MEDICAL SURGICAL

NURSING
By: Mr. Emerson Aliswag

1. A client is receiving NPH

insulin 20 units subQ at 7am
daily. At 3pm the nurse finds
the client apparently asleep.
How would the nurse know if
the client were having a
hypoglycemic reaction?

a.Feel the client and bed

for dampness
b.Observe client for
Kussmaul respirations
c. Smell the clients breath
for acetone odor
d. Check the clients pupils
for dilatation

2. Postoperative
thyroidectomy nursing
care includes which
measures?

a.Have the client speak every

5 to 10 minutes if
hoarseness is present
b.Provide a low-calcium diet
to prevent hypercalcemia
c.Check the dressing at the
back of the neck for
bleeding
d. Apply a soft cervical collar
to restrict neck movement

3. What would the nurse

note a typical findings on the
assessment of a client with
acute pancreatitis?

a.Steatorrhea, abdominal
pain, fever
b.Fever, hypoglycemia,
dehydration
c.Melena, persistent vomiting,
hyperactive bowel sounds
d. Hypoactive bowel sounds,
decreased amylase and lipase
level

4. A client is found to be
comatose and hypoglycemic
with a blood sugar level of
50mg/dl. What nursing
action is implemented first?

a.Infuse 1000ml of D5W over a

12-hour period
b.Administer 50% glucose IV
c.Check the clients urine for the
presence of sugar and acetone
d. Encourage the client to drink
orange juice with added sugar

5. Which medication will the

nurse have available for
emergency treatment of
tetany in the client who has
had thyroidectomy?

a.Calcium chloride
b.Potassium chloride
c.Magnesium sulphate
d.Sodium bicarbonate

When instructing a client

in the proper administration
of sublingual nitroglycerin
(NTG), the nurse would
include in the teaching plan
that the client should
6.

a. Store NTG tablets in the refrigerator.

b. Repeat the dosage every 5 minutes for
three times if pain is not relieved.
c. Assess blood pressure for reactive
hypertension after each dose.
d.
Take an aspirin before each dose of
NTG.

7. The nurse would

explain that angina pain
usually differs from the
pain of a myocardial
infarction (MI) in that
angina pain

a. Lasts less than 15

minutes.
b. Radiates to the arm, jaw,
or throat.
c. Is seldom relieved by rest.
d. Is accompanied by
palpitations.

8. A nurse is telephoned by a
neighbor who describes nonradiating substernal chest pain
that was precipitated by climbing
three flights of stairs. The neighbor
has taken one sublingual (SL)
nitroglycerin tablet and asks what
he should do since the pain is
unrelieved. The nurses best
response would be

a. Take another nitroglycerin

tablet in 5 minutes and lie
down.
b. Drive to the emergency
department at once.
c. Call 911.
d. Im not qualified to advise
you about this. Let me call your
doctor.

9. Before administering
digoxin (Lanoxin), what is
the most important action
for the nurse to take?

a. Provide foods high in

+
potassium (K ).
b. Take the client's blood
pressure.
c. Take an apical pulse.
d. Weigh the client daily.

10. The client is

complaining of a
headache after
administration of
nitroglycerine. What
should the nurse instruct
the client to do?

a. Decrease the nitroglycerine

dose.
b. Do not take the next
scheduled dose of
nitroglycerine.
c. Lie down in a cool
environment and rest.
d. Tell a healthcare worker
immediately.

11. What is the

primary action of
insulin in the body?

a. Enhances the transport of

glucose across the cell walls
b. Aids in the process of
gluconeogenesis
c. Stimulates the pancreatic beta
cells
d. Decreases the intestinal
absorption of glucose

12. What will the nurse

teach the diabetic client
regarding exercise in his
or her treatment
program?

a.During exercise the body will use

carbohydrates for energy production, which
in turn will decrease the need for insulin
b. With an increase in activity, the body will
utilize more carbohydrates; therefore more
insulin will be required
c. The increase in activity results in an
increase in the utilization of insulin; therefore
the client should decrease his or her
carbohydrates intake
d. Exercise will improve pancreatic circulation
and stimulate the islets of Langerhans to
increase the production of intrinsic insulin

13. The nurse is caring for a

client who has exophthalmos
associated with her thyroid
disease. What is the cause of
exophthalmos?

