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INSTRUCTIONS: Select the correct answer for each of the following questions. Mark only one answer for each item by making the
box corresponding to the letter of your choice on the answer sheet provided.
Situation: Mrs. de Vera, an 89-year-old widow, is admitted to a hospital because of Dehydration brought about by 2-day-history of
LBM and occasional vomiting. She needs to be in bed because of her generalized weakness and occasional confusion and
disorientation.
1.
From the knowledge of temperature regulation in the elderly, the nurse should:
A. make sure that the environmental temperature is adequately controlled
B. palpate the clients skin periodically to assess for warmth
C. place extra blanket at bedside in case she becomes cold especially at night
D. do all of the above
2.
3.
The nurse initiates a 2-hourly-turning schedule based on the knowledge that the underlying cause of bedsore formation is:
A. altered skin turgor
B. nutritional deficiency
C. pressure
D. vasoconstriction
4.
On diaper change, the nurse noted blister formation on an erythematous background of the sacral area; this is stage
____________of bedsore formation:
A. ONE
B. TWO
C. THREE
D. FOUR
Situation: Mr. Castro, a 67-year-old retired carpenter is admitted to the hospital because of anorexia and afternoon fever.
5.
Mr. Castros PPD tuberculin test yields an induration of 10mm that indicates that:
A. an active disease is present
B. he has been exposed to M. tuberculosis
C. preventive treatment should be initiated
D. reaction is doubtful, a repeat test is necessary
6.
7.
Mr. Castro is started on quadruple drug regimen. Nursing management includes observing for ototoxicity and nephrotoxicity
when _____is used:
A. ETHAMBUTOL
B. ISONIAZID
C. RIFAMPICIN
D. STREPTOMYCIN
8.
Situation: Miko, a 19-year-old student nurse, is admitted to the hospital with a possible diagnosis of appendicitis. He has been
vomiting every after meal.
9.
On assessment, the nurse is looking for positive indicators of appendicitis, which includes all of the following except:
A. a low grade fever
B. abdominal tenderness on palpation
C. leukocytosis
D. thrombocytopenia
C. ileum
D. Jejunum
11. Rebound tenderness is elicited by:
A. palpating the left hypogastrium resulting in right hypogastric tenderness
B. hip flexion or internal rotation of the hip joint
C. pain relief on palpation and pain on release of pressure
D. none of the above is the answer
12. To ensure a patent airway following a tonsillectomy, it is important for the nurse to:
A. Place the client in semi-fowlers position
B. Begin nasal oxygen at 4 L/min.
C. Maintain strict bed rest
D. Keep the head of the bed flat
13. To monitor the nutritional status of a total laryngectomy client, the nurse should include which of these actions in the plan of care:
A. Monitor WBC count
B. Observe activity tolerance
C. Assess daily weight
D. Monitor bleeding levels
14. The type of breathing pattern commonly seen in children described as hyperpnea with periods of apnea?
A. Biots
B. Apneustic breathing
C. Cheyne-Stoke
D. Normovesicular
15. The priority nursing diagnosis for a client with a nasal fracture is:
A. Body-Image disturbance
B. Pain
C. Ineffective airway clearance
D. Impaired tissue integrity
16. Which of these risk factors is associated with the development of laryngeal cancer?
A. Tonsillitis
B. Obesity
C. Smoking
D. Fatty diet
17. All of the following are true in ABG extraction, EXCEPT?
A. Heparinize the syringe
B. Put pressure dressing on the punctured site
C. Aspirate the syringe when collecting blood from the artery
D. Use to evaluate gas exchange in the lungs
18. Oxygen is carried by which of these tissues of the body?
A. platelets
B. WBCs
C. lymphocytes
D. hemoglobin
19. Which measure should the nurse use to help liquefy and facilitate expectoration of chest secretions in the client with pneumonia?
A. Administer frequent oral feedings
B. Encourage a fluid intake of at least 2-3 liters a day
C. Place the client in supine position
D. Administer oxygen as ordered
20. In providing discharge instructions for a client with a new diagnosis of tuberculosis, the nurse should give the highest priority to
which nursing diagnosis?
A. Knowledge deficit
B. Activity intolerance
C. Altered nutrition
D. Anxiety
21. In preparing a client for a thoracentesis, the nurse should include which of these measures?
A. Withhold food and liquids.
B. client leaning forward with head and arms supported on an overbed table
C. Hold all scheduled medications
D. Position the client flat in bed
22. In conducting a physical assessment, which of these findings is most suggestive of pneumonia?
A. Clubbing of fingers and toes
B. Diminished bowel sounds
A.
B.
C.
D.
