SUCCEED REVIEW CENTER

NOVEMBER 2014 SIMULATED NLE

DAY 1, PM SESSION
PREPARED BY: DR. ERIC TACLAWAN
Situation: Physical Assessment is a basic skill that every nurse should possess. The nurse is doing her physical assessment on
several clients admitted during the previous shift.
1. The nurse should wear gloves when assessing which of the following areas?
A. Mouth
B. Eyes
C. Breast
D. Ears
2. The nurse can conclude that a client has no bowel sounds after how many minutes of auscultation?
A. 2 minutes
B. 3 minutes
C. 4 minutes
D. 5 minutes
3. Which data should be prioritized when completing the nursing assessment of an 80 year old female client hospitalized for
Bronchopneumonia?
A. Hemoglobin concentration of 110 mg/dl and leukocyte count of 14,000/mm 3
B. Rales and productive cough
C. Disorientation to time and place but not to person
D. BP of 70/50 and faint peripheral pulses
4. The nurse ensures the clients safety when doing the Rombergs test by implementing which of the following?
A. Let the client hold on to a furniture
B. Allow the client to open his eyes
C. Stand close to the client to provide support
D. Instruct the client to spread the feet wide apart for support
5. The nurse wants to prevent discomfort and injury in the client while doing an otoscopic examination. Which of the following
should be avoided?
A. Holding the clients head with the examiners hand
B. Inserting the otoscope superiorly into the proximal two thirds of the external canal
C. Inserting the otoscope inferiorly into the distal portion of the external canal
D. Tipping the clients head away from the examiner and pulling the ear up and back
6.

7. Situation: Pain is the most common reason for seeking health care. It occurs with many disorders, diagnostic tests and
treatments. Since nurses spend more time with the patient in pain than do other health care providers, nurses need to have a
deep understanding of pain management.
8. A 58/M client was rushed to the hospital unconscious. He was complaining of the most severe headache he has ever
experienced minutes before lost consciousness. The nurse would readily suspect that the client may have had
A. Acute Migraine Attack
C. Embolic Stroke
B. Post- Alcohol Hangover
D. Ruptured Cerebral Aneurysm
9. A 44/F, slightly overweight with four children client complains of pain under her right rib that radiates to her right chest. The
nurse would primarily consider
A. Pancreas problem
C. Gall bladder problem
B. Liver Problem
D. Muskuloskeletal problem
10. A 72/M client with a pulsating abdominal mass complains of pain at the abdominal area radiating to the back and to the
groin. The nurse will start assessing for the presence of
A. Abdominal aortic aneurysm
C. Malignant abdominal tumor
B. Urinary stones
D. Testicular torsion
11. A 24/F, newly wed, complains of lower abdominal pains, fever, and difficulty of urinating. The prime consideration of the
nurse should be
A. Ectopic pregnancy
C. Spontaneous abortion
B. Ureteral stones
D. Cystitis
12. A 35/F secretary complains of shooting pain from her neck to the tips of her fingers. The nurse would characterize this type
of pain as
A. Radiating pain
C. Referred pain
B. Projected pain
D. Diffuse pain
E.

F. Situation: Appropriate pain relief is important for physiological as well as psychological reasons. Proper and effective pain
management promotes wound healing and decreases the length of hospital stay.
13. Which statements best describes the management of pain?
A. Alternative therapy is best treatment of chronic intractable pain.
B. Non-steroidal anti-inflammatory agents are used for the treatment for pain with a rating of 7.
C. For pain with a rating of 9/10, adjuvant therapy and opioids are the pharmacologic treatment given.
D. Pain unresponsive to opioids may be treated with anticonvulsants.
14. The enzyme cyclooxygenase II is able to mediate which of the following?
I. Fever
IV. Blood clotting
II. Inflammation
V. Protection of stomach lining
III. Pain
VI. Prevents renal damage
A) I, II, and III
C) IV, V, and VI
B) II, III and IV
D) I, II, III, IV, V and VI
15. Which of the following drugs will the nurse recognize as an NSAID that inhibits both cyclooxygenase 1 and 2?
I. Ibuprofen
III. Celecoxib
II. Mefenamic Acid
IV. Morphine
A) I, II, and III
C) III only
B) I and II
D) III and IV
16. Of the following statements, which best represents the rationale for using non-invasive and non-pharmacologic measures to
control pain?
A. These measures are more effective than analgesics
B. These measures decrease the input to pain fibers
C. These measures potentiate the effects of analgesics
D. These measures increase the effects of morphine
17. The substance that is naturally produced by the body to block the pain sensation minimizing pain perception is

A. Endorphin
B. Substance P

C. Interleukin
D. Interferon

E.