23.
An
optimal
supportive
environment for a person with
dementia includes all, except:
a. Simple nurse care for the patient
day after day
b.
Handling
memory
loss
by
distracting or diverting patients
attention to something more positive
c. Developing a realistic uniformed
and consistent daily schedule
d. Engaging the elderly in logical and
abstract thinking

communication
with
the
elderly, which of the following
ways of verbal communication
should
the
nurse
use
minimally?
a. Asking for open ended
questions
b. Guiding the patient one step
at a time
c. Asking simple questions

a. Fluid and edema in the retroorbital tissues, which force the yes
to protrude
b. Impaired vision, which causes the
client to squint in order to see
c. Increased eye lubrication, which
makes the client blink less
d. Decrease in extraocular eye
movements, which results in the
thyroid stare

14. What is a characteristic

symptom of hypoglycemia
that should alert the nurse
to an early insulin reaction?

a.Diaphoresis
b.Drowsiness
c. Severe thirst
d.Coma

15. A client is scheduled

for routine glycosylated
hemoglobin (HbA1c) test.
What is important for the
nurse to tell the client
before this test?

a. Drink only water after midnight

and come to the clinic early in the
morning
b. Eat a normal breakfast and be at
the clinic 2 hours later
c. Expect to be at the clinic for
several hours because of the
multiple blood draws
d. Come to the clinic at the earliest
convenience to have blood drawn

complaining of chest pain.

He categorizes his chest
pain as a 6 (on a 1 to 10
scale). His BP is 108/72. The
nurse gives the client NTG
1/150 sublingual. After 5
minutes, the client states
that his chest pain is now a
2. What should the nurse do

a.Administer another NTG.

b. Check the blood pressure.
c. Check the pulse rate.
d. Obtain an EKG.

17. When caring for a

client immediately after
an MI, the nurses first
priority would be

a. Relief of pain.
b. Monitoring for presence of
dysrhythmias.
c. Prevention of embolism.
d. Relieving clients
apprehension.

18. When the immediate

post-MI client complains
about the soft, high-fiber
diet, the nurse would
inform the client that the
pupose of such a diet is
to

a. Maintain bowel health to

decrease gas.
b. Create a high-bulk, soft stool
to minimize Valsalvas
maneuver.
c. Lower cholesterol levels.
d. Promote easy digestion.

19. a 40-year-old client

who wants to be more
active the first 24 hours
after an MI, the nurse
could safely suggest that
the client

a. Use the bedside commode

for bowel movements.
b. Take a bath in the shower.
c. Ambulate in the hall.
d. Perform gentle isometric
exercises.

20. In the discharge

teaching plan for a
client after MI, the
nurse would include
that the client should

a. Resume sexual
intercourse in 3 months.
b. Begin walking for short
periods every day.
c. Take 1 aspirin every 8
hours as ordered.
d. Continue previous
lifestyle when ready

21. Promotion of
team spirit builds
harmony and unity
within the
organization

a.
b.
c.
d.

Scalar chain
Unity of direction
Esprit d Corp
Discipline

22. The Head Nurse

implements her supervisory
plan accordingly from
institutional needs. As Fayol
identified the management
functions:

a.Planning, organization,
consistent, control, conduct
b.Personal role, organizing,
control, command, centralized
c.Planning, organization,
command, coordinate, control
d. Plan, organizing, centralized,
command, control

23. The Nursing Director

emphasizes a theory that
assumes that the capacity
for leadership is inherent,
that great leaders are born,
not made

a.Great man theory

b. Trait theory
c. Individual character
theory
d.Field theory of human
behavior

24. Change process is

developed to help the
organization cope and innovate
new approaches. Which of the
following stages best explains
that if nurse is made aware of
problems, performance gap or
need for change?

a. Unfreezing
b. Changing
c. Refreezing
d. Unchanging

primary responsibility to ensure a

safe environment for the patients
at the Psychiatry ward.
47. All of the following concepts are
true EXCEPT:
a. hostility is destructive
b. frustration develops in response to
unmet needs, wants and desire
c. anger is always incompatible with
love
d. aggression can be expressed in a
constructive as well as a destructive

aggressive feeling by kicking the

chairs in the room. The MOST
effective way to deal with Carlos
behavior is initially to:
a. set limits on the behavior by
verbal command
b. administer prn tranquilizer
c. remove the chairs from the
room
d. restrain the patient and place
him in the Isolation Room

