8.

Which of the following combinations of adverse effects must be

carefully monitored when administering I.V. insulin to a client
diagnosed with diabetic ketoacidosis?
A. Hypokalemia and hypoglycemia
B. Hypocalcemia and Hyperkalemia
MEDICAL SURGICAL NURSING C. Hyperkalemia and hyperglycemia
FINAL COACHIING D. Hypernatremia and hypercalcemia
PROF. JOHDEL CABULUNA 9. A client is brought to the emergency room in an unresponsive
state, and a diagnosis of hyperglycemic hyperosmolar nonketotic
ENDOCRINE syndrome is made. The nurse would prepare immediately to initiate
which of the following anticipated physician orders?
1. A client newly diagnosed with diabetes mellitus has been A. 100 units of NPH insulin
stabilized with insulin injections daily. A nurse prepares a discharge B. Endotracheal intubation
teaching plan regarding the insulin. The teaching plan should C. Intravenous replacement of sodium bicarbonate
reinforce which of the following concepts? D. Intravenous infusion of normal saline
A. Increase the amount of insulin before unusual exercise.
B. Ketones in the urine signify a need for less insulin. 10. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can
C. Always keep insulin vials refrigerated. be differentiated from diabetic ketoacidosis by which of the following
D. Systematically rotate insulin injection sites. conditions?
A. Hyperglycemia
2. The nurse is instructing the newly diagnosed diabetic client how to B. Serum osmolarity
mix regular insulin and NPH insulin. What should the nurse tell the C. Absence of ketosis
client? D. Hypokalemia
A. Shake the bottle of intermediate insulin before withdrawing
the amount 11. In case of hypoglycemia, which among the ff would be best to
B. Withdraw the longer-acting insulin correct this condition?
C. Withdraw the shorter-acting insulin first A. Coke diet
D. Never inject air into the bottles before withdrawing B. Tongkat ali
C. Cake
3. The following are the nursing interventions for administering D. Regular softdrinks
insulin, EXCEPT
A. administer insulin at room temperature 12. A client is found to be comatose and hypoglycemic with a blood
B. rotate site of injection sugar of 50mg. what nursing action is implemented FIRST?
C. aspirate clear liquid before cloudy insulin to combine in one A. infuse 1,000 cc D5W over a 12 hour period
syringe B. administer 50% glucose intravenously
D. shake the insulin to redistribute particles C. check the client’s urine for the presence of sugar & acetone
D. encourage the client to drink orange juice with added sugar
4. Capillary glucose monitoring is being performed every 4 hours for
a client diagnosed with diabetic ketoacidosis. Insulin is administered 13. When assessing a client with Grave’s disease, the nurse should
using a scale of regular insulin according to glucose results. At 2 expect to find:
p.m., the client has a capillary glucose level of 250 mg/dl for which he A. Constipation, dry skin and weight gain
receives 8 U of regular insulin. The nurse should expect which of the B. Lethargy, weight gain and forgetfulness
following: C. Weight loss, exophthalmos and restlessness
A. Onset to be at 2 p.m. and its peak at 3 p.m. D. Weight loss, protruding eyeballs and lethargy
B. Onset to be at 2:15 p.m. and its peak at 3 p.m.
C. Onset to be at 2:30 p.m. and its peak at 4 p.m. 14. The nurse is caring for a client with exophthalmos secondary to
D. Onset to be at 4 p.m. and its peak at 6 p.m. her thyroid disease. What is the cause of exophthalmos?
A. Fluid and edema in the retro-orbital tissues, which forces
5. A client with type 1 diabetes mellitus calls the nurse to report the eyes to protrude
recurrent episodes of hypoglycemia with exercising. Which statement B. Impaired vision which causes the patient to squint in order
by the client indicates an inadequate understanding of the peak of to see
action of NPH insulin and exercise? C. Increased eye lubrication, which makes the patient blink
A. “The best time for me to exercise is every afternoon.” less
B. “The best time for me to exercise is after I eat.” D. Decrease in the extraocular eye movements, which results
C. “The best time for me to exercise is after breakfast.” in the “thyroid stare’
D. “The best time for me to exercise is after my morning
snack.” 15. Chona was prescribed with Methimazole (Tapazole) to inhibit
thyroid hormone secretions. The nurse should monitor the patient for
6. A nurse is caring for a client admitted to the emergency room with which life-threatening adverse effect of this medication?
diabetic ketoacidosis (DKA). In the accurate phase the priority A. Hemorrhagic stroke
nursing action is to prepare to B. Myxedema coma
A. Administer regular insulin intravenously. C. Agranulocytosis
B. Administer 5% dextrose intravenously. D. Hyperthermia
C. Correct the acidosis.
D. Apply an electrocardiogram monitor. 16. A client who has had thyroidectomy does not understand how
hypothyroidism could develop when the problem was
7. In case of DKA, which of the ff clinical manifestations is expected? hyperthyroidism. The nurse should base the response on the
A. Oliguria knowledge that
B. Kussmaul’s respiration A. Hypothyroidism is a gradual slowing of body’s function
C. Ammonia odor of breath B. There will be a decrease in pituitary thyroid stimulating
D. All of these hormone
C. There may not be enough thyroid tissue left to supply
adequate thyroid hormones
D. Atrophy of tissue remaining after surgery reduces secretion
of thyroid hormones
17. A patient has hyperthyroidism is taking methimazole (Tapazole) 27. For a client in Addisonian crisis, it would be very risky for a nurse
and attends the clinic regularly. To evaluate the effectiveness of to administer:
Tapazole therapy, the nurse should consider which of the following A. potassium chloride
questions? B. normal saline solution
A. “Has the patient’s vision improved?” C. hydrocortisone
B. “Has the patient’s appetite improved?” D. fludrocortisones
C. “Has the patient’s need for sleep decreased?”
D. “Has the patient’s pulse rate decreased?” 28. A nurse is caring for a client with pheochromocytoma. The client
asks for a snack and something warm to drink. The most appropriate
18. Thyroid replacement therapy is prescribed for the client choice for this client to meet nutritional needs would be which of the
diagnosed with hypothyroidism. The client asks the nurse when the following?
medication will no longer be needed. The most appropriate response A. Graham crackers and warm milk
is which of the following? B. Toast with peanut butter and cocoa
A. “The medication will need to be continued for life.” C. Cracker with cheese and tea
B. “It depends on the results of the laboratory values.” D. Vanilla wafers and coffee with cream and sugar
C. “Most clients will require medication therapy for about 1
year.” 29. A nurse is performing an assessment on a client with
D. “You will need to ask your physician.” pheochromocytoma. The nurse assesses for the major symptom
associated with pheochromocytoma when the nurse
19. A client diagnosed with hyperparathyroidism is at risk for: A. Test the client’s urine glucose.
A. Hypercalcemia B. Obtains the client’s weight.
B. Urolithiasis C. Palpates the skin for its temperature.
C. Fractures D. Takes the client’s blood pressure.
D. All of these
30. Nurse Beatriz is performing physical assessment to patient
20. Which of the following symptoms is the chief sign of Ursula with acromegaly and she noted the following characteristic of
hypoparathyroidism? this disease EXCEPT:
A. Chest pain A. Enlarged hands and feet
B. Shortness of breath B. Distorted facial features
C. Exophthalmos C. Increasing height
D. Tetany D. Ulnar nerve entrapment at the elbow

