irrigation is to:

Comprehensive Quiz A.) Cleanse the colon

SITUATION: the client 65 y/o has been B.) Regulate the bowel
experiencing cramping pain in her lower C.) Dilate the sphincter
abdomen and has noticed a gradual change in D.) Stimulate peristalsis
her elimination pattern. She is admitted to the
hospital for a diagnostic workup and probable Ans: D
surgery
6.) Which of the following preparations would be
1.) The client is scheduled for barium enema. best to apply around the colostomy?
Preparation includes administration of 60ml of A.) Karaya
castor oil orally. Castor oil facilitates cleansing of B.) Petroleum
the bowel primarily by: C.) Cornstarch
A.) softening of feces D.) Antiseptic cream
B.) Lubricating the stool
C.) Increasing the volume of intestinal content Ans: A
D.) Irritating the nerve endings in the intestinal
mucosa SITUATION: Mr. H. Sy, 51 y/o is admitted with a
diagnosis of end-stage, irreversible chronic renal
Ans: D failure. He has been scheduled for hemodialysis.
He has an A-V fistula created in his left forearm.
2.) Following barium enema, the nurse should
be prepared to administer which type of 7.) Mr. Sy, is being given aluminum hydroxide
medication? gel (Amphogel) 40 ml. after meals and at
A.) Laxative bedtime. The primary purpose of prescribing this
B.) Antiemetic medication is to:
C.) Antacid A.) Relieve gastric irritation
D.) antibiotic B.) Prevent metabolic acidosis
C.) Prevent peptic ulcer formation
Ans: A D.) Phosphate levels lower serum

3.) The diagnosis of cancer is confirmed. The Ans: D

client is scheduled for permanent colostomy.
The preferred site would be: 8.) The nursing care plan states to observe for
A.) Ascending colon hyperkalemia. The nurse should recognize that
B.) Lower portion of the descending colon the greatest risk of hyperkalemia is:
C.) Middle portion of the transverse colon A.) Tetany
D.) Ileum B.) Cardiac arrest
C.) Fluid overload
Ans: B D.) Internal bleeding

4.) The patient had NGT inserted at the time of Ans: B

surgery. The tube will most likely be removed
when the client demonstrates 9.) The physician orders sodium polysterene
A.) Absence of bowel sounds sulfonate 15g (exchange resin kayexalate) four
B.) Passage of mucus from the rectum times a day. The expected outcome of this
C.) Passage of flatus and feces from the medication is to:
colostomy A.) Lower serum potassium
D.) Absence of gastric drainage for about B.) Lower BP
24hours C.) Increase urinary output
D.) Prevent hemorrhage
Ans: C
Ans: A

5.) A colostomy irrigation is ordered on the 5th 10.) The physician orders regular insulin, 10 U
postop day. The primary purpose of this first added to 50 ml of 50% dextrose to be given
intravenously. The expected outcome is to: Ans: C
A.) Lower the blood sugar
B.) Decrease the serum potassium 16.) Signs and symptoms of ECF volume excess
C.) Reduce cerebral edema include the following EXCEPT:
D.) Prevent tetany A.) Weight gain
B.) Tight, smooth shiny skin
Ans: B C.) Puffy eyelids
D.) Flushed, dry skin
11.) While caring for Mr. Sy who is now having
hemodialysis via A-V shunt, the nurse should Ans: D
recognize that:
A.) The use of stethoscope to auscultate the 17.) The following are manifestations of
fistula is contraindicated dehydration EXCEPT:
B.) The client feels best immediately after the A.) Thirst
hemodialysis B.) Diluted urine and polyuria
C.) Taking BP on the affected arm can cause C.) Weight loss
clotting D.) Poor skin turgor
D.) No pain should be experienced during
initiation of the dialysis Ans: B

Ans: C Situation: Mike’s history was taken upon

admission. Impression is peptic ulcer disease
12.) Following hemodialysis, the nurse should (P.U.D.)
anticipate
A.) weight loss 18.) Mike was prescribed antacids. The rationale
B.) Polyuria for prescribing antacids to Mike is to:
C.) Increased BP A.) Decrease gastric motility
D.) Glycosuria B.) Neutralize gastric acid
C.) Aid in the digestion process
Ans: A D.) Prevent constipation

