Medical Surgical Nursing Set 1

John Patrick Jacomille, RN

1. Heart rate is stimulated by all of the following except:

1. Excess thyroid hormone
2. Carotid massage
3. Increased level of circulating catecholamines
4. Stress response
5. Chemoreceptor response
6. The vagus nerve
A. Except 1, 2, 3, 4
B. 2 and 6 only
C. 2, 5 and 6
D. 6 only

2. A Clinical Instructor is giving lecture to a group of fourth year nursing students. The CI emphasizes the relieving
and supporting nursing measures that they may have in managing patient with angina pectoris. Which of the
following will be the appropriate nursing action?
A. Encourage bed rest to decrease oxygen demands
B. Give sublingual nitroglycerin
C. Undergo PTCA to flatten plaques to improve blood flow to the heart
D. All are correct

3. Cardiac output is dependent on the relationship between heart rate and stroke volume. What is the estimate
cardiac output for an adult heart rate of 76? It will reveal:
A. 4.6 L/min
B. 6.4 L/min
C. 5.3 L/min
D. 7.1 L/min

4. A client underwent cardiac catheterization using the right femoral artery. In the immediate period after the
procedure, the nursing care for this client include/s:
A. Assessing the distal pulses of the upper extremities
B. Informing the client that he will be placed on bed rest with the affected thigh flexed 90 degrees
C. Encouraging the client to drink more fluids to flush out the dye used if not contraindicated
D. All of the above

5. Which of the following appears abnormal on the ECG when ischemia and injury occur in the myocardium?
A. QRS interval
B. ST segment and T wave
C. P wave
D. PR interval

6. A 59-year-old male is admitted to the cardiac unit with chest pain radiating to the jaw and left arm. Which
enzyme would be most specific in the diagnosis of a myocardial infarction?
A. CK – MB
B. Lactic dehydrogenase
C. Troponin
D. Myoglobin

7. The nurse should teach the client with history of chest pain to report immediately which of the following
symptoms to his physician?
A. A change in the pattern of her pain
B. Pain during sexual intercourse
C. Pain during an argument with his wife
D. Absence of pain during or after an activity

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8. During the acute phase following myocardial infarction, the nurse should prepare the client’s bed by:
A. Changing the top linen and only the necessary bottom linen
B. Changing all linen from top to bottom without lowering the head of the bed
C. Lifting rather than rolling the client from side to side while changing the linen
D. Sliding the client onto a stretcher, remaking the bed, then sliding the client back to the bed

9. The physician orders Propanolol (Inderal) for a client's angina. The effect/s of the drug is/are:
1. To act as a vasoconstrictor
2. To act as a vasodilator
3. To block beta stimulation in the heart
4. To increase the heart rate
5. To act as a bronchodilator
A. 1, 3 and 4
B. 2 and 3
C. 3, 4 and 5
D. 3 only

10. Contraindications to the administration of t-PA include which of the following?

A. Age greater than 60 years
B. History of cerebral hemorrhage
C. History of heart failure
D. Cigarette smoking

11. A client who recently had an MI is scheduled to have a percutaneous transluminal coronary angioplasty. The
nurse plans to teach the client that during the procedure a balloon tipped catheter will
A. cut away the plaque from the coronary blood vessel
B. be used to compress the plaque against the coronary blood vessel wall
C. expand a mesh-like device that will spring open and keep the plaque against the coronary blood vessel
wall
D. be positioned in a coronary artery for visualization

12. The wife of a client who has had emergency coronary artery bypass surgery asks why her husband has a
dressing on his leg. The nurse explains:
A. This is the access site for the heart lung machine
B. A filter is inserted in the leg to prevent embolization
C. The saphenous vein was used to bypass the coronary artery
D. The arteries is distal extremities are examined during surgery

13. The nurse is caring for a client who had a permanent pacemaker inserted because of complete heart block. The
nurse determines that which of the following client outcomes indicates a successful procedure?
A. Client ambulating in the hall within 4 hours of the procedure without dyspnea or chest pain
B. Client’s ECG monitor demonstrates normal sinus rhythm
C. Heart rate of 80 beats per minute, blood pressure 120/80
D. Client’s ECG monitor shows paced beats at the rate of 68 per minute