21. A client is admitted for treatment of the syndrome of inappropriate

antidiuretic hormone (SIADH). Which nursing intervention is
GASTROINTESTINAL
appropriate?
A. Infusing I.V. fluids rapidly as ordered 31. Which of the following symptoms is common with a hiatal hernia?
B. Encouraging increased oral intake A. Left arm pain
C. Restricting fluids B. Lower back pain
D. Administering glucose-containing I.V. fluids as ordered C. Esophageal reflux
D. Abdominal cramping
22. Which of these signs suggests that a client with SIADH is
experiencing complication? 32. Patient was diagnosed to have hiatal hernia. What is the problem
A. Polyuria if there is herniation?
B. Polydipsia A. Protrusion of a part due to muscle weakness
C. Weight loss B. Reflux esophagitis
D. Distended neck veins C. Small meal is advise
D. All of the above
23. Which of the following may be seen in a client with DI?
A. Low serum hematocrit 33. A client with a history of hiatal hernia states he has trouble
B. High urine specific gravity sleeping because the pain is worse at night. Which response by the
C. High serum specific gravity nurse is most appropriate?
D. Oliguria A. "Try sleeping with your upper body elevated."
B. "What sleep medication do you take?"
24. A client is seen in the clinic for complaints of thirst, frequent C. "Try lying flat or on your side."
urination, and headaches. Following a diagnostic studies, diabetes D. "Sleep with your feet elevated."
insipidus in diagnosed. Lypressin (Diapid) is prescribed. The nurse
instructs the client that the medication is prescribed to 34. A client has recently been diagnosed with peptic ulcer disease.
A. Relieve the headaches. Diagnostic studies confirm the presence of the gram-negative
B. Increase water reabsorption. bacteria Helicobacter pylori in his gastrointestinal tract. If the client
C. Decrease the production of the antidiuretic hormone. has a duodenal ulceration, the nurse would expect the client to
D. Stimulate the production of aldosterone. describe the “ulcer pain” as
A. Located in the upper right epigastric area radiating to his
25. The nurse understands that the cause of Cushing’s syndrome is right shoulder or back
most commonly: B. Relieved by vomiting
A. pituitary hypoplasia C. Occurring two to three hours after a meal, often awakening
B. Hyperplasia of the adrenal cortex him between 1:00 and 2:00 A.M.
C. Insufficient ACTH production D. Worsening with the ingestion of food
D. deprivation of adrenocortical hormones
35. The client with duodenal ulcer may exhibit which of the following
26. A client who is diagnosed as having Addison’s disease is findings on assessment?
receiving teaching about his disease from the nurse. Which A. Hematemesis
statement the client makes indicates to the nurse that he B. Malnutrition
understands the teaching? C. Melena
A. ”I should avoid strenuous exercise during hot weather” D. Pain with eating
B. “I should not eat salty foods”
C. “I need to take medication only when I am having 36. A client is taking an antacid for treatment of PUD, Which of the
symptoms.” following statements indicate that the client understands how to
D. “I should eat foods such as bananas and oranges several correctly take the antacid?
times daily.” A. I should take the antacid before my other medications
 B. I need to decrease my intake of fluid so that I don’t dilute 46. The husband of a client asks the nurse about the protein-
effects of my antacids restricted diet ordered because of advanced liver disease. What
C. My antacid will be most effective if I take it whenever I have statement by the nurse would best explain the purpose of the diet?
pain A. “The liver cannot rid the body of ammonia that is made by
D. It is best for me to take antacid 1 – 3 hours after meals the breakdown of protein in the digestive system.”
B. “The liver heals better with a high carbohydrates diet rather
37. After Billroth II Surgery, the client developed dumping syndrome. than protein.”
Which of the following should the nurse exclude in the plan of care? C. “Most people have too much protein in their diets. The
A. Sit upright for at least 30 minutes after meals amount of this diet is better for liver healing.”
B. Take only sips of H2O between bites of solid food D. “Because of portal hyperemesis, the blood flows around
C. Eat small meals every 2-3 hours the liver and ammonia made from protein collects in the
D. Reduce the amount of simple carbohydrate in the diet brain causing hallucinations.”

38. Mr. Jose is being evaluated for Rovsing’s sign. Rovsing’s sign 47. The client who has liver disease asks the nurse why the bruises
involves which of the following? so easily. Which of the following information should the nurse include
A. Checking for abdominal rigidity. in the response?
B. Palpation of the left lower quadrant going anti – clockwise A. “Your liver is unable to make the proteins that are needed
towards the appendix and assessing for pain. to making clotting factors.”
C. Applying pressure on the painful area and releasing to B. “Your liver can no longer metabolize drugs and render
check for increasing pain. them inactive.”
D. Assessing for the location of the pain. C. “Your liver is breaking down blood cells too rapidly.”
D. “Your liver can’t store vitamin C any longer.”
39. Melanie, 23 years old, was rushed to the emergency room with
chief complaint of right lower quadrant pain. Appendicitis was ruled 48. You're teaching the family of a client with liver failure. You instruct
out and the patient underwent emergency appendectomy. After them to limit which foods in the client's diet?
surgery, the nurse should place the patient in which position? A. Meats and beans
A. Trendelenburg B. Butter and gravies
B. Sim’s C. Potatoes and pasta
C. Left side lying D. Cakes and pastries
D. High Fowler
49. When caring for a client with esophageal varices, the nurse
40. You're caring for a 62-year-old woman diagnosed with knows that this disorder usually stems from:
diverticulosis. Which of the following measures do you expect to A. esophageal perforation
institute? B. pulmonary hypertension
A. Low-fiber diet and fluid restrictions C. portal hypertension
B. Total parenteral nutrition and bed rest D. peptic ulcers
C. High-fiber diet
D. Administration of analgesics and antacids 50. A Sengstaken-Blakemore tube is inserted in the effort to stop the
bleeding esophageal varices in a patient with complicated liver
41. Which of the following definitions best describes diverticulosis? cirrhosis. Upon insertion of the tube, the client complains of difficulty
A. An inflamed outpouching of the intestine of breathing. The first action of the nurse is to:
B. A non – inflamed outpouching of the intestine A. Deflate the esophageal balloon
C. The partial impairment of the forward flow of intestinal B. Monitor VS
contents C. Encourage him to take deep breaths
D. An abnormal protrusions of an oxygen through the D. Notify the MD
structure that usually holds it
51. A client with alcoholic cirrhosis with ascites and portal
42. To improve Mr. Trinidad’s condition, a client with diverticulosis, hypertension is to receive neomycin. The desired effect of this drug is
your best nursing intervention and teaching is: to
A. Reduce fluid intake A. Sterilize the bowel
B. Increase fiber in the diet B. Reduce abdominal distention
C. Administering of antibiotics C. Decrease the serum ammonia
D. Exercise to increase intra-abdominal pressure D. Prevent infection

43. The symptom most characteristic of ulcerative colitis is: 52. The serum ammonia level of a client with hepatic cirrhosis and
A. weight gain ascites is elevated. The priority nursing intervention should be to:
B. constipation A. Weigh the client daily
C. vomiting B. Restrict the client’s intake of fluid
D. abdominal pain C. Measure the client’s urine specific gravity
D. Observe the client for increasing confusion
44. Ulcerative colitis is:
A. inflammation of the colon which begins initially in the 53. You're developing a care plan for a 67-year-old client with hepatic
rectum and sigmoid colon encephalopathy. Which of the following do you include?
B. superficial erosion of the gastric lining with little A. Administering a Lactulose enema as ordered
inflammation B. Encouraging a protein-rich diet
C. decreased or absent peristalsis in the colon C. Administering sedatives, as necessary
D. herniation of the mucosa of the colon D. Encouraging ambulation at least four times a day

