1. Mrs. Chua a 78 year old client is 1. B.

Left sided heart failure

admitted with the diagnosis of mild causes fluid accumulation in
chronic heart failure. The nurse the capillary network of the
expects to hear when listening to lung. Fluid eventually enters
client’s lungs indicative of chronic alveolar spaces and causes
heart failure would be: crackling sounds at the end of
a. Stridor inspiration.
b. Crackles 2. B. Morphine is a central
c. Wheezes nervous system depressant
d. Friction rubs used to relieve the pain
2. Patrick who is hospitalized associated with myocardial
following a myocardial infarction infarction, it also decreases
asks the nurse why he is taking apprehension and prevents
morphine. The nurse explains that cardiogenic shock.
morphine: 3. D. Seeing yellow spots and
a. Decrease anxiety and colored vision
restlessness are commonsymptoms of
b. Prevents shock and relieves digitalis toxicity
pain 4. C. When diuretics are taken
c. Dilates coronary blood in the morning, client will void
vessels frequently during daytime and
d. Helps prevent fibrillation of will not need to void
the heart frequently at night.
3. Which of the following should the 5. B. The primary goal of
nurse teach the client about the therapy for the client with
signs of digitalis toxicity? pulmonary edema or heart
a. Increased appetite failure is increasing cardiac
b. Elevated blood pressure output. Pulmonary edema is
c. Skin rash over the chest and an acute medical emergency
 back requiring immediate
d. Visual disturbances such as intervention.
seeing yellow spots 6. C. Decerebrate posturing is
4. Nurse Trisha teaches a client with the extension of the
heart failure to take oral extremities after a stimulus
Furosemide in the morning. The which may occur with upper
reason for this is to help… brain stem injury.
a. Retard rapid drug absorption 7. C. The most frequent side
b. Excrete excessive fluids effects of Cascara Sagrada
accumulated at night (Laxative) is abdominal
c. Prevents sleep disturbances cramps and nausea.
during night 8. D. Administration of
d. Prevention of electrolyte Intravenous Nitroglycerin
imbalance infusion requires pump for
5. What would be the primary goal of accurate control of
therapy for a client with pulmonary medication.
edema and heart failure? 9. A. By the 2 day of
nd

a. Enhance comfort hospitalization after suffering

b. Increase cardiac output a Myocardial Infarction,
c. Improve respiratory status Clients are able to perform
d. Peripheral edema decreased care without chest pain
6. Nurse Linda is caring for a client 10. B. The left side of the body
with head injury and monitoring the will be affected in a right-
client with decerebrate posturing. sided brain attack.
Which of the following is a 11. A. After nephrectomy, it is
characteristic of this type of necessary to measure urine
posturing? output hourly. This is done to
a. Upper extremity flexion with assess the effectiveness of
lower extremity flexion the remaining kidney also to
 b. Upper extremity flexion with detect renal failure early.
lower extremity extension 12. B. The lumen of the arteries
c. Extension of the extremities can be assessed by cardiac
after a stimulus catheterization. Angina is
d. Flexion of the extremities usually caused by narrowing
after stimulus of the coronary arteries.
7. A female client is taking Cascara 13. C. Blood pressure is
Sagrada. Nurse Betty informs the monitored to detect
client that the following maybe hypotension which may
experienced as side effects of this indicate shock or hemorrhage.
medication: Apical pulse is taken to detect
a. GI bleeding dysrhythmias related to
b. Peptic ulcer disease cardiac irritability.
c. Abdominal cramps 14. A. Protamine Sulfate is used
d. Partial bowel obstruction to prevent continuous
8. Dr. Marquez orders a continuous bleeding in client who has
intravenous nitroglycerin infusion undergone open heart
for the client suffering from surgery.
myocardial infarction. Which of the 15. C. The use of electronic
following is the most essential toothbrush, irrigation device
nursing action? or dental floss may cause
a. Monitoring urine output bleeding of gums, allowing
frequently bacteria to enter and
b. Monitoring blood pressure increasing the risk of
every 4 hours endocarditis.
c. Obtaining serum potassium 16. B. Weight gain due to
levels daily retention of fluids and
d. Obtaining infusion pump for worsening heart failure
the medication causes exertional dyspnea in
9. During the second day of clients with mitral
hospitalization of the client after a regurgitation.
