Nurse Joy is caring for multiple clients with renal failure.

1. Nurse Joy is assigned to Mr. Ramon who is a patient who underwent hemodialysis. Before discharge,
Nurse Joy discussed care at home with Mr. Ramon and his wife. Which statement by Mr. Ramon’s wife
indicates that further teaching is required?

0/1

A. "I must touch the shunt several times a day to feel for the bruit."

B. "I have to take his blood pressure every day in the arm with the fistula."

C. "I will remind my husband to be careful not to lie on the arm with the fistula"

D. "We should check the fistula every day for signs of redness and swelling”

2. Nurse Joy obtained the laboratory results of all her clients. Which of the following can cause
glomerular injury and an increased risk of renal failure for a client?

1/1

A. Cystitis with urine culture positive for E. coli

B. Presence of red blood cell casts in the urine Blood urea nitrogen (BUN) level of 15mg/dL

C. Hypotension and increased volume of very dilute urine

D. Absence of red blood cells and white blood cells in the urine

3. Nurse Joy is caring for a client diagnosed with acute renal failure. Which of the following would
indicate that the client is uremic?

0/1

A. BUN of 35mg/dl

B. Serum calcium of 9.2 mg/dl

C. Serum potassium of 2.8 mg/dl

D. Urine specific gravity of 1.030

4. Nurse Joy is reviewing the client's morning laboratory results. Which of these results most concern
Nurse Joy?

0/1

A. Serum potassium level of 5.2 mEq/L

B. Serum sodium level of 134 mEq/L

C. Serum calcium level of 10.6 mg/dL

D. Serum magnesium level of 0.5 mEq/L

Situation

4 of 5 points

Peptic ulcer disease (PUD) is a common and often painful condition affecting millions of people
worldwide.

5. A client is experiencing peptic ulcer disease caused by Helicobacter pylori. The nurse should plan to
administer Clarithromycin (Biaxin) with which of the following oral drugs?

1/1

A. Tetracycline (Achromycin) with sodium bicarbonate (baking soda)

B. Metronidazole (Flagyl) and aluminum hydroxide (Amphogel)

C. Amoxicillin (Amoxil) and Omeprazole (Prilosec)

D. Penicillin (Pen-G) and nizatidine (Axid)

6. The nurse is caring for Mrs. Rivera who is admitted due to 6-year history of gastric ulcers. The nurse
instructs this client to take which of the following drugs for minor aches and pains?

1/1

A. Acetaminophen (Tylenol)

B. Buffered aspirin

C. Plain aspirin

D. Ibuprofen (Motrin)
7. Mr. Quezon develops dumping syndrome after a subtotal gastrectomy for cancer of the stomach.
When caring for this client, the nurse understands that dumping syndrome refers to:

0/1

A. Nausea resulting from a full stomach

B. Reflux of intestinal contents into the esophagus

C. Passage of osmotic fluid into the jejunum

D. Build-up of feces and gas within the large intestine

8. A client with gastric tumor is scheduled for a Billroth II procedure. The nurse explains the procedure to
the client and tells the client that the:

1/1

A. Proximal end of the distal stomach is anastomosed to the duodenum.

B. Antrum of the stomach is removed with the remaining portion anastomosed to the duodenum.

C. Entire stomach is removed and the esophagus is anastomosed to the duodenum.

D. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum.

9. Alvin, a client who has a history of seizure disorder is newly diagnosed with a gastric ulcer, has
maintained seizure-free status using phenytoin (Dilantin). The nurse would question a new order for
which of the following drugs to treat symptoms caused by the ulcer?

1/1

A. Famotidine (Pepcid)

B. Cimetidine (Tagamet)

C. Nizatidine (Axid)

D. Ranitidine (Zantac)

Situation

3 of 4 points
Nurse Brian is caring for patients with congestive heart failure in the medical ward of Toprank Hospital
and Medical Center.

