1. The nurse discussing the prevention of UTI with female client.
What would be
important to include in the discussion?*
1/1
a. Decrease fluid intake to decrease burning on urination
b. Take warm Sitz baths with a mild bubble bath
c. Urinate before and after intercourse
d. Maintain a record of daily weight, intake and output
2. Which of the following are the signs and symptoms of cystitis? Select all that apply
1. Increased bladder capacity
2. Frequency
3. Dysuria
4. Nocturia
5. Urgency
6. Polydipsia
*
1/1
a. 1,2,3,4
b. 2,3,4,5
c. 1,2,3,5,6
d. 2,3,4,6
3. The physician orders the removal of an in-dwelling catheter the second post-
operative day for a client with a prostatectomy. The client complains of pain dribbling of
urine the first time he voids. The nurse should tell the client that:*
0/1
a. Using warm compress over the bladder will lessen the discomfort
b. Perineal exercises will be started in a few days to help relieve his symptoms
c. If the symptoms don't improve, the catheter will have to be reinserted
d. His complaints are common and will improve over the next few days
4. Immediately following TURP, the nurse should:*
1/1
a. Observe for signs of hemorrhage and shock
b. Check the connection of 2 way catheter cystoclysis
c. Note suprapubic catheter for leakage
d. Check for signs of infection at incision site
5. Nursing care of the patient who had undergone TURP include the following,
EXCEPT:*
0/1
a. Use sterile water for the irrigating solution
b. Monitor I and O accurately
c. Increase fluid intake to prevent staining at stool
d. Position extremity to which the catheter is anchored in extension
6. The nurse is assessing a client who had TURP 6 hours ago. He has a urinary catheter
with continuous bladder irrigation running. What nursing action observations would
indicate a complication is developing?*
1/1
a. Catheter drainage of 50 mL in the past hour and increase in suprapubic pain
b. Dark, grossly bloody catheter drainage with pieces of tissue
c. Client complains that he feels like he needs to void
d. Moderate amount of light red discharge from around the catheter
7. Which of the following is an appropriate nursing action for a client with
glomerulonephritis?*
0/1
a. Initiating contact isolation precautions
b. Encouraging increased fluid intake
c. Encouraging rigid exercises
d. Providing a high-calorie, low-protein diet
8. A patient passes a urinary stone and lab analysis of the stone indicates that it is
composed of calcium oxalate. On the basis of this analysis, which of the following would the