Myocardial Infarction. Which of the 17. D. Discomfort or pain is a
following is an expected outcome? problem that originates in the
a. Able to perform self-care kidney. It is felt at the
activities without pain costovertebral angle on the
b. Severe chest pain affected side.
c. Can recognize the risk factors 18. A. Perfusion can be best
of Myocardial Infarction estimated by blood pressure,
d. Can Participate in cardiac which is an indirect reflection
rehabilitation walking of the adequacy of cardiac
program output.
10. A 68 year old client is diagnosed 19. C. Myoclonic seizure is
with a right-sided brain attack and characterized by sudden
is admitted to the hospital. In uncontrollable jerking
caring for this client, the nurse movements of a single
should plan to: or multiple muscle group.
a. Application of elastic 20. D. Nicotine (Nicotrol) is
stockings to prevent flaccid given in controlled and
by muscle decreasing doses for the
b. Use hand roll and extend the management of nicotine
left upper extremity on a withdrawal syndrome.
pillow to prevent contractions 21. D. Raynaud’s disease is
c. Use a bed cradle to prevent characterized by vasospasms
dorsiflexion of feet of the small cutaneous
d. Do passive range of motion arteries that involves fingers
exercise and toes.
11. Nurse Liza is assigned to care for 22. A. Urine testing provides an
a client who has returned to the indirect measure that maybe
 nursing unit after left nephrectomy. influenced by kidney function
Nurse Liza’s highest priority would while blood glucose testing is
be… a more direct and accurate
a. Hourly urine output measure.
b. Temperature 23. C. One liter of fluid
c. Able to turn side to side approximately weighs 2.2
d. Able to sips clear liquid pounds. A 4.5 pound weight
12. A 64 year old male client with a loss equals to approximately
long history of cardiovascular 2L.
problem including hypertension 24. A. Osmosis is the
and angina is to be scheduled for movement of fluid from an
cardiac catheterization. During pre area of lesser solute
cardiac catheterization teaching, concentration to an area of
Nurse Cherry should inform the greater solute concentration.
client that the primary purpose of 25. D. Forearm muscle
the procedure is….. weakness is a probable sign
a. To determine the existence of of radial nerve injury caused
CHD by crutch pressure on the
b. To visualize the disease axillae.
process in the coronary 26. B. Neutropenic client is at
arteries risk for infection especially
c. To obtain the heart chambers bacterial infection of the
pressure gastrointestinal and
d. To measure oxygen content respiratory tract.
of different heart chambers 27. C. Semi-fowlers position will
13. During the first several hours after localize the spilled stomach
a cardiac catheterization, it would contents in the lower part of
be most essential for nurse Cherry the abdominal cavity.
to… 28. C. Positioning the client
 a. Elevate clients bed at 45° laterally with the neck
b. Instruct the client to cough extended does not obstruct
and deep breathe every 2 the airway so that drainage of
hours secretions and oxygen and
c. Frequently monitor client’s carbon dioxide exchange can
apical pulse and blood occur.
pressure 29. B. Excessive bubbling
d. Monitor clients temperature indicates an air leak which
every hour must be eliminated to permit
14. Kate who has undergone mitral lung expansion.
valve replacement suddenly 30. C. Wheat cereal has a low
experiences continuous bleeding sodium content.
from the surgical incision during 31. A. Enlarged cirrhotic liver
postoperative period. Which of the impinges the portal system
following pharmaceutical agents causing increased hydrostatic
should Nurse Aiza prepare to pressure resulting to ascites.
administer to Kate? 32. C. Assessing for an open
a. Protamine Sulfate airway is the priority. The
b. Quinidine Sulfate procedure involves the neck,
c. Vitamin C the anesthesia may have
d. Coumadin affected the swallowing reflex
15. In reducing the risk of or the inflammation may have
endocarditis, good dental care is closed in on the airway
an important measure. To promote leading to ineffective air
good dental care in client with exchange.