14. The following will produce symptoms of right sided heart failure, except
A. COPD
B. Left sided heart failure
C. Aortic stenosis
D. Pulmonic stenosis

15. In clients with congestive heart failure, the associated dyspnea is primarily due to:
A. blockage of a pulmonary artery by an embolus
B. accumulation of fluid in the interstitial spaces and alveoli of the lungs
C. blockage of bronchi by mucous secretions
D. compression of lungs by the dilated heart

16. A nurse is caring for a client receiving dopamine (Intropin). Which of the following potential nursing diagnoses
is appropriate for this client?
A. Impaired tissue perfusion

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 B. Disturbed sensory perception
C. Increased cardiac output
D. Excess fluid volume

17. A client 3 months old with a congenital hear deformity has an order from her physician to give “3.00cc of
Lanoxin today for 1 dose only.” Which of the following actions is most appropriate by the nurse?
A. Clarify the order with the physician
B. Discuss the order with the pediatric heart specialist in the unit
C. Administer Lanoxin
D. Refer to the medication administration record for the previously administered Lanoxin

18. Which of the following may predispose the client to develop Digoxin toxicity?
A. Intake of Furosemide
B. Intake of Morphine
C. Intake of Propanolol
D. Intake of Nitroglycerin

19. Mr. Sam, a client with CHF, has been receiving a cardiac glycoside, a diuretic, and a vasodilator drug. His apical
pulse rate is 44 and he is on bed rest. Nurse Angela concludes that his pulse rate is most likely the result of the:
A. Diuretic
B. Vasodilator
C. Bed-rest regimen
D. Cardiac glycoside

20. Bentong, a client with CHF, was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug?
A. It has positive inotropic and negative chronotropic effects
B. The positive inotropic effect will decrease urine output
C. Toxicity can occur more easily in the presence of hypokalemia, liver and renal problems
D. Do not give the drug if the apical rate is less than 60 beats per minute.

21. Which of the following should the nurse teach the client about the signs of digitalis toxicity?
A. Increased appetite
B. Elevated blood pressure
C. Skin rash over the chest and back
D. Visual disturbances

22. Which of the following will most likely be observed in assessing Maria, a patient with pericarditis?
A. Friction rub
B. Fever
C. Murmurs
D. Chest pain

23. The nurse learns that an assigned client with cardiac tamponade is about to have a pericardiocentesis
performed. In preparation for this procedure, the nurse positions the client:
A. Lying on the left side with a pillow on the chest wall
B. Lying on the right side with a pillow under the head
C. Supine with the head of the bed elevated at an angle of 45 to 60 degrees
D. Supine with slight Trendelenburg position

24. Which of the following is contraindicated in a hypertensive client with COPD?

A. Atenolol
B. Valsartan
C. Felodipine
D. Diuril

25. Which is the most important medical management in a client with Buerger’s disease?
A. Administer vasodilators as ordered
B. Stop smoking
C. Improve oxygenation to legs
D. All of the above

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26. A nurse would expect a patient to describe the symptoms of arterial insufficiency in the lower extremities in
which of the following ways?
A. "My legs feel weak when I get up to walk."
B. “My legs hurt when I walk, but they feel better when I sit down."
C. "My feet and ankles become swollen after walking."
D. "My feet burn if I walk on a hard surface."

27. A nurse is performing an admission assessment for a client admitted to the hospital with a diagnosis of
Raynaud’s disease. The nurse assesses for the symptoms associated with Raynaud’s disease by:
A. observing for softening of the nails or nail beds
B. palpating for diminished or absent peripheral pulses
C. checking for a rash on the digits
D. palpating for a rapid or irregular peripheral pulse

28. The nurse should instruct a client who has been diagnosed with Raynaud’s disease to:
A. Immerse her hands in cold water during an episode
B. Wear light garments when the temperature gets below 50oF (10oC)
C. Wear gloves when handling ice or frozen foods
D. Limit cigarette smoking to 3 sticks per day