45. The patient was admitted at the Emergency room with a 54. The ascites seen in cirrhosis results in part from:
diagnosis of ulcerative colitis. As a competent nurse, where are you A. the escape of lymph into abdominal cavity directly from the
going to position the patient? inflamed liver sinusoid
A. near the nurse station B. increased plasma colloid osmotic pressure due to
B. near the attending physician excessive liver growth and metabolism
C. near the comfort room C. the decreased levels of ADH and aldosterone due to
D. near the laboratory increasing metabolic activity in the liver
D. compression of the portal vein with resultant increased
HEPATOBILIARY back pressure in the portal veins system
55. You're caring for a 67-year-old male client with liver cirrhosis who C. Serum bilirubin level
develops ascites and requires paracentesis. Relief of which symptom D. White blood cell count
indicates that the paracentesis was effective?
A. Pruritus
B. Dyspnea
URINARY
C. Jaundice
D. Peripheral neuropathy 66. A patient with acute renal failure is being assessed to determine
whether the cause is pre-renal, renal, or post-renal. If the cause is
56. The nurse assesses the client with cholecystitis for the pre-renal, which condition most likely caused it?
development of obstructive jaundice, which would be evidenced by: A. Heart failure
A. Inadequate absorption of fat-soluble vitamin K B. Glomerulonephritis
B. Light amber urine, dark brown stools, yellow skin C. Ureterolithiasis
C. Dark-colored urine, clay colored stools, itchy skin D. Aminoglycoside toxicity
D. Straw-colored urine, putty-colored stools, yellow sclera
67. All of the following are post renal causes except:
57. A client with cholelithiasis experience discomfort after ingesting A. Hydronephrosis
fatty foods because B. Urinary tract infection
A. Fatty foods are hard to digest C. Glomerulonephritis
B. Bile flow into the intestine is obstructed D. BPH
C. The liver is manufacturing inadequate bile
D. There is inadequate closure of the Ampulla of Vater 68. In assessing the laboratory findings, which result would the nurse
most likely expect to find in a client with chronic renal failure?
58. When a client develops steatorrhea, the nurse should describe A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5
the stool as to 1.5 mg/dl
A. Dry and rock hard B. Decreased serum calcium, blood pH 7.2, potassium 6.5
B. Clay colored and Chubby mEq/L
C. Bulky and foul smelling C. BUN 15 mg/dl, increased serum calcium, creatinine l.0
D. Black and blood streaked mg/dl
D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35,
59. Following an abdominal cholecystectomy, the nurse should decreased serum calcium
assess for signs of respiratory complications because the:
A. Incision is in close proximity to the diaphragm 69. A client with chronic renal failure asks the nurse why he has
B. Length of time required for surgery is prolonged developed anemia. The most accurate response by the nurse is:
C. Client's resistance is lowered because of bile in the blood A. "The increase in nitrogen waste in your blood destroys your
D. Bloodstream is invaded by microorganisms from the biliary bone marrow"
tract B. "A hormone in your kidney that stimulate your bone marrow
is lacking"
60. Immediately after cholecystectomy, the nursing action that should C. "You have lost some blood through your urine"
assume the highest priority is: D. "The low protein diet that you are on causes the anemia"
A. encouraging the client to take adequate deep breaths by
mouth 70. Which of the following clinical findings would the nurse look for in
B. encouraging the client to cough and deep breathe a client with chronic renal failure?
C. changing the dressing at least BID A. Hypotension
D. irrigate the T-tube frequently B. Uremia
C. Metabolic alkalosis
61. An acute attack of pancreatitis may be precipitated by heavy D. Polycythemia
drinking because:
A. promotes the formation of calculi in the cystic duct 71. The nurse is instructing a patient with end-stage renal disease
B. the pancreas is stimulated to secrete more insulin than it related to chronic glomerulonephritis on dietary restrictions. Which of
can immediately produce the following restrictions will apply to this patient?
C. the alcohol alters the composition of enzymes so they are A. Fluid, sodium, protein, and glucose
capable of damaging pancreas B. Fluid, potassium, calcium, and iron
D. alcohol increases enzymes secretion and pancreatic duct C. Fluid, calcium, glucose, and iron
pressure, which causes backflow of enzymes into the D. Fluid, sodium, protein, and potassium
pancreas
72. The physician orders regular insulin, 10U added to 50 ml of 50
62. What would the nurse note as typical findings on the assessment percent dextrose to be given intravenously to a patient with chronic
of a client with acute pancreatitis? renal failure. The expected outcome of this is to:
A. Steatorrhea, abdominal pain, fever A. lower the blood sugar
B. Melena, persistent vomiting, hyperactive bowel sounds B. decrease the serum potassium
C. fever, hypoglycemia, dehydration C. reduced cerebral edema
D. hypoactive bowel sounds, decreased amylase and lipase D. prevent tetany

63. As a client’s symptoms of pancreatitis subside, it is most 73. The physician orders aluminum hydroxide (Amphojel) with each
important that the nurse instruct the client to meal for a patient with end-stage renal disease. This drug is given to:
A. Avoid eating hot spicy food A. Remove protein waste of metabolism
B. Avoid ingesting alcoholic beverages B. Bind phosphorus in the GI tract
C. Eat a bland diet with 6 meals a day C. Exchange sodium for potassium in the colon
D. Eat a high carbohydrate, low fat, low protein diet D. Inhibit development of a stress ulcer

