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MS SAS 1 11 - Basaha

Nursing (Southwestern University PHINMA)

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MS SAS 1 – 11
SAS 1
1. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?
A. Observation, percussion, palpation, auscultation
B. Observation, auscultation, percussion, palpation
C. Percussion, palpation, auscultation, observation
D. Palpation, percussion, observation, auscultation

2. While palpating a female client’s right upper quadrant (RUQ), the nurse would expect to find which of the following
structures?
[Link] colon
[Link]
C. Spleen
D. Liver

3. A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse
writes down which instruction for the client to follow before the test?
A. Fast for 8 hours before the test
B. Eat a regular supper and breakfast
C. Continue to take all oral medications as scheduled
D. Monitor own bowel movement pattern for constipation

4. Which diagnostic test would be used first to evaluate a client with upper GI bleeding?
A. Endoscopy
B. Upper GI series
C. Hemoglobin (Hb) levels and hematocrit (HCT)
D. Arteriography

5. A patient complains about an inflamed salivary gland below his right ear. The nurse documents probable inflammation
of which gland/s?
A. Buccal
B. Parotid
C. Sublingual
D. Submandibular

6. Parotitis caused by bacteria is treated with which of the following drug classifications?
A. Analgesics
B. Corticosteroids
C. Antipyretics
D. Antibiotics

7. Which of the following are the possible causes of sialadenitis? Select all that apply.
A. Dehydration
B. Stress
C. Dental extraction
D. Improper oral hygiene
E. Frequent ingestion of cold beverages

8. A patient asks, “Is surgery always the treatment of choice for inflamed salivary glands?” Your best response would be:
A. Yes, surgery is always the answer.
B. Surgery is only recommended for children.
C. Elderly is not a candidate for parotidectomy.
D. The procedure is advised for chronic sialadenitis and uncontrolled pain.

9. Which of the following conditions described as presence of calculi in the salivary glands?
A. Parotitis
B. Sialolithiasis
C. Sialadenitis

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D. Mumps

10. Which of the following medical management is recommended for salivary calculus?
A. Lithotripsy
B. Antibiotic therapy
C. Nephrectomy
D. Endoscopy

SAS 2
1. Acute gastritis is often caused by:
A. Ingestion of strong acids
B. Irritating foods
C. Overuse of Aspirin
D. All of the above

2. Which of the following definitions best describes gastritis?

A. Erosion of the gastric mucosa
B. Inflammation of a diverticulum
C. Inflammation of the gastric mucosa
D. Reflux of stomach acid into the esophagus

3. Which of the following substances is most likely to cause gastritis?

A. Milk
B. Bicarbonate of soda, or baking soda
C. Enteric coated aspirin
D. Nonsteriodal anti-imflammatory drugs

4. The nurse is caring for a client with chronic gastritis. The nurse monitors the client, knowing that this client is at risk
for which of the following vitamin deficiencies?
A. Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin E

5. The nurse is reviewing the medication record of a client with gastritis. Which medication, if noted on the
client’s record, would the nurse question?
A. Amoxicillin (Amoxil)
B. Indomethacin (Indocin)
C. Lansoprazole (Prevacid)
D. Clarithromycin (Biazin)

6. Which of the following treatments should be included in the immediate management of acute gastritis?
A. Reducing work stress
B. Completing gastric resection
C. Treating the underlying cause
D. Administering enteral tube feedings

7. Which of the following risk factors can lead to chronic gastritis?

A. Young age
B. Antibiotic usage
C. Gallbladder disease
D. Helicobacter pylori infection

8. Which of the following factors associates chronic gastritis with pernicious anemia?
A. Chronic blood loss
B. Inability to absorb vitamin B12
C. Overproduction of stomach acid
D. Overproduction of vitamin B12

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9. Which of the following measures helps relieve pain to a client with gastritis?
A. Avoid foods and beverages that may be irritating to the gastric
mucosa.
B. Monitor fluid intake and output daily to detect early signs of dehydration.
C. Administer Amoxicillin (Amoxil) twice a day.
D. Start intravenous fluid therapy.

10 A patient with gastritis is nauseated and vomited 10 times at home, which of the following nursing diagnoses
is appropriate for this patient? Select all that apply.
A. Acute pain related to irritated stomach mucosa
B. Anxiety related to treatment
C. Imbalanced nutrition, less than body requirements related to inadequate intake of
nutrients
D. Risk for imbalanced fluid volume related to insufficient fluid intake and excessive fluid
loss

11. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76,
pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes
an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate
explanation?
A. “It empties the stomach of fluids and gas.”
B. “It prevents spasms at the sphincter of Oddi.”
C. “It prevents air from forming in the small intestine and large intestine.”
D. “It removes bile from the gallbladder.”

12. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you immediately do after inserting an
NG tube for liquid enteral feedings?
A. Aspirate for gastric secretions with a syringe.
B. Begin feeding slowly to prevent cramping.
C. Get an X-ray of the tip of the tube within 24 hours.
D. Clamp off the tube until the feedings begin.

13. Stephanie, a 28 y.o. accident victim, requires TPN. The rationale for TPN is to provide:
A. Necessary fluids and electrolytes to the body.
B. Complete nutrition by the I.V. route.
C. Tube feedings for nutritional supplementation.
D. Dietary supplementation with liquid protein given between meals.

14. Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of
feeding for your patient?
A. TPN
B. PPN
C. NG feeding
D. Oral liquid supplements

15. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric
residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first
response to this finding?
A. Notify the doctor immediately.
B. Stop the feeding, and clamp the NG tube.
C. Discard the 220ml, and clamp the NG tube.
D. Give a prescribed GI stimulant such as metoclopramide (Reglan).

SAS 3
1. Based from the symptoms presented, Nurse Melinda might suspect:
A. Esophagitis

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B. Hiatal hernia
C. GERD
D. Gastric Ulcer

2. What diagnostic test would confirm the type of problem Mrs. Cruz have?
A. barium enema
B. barium swallow
C. colonoscopy
D. lower GI series

3. Mrs. Dela Cruz complained of pain and difficulty in swallowing. The terms are referred as:
A. Odynophagia
B. Dysphagia
C. Pyrosis
D. Dyspepsia

4. To avoid acid reflux, Nurse Melinda should advice Mrs. Dela Cruz to avoid which type of diet?
A. cola, coffee and tea
B. high fat, carbonated and caffeinated beverages
C. beer and green tea
D. All of the above

Situation: Nurse Marishka is the staff nurse assigned at the Emergency Department. During her shift, a patient was
rushed in the ED complaining of severe heartburn, vomiting and pain that radiates to the flank. The doctor suspects
gastric ulcer.