mitral stenosis in teaching plan 33. A. Typical signs and
should include proper use of… symptoms of hypovolemic
a. Dental floss shock includes systolic blood
b. Electric toothbrush pressure of less than 90 mm
 c. Manual toothbrush Hg.
d. Irrigation device 34. D. Aspirin containing
16. Among the following signs and medications should not be
symptoms, which would most likely taken 14 days before surgery
be present in a client with mitral to decrease the risk of
gurgitation? bleeding.
a. Altered level of 35. A. Metabolic acidosis is
consciousness anaerobic metabolism caused
b. Exceptional Dyspnea by lack of ability of the body
c. Increase creatine to use circulating glucose.
phospholinase concentration Administration of insulin
d. Chest pain corrects this problem.
17. Kris with a history of chronic 36. D. Beta-carotene and
infection of the urinary system Vitamin E are antioxidants
complains of urinary frequency and which help to inhibit
burning sensation. To figure out oxidation. Vitamin E is found
whether the current problem is in in the following foods: wheat
renal origin, the nurse should germ, corn, nuts, seeds,
assess whether the client has olives, spinach, asparagus
discomfort or pain in the… and other green leafy
a. Urinary meatus vegetables. Food sources of
b. Pain in the Labium beta-carotene include dark
c. Suprapubic area green vegetables,
d. Right or left costovertebral carrots, mangoes and
angle tomatoes.
18. Nurse Perry is evaluating the 37. A. Gravity speeds up
renal function of a male client. digestion and prevents reflux
After documenting urine volume of stomach contents into the
and characteristics, Nurse Perry esophagus.
 assesses which signs as the best 38. B. Abdominal distension
indicator of renal function. may be associated with pain,
a. Blood pressure may indicate perforation, a
b. Consciousness complication that could lead
c. Distension of the bladder to peritonitis.
d. Pulse rate 39. D. It may take 4 to 6
19. John suddenly experiences a months to eat anything, but
seizure, and Nurse Gina notice most people can eat anything
that John exhibits uncontrollable they want.
jerking movements. Nurse Gina 40. D. Clay colored stools are
documents that John experienced indicative of hepatic
which type of seizure? obstruction
a. Tonic seizure 41. D. Streptomycin is an
b. Absence seizure aminoglycoside and damage
c. Myoclonic seizure on the 8 cranial nerve
th

d. Clonic seizure (ototoxicity) is a common side

20. Smoking cessation is critical effect of aminoglycosides.
strategy for the client with 42. D. Most peptic ulcer is
Burgher’s disease, Nurse Jasmin caused by Helicopter pylori
anticipates that the male client will which is a gram negative
go home with a prescription for bacterium.
which medication? 43. D. 12 to 24 hours after
a. Paracetamol subtotal gastrectomy gastric
b. Ibuprofen drainage is normally brown,
c. Nitroglycerin which indicates digested food.
d. Nicotine (Nicotrol) 44. C. Watching TV is
21. Nurse Lilly has been assigned to permissible because the eye
a client with Raynaud’s disease. does not need to move
Nurse Lilly realizes that the rapidly with this activity, and
 etiology of the disease is unknown it does not increase
but it is characterized by: intraocular pressure.
a. Episodic vasospastic disorder 45. A. Common signs and
of capillaries symptoms of fracture include
b. Episodic vasospastic disorder pain, deformity, shortening of
of small veins the extremity, crepitus and
c. Episodic vasospastic disorder swelling.
of the aorta 46. C. The dropper should not
d. Episodic vasospastic disorder touch any object or any part
of the small arteries of the client’s ear.
