Situation I -- Nurse Caria is assigned in the emergency unit meeting.
Weight-Height relationship indicating obesity
Varied opportunities that developed her nursing skills.
1. A 17-year old is admitted following an automobile accident He is
very anxious, dyspneic, and in severe pain. The left chest wall
moves in during inspiration and balloons out when he exhales. The
nurse understands these symptoms are most suggestive of:
a. Hemothorax
b. Flail chest
c. Atelectasis
d. Pleural effusion
2. A young man is admitted with a flail chest following a car
accident. He is intubated with an endotracheal tube and is placed
on a mechanical ventilator (control mode, positive pressure).
Which physical finding alerts the nurse to an additional problem in
respiratory function?
a. Dullness to percussion in the third to 5th intercostals space,
midclavicular line
b. Decreased paradoxical motion
c. Louder breath sounds on the right chest
d. pH of 7.36 In arterial blood gases
3. The nurse is caring for a client who has just had a chest tube
attached to a water seal drainage system (Pleur-evac). To ensure
that the system functions effectively the nurse should:
a. Observe for intermittent bubbling in the water seal chamber
b. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hours
c. Maintain the client in an extreme lateral position
d. Strip the chest tubes in the direction of the client
4. The nurse enter the room of a client who has a chest tube
attached to a water seal drainage system and notices the chest
tube is dislodge from the chest. The most appropriate nursing
intervention is to:
a. Notify the physician
b. Insert a new chest tube
c. Cover the insertion site with new petroleum gauze
d. Instruct the client to breath deeply until the help arrives
5. A 71-year old is admitted to the hospital with congestive heart
failure. She has shortness of breath and a +3 - 4 peripheral edema.
The care plan to reduce the client's edema should include nursing
strategies for:
a. Establishing limits on activity
b. Fostering a relaxed environment
c. Identifying goals for self care
d. Restricting IV fluids
Situation 2 - Oxygen is the most vital physiologic need for survival.
6. Mr. Sison, 65 years old has been smoking since he was 11 years
old. He has long history of emphysema. Mr. Sison is admitted to
the hospital because of a respiratory infection, which has not
improved with outpatient therapy. Which finding would the nurse
expect to observe during Mr. Sison's nursing assessment?
a. Electrocardiogram changes
b. Increased anterior-posterior chest diameter
c. Slow labored respiratory pattern
d.
7. Mr. Sison is ordered oxygen via nasal prongs. The nurse
administering the oxygen via the low-flow system recognizes that
this method of delivery:
a. Mixes room air with oxygen
b. Delivers a precise concentration of oxygen
c. Requires humidity during delivery
d. Is less traumatic to the respirator tract
8. Which statement by Mr. Sison indicates that client teaching
regarding oxygen therapy has been effective?
a. "I was feeling fine so I removed my nasal prongs."
b. "I've increased my fluids to six glasses of water daily."
c. "Don’t forget to come back quickly when you get me out of the
bed; I don't want to be without my oxygen for too long."
d. "My family was angry when I told them they could not smoke in
my room."
9. Supplemental low-flow oxygen therapy is prescribed for a man
with emphysema. Which is the most essential for the nurse to
initiate?
a. Anticipate the need for humidification
b. Notify the physician that this order is contraindicated
c. Place client in high Fowler's position
d. Schedule nursing care to allow frequent observations of the client
Situation 3 - Mr. Silverio, 56 years old, has had significant problem
with alcohol abuse for the past 15 years. His wife brings him to the
emergency department because he is increasingly confused and is
coughing blood. His medical diagnosis is cirrhosis of the liver. He has
ascites and esophageal varices.
10. Assessment of Mr. Silverio would reveal all of the following,
except:
a. Bulging flanks
b. Protruding umbilicus
c. Abdominal distension
d. Bluish discoloration of the umbilicus
11. Which laboratory value would the nurse expect to find in a
client as a result of liver failure?
a. Decreased serum creatinine
b. Decreased sodium
c. Increased ammonia
d. Restricted sodium
12. The major dietary treatment for ascites calls for:
a. High protein
b. Increased potassium
c. Restricted fluids
d. Restricted sodium
13. A Sengstaken-BIakemore tube is inserted in an effort to stop
the bleeding. Base on this information, the first action the nurse
should take is to:
a. Deflate the esophageal balloon
b. Encourage him to take the deep breath
c. Monitor his vital signs
d. Notify the physician
