emergency

1. A client arrives in the emergency department after being in an automobile accident. The client was
physically unharmed yet was hyperventilating and complaining of dizziness and nausea. In addition, the client
appeared confused and had difficulty focusing on what was going on. The nurse assesses the client’s level of
anxiety as:

a. Mild
b. Moderate
c. Severe
d. Panic

Answer. C – The person whose anxiety is assessed as severe is unable to solve problems and has difficulty
focusing on what is happening in the environment. Somatic symptoms are usually present. The individual with
mild anxiety is only mildly uncomfortable and may even find performance enhanced. The individual with
moderate anxiety grasps less information about a situation and has some difficulty problem solving. The
individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.

2. The nurse is caring for a client with spinal cord injury who has spinal shock. The nurse performs an
assessment on the client, knowing that which assessment will provide the best information about recovery from
spinal shock?

a. Blood pressure
b. Pulse rate
c. Reflexes
d. Temperature

3. The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after
hearing the report?
a. The client with asthma who is now ready for discharge
b. The client with a peptic ulcer who has been vomiting all night
c. The client with chronic renal failure returning from dialysis
d. The client with pancreatitis who was admitted yesterday

Answer is B: The client with a peptic ulcer who has been vomiting all night A perforated peptic ulcer could
cause nausea, vomiting and abdominal distention, and may be a life threatening situation. The client should be
assessed immediately and findings reported to the health care provider

4. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client
should the triage nurse send back to be seen first?
a. A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying
b. A teenager who got a singed beard while camping
c. An elderly client with complaints of frequent liquid brown colored stools
d. A middle aged client with intermittent pain behind the right scapula

Answer is B: A teenager who got singed a singed beard while camping

This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has
been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that
the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

Answer. C – Areflexia characterizes spinal shock. Therefore reflexes would provide the best information about
recovery. Vital signs are not consistently affected by spinal shock because they are affected by many factors
therefore they do not give reliable information about spinal shock recovery.

5. The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should
first
a. Assess the client's airway
b. Call for help
c. Establish that the client is unresponsive
d. See if anyone saw the client fall
Answer is C: Establish that the client is unresponsive the first step in CPR is to establish unresponsiveness.
Second is to call for help. Third is opening the airway

6. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for
help, the first action the nurse should take is
a. Start a peripheral IV
b. Initiate closed-chest massage
c. Establish an airway
d. Obtain the crash cart
Answer is C: Establish an airway
Establishing an airway is always the primary objective in a cardiopulmonary arrest.

7. The nurse is assigned to care for 4 clients. Which of the following should be assessed immediately after
hearing the report?
a. The client with asthma who is now ready for discharge
b. The client with a peptic ulcer who has been vomiting all night
c. The client with chronic renal failure returning from dialysis
d. The client with pancreatitis who was admitted yesterday
Answer is B: The client with a peptic ulcer who has been vomiting all night A perforated peptic ulcer could
cause nausea, vomiting and abdominal distention, and may be a life threatening situation. The client should be
assessed immediately and findings reported to the health care provider

8. The nurse has been assigned to these clients in the emergency room. Which client would the nurse go
check first?
a. Viral pneumonia with atelectasis
b. Spontaneous pneumothorax with a respiratory rate of 38
c. Tension pneumothorax with slight tracheal deviation to the right
d. Acute asthma with episodes of bronchospasm
Answer is C: Tension pneumothorax with slight tracheal deviation to the right
Tracheal deviation indicates a significant volume of air being trapped in the chest cavity with a mediastinal
shift. In tension pneumothorax the tracheal deviation is away from the affected side. The affected side is the
side where the air leak is in the lung. This situation also results in sudden air hunger, agitation, hypotension,
pain in the affected side, and cyanosis with a high risk of cardiac tamponade and cardiac arrest

9. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client
should the triage nurse send back to be seen first?
a. A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying
b. A teenager who got a singed beard while camping
c. An elderly client with complaints of frequent liquid brown colored stools
d. A middle aged client with intermittent pain behind the right scapula
Answer is B: A teenager who got singed a singed beard while camping
This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has
been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that
the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

10. Which of these clients would the triage nurse request for the health care provider to examine immediately?
a. A 5 month-old infant who has audible wheezing and grunting
b. An adolescent who has soot over the face and shirt
c. A middle-aged man with second degree burns over the right hand
d. A toddler with singed ends of long hair that extends to the waist
Answer is A: A 5 month-old infant who has audible wheezing and grunting
The age and the findings put this client at immediate risk for respiratory complications.