25. Systems approach

conceptualize by Likert gave
special attention to
leadership-management
styles that uses threats and
fear which superiors and
subordinates are distant

a.Benevolentauthoritative
b.Exploitiveauthoritative
c.Consultative
d. Participative group
management

26. A client has been

receiving
inhalation
vasopressin therapy. What
will the nurse evaluate to
determine the therapeutic
response to this medication?

a.Urine specific gravity

b. Blood glucose
c. Vital signs
d. Oxygen saturation
levels

27. A client with a diagnosis of

type 2 diabetes has been
ordered a course of prednisone
for her severe arthritic pain. An
expected change that requires
close monitoring by the nurse
is

a. Increased blood glucose

level
b. Increased platelet
aggregation
c. Increased creatinine
clearance
d. Increased ketone level in
urine

28. The nurse is

performing an
assessment on a client
who has been receiving
long-term steroid therapy
would expect to find

a. Jaundice
b. Flank pain
c. Bulging eyes
d. Central obesity

29. A diabetic patient

receives a combination of
regular and NPH insulin at
0700 hours. The nurse
teaches the client to be alert
for signs of hypoglycemia at

a. 1200 and 1300 hours

b. 1100 and 1700 hours
c. 1000 and 2200 hours
d. 0800 and 1100 hours

30. It is important for

the nurse to teach the
client that metformin
(Glucophage)

a. May cause nocturia

b. Should be taken at
night
c. Should be taken with
meals
d. May increase the
effects of aspirin

31. A clients record contains a

notation that the client is
orthopneic. The most beneficial
nursing intervention to address
this problem would be
a. limit fluids.
b. encourage ambulation.
c. provide several pillows.
d. offer extra blankets.

client would detect the early

manifestations of heart failure
by
a. obtaining daily weights.
b. monitoring cardiac
enzymes.
c. checking vital signs
frequently.
d. evaluating the
electrocardiogram (ECG).

33. The nurse would explain

to a client that the
isoenzyme specific for
damage to the myocardial
muscle is
a. CK-MM.
b. CK-MB.
c. CK-BB.
d. LDH-5.

34. Nursing care of a client after a

percutaneous transluminal
coronary angioplasty (PTCA)
generally would include
a. administration of heparin.
b. maintaining the client flat in
bed for 24 hours.
c.forcing fluids.
d. assessing for clinical
manifestations of shock

35. When a client is admitted

to the hospital with clinical
manifestations of left
ventricular heart failure, the
nurse would question the client
about
a. leg swelling.
b. breathlessness.
c. abdominal pain.
d. nausea

36. A nurse assessing a client with

SIADH would expect to find laboratory
values of
a. Serum Na= 150mEq/L and low
urine osmolality
b. Serum K = 5mEq/L and low serum
osmolality
c. Serum Na = 120 mEq/L and low
serum osmolality
d. Serum K = 3 mEq/L and high
serum osmolality

37. A priority nursing diagnosis for a

client admitted to the hospital with a
diagnosis of diabetes insipidus is
a. Sleep pattern deprivation related
to nocturia
b. Activity intolerance related to
muscle weakness
c. Fluid volume excess related to
intake greater than output
d. Risk for impaired skin integrity
related to generalized edema

38. A client is admitted with

pheochromocytoma returns from
the operating room after
adrenalectomy. The nurse should
carefully assess this client for
a. Hypokalemia
b. Hyperglycemia
c. Marked sodium and water
retention
d. Marked fluctuations in blood
pressure

39. What caring for a client

in a thyroid crisis, the nurse
would question on order for
a. IV fluids
b. Propranolol (inderal)
c. Propylthiouracil
d. A hyperthermia blanket

40. A client is prescribed levothyroxine

(Synthroid) daily. The most important
instruction to give the client for
administration of this drug is
a. Taper dose and discontinue if mental
and emotional statuses stabilizes
b. Take it at bedtime to avoid the side
effects of nausea and flatus
c. Call the doctor immediately at the
onset of palpitations or nervousness
d. Decrease intake of juices and fruits
with high potassium and calcium
contents

41. When auscultating the

respirations of a client in left
ventricular heart failure, the
nurse would most likely
detect
a. wheezing.
b. Loud expiratory sounds.
c. Loud inspiratory sounds.
d. crackling sounds.