64. In acute pancreatitis, an early nutrition is ordered. This is via: 74. A 45-year-old man with diabetic nephropathy has end-stage renal
A. Mouth failure and is considering starting dialysis. The nurse includes which
B. Nasogastric tube of the following in teaching about hemodialysis?
C. Jejunostomy tube A. Hemodialysis is a treatment option that is required 3 times
D. Intravenous line a week.
B. Hemodialysis is a treatment option that is required daily
65. The nurse is aware that the laboratory test result that most likely C. You will have surgery, and a catheter will be inserted into
would indicate acute pancreatitis is an elevated the abdomen
A. Blood glucose levels D. Hemodialysis is a treatment that is used for a few months
B. Serum amylase level until your kidney heals and starts to produce urine again
75. In caring for Jenny with chronic renal failure, which has had AV
shunt inserted for hemodialysis, the nurse should: 85. The nurse is providing post-procedure care for a client who
A. notify the physician if a bruit is heard in the cannula underwent extracorporeal shock wave lithotripsy. In this procedure,
B. use strict aseptic technique when giving shunt care an ultrasonic probe inserted that generates ultra-high-frequency
C. cover the entire cannula with an elastic bandage sound waves to shatter renal calculi. The nurse should instruct the
D. take BP ever 4h from the arm that contains the shunt client to:
A. limit oral fluid intake for 1 to 2 weeks
76. The nurse is evaluating the client’s response to hemodialysis. B. report the presence of fine, sand-like particles through the
The laboratory values reflect that dialysis is achieving positive nephrostomy tube
results. Which laboratory values would not reflect changes from C. Notify the physician about cloudy or foul-smelling urine
hemodialysis? D. Report bright pink urine within 24 hours after the procedure
A. Serum creatinine level
B. Serum urea 86. Which vitamin should the nurse recommend to a client to
C. Serum potassium levels maintain acidic urine and help with recurrent UTI?
D. Hemoglobin levels A. Anti-protozoal
B. Antibiotics
77. A client recently started on hemodialysis wants to know how the C. Ascorbic Acid
dialysis will take the place of his kidneys. The nurse's response is D. Anti-Ecoli
based on the knowledge that hemodialysis works by:
A. Passing water through a dialyzing membrane 87. A client is diagnosed with cystitis. Client teaching aimed at
B. Eliminating plasma proteins from the blood preventing a recurrence should include which of the following
C. Lowering the pH by removing non-volatile acids instructions?
D. Filtering waste through a dialyzing membrane A. Bath in a tub
B. Wear cotton underwear
78. During the first peritoneal dialysis exchange, the fluid that drains C. Use feminine hygiene spray
from the outflow tubing is tinged with blood. The nurse should: D. Limit your intake of cranberry juice
A. realize that this is a normal occurrence for the first few
exchanges 88. A client complains of severe burning sensation on urination.
B. apply a pressure dressing to the insertion site Which of the following instructions is best to give the client?
C. recognize that the abdominal blood vessels have been A. Wear nylon panties
inadvertently punctured B. Drink coffee to increase urination
D. check the urine output for hematuria C. Soak in warm water with bubble bath
D. Drink 2,500 to 3,000 ml of water per day
79. A client with chronic renal failure is on continuous ambulatory
peritoneal dialysis. Which nursing diagnosis should have the highest 89. Nursing management with a client with UTI includes:
priority? A. Taking medication until feeling better
A. Powerlessness B. Restricting fluids
B. High risk for infection C. Decreasing caffeine drinks and alcohol
C. Altered nutrition: Less than body requirements D. Douching daily
D. High risk for fluid volume deficit
90. May, 40 years old admitted to the hospital with urethritis. Prior to
80. The nurse is aware that a client is receiving Azathioprine initiating treatment plans, the nurse should plan to:
(Imuran), Cyclosporine and Prednisone before a kidney transplant A. Prepare for urinary catheterization
surgery to: B. Start a 24-hour urine collection
A. Stimulate leukocytosis C. Administer an oil-retention enema
B. Provide passive immunity D. Obtain a urine specimen of culture and sensitivity
C. Prevent iatrogenic infections
D. Reduce antibody production
BURNS
81. An intravenous pyelogram reveals that Paulo, age 35, has a renal
calculus. He is believed to have a small stone that will pass 91. Second degree burns are described by which of the following
spontaneously. To increase the chance of the stone passing, the statements:
nurse would instruct the client to force fluids and to 1. destruction of the subcutaneous layer
A. Strain all urine 2. has a moist appearance with blister formation
B. Ambulate 3. involvement of dermis
C. Remain on bed rest 4. otherwise known as partial thickness superficial burns
D. Ask for medications to relax him 5. most painful degree of burns
A. 1, 4, 5
82. A client is complaining of severe flank pain and abdominal pain. B. 2, 3, 5
A flat plate of abdomen shows urolithiasis. Which of the following C. 1, 2, 3
interventions is most important? D. 3, 4, 5
A. Strain all urine
B. Limit fluid intake 92. Third degree burn s is described by which of the following
C. Enforce strict bed rest statements?
D. Encourage a low calcium diet A. Destruction of the epidermis and dermis
B. It has moist appearance with blisters
83. Diet therapy for renal calculi of calcium phosphate composition C. Destruction of the subcutaneous layer
would probably be: D. It appears charred
A. High calcium and phosphorus, alkaline ash
B. High calcium and phosphorus, acid ash 93. Palm method in determining the extent of burn uses the:
C. Low purine and phosphorus, alkaline ash A. Palm of the examiner in patient with scattered burn injury
D. Low calcium and phosphorus, acid ash B. Palm of the patient with scattered burn injury
C. Palm of the examiner with one sided burn injury
84. A client passed a kidney stone. The nurse sends the specimen to D. Palm of the patient with one sided burn injury
the laboratory so it can be analyzed for which of the following
factors? 94. The client suffered burn injury on the anterior trunk, genitalia, left
A. Antibodies anterior thigh and left posterior leg. What is the classification and he
B. Type of infection estimated TBSA burned using the rule of nine?
C. Composition of stone A. 32.5%, Moderate burns
D. Size and no. of stones B. 32.5%, Major burns
C. 28%, Moderate burns
 D. 28%, Major burns B. Abdominal girth
C. Serum ammonia level
95. Which clinical manifestation indicates that the burned client is D. Hepatic encephalopathy
moving into the fluid remobilization phase of recovery?
A. Increased urine output, decreased serum sodium 105. A client's IV fluid orders for 24 hour's are 1500 ml D5W followed
B. Increased peripheral edema, decreased blood pressure by 1250 ml of NS. The IV tubing has a drop factor of 15 gtts / ml. To
C. Decreased peripheral pulses, slow capillary refill administer the required fluids the nurse should set the drip rate at;
D. Decreased serum sodium level, increased hematocrit A. 13 gtt/min
B. 16 gtt/min
96. In the acute phase of a burn the nurse should assess for which of C. 29 gtt/min
the following? D. 32 gtt/min
A. Dehydration status because of fluid shifting
B. Circulatory status because of fluid overload 106. Which assessment finding indicates dehydration?
C. ABG due to metabolic alkalosis A. Tenting of chest skin when pinched
D. Hematocrit level due to hypovolemia B. Rapid filling of hand veins
C. A pulse that isn’t easily obliterated
97. During the first 24 hours after thermal injury, you should assess a D. Neck vein distention
burn patient for:
A. hypokalemia and hypernatremia, metabolic acidosis 107. Fluid moves by passing through a permeable membrane, from
B. hypokalemia and hyponatremia, metabolic alkalosis an area of a lower pressure to an area of high pressure?
C. hyperkalemia and hyponatremia, metabolic acidosis A. Diffusion
D. hyperkalemia and hyponatremia, metabolic alkalosis B. Filtration
C. Osmosis
98. While Sergio was lighting a barbecue grill with a lighter fluid, his D. Hydrostatic Pressure
shirt burst into flames. The most effective way to extinguish the
flames with as little further damage as possible is to: 108. Which of the following clients is least likely at risk of the
A. log roll on the grass/ground development of third spacing?
B. slap the flames with his hands A. The client with renal failure
C. immediately call for help B. The client with liver failure
D. bring Sergio to the nearest hospital C. The client with diabetes mellitus
D. The client with cirrhosis
99. When assessing a client with partial thickness burns over 60% of
the body, which of the following should the nurse report immediately? 109. Intravenous Ringer’s lactate solution is prescribed for the
A. Complaints of intense thirst postoperative client. The nursing instructor asks the nursing student
B. Moderate to severe pain who is caring for the client about the tonicity of the prescribed
C. Urine output of 70 ml the 1st hour intravenous solution. The nursing student responds correctly by
D. Hoarseness of the voice stating that this solution is
A. Hypertonic
100. A nurse develops a plan of care for a client recovering from a B. Hypotonic
serious thermal burn. Which of the following is the most immediate C. Isotonic
nursing goal for the client? D. Normotonic
A. Assess the client’s coping towards the change in body
image 110. During and 8 hour shift, Ryan drinks two 6 oz. cups of tea and
B. Providing emotional support to the client and family vomits 125 ml of fluid. During this 8 hour period, his fluid balance
C. Maintaining the client’s fluid, electrolyte, and acid-base would be:
balance A. +55 ml
D. Preventing potential complications such as contractures B. +137 ml
C. +235 ml
FLUIDS AND ELECTROLYTES D. +485 ml