11. A nurse is assessing a client with a bran stem injury. In addition to performing the Glasgow Coma Scale,
the nurse plans to
a. Check cranial nerve functioning and respiratory rate and rhythm
b. Perform ABG
c. Assist with a lumbar puncture
d. Perform a pulmonary wedge pressure
ANS: A – Assessment should be specific to the area of the brain involved. Assessing the respiratory status and
cranial nerve function is a critical component of the assessment process in a client with brain stem injury.
B, C, D – not necessary based on the data in the question.

12. An unresponsive and pulse less clients is brought into the emergency room after being in a car accident,
and a neck injury is suspected. The nurse opens the client’s airway by which method.
a. Head tilt/chin lift
b. Lift the head up and place the head on two pillows and attempt to ventilate
c. Jaw-thrust maneuver
d. Keeping the client flat and grasping the tongue
ANS. C – In suspected neck injuries, the appropriate way to open the airway is the jaw-thrust maneuver. If a
neck injury is resent this maneuver will prevent further injury. Options A, B, and D are incorrect.
13. A client is having a tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed.
b. Restrain the client's arms and legs.
c. Place a tongue blade in the client's mouth.
d. Take measures to prevent injury.

ANSWER: D - Protecting the client from injury is the immediate priority during a seizure.
A - Elevating the head of the bed would have no effect on the client's condition or safety. B - Restraining the
client's arms and legs could cause injury.
C - Placing a tongue blade or other object in the client's mouth could damage the teeth.

14. An unresponsive and pulse less clients is brought into the emergency room after being in a car accident,
and a neck injury is suspected. The nurse opens the client’s airway by which method.
a. Head tilt/chin lift
b. Lift the head up and place the head on two pillows and attempt to ventilate
c. Jaw-thrust maneuver
d. Keeping the client flat and grasping the tongue

ANS. C – In suspected neck injuries, the appropriate way to open the airway is the jaw-thrust maneuver. If a
neck injury is resent this maneuver will prevent further injury. Options A, B, and D are incorrect.
15. A client arrives at the emergency room with a chemical burn of the left eye. The nurse immediately:
a. Flushes the eye continuously with a sterile solution
b. Applies a cold compress to the injured eye
c. Applies a light bandage to the eye
d. Performs an assessment on the client

ANS. A – When the client has suffered a chemical burn of the eye, the nurse immediately flushes the site with
a sterile solution continuously for 15 minutes. If a sterile eye irrigation solution is not available, running water
be used. Performing an assessment may be helpful but is not the priority action. Applying compresses or
bandages is incorrect. Cold compresses are used for blows to the eye, whereas light bandages may be placed
over cuts of the eye or eyelid.

16. A mother arrives at the emergency room with her child, stating that she just found the child sitting on the
floor next to an empty bottle of aspirin. On assessment, the nurse notes that the child is drowsy but conscious.
The nurse anticipates that the physician will prescribe which of the following?
a. Ipecac syrup
b. Activated charcoal
c. Magnesium citrate
d. Magnesium sulfate

Answer. A – Ipecac is administered to induce vomiting in certain poisoning situations. In this situation, the child
is conscious and the ingested substance (aspirin) will not damage the esophagus of lungs from vomiting.
Activated charcoal may be prescribed as an antidote in some poisoning situations, but its action is to absorb
ingested toxic substances. Options C and D are unrelated to treatment for this occurrence.