F. Situation: Perioperative nursing includes a wide range of activities that the nurse performs using the nursing process and
based on standards of practice. Research defining best practices has resulted in improved outcomes in all areas of the
perioperative experience.
18. A 32/M client is to undergo surgical correction of a bifid ureter. Several weeks before the surgery, the client was asked to
undergo autologous blood donations. This nurse recognizes that this is done primarily to
A. Reduce the need for intraoperative blood transfusion
B. Decrease the cost of surgery
C. Prevent transfusion reactions
D. Eliminate need for cross matching of blood
19. The nurse is studying the nutritional status of a pre-op patient. She understands that surgery can have which of the following
effects on nutrition
I. Increases metabolic rate
III. Decreases vitamin C
I. Depletes potassium stores
IV. Decreases vitamin B
II. Increases potassium blood levels
A) I, III, and IV
C) II, III, IV, and V
B) III, IV, and V
D) I, II, III, IV, V
20. A client failed to adhere to a strict NPO order before a scheduled abdominal surgery. The nurse will explain to the patient that
A. Extra precautions will have to be done during the surgery.
B. The patients schedule may have to be moved later in the day.
C. The patient will have to prepare for terse reprimand from the surgeon.
D. The surgery will have to be cancelled and rescheduled.
21. After explaining to the client what to expect during the surgery and determining that the client has understood each aspect,
the nurse will expect the client to
A. Declare that he is totally free from any anxiety
C. Express a reduced level of anxiety
B. Display hand wringing, facial tension, and sweating
D. Sign the consent for surgery
22. The nurse noted that the clients explanation of the scheduled surgery is not consistent with the documentation, the nurse
should
A. Document the discrepancy and correct the clients misinformation.
B. Assess for other possible signs of confusion and change in mental status.
C. Allow the client to express his fears regarding the surgery.
D. Notify the surgeon and request that the surgeon speak to the client.
23.

24. Situation: Oxygen is essential for life, as well as a potent drug used for relief of hypoxemia and hypoxia. Therapeutic oxygen
is prescribed when the oxygen needs of the client cannot be met by room air alone.
25. When documenting Fi02 in a client without supplemental oxygen and relying entirely on room air, the nurse would record this
as
A. 0%
B. 13%
C. 21%
D. 100%
26. A client with chronic lung disease was determined by the pulmonologist to be suffering from CO 2 narcosis. The nurse
understands that this is a condition wherein
A. The patients blood is suffering from hypercarbia.
B. The patients tissues are intoxicated with carbon dioxide.
C. The patients lungs have stopped excreting carbon dioxide.
D. The patients central chemoreceptors have lost sensitivity to high CO 2 levels.
27. A nurse is studying the mechanism of hypoxic drive. Which of the following is true regarding hypoxic drive?
I. Low levels of oxygen are sensed by peripheral chemoreceptors.
II. The brain is signaled by hypoxemia to increase respiratory rate and depth.
III. The hypoxic drive occurs only in the presence of severely elevated PaCO 2 level.
IV. The client being ventilated is not at risk for this complication.
A) I, II, and III
C) III and IV
B) I and II
D) I, II, III, IV
28. Oxygen therapy is usually prescribed at the lowest liter flow needed to treat hypoxemia. Except for clients with COPD, the
oxygen delivery system best used is
A. Nasal canula
C. Non-rebreather mask
B. Venturi mask
D. Partial rebreather mask
29. At 5 liters/min oxygen flow rate, the nurse should prepare to always deliver the oxygen with
A. Nasal canula
C. Venturi mask
B. Humidifier
D. Ventilator
E.