nurse include in the dietary instructions?*
1/1
a. increase intake of meat, fish, plums and cranberries
b. avoid citrus fruits and juices
c. avoid green leafy vegetables such as spinach
d. increase intake of dairy products
9. To decrease the possibility of stone formation, the following health instruction
should be given by the nurse, EXCEPT:*
1/1
a. Increasing fluid intake to 3 liter/day
b. Maintaining a well balanced diet
c. Decreasing salt and spices in the diet
d. Straining all urine
10. Leg cramps are NOT uncommon post cystoscopy. Nursing interventions include:*
1/1
a. A. Warm moist soak
b. B. Bed rest
C. Early ambulation
D. Hot sitz bath
11. Causes of renal failure could be categorized as prerenal, intrarenal, and postrenal.
The following conditions may be considered intrarenal causes:
1. Diabetes mellitus
2. Systemic lupus erythematosus
3. Myocardial infarction
4. Electrocution
5. Vomiting
6. Streptomycin therapy
7. Muscular damage
8. Severe burns
*
0/1
a. 1,2,3,4,6,7
b. 1,4,6,7,8
c. 4,6,7
d. 1,2,4,6,7,8
12. The following are problems expected in urinary dysfunction except:*
0/1
a. elevation of electrolytes like potassium, phosphate, sodium, and bicarbonate
b. retention of metabolic waste products which include urea and creatinine
c. anemia due to loss of erythropoietin secretion by the kidneys
d. fluid and electrolyte imbalance and blood pressure elevation
13. If a patient is admitted in the hospital and undergoes serum creatinine
determination the nurse is aware that if the laboratory test result is 1.7 mg/dl it is initially
considered a possible indicator of:*
0/1
a. renal failure
b. urinary abnormality
C. dehydration
D. congestion
14. What nursing measures are included in the plan of care for a client with acute renal
failure?*
1/1
a. Observe for signs of a secondary infection
b. Provide a high-protein, low carbohydrate diet
c. In and out catheterization for residual urine
d. Force fluid to 2000mL in 24 hours
15. A client with acute renal failure has been prescribed calcium carbonate. What is the
rationale for the particular medication?*
0/1
a. Diminishes incidence of ulcer formation
b. Alleviates constipation
c. Bind with phosphorus to eliminate in from the body
d. Increases tubular reabsorption of sodium
16. Which client is the highest risk for developing chronic renal failure?*
1/1
a. Client with severe glomerulonephritis
b. Client with placenta previa and hemorrhage at delivery
c. Client with poorly controlled long-term hypertension
d. Client with received aminoglycoside for an infection
17. Nursing measures to eliminate the cause of joint pain from chronic renal failure
would include:*
0/1
a. Using Amphojel (aluminum hydroxide) to lower the elevated blood phosphate that occurs
with renal failure
b. Preparing for dialysis to decrease serum-creatinine levels
c. Increasing the client's activity level.
d. Implementing a low purine diet to decrease uric acid level.
18. What will the nurse identify as the goal of treatment for a client with chronic renal
insufficiency?*
1/1
a. Increase the urine output by increasing liver and renal perfusion
b. Prevent the loss of electrolytes in the urine
c. Increase the concentration of electrolytes in the urine
d. Maintain present renal function and decrease renal workload
19. A client with acute renal failure complains of nausea, pain in the abdomen, diarrhea,
and muscular weakness. The nurse notes an irregularity in pulse and signs of pulmonary
edema. These are probably manifestations of:*
1/1
a. Calcium excess
b. Sodium deficiency
c. Potassium excess
d. Calcium deficiency
20. Nursing priorities in the care of patient undergoing peritoneal dialysis include
which of the following?*
1/1
a. Use strict sterile technique in preparation solution
b. Maintain patient in supine position all thru out the procedure
c. Observe “Arm Precaution”
d. Place patient on NPO
21. Which of the following assessments would be most appropriate for the nurse to
make while he peritoneal dialysis solution is dwelling within the client’s abdomen?*
1/1
a. Assessing for urticaria.
b. Observing respiratory status.
c. Checking capillary refill time.
d. Monitoring electrolyte status.
22. The best rationale for using a warm dialyzing solution in peritoneal dialysis is that it
helps to:*
0/1
a. Promote relaxation of abdominal muscles
b. Prevent the body temperature form failing
c. Decrease the risk of peritoneal infection
d. Dilate the blood vessels in the peritoneum
23. During the client’s dialysis, the nurse observes that the solution draining from his
abdomen is consistently blood-tinged. Which interpretation of this observation would be
correct? Bleeding*
1/1
a. Is common when the client has peritoneal catheter
b. Indicates abdominal vessel damage.
c. Can indicate kidney damage.
d. Is caused by too-rapid infusion of the dialysate.
24. The most important information to include when teaching a client who is being
discharged on continuous ambulatory peritoneal dialysis (CAPD) would be the need to:*
1/1
a. Use sterile technique to prevent infection
b. Increase protein in the diet
c. Record blood pressure and weight daily
d. Wear a medical identification bracelet
25. A client receiving hemodialysis has an external shunt for circulatory access. A
nursing diagnosis concerned with a life–threatening complication associated with external
cannula would be:*
0/1
a. Risk of infection
b. Altered tissue perfusion
c. Impaired skin integrity
d. Risk for injury, hemorrhage
26. The nurse is evaluating a client’s response to hemodialysis. The lab values reflect
that dialysis is achieving position results. Which lab values would not reflect changes
resulting from the hemodialysis?*
0/1
a. Serum creatinine levels
b. Dissolved pressure of carbon dioxide
c. Serum potassium levels
d. Hemoglobin levels
27. A The nurse should do the following for a patient scheduled for hemodialysis with
an AV shunt, EXCEPT:*
1/1
A. avoid needle pricks on the affected arm
B. strict aseptic technique is observed in shunt care
C. observe for bruit and thrill to observe patency
D. cover the entire area with elastic bandage and put the arm in a sling
28. The nurse initiates the client’s first hemodialysis treatment. The client develops a
headache, confusion, and nausea. These symptoms indicate which of the following potential
complications?*
1/1
a. disequilibrium syndrome.
b. myocardial infarction.
c. air embolism.
d. peritonitis.