13.) After hemodialysis, the expected outcome is Ans: B

decreased serum
A.) Bicarbonate 19.) The nurse recognizes that the diet best
B.) Creatinine indicated and must be prescribed for Mike is:
C.) Proteins A.) Bland diet
D.) Glucose B.) Full Diet
C.) Sippy diet
Ans: B D.) Karrel’s diet

14.) The nurse observe symptoms of Ans: A

disequilibrium syndrome which includes
A.) Headache, confusion, and seizure SITUATION: Mr. M is a 35 y/o bus driver.
B.) Ankle edema, rales, weight gain Accidentally, he sustained second and third
C.) Fever, joint pain and chills degree burns of the chest, anterior portion of
D.) Decreased BP, tachycardia and chest pain both arms and anterior and posterior portions of
his right leg.
Ans: A
20.) At the scene of the accident, the burning
15.) Which of the following blood values will not process may be stopped by:
be improved by hemodialysis? A.) Immersing the burned parts in cold water
A.) Elevated serum creatinine B.) Applying oil to the burned parts
B.) Hyperkalemia C.) Flushing the burned areas with a weak
C.) Low hemoglobin solution of vinegar
D.) Hypernatremia D.) Covering the burned areas with dry, sterile
dressings
 Ans: C
Ans: A
26.) The M.D. orders hourly CVP readings. The
21.) Based on the rule of 9’s, which percentage serial CVP readings are as follows: 3, 4, 6, 7, 8,
is the best estimate of the extent of the client’s cm of water. The nurse recognizes this as:
burns? A.) As indication to increase the flow rate of the
A.) 36 IV fluid
B.) 27 B.) A sign of fluid overload
C.) 26 C.) The desired response to the fluid therapy
D.) 46 D.) An indication of the need to decrease the
flow rate of the IV therapy
Ans: A
Ans: C
22.) Deep partial thickness burns (2nd degree)
involves the: 27.) The physicians prescribes Cimetidine
A.) Epidermis only (Tagamet) 400 mg every 6 hours per IV. The
B.) Entire epidermis and the dermis primary action of this drug is to prevent:
C.) Epidermis, dermis and the muscle A.) Vomiting
D.) Epidermis, dermis, muscle and the bones B.) Esophageal Varices
C.) Paralytic Ileus
Ans: B D.) Duodenal ulcers

23.) Visual inspection of full-thickness burns Ans: D

would reveal
A.) Dry skin surface with a pearly white or 28.) The physician has ordered reverse isolation
charred appearance for Mr. M the nurse should understand that:
B.) Blisters of varying sizes, with a cherry red A.) It is necessary to use sterile linens if the
base linens are properly washed
C.) Moist skin surface with a mottled, reddened B.) Sterile gowns, masks and gloves must be
area worn while caring for the client
D.) A swollen, reddened area that blanches C.) Only some persons coming in contact with
when pressure is applied the patients need to wear marks and gloves
D.) It is not necessarily to wear mask while
Ans: A administering medication

Ans: B
24.) What is the priority of care in the emergency
room during the initial management of the burn 29.) Mr. M becomes confused and restless. His
client? CVP reading is 17 cm water, weight gain of 5 lbs
A.) Obtaining a medical history and urine output of 100ml/hr. The nurse should
B.) Caring for the burn wound recognize this as a signs of:
C.) Providing for fluid resuscitation A.) Hypovolemia
D.) Administration of tetanus antitoxin as B.) Circulatory overload
ordered C.) The diuretic stage
D.) Septic Shock
Ans: C
Ans: B
25.) During the first 24 hours post-burn, there is
a fluid shift from the intravascular compartment 30.) During the diuretic phase of burns, fluid
to the site of burns. The nurse anticipates the shifts from the interstitial compartment to the
following observations EXCEPT: intravascular. There is increase urinary output.
A.) Decreased urine output The ff changes occur during this stage:
B.) Increased serum potassium A.) Hypernatremia, hypokalemia, bicarbonate
C.) Decreased hematocrit excess
D.) Decreased serum sodium B.) Hyponatremia, hyperkalemia, carbonic acid
deficits
C.) Hyponatremia, hyperkalemia, carbonic acid Ans: B
excess
D.) Hyponatremia, hypokalemia, bicarbonate 35.) One change in the ECG that indicates MI is:
deficit A.) Inverted T wave
B.) Prolonged PR interval
Ans: D C.) Narrowing of the QRS complex
D.) Absence of P wave
31.) The physician has ordered Mefenide
Acetate (Sulfamylon) for the burn site every 12 Ans: A
hours. The nurse should recognize that:
A.) There is a great deal of pain associated with 36.) If the client develops cardiogenic shock,
the application which characteristic sign of the condition should
B.) A thick layer of the preparation should e the nurse expect to observe?
applied for maximum effect A.) Pulmonary rales
C.) Cover the application with pressure dressing B.) A slow pulse rate
for better effect C.) Sudden onset of fever
D.) It is not necessary to use sterile technique D.) A low blood pressure
during application of the preparation because it
is antimicrobial Ans: D