14. Because the detoxification of alcohol damages tissues a high-
calorie diet, fortified with vitamins should be encouraged to
protect Mr. Silverio's:
a. Liver
b. Kidneys
c. Adrenals
d. Pancreas
Situation 4 - Rape is one of the most tragic things that could happen
to anyone especially with young girls. Incidence such as these could
develop into a crisis situation involving not only the rape victims but
also their families.
15. This type of crisis could be an example of which of the
following?
a. Combination of developmental and situational
b. Situational
c. Emotional
d. Developmental
16. Noemi, a staff nurse in the emergency room, realizes that she
has an important role to play as a patient advocate to rape victims.
To demonstrate this role, she takes note of one of the
responsibilities?
a. Since this is a legal case, call the press about the incidence of rape
b. Perform thorough physical assessment and documenting
objectively all the evidences of rape
c. Ask the patient to stay in one isolated room first to provide
privacy while attending to other patients
d. Provide emotional support first and postponed physical
assessment when patient is already calm
17. Which of the following is a form of active, focused, emotional
environmental first aid for patients in crisis?
a. Attitude therapy
b. Psychotherapy
c. Crisis intervention
d. Re-motivation technique
18. Which of the following is true with regards to crisis?
a. Crisis is self-limiting
b. After crisis, the individual always return to a pre-crisis state or
condition
c. Crisis always result in adaptive behavior
d. The person in crisis is not susceptible for any help
19. If help is not provided in a crisis situation, an individual may
spontaneously resolve in negatively or positively by returning to
pre-crisis state, usually within which of the following duration?
a. 2-3 weeks
b. 3-4 weeks
c. 1-2 weeks
d. 4-6 weeks
Situation 6 - One Important fact that will guide the nurse in the
practice of the profession is her knowledge of the nursing law.
20. The nurse practice Act of 1991 regulates the practice of nursing
in the Philippines. Which of the following statements about this
Act is true?
a. This Act delineates the practice of nursing and midwifery
b. It was enacted in November 1991
c. The primary purpose is to protect the public
d. The Act defines the practice of nursing in the Philippines
21. When a nurse starts working In a hospital but without a written
contract, which of the following is expected of her?
a. She's not bound to perform according to the standards of nursing
practice
b. Provides nursing care within the acceptable standards of nursing
practice
c. She's not obligated to provide professional service
d. The employer does not hold the nurse responsible for her action
22. A patient, G8P5, refused to be injected with the 3rd dose of
Depoprovera. The
nurse insisted inspite of the patients refusal and forcibly injected
the contraceptive. She can be sued for which of the following?
a. Misrepresentation
b. Assault and Battery
c. Malpractice
d. Negligence
23.A patient has been in the ICU for 2 weeks. The relatives have
consented to a "Do not resuscitate order," When the patient
develops a cardiac arrest, the nurse will carry out which of the
following actions?
a. Only medication will be given
b. All ordinary measure will be stopped
c. Basic and advance life support will not be given
d. Mechanical ventilation and NGT will be stopped
24. When a patient falls from bed, which of the following is your
immediate action?
a. Report to the head nurse and calls someone to help
b. Determine any injury or harm
c. Refer to the resident on duty
d. Put back patient to bed
Situation 7 - Ms. May Mansur encountered vehicular accident on her
way to the office and he remains conscious. Police officers brought
her to the hospital.
25. You have to observe for increase intracranial pressure. Which
of the following is not a sign of increased intracranial pressure?
a. Headache
b. Vomiting
c. Vertigo
d. Changes on the level of consciousness
26. Which of the following drug may be given to reduce increase
intracranial pressure?
a. Scopalamine
b. Lanoxin
c. Coumadin
d. Mannitol a. Imaginative activity to escape reality
b. Ignoring unpleasant aspects of reality
27. Since she medicated to reduce increased intracranial pressure. c. Resisting any demands made by others
What nursing measure must be done to prevent further d. Pent-up emotion directed to other than the primary source
complication?
Situation 9 - Joan, age 34, is hospitalized because of alcoholism.
a. Encourage her to observe bed rest
b. Check blood pressure every shift 35. Joan denied that she has a problem with alcohol. The nurse
c. Observe complete best rest understands that Joan uses denial for which of the following
d. Measure intake and output reasons:

28. In what manner would you be able to assess accurately her a. To reduce her feelings of guilt
motor strength? b. To iive up to others' expectation
c. To make her seem more independent
a. Observe how he talks d. To make her look better in the eyes of others
b. Instruct her to squeeze her hands
c. Allowing him to stand alone 36. Joan appears suspicious of others and blames them for her
d. Pricking her skin with pin personal problems. The nurse understands the client is using this
behavior because which of the following difficulties?
29.Which of the following activities would cause her a risk in the
increase of intracranial pressure? a. In telling the truth
b. Meeting an ego ideal
a. Coughing c. With dependence and independence
b. Reading d. In identifying who is creating the problem
c. Turning
d. Sleeping 37. When thinking about alcohol and drug abuse, the nurse is
aware that:
Situation 8 - Basic Psychiatric concepts a nurse should be aware of...
a. Most polydrug abusers also abuse alcohol
30. Mental experiences, operate on different levels of awareness. b. Most alcoholics become polydrug abusers
The level that best portrays one's attitudes, feelings, and desire is c. Addictive individuals tend to use hostile abusive behavior
the: d. An unhappy childhood is a causative factor in many addictions

a. Conscious 38. The most important factor in rehabilitation of a client addicted

b. Unconscious to alcohol is:
c. Preconscious
d. Foreconscious a. The availability of community resources
b. The accepting attitude of the client’s family
31. The ability to tolerate frustration is an example of one of the c. The client's emotional or motivational readiness
functions of the: d. The qualitative level of the client's physical state

a. Id 39. Joan asks if attendance of Alcoholics Anonymous is required.

b. Ego Which of the following would reflect the nurse's reply?
c. Superego
d. Unconscious a. "You'll find you need their support."
b. "Do you have feelings about going to these meetings?"
32. In the process of development the individual strives to c. "No its best to wait until you feet you really need them."
maintain, protect, and enhance the integrity of the self. This d. "Yes, because you will learn how to cope with your problem."
normally accomplished through the use of:
Situation 10 - Nurse Medie has been encountering schizophrenic and
a. Affective reactions different psychotic disorders. .
b. Ritualistic behavior
c. Withdrawal patterns 40. A male client who has delusions of persecution and auditory
d. Defense mechanisms hallucination is admitted for psychiatric evaluation after stabbing a
friend. Later a nurse on the unit greets the client by saying, "Good
33. Sublimation is a defense mechanism that helps the individual: evening. How are you?" The client who has been referring to
himself as "man," answers, "The man is bad." This is example of:
a. Act out in a reverse something already one or thought
b. Return to an earlier, less mature stage of development a. Dissociation
c. Exclude fro the conscious things that are psychologically disturbing b. Transference
d. Channel an acceptable sexual desire into socially approved c. Displacement
behavior d. Reaction formation