58. In DVT the possibility of dislodging the thrombi increases if necessary precautions are not observed. You will suspect that
possible complication is/are:
A. arterial occlusion and gangrene
B. air embolism
C. pulmonary embolism
D. all of the above
59. Digitalis toxicity will increase if there is:
A. low potassium
B. high potassium
C. low calcium
D. high calcium
60. The primary reason of pursed-lip-breathing in a client with Emphysema is:
A. to promote O2 intake
B. to promote carbon dioxide excretion
C. to promote lung expansion
D. to prevent lung collapse
61. When developing a discharge plan to client with COPD, the nurse would anticipate?
A. the client will develop infections easily
B. the client will require less oxygen
C. the client will show permanent improvement
D. all of the above
62. In assessing the correct placement of an endotracheal tube, the nurse would:
A. auscultate lung sounds bilaterally
B. monitor respiratory rate
C. assess for crackles
D. all of the above
63. Signs of digitalis toxicity include which of the following?
A. skin rash over the chest and the back
B. anorexia and visual disturbances such as seeing yellow spots
C. elevate blood pressure and respiratory distress
D. increased appetite and diarrhea
64. Contraindication to administration of tissue plasminogen activator includes which of the following?
A. age greater than 60
B. cigarette smoking
C. history of cerebral hemorrhage
D. history of CHF
65. During the acute phase of MI, the nurse should make the client bed by:
A. changing the top linen from top to bottom without lowering the head part
B. lift the client when changing the linen to limit activity
C. changing the top linen and only the necessary bottom linen
D. sliding the client onto the stretcher, remake the bed without delay then return the patient to bed immediately
66. The nurse has been assigned to a client with a history of PVD who has symptoms of claudication. This symptom result when?
A. oxygen supply exceeds the demand of muscles
B. oxygen is absent
C. oxygen demand by the muscle exceeds the supply
D. all of the above
67. A client has edema on the day and disappears at night. The client states it is not painful and is located in the lower extremities.
The nurse should suspect:
A. pulmonary edema
B. right ventricular failure
C. left ventricular failure
D. myocardial infarction
68. What is the potential side effect of Metaproterenol, a bronchodilator drug?
A. palpitations
B. tremors
C. diaphoresis
D. all of the above
69. A 60 year old male client comes into the ER with complaints of crushing sub-sternal chest pain that radiates to his shoulder and
left arm. The admitting diagnosis acute myocardial infarction. Immediate admission orders include oxygen by nasal cannula
4L/min, blood works, a chest radiograph, a 12 lead ECG and 2 mg morphine sulfate intravenously. The nurse should first:
A. administer the morphine
B. obtain ECG
C. obtain blood work
D. order the chest radiograph
70. In obtaining apical pulse, correct landmark would be:
A. left fifth ICS, midclavicular line
B. right fifth ICS, midclavicular line
C. left fourth ICS, midclavicular line
D. right fourth ICS, midclavicular line
71. Classic sign of Pulmonary Edema?
A. bi-basilar crackles
B. atelectasis
C. pink tinged frothy sputum
D. all of the above
72. Anasarca or generalized edema is best manifested by:
A. periorbital edema
B. edema +4
C. distention of neck veins
D. any of the above
73. Which of the following is an appropriate Nursing diagnosis for Asthma?
A. altered breathing pattern
B. decreased tissue perfusion
C. ineffective airway clearance
D. decreased lung expansion
74. Crackles heard on lung auscultation indicate which of the following?
A. cyanosis
B. bronchospasm
C. airway narrowing
D. fluid filled alveoli
75. What is the primary reason of taking oral Furosemide in the morning?
A. prevent electrolyte imbalance
B. reduce rapid drug absorption
C. excrete excessive fluids accumulated during the night
D. prevent sleep disturbance during the night
76. Which of the following is the primary function of osteoblast activity:
A. Bone Formation
B. Bone Destruction
C. Estrogen Function
D. Hematopoiesis
77. Which of the following would the nurse most likely assess as an early manifestation of Rheumatoid Arthritis?
A. Limited motion of joints
B. Deformed joints of the hand
C. Early morning stiffness
D. Rheumatoid Nodules
78. Heberdens nodes are a common sign of OA. What is the correct statement about this deformity?
A. It appears only in men
B. It appears on the distal interphalangeal joint
C. It appears on the proximal interphalangeal joint
D. It appears on the metatarso phalangeal joint
79. The primary consideration when caring for a client with Rheumatoid Arthritis is?
A. Surgery
B. Comfort
C. Education
D. Motivation
80. A physician tells a client diagnosed with Gout that her X-rays are normal. Which if the following responses would be the most
appropriate when the client asks if she still has Gout?
A. No, youre cured
B. Yes, X-rays are unreliable
C. Yes, X-rays are normal in the early stages of gout.