F. Situation: Conditions affecting the lower respiratory tract range from acute problems to long-term chronic problems. Many
are serious and life-threatening. Patients with lower respiratory tract disorder requires care from nurses with astute
assessment and clinical management skills.
30. A client was diagnosed to have atelectasis of the right lung. The primary goal in the treatment of clients with atelectasis is
A. Prompt re-establishment of airway
B. Preventing the occurrence of hypoxia and cyanosis
C. Improvement of ventilation and removal of secretions
D. Implementing compensatory mechanisms of breathing
31. First line measures to minimize or treat atelectasis that the nurse should help establish include
I. Frequent turning and early ambulation
III. Positive expiratory pressure
II. Deep breathing exercises an incentive
IV. Bronchoscopy
spirometry
A) I, II, III, and IV
C) I and II
B) I, II, and IV
D) III and IV
32. A patient who was hospitalized for acute bacterial pneumonia is recovering after a course of Penicillin G. Which of the
following best demonstrates the effectiveness of care?
A. The client has PO2 of 85 mm Hg or higher
B. The client has PCO2 of 80 mm Hg or less

C. The client has decreased breath sounds

restlessness
D. The client displays deeper sleep and less
33. Which data would the nurse expect to assess in a client suffering from fever and complaining of hacking cough and
generalized malaise?
A. Conjunctivitis and nasal congestion
C. Bronchial breath sounds and bronchophony
B. Odynophagia and presence of tonsillar abscess
D. Productive cough with excessive mucus
34. A client was discovered to be suffering from Extremely Drug Resistant Tuberculosis. The nurse understands that the
appropriate treatment for the client is
A. 2 HRZE; 4 HR
B. 2 HRZES; 1 HRZE; 5 HRE
C. Use at least 4 to 5 drugs as long as 2 of these were not previously taken
D. No treatment is effective
35.

36. Situation: Pericarditis is an inflammation of the pericardium which may be a primary illness or may develop as a result of a
variety of medical or surgical disorders. Nursing care requires immediate recognition of the condition, relief of the clients
symptoms, and monitoring of possible complications.
37. A client with pericarditis was diagnosed medically to be suffering from Dresslers Syndrome. Being aware of the variety of
causes of Pericarditis, the nurse recognizes that the clients condition is most likely the result of
A. A previous myocardial infarction
B. A viral infection probably Coxsackie virus
C. Connective tissue disease, probably rheumatic fever
D. A neoplastic disease caused by metastasis from the lungs
38. The nurse is assessing a client who was admitted for pericarditis. The nurse takes note that the most characteristic sign of
pericarditis is
A. Chest pain
C. Mild fever
B. Friction rub
D. Increased ESR
39. To relieve the symptoms being experienced by the client with pericarditis, the nurse will include in her plans which of the
following?
I. Encourage deep breathing
II. Place the client on a supine position and turn the client every hour
III. Place the client on a forward-leaning or sitting position
IV. Prepare the client for possible surgical treatment
V. Give NSAIDs as prescribed
VI. Give steroids simultaneously with the NSAIDs as prescribed
A) I, II, III
C) III, IV, V
B) II, III, IV
D) All may be included
40. The nurse monitors closely for the occurrence of cardiac tamponade, a life-threatening complication of pericarditis. Which
triad of symptoms should the nurse be most watchful for?
A. Falling BP, increased Heart Rate, rapid Breathing
C. Rising SBP, falling DBP, irregular breathing
B. Falling SBP, stable or rising DBP, faint heart
D. Falling BP, rapid change in LOC, ataxic breathing
sounds
41. The nurse is assessing for the presence of pericardial friction rub. What maneuvers will the nurse do to amplify the
sound?
I. Assist the patient to a Semi-Fowlers position
II. Place the diaphragm tightly against the thorax
III. Auscultate at the left sterna edge of the 4th ICS
IV. Listen intently for a leathery or scratching sound at the end of exhalation.
V. Let the client hold their breath while auscultating to differentiate pericardial from pleural friction rub.
A) I, II, III, IV
C) I, II, IV, V
B) II, III, IV, V
D) All should be included
E)