29. All of the following are appropriate health teachings for a patient taking Coumadin, EXCEPT:
A. Avoid activities which are likely to cause injury
B. The patient’s diet should include several servings of fruits and vegetables
C. Report bleeding manifestations like epistaxis immediately
D. Avoid medications like Ecotrin

30. A client has been diagnosed with deep vein thrombosis (DVT) of the left leg. The nurse would determine that
the clients condition is improving if which of the following outcomes is noted?
A. skin on the left leg is reddened and warm
B. calf circumference is inch greater than the baseline
C. Homan’s sign is positive
D. Edema is resolving

31. For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action is/are incorrect
in promoting adequate gas exchange?
1. Encouraging the client to drink three glasses of fluid daily
2. Keeping the client in semi-Fowler’s position
3. Using a high-flow Venturi mask to deliver oxygen as prescribed
4. Administering Inderal as ordered
A. except 3 and 4
B. 1 and 3
C. Except 1 and 4
D. Except 2

32. The nurse understands that in the absence of pathology, a person’s respiratory center is stimulated by:
A. Oxygen
B. Lactic Acid
C. ATP
D. Carbon dioxide

33. A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease.
Which of the following would the nurse expects to note on assessment of this client?
A. Hypocapnia
B. A hyperinflated chest on x-ray film
C. Metabolic Acidosis
D. Hemoptysis

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34. Pedro, a postoperative client with emphysema is receiving oxygen at 2 L/min via nasal cannula when he
complains of feeling dyspneic. The spouse asks the nurse to increase the oxygen intake to help him breathe easier.
Which response by the nurse is appropriate?
A. Switch the oxygen to a 100% non-rebreather mask
B. Explain to the spouse that high concentration of oxygen may depress breathing
C. Ask the spouse to leave the room to let the client get some sleep
D. Sedate the wife

35. The nurse enters the room of a client diagnosed with COPD. The client’s skin is pink, and respirations are 8 per
minute. The client’s oxygen is running at 6 liters per minute. What should be the nurse’s first action?
A. Call the health care provider
B. Put the client in Fowler’s position
C. Lower the oxygen rate
D. Take the vital signs

36. A client is admitted in an acute care facility with pneumonia is receiving supplemental oxygen, 2 LPM via nasal
cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease.
Because of these history findings, the nurse closely monitors the oxygen and the respiratory status. Which
complication may arise if the client receives high oxygen concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis

37. Which exercise would you expect a patient with emphysema will perform?
A. Blowing candles
B. Abdominal exercises to increase inspiration
C. Blowing rapidly into a paper bag
D. Panting exercises

38. A 19-year old client comes to the emergency department with an acute asthma. His respiratory rate is 44
breaths per min, and he appears to be in acute respiratory distress. Which of the following actions should be taken
first?
A. Give oxygen at 2 LPM
B. Give a bronchodilator by nebulizer
C. Apply a cardiac monitor to the client
D. Provide emotional support to the client

39. Carlo with asthma stops wheezing and breath sounds are not audible. The nurse should be alert since the
reason for this change is:
A. The attack is over
B. The airways are so swollen that no air can get through
C. The swelling has decreased
D. Crackles have replaced wheezes

40. As a nurse, you are always alerted to monitor status asthmaticus who will likely manifest symptoms of:
A. Metabolic alkalosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic acidosis

41. An elderly client with pneumonia may appear with which of the following symptoms first?
A. Altered mental status and dehydration
B. Pleuritic chest pain and cough
C. Fever and chills
D. Hemoptysis and dyspnea

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42. A client with pneumonia is experiencing pleuritic chest pain. Which of the following describes pleuritic chest
pain?
A. A mild but constant aching in the chest
B. Severe midsternal chest pain
C. Moderate pain that worsens on inspiration
D. Muscle spasm pain that accompanies coughing

43. A client with pneumonia has laboratory reports that show RBC: 2,000,000 WBC: 5,000 and Platelets: 300,000.
Considering the findings, which of the following clinical manifestation is the most likely manifestation the client to
exhibit?
A. Decrease respiration and increase pulse
B. Increase respiration and normal pulse
C. Normal respiration and increase pulse
D. Increase pulse and increase respiration