10. What interventions should Nurse Brian prioritize when managing an exacerbation of left-sided heart
failure? Select all that apply:

1. Metered dose Inhaler of albuterol

2. High-Fowler's position

3. Oxygen

4. IV fluids

5. Incentive Spirometer

6. Diuretics

1/1

A. 2,3,6

B. 1,5,6

C. 3,4,5

D. 4,5,6

11. A nurse is assessing the client with left-sided heart failure. The client states that he needs to use
three pillows under the head and chest at night to be able to breathe comfortably while sleeping. The
nurse documents that the client is experiencing:

1/1

A. Dyspnea on exertion

B. Dyspnea at rest

C. Orthopnea

D. Paroxysmal nocturnal dyspnea

12. Jhana, a client with congestive heart failure, has digoxin (Lanoxin) ordered every day. Prior to giving
the medication, the nurse assesses that the digoxin level is 12mg/mL and auscultates a one-minute
apical pulse rate of 62. The nurse should:
0/1

A. Withhold the digoxin

B. Withhold the dose and request an order for a potassium level

C. Notify the physician

D. Give the digoxin as ordered

13. Iyaz, another client hospitalized for heart failure, is receiving digoxin (Lanoxin) IV push. The nurse
obtains the following data on the client. Place the data in order from that of highest concern to least
concern to the nurse.

1. Potassium (K+-) level is 3.2 mEq/L

2. Apical pulse is 53 beats per minute

3. Client has been taking Furosemide (Lasix) 20mg

4 Client enjoys orange juice with breakfast

1/1

A. 1,2,3,4

B. 1,3,4,2

C. 2,1,3,4

D. 2,3,4,1

Situation

2 of 5 points

Nurse Angie is caring for multiple patients assigned in their ward with a diagnosis of Buerger’s disease.

14. Nurse Angie has been assigned to Mr. Reyes; a client diagnosed with Thromboangiitis Obliterans.
Which of the following anatomic areas are most often affected by this vascular condition?

0/1

A. Hands and fingers.

B. Lower legs and feet.

C. Head and neck.

D. Lower back.

15. Mr. Corpuz, a 30-year-old male client, is admitted with Buerger’s disease. Which of the following
factors has increased the client's risk for development of Burger's disease?

1/1

A. History of cigarette smoking.

B. Occupational exposure to radiation.

C. Age and gender.

D. History of hypertension.

16. The primary goal for Mr. Corpuz, the client with Buerger's disease, is to prevent

1/1

A. Embolus formation.

B. Fat embolus formation.

C. Thrombus formation.

D. Thrombophlebitis.

17. Mr. Corpuz, a client with Buerger's disease, smokes two packs of cigarettes a day. Smoking cessation
is critical or the client may lose the affected extremity. When helping a client change behavior it is
important to know the client's

0/1

A. Ability to attend support groups.

B. Goals of the treatment.

C. Perception of the behavior.

D. Motivation
18. Mr. Corpuz’s disease experiences which of the following signs or symptoms?

0/1

A. A Thickening of the intima and media of the artery.

B. Inflammation and fibrosis of arteries, veins, and nerves

C. Vasospasm lasting several minutes.

D. Pain, pallor, and pulselessness.

Situation

4 of 5 points

According to World Health Organization, Cardiovascular diseases (CVDs) are the leading cause of death
globally, taking an estimated 17.9 million lives each year. CVDs are a group of disorders of the heart
and blood vessels and include coronary heart disease, cerebrovascular disease, rheumatic heart
disease and other conditions.

19. A client with cardiac disease is on a monitor and Nurse Van observes ventricular tachycardia at a rate
of 160 beats/mm. The client is awake and coherent, and oxygen is being administered at rate of 6 L/ min
via a nasal cannula, what is the first nursing action?

1/1

A. Immediately defibrillate.

B. Administer Lidocaine IV push as ordered.

C. Begin cardiopulmonary resuscitation.

D. Obtain arterial blood gas values

20. Nurse Van is taking the history from a client with Congestive Heart Failure caused by hypertension.
The nurse identifies what data as supportive of the client's medical diagnosis?

0/1

A. Dyspnea after walking one block.

B. Weight loss of 15 pounds over last 3 months.

C. Lower extremity edema in the evenings.

D. Dizziness and fainting when rising too quickly.

21. Nurse Van is preparing another patient scheduled for CABG. What is the primary pathophysiological
reason for performing coronary artery bypass surgery?

1/1

A. Decrease oxygen overload to the cardiac muscle.

B. Increase oxygen supply to the heart muscle

C. Reduce plaque build-up in the carotid artery.

D. Reduce overall contractility of the heart muscle.

22. Nurse Van is administering nitroglycerin intravenously to relieve chest pain. What is the therapeutic
action of this medication?