F) Situation: Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for
oxygen and nutrients. As such, the professional nurse should be knowledgeable and well-trained in managing the
different symptoms that result from this inadequate supply to the body organs.
42. A client has just undergone Swan-Ganz catheterization for determination of cardiopulmonary pressures. The PCWP was
measured to be 22 mm Hg. Which of the following is the nurses best assumption regarding the finding?
A. Place the client in an orthopneic position and perform chest physiotherapy regularly.
B. Prepare for the administration o f diuretics to decrease the fluids causing the congestion.
C. Make the client feel as comfortable as possible while waiting for a confirmatory test to be done.
D. Assure the client that the results are still within normal parameters and that inotropic drugs will be started as soon as
possible.
43. A client with heart failure is being maintained on digoxin 250 ug OD. The nurse will teach the client regarding warning signs
that should be reported immediately once experienced by the client. Which of the following will the nurse advice about
digoxin toxicity?
I. Late symptoms of fatigue, anorexia, yellow or green halo around lights
II. Changes in the heart rhythm, decreased heart rate
III. Paranoia, hallucinations, social withdrawal
IV. Snowy vision
A) I only
C) I, II, and III
B) II, III, and IV
D) I and II
44. Who among the following clients with heart failure will the nurse identify as possible candidates for digoxin maintenance?
I. Client with cardiac disease but is able to perform daily activities without limitations.
II. Client with cardiac disease who is able to complete his daily activity but is symptomatic at the end of the activities.
III. Client with cardiac disease who is symptomatic at the middle of his activities.
IV. Client with cardiac disease who is symptomatic even at rest.
A) I, II, III, and IV
C) III and IV
B) II, III, and IV
D) IV only

45. The nurse should be able to detect warning signs in clients with cardiac problems. Compared to adults, a late sign of heart
failure among children is the presence of which physical assessment finding?
A. Bipedal edema
C. Presence of arrhythmias
B. Dyspnea on exertion
D. An enlarged liver and spleen
46. A client with cardiac disease suddenly develops breathlessness, cold diaphoresis, cyanosis, and cough with frothy pink
sputum. Which of the following is/are appropriate interventions by the nurse?
I. Prevent the occurrence of hypotension, respiratory depression, and hyperkalemia after drugs are administered
II. Position client upright with the legs firmly positioned on the floor
III. Prepare to administer inotropic drugs, morphine and diuretics
IV. Hook the client to oxygen via nonrebreathing mask
A) I and II
C) II, III, and IV
B) III and IV
D) I, II, and III
E)

F) Situation: In obtaining a history of clients with suspected endocrine problems, the nurse must use a systems
approach. This can be difficult because of the variety and combination of clinical manifestations. The nurse should
identify the clients response to actual or perceived changes and discuss the potential diagnostic and treatment
plans.
47. A 24/F 150 cm in height and 56 kg in weight, presents with frontal bossing, macroglossia, bulbous nose, and large hands
and feet. The client says that she did not notice the changes because they were insidious. A practical approach by the nurse
to assess the changes would be
A. Do a wallet biopsy
B. Refer the client to an endocrinologist
C. Assure the client that the changes are reversible
D. Tell the client that the changes are due to excessive somatotropin
48. A male client who has a history of head injury 10 months ago complains to the nurse that he has been having decreased
urination. On assessment, the nurse noted an elevated BP and some signs of fluid retention. The nurse would strongly
consider looking for other signs of
A. Diabetes Mellitus
C. Addisons Disease
B. Traumatic Brain Injury
D. Syndrome of Inappropriate Antidiuretic Hormone
49. A 25/M gym buff tells the nurse that he is having colds. He further informs the nurse that he has noticed increased
susceptibility to cough and colds lately despite taking his multivitamins regularly. He tells the neither nurse that he is not
sexually active nor does he possess an active night life. The nurse should ask about which important information?
A. Ask the client if he is married?
B. Ask the client if he engages in illicit sex?
C. Ask the client about the use of performance-enhancing medications.
D. Ask the client regarding his religious beliefs.
50. A 7 year old boy was brought to the clinic by his parents because they have noted that he has been growing pubic hair and
that his Adams apple has developed. The nurse understands that the boy may have an endocrine problem. An important
question that the nurse should ask would be
A. Is the boy sexually abused?
B. Was the boy given any hormonal medications before?
C. Are the parents giving the boy sufficient emotional support?
D. Is there anybody in the family who may have similar disorder?
51. A test was being ordered to determine the level of hormones from the adrenal glands. If the test ordered was a urine test, the
nurse will recognize that the most useful specimen would be
A. Midstream, clean catch specimen
C. Urine sample after diuretic induction
B. Random, morning urine sample
D. 24 hour urine collection
E.