44. An emergency room nurse is assessing a client who sustained a blunt injury to the chest wall. Which of these
signs would indicate the presence of pneumothorax in this client?
1. The presence of barrel chest
2. Tracheal deviation towards the affected side
3. Diminished breath sounds on the affected lung
4. A sucking chest wound
A. 2, 3 and 4
B. all or correct
C. Except 1 and 4
D. 3 Only

45. A client in the ER who suffered chest injury in a motor vehicle accident has overheard conversation during the
course of rapid treatment. He asks the nurse about hemothorax and pneumothorax, which were discussed in his
presence. The nurse explains that the difference between these two is the:
A. Cause
B. Involved part of lung
C. Presence if air versus blood in the pleural cavity
D. Difference in treatment options

46. What manifestation with a client with pleural effusion display?

A. Pain
B. Swelling
C. Dyspnea
D. Increase sputum production

47. Mrs. Reyes who is for thoracentesis is assisted by the nurse to any of the following positions, EXCEPT:
A. straddling a chair with arms and head resting on the back of the chair
B. lying on the unaffected side with the bed elevated 30-40 degrees
C. lying prone with the head of the bed lowered 15-30 degrees
D. sitting on the edge of the bed with her feet supported and arms and head on a padded overhead table

48. The doctor removed 500mL of solution by a thoracentesis. Following the procedure, which assessment would
require immediate notification of the doctor?
A. Increased lung sounds in the area where the pleural effusion was located
B. Increased coughing after the procedure
C. Decreased crackles noted at the base of the lungs
D. Decreased cyanosis and pallor

49. A client with pneumothorax asks, “Why did they put tubes on my chest?” The nurse should explain that the
purpose of the chest tube is to
1. Check the bleeding in the lung

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 2. Monitor the function of the lung
3. Drain fluid from the pleural space
4. Remove air from the pleural space
A. 2 and 4
B. 3 and 4
C. except 1, 2 and 3
D. 2, 3 and 4

50. A client with pneumothorax receives a chest tube attached to 3 bottle system. The nurse notices that the fluid
in the second chamber isn’t bubbling. Which nursing assumption is most invalid?
A. the tubing from the client to the chamber is blocked
B. there is a leak somewhere in the tubing
C. the client’s affected lung has re-expanded
D. the tubing needs to be cleared out of fluid

51. While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water
level in the water seal chamber. The nurse should take which if the following actions?
A. Notify the physician immediately
B. Have the client cough
C. Continue to monitor the system
D. Reposition the chest tube

52. A male client who had a left lobectomy for treatment of a lung carcinoma returns from surgery with a left
posterior-lateral chest tube attached to a 3 bottle chest drainage system. Which of the following signs would
indicate that the drainage system is working properly?
A. Air is bubbling in the water-seal chamber
B. The fluid level in the drainage chamber remains constant
C. The fluid level in the water-seal chamber fluctuates
D. A pneumothorax is present

53. A client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of
flail chest?
A. Cyanosis
B. Hypotension
C. Dyspnea, especially on exhalation
D. Paradoxical chest movement

54. The nurse expects to administer which of the following as the most important initial pharmacological
treatment for a cardiac client on bed rest just diagnosed with pulmonary embolism (PE)?
A. Heparin
B. Low-molecular weight heparin
C. Warfarin
D. Tissue plasminogen activator

55. For a hospitalized client, which factor would the nurse assess to be a symptom of pulmonary embolism?
A. A slow increase in heart rate and respiratory rate
B. Sudden chest pain
C. Abrupt onset of dyspnea and apprehension
D. Significant bilateral wheezing

56. What action should the nurse take initially to avoid acid-base imbalance when a client becomes anxious and
starts to hyperventilate?
A. Tell the client to stop breathing so fast because he could pass out
B. Give the client a sedative to decrease anxiety and stop hyperventilation
C. Give the client a paper bag into which to breathe
D. Notify the physician

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57. Which of the following blood gas reports would the nurse expect in a client with a progressive chronic
obstructive pulmonary disease (COPD)?
A. pH 7.55; paCO2 30 mmHg; paO2 80 mmHg; HCO3 24 mEq/L
B. pH 7.40; paCO2 40 mmHg; paO2 94 mmHg; HCO3 22 mEq/L
C. pH 7.38; paCO2 45 mmHg; paO2 88 mmHg; HCO3 20 mEq/L
D. pH 7.30; paCO2 60 mmHg; paO2 70 mmHg; HCO3 30 mEq/L