Ans: A 37.) After one attack of pain, the client says to

the nurse “husband died of heart attack and I
Situation: A female client, 60 y/o, is admitted suppose I will too” Which of the ff would be the
through the emergency department with most response for the nurse to make.
crushing substernal chest pain that radiates to A.) “Are you thinking that you won’t recover from
her shoulder, jaw and left arm. The admission this illness?”
diagnosis is acute MI. The client is extremely B.) “You have a fine doctor. Everything will be
restless and frightened alright”
C.) “Tell me more about what you are feeling”
32.) The pain associated with MI is due to: D.) “Would you agree that this would be very
A.) An overload left ventricle unlikely?”
B.) Impending circulatory collapse
C.) Imbalances in extracellular electrolytes Ans: C
D.) Insufficient oxygen reaching the heart
muscle 38.) Which of the following orders should appear
on the client’s NCP to help prevent Valsalva
Ans: D maneuver?
A.) Have the client take fewer but deep breathes
33.) Which of the following hematological B.) Have the client clench her teeth while
studies is typical finding of MI? moving in
A.) Elevated CPK value C.) Have the client avoid holding her breath
B.) Elevated cholesterol level during activities
C.) A below normal WBC count D.) Have the client take oral fluids through a
D.) A below normal ESR straw

Ans: A Ans: C

34.) If the client has 8 PVC’s per minute, the 39.) Oral furosemide (Lasix) is prescribed for the
nurse’s first course of action should be to: client. Which of the ff signs and symptoms
A.) Increase the rate of IV infusion indicates the need for this medication?
B.) Notify the physician promptly A.) The client is anxious
C.) Increase the concentration of oxygen B.) The client is restless
therapy C.) The client has anterior chest pain
D.) Administer an analgesic prescribed for the D.) The client has rales in the lower lobes of the
client lungs
Ans: D
Ans: D
Situation: Miss L, an acutely ill 17 y/o is admitted
to the hospital with the chief complaint of upper 44.) Which of the following measure would be
respiratory infection. She is pale and weak. She contraindicated when the nurse gives the client
has been diagnosed to have leukemia when she oral hygiene?
was 15. A.) Applying petroleum jelly to the lips
B.) Cleaning the teeth with hard-bristled
40.) Which of the following statements best toothbrush
describes leukemia? C.) Swabbing the mouth with moistened cotton
A.) A disease is infectious in nature and swabs
characterized by increased WBC production D.) Rinsing the mouth with a non-irritating mouth
B.) The disease is neoplastic in nature and wash
characterized by a proliferation of immature
white blood cells Ans: B
C.) The disease is inflammatory in nature and
characterized by solid tumor formation in the 45.) The nurse should question the order if the
lymph nodes drug prescribed for Miss L. T o help control
D.) The disease is allergic in nature and discomfort is:
characterized by an increased number of A. Acetaminophen (Tylenol)
circulating antibodies in the bloodstream B.) Acetylsalicylic (Aspirin)
C.) Paracetamol (Biogesic)
Ans: B D.) Acetophenetidin (Phenacetin)