F. Situation: Diabetes Mellitus is a common chronic disease requiring lifelong behavioral and lifestyle changes. It is best
managed with a team approach to empower the client to successfully manage the disease. As part of the team the nurse plans,
organizes, and coordinates care among the various health disciplines involved, provides care and education; and promotes the
clients health and well-being.
52. For all types of diabetes mellitus, the nurse would recognize that the main feature is
A. Lack of insulin secretion
C. Polyuria, polydipsia, and polyphagia
B. Decreased sensitivity of cells to insulin
D. Hyperglycemia
53. A nurse reviews the physiology of insulin and recognizes that the first organ to be reached by insulin in the blood is the
A. Liver
C. Heart
B. Intestines
D. Muscle tissues
54. Due to the dehydration that occurs with diabetes, possible problems that may occur in the circulatory system include
I. Hemoconcnetration
IV. Hypoxia
II. Hypovolemia
V. Hypoviscosity
III. Hypoperfusion
A) I, II and III
C) I and II
B) I, II, III, and IV
D) I, II, III, IV, V
55. Complications that the nurse would recognize among clients with Diabetes Mellitus would include Diabetic Neuropathy. The
most common presenting symptom of this complication is
A. Visual disturbance
C. Poor healing wounds
B. Foot ulcers
D. Polyuria
56. For diabetic clients undergoing medications with oral hypoglycemic agents, which of the following drugs will the nurse
recognize as having the highest risk for hypoglycemic reactions?
A. Chlorpropamide
C. Glibenclamide
B. Metformin
D. Insulin
E.

F. Situation: A 33/M was brought to the hospital complaining of severe abdominal pains after a night long drinking spree. He
appears acutely ill and he is vomiting bile-stained emesis.
57. The admitting diagnosis was acute pancreatitis. The nurse would recognize that the characteristic pain in this disease is
A. Epigastric pain radiating to the right shoulder
C. Epigastric pain radiating to the back
B. Epigastric pain radiating to the sternum
D. Epigastric pain radiating to the periumbilical area

58. The most reliable diagnostic examination for Acute pancreatitis among the following test would be
A. Elevated Serum amylase
C. Elevated Serum trypsin
B. Elevated Serum lipase
D. Contrast-induced CT Scan
59. A patient was admitted for acute pancreatitis. The nurse will prepare which of the following as the first line treatment
I. NGT for decompression
IV. Opioids for the severe pain
II. Strict NPO
V. Anticholinergics
III. IV fluids for hydration
A) I, II, III
C) I and III only
B) I, II, III, IV
D) I, II, III, IV, V
60. Orders from the physician included feeding via a nasogastric tube. The best nursing action would be
A. Assess for tube placement by aspirating stomach content.
B. Place the patient in a left-lying position.
C. Administer feeding with 50% Dextrose.
D. Clarify the orders.
61. After enzymatic fat necrosis has been confirmed in a client with acute pancreatitis, the nurse should be most watchful for
signs and symptoms of
A. Steatorrhea
C. Biliary obstruction
B. Vitamin K deficiency
D. Tetany
E.

F. Situation: Renal disorders reduce the ability of the kidneys to filter wastes and to balance fluid, electrolytes, acids, and
bases. The kidneys work together with many other organ systems; thus renal disorders affect systemic health and can
lead to life-threatening outcomes.
62. A patient in renal failure has decreased ability to excrete protein wastes. Which test reflects this condition?
A. An elevated BUN
C. Increased levels of WBC in the urine
B. A drop in creatinine
D. An elevated creatinine clearance level
63. An ICU nurse observes the patient with DM in renal failure for ECG changes, Kussmauls breathing, and decreased LOC.
This is to assess for
A. Response to dialysis
C. Electrolyte imbalance
B. Metabolic alkalosis
D. Cardiac complications
64. In caring for the patient in acute renal failure, the nurse is aware that a major complication is
A. Hypertension
C. Hyperkalemia
B. Hypocalcemia
D. Hypokalemia
65. A client with chronic renal failure receives hemodialysis and his condition stabilizes. The doctor orders amphojel with each
meal. This drug is given to
A. Remove protein wastes of metabolism
C. Exchange sodium for potassium in the colon
B. Bind phosphorous in the GI tract
D. Inhibit development of a stress ulcer
66. A client has nephrotic syndrome and the nurse notices edema in the client. The nurse understands that the edema is due to
A. Inability to excrete urine
C. Hypertension
B. Renal insufficiency
D. Hypoalbuminemia
E.