58. A client has the following arterial blood gas values: pH, 7.52; PaO2 50 mmHg; PaCO2, 28 mmHg; HCO3, 24
mEq/L. from the client’s PaCO2 level, the nurse determines that the client is experiencing which of the following
conditions?
A. Hypoxemia
B. Hypoventilation
C. Hyperventilation
D. Oxygen toxicity

59. A client has the following arterial gas values: pH, 7.52; PaO2, 50 mmHg, Pa CO2, 28 mmHg: HCO3 24 mEq/L.
Based upon the client’s PaO2, Which of the following conclusions would be accurate?
A. The client is severely hypoxic
B. The oxygen level is low but poses no risk for the client
C. The client’s PaO2 level is within normal range
D. The client requires oxygen therapy with very low oxygen concentrations

60. A nurse reviews the arterial respiratory blood gas values of a client. The results indicate respiratory acidosis.
Which of the following values would indicate that this acid-base imbalance exists?
A. pH of 7.48
B. PCO2 of 32
C. pH of 7.30
D. HCO3 of 20

61. The client has been diagnosed to have aplastic anemia. Which of the following statements of the client
indicates the need for further teaching?
A. “I will brush my teeth with soft-bristled toothbrush.”
B. ‘I will avoid eating raw fruits and vegetables.”
C. “I am allowed to go and watch basketball games.”
D. None of the above

62. Bone marrow aspiration reveals pancytopenia and fatty marrow, confirming aplastic anemia. Because of the
patient’s granulocytopenia, the nurse should try to prevent:
A. Hemorrhage
B. Bruises
C. Infection
D. Fatigue

63. A nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most
important concept to teach for health maintenance?
A. Eat animal protein and dark leafy vegetables daily
B. Avoid exposure to others with acute infections
C. Practice yoga and meditation to decrease stress and anxiety
D. Get 8 hours of sleep at night and take naps during the day

64. Which client is most likely to have iron deficiency anemia?

A. A client with cancer receiving radiation therapy twice a week
B. A toddler whose primary nutritional intake is milk
C. A client with peptic ulcer who had surgery 6 weeks ago
D. A 15-year old client in sickle cell crisis

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65. A client with iron deficiency anemia has hemoglobin of 6.5 g/dL. The client is experiencing symptoms of
cerebral tissue hypoxia. Which of the following nursing interventions would be the most important in providing
care?
A. Providing rest periods throughout the day
B. Instituting energy conservation techniques
C. Assisting in ambulation to the bathroom
D. Checking temperature of water prior to bathing

66. The microscopic features of RBC with iron deficiency is

A. Macrocytic hypochromic
B. Microcytic hypochromic
C. Megaloblastic hypochromic
D. Microcytic hyperchromic

67. The client understands the health teaching about ferrous sulfate intake when the client says
A. “If my stool becomes black, I should call my physician”
B. “I should not take vitamin C with my ferrous sulfate”
C. “I should increase my fluid intake while taking ferrous sulfate”
D. “I should use straw when I take may ferrous sulfate tablet supplement”

68. The BEST initial nursing management in iron deficiency anemia is:
A. Advise the patient that iron preparation like Ferrous Sulfate should be taken with an empty stomach
B. Advise the patient that a diet rich in iron is very important
C. Advise the patient that ascorbic acid is an essential component of treatment
D. Advise the patient that Iron Dextran is an alternative if he cannot

69. You're preparing to administer iron dextran (Imferon) to a client with iron deficiency anemia. Which of the
following is appropriate?
1. Be aware that the drug may stain teeth
2. Administering a Z-track SQ injection
3. Using the same needle to draw up the solution and to administer the injection
4. Give before meals
A. 1, 2 and 3
B. 2 only
C. 2 and 3
D. none of the above

70. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the
following would the nurse include in the physical assessment?
A. Palpate the spleen
B. Examine the feet for petechiae
C. Take the blood pressure
D. Examine the tongue