29. Two days before discharge following a left nephrectomy, a client expressed renewed
concern over the ability to continue many activities with only one kidney. The nurse
responds:*
1/1
a. “You seem depressed. Actually you are very lucky, since the pathology reports indicate your
tumor was encapsulated.”
b. “Lots of people do quite well with only one kidney,”
c. “Would you like me to call the doctor so you two can discuss it?”
d. “I can understand your concern, but your remaining kidney is sufficient to maintain normal
renal functions.”
30. Knowing the consequences of hypervolemia in a patient with congestive heart
failure, important nursing intervention will be:
1. Accurate parenteral regulation
2. Restrict patient from any type of activity
3. Accurate I and O
4. Limit Na intake in the diet
*
1/1
a. 1, 2, 3 are correct
b. 2, 3, 4 are correct
c. 1, 3, 4 are correct
d. 1,2, 4 are correct
31. Fluid shifts are a great danger to the client with partial-and full-thickness burns. The
nurse should initially expect to observe:*
0/1
a. A rise in blood volume
b. Decreased capillary permeability
c. A loss of sodium and an increase in blood potassium
d. Increased fluid shift and irreversible shock after 2 hours
32. Burn wound infection can be prevented by:
1. Use of sterile linen
2. Use of mask, gown and gloves
3. Reverse isolation
4. Strict handwashing
*
1/1
A. 3 only
B. 1 and 2
C. 1 and 4
D. ALL
33. The client receiving TPN complains of nausea, excessive thirst, and increased
frequency of voiding. The nurse next assesses which of the following client data?*
1/1
a. Rectal Temperature
b. Last serum potassium
c. Capillary blood glucose
d. Serum BUN and Creatinine
34. On admission to the hospital, a client has a serum sodium concentration of 125
mEq/L. The nurse describes the pathophysiologic effect of this at the cellular level as*
0/1
a. sodium in the cells moves into the extracellular fluid (ECF), causing a decrease in cellular size
and decreasing cell excitability.
b. sodium in the ECF moves into the cells and causes cellular swelling and damage.
c. water in the ECF moves by osmosis into the cells and results in delayed membrane
depolarization.
d. water in the cell moves by osmosis into the ECF and the cells become hyperexcitable.
35. The nurse suspects that the client is experiencing hypokalemia when which of the
following manifestations are observed?*
0/1
a. Edema, bounding pulse, confusion
b. Apathy, weakness, abdominal distention
c. Spasms, colic, tachycardia
d. Sunken eyeballs, thirst, deep and rapid respiration
A patient is brought to the ER because of body weakness and altered level of sensorium.
She is disoriented VS: BP 140/90, CR 110/min RR 24/ min. afebrile, distended neck veins
with grade 2 bipedal edema. Laboratories: CBC- normal, Serum crea- 1.8 mg/dl, Na- 118
mEq/L K- 3.2 mEq/L.
36. What best describe the patients fluid and electrolyte status?*
1/1
a. Hypovolemic, hyponatremia
b. Hypervolemia, hyponatremia
c. Euvolemic, hypernatremia
d. Hypervolemia, Hyperkalemia
37. Management of this case should include:
1. Limit free water intake
2. Use of hypertonic IV solution to correct sodium
3. Administer diuretics as ordered
4. Use isotonic solution to correct sodium
*
0/1
a. 1,2,3
b. 1,3,4
c. 1 and 2 only
d. 3 and 4 only
38. The most probable cause of altered sensorium of this patient is:*
1/1
a. Hypokalemia
b. Azotemia
c. Hyponatremia
d. Hypertension
39. Ideal management of hypokalemia in this case is:*
0/1
a. Intravenous calcium
b. Hemodialysis
c. Serial monitoring of potassium level
d. Oral replacement of potassium
Michael, 45 y/o diabetic and hypertensive was admitted because of dyspnea. On PE: VS BP-
160/80 CR 110, RR 30, T 37.8 C, distended neck veins, (+) crackles both lung fields,
dynamic precordium, AB 6th LICS AAL, (+) fluid wave, (+) grade 2 edema. Labs: CBC: Hgb