34. An example of displacement is: 41. A disturb client starts to repeat phrase that others have just
said. This type of speech is known as: b. Allergic response
c. Pulmonary edema
a. Autism d. Hemolytic reaction
b. Echolalia
c. Neologism Situation 12 - Eric Pineda is admitted to hospital to have his urethra
d. Echopraxia dilated by the physician. A urinary retention catheter is inserted
following the procedure.
42. Projection, rationalization, denial, and distortion by
hallucinations and delusions are examples of a disturbance in: 49. A routine urinalysis is ordered for Mr. Pineda. If the specimen
cannot be sent immediately to the laboratory, the nurse should:
a. Logic
b. Association a. Take no special action
c. Reality testing b. Refrigerate the specimen
d. The thought process c. Store on dry side of utility room
d. Discard and collect a new specimen later
43. The major reasons for treating severe emotional disorders with
tranquilizers is to: 50. The nurse understands that the structure that encircles the
male urethra is the:
a. Reduce the neurotic syndrome
b. Prevent secondary complication a. Epididymis
c. Prevent destructiveness by the client b. Prostate gland
d. Make the client more amenable to psychotherapy c. Seminal vesicle
d. Bulbourethral gland
44. The nurse recognizes that dementia of the Alzheimer's type is
characterized by : 51. The nurse can best prevent the contamination from Mr.
Pineda's retention catheter by:
a. Aggressive acting out behavior
b. Periodic remissions and exacerbations a. Perineal cleansing
c. Hypoxia of selected areas of brain tissue b. Encouraging fluids
d. Areas of brain destruction called senile plaques c. Irrigating the catheter
d. Cleansing around the meatus periodically
Situation 11 - Aisa, is a 4-year old with severe anemia. She is seen by
the nurse in the clinic. 52. When Mr. Pineda, who has urinary retention catheter in place,
complaints of discomfort in the bladder and urethra the nurse
45. In addition to weakness and fatigue, which of the following should first:
problems should the nurse expect Aisa to exhibit?
a. Notify the physician
a. Cold, clammy skin b. Milk the tubing gently
b. Increased pulse rate c. Check the patency of the catheter
c. Elevated blood pressure d. Irrigate the catheter with prescribed solutions
d. Cyanosis of the nail beds
53. Mr. Pineda experiences difficulty in voiding after his indwelling
46. Which of the following problems associated with anemia best urinary catheter is removed. This is probably related to:
explains why Aisa becomes dizzy during periods of physical
activity? a. Fluid imbalance
b. Mr. Pineda's recent sedentary lifestyle
a. An inflammation of the inner ear c. An interruption in normal voiding habits
b. Insufficient cerebral oxygenation d. Nervous tension following the procedure
c. A sudden drop in blood pressure
d. Decreased level of serum glucose Situation 13 - Helen Alcantara is admitted to hospital with
complaints of hematuria, frequency, urgency, and dysuria.
47. Aisa is to receive a liquid iron preparation. Which of the
following directions would be appropriate for the nurse to teach 54. Mrs. Alcantara's signs and symptoms would most likely be
Aisa's mother? associated with:

a. Administer this at least an hour before meals a. Pyelitis

b. Explain that loose stools are common with iron b. Cystitis
c. Have Aisa take the diluted iron preparation through a straw c. Nephrosis
d. Avoid giving Aisa orange or other citric juices with the iron d. Pyelonephritis
preparation
55. Mrs. Alcantara has a higher risk of developing cystitis than does
48. Aisa is to have blood transfusion. Which of the following a male. This is
problems is most likely associated with blood transfusion? due to:

a. Serum hepatitis a. Altered urinary pH

b. Hormonal secretions c.15cm
c. Position of the bladder d.20cm
d. Proximity of the urethra and anus
63.Mr. Adriatico should follow a diet that is:
56. The family of an elderly, aphasic client complain that the nurse
failed to obtain a signed consent before insertion of indwelling a. Rich in protein
catheter to measure hourly output. This is an example of: b. Low in fiber content
c. High in carbohydrate
a. A catheter inserted for the client's benefit d. As close to normal possible
b. A treatment that does not need a separate consent form
c. Treatment without consent of the client, which is an invasion of Situation 15 - Richard Gabatan, a 32-year-old car salesman, suffered
rights a spinal cord injury in a motor vehicle accident resulting to
d. Inability to obtain consent for treatment because the client was paraplegia.
aphasic
64. A nurse finds Mr. Gabatan under the wreckage of the car. He is
57. When caring for a client with continuous bladder irrigation, the conscious, breathing satisfactorily, and lying on the back
nurse should: complaining of pain in the back and an inability to move his legs.
The nurse should first:
a. Monitor urinary specific gravity
b. Record urinary output every hour a. Leave Mr. Gabatan lying on his back with instructions to move and
c. Subtract irrigant from output to determine urine volume then go seek additional help
d. Include irrigating solution in any 24 hour urine tests order b. Gently raise Mr. Gabatan to a sitting position to see if the pain
either
58. When urinary catheter is removed, the client is unable to c. Roll Mr. Gabatan on his abdomen, place, a pad under his head,
empty the bladder. A drug is used to relieve urine retention is: and cover
him with any material available
a. Carbachol injection d. Gently lift Mr. Gavatan into a flat piece of lumber and using any
b. Neosporin GU irrigant available transportation, rush him to the nearest medical institution
c. Bethanecol (Urecholine)
d. Pilocarpine hydrochloride (Pilocar) 65. Once admitted to hospital the physician indicates that Mr.
Gubatan is a paraplegic. The family asks the nurse what that
Situation 14 - Arman Adriatico is admitted to hospital with extensive means. The nurse explains that:
carcinoma of the descending portion of the colon with metastasis to
the lymph nodes. a. Upper extremities are paralyzed
b. Lower extremities are paralyzed
59. The operative procedure that would probably be perform to c. One side of the body is paralyzed
Mr. Adriatico is a (an): d. Both lower and upper extremities are paralyzed