42. When a female client

tells the nurse, I always get
pains in my legs when
walking, the nurse would
question her about
a. number of pregnancies.
b. presence of swelling.
c. history of hypertension.
d. amount of activity

43. For a client admitted to

the hospital with chronic
venous disease, the nurses
assessment of the clients
legs would most likely reveal
a. erythema.
b. reduced muscle mass.
c. overgrowth of hair.
d. decreased pulses

complaints of pain after walking

five blocks is experiencing
intermittent claudication, the
nurse would ask
a. Is the pain in the calf
muscle?
b. Does pain always occur when
you walk that distance?
c.Do you experience leg
swelling?
d. Is the pain cramp-like?

45. For a female client with severe

arterial disease having difficulty
falling asleep due to pain in her
legs, the nurse first would
a. elevate the clients legs 30
degrees.
b. assist the client to dangle her
legs.
c.call the physician for an
analgesic order.
d. call the physician for a

46. Managerial Grid Model

that conceptualizes leaders
has low concern for both
people and production.
a. Impoverished style
b. Country club style
c. Produce or perish style
d. Team style

47. William G. Ouchi expounded

seven basic criteria that are
characterized in Theory Z. Which
of the following S refers to
coherence of all parts of the
organization for a common goal?
a. Systems
b. Structure
c. Strategy
d. Superordinate goals

48. Top management

implements practices that
encourages long-term
commitment of employees,
particularly of managers in the
institution
a. Discipline
b. Stability and tenure of
personnel
c. Equity

49. Martha wants to do study

on this topic: Effects of
massage and meditation on
stress and pain. The type of
research that best suits this
topic is:
a. Basic research
b. Applied research
c. Quantitative research
d. Qualitative research

50. Clients rights should be

protected when doing research
using human subjects. Martha
identifies these rights as
follows EXCEPT:
a. Right of self-determination
b. Right to compensation
c. Right not to be harmed
d. Right of privacy

cystic fibrosis ask what determines

the prognosis of the disease. The
nurse knows that the greatest
determinant of the prognosis is:
A.The ability to maintain an ideal
weight
B.The secretion of lipase by the
pancreas
C.The regulation of sodium and
chloride excretion
D.The degree of pulmonary

52. The mother of a 9-year-old with asthma

has brought an electric CD player for her
son to listen to while he is receiving oxygen
therapy. The nurse should:
A.Explain that he does not need the added
stimulation
B. Ask the mother to bring a batteryoperated CD instead
C.Allow the player, but ask him to wear
earphones
D.Tell the mother that he cannot have
items from home

53. The mother of a child with

cystic fibrosis tells the nurse that
her child makes snoring sounds
when breathing. The nurse is
aware that many children with
cystic fibrosis have:
A.Choanal atresia
B. Enlarged adenoids
C.Nasal polyps
D.Septal deviations

54. The child with a history of

respiratory infections has an
order for a sweat test to be
done. Which finding would be
positive for cystic fibrosis?
A. A serum sodium of
135meq/L
B. A potassium of 4.5meq/L
C. A calcium of 8mg/dL
D. A sweat analysis of 69

55. The nurse is caring for a 9year-old child admitted with

asthma. Upon the morning rounds,
the nurse finds an O2 sat of 78%.
Which of the following actions
should the nurse take first?
A. Notify the physician
B. Apply oxygen
C. Do nothing; this is normal O2
sat for a 9 year old
D. Assess the childs pulse

56. The client who would be at highest

risk for chronic venous disease is
a.an 85-year-old underweight client
who is a retired schoolteacher.
b.a 75-year-old client who has had
paraplegia for 25 years.
c. a 62-year-old overweight client who
stands on an assembly line 8 hours a
day.
d.a 54-year-old client with colon
cancer who works 8 hours daily as a
typist

57. To a client scheduled for

angiography, the nurse would state
that
a.The general hospital consent you
signed will permit this procedure.
b.The procedure will take place in the
operating room.
c. A local anesthetic will be used to
numb the area before catheter
insertion.
d.You can eat and drink until the time
you leave the unit for the procedure.