22. Nurse Jamie should explain to 47. A. Sudden decrease in
male client with diabetes that self- drainage or onset of severe
monitoring of blood glucose is abdominal pain should be
preferred to urine glucose testing reported immediately to the
because… physician because it could
a. More accurate mean that obstruction has
b. Can be done by the client been developed.
c. It is easy to perform 48. B. Complications of acute
d. It is not influenced by drugs appendicitis are peritonitis,
23. Jessie weighed 210 pounds on perforation and abscess
admission to the hospital. After 2 development.
days of diuretic therapy, Jessie 49. D. A client with acute
weighs 205.5 pounds. The nurse pancreatitis is prone to
could estimate the amount of fluid complications associated with
Jessie has lost… respiratory system.
a. 0.3 L 50. B. Liver inflammation and
b. 1.5 L obstruction block the normal
c. 2.0 L flow of bile. Excess bilirubin
d. 3.5 L turns the skin and sclera
24. Nurse Donna is aware that the yellow and the urine dark and
shift of body fluids associated with frothy.
Intravenous administration of
albumin occurs in the process of:
a. Osmosis
b. Diffusion
c. Active transport
d. Filtration
25. Myrna a 52 year old client with a
fractured left tibia has a long leg
cast and she is using crutches to
ambulate. Nurse Joy assesses for
which sign and symptom that
indicates complication associated
with crutch walking?
a. Left leg discomfort
b. Weak biceps brachii
c. Triceps muscle spasm
d. Forearm weakness
26. Which of the following statements
should the nurse teach the
neutropenic client and his family to
avoid?
a. Performing oral hygiene after
every meal
b. Using suppositories or
enemas
c. Performing perineal hygiene
after each bowel movement
 d. Using a filter mask
27. A female client is experiencing
painful and rigid abdomen and is
diagnosed with perforated peptic
ulcer. A surgery has been
scheduled and a nasogastric tube
is inserted. The nurse should place
the client before surgery in
a. Sims position
b. Supine position
c. Semi-fowlers position
d. Dorsal recumbent position
28. Which nursing intervention
ensures adequate ventilating
exchange after surgery?
a. Remove the airway only
when client is fully conscious
b. Assess for hypoventilation by
auscultating the lungs
c. Position client laterally with
the neck extended
d. Maintain humidified oxygen
via nasal canula
29. George who has undergone
thoracic surgery has chest tube
connected to a water-seal
drainage system attached to
suction. Presence of excessive
bubbling is identified in water-seal
 chamber, the nurse should…
a. “Strip” the chest tube catheter
b. Check the system for air
leaks
c. Recognize the system is
functioning correctly
d. Decrease the amount of
suction pressure
30. A client who has been diagnosed
of hypertension is being taught to
restrict intake of sodium. The nurse
would know that the teachings are
effective if the client states that…
a. I can eat celery sticks and
carrots
b. I can eat broiled scallops
c. I can eat shredded wheat
cereal
d. I can eat spaghetti on rye
bread
31. A male client with a history of
cirrhosis and alcoholism is
admitted with severe dyspnea
resulted to ascites. The nurse
should be aware that the ascites is
most likely the result of
increased…
a. Pressure in the portal vein
b. Production of serum albumin
 c. Secretion of bile salts
d. Interstitial osmotic pressure
32. A newly admitted client is
diagnosed with Hodgkin’s disease
undergoes an excisional cervical
lymph node biopsy under local
anesthesia. What does the nurse
assess first after the procedure?
a. Vital signs
b. Incision site
c. Airway
d. Level of consciousness
33. A client has 15% blood loss.
Which of the following nursing
assessment findings indicates
hypovolemic shock?
a. Systolic blood pressure less
than 90mm Hg
b. Pupils unequally dilated
c. Respiratory rate of 4
breath/min
d. Pulse rate less than 60bpm
34. Nurse Lucy is planning to give pre
operative teaching to a client who
will be undergoing rhinoplasty.
Which of the following should be
included?
a. Results of the surgery will be
immediately noticeable
 postoperatively
b. Normal saline nose drops will
need to be administered
preoperatively
c. After surgery, nasal packing
will be in place 8 to 10 days
d. Aspirin containing
medications should not be
taken 14 days before
surgery
35. Paul is admitted to the hospital
due to metabolic acidosis caused
by Diabetic ketoacidosis (DKA).