a. lleostomy 66. The nurse recognizes that the major early problem for Mr.
b. Colectomy Gabatan will be:
c. Colostomy
d. Cecostomy a. Bladder control
b. Client education
60. The primary step toward long-range goals in Mr. Adriatico's c. Quadriceps setting
rehabilitation involves his: d. Use of aids for ambulation

a. Mastery of techniques of ostomy care 67. The nurse should expect Mr. Gabatan to have some spasticity
b. Readiness to accept an altered body function of the lower extremities. To prevent the development of
c. Awareness of available community resources contractures, careful consideration must be given to:
d. Knowledge of the necessary dietary modifications
a. Active exercise
61. When teaching Mr. Adriatico to care for a new stoma, the nurse b. Deep massage
should advice him that irrigations be done at the same time every c. Use of tilt board
day. The time selected should: d. Proper positioning

a. Be appropriate hour before breakfast
b. Provide ample uninterrupted bathroom use at home
c. Approximate Mr. Adratico's usual daily time for elimination
d. Be about halfway between the two largest meals of the day
62. When performing the colostomy irrigation, the nurse inserts
the catheter into the stoma:
68. Rehabilitation plans for Mr. Gabatan;
a. Should be left up to Mr. Gabatan and his family
b. Should be considered and planned for early in his care
c. Are not necessary, because he will return to former activities
d. Are not necessary, because he will probably not able to work
again