71. Schilling’s test was ordered for a client suspected of having pernicious anemia, the nurse prepares for
collection of
A. Venous blood specimen
B. Arterial blood specimen
C. Urine specimen
D. Stool specimen

72. A client with a probable pernicious anemia is undergoing Schilling’s test. The nurse instructs the client that
primary purpose of this test is to measure the body’s ability to do which of the following?
A. Digest vitamin B12
B. Produce vitamin B12
C. Store vitamin B12
D. Absorb vitamin B12

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73. The nurse is teaching a client with pernicious anemia secondary to Billroth II who requires vitamin B 12
replacement therapy. Which statement indicates that the client understands the treatment program?
A. “I’ll swallow one vitamin B12 pill every morning for 2 weeks.”
B. “I’ll take a vitamin B12 pill once each month for life.”
C. “I’ll need an injection of vitamin B12 every month for life.”
D. “I’ll only need daily injections of vitamin B12 until my blood count improves.”

74. While anticipating the needs of a patient with cyanocobalamine deficiency, the nurse should:
A. encourage him to use seasonings in his foods to make his meals more palatable
B. explain the importance of providing frequent rest periods to conserve energy
C. encourage the use of electric heating pad to provide warmth in his feet
D. tell his wife to wear a mask when in direct contact with him

75. Which foods are the best sources of folic acid?

A. Green, leafy vegetables
B. Kidney beans and chicken
C. Liver and asparagus
D. Carrots and fish

76. Which assessment finding is not a clinical manifestation of folic acid deficiency anemia?
A. Dyspnea
B. Paresthesia
C. Fatigue
D. Tachycardia

77. Francis is admitted to the hospital for treatment of hemolytic anemia. Which of the following measures, if
incorporated into the nursing care plan, would best address the client’s needs?
A. Encourage activities with other clients in the day room
B. Isolate him from visitors and clients to avoid infection
C. Provide a diet high in vitamin C
D. Provide a quiet environment to promote adequate rest

78. What is the primary nursing objective in caring for a child with sickle anemia in vaso-occlusive crisis?
A. Managing pain
B. Promoting activity
C. Promoting sickling
D. Promoting rest

79. Which of the following nursing measures would not be included in the care of a child in vaso-occlusive crisis to
maximize tissue perfusion?
A. Increasing fluids
B. Encouraging activity as tolerated
C. Monitoring fluid restrictions
D. Administering oxygen as prescribed

80. The client has been diagnosed to have polycythemia Vera. Which of the following measures is not included in
the nursing care plan of the client?
A. Increase fluid intake
B. Monitor the clients for signs and symptoms of thromboembolism
C. Advise the client to avoid high altitude
D. Implement isolation precaution

81. The nurse is caring for Joana, 45 years old, diagnosed with polycythemia Vera. The nurse knows that in
polycythemia Vera:
A. The erythrocyte and leukocyte counts are elevated while the platelet count is low
B. The erythrocyte count is low while leukocyte and platelet counts are elevated
C. The erythrocyte, leukocyte, and platelet counts are elevated
D. The erythrocyte, leukocyte, and platelet counts are low

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82. A 35-year-old man is seen in an urgent care clinic. He presents with symptoms of polycythemia Vera. The
laboratory value that would confirm the possible diagnosis is an extremely:
A. high hemoglobin level
B. low platelet count
C. low white cell count
D. high iron level

83. Which nursing intervention would not be appropriate for a patient with polycythemia Vera?
A. Restricting fluid to reduce overload
B. Encouraging frequent ambulation
C. Applying extra lotion during skin care
D. Recording the patient’s weight and abdominal girth daily

84. The client understands the health teaching about agranulocytosis when the client says
A. “I need to avoid crowded places”
B. “I will avoid medications containing aspirin”
C. “I need to use soft toothbrush”
D. “I will avoid flossing my teeth”

85. The patient wants to know more about her condition. You would start by telling her that the main cause of ITP
is that:
A. “Your body makes antibodies that destroy your platelets which causes you to bleed.”
B. “ITP is caused by recent bacterial infection.”
C. “Your excessive intake of aspirin has caused this problem.”
D. “This form of anemia will improve with iron supplements.”