F. Situation: Chronic Renal Failure is a progressive, irreversible kidney injury where the kidney does not recover. When the
kidney function is too poor to sustain life, CRF is termed End Stage Renal Disease.
67. The presence of nitrogenous wastes in the blood is commonly known as
A. Azotemia
C. Uremic syndrome
B. Uremia
D. ESRD
68. In terms of urine output, Renal insufficiency is underlined by the presence of
A. Anuria
C. Normal urine output
B. Oliguria
D. Polyuria
69. The most important reason for instituting hemodialysis in clients with renal failure, whether acute or chronic is
A. Uremia
C. Fluid overload
B. Hypertension
D. Electrolyte imbalance
70. The electrolyte with the most devastating effect among clients with ESRD is recognized as
A. Hyperkalemia
C. Hypernatremia
B. Hypocalcemia
D. Hypermagnesemia
71. Among clients with CRF but not in ESRD, the antihypertensive medication of choice is
A. Calcium channel blockers
C. Beta blockers
B. ACE inhibitors
D. Thiazide diuretics
E.

F. Situation: Hematologic disorders pose a lot of challenge to health care personnel because of their unpredictable nature.
For clients to be given utmost care, the nurse is required to have a good understanding of the nature of these disorders.
72. The client with hematologic disorder is being prepared for bone marrow aspiration. The nurse will advise which of the
following to the client as part of the procedure?
A. The client will be positioned on a side lying or prone position during the procedure.
B. No incisions will be done during the procedure, only a slight puncture from the core needle.
C. Anesthesia will be applied as some severe pain is expected during the procedure itself.
D. The anterior iliac crest on the hips will be the preferred area for aspiration.
73. A patient asks what commonly causes anemia? The nurses reply would include which information?
I. Anemia is related to the inability of the kidneys to respond to low oxygen content of the blood.
II. Anemia is affected by certain medications taken by the patient.
III. Anemia can be accompanied by leucopenia and thrombocytopenia.
IV. Iron deficiency is the most common cause of anemia all over the world.
V. Anemia is related to malaria.
A) I, II, III, and IV
C) II, III, and IV
B) II, III, IV, and V
D) All are included
74. A client with anemia manifests mild jaundice, patchy loss of skin pigmentation, premature graying of the hair, and some
disturbance in the position sense. The nurse would suspect that the clients anemia is most probably caused by
A. Aplastic anemia
B. Myelodysplastic anemia due to acute myeloid leukemia

C. Hemolytic anemia
D. Megaloblastic anemia
75. The nurse is teaching a patient with iron deficiency anemia on how to take iron supplements. The nurse will include the
following in her instructions.
I. Take iron with food specially dairy products to enhance absorption
II. Gradually increase the dosage of iron tablets to prevent GI distress
III. Increase intake of strawberries, tomatoes, broccoli
IV. Eat foods high in fiber
V. Use straw or place tablet at the back of the mouth when taking iron tablets
A) I, II, III
C) III, IV, V
B) II, III, IV
D) All except V
76. A client with sickle cell anemia is being maintained on medications to increase the production of hemoglobin F. As part of
her care plan, the nurse will monitor for side effects of which drug?
A. Ferrous sulfate
C. Aspirin
B. Hydroxyurea
D. Steroids
E.