41.) Laboratory findings of the client shows that Ans: B

she is anemic, which has most probably resulted
from blood loss and 46.) Miss L is scheduled for bone marrow
A.) An inadequate intake of iron in the diet aspiration. Over which of the following bone
B.) An increase in destruction of RBC by sites should the nurse prepare the client’s skin
lymphocytes for entry of the needle?
C.) A progressive replacement of the bone A.) The radius
marrow with scar tissue B.) A sternum
D.) A decrease in the production of RBC C.) A cervical vertebra
D.) The posterior iliac crest
Ans: D
Ans: D
42.) The nurse notes that the client has
petechiae, her gums, lips and nose bleed easily, 47.) The following are nursing consideration
and that there are bruises on various parts of his when administering oral iron preparation
body. Which of the following laboratory findings EXCEPT:
would be typical when theses symptoms A.) Use straw when taking liquid iron preparation
appear? B.) Take the medication with orange juice
A.) Low platelet count C.) Inform that stool may become black and
B.) Low serum calcium level tarry
C.) Faulty thrombin production D.) Take the medication before meals for better
D.) Insufficient fibrinogen concentration absorption

Ans: A Ans: D

43.) Which of the following measures should be

kept at a minimum, when possible because the Situation: Mr. G, is a 45 y/o man, who has been
client is prone to bruises and bleed easily? diagnosed to have acute renal failure
A.) Giving her stool softener
B.) Changing her position in bed 48.) Mr. G has been prescribed low protein,
C.) Offering her food at frequent intervals potassium, and sodium diet. A touching program
D.) Administering drugs to her intramuscularly should include:
A.) Encourage to include raw fruits and C.) Decrease chest pain
vegetables in the diet D.) Maintain adequate circulating volume
B.) Inform that eggs, poultry and lean meat may
be included in the diet Ans: B
C.) Point out that raw fruits such as bananas,
watermelon and oranges have low potassium 53.) Which of the following findings would
content confirm the presence of pneumothorax?
D.) Dried fish may be allowed in the diet A.) Pronounced rales
B.) Inspiratory wheezes
Ans: B C.) Dullness to percussion
D.) Absence of breath sounds
49.) During the first peritoneal dialysis
exchange, the fluid that drains from the outflow Ans: D
tubing is tinged with blood. The nurse should:
A.) Check the urine output for hematuria 54.) The nurse administers oxygen to the client
B.) Apply a pressure dressing to the insertion by nasal cannula at 3L/min. What percentage of
site oxygen is the patient receiving?
C.) Recognize that the abdominal blood vessels A.) %% to 10%
have been inadvertently punctured B.) 15% to 20%
D.) Realize that this is an expected occurrence C.) 30% to 35%
for the first few exchange D.) 50% to 60%

Ans: D Ans: C

50.) To prevent abdominal cramps during 55.) A chest tube has been inserted, and has
peritoneal dialysis, the nurse should: been removed on the 6th post op day. The chest
A.) Instruct the client to lie flat during the entire tube is best removed
exchange cycle A.) at the end of inhalation or during exhalation
B.) Infuse the dialyzing solution at a slow rate and do valsalva maneuver
C.) Warm the dialysate solution to body B.) During inhalation
temperature C.) As the patient do keep breathing exercises
D.) Drain the solution as soon as the inflow D.) Anytime
period is completed
Ans: A
Ans: C
56.) Which of the following items should the
51.) To promote drainage of fluid during the nurse have ready to be placed directly over the
outflow period, the nurse should wound when the chest tube is removed?
A.) Keep the head of the bed flat A.) A butterfly dressing
B.) Attach the outflow tubing to low suction B.) A petrolatum gauze dressing
C.) Move the outflow tubing an inch in or out C.) A scultetus binder
D.) Turn the client from side to side D.) A 4x4 sterile gauze moistened with NSS