101. After a Whipple procedure for cancer of the pancreas, a client is PERIOPERATIVE
to receive the following intravenous (IV) fluids over 24 hours; 1000 ml
D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic Situation - Indicators are essential in the measurement and
piggyback in 50 ml D5W is ordered every 8 hours. The nurse monitoring of quality health care. The nurse plays a key role in the
calculates that the clients IV fluid intake Tor 24 hours will be: consistent implementation of standards of care in any unit in the
A. 3150ml hospital. The following questions apply.
B. 3200 ml
C. 3650 ml 111. You admitted Lydia, a 26 year old mother, from the Emergency
D. 3750ml Room for emergency appendectomy. Which of the following will you
use to PROPERLY identify the client?
102. When evaluating a client's response to fluid replacement A. Read the name of the client from the chart and name tag
therapy, the observation that indicates adequate tissue perfusion to B. Ask the companion to state the client’s name and address.
vital organ is: C. Ask the client to state her name and birthday
A. Urinary output of 30 ml in an hour D. Request the client to state her name and the complete
B. Central venous pressure reading of 2 cm H20 name of her physician
C. Pulse rates of 120 and 110 in a 15 minute period
D. Blood pressure readings of 50/30 and 70/40 mm Hg within 112. You are to do the initial assessment. Which standard precaution
30 minutes guideline should be observed?
A. Drape the client appropriately
103. When monitoring for hypernatremia, the nurse should assess B. Introduce yourself
the client for: C. Greet the client by her first name
A. Dry skin D. Observe hand hygiene
B. Confusion
C. Tachycardia 113. It is medication time. The nurse is aware that distraction during
D. Pale coloring any phase of drug administration can cause errors. Select which
strategy can give MOST protection while preparing the medication?
104. Serum albumin Is to be administered intravenously to client with A. Inform your co-staff that you are going to prepare
ascites, The expected outcome of this treatment will be a decrease medications for your clients
in: B. Don a medication vest with visible warning. “Don’t Disturb”
A. Urinary output C. Prepare medication at the bedside
 D. Put your cell phone on silent mode 120. Sandra complained of incisional wound pain as soon as she
recovered from anesthesia. She has an order of Demerol 75mg
114. Personal Protective Equipment (PPE) like the face mask when every four hours round the clock for pain. The nurse’s CORRECT
worn correctly offers maximum protection against transmission of intervention to relieve the patient’s complaint is to:
droplets. Below are descriptions of how a mask is worn. Which A. offer the client some hot tea and crackers
statement describes a CORRECTLY WORN MASK? B. encourage Sandra to do deep breathing
A. The mask is placed to cover the nose and mouth with the C. inject Demerol 75mg as ordered for pain
four sides snugly fitting against the skin and with the two D. instruct the client to apply pressure over the operative site
pairs of ties tied separately at the back of the head
B. Place the mask to cover the nose and mouth with two ties 121. Because of the fear of wound gaping and pain, Sandra was
tied at the back of the head observed suppressing her cough reflex. The MOST appropriate
C. With the two loops on either side of the mask, anchor it to nursing intervention to minimize pain in every coughing episode is to:
both ears and adjust to cover the nose and the mouth A. advise the client to turn sides every 30 minutes
D. The mask is placed to cover the nose, ear and mouth tied B. instruct the client to splint the incision wound with a pillow
at the back of the head C. give sedation round the clock to minimize coughing and
pain
Situation – Potential environment hazards exist in various modalities D. splint the operative site with wide plaster
in the Operating room that may affect the well being of the client and
health care workers. It is the responsibility of the perioperative nurse 122. Which psychological nursing intervention can you offer to
to maintain a positive environment for all concerned. minimize postoperative pain?
A. Stay with the client and offer to comb her and put some
115. The circulating nurses are aware that many factors combine to make up in front of the mirror
contribute hypothermia or hyperthermia in the surgical patients. B. Restricts visitors that can aggravate noise and destruction
Below are options that the perioperative nurse can adopt to maintain of rest
the desired temperature. Select all that apply. C. Instruct client and significant others to avoid talking about
1. Adjusting the OR suite temperature pain within the hearing distance of the client
2. Limiting area of skin preparation and surface surgical D. Allow client to converse with other clients regarding their
draping experience in coping operative pain
3. Applying warm blankets to client upon arrival in the OR and
after sterile drapes have been removed 123. One cause of post operative pain is incision wound
4. Keeping the OR door closed throughout the surgical contamination. Hence, nurses and other members of the health team
procedure are expected to do cheap and effective infection prevention
5. Limiting the exposed skin area during positioning measures such as:
6. Placing rolled linen on both sides of the client during skin A. hand washing between client
preparation to catch excess water B. no touch technique
A. 1, 2, 3 and 6 C. use alcohol swab if hand washing is not permissible
B. all except 2 and 5 D. change gloves in between patient
C. all of these
D. 1, 2, 4 and 5 124. Post operative pain keeps surgical clients in bed. Most surgical
clients like Sandra are encouraged to ambulate:
116. During transportation of postoperative clients, which of the A. within 6 to 8 hours after surgery
following would you NOT recommend to be adopted? B. between 10 and 12 hours after surgery
A. Hanging and securing IV containers over the client’s head C. on the second postoperative day
B. Keeping the client warm with blanket D. as soon as indicated
C. Elevating the side rails and using safety straps
D. Pushing the patient’s feet first avoiding rapid movement on Situation – Ann and Von, scrub nurse and circulating nurse,
the hallways and corners respectively, are preparing for hydrocolectomy, their last case for the
day.
117. The surgeon of a client for Dilatation and Curettage (D & C) who
is on triple Anti TB drugs complained why his case is scheduled “last” 125. Ann discovered a cut in her palm while she was opening the
for the day. The OR nurse offers which of the following BEST sterile packs. Ann should:
reason? A. Scrub but put on double gloves
A. “Foremost, we considered the safety of others clients.” B. Ask to be relieved as scrub nurse
B. “Your anesthesiologist preferred the time slot.” C. Scrub if the cut is properly bandaged
C. “The case is relatively short and easy.” D. Scrub after writing an incident report
D. “There is no emergent need to do the case ahead of the
other schedule”. 126. Before any member of the sterile surgical team to do the
surgical hand scrub, she/he should have complete operating room
118. You are preparing case-assignment for the following day. Which attire. Identify all the attire appropriate for this case.
of the following assignment is SAFE for Nurse Kat who is her 1st 1. Head cap
trimester of pregnancy? 2. Goggles
A. Cast room with X-ray facilities 3. Face mask
B. Endoscopy room where clients are given intravenous mild 4. Sterile gown
sedation 5. Gloves
C. Laparoscopic cholecystectomy A. 2, 3, 4
D. Billroth 11 under general anesthesia B. 1, 3, 4
C. 1, 2, 3
119. Before the end of the shift, waste management was discussed. D. 3, 4, 5
The different kinds of waste and their proper disposal were
presented. The following falls under the pathologic waste category, 127. A “sterile set up” has been prepared. The OR was notified of a
EXCEPT: delay in transporting the client from the ward to the OR. Which of the
A. amputated limbs following guidelines should the circulating nurse follow?
B. specimens A. Keep door of the operating room closed all the time to
C. patients personal belongings maintain “sterile set up”
D. blood and body fluids B. “sterile set up” should be replaced after an hour
C. Cover appropriately “sterile set up”
Situation – Sandra, 40 years and weighed 180Ibs, underwent D. Prepare another “sterile set up”
cholecystectomy for cholelithiasis and gall stones.
128. Identify which appropriate gloving technique will the assistant
surgeon use when he performs the skin preparation?
 A. Gloving self closed technique B. discard the sterile linen packs
B. Gloving self open technique C. open the sterile linen packs in front of an electric fan
C. Scrub nurse serves the gloves D. bring the sterile linen packs back to the sterilizer
D. Any gloving technique is accepted
134. When the nursing student performs the surgical hand scrub,
129. The intern 2nd assistant surgeon contaminated his gown while which of the following observations will you report as non
the surgery is ongoing. He is expected to change his gown and conformance?
gloves. Which of the following is the correct technique to be A. Move arm in one direction through the water
followed? B. Scrub arms keeping the hands higher than the arms at all
A. The intern removes his gown and gloves then puts on times
another sterile gown and gloves C. Scrub each side of the arm to 3 inches above the elbow
B. The intern removes his gloves, then his gown; does a 3 D. Rinse hands and arms by passing through the water from
minute hand scrub, and don another sterile gown and the elbow to the fingertips
gloves
C. The intern unties his gown, removes his gown and put on 135. After a ten minute surgical hand scrub, the assistant surgeon
another gown and gloves. came into the OR suite swinging her hands casually. The scrub
D. The circulating nurse unties the gown. The intern removes nurse would do which of the following APPROPRIATE action?
his gown, then removes the gloves and puts another sterile A. Offer a sterile towel to dry hands
gown and gloves B. Oblige the assistant surgeon to scrub again
C. Instruct the circulating nurse to pour alcohol 70% to the
Situation – Ralph, a 45 year old teacher just returned to the ward assistant surgeon’s hands
from the Post anesthesia care unit (PACU). Ralph underwent D. Serve the assistant surgeon the sterile gown and gloves as
subtotal thyroidectomy in the morning. usual