F. Situation: Clients who have burn injuries experience many physiologic, metabolic, and psychological changes. When the
skin is injured, fluid loss and large inflammatory responses change the function of most body systems.
77. A patient has burns affecting the anterior trunk and the whole of the right upper extremity. Using the rule of nines, how much
of the body is affected?
A. 18%
B. 27%
C. 36%
D. 45%
78. A patient who suffered from burns was brought to the ER. Most of the areas burned had weeping lesions. The nurse knows
that these burns are classified as
A. 1st degree
B. 2nd degree
C. 3rd degree
D. 4th degree
79. The nurse is assigned to care for a patient with 2nd degree burns. Which among the following is the nurse expected to do?
A. Escharatomy
C. Debridement
B. Debridement with skin grafted
D. Keep the wound clean and apply topical antibiotics
80. 33/F was involved in a house fire. The patients burn is described as white and leathery with no blisters. Which degree of
severity is this burn?
A. First degree
C. Third degree
B. Second degree
D. Fourth degree
81. The patient with burn was scheduled for escharotomy. The nurse will explain that the procedure will
A. Remove the brown leathery burned skin
C. Require general anesthesia
B. Be followed by skin grafting
D. Allow blood flow to be reestablished
E. Situation: A nurse assigned at the burn unit is caring for several clients with varying degrees of burn severities.
Recognizing the need for comprehensive care, the nurse plans individualized care for the clients according to their
prioritized needs.
82. A 28/M client with a dry weight of 70 kg sustained 10% third degree burns on his trunk. A nurse would be correct in doing
which of the following nursing actions?
A. Ordering 5 liters of 0.9% NaCl to be administered in 24 hours
B. Washing the burned skin with warm, sterile saline solution, as ordered
C. Preparing topical anesthetics and antibiotics to be applied round the clock, as prescribed
D. Giving 1.4 liters of NSS during the first 8 hours as ordered
83. The patient with severe burns was to undergo skin grafting by allograft. The nurse understands that this will involve
A. The patients own skin being applied to the wound.
C. Animal skin applied to the wound
B. Skin from a cadaver applied to the wound
D. Synthetic skin substitutes
84. To promote adherence and vascularization of a newly grafted area, the nurse should ensure
A. Fluid resuscitation
C. Complete covering with sterile gauze
B. Immobilization of the area for 5 days
D. Regulation of temperature
85. Which is the most important, immediate goal of therapy for a burn patient?
A. Maintaining fluid, electrolyte, and acid-base balance
B. Planning for rehabilitation and discharge
C. Preserving full range of motion to all affected joints
D. Preventing infections
86. One client admitted at the burn unit was a survivor of a house burn. He was assigned the diagnosis of possible smoke
inhalation injury. Which assessment findings will the nurse expect to find consistent with smoke inhalation injury? Select all
that apply.
I. Scalp burns
IV. Unconsciousness
II. Facial burns
V. Bluish to reddish skin
III. Black, sooty sputum
A) 1, 2, and 3
C) All except 5
B) All except 4
D) All are applicable
E)

F) Situation: Injury and infections are common. Most people, however, are healthy more often than they are ill. The
nurse recognizes the fact that inflammation and immunity are the two major defenses that protect a person against
diseases and other problem when the body is invaded by organisms.
87. A nurse understands that when a client receives vaccination, the type of immunity being afforded to the client is
A. Passive and acquired
C. Passive and natural
B. Active and natural
D. Active and acquired
88. A nurse reviews the basic information regarding the immune systems present in the body. Which of the following statements
confirm her knowledge regarding humoral immunity?
A. Humoral immunity is governed mostly by the T cells.
B. Humoral immunity is not present at birth and needs sensitization to be activated.
C. Humoral immunity needs the presence of white blood cells and their interactions with a host of antigens.
D. Humoral immunity is exemplified by the presence of secretory antibodies in most bodily secretions.
89. In transplant rejection, the mechanism responsible for rejection during the early stages is
A. Antibody mediated
C. Delayed hypersensitivity reaction
B. Cytotoxic T cell mediated
D. Immune Complex Mediated

90. After eating a sumptuous dinner of seafoods, a client rapidly experiences itchiness all over followed by development of
wheals and swelling of the lips and eyelids. The nurse recognizes that this is most probably a Type I Hypersensitivity
reaction. The nurse understands that which substance is responsible for mediating this type of reaction?
A. IgA
B. IgE
C. IgG
D. IgM
91. A client who suffers from frequent severe allergic reactions to many substances is best advised to do which of the following
to rapidly manage life threatening attacks?
A. Have a skin test done
B. Minimize exposure to the environment
C. Avoid getting near plants and animals known to cause allergies
D. Always carry an EpiPen with him
92.