Ans: D Ans: B

Situation: After a serious automobile accident, a 57.) The best position for the client undergoing
male client age 36 is transported by ambulance thoracentesis is to maintain very still in
to the emergency room. He complains of severe A.) Lateral Position
pain in his right chest where he struck the B.) Supine position
steering wheel. He also experienced multiple C.) Sitting position and bending over an overbed
lacerations and contusions table
D.) Prone position
52.) The primary nursing goal at this point
should be to: Ans: C
A.) Reduce anxiety
B.) Maintain effective respirations 58.) Nursing care during thoracentesis include
the ff. EXCEPT:
A.) Observe for the rate, character of pulse and Ans: A
respiration, color and general appearance during
the procedure 64.) Risk factors that may produce pulmonary
B.) Encourage the patient to cough and deep emboli and deep vein thrombosis include the ff
breathe after the needle is inserted EXCEPT:
C.) Place the patient on the unaffected side for A.) Immobility
one hour after the procedure B.) Obesity
D.) Monitor VS after the procedure to detect C.) Pelvic surgeries, orthopedic surgeries of
hemorrhage and impending shock lower
D.) Early ambulation post op
Ans: B
Ans: D
59.) Health teachings to a client with bronchial
asthma include the following EXCEPT: 65.) In chest injury, cautious and judicious
A.) Avoid emotional stress, extremes of administration of analgesic is indicated to
temperature prevent respiratory depression. Which of the ff
B.) Avoid personal pollution such as smoking drug may be given in small doses?
C.) Avoid dust, pollens, and animal danders A.) Pancuronium Hydrobromide (Pavulcon)
D.) Practice respiratory isolation B.) Morphine Sulfate
C.) Succinylcholine (Anectine)
Ans: D D.) Meperidine HCL ( Demerol)

60.) A patient as diagnosed to have laryngeal Ans: D

CA. which of the following is viewed as the
primary predisposing factors? 66.) Nursing interventions to a client with
A.) Cigarette smoking bronchogenic CA include the ff EXCEPT:
B.) Excessive alcohol A.) Administration of oxygen inhalation therapy
C.) Voice strain as ordered
D.) Environmental pollutants B.) performing chest percussion and vibration
C.) Administration of medimist inhalation therapy
Ans: A as ordered
D.) Promotion of physical comfort and
61.) An early manifestation of laryngeal CA is physiological support
A.) Weight loss
B.) Dysphagia Ans: B
C.) Hoarseness of voice
D.) Lump in the neck 67.) The following are nursing responsibilities
when caring for a patient with tracheostomy
Ans: C tube:
A.) Apply suction for no longer than 10-15
62.) The patient had laryngectomy. The following seconds
are expected after the surgery EXCEPT: B.) Instill 5 mls of sterile NSS to the
A.) A tracheostomy in place tracheostomy tube to liquefy mucous secretions
B.) Constipation as needed
C.) Loss of sense of smell C.) use clean technique when suctioning
D.) An Endotracheal tube in place tracheostomy tube
D.) Insert 3-5 inches length of suction catheter
Ans: D
Ans: C
63.) A client has pleural effusion. Percussion
sound would most likely be: 68.) The following are nursing responsibilities to
A.) Dull a patient who had undergone tonsillectomy
B.) Flat EXCEPT:
C.) Tympanic A.) Place in lateral position with the head down
D.) Resonant until fully awake
B.) Observe for frequent swallowing 73.) Which of the following would be included in
C.) Instruct to avoid clearing the throat, coughing the discharge teaching for a prostectomy client?
D.) Allow to drink fluids through a straw A.) “Avoid straining at stools”
B.) “Avoid heavy lifting for approximately one
Ans: D week after surgery”
C.) “Drive your care whenever you are ready to
69.) The first aid treatment of epistaxis includes do so”
which of the following? D.) “Refrain from sexual intercourse for 12
A.) Exerting pressure at the soft tissues of the weeks”
nose
B.) Tilting the head back Ans: A
C.) Inserting cotton swabs into nares
D.) Applying hot compress over the nose 74.) Which of the following statements indicates
that a prostectomy client understand his
Ans: A discharge instruction?
A.) “I know my urine maybe slightly pink-tinged”
70.) A client is scheduled for a transurethral B.) “I know my urine should be clear all the time”
resection of the prostate (TURP) tomorrow. C.) “I know my urine should be clear most of the
During outpatient preop teaching, he asks where time
his incision will be. What is the most appropriate D.) “I’ll let my doctor knows if I have any urinary
response? dribbling, retention or bleeding”
A.) “The incision is made in the abdomen”
B.) “The incision is made in the lower abdomen” Ans: D
C.) “The incision is made in the perineum
between the scrotum and the rectum” 75.) Which of the following is a common early
D.) “There is no incision. The Doctor inserts an symptom of prostate hypertrophy?
instrument through the urethra, the opening in A.) Difficulty urinating
the penis B.) Impotence
C.) Urinary Infection
Ans: D D.) Hematuria