1/1

A. Increases diuresis and glomerular filtration, which results in decreased venous return.

B. Increases the force of contraction of the myocardium, thereby increasing oxygen delivery.

C. Produces an immediate analgesic effect and relieves chest pain.

D. Increases the coronary blood supply and decreases the afterload.

23. In discharge planning for the client with Congestive Heart Failure, Nurse Van discusses the
importance of adequate rest. What information is most important?

1/1

A. A warm, quiet room is necessary.

B. Bad rest promotes venous return.

C. A hospital bed is necessary.

D. Adequate rest decreases cardiac workload

Situation

1 of 4 points
Tomorrow, you will be assigned to the Medical Step-down Unit, where you anticipate encountering
many patients with acid-base imbalances. To ensure you are well-prepared as a professional nurse,
you decide to review relevant information on managing patients with different types of acid-base
imbalances.

24. As a nurse you were taught how to evaluate arterial blood gas (ABG) values. Which of the following
steps would you do FIRST?

1/1

A. Evaluate HCO3

B. Evaluate pH

C. Determine acid base status

D. Evaluate PaCO2

25. Which of the following conditions may cause metabolic acidosis due to a decrease in bicarbonate
(HC03) level?

1. Loss of gastric fluids from vomiting or nasogastric suction

2. Loss of body fluids from drains below the umbilicus

3. Gastrointestinal fistulas

4. Aspirin ingestion

0/1

A. 3 and 4

B. 1 and 2

C. 1 and 4

D. 2 and 3

26. For clients with diabetic ketoacidosis, their body employs several mechanisms to compensate for the
acidosis. While caring for these clients, which of the following manifestations should you expect to
observe?

1. Nausea and vomiting

2. Oliguria

3. Kussmaul breathing

4. Polyuria

0/1

A. 1 and 2

B. 3 and 4

C. 1, 3 and 4

D. all of the above

27. Brian, 30 years old, was brought to the Emergency Department (ED) with nausea confusion,
dehydration and oliguria. Her mother informs you that Brenda has been depressed after losing her job as
a bank executive. An empty bottle of aspirin was found in her bathroom sink. Her laboratory values
revealed the if.: pH = 7.35, PaCO2=16 mmHg, PaO2=130 mmHg, and HCO3=15mEq/L. What is the
CORRECT acid-base interpretation of her ABG?

0/1

A. Partially compensated respiratory acidosis

B. Uncompensated metabolic acidosis

C. Partially compensated metabolic: acidosis

D. Compensated metabolic acidosis.

Situation

12 of 13 points

Nurse Benedict is caring for clients in various clinical settings.

28. A patient named Jessie who had a total gastrectomy is given instructions on measure to prevent the
developing of dumping syndrome. Which of the following statements, if made by Jessie, would indicate a
correct understanding of the instructions?

1/1

A. "I will have a bedtime snack"

B. "I will rest one hour before each meal"

C. "I will avoid concentrated sugar"

D. "I will include high-carbohydrate foods in my diet.”

29. Which of the following findings, if identified in a patient in the immediate postoperative period
following coronary artery bypass grafting (CABG), would indicate the need for immediate follow-up by
Nurse Benedict?

1/1

A. Chest tube drainage of 75 ml/hr

B. Urinary output of 100 ml/hr

C. Blood pressure of 124/60 mmHg

D. Oxygen saturation of 92%

30. Given a patient with venous insufficiency, which of the following nursing interventions would be the
most appropriate for their care?

1/1

A. Elevating the legs

B. Increasing the fluid intake

C. Limiting the activity level

D. Massaging the extremities

31. Which of the following conditions if reported in a patient's history, should Nurse Benedict recognize
as a contributing factor to the development of metabolic alkalosis:

1/1

A. Chronic obstructive pulmonary disease. (COPD)

B. Type I Diabetes Mellitus

C. Cushing's syndrome
D. Reynaud's syndrome

32. Which of the following conditions would Nurse Benedict recognize as contributing factor to the
development of respiratory alkalosis?

1/1

A. Chronic obstructive pulmonary disease (COPD)

B. Episodes hyperventilation

C. Frequent loose stools

D. Hiatal Hernia

33. Which of the following signs and symptoms would Nurse Benedict expect to identify when assessing
a patient who has chronic obstructive pulmonary disease (COPD)?

1/1

A. Increase anterior-posterior chest diameter

B. Decreases residual lung volume

C. Bronchovesicular breath sounds

D. Kussmauls respirations

34. When instructing a patient who rides to restrict potassium intake, which of the following food's
would Nurse Benedict identify as being the lowest in potassium?