130. The watcher ask the nurse, “When can Ralph start to eat? His 136. The intern in charge did the skin preparation and catheterization
last food intake was last supper.” The correct response of the nurse of the client. The circulating nurse noticed that the intern withdrew
is: the catheter from the vaginal orifice instead of the urinary meatus
A. “Ralph can start on clear liquids as soon as he is fully and is about to re insert the same catheter. What is your PRIORITY
conscious.” action?
B. “The doctor will evaluate the client when he is ready to A. Stop the intern and do the catheterization yourself
eat.” B. Alcoholize the tip of the catheter before reinserting the
C. “Ralph is still on intravenous fluids and is doing fine.” catheter again
D. “As soon as bowel sounds are present.” C. Offer to change the catheter
D. Stop the intern from reinserting the catheter by tapping his
131. A nurse observed a co-worker administering medication several shoulder
hours after scheduled time. When confronted, the co worker just
charted as if the medication was given on time schedule. You 137. After the last stitch the surgeon is ready to apply dressings on
reported to your senior nurse and expected the following steps will be the incision wound. Which of the following does the nurse expects
done. Arrange the following steps in chronological order using all the surgeon to do?
options. A. Tape the dressings and remove gloves
1. The senior nurse will schedule a private meeting to discuss B. Apply the dressings and tape, then remove his gloves
the observation C. Put the dressings, remove his gloves to apply the tape
2. The concerned staff nurse will be encouraged to take D. Remove his gloves and apply the dressings
responsibility
3. The senior nurse will clearly inform the concerned staff that Situation – Arianne, 42 years old was brought to the OR suite for
her behavior is unethical vaginal hysterectomy under spinal anesthesia.
4. If with resistance, the charge nurse will be informed
5. The senior nurse will approach the concerned staff in a 138. The circulating nurse welcomes the client to the OR suite.
calm and professional manner Which of the following is the PRIORITY nursing intervention at this
A. 5, 3, 2, 1, 4 point?
B. 5, 1, 3, 2, 4 A. Validates the OR schedule
C. 3, 2, 1, 5, 4 B. Checks the client for presence of denture, ring and nail
D. 2, 3, 5, 1, 4 polish
C. Validates if the client observed NPO appropriately
132. The nurse initiated an IV of Dextrose 5% Lactated Ringer 1 liter D. Checks the ID bracelet and call the client by name
and instructed the client that she will be back to monitor in an hour.
After about 30 minutes, the client called for help to check the IV. 139. Because of the complexity of the surgical environment each
Upon assessment, the nurse observed the IV site to be reddish, member of the surgical team has a vital role to play. Who is the
bulging and the flow rate was very slow. Select and arrange the guardian of asepsis while Arianne is undergoing the procedure?
interventions of the nurse in the proper sequence. A. The scrub nurse
1. Slow down the infusion B. The anesthesiologist
2. Apply warm compress over the IV site C. The surgeon
3. Re-site the infusion in the opposite arm D. The circulating nurse
4. Document the assessment and nursing intervention
5. Discontinue the infusion 140. Research studies have shown that client’s awareness during
6. Restart the IV distal to the former IV site intraoperative period maybe greater than once believed. For this
reason the circulating nurse should consistently remind the surgical
A. 1, 2 and 4 only team to keep the conversation during surgical procedure:
B. 5, 2, 6 and 4 A. modulated
C. 5, 2, 3 and 4 B. tolerated
D. 1, 5, 2 and 4 C. limited
D. professional
Situation – Postoperative infection is still a concern among surgical
clients. It is essential for health care workers to adhere to standards
of care to improve quality care delivery.
ONCOLOGY
133. Nurse Abby is setting up for an emergency Caesarean Section. 141. The ABCD method offers one way to assess skin lesions for
The sterile linen packs were damp. The MOST appropriate action is possible skin cancer. What does the A stand for?
to: A. Actinic
A. allow the sterile linen packs to dry before opening B. Asymmetry
C. Arch
 D. Assessment C. viral agents like the Human Papilloma Virus
D. smoking
142. A client is diagnosed with multiple myeloma. The client asks the
nurse about the diagnosis. The nurse bases the response on which 152. Radiation therapy is used to treat colon cancer before surgery
of the following descriptions of this disorder? for which of the following reasons?
A. Malignant exacerbation in the number of leukocytes A. Reducing the size of the tumor
B. Altered RBC production B. Eliminating the malignant cells
C. Altered production of lymph nodes C. Curing the cancer
D. Malignant proliferation of plasma cells and tumors within D. Helping heal the bowel after surgery
the bone
153. PSA is used not for the detection but to know if the cancer
143. The nurse is assessing a client with multiple myeloma. The is responding to treatment or advancing. The nurse knows that
nurse should keep in mind that the clients with multiple myeloma are the abbreviation PSA stands for:
at risk for: A. Prostate specific antibody
A. Chronic liver failure B. Prostate specified antibody
B. Acute heart failure C. Prostate specific antigen
C. Pathologic bone fractures D. Prostate specified antigen
D. Hypoxemia
154. The nurse is caring for a client post mastectomy. Which action
144. The nurse is reviewing the laboratory results of a client would be contraindicated?
diagnosed with multiple myeloma. Which of the following would the A. Take BP in the side of mastectomy
nurse expect to note in this disorder? B. Elevating arm on the side of mastectomy
A. Decreased number of plasma cells in the bone marrow C. Positioning the client on the unaffected side
B. Increased WBC count D. Performing venipuncture in the unaffected side
C. Increased serum calcium levels
D. Decreased BUN level 155. When turning a client following right pneumonectomy, the nurse
should plan to place the client in either the:
145. A patient was diagnosed as having laryngeal cancer. He has A. Right or left side lying position
undergone total laryngectomy. Which of the following is the priority B. High fowler’s or supine position
nursing diagnosis for post op laryngectomy patient? C. Semi Fowlers or right side lying position
A. Impaired verbal communication D. Left side lying position or low fowler’s position
B. nxiety related to surgical outcome
C. Powerlessness 156. The client with breast cancer who is receiving chemotherapy
D. Self esteem disturbance tells the nurse that some foods on the meal tray taste bitter. The
nurse would try to limit which food that is most likely to cause this
146. In reviewing preoperative teaching for a client scheduled for taste for the client?
palliative surgery related to esophageal cancer. Which statement by A. Beef
the client indicates that teaching was effective? B. Potatoes
A. “This surgery will help the physician know the stage of my C. Custard
cancer.” D. Chicken
B. “This procedure is the only way a biopsy can be obtained.”
C. “This procedure will hopefully make it easier for me to 157. Which of the following measures helps prepare the parent and
swallow.” child for alopecia, a common adverse effect of several
D. “This surgery is my only hope for a cure.” chemotherapeutic agents?
A. Introducing the idea of a wig after hair loss occurs
147. In providing care to a client with the oncologic emergency B. Explaining that hair typically begins to grow in 6 to 9
hypercalcemia, the nurse prioritizes which action? months
A. Monitor for signs of diarrhea C. Stressing that hair loss during a second treatment with the
B. Assessing for signs of hyperactive reflexes same medication will be more severe
C. Administering normal saline intravenously D. None of the above
D. Restricting oral fluids
158. A 58-year old client is receiving chemotherapy for lung cancer.
148. Which of the symptoms is most commonly an early indication of He asks the nurse how the chemotherapeutic drugs will work. The
stage 1 Hodgkin’s disease? most accurate explanation the nurse can give is which of the
A. Pericarditis following?
B. Night sweats A. “Chemotherapy affects all rapidly dividing cells”
C. Splenomegaly B. “The molecular structure of the DNA is altered”
D. Persistent hypothermia C. “Cancer cell are susceptible to drug toxins”
D. “Chemotherapy encourages cancer cells to divide”
149. A 22-year-old male is suspected of having Hodgkin’s disease. It
is most important that a nurse perform which of the following 159. A client with cancer is receiving cisplatin (Platinol). On
assessments during the initial physical examination? assessment of the client, which of the following findings indicates that
A. Inspection of the mucous membranes the client is having an adverse reaction to the medication?
B. Percussion of the kidneys A. Tinnitus
C. Palpation of the lymph nodes B. Yellow halos
D. Auscultation of the bowel sounds C. Excessive urination
D. Increased appetite
150. A client is undergoing a diagnostic workup for suspected
testicular cancer. When obtaining the client’s history, the nurse 160. A client is receiving methotrexate (Folex) to treat osteogenic
checks for known risk factors for this type of cancer. Testicular carcinoma. During therapy, the nurse expects the client to receive
cancer has been linked to: which other drug to protect normal cells?
A. Testosterone therapy during childhood A. Probenecid (Benemid)
B. Sexually transmitted disease B. Cytarabine (Cytosar)
C. Early onset of puberty C. Thioguanine (6-TG)
D. Cryptorchidism D. Leucovorin (Wellcovorin)