71.) When a client after prostectomy returns Ans: A

from the recovery room he has an IV infusing at
100ml/hr., a three Foley catheter in place, and 76.) The physician wants to examine a client’s
continuous bladder irrigation. What would the prostate gland. What equipment will be
nurse do first when increase blood in the urine is necessary for the exam?
detected? A.) A Foley catheter
A.) Increase the speed of the irrigation B.) Lubricant and gloves
B.) Release the traction on the Foley C.) Urethral dilators
C.) Irrigate the catheter manually D.) A rectal tube
D.) Notify the physician
Ans: B
Ans: A
77.) A client undergoes TURP under spinal
72.) A client who had a TURP complains of pain anesthesia. He returns to his room with
and bladder spasms. Which of the following continuous bladder irrigation (CBI). Which of
nursing actions is most appropriate after these statements best explains the reason for
determining that the drainage system is patent? the CBI?
A.) Administer narcotics plus anticholinergic A.) To decrease bladder atony
drugs, as ordered B.) To remove blood clots from the bladder
B.) Help him to sitz bath C.) To maintain patency of the urethral catheter
C.) Decrease the speed of the irrigation D.) To dilute the concentrated urine
D.) Decrease the traction on the Foley
Ans: B
Ans; A
78.) Which of the following symptoms can be
expected temporarily when a client’s Foley procedure, because a topical anesthetic will be
catheter is removed? applied to the anus”
A.) Urgency
B.) Dribbling Ans: B
C.) Urinary retention
D.) Decreased urinary output 83.) Which of the following is most characteristic
of the stools in ulcerative colitis?
Ans: B A.) Diarrhea
B.) Clay-colored with blood and mucus
79.) Which of the following is the most common C.) Gray and foamy
complication following a prostectomy that has D.) Semisolid, green with blood and mucus
implications for nursing assessment and
intervention? Ans: A
A.) Urinary tract infection
B.) Cardiac Arrest 84.) A colectomy and ileostomy are proposed for
C.) Pneumonia a client. This surgery involves which of the
D.) Thrombophlebitis following?
A.) Removal of the rectum with a portion of the
Ans: D colon brought through the abdominal wall
B.) Removal of the colon with a portion of the
80.) Which of the following is the most ileum brought through the abdominal wall
appropriate when preparing a client for a C.) Removal of the ileum with portion of the
proctosigmoidoscopy? colon brought through the abdominal wall
A.) On the morning of the examination D.) A “pull-through” procedure
administer enemas until the returns are clear
B.) Maintain the client NPO for 24 hours Ans: B
preceding the examination
C.) Give a strong cathartic on both the evening 85.) Which of the following is not anticipated
before and the morning of the examination after an ileostomy?
D.) Give sitz bath three times daily for 3 days A.) Weight gain
preceding the examination B.) Liquid stool
C.) Reestablishment of a regular bowel pattern
Ans: A D.) Irritation of the skin around the stoma