58. As part of routine care for a client who

just underwent angiography using the right
femoral artery as the catheter insertion
site, the nurse would
a. maintain bed rest for 6 to 8 hours with
the leg straight.
b. limit fluid intake for the next 8 hours.
c. measure vital signs and peripheral pulses
every 4 hours.
d. explain that the client can eat within 6
hours.

59. The nurse would explain to a

client that anticoagulant therapy is
used in the treatment of
thromboembolic disease because
anticoagulants can
a. dissolve the thrombi.
b. inhibit the synthesis of clotting
factors.
c.prevent absorption of vitamin K.
d. decrease blood viscosity.

60. For a client with deep vein

thrombosis (DVT), the nurse would
include in the plan of nursing care
the intervention of
a. raising the foot of the bed 6
inches.
b. maintaining the legs in the
dependent position.
c.restricting fluids.
d. applying cool compresses to
the area.

61. The most appropriate means of

rehydration of a 7-month-old with
diarrhea and mild dehydration is:
A.Administering intravenous Dextrose
5% normal saline
B.Replacing milk-based formula with a
lactose-free formula
C.Oral rehydration therapy with an
electrolyte solution
D.Offering bananas, rice, and
applesauce along with oral fluids

62. The nurse is caring for an infant

receiving intravenous fluid. Signs of
fluid overload in an infant include:
A.Increased heart rate and increased
blood pressure
B.Swelling of the hands and increased
temperature
C.Swelling of the feet and increased
temperature
D.Decreased heart rate and decreased
blood pressure

63. A priority nursing diagnosis

for a child being admitted from
surgery following a
tonsillectomy is:
a. Body image disturbance
b. Impaired verbal
communication
c. Pain
d. Risk for aspiration

64. The physician has

ordered cortisporin ear drops
for a 2-year-old. To
administer the ear drops, the
nurse should:
A.Pull the ear straight out
B.Pull the ear down and back
C.Pull the ear up and back
D.Leave the ear undisturbed

65. Which information obtained

from the mother of a child with
cerebral palsy correlates to the
diagnosis?
a. She was born at 40 weeks
gestation.
b. She has frequent sore throats.
c. She had physiologic jaundice
after delivery.
d. She had meningitis when she
was 6 months old.

66. After a posterior nasal pack is inserted

by the physician, the client is very anxious
and states, I dont feel like Im breathing
right. The immediate intervention the
nurse would initiate is
a. monitor arterial blood gases (ABGs).
b. direct a flashlight into the clients mouth
and inspect the oral cavity.
c. cut the pack strings and pull the packing
out with a hemostat.
d. reassure the client that this is normal
discomfort.

67. On entering the emergency

department (ED), a client is short of
breath and appears frightened. The
nurse beginning the assessment of the
client would be aware that an early
clinical manifestation often associated
with asthma is
a.cyanosis.
b.hypercapnia.
c. anxiety.
d.bradycardia.

68. A client receives a beta-adrenergic

bronchodilator and supplemental oxygen
when entering the ED for treatment of
asthma, but the clients condition remains
unchanged. The nurse would anticipate
that the client
a. will be coached immediately in
biofeedback techniques.
b. will increase the amount of oral fluids
taken.
c. will undergo stat pulmonary function
tests.
d. will receive intravenous (IV) steroids

43. For a client admitted to

the hospital with chronic
venous disease, the nurses
assessment of the clients
legs would most likely reveal
a. erythema.
b. reduced muscle mass.
c. overgrowth of hair.
d. decreased pulses

69. The nurse caring for a

client with asthma would
place the client in the
a. supine position.
b. side-lying position.
c. Fowlers position.
d. lithotomy position

70. The nurse is caring for a young

woman with a pulmonary emboli who
is receiving heparin and must have an
arterial blood gas (ABG) sample
drawn. The nurse would arrange to
remain in the room to be available to
hold pressure on the puncture site for
at least
a.1 minute.
b.2 minutes.
c. 5 minutes.
d.minutes 10 MINUTES

