when turning his head to the right.
c. The patient spontaneously flexes his wrist when the blood pressure is obtained.
d. The patient is drowsy and complains of sore throat.
93. Answer: (C) The patient spontaneously flexes his wrist when the blood pressure is
obtained.
Carpal spasms indicate hypocalcemia.
94. Julius is admitted with complaints of severe pain in the lower right quadrant of the abdomen.
To assist with pain relief, the nurse should take which of the following actions?
.
a. Encourage the patient to change positions frequently in bed.
b. Administer Demerol 50 mg IM q 4 hours and PRN.
c. Apply warmth to the abdomen with a heating pad.
d. Use comfort measures and pillows to position the patient
94. Answer: (D) Use comfort measures and pillows to position the patient.
Using comfort measures and pillows to position the patient is a non-pharmacological
methods of pain relief.
95. Nurse Tina prepares a patient for peritoneal dialysis. Which of the following actions should
the nurse take first?
a. Assess for a bruit and a thrill.
b. Warm the dialysate solution.
c. Position the patient on the left side.
d. Insert a Foley catheter
95. Answer: (B) Warm the dialysate solution.
Cold dialysate increases discomfort. The solution should be warmed to body
temperature in warmer or heating pad; don’t use microwave oven.
96. Nurse Jannah teaches an elderly patient with right-sided weakness how to use cane. Which of the
following behaviors, if demonstrated by the patient to the nurse, indicates that the teaching was effective?
a. The patient holds the cane with his right hand, moves the can forward followed by
the right leg, and then moves the left leg.
b. The patient holds the cane with his right hand, moves the cane forward followed by
his left leg, and then moves the right leg.
c. The patient holds the cane with his left hand, moves the cane forward followed by
the right leg, and then moves the left leg.
d. The patient holds the cane with his left hand, moves the cane forward followed by
his left leg, and then moves the right leg.
96. Answer: (C) The patient holds the cane with his left hand, moves the cane forward
followed by the right leg, and then moves the left leg.
The cane acts as a support and aids in weight bearing for the weaker right leg.
97. An elderly patient is admitted to the nursing home setting. The patient is occasionally confused and her
gait is often unsteady. Which of the following actions, if taken by the nurse, is most appropriate?
.
a. Ask the woman’s family to provide personal items such as photos or mementos.
b. Select a room with a bed by the door so the woman can look down the hall.
c. Suggest the woman eat her meals in the room with her roommate.
d. Encourage the woman to ambulate in the halls twice a day
97. Answer: (A) Ask the woman’s family to provide personal items such as photos or
mementos.
Photos and mementos provide visual stimulation to reduce sensory deprivation.
98. Nurse Evangeline teaches an elderly patient how to use a standard aluminum walker. Which of the
following behaviors, if demonstrated by the patient, indicates that the nurse’s teaching was effective?
a. The patient slowly pushes the walker forward 12 inches, then takes small steps
forward while leaning on the walker.
b. The patient lifts the walker, moves it forward 10 inches, and then takes several
small steps forward.
c. The patient supports his weight on the walker while advancing it forward, then
takes small steps while balancing on the walker.
d. The patient slides the walker 18 inches forward, then takes small steps while
holding onto the walker for balance.
98. Answer: (B) The patient lifts the walker, moves it forward 10 inches, and then takes
several small steps forward.
A walker needs to be picked up, placed down on all legs.
99. Nurse Derek is supervising a group of elderly patients in a residential home setting. The nurse knows
that the elderly are at greater risk of developing sensory deprivation for what reason?
a. Increased sensitivity to the side effects of medications.
b. Decreased visual, auditory, and gustatory abilities.
c. Isolation from their families and familiar surroundings.
d. Decrease musculoskeletal function and mobility.
99. Answer: (C) Isolation from their families and familiar surroundings.
Gradual loss of sight, hearing, and taste interferes with normal functioning.
100. A male patient with emphysema becomes restless and confused. What step should nurse
Jasmine take next?
a. Encourage the patient to perform pursed lip breathing.
b. Check the patient’s temperature.
c. Assess the patient’s potassium level.
d. Increase the patient’s oxygen flow rate.
100. Answer: (A) Encourage the patient to perform pursed lip breathing.
Pursed lip breathing prevents the collapse of lung unit and helps patient control rate
and depth of breathing.