5. What other symptoms will validate the diagnosis of gastric ulcer?

A. right epigastric pain
B. pain occurs when stomach is empty
C. pain occurs immediately after meal
D. pain not relieved by vomiting

6. What diagnostic test would yield good visualization of the ulcer crater?
A. Endoscopy
B. Gastroscopy
C. Barium Swallow
D. Histology

7. Peptic ulcer disease particularly gastric ulcer is thought to be cause by which of the following microorgamisms?
A. E. coli
B. H. pylori
C. S. aureus
D. K. pnuemoniae

8. She is for occult blood test; what specimen will you

collect?
A. Blood
B. Urine
C. Stool
D. Gastric Juice

9. What Diagnostic test will confirm Achalasia?

A. Barium Swallow
B. X- ray Studies
C. Manometry
D. Barium Enema

[Link] Sliding Hiatal Hernia, all are clinical manifestations except:

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A. Heartburn
B. Halitosis
C. Regurgitation
D. Dysphagia

SAS 4
1. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?
A. Observation, percussion, palpation, auscultation
B. Observation, auscultation, percussion, palpation
C. Percussion, palpation, auscultation, observation
D. Palpation, percussion, observation, auscultation

2. When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse
include?
A. “Drink 6 glasses of fluid each day.”
B. “Avoid grain products and nuts.”
C. “Add at least 4 grams of bran to your cereal each morning.”
D. “Be sure to get regular exercise.”

3. The nurse would monitor for which of the following adverse reactions to aluminum-containing antacids such as
aluminum hydroxide (Amphojel)?
A. Diarrhea
B. Constipation
C. GI upset
D. Fluid retention

4. Nursing suggestions to help a person break the constipation habit include all of the following except:
A. A low-residue, bland diet.
B. A fluid intake of at least 2 L/day.
C. Establishing a regular schedule of exercise.
D. Establishing a regular time for daily elimination.

5. All of the following are considered complications of constipation except:

A. Hemorrhoids
B. Fecal impaction
C. Hypokalemia
D. Hypertension

6. In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?
A. The client passes formed stools at regular intervals
B. The client reports a decrease in stool frequency and liquidity
C. The client exhibits firm skin turgor
D. The client no longer experiences perianal burning.

7. The mechanism of action of diphenoxylate (Lotomil) is:

A. An increase in intestinal excretion of water
B. An increase in intestinal motility
C. A decrease in peristalsis in the intestinal wall
D. A decrease in the reabsorption of water in the bowel

8. Which of the following statements best describes fecal incontinence?

A. It is a common disorder that affects the large intestine characterized by cramping, abdominal pain, bloating, gas, and
diarrhea or constipation, or both.
B. It is the involuntary passage of stool from the rectum.
C. It is an infrequent bowel movements or difficult passage of stools that persists for several weeks or longer.
D. It is condition with loose and watery stools during a bowel movement.

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9. Which of the following drugs may be administered to patient with diarrhea?

A. Loperamide (Imodium)
B. Bisacodyl (Dulcolax)
C. Senna Concentrate (Senokot)
D. Docusate (Colace)

10. Which of the following measures helps control fecal incontinence?

A. Increase fiber in the diet during episodes of diarrhea.
B. Initiate a bowel-training program.
C. Encourage use of laxatives 3 times a day.
D. Use incontinence brief/adult diaper.

SAS 5
1. Which of the following best describes Malabsorption syndrome?
A. Are open sores that develop on the inside lining of your stomach and the upper portion of your small intestine.
B. It is the inability of the digestive system to absorb one or more of the major vitamins, minerals, and nutrients.
C. It is a digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the
esophagus.
D. An inflammatory disease which can lead to abdominal pain, severe diarrhea, fatigue, and weight loss.

2. A patient complains of abdominal pain and distention is suspected of having malabsorption syndrome when he/she
has:
A. A bulky, foul-smelling stools with steatorrhea
B. Episodes of constipation and diarrhea
C. Chronic constipation
D. Severe abdominal pain after eating

3. Which of the following diagnostic tests confirms malabsorption syndrome?

A. Complete blood count
B. Abdominal ultrasound
C. Panceatic function test
D. Endoscopy with biopsy

4. Which of the following recommended to a patient with malabsorption syndrome?

A. Encourage patient to eat pasta three times a day.
B. Instruct patient to increase milk consumption.
C. The patient is advised to limit fluid intake.
D. Vitamin supplementation is prescribed.

5. A client with irritable bowel syndrome is being prepared for discharge. Which of the following meal plans should
the nurse give the client?
A. Low fiber, low-fat
B. High fiber, low-fat
C. Low fiber, high-fat
D. High-fiber, high-fat

6. Katrina is diagnosed with lactose intolerance. To avoid complications with lack of calcium in the diet, which food
should be included in the diet?
A. Fruit
B. Whole grains
C. Milk and cheese products
D. Dark green, leafy vegetables

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7. A patient with IBS asks, “How can I manage abdominal discomfort?” Your best response would be:
A. “It is best managed by eating dry crackers.”
B. “Some patients maintain an antidepressant drugs.”
C. “You will be the one to choose what is best for you.”
D. “Abdominal pain can be reduced by avoiding carbonated beverages.”

8. Care for the postoperative client after gastric resection should focus on which of the following problems?
A. Body image
B. Nutritional needs
C. Skin care
D. Spiritual needs

9. A 30-year old client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea
after birth of her 2nd child. Diagnostic tests reveal gluten-induced enteropathy. Which foods must she eliminate from her
diet permanently?
A. Milk and dairy products
B. Protein-containing foods
C. Cereal grains (except rice and corn)
D. Carbohydrates

10. Which of the following conditions cause/s malabsorption? Select all that apply.
A. Celiac disease
B. Lactose intolerance
C. Gastritis
D. Gastric resection
E. GERD

SAS 6
1. During assessment, the nurse is looking for positive indicators of appendicitis, which include all of the following
except:
A. vomiting
B. low-grade fever
C. Thrombocytopenia
D. Abdominal tenderness upon palpation

2. On physical examination, the nurse should be looking for tenderness on palpation at Mcburney’s point, which is
located in the:
A. Right lower quadrant
B. Right upper quadrant
C. Left lower quadrant
D. Left upper quadrant

3. Which of the following complications is thought to be the most common cause of appendicitis?
A. A fecalith
B. Bowel kinking
C. Internal bowel occlusion
D. Abdominal bowel swelling

4. An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?
A. Prepare 750 ml of irrigating solution warmed to 100*F.
B. Question the physician about the order.
C. Provide privacy and explain the procedure to the client.
D. Assist the client to left lateral Sim’s position.

5. A client with acute appendicitis develops fever, tachycardia, and hypotension. Based on these assessment findings,
the nurse suspects which of the following complications?
A. Peritonitis

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B. Bowel ischemia
C. Intestinal obstruction
D. Deficient fluid volume

6. Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect to include in her
care?
A. Low-fiber diet and fluid restrictions.
B. Total parenteral nutrition and bed rest.
C. High-fiber diet and administration of psyllium.
D. Administration of analgesics and antacids.

7. Which of the following types of diets is implicated in the development of diverticulosis?

A. Low-fiber diet
B. High-fiber diet
C. High-protein diet
D. Low-carbohydrate diet

8. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:

A. Periodic rectal hemorrhage.
B. Hypertension and tachycardia.
C. Vomiting and elevated temperature.
D. Crampy and lower left quadrant pain and low-grade fever.