The nurse prepares which of the
following medications as an initial
treatment for this problem?
a. Regular insulin
b. Potassium
c. Sodium bicarbonate
d. Calcium gluconate
36. Dr. Marquez tells a client that an
increase intake of foods that are
rich in Vitamin E and beta-
carotene are important for
healthier skin. The nurse teaches
the client that excellent food
sources of both of these
substances are:
a. Fish and fruit jam
 b. Oranges and grapefruit
c. Carrots and potatoes
d. Spinach and mangoes
37. A client has Gastroesophageal
Reflux Disease (GERD). The nurse
should teach the client that after
every meals, the client should…
a. Rest in sitting position
b. Take a short walk
c. Drink plenty of water
d. Lie down at least 30 minutes
38. After gastroscopy, an adaptation
that indicates major complication
would be:
a. Nausea and vomiting
b. Abdominal distention
c. Increased GI motility
d. Difficulty in swallowing
39. A client who has undergone a
cholecystectomy asks the nurse
whether there are any dietary
restrictions that must be followed.
Nurse Hilary would recognize that
the dietary teaching was well
understood when the client tells a
family member that:
a. “Most people need to eat a
high protein diet for 12
months after surgery”
 b. “I should not eat those foods
that upset me before the
surgery”
c. “I should avoid fatty foods as
long as I live”
d. “Most people can tolerate
regular diet after this type of
surgery”
40. Nurse Rachel teaches a client
who has been recently diagnosed
with hepatitis A about untoward
signs and symptoms related to
Hepatitis that may develop. The
one that should be reported
immediately to the physician is:
a. Restlessness
b. Yellow urine
c. Nausea
d. Clay- colored stools
41. Which of the following
antituberculosis drugs can damage
the 8th cranial nerve?
a. Isoniazid (INH)
b. Paraoaminosalicylic acid
(PAS)
c. Ethambutol hydrochloride
(myambutol)
d. Streptomycin
42. The client asks Nurse Annie the
 causes of peptic ulcer. Nurse
Annie responds that recent
research indicates that peptic
ulcers are the result of which of the
following:
a. Genetic defect in gastric
mucosa
b. Stress
c. Diet high in fat
d. Helicobacter pylori infection
43. Ryan has undergone subtotal
gastrectomy. The nurse should
expect that nasogastric tube
drainage will be what color for
about 12 to 24 hours after
surgery?
a. Bile green
b. Bright red
c. Cloudy white
d. Dark brown
44. Nurse Joan is assigned to come
for client who has just undergone
eye surgery. Nurse Joan plans to
teach the client activities that are
permitted during the post operative
period. Which of the following is
best recommended for the client?
a. Watching circus
b. Bending over
 c. Watching TV
d. Lifting objects
45. A client suffered from a lower leg
injury and seeks treatment in the
emergency room. There is a
prominent deformity to the lower
aspect of the leg, and the injured
leg appears shorter that the other
leg. The affected leg is painful,
swollen and beginning to become
ecchymotic. The nurse interprets
that the client is experiencing:
a. Fracture
b. Strain
c. Sprain
d. Contusion
46. Nurse Jenny is instilling an otic
solution into an adult male client
left ear. Nurse Jenny avoids doing
which of the following as part of
the procedure
a. Pulling the auricle backward
and upward
b. Warming the solution to room
temperature
c. Pacing the tip of the dropper
on the edge of ear canal
d. Placing client in side lying
position
47. Nurse Bea should instruct the
male client with an ileostomy to
report immediately which of the
following symptom?
a. Absence of drainage from the
ileostomy for 6 or more
hours
b. Passage of liquid stool in the
stoma
c. Occasional presence of
undigested food
d. A temperature of 37.6 °C
48. Jerry has diagnosed with
appendicitis. He develops a fever,
hypotension and tachycardia. The
nurse suspects which of the
following complications?
a. Intestinal obstruction
b. Peritonitis
c. Bowel ischemia
d. Deficient fluid volume
49. Which of the following
compilations should the nurse
carefully monitors a client with
acute pancreatitis.
a. Myocardial Infarction
b. Cirrhosis
c. Peptic ulcer
d. Pneumonia
50. Which of the following symptoms
during the icteric phase of viral
hepatitis should the nurse expect
the client to inhibit?
a. Watery stool
b. Yellow sclera
c. Tarry stool
d. Shortness of breath