a. 5cm Situation 16- Karen Boltron, age 16, is withdrawn and non
b.10cm communicative. She spends
most of her time lying on her bed.
69. Which nursing intervention would be the most appropriate way
to help Karen accept the realities of daily living?
a. Assist her to care for personal hygiene needs
b. Encourage her to keep up with school studies
c. Encourage her to join the other clients in group singing
d. Leave her alone when these appears to be a disinterest in the
activities at hand
70. Which is the best plan of nursing intervention to encourage
Karen to talk:
a. Try to get her discuss feelings
b. Focus oh non threatening subjects
c. Ask simple questions that require answers
d. Sit and look magazines with her
71. Which of the following is an important aspect of nursing
intervention when caring for Karen?
a. Help keep her oriented to reality
b. Involve her in activities throughout the day
c. Encourage her to discuss why mixing with other people is avoided
d. Help her understand that it is harmful to withdraw from situations
72. One day Karen suddenly walks up to the nurse and shouts.
"You think you're so damned perfect ad good. i think you stink,"
Which response should the nurse make?
a. "You seem angry with me."
b. "Stink? I don't understand."
c. "Boy, you're in a bad mood."
d. "I can't be all that bad, can I?"
73. On being discharged, a client with psychiatric problems should
be encouraged to:
a. Go back to regular activities
b. Call the unit whenever upset
c. Continue in an after care situation
d. Find a group that has similar problem
Situation 17 - Danny Dasigao, age 63, has an obsessive-compulsive
behavior disorder. He believes that the doorknobs are contaminated
and refuses to touch them except with the tissue.
74. Which intervention should the nurse make when dealing with
Danny's fear of doorknobs?
a. Supply rim with paper tissue to help him function until his anxiety
is reduced
b. Explain to him that this idea about doorknob is part of his illness
and is not necessary
c. Encourage him to scrub the doorknobs with a strong antiseptic so
he does not need to use tissues
d. Encourage him to touch doorknobs by removing all available
paper tissue until he learns to deal with the situation
75. Which stimulus is possibly motivating Danny to use paper
towels to open doors?
a. He is using the method to punish himself
b. He is listening to voices telling him that the doorknobs are unclean
c. He wants to unconsciously control unacceptable impulses or
feelings
d. He has a need to punish others by carrying out an annoying
procedure
76. Which action by the nurse would most likely decrease Danny's
anxiety?
a. Explore with him the nature of his anxiety
b. Stimulate him to express his ritualistic actions regularly
c. Encourage him to participate in his therapeutic plan of care
d. Provide him with an environment that is both supportive and non-
opinionated
77. Which intervention should be included in Danny's initial
treatment plan?
a. Deny his time for the ritualistic behavior
b. Give a schedule for the ritualistic behavior
c. Determine the purpose of the ritualistic behavior
d. Suggest a symptom substitution technique to refocus the behavior
78. The most appropriate way to decrease a clients anxiety is by:
a. Avoiding unpleasant objects and events
b. Prolonged exposure to fearful situation
c. Acquiring skills with which to face stressful events
d. Introducing an element of pleasure into fearful situations
Situation 18 - Jennifer Yadao, age 16, is admitted with the diagnosis
of anorexia nervosa. She has lost 10 kg in 5 weeks. She is very thin
but excessively concerned about being overweight. Her daily intake
is 10 cups of coffee.
79. Which nursing intervention should the nurse initially perform
for Jennifer?
a. Explain the value of good nutrition
b. Compliment her on her lovely figure
c. Try to establish a relationship of trust
d. Explore the reasons why she does not eat
80. Which stimulus is the most likely cause of Jennifer's disorder?
a. Allow self-esteem
b. Feelings of unworthiness
c. Anger directed at the parents
d. An unconscious fear of growing up
81 Jenifer is to be placed on behavior modification. Which is
appropriate to include in the nursing care plan?
a. Remind frequently the client to eat all the food served on the tray
b. Increase phone calls allowed the client by or a per day for each
pound gained
c. Include the family with the client in therapy sessions two times
per week
d. Weigh the client each day at 6:00 A.M. in hospital gown and
slippers after she voids
82. Another patient, Kara, 17 years old, is also diagnosed with
anorexia nervosa. You have been assigned to sit with her while she
eats her dinner. Kara says to you, "My primary nurse trusts me. I
don't see why you don't." Your best response is:
a. "I do trust you, but S was assigned to be with you."
b. "It sounds as if you are manipulating me."
c. "OK. When S return, you should have eaten everything."
d. "Who is your primary nurse."
83. Which observation of the client with anorexia indicates that the
client is improving?
a. The client eats meals in the dining room
b. The client gains one pound per week
c. The client attends group therapy sessions
d. The client has a more realistic self-control
Situation 19 - Mr. Pascua is pacing about the unit and wringing his
hands. He is breathing rapidly and complains of palpitations and
nausea and he has difficulty focusing on what the nurse is saying. •
84. Mr. Pascua is experiencing a high degree of anxiety. It is
important to recognize if additional help is required because:
a. If the client is out of control, another person will help to decrease
his anxiety level
b. Being alone with an anxious client is dangerous
c. It will take another person to direct the client into activities to
relieve anxiety
d. Hospital protocol for handling anxious clients requires at least two
people
85. He says he is having a heart attack but refuses to rest. The
nurse would be Interpret his level of anxiety as:
a. Mild
b. Moderate
c. Severe
d. Panic
86.What should the nurse include in the care plan to Mr. Pascua
when he is having
a panic attack?
a. Calm reassurance, deep breathing and modication as ordered
b. Teach Mr. Pascua problem solving in relation to his anxiety
c. Expiam the physiologic responses of anxiety
d. Explore alternate methods for dealing with the cause of his
anxiety
Situation 20 - Joel is a toddler who has classical hemophilia.
87. Which of the following statements is true regarding Joel's
disorder?
a. Hemophilia is an autosomal dominant disorder in which the
woman carries
the trait
b. Hemophilia follows regular laws of Mendelian inherited disorders
such as sickle ceil anemia
c. This disorder can be carried by either male or female but occurs in
the sex opposite that of the carrier
d. Hemophilia is an X-linked disorder in which the mother is usually
the carrier of the illness but is not affected by it
88. Joel has some internal bleeding. At which of the following sites
is the most common for the child with hemophilia to bleed?
a. Joints
b. Intestines
c. Cerebrum
d. Ends of the log bones
89. Which of the following blood products is most likely to be given
to Joel?
a. Albumin
b. Fresh frozen plasma
c. Factor VIII concentrate
d. Factor II, Vll, IX, X complex
90. Joel's parents ask if-their other children will be affected by the
disorder. Which of the following statements should guide the
nurse in her response?
a. All the girls will be normal and the other son a carrier
b. All the girls will be carriers and one half the boys will be affected
c. Each son has a chance of being affected and each daughter a 50%
chance of being a carrier
d. Each son has 50% chance of being affected or a carrier, and the
girls will be all carriers.
91. A child is to receive a blood transfusion, if an allergic reaction
to the blood occurs, the nurse's first intervention should be:
a. Call the physician
b. Slow the flow rate
c. Stop the blood immediately
d. Relieved the symptoms with an ordered antihistamines
Situation 19 - Mr. Villa who was admitted to the respiratory floor
with COPD. The nurse finds him extremely restless, incoherent, and
showing signs of acute respiratory distress. He Is using accessory
muscles for breathing and Is diaphoretic and cyanotic.
92. The best initial action by the nurse is to:
a. Administered oxygen as ordered
b. Assess vital signs and neural vital signs
c. Administered medication which has been ordered for pain
d. Call respiratory therapy for a prescribed ABG (arterial -blood gas)
analysis
93. An order is written for oxygen by nasal cannula at 2 liters per
minute. Which assessment is most useful in assessing the adequacy
of the oxygen therapy?
a. Respiratory rate
b. Color of mucus membranes
c. Pulmonary function tests
d. Arterial blood gases
94. Mr. Villa needs frequent monitoring of arterial blood gases.
Following the drawing of arterial blood gasses it is essential for the
nurse to do which of the following?
a. Encourage the client to cough an deep breath
b. Apply pressure to the puncture site for 5 minutes
c. Shake the vial of blood before transporting it to the lab
d. Keep the client on bed rest for 2 hours
95. The nurse is interpreting the results of a blood gas analysis
performed on an adult client. The value include pH of 7.35, pC02 of
60, HC03 of 35. and 02 of 60. Which interpretation is most
accurate?