SITUATION: A nursing professor assigns a

group of students to do data gathering by
interviewing their classmates as the
subjects.
71. She instructed the interviewers not to
tell the interviewees that the data gathered
are for her own research project for
publication. This teacher has violated the
students right to:
a. Disclosure
b. Not to be harmed
c. Privacy
d. Self-determination

many clients are being readmitted in

the ward for post-operative
infections. She suggests to the
students that they do a research on
this topic. What research activity is
this?
a. Sharing research results with
colleagues
b. Data collection
c. Developing guidelines for patient
care
d. Identifying clinical problem

73. Quantitative research involves

numerical data. Which of the following is
based on quantitative research?
a. The effects of regular nurse visits to
clients bedside on the number of clients
calls to the nurse
b. A study on the effects of the white
uniform of hospital personnel on pediatric
patients
c. A study on benefits of pre-operative
health instructions to clients feeling of
anxiety
d. A study on the effects of touch on the
clients feelings of isolation

74. Before the nurse researcher

starts her study, she analyzes how
much time, money, materials and
people she will need to complete
the research project. This analysis
prior to beginning the study is
called:
a. Validity
b. Researchability
c. Feasibility
d. Reliability

75. Data analysis is to be done

and the nurse researcher wants to
include measures of variability.
These include the following
EXCEPT:
a. Range
b. Variance
c. Mean
d. Standards of Deviation

76. The nurse is caring for a client with

cerebral palsy. The nurse should
provide frequent rest periods because:
A. Stretch reflexes are increased with
rest.
B. Hypoactive deep tendon reflexes
become more active with rest.
C. Grimacing and writhing movements
decrease with relaxation and rest.
D. Fine motor movements are
improved by rest.

77. A 6-year-old with cerebral

palsy functions at the level of an
18-month-old. Which finding would
support that assessment?
a. She pulls a toy behind her.
b. She dresses herself.
c. She can build a tower of eight
blocks.
d. She can copy a horizontal or
vertical line.

78. The nurse caring for the child

with a large meningomylocele is
aware that the priority care for this
client is to:
A. Feed the infant slowly
B. Place the infant in a supine
position
C.Cover the defect with a moist,
sterile saline gauze
D. Measure the intake and output

79. A client has been receiving

cyanocobalamine (B12) injections
for the past six weeks. Which
laboratory finding indicates that
the medication is having the
desired effect?
A. Neutrophil count of 60%
B. Reticulocyte count of 1%
C. Monocyte count of 2%
D. Basophil count of 0.5%

80. The client has an order for

FeSO4 liquid. Which method of
administration would be best?
a. Administer the medication with
orange juice
b. Administer the medication with
a meal
c. Administer the medication with
milk
d. Administer the medication
undiluted

81. A patient with asthma is

producing thick, white secretions.
Which of the following nursing
measures would be most
appropriate for the nurse to
include in her plan of care?
a. Increase fluid intake
b. Promote exercise
c. Administer oxygen
d. Encourage coughing

82. A patient with asthma is

producing thick, white secretions.
Which of the following nursing
measures would be most
appropriate for the nurse to
include in her plan of care?
a. Increase fluid intake
b. Promote exercise
c. Administer oxygen
d. Encourage coughing

83. A one-month old infant in

respiratory distress is brought to
the emergency department. The
nurse should observe the infant for
which of the following signs?
a. Clubbing of fingers and toes
b. Jugular venous distension
c. Nasal flaring and chest
retractions
d. Cool, clammy moist skin

84. When assessing the patient,

the nurse notes pallor and
mottling of the skin, dyspnea with
periods of apnea and a decline in
blood pressure. These
manifestation are indicative of
a. Imminent death
b. A transient ischemic attack
c. Seizure onset
d. A cerebrovascular accident

85. Thirty minutes after the nurse removes a

nasogastric tube that has been in place for seven
days, the patient experiences epistaxis
(nosebleed). Which of the following nursing
actions is most appropriate to control the
bleeding?
a. Apply pressure by pinching the anterior portion
of the nose for five to ten minutes
b. Place the patient in a sitting position with the
neck hyperextended
c. Pack the nostrils with gauze and keep the
gauze in place for four to five days
d. Apply ice compresses to the patients forehead
and back of the neck

86. Vitamin K is
administered to the newborn
shortly after birth for which
of the following reasons?
a. To facilitate clotting
b. To treat infection
c. To replace electrolytes
d. To stop hemorrhage

87. A client with acute leukemia is

admitted to the oncology unit. Which
of the following would be most
important for the nurse to inquire?
a. "Have you noticed a change in
sleeping habits recently?"
b. "Have you lost weight recently?
c. "Have you had a respiratory
infection in the last 6 months?
d. "Have you noticed changes in your
alertness?"