9. Medical management of the client with diverticulitis should include which of the following treatments?
A. Reduced fluid intake
B. Increased fiber in diet
C. Administration of antibiotics
D. Exercises to increase intra-abdominal pressure

10. Which of the following mechanisms can facilitate the development of diverticulosis into diverticulitis?
A. Treating constipation with chronic laxative use, leading to dependence on laxatives
B. Chronic constipation causing an obstruction, reducing forward flow of intestinal contents
C. Herniation of the intestinal mucosa, rupturing the wall of the intestine
D. Undigested food blocking the diverticulum, predisposing the area to bacterial invasion.

SAS 7
1. A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection
is most likely the best choice for this patient?
A) Spinach
B) Tofu
C) Multigrain bagel
D) Blueberries

2. A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital
admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have
what characteristics?
A) Watery with blood and mucus
B) Hard and black or tarry
C) Dry and streaked with blood
D) Loose with visible fatty streaks

3. Annabelle is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement
correctly describes a healthy stoma?
A. “At first, the stoma may bleed slightly when touched.”
B. “The stoma should appear dark and have a bluish hue.”
C. “A burning sensation under the stoma faceplate is normal.”
D. “The stoma should remain swollen away from the abdomen.”

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4.. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you recommend?
A. Peas
B. Cabbage
C. Broccoli
D. Yogurt

5. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?
A. Obtain daily weights.
B. Measure abdominal girth.
C. Keep strict intake and output.
D. Encourage her to increase fluids.

SAS 8
1. A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the
presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action
would be most effective in ensuring safe care?
A. Measuring serum potassium for hyperkalemia
B. Assessing the client for hypervolemia
C. Measuring the client’s weight weekly
D. Documenting precise intake and output

2. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive
accumulation of serous fluid in her peritoneal cavity?
A. Restrict fluids
B. Encourage ambulation
C. Increase sodium in the diet
D. Give antacids as prescribed

3. A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The
nurse should monitor the client closely for which of the following drug-related side effects?
A. Constipation
B. Hyperkalemia
C. Irregular pulse
D. Dysuria

4. For which of the following positions would be appropriate for a client with severe ascites?
A. Fowler’s
B. Side-lying
C. Reverse Trendelenburg
D. Sims’

5. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Before
her paracentesis, you instruct her to:
A. Empty her bladder.
B. Lie supine in bed.
C. Remain NPO for 4 hours.
D. Clean her bowels with an enema.

6. Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the
rationale for instituting skin care measures for the client?
A. “Jaundice is associated with pressure ulcer formation.”
B. “Jaundice impairs urea production, which produces pruritus.”
C. “Jaundice produces pruritus due to impaired bile acid excretion.”
D. “Jaundice leads to decreased tissue perfusion and subsequent breakdown.”

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7. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you
include?
A. “You’ll need to lie on your stomach during the test.”
B. “You’ll need to lie on your right side after the test.”
C. “During the biopsy you’ll be asked to exhale deeply and hold it.”
D. “The biopsy is performed under general anesthesia.”

8. Immediately after a liver biopsy, which of the following complications should the client be closely monitored for?
A. Abdominal cramping
B. Hemorrhage
C. Nausea and vomiting
D. Potential infection

9. Which of the following tests confirms that the origin of the disorder is in the liver?
A. Alanine Aminotransferase (ALT)
B. Aspartate Aminotransferase (AST)
C. Gamma-glutamyl Transferase (GGT)
D. Serum Alkaline Phosphatase

10. Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic
encephalopathy? Select all that apply.
A. Assessing the client’s neurologic status every 2 hours
B. Monitoring the client’s hemoglobin and hematocrit levels
C. Evaluating the client’s serum ammonia level
D. Monitoring the client’s handwriting daily
E. Preparing to insert an esophageal tamponade tube
F. Making sure the client’s fingernails are short

SAS 9

1. When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the
client’s family?
A. Keeping the client in complete isolation.
B. Using good sanitation with dishes and shared bathrooms.
C. Avoiding contact with blood-soiled clothing or dressing.
D. Forbidding the sharing of needles or syringes.

2. Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis?
A. Increase fluid intake to 3000 ml per day
B. Adequate bed rest
C. Bland diet
D. Administer antibiotics as ordered

3. Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort?
A. Give tepid baths.
B. Avoid lotions and creams.
C. Use hot water to increase vasodilation.
D. Use cold water to decrease the itching.

4. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?
A. “Now I can never get hepatitis again.”
B. “I can safely give blood after 3 months.”
C. “I’ll never have a problem with my liver again, even if I drink alcohol.”
D. “My family knows that if I get tired and start vomiting, I may be getting sick again.”

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5. A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis?
A. Elevated hemoglobin level
B. Elevated serum bilirubin level
C. Elevated blood urea nitrogen level
D. Decreased erythrocyte sedimentation rate

6. A female client who has just been diagnosed with hepatitis A asks, “How could I have gotten this disease?” What is the
nurse’s best response?
A. “You may have eaten contaminated restaurant food.”
B. “You could have gotten it by using I.V. drugs.”
C. “You must have received an infected blood transfusion.”
D. “You probably got it by engaging in unprotected sex.”

7. A male client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:
A. Severe abdominal pain radiating to the shoulder.
B. Anorexia, nausea, and vomiting.
C. Eructation and constipation.
D. Abdominal ascites.

8. For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important?
A. Allowing complete independence of mobility
B. Applying pressure to injection sites
C. Administering antibiotics as prescribed
D. Increasing nutritional intake

9. A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for:
A. Malaise
B. Stomatitis
C. Hand tremors
D. Weight loss

10. A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic
encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown? Select all that
apply.
A. Range of motion every 4 hours
B. Turn and reposition every 2 hours
C. Abdominal and foot massages every 2 hours
D. Alternating air pressure mattress
E. Sit in chair for 30 minutes each shift

11. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s blood pressure
because of which change that is associated with the liver failure?
A. Hypoalbuminemia
B. Increased capillary permeability
C. Abnormal peripheral vasodilation
D. Excess rennin release from the kidneys

12. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic
encephalopathy in her?
A. Asterixis
B. Chvostek’s sign
C. Trousseau’s sign
D. Hepatojugular reflex

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13. Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches
the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the
dietary measures to follow if the client states an intention to increase the intake of:
A. Pork
B. Milk
C. Chicken
D. Broccoli

14. The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient
vitamin K absorption caused by this hepatic disease?
A. Dyspnea and fatigue
B. Ascites and orthopnea
C. Purpura and petechiae
D. Gynecomastia and testicular atrophy

15. A patient with severe cirrhosis of the liver develops hepatorenal syndrome. Which of the following nursing
assessment data would support this?
A. Oliguria and azotemia
B. Metabolic alkalosis
C. Decreased urinary concentration
D. Weight gain of less than 1 lb. per week

SAS 10
1. Which of the following tests is the most accurate for diagnosing liver cancer?
A. Abdominal ultrasound
B. Abdominal flat plate X-ray
C. Cholangiogram
D. Computed tomography (CT) scan

2. Which of the following considerations has highest priority when preparing to administer a medication to a client with
liver cancer?
A. Frequency of the medication
B. Purpose of the medication
C. Necessity of the medication
D. Metabolism of the medication

3. Early manifestation of a patient with liver cancer includes:

A. Ascites
B. Hepatomegaly
C. Continuous dull abdominal pain at RUQ
D. Jaundice

4. Which of the following are considered as complications of liver transplant? Select all that apply.
A. Hemorrhage
B. Hypertension
C. Infection
D. Hyperglycemia
E. Rejection

5. Which of the following interventions is appropriate after liver transplant?

A. Place patient in an environment free from bacteria, viruses, and fungi as possible.
B. Antibiotic agents are used as long-term therapy to prevent rejection of the transplanted liver.
C. Place patient in Trendelenburg position to facilitate pulmonary drainage.
D. Monitor cardiac output, oxygen saturation, urine output, heart rate, and blood pressure every 8 hours to evaluate
hemodynamic status and intravascular fluid volume.