109 Hct 0.29 WBC 12, serum crea- 6.8 mg/dl, Na -120mEq, K- 6.0, Mg 3.8 mg/dl. ABG: pH
7.20 PCO2 40mmHg, PO2 50 mmHg, HCO3 15mEq.
40. Base from the presented case, Michael has multiple electrolyte imbalances that
include:*
1/1
a. Hyponatremia, hypokalemia, hypermagnesemia
b. Hypernatremia, hypokalemia, Hypermagnesemia
c. Hyponatremia, hyperkalemia, hypermagnesemia
d. Hypernatremia, hyperkalemia, hypomagnesemia
41. Based on the above ABG, the patient has:*
1/1
a. Uncompensated respiratory acidosis
b. Compensated respiratory acidosis
c. uncompensated metabolic acidosis
d. uncompensated metabolic alkalosis
42. Immediate management of hyperkalemia must be done because of:*
1/1
a. Risk for cardiac arrhythmias
b. Potential alteration in level of consciousness
c. aggravates further metabolic acidosis
d. can lead to paralytic ileus
43. Early ECG change of hyperkalemia:*
1/1
a. Prolonged repolarization and prominent U waves
b. Shortened repolarization and peak T waves
c. Prolonged repolarization and depressed T waves
d. Shortened repolarization and depressed T waves
44. In a patient with increased levels of magnesium, which of the following should be
the priority for the nurse to monitor?*
0/1
a. Level of consciousness
b. Deep tendon reflexes
c. urinary output
d. respiratory rate
Mariz, 3rd year nursing students is currently rotating in a MS ward. She is assigned to Mrs.
Santos, a 65 y/o female and weighs about 135 lbs., who was admitted because of burn
injury.
45. On initial assessment, Mariz knows that several factors may affect the patient’s
survival and influence the plan of care for the patient. Which among the statements are
true?
1. Her age may affect the likelihood of success in the care
2. She is a diabetic on insulin and this may affect wound healing.
3. Deep partial thickness burn can completely recover within a week
4. Burns that exceed 20% TBSA may produce primarily a local response
*
1/1
a. 1 and 2 are correct
b. 2 and 4 are correct
c. 1 and 3 are correct
d. 2 and 4 are correct
46. The affected areas were her anterior trunk, her entire R arm and R thigh and leg.
Her estimated total burned surface area will be:*
1/1
a. 35%
b. 45%
c. 55%
d. 65%
47. On history taking, Mariz found out that the patient was involved in an explosive
injury secondary to an unattended LPG cooking stove. She must be observed for signs of
respiratory distress from upper airway injury and inhalation injury which maybe
secondary to:
1. Severe bronchoconstriction secondary to released histamines.
2. Chest constriction from circumferential full-thickness chest burn
3. Upper airway edema from direct heat in effect to the epithelium
4. Inhalation of products of incomplete combustion or noxious gases
*
0/1
a. 1 and 2 are correct
b. 3 and 4 are correct
c. 1 and 3 are correct
d. all are correct
48. Expected Fluid and Electrolyte problems during emergent and resuscitative phase
will include the following:
1. Hemodilution
2. Hyperkalemia
3. Hyponatremia
4. Oliguria
*
0/1
a. 1,2,3 are correct
b. 2,3,4 are correct
c. 1,3,4 are correct
d. All are correct
49. When caring for a severely burned client, the nurse notes that the client’s urine is
dark brown. The nurse would*
0/1
a. titrate systolic blood pressure to 110 mm Hg.
b. ensure that intravenous (IV) fluid is maintained at the prescribed rate.
c. insert a new urinary catheter.
d. notify the physician immediately.
50. A client has a circumferential third-degree burn on the upper left arm. The nursing
assessments for this client would be modified by:*
0/1
a. monitoring blood pressure in the left arm.
b. evaluating left hand strength.
c. assessing capillary refill in the left hand.
d. measuring left forearm circumference.