1/1

A. Raisins

B. Grapes

C. Spinach

D. Potato
35. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness
of breath and is visibly anxious. The nurse on duty, Nurse Benedict, immediately assesses the client for
other signs and symptoms of:

1/1

A. Myocardial Infarction

B. Pneumonia

C. Pulmonary embolism

D. Pulmonary edema

36. Mr. Jeffrey will undergo insertion of central venous catheter. The nurse on duty should assist Mr.
Jeffrey to assume which of the following positions?

1/1

A. Supine

B. Trendelenburg's

C. Reverse Trendelenburg's

D. High-Fowlers

37. Nurse Benedict is caring for a client with suspected carbon monoxide poisoning. Of the following
interventions that the nurse assists in implementing, which is the highest priority?

1/1

A. Requesting a building inspection at the site of the incident from the local health department

B. Drawing blood for carboxyhemoglobin levels

C. Frequently observing the client

D. Administering 100% oxygen

38. In peritoneal Dialysis the inflow time to allow 2-3L of dialysate to flow into the peritoneal cavity is:

0/1
A. 5-10mins

B. 10-20mins

C. 10-30mins.

D. 1 hour

39. The client reports mid-calf pain when walking a block or more, which is alleviated by resting. Nurse
Benedict suspects the client may have intermittent claudication. At what percentage of arterial occlusion
does intermittent claudication typically occur?

1/1

A. 20%

B. 40%

C. 50%

D. 100%

40. While the client with hepatitis B is eating, she accidentally dislodges her IV line, resulting in blood on
the over-the-bed table. What should Nurse Benedict direct the housekeeper to use for cleaning the
table?

1/1

A. Alcohol

B. Acetone

C. Ammonia

D. Bleach

Situation

2 of 2 points

Nurse Ryan, a competent nurse in medical-surgical ward C, is assigned to care for clients with liver
cirrhosis.
41. Nurse Ryan assesses a client with hepatic encephalopathy for asterixis by:

1/1

A. Asking the client to extend an arm, dorsiflex the wrist and extend the finger.

B. Assessing the client for azotemia, oliguria and intractable ascites

C. Assessing the client for a musty sweet breath door

D. Asking the client to draw a cross and noting any deterioration in the figure construction.

42. Nurse Ryan is assessing an older male client. Which of the following findings would strongly indicate
the possibility of cirrhosis?

1/1

A. Dry skin

B. Hepatomegaly

C. Peripheral edema

D. Pruritus

SITUATION

1 of 5 points

Vivian is assigned in the medical unit and was assigned to 6 patients.

43. While Vivian was preparing to administer medication, the patient complained of dyspnea, and
appeared to be severely cyanotic. Which of the following interventions will Vivian do FIRST?

0/1

A. Assess vital signs.

B. Administer supplemental oxygen.

C. Reposition the patient.

D. Administer the medication.

44. Vivian evaluated the patient's complaints and performed a head-to-toe assessment. WhenN the
physician came, he suspected pulmonary embolism. Which of the following data about the client would
have least predisposed her?

0/1

A. Post Cholecystectomy

B. On-going intravenous infusion

C. Strict bed rest

D. Obesity

45. To confirm his diagnosis of pulmonary embolism, which of the following diagnostic tests will Nurse
Vivian expect the physician to order?

0/1

A. Chest X-ray.

B. Arterial blood gases.

C. Cardiac catheterization.

D. Computed tomography scan (CT scan)

46. Another patient of Nurse Vivian called and asked for assistance. When Nurse Vivian entered the
room of the patient, the thoracostomy tube was disconnected from the closed drainage system and
patient was about to walk to the bathroom. Which of the following will Vivian do FIRST?

0/1

A. Clamp the thoracostomy tube and reconnect to the closed drainage.

B. Reconnect to the closed drainage and put patient back to bed.

C. Put the patient back to bed and reconnect to the closed drainage.

D. Clamp the thoracostomy tube and refer to physician for evaluation.

47. While Nurse Vivian was in the nurses' station, which of the following should she attend to FIRST?

1/1

A. A relative asks Vivian to check on gastrostomy tube because it leaks.

B. Nursing student informs Vivian the IV infusion of a patient has only 100ml left in the bottle

C. Nursing Aide reports that the siderails of the bed of the patient could not be moved down.

D. An ambulatory patient approaches Vivian in the nurses' station and asks for a glass of water.

Situation

3 of 3 points

Misyel, a 45-year-old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing
severe flank pain, nauseated and with a temperature of 39 C.