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SAS 11
1. When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which
function?
A. Transports fatty acids into the brush border.
B. Breaks down fat into fatty acids and glycerol.
C. Triggers cholecystokinin to contract the gallbladder.
D. Breaks down protein into dipeptides and amino acids.

2. What laboratory finding is the primary diagnostic indicator for pancreatitis?

A. Elevated blood urea nitrogen (BUN)
B. Elevated serum lipase
C. Elevated aspartate aminotransferase (AST)
D. Increased lactate dehydrogenase (LD)

3. Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse
include in the care plan for the client?
A. Administration of vasopressin and insertion of a balloon tamponade
B. Preparation for a paracentesis and administration of diuretics
C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent
suction
D. Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day

4. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal
for this patient?
A. Serum creatinine and BUN
B. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
C. Serum amylase and lipase
D. Cardiac enzymes

5. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse
96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG
tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation?
A. “It empties the stomach of fluids and gas.”
B. “It prevents spasms at the sphincter of Oddi.”
C. “It prevents air from forming in the small intestine and large intestine.”
D. “It removes bile from the gallbladder.”

6. Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated?
A. Calcium
B. Glucose
C. Magnesium
D. Potassium

7. For Rico who has chronic pancreatitis, which nursing intervention would be most helpful?
A. Allowing liberalized fluid intake.
B. Counseling to stop alcohol consumption.
C. Encouraging daily exercise.
D. Modifying dietary protein.

8. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment
is effective?
A. There is no skin breakdown.
B. Her appetite improves.
C. She loses more than 10 lbs.
D. Stools are less fatty and decreased in frequency.

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9. To inhibit pancreatic secretions, which pharmacologic agent would you anticipate administering to a patient with
chronic pancreatitis?

A. Nitroglycerin
B. Somatostatin
C. Pancrelipase
D. Pepcid

10. A clinical manifestation of chronic pancreatitis is epigastric pain. Your nursing intervention to facilitate relief of pain
would place the patient in a:
A. Knee-chest position
B. Semi-Fowler’s position
C. Recumbent position
D. Low-Fowler’s position

MS SAS 12 – 20

SAS 12

1. A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a
hypoglycemic reaction to occur is:
A. 2-4 hours after administration
B. 6-14 hours after administration
C. 16-18 hours after administration
D. 18-24 hours after administration

2. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the ER. Which finding would a nurse expect
to note as confirming this diagnosis?
A. Elevated blood glucose level and a low plasma bicarbonate
B. Decreased urine output
C. Increased respirations and an increase in pH
D. Comatose state

3. A nurse is preparing a plan of care for a client with DM who has hyperglycemia. The priority nursing diagnosis would
be: A. High risk for deficient fluid volume
B. Deficient knowledge: disease process and treatment
C. Imbalanced nutrition: less than body requirements
D. Disabled family coping: compromised.

4. A nurse is caring for a client admitted to the ER with DKA. In the acute phase the priority nursing action is to prepare
to: A. Administer regular insulin intravenously
B. Administer 5% dextrose intravenously
C. Correct the acidosis
D. Apply an electrocardiogram monitor.

5. A nurse performs a physical assessment on a client with type 2 DM. Findings include a fasting blood glucose of
120mg/dl, temperature of 101, pulse of 88, respirations of 22, and a bp of 140/84. Which finding would be of most
concern of the nurse?
A. Pulse
B. BP
C. Respiration
D. Temperature

6. A client with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia with exercise. Which statement by
the client indicated an inadequate understanding of the peak action of NPH insulin and exercise?
A. “The best time for me to exercise is every afternoon.”
B. “The best time for me to exercise is right after I eat.”
C. “The best time for me to exercise is after breakfast.”
D. “The best time for me to exercise is after my morning snack.”

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7. Glucose is an important molecule in a cell because this molecule is primarily used for:
A. Extraction of energy
B. Synthesis of protein
C. Building of genetic material
D. Formation of cell membranes.

8. When a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS), the nurse’s priority is to
provide:
A. Oxygen
B. Carbohydrates
C. Fluid replacement
D. Dietary instruction

9. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all
that apply.
A. Thirst
B. Palpitations
C. Diaphoresis
D. Slurred speech
E. Hyperventilation

10. When a client is in diabetic ketoacidosis, the insulin that would be administered is:
A. Human NPH insulin
B. Human regular insulin
C. Insulin lispro injection
D. Insulin glargine injection

SAS 13

1. When caring for a male client with diabetes insipidus, nurse Juliet expects to administer:
A. Vasopressin (Pitressin Synthetic).
B. Furosemide (Lasix).
C. Regular insulin.
D. 10% dextrose.

2. Nurse Louie is developing a teaching plan for a male client diagnosed with diabetes insipidus. The nurse should
include information about which hormone lacking in clients with diabetes insipidus?
A. Antidiuretic hormone (ADH).
B. Thyroid-stimulating hormone (TSH).
C. Follicle-stimulating hormone (FSH).
D. Luteinizing hormone (LH).

3. Which outcome indicates that treatment of a male client with diabetes insipidus has been effective?
A. Fluid intake is less than 2,500 ml/day.
B. Urine output measures more than 200 ml/hour.
C. Blood pressure is 90/50 mm Hg.
D. The heart rate is 126 beats/minute.

4. An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue
squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia,
hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe
hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of:
A. Thyroid storm
B. Cretinism
C. Myxedema coma
D. Hashimoto’s thyroiditis

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5. Vasopressin is administered to the client with diabetes insipidus (DI) because it:
A. Decreases blood sugar.
B. Increases tubular reabsorption of water.
C. Increases release of insulin from the pancreas.
D. Decreases glucose production within the liver.

6. A male client 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.

7. What test should be ordered if hypothyroidism is suspected?

A. Liver function tests
B. Hemoglobin A1c
C. T4 and thyroid-stimulating hormone
D. 24-hour urine free cortisol measurement

8. Which of the following conditions is caused by excessive secretion of vasopressin?

A. Thyrotoxic crisis
B. Diabetes insipidus
C. Primary adrenocortical insufficiency
D. Syndrome of inappropriate antidiuretic hormone (SIADH)

9. A client represents with flushed skin, bulging eyes, and perspiration, and states that he has been irritable and having
palpitations. This client is presenting with symptoms of which disorder?
A. Pancreatitis
B. Hypothyroidism
C. Hyperthyroidism
D. Diabetes insipidus

10. The appropriate nursing diagnosis for a patient with SIADH is:
A. Fluid volume deficit related to excessive fluid loss
B. Fluid volume excess related to fluid retention
C. Risk for injury related to decreased blood pressure
D. Impaired skin integrity related to dehydration

11. A male client has recently undergone surgical removal of a pituitary tumor. Dr. Wong prescribes corticotropin (Acthar),
20 units I.M. q.i.d. as a replacement therapy. What is the mechanism of action of corticotropin?
A. It decreases cyclic adenosine monophosphate (cAMP) production and affects the metabolic rate of target organs.
B. It interacts with plasma membrane receptors to inhibit enzymatic actions.
C. It interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat, and
carbohydrate metabolism.
D. It regulates the threshold for water resorption in the kidneys.