51. The nurse caring for a burn client would monitor the client’s stools for occult blood
as assessment for development of*
1/1
a. stress ulcers.
b. intestinal ileus.
c. gastric irritation related to smoke.
d. bleeding due to bowel distention.
52. To detect an early warning of a common complication in a client with severe
electrical burns, the nurse would closely monitor:*
0/1
a. blood urea nitrogen (BUN) and creatinine.
b. white blood cell (WBC) and platelet counts.
c. serum glucose and iron.
d. serum calcium and phosphorus.
53. The physician orders 1% silver sulfadiazine cream applied to a client’s burn wound
two times daily. The nurse would be aware that this medication can affect*
0/1
a. serum electrolytes.
b. blood pH.
c. hemoglobin level.
d. white blood cell count.
54. A client has received a meshed split-thickness skin graft for coverage of a burn
wound. The nurse would explain that the graft is meshed in order to*
0/1
a. allow fluid to escape from the wound.
b. facilitate débridement of the wound.
c. avoid the need for sutures to hold the graft in place.
d. observe the wound more carefully.
55. A burn victim in the emergency department who was trapped in a closet during a
fire becomes agitated and has a rapid deterioration in level of consciousness. The nurse
would anticipate that the laboratory report will support the neurologic changes and show
an increase in*
1/1
a. hematocrit.
b. BUN.
c. COHb.
d. CPK.
56. The ambulatory pediatric nurse teaching parents about prevention of burn injury
would emphasize that the leading cause of burn injury for toddlers is:*
0/1
a. playing with matches.
b. contact with scalding liquids.
c. touching hot radiators.
d. open flames, including space heaters.
57. Fifty four hours after deep partial thickness burns of the left leg and thigh, the
client’s urine output increased from 1000 to 2300 mL/24hr; serum sodium, 136 mEq/L;
serum potassium, 4 mEq/L; and hematocrit, 34%. The client’s urinary output and lab
studies indicate*
1/1
a. Beginning of the interstitial to plasma fluid shift phase of burns
b. Kidney failure
c. Circulatory overload due to rapid IV infusion rate
d. Hyponatremia
58. Why are alkali burns more serious than acid burns?*
0/1
a. They are generally full thickness
b. They produce liquefaction necrosis
c. They produce coagulation necrosis
d. They cause extensive damage to fascia and muscle
59. What would be the appropriate position in which to place a client with ear, face and
neck burns?*
0/1
a. Without pillows
b. Sim’s position
c. Prone
d. Padding and support to neck area
60. Which of the following foods could be taken by a patient with fluid volume deficit?*
0/1
a. Fruit shake like apple, banana, and melon
b. Vegetable salad with pickles
c. Canned tuna and sausage
d. Roasted halibut with spices
61. Which of the following foods could be taken by a patient with fluid retention?*
1/1
a. Fruit shake like apple, banana and melon
b. Vegetable salad with pickles
c. Canned tuna and sausage
d. Roasted halibut with spices
62. You administered 3% saline to Wanda who has hyponatremia. As Wanda’s nurse
which one of yours assess finding will require your most rapid response?*
1/1
a. Her BP increases freom 120/80 to 142/94
b. There is sediment and blood in Wanda’s urine
c. Wanda’s radial pulse is 105 beats per minute
d. There are crackles audible throughout both lung fields
63. A client is brought to the emergency department in cardiac arrest. The nurse is
aware that the associated acid-base imbalance that will require treatment is*
1/1
a. respiratory acidosis.
b. respiratory alkalosis.
c. both respiratory and metabolic acidosis.
d. both respiratory and metabolic alkalosis.
64. The nurse caring for a trauma victim who has received massive transfusions of
whole blood is diligent in assessment for metabolic alkalosis because*
0/1
a. the anticoagulant in the blood is metabolized to bicarbonate.
b. whole blood utilizes bicarbonate as a preservative.
c. transfused blood is less stable, releasing bicarbonate from the blood cells.
d. multiple transfusions of whole blood cause a decrease in serum potassium.