151. The following are risk factors for cervical cancer EXCEPT: 161. Which of the following interventions can prevent hemorrhagic
A. immunosuppressive therapy cystitis caused by bladder irritation from chemotherapeutic
B. sex at an early age, multiple partners, exposure to socially medications?
transmitted diseases, male partners sexual habits A. Giving antacids
 B. Giving antibiotics 169. The client had undergone external radiation treatment. The
C. Restricting fluid intake most common systemic side effects of the treatment include the
D. Increasing fluid intake following except:
A. Anorexia
162. Which of the following is the drug of choice for breast cancer? B. Fatigue
A. Tamoxifen C. Malaise
B. Methotrexate D. Dry desquamation of skin
C. Leucovorin
D. Thiopental Sodium 170. In caring for a client undergoing teletherapy, it is essential that
the nurse:
163. A client with breast cancer is being treated with A. Restrict visitors 3 days after last treatment
cyclophosphamide (Cytoxan). A nurse understands that the B. Teach the client to monitor for signs of infection
medication is: C. Discard client’s urine in a special lead container
A. Cell cycle phase specific, affecting cells only during a D. Ensure that the client maintains proper positioning during
certain phase of the cell reproductive cycle therapy
B. Cell cycle phase non-specific, affecting cells in any phase
of the cell reproductive cycle
C. Cell cycle phase specific, affecting the S phase of the cell
EMERGENCY AND DISASTER
reproductive cycle
D. Cell cycle phase specific, affecting the M phase of the cell Situation – The Hospital can be hazardous to fire like any other
reproductive cycle establishments.

164. The community health nurse who is conducting a teaching 171. Which of the 3 elements present in the workplace would support
session about the risks of testicular cancer has reviewed a list of combustion most?
instructions regarding testicular self-examination. Which statement A. oxygen tank, suction machine, water cylinder
by a client indicates a need for further teaching? B. disposable drapes, gas tanks, open windows
A. “TSE is performed once a month.” C. disposable drapes, gases, people
B. ”TSE should be performed on the same day of each D. linen, vials of drugs, syringes
month”
C. “The scrotum is held in one hand and the testicle is rolled 172. A staff nurse is called to a client’s room. When the nurse arrived
between the thumb and forefinger of the other hand.” in the room, she noted that the waste basket is on fire. However the
D. “It is best to do TSE first thing in the morning before a bath client has been moved out of the room. Which of the following is the
or shower.” PRIORITY action of the nurse?
A. Confine the fire
165. The nurse puts a folded towel under the Left shoulder of B. Extinguish the fire
the Client to be examined for clinical BSE. Why is this so? C. Activate the fire alarm
A. To make the left shoulder nearer to the hands of the D. Evacuate the unit
clinician for palpation
B. To make the pectoralis muscle prominent, toning the 173. In a semi-private ward of four patients, which of the following
breast tissue for better palpation clients would you move out FIRST in case of fire?
C. To put the breast in a more lateral position to better A. A post below-knee amputation patient with referral for
ease the palpation crutches walking.
D. To balance and spread the breast tissue thus easing B. A post herniorrhaphy patient under spinal anesthesia and
palpation maintained flat on bed for two hours.
C. A post thyroidectomy patient with discharge order.
166. Mrs. Gavin, age 38, has cancer of the cervix. She is hospitalized D. A two day post radical mastectomy patient with IV infusion.
for internal radiation therapy with radium. When Mrs. Gavin returns to
her room, after the insertion of radium, the nurse should: Situation – The second floor of a building under construction
A. Immediately place her in a high Fowler’s position to prevent collapsed sand injured some construction workers. The victims were
dislodging the radium brought to the nearest hospital.
B. Check her voiding and catheterize her if necessary, since a
distended bladder can interrupt the path of radiation 174. Manny, a 45 year old sustained multiple bruises and abrasions
C. Check that a low – residue diet has been ordered to on the right side of his chest, auscultation revealed decreased breath
prevent bowel movements and the possibility of dislodging sounds on the right side. Respiratory rate is 36 per minute. Which of
the radium the following is the MOST appropriate nursing diagnosis?
D. Stay with her for half an hour to watch for symptoms of A. Airway obstruction
radiation sickness B. Impaired gas exchange
C. Ineffective breathing pattern
167. After a series of cervical Pap smear and cytological D. Ineffective airway clearance
examination, Ms. Reyes was diagnosed of having cervical cancer.
The patient had received internal radiation therapy as an adjuvant to 175. Herm, 48 years old, is diagnosed to be positive for open
the surgery. Which of the following should the nurse do in taking care pneumothorax due to a penetrating chest trauma. Which of the
of the client? following will you expect to be the IMMEDIATE treatment?
A. Do not remove skin markings A. Thoracentesis
B. Avoid wearing constrictive clothing B. Placement of chest tube
C. If the doctor prescribed, may apply Vitamin A and D C. Cardiopulmonary resuscitation
ointment D. Mechanical ventilation
D. Visitors below 18 years old should not be allowed to enter
the private room 176. The nurse is caring for client in the Emergency Department of
an acute care facility. Four clients have been admitted in the last 10
168. A client is being admitted to the hospital after receiving a radium minutes. Which of the following admissions should the nurse see
implant for cervical cancer. The nurse takes which priority action in FIRST?
the care of this client? A. A client complaining of chest pain that is unrelieved by
A. Encourages the family to visit nitroglycerin
B. Encourages the client to take frequent rest periods B. A client with third-degree burns to the face
C. Admits the client to a private room C. A client with a fractured hip
D. Places the client on reverse isolation D. A client complaining of epigastric pain