86. For a client diagnosed with idiopathic thrombocytopenia purpura (ITP), which nursing intervention is
appropriate?
A. Teaching coughing and deep-breathing techniques to help prevent infection
B. Engage in activities like contact sports
C. Giving aspirin, as prescribed, to control body temperature
D. Administering stool softeners, as ordered, to prevent straining during defecatio
87. Which of the following nursing interventions is appropriate for a client with a platelet count of 31,000/mm3?
A. Pad sharp surfaces to avoid minor trauma when walking
B. Assess for spontaneous petechiae in the extremities
C. Keep the room darkened
D. Check for blood in the urine

88. A client is diagnosed with multiple myeloma. The client asks the nurse about the diagnosis. The nurse bases the
response on which of the following descriptions of this disorder?
A. Malignant exacerbation in the number of leukocytes
B. Altered RBC production
C. Altered production of lymph nodes
D. Malignant proliferation of plasma cells and tumors within the bone

89. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which of the
following would the nurse expect to note in this disorder?
A. Decreased number of plasma cells in the bone marrow
B. Increased WBC count
C. Increased serum calcium levels
D. Decreased BUN level

90. Which of the following conditions or symptoms is often a secondary complication of hypercalcemia in a client
with multiple myeloma (MM)?
A. Pneumonia
B. Muscle spasms
C. Renal dysfunction
D. Myocardial irritability

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91. Joseph was brought to the hospital with second degree burns coming from a residential fire. What type of burn
does the patient sustain?
A. Radiation
B. Chemical
C. Electrical
D. Thermal

92. Which of the following statements is true regarding pain severity in burns?
A. Pain is directly proportional to the depth of injury
B. Pain is inversely proportional to the depth of injury
C. Pain severity increases as the depth of injury increases
D. Pain is not related to the depth of injury

93. Second degree burns are described by which of the following statements:
1. destruction of the subcutaneous layer
2. has a moist appearance with blister formation
3. involvement of dermis
4. otherwise known as partial thickness superficial burns
5. most painful degree of burns
A. 1, 4, 5
B. 2, 3, 5
C. 1, 2, 3
D. 3, 4, 5

94. Sergio is brought to the Emergency Room after a burn injury accident. Based on the assessment of the
physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower
extremities. His wife asks what that mean. Your most accurate response would be:
A. Structures beneath the skin are damaged
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged

95. Which of the following clusters of symptoms would the nurse note when suspecting a client suffering from
deep partial-thickness burn?
A. Tingling and hyperesthesia
B. Pain, hyperesthesia, sensitivity to cold air
C. Pain free and shock
D. Hyperesthesia and pain that is soothed by cooling

96. Kristina is a 37-year old cook. She is admitted for treatment of partial and full-thickness burns of her entire
right lower extremity and the anterior portion of her right upper extremity. Her respiratory status is compromised,
and she is in pain and anxious. Performing an immediate appraisal, using the rule of nines, the nurse estimates the
percent of Clara’s body surface that is burned is:
A. 4.5%
B. 9%
C. 18 %
D. 22.5%

97. The client suffered burn injury on the anterior trunk, genitalia, left anterior thigh and left posterior leg. What is
the classification and he estimated TBSA burned using the rule of nine?
A. 32.5%, Moderate burns
B. 32.5%, Major burns
C. 28%, Moderate burns
D. 28%, Major burns

98. Palm method in determining the extent of burn uses the:

A. Palm of the examiner in patient with scattered burn injury
B. Palm of the patient with scattered burn injury
C. Palm of the examiner with one sided burn injury
D. Palm of the patient with one sided burn injury

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99. The client was rescued from a fire in his home. He was observed to have a nasal singed hair. Which of the
following should be given highest priority when caring for this client?
A. Initiation of fluid replacement
B. Securing an airway
C. Relief of pain
D. Prevention of infection

100. Nurse Faith should recognize that fluid shift in a client with burn injury results from increase in the:
A. Total volume of circulating whole blood
B. Total volume of intravascular plasma
C. Permeability of capillary walls
D. Permeability of kidney tubules

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