12. A female client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup.
Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the
surgery, nurse Jacob reviews preoperative and postoperative instructions given to the client earlier. Which postoperative
instruction should the nurse emphasize?
A. “You must lie flat for 24 hours after surgery.”
B. “You must avoid coughing, sneezing, and blowing your nose.”
C. “You must restrict your fluid intake.”
D. “You must report ringing in your ears immediately.”

13. A somatotropin-secreting tumor of which of the following glands would lead to the development of acromegaly,
Cushing’s syndrome, and hypopituitarism?

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A. Adrenal gland
B. Hypothalamus
C. Pituitary gland
D. Thyroid gland

14. Surgical management for large, invasive pituitary tumors is a transphenoidal hypophysectomy. The nurse would
explain that the surgery will be performed through an incision in the:
A. Nose
B. Back of the mouth
C. Sinus channel below the right eye
D. Upper gingival mucosa in the space between the upper gums and lip

15. Initial treatment for a CSF leak after transphenoidal hypophysectomy would most likely involve:
A. Repacking the nose.
B. Returning the client to surgery.
C. Enforcing bed rest with the head of the bed elevated.
D. Administering high-dose corticosteroid therapy.

SAS 14

1. A female adult client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial
assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis
statement for this client, which “related-to” phrase should the nurse add?
A. Related to bone demineralization resulting in pathologic fractures
B. Related to exhaustion secondary to an accelerated metabolic rate
C. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
D. Related to tetany secondary to a decreased serum calcium level

2. A 67-year-old male client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability,
depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, nurse Richard
would suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism

3. When instructing the female client diagnosed with hyperparathyroidism about diet, nurse Gina should stress the
importance of which of the following?
A. Restricting fluids
B. Restricting sodium
C. Forcing fluids
D. Restricting potassium

4. Which nursing diagnosis takes highest priority for a female client with hyperthyroidism?
A. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess
B. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing
C. Body image disturbance related to weight gain and edema
D. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

5. Which of the following laboratory results supports a diagnosis of primary hyperparathyroidism?

A. High parathyroid hormone and high calcium levels
B. High magnesium and high thyroid hormone levels
C. Low parathyroid hormone and low potassium levels
D. Low thyroid-stimulating hormone and high phosphorous levels

6. Following a unilateral adrenalectomy, nurse Betty would assess for hyperkalemia shown by which of the following?
A. Muscle weakness
B. Tremors
C. Diaphoresis

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D. Constipation

7. A female client has a serum calcium level of 7.2 mg/dl. During the physical examination, nurse Noah expects to
assess:
A. Trousseau’s sign.
B. Homans’ sign.
C. Hegar’s sign.
D. Goodell’s sign.

8. Nurse Wayne is aware that a positive Chvostek’s sign indicate?

A. Hypocalcemia
B. Hyponatremia
C. Hypokalemia
D. Hypermagnesemia

9. Hyperphosphatemia and hypocalcemia are indicative of which of the following disorders?

A. Grave’s Disease
B. Hypothyroidism
C. Cushing’s Syndrome
D. Hypoparathyroidism

10. Which of the following symptoms is the chief sign of hypoparathyroidism?

A. Chest pain
B. Exophthalmos
C. Shortness of breath
D. Tetany

11. Nurse Ronn is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse
would expect to find:
A. Hypotension.
B. Thick, coarse skin.
C. Deposits of adipose tissue in the trunk and dorsocervical area.
D. Weight gain in arms and legs.

12. In a 29-year-old female client who is being successfully treated for Cushing’s syndrome, nurse Lyzette would expect
a decline in:
A. Serum glucose level.
B. Hair loss.
C. Bone mineralization.
D. Menstrual flow.

13. A female client with Cushing’s syndrome is admitted to the medical-surgical unit. During the admission assessment,
nurse Tyzz notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears
disheveled. These findings are consistent with which problem?
A. Depression
B. Neuropathy
C. Hypoglycemia
D. Hyperthyroidism

14. Which of the following nursing diagnoses is appropriate for a client with Cushing’s syndrome?
A. Risk for infection
B. Deficient fluid volume
C. Acute pain with movement
D. Functional urinary incontinence

15. A client has thin extremities but an obese truncal area and a “buffalo hump” at the shoulder area. The client also
complains of weakness and disturbed sleep. Which of the following disorders is the most likely diagnosis?

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A. Addison’s disease
B. Cushing’s syndrome
C. Grave’s disease
D. Hyperparathyroidism

16. Adrenal insufficiency develops secondary to inadequate secretion of which of the following pituitary hormones?
A. Corticotropin
B. Antidiuretic hormone (ADH)
C. Follicle-stimulating hormone (FSH)
D. Thyroid-stimulating hormone (TSH)

17. Laboratory findings indicating decreased levels of glucose and sodium and increased levels of potassium and white
blood cells (WBC) would correlate with which diagnosis?
A. Addison’s disease
B. Cushing’s syndrome
C. Diabetes mellitus
D. Hypothyroidism

18. An appropriate nursing diagnosis for a client with Addison’s disease would include which of the following
assessments?
A. Risk for injury
B. Excess fluid volume
C. Impaired gas exchange
D. Ineffective thermoregulation

19. Nursing care for a client with Addison’s disease may include which of the following goals?
A. Limiting fluid intake to 100 mL/day.
B. Participating in relaxation techniques.
C. Ambulating in the hall five to six times per day.
D. Knowing which high-sodium foods to avoid.

20. Which of the following outcomes are expected for a client being treated for Addison’s disease?
A. Avoiding alcohol to decrease abdominal girth.
B. Avoiding hot and uncomfortable environments.
C. Reporting absence of postural hypotension symptoms.
D. Selecting and eating foods high in protein, calcium, and vitamin

SAS 15

1. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to
use which of the following to test the client’s peripheral response to pain?
A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle

2. A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A. Unequal pupil size
B. Decreasing systolic blood pressure
C. Tachycardia
D. Decreasing body temperature

3. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
A. Give the client a warming blanket.
B. Administer low-dose barbiturate.
C. Encourage the client to hyperventilate.

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D. Restrict fluids.

4. A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition?
A. Widening pulse pressure
B. Decrease in the pulse rate
C. Dilated, fixed pupil
D. Decrease in LOC

5. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line.
Which nursing intervention protects the client without increasing her ICP?
A. Place her in a jacket restraint.
B. Wrap her hands in soft “mitten” restraints.
C. Tuck her arms and hands under the draw sheet.
D. Apply a wrist restraint to each arm.

6. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is
contraindicated when positioning the client?
A. Keeping the client flat on one side or the other.
B. Elevating the head of the bed to 30 degrees.
C. Log rolling or turning as a unit when turning.
D. Keeping the head in neutral position.

7. A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized
tonicclonic seizures. Which nursing activities included in the patient’s care? Select all that apply.
A. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures.
B. Administer phenytoin (Dilantin) 200 mg PO daily.
C. Teach patient about the need for good oral hygiene.
D. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.

8. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The
physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if
needed and prescribed?
A. In 30 to 45 seconds
B. In 10 to 15 minutes
C. In 30 to 45 minutes
D. D. In 1 to 2 hours

9. A male client is having tonic-clonic seizures. What should the nurse do first?
A. Elevate the head of the bed.
B. Restrain the client’s arms and legs.
C. Place a tongue blade in the client’s mouth.
D. Take measures to prevent injury.

10. The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following
actions by the nurse would be contraindicated?
A. Loosening restrictive clothing.
B. Restraining the client’s limbs.
C. Removing the pillow and raising padded side rails.
D. Positioning the client to side, if possible, with the head flexed forward.

SAS 16

1. Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing
measures is inappropriate when providing oral hygiene?
A. Placing the client on the back with a small pillow under the head.

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B. Keeping portable suctioning equipment at the bedside.

C. Opening the client’s mouth with a padded tongue blade.
D. Cleaning the client’s mouth and teeth with a toothbrush.

2. A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred
speech. Which nursing intervention is a priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consult.

3. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA)
administration. Which is the priority nursing assessment?
A. Current medications.
B. Complete physical and history.
C. Time of onset of current stroke.
D. Upcoming surgical procedures.

4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s:
A. Pulse
B. Respirations
C. Blood pressure
D. Temperature

5. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
A. Cholesterol level
B. Pupil size and pupillary response
C. Bowel sounds
D. Echocardiogram

6. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
A. A blood glucose level of 480 mg/dl.
B. A right-sided carotid bruit.
C. A blood pressure of 220/120 mmHg.
D. The presence of bronchogenic carcinoma.

7. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity,
and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the
following circumstances?
A. Vomiting continues
B. Intracranial pressure (ICP) is increased
C. The client needs mechanical ventilation
D. Blood is anticipated in the cerebrospinal fluid (CSF)

8. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician
orders mannitol for which of the following reasons?
A. To reduce intraocular pressure
B. To prevent acute tubular necrosis
C. To promote osmotic diuresis to decrease ICP
D. To draw water into the vascular system to increase blood pressure

9. A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions
about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
A. The client leaves the side rails down.
B. The client uses a mirror to inspect the skin.

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C. The client repositions only after being reminded to do so.

D. The client hangs the left arm over the side of the wheelchair.

10. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent
aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once
each shift. This assessment evaluates:
A. Cranial nerves I and II.
B. Cranial nerves III and V.
C. Cranial nerves VI and VIII.
D. Cranial nerves IX and X.

SAS 17

1. A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the
following to ensure client to ensure client safety?
A. Speak loudly to the client
B. Test the temperature of the shower water
C. Check the temperature of the food on the delivery tray.
D. Provide a clear path for ambulation without obstacles

2. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows
an upward trend. Which intervention should the nurse perform first?
A. Reposition the client to avoid neck flexion
B. Administer 1 g Mannitol IV as ordered
C. Increase the ventilator’s respiratory rate to 20 breaths/minute
D. Administer 100 mg of pentobarbital IV as ordered.

3. A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing
interventions should be done first?
A. Assess full ROM to determine extent of injuries
B. Call for an immediate chest x-ray
C. Immobilize the client’s head and neck
D. Open the airway with the head-tilt-chin-lift maneuver

4. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and
nose. Which of the following nursing interventions should be done first?
A. Position the client flat in bed
B. Check the fluid for dextrose with a dipstick
C. Suction the nose to maintain airway patency
D. Insert nasal and ear packing with sterile gauze

5. An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his
mother, the nurse gives which of the following instructions?
A. “Watch him for keyhole pupil the next 24 hours.”
B. “Expect profuse vomiting for 24 hours after the injury.”
C. “Wake him every hour and assess his orientation to person, time, and place.”
D. “Notify the physician immediately if he has a headache.”

6. A client has been pronounced brain dead. Which findings would the nurse assess? Select all that apply.
A. Decerebrate posturing
B. Dilated nonreactive pupils
C. Deep tendon reflexes
D. Absent corneal reflex

7. A client with a C6 spinal injury would most likely have which of the following symptoms?
A. Aphasia

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B. Hemiparesis
C. Paraplegia
D. Tetraplegia

8. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities.
Which of the following medications would be used to control edema of the spinal cord?
A. Acetazolamide (Diamox)
B. Furosemide (Lasix)
C. Methylprednisolone (Solu-Medrol)
D. Sodium bicarbonate

9. A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate
of 50 bpm. Which of the following nursing interventions should be done first?
A. Place the client flat in bed
B. Assess patency of the indwelling urinary catheter
C. Give one SL nitroglycerin tablet
D. Raise the head of the bed immediately to 90 degrees

10. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal
cord injury?
A. Insert an indwelling urinary catheter to straight drainage
B. Schedule intermittent catheterization every 2 to 4 hours
C. Perform a straight catheterization every 8 hours while awake
D. Perform Crede’s maneuver to the lower abdomen before the client voids.

SAS 18

1. lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A
nurse reviews the results of the CSF analysis and determines that which of the following results would verify the
diagnosis?
A. Cloudy CSF, decreased protein, and decreased glucose
B. Cloudy CSF, elevated protein, and decreased glucose
C. Clear CSF, elevated protein, and decreased glucose
D. Clear CSF, decreased pressure, and elevated protein

2. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection,
which of the following would be included in the plan of care?
A. No precautions are required as long as antibiotics have been started
B. Maintain enteric precautions
C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
D. Maintain neutropenic precautions

3. Which of the following assessment data indicated nuchal rigidity?

A. Positive Kernig’s sign
B. Negative Brudzinski’s sign
C. Positive homan’s sign
D. Negative Kernig’s sign

4. Which of the following are considered as the initial symptoms of HSV-1 encephalitis? Select all that apply.
A. Confusion
B. Seizure
C. Headache
D. Behavioral changes
E. Fever

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5. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would
the nurse expect to find?
A. Vision changes
B. Absent deep tendon reflexes
C. Tremors at rest
D. Flaccid muscles

6. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse
should tell the client to:
A. Take a hot bath.
B. Rest in an air-conditioned room.
C. Increase the dose of muscle relaxants.
D. Avoid naps during the day.

7. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3
hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting
condition would contraindicate the use of pyridostigmine?
A. Ulcerative colitis
B. Blood dyscrasia
C. Intestinal obstruction
D. Spinal cord injury

8. A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has
precipitating factors such as:
A. Getting too little exercise
B. Taking excess medication
C. Omitting doses of medication
D. Increasing intake of fatty foods

9. A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the
nursing admission interview if the client has a history of:
A. Seizures or trauma to the brain
B. Meningitis during the last five (5 years
C. Back injury or trauma to the spinal cord
D. Respiratory or gastrointestinal infection during the previous month.