93. Situation: AIDS is the most common secondary immunodeficiency disease in the world. Although advances have been
made in its management, this disease is still incurable and numbers in terms of morbidity and mortality are getting higher
every year.
94. The nurse recognizes the fact that the virus that causes HIV infection is
A. Adenovirus
C. DNA virus
B. Rotavirus
D. RNA virus
95. According to CDC guidelines, who among the following are recommended for HIV Testing?
I. People with STD
IV. People who consider themselves at risk
II. Injection drug users
V. Prostitutes and their customers
III. People planning to get married
VI. All health care personnel
A) All except VI
C) All except IV and VI
B) I, II, III, IV ,V, VI
D) I, II, and V
96. In diagnosing HIV AIDS, the screening method being employed that reduces the window period to just mere 12 days is
A. Enzyme immunosorbent assay
C. Rapid antibody assay
B. Western blot
D. PCR - Antigen testing
97. An HIV positive client who was admitted for PCP was also seen to have small, purplish brown, non-painful lesions on the
trunk. The nurse will correctly identify the client as having
A. Primary HIV Infection
C. Symptomatic HIV
B. Stage II HIV
D. AIDS
98. The combination drugs most effective in minimizing the effects of HIV infection are known as
A. Antiretrovirals
C. Adjuvant antiviral therapy
B. Antiviral combination therapy
D. Highly active antiretroviral therapy
E. Situation: Parkinsons disease, also known as paralysis agitans, is a very common disease among older adults. The
nurse caring for a PD client should have deep knowledge regarding the course and management of the disease.
99. The nurse understands that diagnosis of Parkinsons disease requires the presence of 2 of the following:
I. Tremors
IV. Postural instability
II. Rigidity
V. Masklike face
III. Akinesia
A) I, II, and III
B) I,III, and IV

C) I, II, III, and IV

D) All are included

100. A client with Parkinsons disease finds the resting tremor he is experiencing in his right hand very frustrating. The nurse
advises him to:
A. take a warm bath
B. hold an object

C. practice deep breathing

D. take diazepam as needed

101. Among the following manifestations, which would the nurse identify as a sign of severe disability among clients with
Parkinsons Disease?
A. Unilateral arm weakness
B. Bradykinesia

C. Shuffling gait
D. Rigidity

102. A client receiving medications for Parkinsons disease was seen to have signs and symptoms of drug toxicity. Which of the
following signs of drug toxicity is the most difficult to assess?
A. Delirium
B. Cognitive impairment

C. Decreased effectiveness of the drug

D. Hallucinations

103. To manage possible difficulties in communication among clients with long standing Parkinsons Disease, the nurse would
be right to employ which of the following plans?
A. Keep the client mobile and flexible by incorporating AROM and PROM exercises.
B. Allow the client to participate as much as possible in self are or ADLs
C. Teach the client and family to monitor the sleeping patterns
D. Teach client to exercise muscles for breathing and swallowing.
104. Situation: Myasthenia gravis is a chronic disease characterized by fatigue and weakness primarily in muscles innervated by
the cranial nerves as well as in skeletal and respiratory muscles.
105. The nurse understands that this disease may be characterized by which of the following?
I. It is an autoimmune disease.
II. It affects women more than men
III. It is characterized by exacerbations and remissions
IV. Death commonly results from respiratory failure
A) I, II, III, IV
B) I, II, III

C) I and IV
D) II and IV

106. The area of attack by the autoantibodies in clients with MG is the

A. Neuromuscular junction
B. Acetylcholine receptors

C. Synaptic junctions
D. Acetycholine

107. A very practical screening test for clients in the early stages of MG is
A. Tensilon test
B. Deep tendon reflexes

C. Upward gaze test

D. Autoantibody assay

108. The nurse would recognize that in many clients with MG, a tumor may accompany this disorder. The nurse would therefore
prepare the client for possible
A. Sternotomy
B. Exploratory laparotomy

C. Tumor resection
D. Thymectomy

109. A client with myasthenic crisis would best benefit with

A. Atropine treatment
B. Tensilon test

C. Neostigmine treatment adjustment

D. Intubation and mechanical ventilation