177. A nurse is assigned to all of the following patients. Which patient

should the nurse assess first?
A. The patient requesting medication for chest pain
 B. The patient who has an intravenous medication due in 30 C. Sucking the bite part to remove the venom
minutes D. Placing the area of the bite below level of the heart and
C. The patient who has a temperature of 101 degrees F keep the snake bite victim calm.
D. The patient who is scheduled to go to surgery within an
hour 187. The nurse should seek clarification of which order for a child
that has ingested a large amount of gasoline?
178. During the disaster you see a victim with a green tag, you know A. Syrup of ipecac
that the person: B. Activated charcoal
A. has injuries that are significant and require medical care C. Oxygen delivered at 2L/min
but can wait hours with threat to life or limb D. Gastric lavage
B. has injuries that is life threatening but survival is good with
minimal intervention 188. Which drug should be administered to the client who has taken
C. indicates injuries that are extensive and chances of survival an overdose of fentanyl (Sublimaze)?
are unlikely even with definitive care A. Atropine
D. has injuries that are minor and treatment can be delayed B. Flumazenil (Romazicon)
C. Naloxone (Narcan)
179. Following a bee sting, you know that the best nursing D. Physostigmine (Antilirium)
intervention is:
A. Use vinegar to remove the sting 189. A client is admitted with carbon monoxide poisoning. The
B. Use warm water to counteract the pain nurse understands that the poisonous nature of carbon monoxide
C. Scrape bite area using a blunt object results from:
D. Give antihistamine A. its tendency to block CO2 transport
B. the inhibitory effect it has on vasodilation
180. An adult has been stung by a bee and is in anaphylactic shock. C. its preferential combination with hemoglobin
Epinephrine injection was given. The nurse would expect which of D. the bubbles it tends to form in blood plasma
the following if the injection has been effective:
A. The client’s breathing will become easier 190. Intervention for a pt. who has swallowed a Muriatic Acid
B. The client’s BP will decrease includes all of the following except:
C. There will be increase in respiratory rate A. administering an irritant that will stimulate vomiting
D. There will be decrease in the client’s LOC B. aspirating secretions from the pharynx if respirations are
affected
181. A patient suffered a diving accident and is being catered by an C. neutralizing the chemical
ambulance intubated and on a backboard with cervical collar. What is D. washing the esophagus with large volumes of water via
the first action the nurse would take upon arrival of patient in the gastric lavage
hospital?
A. Take vital signs 191. Chemical burns of the eye are treated with:
B. Insert large bore IV line A. local anesthetics and antibacterial drops for 24 – 36 hrs
C. Check lungs for equal breath sounds B. hot compresses applied at 15-minute intervals
D. Perform neurologic check using GCS C. Flushing of the lids, conjunctiva and cornea with tap or
preferably sterile water
182. A client is rushed to the ER after a vehicular accident. After CT- D. cleansing the conjunctiva with a small cotton-tipped
scan, cerebral edema is confirmed. Nurse Van will most likely expect applicator
the physician to prescribe the client with:
A. Mannitol 192. The nurse walks into a client’s room and found the client lying
B. Carbamazepine still and silent on the floor. The nurse should first
C. Furosemide A. Assess the client’s airway
D. Spironolactone B. Call for help
C. Establish that the client is unresponsive
Situation – BLS is a means of providing oxygen to the brain, heart D. See if anyone saw the client fall
and other organs until help arrives. You were hired as an emergency
nurse and encountered these questions. 193. A home care nurse is planning activities for the day. Which of
the following clients should the nurse see first?
183. In medical and nursing practice, code means a call for: A. A new mother is breastfeeding her two day old infant who
A. DNR state was born five days early
B. Order B. A man discharged yesterday following treatment with IV
C. Clinical case heparin for a deep vein thrombosis
D. Cardiopulmonary resuscitation C. An elderly woman discharged from the hospital three days
ago with pneumonia
184. You respond to a call for help from the ED waiting room. There D. An elderly man who used all his diuretic medication
is an elderly patient lying on the floor. Which of the following is your showing signs of distress
initial action?
A. Perform the chin lift or jaw thrust maneuver 194. Nurse Millie is talking to a male client. The client begins choking
B. Establish unresponsiveness on his lunch. He’s coughing forcefully. The nurse should:
C. Initiate CPR A. Stand him up and perform the abdominal thrust maneuver
D. Call for help and activate code team from behind
B. Lay him down, straddle him, and perform the abdominal
185. An unresponsive and pulseless client is brought to the ER after thrust maneuver
being in a car accident, and neck injury is suspected. The nurse C. Leave him to get assistance
opens the client’s airway by which method. D. Stay with him but not intervene at this time
A. Head tilt – chin lift
B. Lift the head and place the head on two pillows and 195. An observation consistent with complete-airway obstruction is:
attempt to ventilate A. Loud crowing when attempting to speak
C. Jaw – thrust maneuver B. Inability to cough
D. Keeping the client flat and grasping the tongue C. Wheezes on auscultation
D. Gradual chest expansion
186. First aid management in a rattle snake bite is:
A. Elevate the legs above the level of the heart to increase 196. Nurse Melody is performing CPR on an adult patient. When
blood supply to the brain and preventing neurotoxicity. performing chest compressions, the nurse understands the correct
B. Agitate the snake immediately then cut the bite part and let hand placement is located over the:
the blood drain on that part. A. upper half of the sternum
 B. upper third of the sternum
C. lower half of the sternum
D. lower third of the sternum

197. When rendering aid to a client who appears to be choking, the

nurse’s first action should be to:
A. administer blow to the client’s back
B. ask the client whether he can speak
C. administer a chest thrust
D. establish an airway

198. What is the universal sign of choking?

A. Holding the neck
B. Coughing
C. Holding the neck and verbally complaining
D. Frequent swallowing

199. The mother of a child called the hospital reporting that her
daughter accidentally drank 1 bottle of aspirin. Which of the following
response by nurse is appropriate?
A. Go to the hospital immediately
B. Force her to vomit
C. Increase Fluid intake
D. Aspirin is not dangerous

200. Are you going to pass the board exam? Your response is:
A. Huhu
B. Huhuhuhuhu
C. Huhuhuhuhuhuhuhuhu
D. Yeah! Not just to pass but to TOP! 