10. The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic
crises. The nurse tells the client that this is most effectively done by:
A. Eating large, well-balanced meals
B. Doing muscle-strengthening exercises
C. Doing all chores early in the day while less fatigued
D. Taking medications on time to maintain therapeutic blood levels

SAS 19

1. Tic douloureux is characterized by paroxysms of pain and burning sensations. It is a disorder of which cranial nerve?
A. Third
B. Fifth
C. Seventh
D. Eighth

2. Which of the following drugs is used for trigeminal neuralgia?

A. Riluzole (Rilutek)
B. Levodopa (Larodopa)

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C. Carbamazepine (Tegretol)
D. Ceftriaxone sodium (Rocephin)

3. A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s response is based on an
understanding that the cause is:
A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem
B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia
C. Primary genetic in origin, triggered by exposure to meningitis
D. Primarily genetic in origin, triggered by exposure to neurotoxins

4. The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing
denervation. The nurse determines that the client needs additional information if the client states that he or she will:
A. Exposure to cold and drafts
B. Massage the face with a gentle upward motion
C. Perform facial exercises
D. Wrinkle the forehead, blow out the cheeks, and whistle

5. The care team has deemed the occasional use of restraints necessary in the care of a patient with Alzheimer’s
disease. What ethical violation is most often posed when using restraints in a long-term care setting?
A. It limits the patient’s personal safety.
B. It exacerbates the patient’s disease process.
C. It threatens the patient’s autonomy.
D. It is not normally legal.

6. An 83-year-old woman was diagnosed with Alzheimer’s disease 2 years ago and the disease has progressed at an
increasing pace in recent months. The patient has lost 16 pounds over the past 3 months, leading to a nursing diagnosis
of Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this patient’s plan
of care?
A. Offer the patient rewards for finishing all the food on her tray.
B. Offer the patient bland, low-salt foods to limit offensiveness.
C. Offer the patient only one food item at a time to promote focused eating.
D. Arrange for insertion of a gastrostomy tube and initiate enteral feeding.

7. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?
A. Imbalanced nutrition: Less than body requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury

8. When evaluating the extent of Parkinson’s disease, a nurse observes for which of the following conditions? A.
Bulging eyeballs
B. Diminished distal sensations
C. Increased dopamine levels
D. Muscle rigidity

9. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrated. I can’t do
anything without help!” This comment best supports which nursing diagnosis?
A. Anxiety
B. Powerlessness
C. Ineffective denial
D. Risk for disuse syndrome

10. Which of the following clinical manifestations suggest ALS?

A. Fatigue, progressive muscle weakness, cramps, fasciculations (twitching), and incoordination
B. Tremor, rigidity, bradykinesia (abnormally slow movements), and postural instability

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C. Paralysis of the facial muscles, increased lacrimation (tearing), and painful sensations in the face, behind the ear,
and in the eye
D. Involuntary contraction of the facial muscles causing sudden closing of the eye or twitching of the mouth

SAS 20

1. The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies
the accurate procedure for this visual acuity test?
A. Both eyes are assessed together, followed by the assessment of the right and then the left eye.
B. The right eye is tested followed by the left eye, and then both eyes are tested.
C. The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart.
D. The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an
individual with unimpaired vision.

2. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as
documented in the client’s chart and understands that normal intraocular pressure is:
A. 2-7 mmHg
B. 10-21 mmHg
C. 22-30 mmHg
D. 31-35 mmHg

3. Which of the following refractive surgeries has high success rate?

A. Laser Vision Correction Photorefractive Keratectomy (PRK)
B. Laser-Assisted In Situ Keratomileusis (LASIK)
C. Phakic Intraocular Lenses
D. Conductive Keratoplasty

4. After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician
prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should
teach the client or a family member to administer the drug by:
A. Instilling one drop of pilocarpine 0.25% into both eyes daily.
B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily.
C. Instilling one drop of pilocarpine 0.25% into the right eye daily.
D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.

5. The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is:
A. “Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to the
treatment plan.
B. “Your vision will return as soon as the medications begin to work.”
C. “Your vision will never return to normal.”
D. “Your vision loss is temporary and will return in about 3-4 weeks.”

6. The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the
nurse include in the plan of care?

A. Decrease fluid intake to control the intraocular pressure

B. Avoid overuse of the eyes
C. Decrease the amount of salt in the diet
D. Eye medications will need to be administered lifelong.

7. The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides
instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the
instructions?
A. “I will take Aspirin if I have any discomfort.”
B. “I will sleep on the side that I was operated on.”
C. “I will wear my eye shield at night and my glasses during the day.”

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D. “I will not lift anything if it weighs more that 10 pounds.”

8. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report:
A. Light flashes and floaters in front of the eye.
B. A recent driving accident while changing lanes.
C. Headaches, nausea, and redness of the eyes.
D. Frequent episodes of double vision.

9. After pneumatic retinopexy, the patient must be placed in:

A. Side-lying position
B. Prone position
C. Trendelenburg position
D. Recumbent position

10. The most common manifestation in dry eye syndrome is:

A. Excessive mucus secretions
B. Difficulty moving the lids
C. Burning sensation
D. Scratchy or foreign body sensation

MS SAS 21-23

SAS 21

1. The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for
performing this test?
A. Stand 4 feet away from the client to ensure that the client can hear at this distance.
B. Whisper a statement and ask the client to repeat it.
C. Whisper a statement with the examiners back facing the client
D. Whisper a statement while the client blocks both ears.

2. During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The
nurse analyzes this result as:
A. A normal finding
B. A conductive hearing loss in the right ear
C. A sensorineural or conductive loss
D. The presence of nystagmus

3. The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate
communication?
A. Speak frequently
B. Speak loudly
C. Speak directly into the impaired ear
D. Speak in a normal tone

4. The nurse has notes that the physician has a diagnosis of presbycusis on the client’s chart. The nurse plans care
knowing the condition is:
A. A sensorineural hearing loss that occurs with aging
B. A conductive hearing loss that occurs with aging.
C. Tinnitus that occurs with aging
D. Nystagmus that occurs with aging

5. The most common fungus associated with external ear infection is:
A. Staphylococcus albus

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B. Staphylococcus aureus
C. Aspergillus
D. Pseudomonas

6. A nurse would question an order to irrigate the ear canal in which of the following circumstances?
A. Ear pain
B. Hearing loss
C. Otitis externa
D. Perforated tympanic membrane

[Link] nursing assessment for a patient who has had a mastoidectomy should include observing for:
A. Facial paralysis
B. Olfactory paralysis
C. Optic paralysis
D. Oculomotor paralysis

8. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a
stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse
should provide which client instruction?
A. “Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours.”
B. “Try to ambulate independently after about 24 hours.”
C. “Shampoo your hair every day for ten (10) days to help prevent ear infection.”
D. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds
for 30 days.”

9. The nurse has conducted discharge teaching for a client who had a fenestration procedure for the treatment of
otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective?
A. “I should drink liquids through a straw for the next 2-3 weeks.”
B. “It’s ok to take a shower and wash my hair.”
C. “I will take stool softeners as prescribed by my doctor.”
D. “I can resume my tennis lessons starting next week.”