a. The client is in metabolic acidosis

b. The client is in compensated metabolic alkalosis
c. The client is in respiratory alkalosis
d. The client is in compensated respiratory acidosis

Situation 20 - The nurse is assigned in a counseling clinic about

preventive measures for cancers.

96. Cancer is the second major cause of death in this country. What
is the first step toward effective cancer control?

a. Increasing governmental control of potential carcinogens

b. Changing habits and customs that predispose the individual to
cancer
c. Conducting more mass screening programs
d. Educating public and professional people about cancer

97. In order to educate clients, the nurse should understand that

the most common site of cancer for a female is the:

a. Uterine cervix
b. Uterine body
c. Vagina
d. Fallopian tube

98.A client has just completed a course in radiation therapy and is

experiencing radio-dermatitis. The most effective method of
treating the skin is to:

a. Wash the area with soap and warm water

b. Apply a cream or lotion to the area
c. Leave the skin alone until it is clear
d. Avoid applying creams or lotion to the area

99.A client with cancer that has metastazised to the liver is started
on chemotherapy- His physician has specified divided doses of the
antimetabolite. The client asks why he could take the drug in
divided doses. The appropriate response is:

a. " There really is no reason your doctor just wrote the orders that
way."
b. "This schedule will reduce the side effect of the drug."
c. "Divided doses produce greater cytotoxic effects on the diseased
cells."
d. "Because these drugs prevent cell division, they are more effective
in divided doses,"

100. A client has possible malignancy of the colon, and surgery is

scheduled. The rationale for administering Neomycin
preoperatively is to:

a. Prevent infection postoperatively

b. Eliminate the need for preoperative enemas
c. Decreased and retard the growth of normal bacteria in the
intestines
d. Treat cancer of the colon