65. The nurse caring for a client who experienced cardiopulmonary arrest and has a
mixed respiratory/metabolic acidosis explains to a concerned family member that the
mechanical ventilator can eliminate*
1/1
a. lactic acid.
b. carbonic acid.
c. sulfuric acid.
d. phosphoric acid.
66. The nurse anticipate that the treatment of metabolic alkalosis will be to administer:*
0/1
a. Hemodialysis
b. Acetylcysteine
c. Insulin
d. Naloxone (Narcan)
67. You are assigned to the following patients. Which of the following is most at
risk to develop metabolic alkalosis?*
1/1
a. Grace, a 30-year-old surgical patient who has continuous nasogastric suction
b. Rachel, a 55-year-old who has just experienced a stroke
c. Helen, a 70-year-old with altered level of consciousness who is unable to access water freely
d. Mary Jane, a 2-year-old infant receiving isotonic sodium chloride IV solution
68. In preparation prior to bronchoscopy, which of the following should be done by the
nurse assigned?
1. secure for a written consent
2. make sure the patient has been on NPO at least 4 hours
3. remove dentures and other oral prosthesis
4. inject lidocaine to minimize discomfort
*
1/1
a. 1 and 2 are correct
b. 3 and 4 are correct
c. 1, 2, 3 are correct
d. 2 and 4 are correct
69. Nurse Nica is planning care for a client whose oxygenation is being monitored by a
pulse oximeter. She includes which intervention in the plan to ensure accurate monitoring
of the client's oxygenation status?*
1/1
a. Instruct the client not to move the sensor
b. Tape the sensor tightly to the client's finger
c. Place the sensor on a finger below the blood pressure cuff.
d. Notify the physician immediately of O2 saturation less than 90%.
70. In assessing one patient, Nurse Nica noted that the client has nasal flaring and use of
accessory muscles, O2 sat is between 90-92%, palpation revealed lagging on the L
hemithorax, decreased tactile fremitus with dullness on percussion and absent breath
sound from 4th rib down L side. Most probable problem is:*
0/1
a. Pneumothorax on the R side
b. Atelectasis on the R side
c. Pleural effusion on the L side
d. Pneumonia on the L side
71. When a client coughs violently and the tracheostomy tube falls out and the client
becomes dyspneic, the nurse attempts to reinsert the tracheostomy tube over the next 60
seconds but is unable to do so. The nurse’s next action would be*
0/1
a. start high-flow oxygen via nasal prongs.
b. place a finger in the stoma.
c. perform a cricoidectomy.
d. call a code.
72. Considering the purpose, operation and complications associated with mechanical
ventilators, the nurse should:*
1/1
a. Regulate PEEP according to the rate and depth of the client’s respirations
b. Deflate the cuff on the endotracheal tube for 5 to 10 minutes every 1 to 2 hours
c. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated
d. Adjust the temperature of fluid in the humidification chamber depending on the volume of
gas delivered
73. The measure that would best aid the nurse in removing heavy, tenacious secretions
during suctioning is which of the following?*
0/1
a. hyperinflating the lungs before suctioning.
b. instilling sterile saline directly into the trachea.
c. encouraging frequent coughing and deep breathing.
d. employing postural drainage before suctioning.
74. Yolly was scheduled for a laryngoscopy followed by tissue biopsy, which of the
following actions of the nurse is least appropriate after the procedure?*
1/1
a. Placing Yolly on lateral position while unconscious
b. Encouraging Yolly to take sips of water immediately after the procedure
c. Placing a tracheostomy tray on standby
d. Using ice collar as ordered
75. The immediate nursing intervention for a client experiencing a laryngospasm would
be*
0/1
a. administering 100% oxygen.
b. calling the resuscitation team to the PACU.
c. positioning the client in a high Fowler’s position.
d. immediately inserting a large-bore intravenous needle.
76. For client returning to the nursing unit after a Caldwell-Luc procedure, the nurse
would plan care based on the knowledge that*
0/1
a. a tracheotomy will be present.
b. chest tubes will drain excess fluid.
c. the client will be unable to breathe through the nose.
d. administering oxygen to the client may cause laryngospasm.