88. Which of the following would be

the priority nursing diagnosis for the
adult client with acute leukemia?
a. Oral mucous membrane, altered
related to chemotherapy
b. Fatigue related to disease process
c. Risk for injury related to
thrombocytopenia
d. Interrupted family processes related
to life-threatening illness of a family
member

89. The mother of a 6-year-old with

autistic disorder tells the nurse that
her son has been much more difficult
to care for since the birth of his sister.
The best explanation for changes in
the childs behavior is:
A.The childs daily routine has been
upset by the birth of his sister
B.The child was not adequately
prepared for the babys arrival.
C.The child did not want a sibling
D.The child is just trying to get the

90. Children with autistic disorder engage in

ritualistic behaviors and are easily upset by
changes in daily routine. Changes in the
environment are usually met with behaviors
that are difficult to control. Answers B, C, and
D are incorrect because they do not focus on
autistic disorder.
A.Red papular rash, desquamation, white
strawberry tongue
B.Epicanthal folds, low-seat ears, protruding
tongue
C.Red edematous cheeks, maculopapular rash
on the trunk and extremities
D.Rhinitis, maculopapular rash,
hepatosplenomegaly

91. A patient has returned to

the unit following a
bronchoscopy. It is most
important that the nurse
monitor the patient for
a. Bladder distention
b. Return of gag reflex
c. Oral fluid intake
d. Ability to speak

92. To which of the following

nursing diagnoses would a nurse
give priority for a patient who has
an elevated serum carbon dioxide
(CO2) level following surgery?
a. Urinary retention
b. Impaired skin integrity
c. Ineffective airway clearance
d. Impaired physical mobility

93. A patient whose

ventilation is inadequate
should be observed for early
symptoms of hypoxia, which
include
a. Pallor
b. Restlessness
c. Mottling of extremities
d. Disorientation

cerebral palsy, a tracheostomy, and is

oxygen (O2) dependent. During an
initial visit to the home, the nurse
would include which of the following
questions in an environmental safety
assessment?
a. Are there drafts or air leaks in the
home?
b. Are there other children in the
home?
c. Does anyone smoke in the home?
d. Are there pets in the home?

95. Which observation in the

newborn of a diabetic
mother would require
immediate nursing
intervention?
a. Jitterness
b. Wakefulness
c. Crying
d. Yawning

SITUATION: You are actively practicing

nurse who just finished your Graduate
Studies. You learned the value of Research
and would like to utilize the knowledge and
skills gained in the application of research
to Nursing Service. The following questions
apply to research.
96. Which type of research inquiry
investigates the issue of human complexity
(e.g. understanding the human expertise)?
a. Ex post facto
b. Naturalistic inquiry
c. Quantitative research

97. Which of the following studies is

based on quantitative research?
a. A study examining the bereavement
process in spouses of clients with
terminal cancer.
b. A study examining clients feelings
before, during and after a bone
marrow aspiration.
c. A study exploring factors influencing
weight control behavior.
d. A study measuring the effects of
sleep deprivation on wound healing

98. Which of the following studies is

based on qualitative research?
a. A study measuring differences in
blood pressure before, during and
after a procedure
b. A study examining clients reactions
to stress after open heart surgery.
c. A study measuring nutrition and
weight loss/gain in clients with cancer.
d. A study examining oxygen levels
after endotracheal suctioning.

99. An 85 year old client in a nursing

home tells a nurse, I signed the
papers for that research study
because the doctor was so insistent
and I want him to continue taking care
of me. Which client right is being
violated?
a. Right of self determination
b. Right to equality
c. Right to privacy and confidentiality
d. Right not to be harmed.

100. A supposition or
system of ideas that is
proposed to explain a given
phenomenon, best defines:
a. A concept
b. A conceptual framework
c. A theory
d. A paradigm

THANK YOU