48. Given the above assessment data, the most immediate goal of the nurse to Misyel would be which of
the following?

1/1

A. Prevent complication

B. Maintain fluid and electrolytes

C. Alleviate pain

D. Alleviating nausea

49. Which of the following menu is appropriate for one with low sodium diet?

1/1

A. Instant noodles, fresh fruits and iced tea

B. Ham and cheese sandwich fresh fruits and vegetables

C. White chicken sandwich vegetables salad and tea

D. Canned soup, potato and salad and diet soda

50. Which of the following indicates the type(s) of acute renal failure?

1/1

A. Four Types: Hemorrhagic with and without clotting and non-Hemorrhagic with and without clotting
B. One type: Acute

C. Three Types: Pre-renal, Intra-renal and post-renal

D. Two Types: Acute and Sub-acute

Situation

1 of 5 points

Cardiovascular diseases are a prevalent health issue in the Philippines, affecting a significant portion of
the population. This widespread problem is influenced by factors such as lifestyle, diet, and genetics,
making it a major public health concern.

51. Which of the following clinical manifestations would Nurse Colet expect to identify when assessing a
patient who has atrial fibrillation?

0/1

A. Pounding headache

B. Visual disturbances

C. Irregular radial pulse

D. Elevated bird pressure

52. Nurse Colet would expect a patient to describe the symptoms of arterial insufficiency in the lower
extremities in which of the following ways?

0/1

A. "My leg feels 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."

53. Which nursing intervention would be most suitable for managing a patient with peripheral venous
insufficiency?

0/1

A. Elevating the legs

B. Increasing the fluid Intake

C. Liming the activity level

D. Massaging the extremities

54. For a client admitted with thrombophlebitis who has been prescribed heparin, what type of
administration method should be used?

1/1

A. Buretrol

B. Infusion controller

C. Intravenous filter

D. Three way stop cock.

55. The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse
knows that nitroglycerin affects the heart by:

0/1

A. Slowing contractions of the heart

B. Dilating coronary blood vessels

C. Increasing the ventricular fill time

D. Strengthening contractions of the heart

Situation

1 of 5 points

Disturbances in the gastrointestinal tract, such as nausea or cramps, can disrupt digestion and cause
discomfort. These issues often require attention to diet and sometimes medical treatment to restore
normal function.

56. Razell, who had a total gastrectomy, is given instructions on measure to prevent the developing of
dumping syndrome. Which of the following statements, if made by the patient, would indicate a correct
understanding of the instructions?
1/1

A. "I will have a bedtime snack."

B. "I will rest one hour before each meal."

C. "I will avoid concentrated sugar."

D. “I will include high-carbohydrate foods in my diet”

57. Which of the following laboratory values should Nurse Razell expect to be elevated in a patient who
has pancreatitis?

0/1

A. Red blood cell count

B. Blood urea nitrogen

C. Glycosylated hemoglobin

D. Serum amylase

58. Which of the following statements, if made by Jam who has had a cholecystectomy, would indicate a
correct understanding of dietary instructions?

0/1

A. "I should limit my intake of citrus products.”

B. "I must avoid carbonated beverages.”

C. "I will Increase high-fiber foods in my diet"

D. "I can eat whatever I can tolerate”

59. The nurse should expect to prepare a patient who has bleeding esophageal varices for which of these
procedures initially?

0/1

A. Nasogastric tube feeding

B. Normal saline lavage

C. Electro cauterization

D. X-ray

60. Nurse Tres is caring for a patient with acute Hepatitis B. To which of the following measures should
she give priority when caring for her patient?

0/1

A. Using disposable dishes and cutlery for the patient

B. Placing the patient in a private room

C. Promoting bed rest

D. Limiting fluid intake

Situation

3 of 5 points

A chest tube thoracostomy is a medical procedure where a tube is inserted into the chest cavity to
remove air, fluid, or pus and allow the lungs to fully expand. It’s often used to treat conditions like
pneumothorax (air in the chest), pleural effusion (fluid in the chest), or empyema (infected fluid in the
chest).