81.) What position is best for a client during a Ans: A

proctoscopic examination?
A.) Prone 86.) Skin care around a stoma is critical. In
B.) Right Sims colostomy skin care, which of the following is
C.) Lithotomy contraindicated?
D.) Knee chest A.) Observe for any excoriated areas
B.) Use karaya paste and rings around the
Ans: D stoma
C.) Apply mineral oil to the area for moisture
82.) Which nursing response is the most D.) Clean the area daily with soap and water
appropriate when preparing a client for a before applying the bag
proctosigmoidoscopy?
A.) “You need have no anxiety concerning this Ans: C
procedure. You will exercise no pain or
discomfort” 87.) Regulation of a colostomy will be most
B.) “You will experience a feeling of pressure enhanced if the client
and the desire to move your bowels during the A.) Eats balanced meals at regular intervals
brief time that the scope is in place” B.) Irrigates after lunch each day
C.) “You can reduce your discomfort during the C.) Restricts exercise to walking only
procedure to a minimum by bearing down as the D.) Eats fruit all three meals
prostoscope is introduced”
D.) “You will experience no discomfort during the Ans: A
 A.)18%
88.) When helping a client to accept his B.) 22%
colostomy, which of the following actions is C.) 36%
inappropriate? D.) 40%
A.) Encourage him to look at the stoma
B.) Emphasize his positive attributes Ans: C
C.) Involve the family in his care
D.) Have him do his own irrigation 93.) Which of the following would be
characteristic of a fresh, second degree burn?
Ans: D A.) Absence of pain and pressure sense
B.) White or dark, dry, leathery appearance
89.) A gastric suction tube was inserted before a C.) Large, thick blisters
client was sent to surgery, in order to: D.) Visible, thrombosed small vessels
A.) Facilitate administration of high caloric,
nutritious liquids immediately after completion of Ans: C
the procedure
B.) Prevent accumulation of gas and fluid in the 94.)with the location of burns over the upper
stomach both during and following surgical torso, what is the nurse’s primary concern?
action A.) Debride and dress the wounds
C.) Provide a reliable means of detecting B.) Initiate and administer antibiotics
gastrointestinal hemorrhage during the operative C.) Frequently observe for hoarseness, stridor
procedure and dyspnea
D.) Serve as s stimulus to restore normal D.) Obtain a thorough history of events leading
peristaltic movement following recovery from to the accident
anesthesia
Ans: C
Ans: B
95.) A narcotic IV was ordered to control the pain
90.) The symptoms of colon cancer vary of a client with burns. Why was the IV route
depending on where in the colon lesion is selected?
located. Which would not be a classic symptom A.) Burns cause excruciating pain, requiring
of colon cancer? immediate relief
A.) Change in bowel habits B.) Circulatory blood volume is reduced,
B.) Excessive flatus delaying absorption from subcutaneous and
C.) pain on the right upper quadrant of the muscle tissue
abdomen C.) Cardiac function is enhanced by immediate
D.) Anorexia and nausea action of the drug
D.) Metabolism of the drug would be delayed
Ans: C because of decreased insulin production

91.) Which of the following diagnostic tests will Ans: B

confirm the diagnosis of colon cancer most
conclusively? 96.) A major goal for the client during the first 28
A.) Carcinoembryonic antigen (CEA) hours after severe burns is to prevent
B.) Barium Enema hypovolemic shock. Which of the following
C.) Biopsy of the lesion would not be a useful monitor of fluid restitution
D.) Stool examination during this period?
A.) Elevated hematocrit
Ans: C B.) Urine output of 30 ml/hr
C.) Change in sensorium
92.) A 30 y/o homemaker fell asleep while D.) Estimate of fluid loss through the burn
smoking a cigarette. She sustained severe eschar
burns of the face, head and neck, anterior chest
and both arms and hands. Using the “rule of Ans: D
nine” which of the following is the best estimate
of total body surface area burned? 97.) Mafenide acetate (Sulfamylon) is applied to
a burned client’s wound every 12 hours, the
nurse’s assessment would include observation
for which of the following side effects of this
drug?
A.) Metabolic acidosis
B.) Discoloration of the skin
C.) Laceration of the skin
D.) Dehydration and electrolytes loss

Ans: A

98.) Contractures are among the most serious of

the long-term complications of a burn. Because
of the burn location on the upper torso, which of
the following measures would most likely cause
a client to have contractures?
A.) Change the location of the bed or the TV set,
or both, daily
B.) Encourage the client to chew gum and blow
up balloons
C.) Avoid using a pillow or place the head in a
portion of hyperextension
D.) Allow the client to assume a position of
comfort

Ans: D

99.) What is the primary aim of all burn-wound

care?
A.) To debride the wound of dead tissue and
eschar
B.) To limit fluid loss through the skin
C.) To prevent growth of microorganisms
D.) To decrease formation of disfiguring scars

Ans: C

100.) Deep partial thickness burns (2nd degree)

involves the:
A.) Epidermis
B.) Entire epidermis and the dermis
C.) Epidermis, dermis and the muscles
D.) Epidermis, dermis, muscle and the bones