101. The most frequent cause of hospitalization for people older than 75 years old is:
A. Angina pectoris
B. Heart failure
C. Hypertension
D. Pulmonary edema
1. Answer: B. Heart failure
B: Heart failure is the most frequent cause of hospitalization for people older than 75 years
old.
A: Angina pectoris also occurs among people more than 75 years of age but it is not the most
frequent cause of hospitalization.
C: Hypertension also occurs among people more than 75 years of age but it is not the most
frequent cause of hospitalization.
D: Pulmonary edema also occurs among people more than 75 years of age but it is not the
most frequent cause of hospitalization.
102. The primary cause of heart failure is:
A. Arterial hypertension
B. Coronary atherosclerosis
C. Myocardial dysfunction
D. Valvular dysfunction
2. Answer: B. Coronary atherosclerosis
B: Coronary atherosclerosis is the primary cause of heart failure.
A: Arterial hypertension is not the primary cause of heart failure.
C: Myocardial dysfunction is not a cause of heart failure.
D: Valvular dysfunction is not the primary cause of heart failure.
103. The dominant function in cardiac failure is:
A. Ascites
B. Hepatomegaly
C. Inadequate tissue perfusion
D. Nocturia
3. Answer C. Inadequate tissue perfusion
C: Inadequate tissue perfusion is the dominant function as low oxygenation occurs
because of this.
A: Ascites may occur in cardiac failure but is not considered as a dominant function.
B: Hepatomegaly is present in heart failure but not a dominant function.
D: Nocturia is not present in heart failure.
104. On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is
symptomatic with increased physical activity would have a heart failure classification of:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
4. Answer: A. Stage I
A: Stage I refer to a patient who reports no symptoms of heart failure at rest but becomes
symptomatic with increased physical activity.
B: Stage II refers to a patient who reports presence of symptoms with increased physical
activities.
C: Stage III refers to a patient who reports presence of symptoms with minimal physical activity.
D: Stage IV refers to a patient who reports presence of symptoms even during at rest.
105. The diagnosis of heart failure is usually confirmed by:
A. Chest x-ray
B. Echocardiogram
C. Electrocardiogram
D. Ventriculogram
2. Answer: B. Coronary atherosclerosis
B: Coronary atherosclerosis is the primary cause of heart failure.
A: Arterial hypertension is not the primary cause of heart failure.
C: Myocardial dysfunction is not a cause of heart failure.
D: Valvular dysfunction is not the primary cause of heart failure.
108. The most common cause of cerebrovascular accident is:
A. Arteriosclerosis
B. Embolism
C. Hypertensive changes
D. Vasospasm
108 Answer: A. Arteriosclerosis
A: Small penetrating artery thrombosis affects one or more vessels and is the most common
cause of cerebrovascular accident.
B: Embolism is not the most common cause ofcerebrovascular accident.
C: Hypertensive changes are not the most common cause of cerebrovascular accident.
D: Vasospasm is not the most common cause ofcerebrovascular accident.
109. The degree of neurologic damage that occurs with an ischemic stroke depends on the:
A. Location of the lesion.
B. Size of the area of inadequate perfusion.
C. Amount of collateral blood flow.
D. Combination of the above factors.
109. Answer: D.
Combination of the above factors.
D: Stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion, the size of the
area of inadequate perfusion, and the amount of the collateral blood flow.
A: The degree of neurologic damage that occurs with an ischemic stroke depends on the location of the lesion.
B: The degree of neurologic damage that occurs with an ischemic stroke depends on the size of the area of
inadequate perfusion.
C: The degree of neurologic damage that occurs with an ischemic stroke depends on the amount of collateral
blood flow.
110. The most common side effect of tPA is:
A. An allergic reaction.
B. Bleeding.
C. Severe vomiting.
D. A second stroke in 6 to 12 hours.
110. Answer: B.
Bleeding.
B: A patient taking tPA should be monitored for bleeding.
A: Allergic reaction is not a side effect of tPA.
C: Severe vomiting is not a side effect of tPA.
D: A second stroke is not a side effect of tPA.
111. The majority of strokes have what type of origin?
A. Cardiogenic emboli.
B. Cryptogenic.
C. Large artery thrombotic.
D. Small artery thrombotic.
111. Answer: D.
Small artery thrombotic.
D: Small artery thrombotic is the most common type of origin for strokes.
A: Cardiogenic emboli is not the most common type of origin for strokes.
B: Cryptogenic is not the most common type of origin for strokes.
C: Large artery thrombotic is not the most common type of origin for strokes.
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