61. Maku returned from thoracic surgery 3 hours ago with two chest tubes placed at 20cm suction.
Which findings would be considered abnormal?

1/1

A. Bubbling in the suction control chamber

B. 350 cc of sanguineous drainage in the drainage chamber over the last 3 hours

C. No fluctuation in the water seal chamber

D. Small amount of sanguineous drainage on the chest tube dressing

62. Nurse Gen is caring for Justine, a client who has just undergone a left pneumonectomy, knows that
she should position Justine on:

0/1
A. The back with the head of the bed flat

B. The left side with the head of the bed flat

C. The left side with the head of the bed elevated

D. The right side with the head of the bed elevated

63. While Nurse Gen is assessing the client who has a chest tube, she notes that the tubing is kinked
between the bedrails. Nurse Gen knows that this places the client at increased risk for:

1/1

A. Tension pneumothorax

B. Air leak

C. Hemorrhage

D. Cardiac tamponade

64. Dianhel is rushed to the emergency department due to a pneumothorax secondary to a gunshot
wound. She complains of shortness of breath and exhibits tracheal and mediastinal shifts to the left. For
which procedure should her nurse prepare Dianhel?

1/1

A. Intubation with an endotracheal tube

B. Insertion of a closed chest drainage tube

C. Paracentesis

D. MRI of the chest

65. Dr. Rocky is preparing to remove the chest tube from the client's left chest. To prepare for the
procedure, the nurse should advise the client to:

0/1

A. Breathe normally

B. Hold his breath and bear down

C. Take a deep breath

D. Sneeze on command

Situation

2 of 5 points

Nurse Neil is reviewing his knowledge regarding Pancreatitis for his upcoming board examination this
November.

66. Nurse Neil knew that the initial diagnosis of pancreatitis is confirmed if the client's blood shows a
significant in elevation which of the following serum values?

1/1

A. Amylase

B. Calcium

C. Potassium

D. Trypsin

67. In a client with acute pancreatitis, Nurse Neil should anticipate observing the following signs and
symptoms:

0/1

A. Diarrhea

B. Jaundice

C. Hypertension

D. Ascites

68. Nurse Neil reviews the client's latest laboratory results. What findings would indicate a diagnosis of
acute pancreatitis?

1/1

A. Hyperglycemia
B. Leukopenia

C. Thrombocytopenia

D. Hyperkalemia

69. Nurse Neil reviews initial plan for a client with pancreatitis would most likely focus on which of the
following as a priority?

0/1

A. Resting the gastrointestinal tract

B. Ensuring adequate nutrition

C. Maintaining fluid and electrolyte balance

D. Preventing the development of an infection

70. Nurse Neil knows that if a client is diagnosed with acute pancreatitis, he should carefully monitor the
client for which of the following complications?

0/1

A. Congestive heart failure

B. Duodenal Ulcer

C. Cirrhosis

D. Pneumonia

Situation

1 of 5 points

Nurse Anne, an infectious control nurse, is caring for a client with Pulmonary Tuberculosis.

71. Which client has special risk factors that warrant testing for tuberculosis?

0/1

A. 45-year-old Caucasian man who has been homeless for 2 years

B. 15-year-old Caucasian woman with asthma

C. 72-year-old woman who is a recent immigrant from Russia

D. 50-year-old Iowa farmer

72. Nurse Anne knows that the priority action for a client admitted with a productive cough, weight loss,
and a suspected diagnosis of tuberculosis is:

1/1

A. Instruction on preventing disease transmission

B. Planning for frequent rest period

C. Recording accurate Intake and output

D. Reviewing current dietary patterns

73. Nurse Anne concludes that an intradermal TB test result is positive in any person if the following is
present:

0/1

A. An induration of 15 mm or more

B. An induration of 10 cm or more

C. An induration of 5-9 mm

D. A hivelike vesicle

74. A client with tuberculosis has a prescription for Myambutol (Ethambutol HCI). Nurse Anne should tell
the client to notify the doctor immediately if he notices:

0/1

A. Gastric distress

B. Changes in hearing

C. Red discoloration of body fluids

D. Changes in color vision

75. The Mantoux test is used to determine whether a person has been exposed to tuberculosis. If the
test is positive, Nurse Anne will find a:

0/1

A. Fluid filled vesicle

B. Sharply demarcated erythema

C. Central area of induration

D. Circular blanched area

Situation

2 of 5 points

Numerous clients with a diagnosis of Benign Prostatic Hypertrophy is confined on the medical-surgical
ward under the care of Dr. Reyes and Nurse Ryan.