77. A client with a posterior pack for severe epistaxis asks how long the packing must
remain in place. The nurse’s response would include the information that the packs stay in
place for*
0/1
a. 24 hours.
b. 2 to 3 days.
c. 5 days.
d. a period that depends on how long it takes to stop the bleeding.
78. For a client who has a posterior nasal plug and anterior nasal packing in place to
control an episode of severe epistaxis, the priority assessment for the nurse would be
assessing for*
1/1
a. presence of hypoxia.
b. swallowing of blood.
c. appearance of nasal pain.
d. presence of generalized discomfort.
79. Post-tonsillectomy the following are appropriate actions EXCEPT:*
1/1
a. Position the client on lateral position once awake to promote drainage
b. Provide ice cream and milk shake to lessen the swelling
c. Apply ice collars within a 15 min period only to prevent rebound effects
d. Offer cold liquids that are non-irritating
80. On the seventh post-tonsillectomy day, a client begins to expectorate blood and calls
the nurse at the clinic for advice. The most appropriate instruction by the nurse would be*
0/1
a. “Come to the emergency department at once.”
b. “Call your physician as soon as possible.”
c. “Lie on your side for the next 5 minutes.”
d. “Drink a very cold liquid.”
81. Sassy, 55 years old music teacher sought admission to the hospital because of
laryngeal tumor. She underwent total laryngectomy and has fully recovered. What
functional changes would the patient expect?*
0/1
a. Difficulty swallowing and minimal loss of voice'
b. Alternative airway, normal swallowing, and loss of voice
c. Loss of voice, mouth breathing and normal sense of taste
d. Sense of taste and smell intact. Alternative airway and loss of voice
82. The nurse is preparing Sassy for discharge. The following are instructions regarding
stoma and post-laryngectomy care EXCEPT:*
1/1
a. Avoid exposure to persons with upper respiratory disease.
b. Instruct client to assume supine position as necessary.
c. Avoid swimming and use care when using the shower.
d. Prevent foreign body from entering the stoma.
83. Post-operatively Sassy was brought back to the ward with a temporary
tracheostomy tube in place, which of the following instruments or supply should the ward
nurse have on standby:*
0/1
a. 10 cc heparinized syringe
b. Sterile forceps
c. Bandage scissors
d. Tongue depressor
84. COPD is characterized by all of the following except:*
1/1
a. affects mostly males above 45 years old
b. chronic inflammation is one of the underlying pathologic mechanism
c. cigarette smoking is the only risk factor
d. bronchodilators is the mainstay of treatment
85. Auscultating the lungs of an asthmatic client, the nurse notes no inspiratory
wheezing, which would suggest:*
0/1
a. airway constriction requiring intensive interventions.
b. an appropriate reaction to the medications used in the client’s management.
c. the need to assess further for manifestations of a pleural effusion.
d. overuse of the intercostal muscles resulting in poor air exchange.
86. The nurse is caring for a client who is experiencing an acute asthmatic attack. He is
dyspneic and experiencing orthopnea; his PR is 120beats/min. In what order will the nurse
provide care to this client?
1. administer humidified oxygen
2. place in semi-upright position
3. provide nebulizer treatment with bronchodilator
4. discuss factors that precipitate attack.
*
1/1
a. 1,2,3,4
b. 2,4,1,3
c. 2,1,3,4
d. 3,2,1,4
87. You are the ER nurse assigned to a COPD patient in exacerbation. The medical
resident ordered bronchodilator nebulization every 15min. for 3 doses then every hour
thereafter. You expect the following while on inhalation therapy except:*
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a. less wheezing on auscultation
b. alteration in sensorium
c. loosening of secretions
d. tachycardia
88. A client receiving prednisone for treatment of asthma should be monitored for
which of the following adverse effects:*
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a. hyperkalemia, hypotension and edema
b. moon facies, hirsutism and weight loss
c. weight gain, elevated sodium levels and edema
d. gastric irritation, congestion and hypotension
89. The nurse would coach the asthmatic client in pursed-lip breathing because this
technique provides which of the following?*
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a. increases pressure in the airway.
b. decreases drying of the mucous membranes.
c. increases oxygenation.
d. decreases anxiety by distraction.