10. Which of the following medications relieves motion sickness symptoms?

A. Corticosteroids
B. Antihistamines
C. Diuretics
D. Antibiotics

11. A client with Meniere’s disease is experiencing severe vertigo. Which instruction would the nurse give to the client to
assist in controlling the vertigo?
A. Increase fluid intake to 3000 ml a day
B. Avoid sudden head movements
C. Lie still and watch the television
D. Increase sodium in the diet

12. The nurse is reviewing the physician’s orders for a client with Meniere’s disease. Which diet will most likely be
prescribed?
A. Low-cholesterol diet
B. Low-sodium diet
C. Low-carbohydrate diet
D. Low-fat diet

13. Canalith repositioning is performed to patients with benign paroxysmal positional vertigo to:
A. Relieve nausea and vomiting

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B. Treat vertigo
C. Enhance disequilibrium
D. Suppress vestibular function

14. A client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client
complaint associated with a disorder in this part of the ear?
A. Hearing loss
B. Pruritus
C. Tinnitus
D. Burning of the ear

15. A client who is complaining of tinnitus is describing a symptom that is:

A. Objective
B. Subjective
C. Functional
D. Prodromal

SAS 22

1. A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the
discharge teaching?
A. Take the medication with milk.
B. Report chest pain.
C. Remain upright after taking for 30 minutes.
D. Allow 6 weeks for optimal effects.

2. Pathophysiologic changes seen with osteoarthritis include:

A. Joint cartilage degeneration.
B. The formation of bony spurs at the edges of the joint surfaces.
C. Narrowing of the joint space.
D. All of the above.

3. A client has been prescribed a diet that limits purine-rich foods. Which of the following foods would the nurse teach him
to avoid eating?
A. Bananas and dried fruits
B. Milk, ice cream, and yogurt
C. Wine, cheese, preserved fruits, meats, and vegetables
D. Anchovies, sardines, kidneys, sweetbreads, and lentils

4. A client with gout is encouraged to increase fluid intake. Which of the following statements best explains why increased
fluids are encouraged for gout?
A. Fluids decrease inflammation.
B. Fluids increase calcium absorption.
C. Fluids promote the excretion of uric acid.
D. Fluids provide a cushion for weakened bones.

5. Alendronate (Fosamax) is given to a client with osteoporosis. The nurse advises the client to?
A. Take the medication in the morning with meals.
B. Take the medication 2 hours before bedtime.
C. Take the medication with a glass of water after rising in the morning.
D. Take the medication during lunch.

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6. The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
A. Lack of exercise
B. Hormonal disturbances
C. Lack of calcium
D. Genetic predisposition

[Link] most common symptoms of osteomalacia are:

A. Bone fractures and kyphosis
B. Bone pain and tenderness
C. Muscle weakness and spasm
D. Softened and compressed vertebrae

[Link] of the following dietary management is recommended to patient with osteomalacia associated with diet?
A. Adequate calcium and low protein intake
B. Adequate protein and moderate vitamin intake
C. Restrict calcium and vitamin D intake
D. Increase calcium and vitamin D intake

[Link] of the following medications used in Paget’s disease which facilitates remodeling of abnormal bone?
A. Plicamycin
B. Calcitonin
C. Dexamethasone
D. Atropine sulfate

[Link] of the following diagnostic tests confirms Paget’s disease?

A. X-ray
B. Bone scan
C. Bone biopsy
D. Serum alkaline phosphate

11.A 20-year-old client developed osteomyelitis 2 weeks after a fishhook was removed from his foot. Which of the
following rationales best explains the expected long-term antibiotic therapy needed?
A. Bone has poor circulation.
B. Tissue trauma requires antibiotics.
C. Feet are normally more difficult to treat.
D. Fishhook injuries are highly contaminated.

[Link] for a patient with sprain includes RICE? Which of the following is the correct meaning of RICE?
A. Rise, Ice, Compression, and Elevation
B. Rest, Ice, Compression, and Elevation
C. Rinse, Immobilize, Cast, and Elevation
D. Rest, Immobilize, Compression, and Elevation

[Link] of the following is the primary treatment of septic arthritis?

A. Aspiration of joint fluid
B. Arhtrotomy
C. Antibiotics
D. Arthroscopy

14.A client who has an above-the-knee amputation is to use crutches until the prosthesis is properly fitted. When
teaching the client about using the crutches, the nurse instructs the client to support her weight primarily on which of the
following body areas?
A. Axillae
B. Elbows

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C. Upper arms
D. Hands

[Link] interventions to treat a musculoskeletal injury may include cold or heat therapy. Cold therapy decreases pain
by which of the following actions?
A. Promotes analgesia and circulation
B. Numbs the nerves and dilates the vessels
C. Promotes circulation and reduces muscle spasms
D. Causes local vasoconstriction and prevents edema or muscle spasm

SAS 23

1. A client describes a foul odor from his cast. Which of the following responses or interventions would be the most
appropriate?
A. Assess further because this may be a sign of infection.
B. Teach him proper cast care, including hygiene measures.
C. This is normal, especially when a cast is in place for a few weeks.
D. Assess further because this may be a sign of neurovascular compromise.

2. To reduce the roughness of a cast, which of the following measures should be used?
A. Petal the edges.
B. Elevate the limb.
C. Break off the rough area.
D. Distribute pressure evenly.

3. A client is put in traction before surgery. Which of the following reasons for the traction is correct?
A. Prevents skin breakdown
B. Aids in turning the client
C. Helps the client become active
D. Prevents trauma and overcomes muscle spasms

4. After a hip replacement, which of the following activity level is usually ordered?
A. Bed rest
B. No restrictions
C. No weight bearing
D. Limited weight bearing

5. Which of the following discharge instructions should be given to a client after surgery for repair of a hip fracture?
A. “Don’t flex the hip more than 30 degrees, don’t cross your legs, get help putting on your shoes.”
B. “Don’t flex the hip more than 60 degrees, don’t cross your legs, get help putting on your shoes.”
C. “Don’t flex the hip more than 90 degrees, don’t cross your legs, get help putting on your shoes.”
D. “Don’t flex the hip more than 120 degrees, don’t cross your legs, get help putting on your shoes.”

6. Which of the following symptoms are considered signs of a fracture?

A. Tingling, coolness, loss of pulses
B. Loss of sensation, redness, coolness
C. Coolness, redness, new site of pain
D. Redness, warmth, pain at the site of injury

7. Which of the following serious complications can occur with long bone fractures? A.
Bone emboli
B. Fat emboli
C. Platelet emboli

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D. Serous emboli

8. Which of the following symptoms is an early sign of compartment syndrome?

A. Heat
B. Paresthesia
C. Skin pallor
D. Swelling

9. Treatment of compartment syndrome includes which of the following measures? A.

Amputation
B. Casting
C. Fasciotomy
D. Observation, no treatment is necessary

10. Which of the following areas would be included in a neurovascular assessment?

A. Orientation, movement, pulses, warmth
B. Capillary refill, movement, pulses, warmth
C. Orientation, pupillary response, temperature, pulses
D. Respiratory pattern, orientation, pulses, temperature

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