76. When taking patient history from a client who has a diagnosis of Pyelonephritis, Nurse Ryan should
expect the patient to report which of the following symptoms?

1/1

A. Pain referred to the left shoulder

B. Low Back Pain

C. Flank Pain

D. Right Upper Quadrant Pain

77. Which of the following instructions would a nurse include in the discharge plan for a patient who had
a transurethral resection of the prostate (TURP)?

1/1

A. Limit the intake of caffeinated beverages

B. Resume normal activities of daily living

C. Maintain a diet low in fiber

D. Strain urine with each voiding

78. A patient who comes to Dr. Reyes’s office is suspected of having hypertrophy of the prostate. Nurse
Ryan should expect that the patient will probably have which of the following symptoms?

0/1

A. Residual urine of more than 60 ml

B. Pain radiating to the scrotum

C. Urethral excoriation

D. Stress incontinence

79. Which of the following findings, if identified in a patient who is being treated for Benign Prostatic
Hypertrophy (BPH), would indicate that the treatment is having the desired effect?

0/1

A. Increased urine concentration

B. Increased sperm count

C. Decreased scrotal swelling

D. Decreased urinary dribbling

80. After transurethral resection of the prostate (TURP), Nurse Ryan must carefully observe for which life
threatening, post-operative complication?

0/1

A. Epididymitis and pneumonia

B. Infection and arrhythmia

C. Thrombophlebitis and pulmonary edema

D. Hemorrhage and shock

Situation
1 of 5 points

Aiah, a client with Chronic Obstructive Pulmonary Disease (COPD) and a history of asthma presents in
the physician's office with complaints of difficulty breathing.

81. While performing the initial assessment, Nurse Maloi becomes concerned that Aiah’s respiratory
status has worsened based on which of the following:

0/1

A. Wheezing throughout the lung field

B. Noticeably diminished breath sounds

C. Loud wheezing only on expiration

D. Mild wheezing on inspiration

82. Nurse Maloi has just received orders to provide chest physiotherapy for a client two times per day.
The nurse evaluates which schedule to be most therapeutic?

0/1

A. 7:00 AM and 1:00 PM

B. 6:00 AM and 4:00 PM

C. 9:00 AM and 5:00 PM

D. 8:00 AM and 8:00 PM

83. Nurse Maloi assesses another college-age client complaining of shortness of breath after jogging and
tightness in his chest. Upon further questioning, the client denies a sore throat, fever, or productive
cough. The nurse notifies the physician that this client's clinical manifestations are most likely related to:

1/1

A. Pneumonia

B. Bronchitis

C. Pneumoconiosis

D. Asthma
84. A client with late-stage emphysema becomes confused and is experiencing tremors. Nurse Maloi
interprets that these symptoms are indicative of which complication of emphysema?

0/1

A. Encephalopathy

B. Carbon dioxide narcosis

C. Carbon monoxide poisoning

D. Cerebral embolism

85. Nurse Maloi is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving
aminophylline (Theophylline) intravenously. A theophylline blood serum level is drawn on the client. She
should monitors the results of this blood test and expects the findings to be at which therapeutic level?

0/1

A. 5 mcg/ ml

B. 8 mcg/ ml

C. 18 mcg/ml

D. 25 mcg/ ml

Situation

1 of 5 points

Nurse Jazz is assigned to care for admitted clients with the diagnosis of Peptic Ulcer Disease (PUD).

86. Which of the following actions of Nurse Jazz will be most effective in treating peptic ulcer disease?

0/1

A. Giving alternating doses of magnesium and aluminum antacids every 2-4 hours

B. Giving antibiotics and HCl secretion inhibitors daily as ordered for one week

C. Obtaining information on enrollment in a stress management class

D. Explaining procedure for insertion of Minnesota or Blakemore tube with traction

87. Nurse Jazz tells a client who is post-operative after a gastrectomy that dumping syndrome is a
significant problem for:

1/1

A. 70%-80% of clients having gastrectomies

B. 20%-50% of clients having gastrectomies

C. 25% of clients having gastrectomies

D. 5%-10% of clients having gastrectomies

88. Nurse Jazz will usually ambulate a client post-gastrectomy beginning:

0/1

A. The day after surgery

B. 3-4 days after surgery

C. After 4 days of bed rest

D. Immediately after awakening from anesthesia

89. Which would Nurse Jazz expect to see to a client with dumping syndrome?

0/1

A. Feeling of hunger

B. Constipation

C. Increased strength

D. Diaphoresis

90. A client is admitted with a diagnosis of duodenal ulcer. During the intake history, Nurse Jazz would
expect the client to report
0/1

A. Epigastric pain that is relieved by eating

B. Weight loss

C. Epigastric pain that is worse after eating

D. Vomiting after eating

Situation

0 of 5 points

TRA Medical Center frequently sees a high volume of admissions from clients dealing with respiratory
disorders. Nurse MJ is assigned to care to these patients.

91. When Nurse MJ conducts a thoracic assessment on a 25-year-old client, what findings should he
anticipate during the inspection?

0/1

A. Hyperresonance on the affected side.

B. A symmetrical chest movement

C. absence of breath sounds

D. Decreased tactile fremitus

92. Dr. Roque performed thoracostomy at the bedside for a patient diagnosed with Pneumothorax on
the left side of the thoracic cavity. What position will the patient assume during the insertion of the
chest tube.

0/1

A. High Fowlers position with the left side of thorax supported with sand bag.

B. Right side lying position

C. Supine with head elevated and left arm raised above the head

D. Head elevated with the client place on his right side

93. To ensure that intrathoracic pressure is maintained, Nurse MJ will observe which of the following
while the thoracostomy tube is being inserted?

0/1

A. Clamped until connected to a close chest drainage system.

B. Introduced gently and carefully into the thoracic activity

C. Maintained open to allow drainage

D. Connected to the closed chest drainage system

94. Four hours post thoracostomy, Nurse MJ checked the water sealed drainage system. He observed
periodic air bubbles in the water sealed chamber. This observation signifies:

0/1

A. possible leak at the site of the insertion of the thoracostomy tube.

B. That air trapped in the thoracic cavity is being removed

C. A disconnected between the chest tube and the drainage tubing.

D. Increased intrathoracic pressure.

95. Before the end of his shift, Nurse MJ made his rounds to get the total intake and output of the client.
He noticed that the drainage was 70 mL. Nurse MJ’s priority action would be to:

0/1

A. Document and hand off to the incoming shift for further observation.

B. Treat the observation as normal.

C. Alert the operating room for an emergency exploratory thoracotomy.

D. Assess the client vital signs and report findings to the physician.

SITUATION

1 of 5 points

Nurse Jean is a proficient nurse assigned to care for Jacob, client with acute episodes of cholecystitis.
96. Nurse Jean did her admission assessment to Jacob. She understands that the pain is characterized as:

0/1

A. A tenderness that is generalized in the upper epigastric area

B. pain in the upper quadrant radiating to the left shoulder

C. tenderness and rigidity at the left epigastric area radiating to the back

D. tenderness and rigidity of the upper right abdomen radiating to midsternal area

97. To confirm the diagnosis of cholecystitis, Dr. Manuel ordered the procedure that can detect gallstone
as small as 1 to 2 cm and inflammation. Nurse Jean would prepare the client for which specific
procedure?

0/1

A. gall bladder series

B. oral cholecystogram

C. cholangiography

D. ultrasonography

98. The diagnosis was confirmed as cholecystitis with gallstone. Dr. Manuel prepares the client for
removal of his gallbladder. The client asks Nurse Jean how will it affect his digestion? Nurse Jean 's MOST
correct response would be:

1/1

A. The removal of the gallbladder usually interferes with digestion but can be aided with dietary
modification.

B. The removal of the gallbladder does not usually interfere with digestion.

C. Your body system will adjust in due time.

D. The removal of the gallbladder would significantly interfere only with digestion food.

99. Reviewing the laboratory finding of the client, Nurse Jean found which finding are elevated?
1. WBC count

2. Total serum bilirubin

3. Alkaline phosphate

4. RBC count

5. Cholesterol

6. Serum amylase

0/1

A. 2,3,4

B. 1,2,3

C. 3,5,6

D. 1,2,6

100. A T-tube was inserted and the doctor ordered to monitor amount, color, consistency and odor of
drainage. Which of the following procedure can the nurse perform without the doctor’s order?

0/1

A. Clamping

B. Aspirating

C. Irrigating

D. Emptying the drainage