90. A client arrives at the emergency room with complains of severe dyspnea after
cleaning her apartment. PE revealed nasal flaring, subcostal retractions, wheezes, and O2
saturation of 80%. What action should the nurse take to initiate care to the patient?*
0/1
a. Provide oxygen therapy and reassess client in 10min.
b. Draw blood samples for arterial blood gas
c. Encourage the client to relax and breathe slowly through the mouth
d. Administer bronchodilator therapy as ordered
You are the ER nurse on duty when Agatha, 38-year-old, 10 pack-year smoker, came in
because of dyspnea. History started 5 days prior when she started to experience cough
mostly occurring at night and wheezing. She self-medicated with antibiotics and continued
to report to work as a bank teller. However, symptoms persisted until 1 day prior to
admission she experienced dyspnea on exertion and severe wheezing. PE revealed:
conscious, speaks in phrases, with alar flaring, intercostal and subcostal retractions. VS are
as follows: BP 130/98, HR 110 and RR 32.
91. Based on your assessment, your nursing care plan is for a patient with:*
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a. COPD
b. Community-Acquired Pneumonia
c. Bronchial asthma
d. Acute bronchitis
92. The most important nursing diagnosis for this patient that need immediate
intervention is:*
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a. risk for activity intolerance
b. impaired ventilation related to airway inflammation
c. pain related to inflammation of the lung tissue
d. altered nutrition related to excessive secretions
93. Based on the above findings, what action should you take to initiate care of your
patient:*
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a. Provide oxygen therapy and reassess client in 10min.
b. draw blood samples for arterial blood gas
c. encourage the client to relax and breathe slowly through the mouth
d. administer bronchodilator therapy as ordered
94. Which of the following arterial blood gases might reflect an individual with
uncompensated respiratory acidosis due to emphysema?*
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a. pH 7.50 PaCO2 40 HCO3 32
b. pH 7.20 PaCO2 60 HCO3 24
c. pH 7.38 PaCO2 40 HCO3 24
d. pH 7.35 PaCO2 50 HCO3 28
95 On discharge from the hospital to home, outcome criteria for the client with COPD
would include that he*
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a. Promise to do pursed lip breathing at home.
b. States action to9 reduced pain caused by the disease process.
c. Exhibits temperature not exceeding 100o F.
d. Agrees to call the physician if dyspnea on exertion increases.
96. Nurse Jane of the ER department is assessing a client who sustained a blunt injury to
the chest wall. Which of the following indicates presence of pneumothorax?*
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a. Sucking wound on the site of injury
b. Diminished breath sounds
c. Low respiratory rate
d. Barrel chest deformity
97. In a client with pleural effusion, the nurse is instructing appropriate breathing
technique. Which of the following is included in teaching?*
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a. Inhale slowly and hold breath for 3 to 5 seconds after each inhalation
b. Practice abdominal breathing
c. Breath normally
d. Hold the breath after each inspiration for 1 full minute
98. A client is about to have a chest tube inserted in the left upper chest. When the tube
is inserted. It begins to drain a large amount of serosanguineous fluid. Which of the
following explanations best describes what caused this?*
0/1
a. The chest tube was inserted improperly
b. This always happens when a chest tube is inserted
c. An artery was nicked when the chest tube was placed
d. The client had hemothorax instead of a pneumothorax
99. A hospitalized client needs a central IV catherer inserted. The physician places the
catheter in the subclavian vein. Shortly afterward, the client develops shortness of breath
and appears restless. Which of the following actions would the nurse do first?*
0/1
a. Administer a sedative
b. Advise the client to calm down
c. Auscultate breath sounds
d. Check to see if the client can have medication
100. Following the diagnosis of Left Pneumothorax, the physician ordered for a 3 - bottle
chest drainage system. On his rounds, Nurse Ulysses noted that the bottle had cracks. In
this situation, it would be appropriate to do which of the following nursing actions?*
1/1
a. Remove the tube from the patient’s chest and cover with vaselinized gauze
b. Clamp the chest tube near the patient’s thorax
c. Provide another suction machine and attached the tube
d. Place the end of the connecting tube into container of sterile water