17. A nurse in the emergency room admits a client who is bleeding freely from a scalp laceration obtained
during a fall from a step-ladder when the client was doing outdoor home repair. The nurse takes which of the
following actions first in the care of this wound?
a. Ask the client about timing of the last tetanus vaccination
b. Cleanses the wound with sterile normal saline
c. Prepares for suturing the area
d. Administers prophylactic antibiotic

Answer. B – This removes the dirt or foreign matter in the wound and allows visualization of the size of the
wound, direct pressure is also applied to control the bleeding. If suturing is necessary the surrounding hair
maybe shave. Prophylactic antibiotics are often prescribes. The date of the clients last tetanus shot is
determined and prophylactics is given.

18. A client was admitted to the nurses unit with a closed head injury 6 hours ago. After report, the nurse finds
that the client has vomited, is confused, and complains of dizziness and headache. Which of the following is
the most important nursing action?
a. Administer an antiemetic
b. Change the client’s gown and bed linens
c. Reorient the client to surroundings
d. Notify the physician

Answer. D – The client with a closed head injury is at risk of developing increased intracranial pressure (ICP).
This is evidenced by symptoms such as headache, dizziness, confusion, weakness, and vomiting. Because of
the implications of the symptoms, the most important nursing action is to notify the physician. Other nursing
actions that are appropriate include physical care of the client and reorientation to surroundings.
19. A client is being brought into the emergency department after suffering a head injury. The first action by the
nurse is to determine the client’s:
a. Respiratory rate and depth
b. Pulse and blood pressure
c. Level of consciousness
d. Ability to move extremities

Answer. A – The first action of the nurse is to ensure that the client has an adequate airway and respiratory
status. In rapid sequence, the client’s circulatory status is evaluated (option B), followed by evaluation of the
neurological status (options C and D).

Situation: Triage is the process of prioritizing sick or injured people for treatment according to the seriousness
of the condition or injury.

20. A 56-year-old male client, unconscious, appears blue and not breathing was rushed to the emergency
room. As a triage nurse, what color are you going to assign to the client?
a. Yellow
b. Red
c. Green
d. Black

Answer: B – Red is applicable for emergency cases. Red is to be prioritized, and not to be delayed.
A – Yellow is for urgent cases, an be delayed from minutes to hours.
C – Green is applied for non-urgent cases, can be delayed from hours to days.
D – Black is applicable only for mass casualties/disaster triage.

21. A client enters the emergency room and is unresponsive. Using the primary assessment, what is the initial
thing action of the nurse?
a. Assess if there is an adequate circulation.
b. Check for breathing pattern of the client.
c. Observe the client for signs of airway obstruction.
d. Initiate CPR.
Answer: C – During the primary assessment, ABC is done. The airway is assessed first, then breathing, and
circulation.
D – Done after assessment, this is an intervention.

22. An example of secondary assessment finding in a patient is:

a. Deep abrasions on the bilateral buttocks and posterior thighs.
b. Warm, dry, pink skin.
c. A palpable carotid pulse.
d. Absent breath sounds in the right lung.

Answer: A – Assessment of the posterior area of a client is done during the secondary assessment.
B, C, D – During the primary assessment, the airway, breathing, and circulation is assessed. B and C indicates
circulation, D is for breathing.

23. In the assessment process, the secondary assessment consists of performing a (an):
a. head-to-toe questions
b. airway and breathing analysis
c. detailed assessment of all problems
b. intervention for problems related to the patient’s complaint

Answer: A – Head-to-toe assessment is done during the secondary assessment.

B – This is done during the primary assessment.
C and D – Done after admission.

24. Of the following patients in the triage area, the one requiring priority treatment is the person who:
a. Fell on his wrist, in which there is no obvious deformity.
b. Has right upper quadrant pain and a temperature of 38.9 °C.
c. Was stung by bee and is wheezing.
d. Cut his leg on a fence, after which the bleeding was controlled.

Answer: C – A client stung by a bee and is wheezing should be prioritized. According to literature, bee sting
can cause hypersensitivity reactions. Wheezing indicates a narrowing airway, may lead to respiratory distress.

25. In anticipation of the needs of a client who is being admitted with a gunshot wound to the chest, the nurse
should first:
a. Reserve an operating room
b. Prepare equipment for a tracheostomy
c. Prepare equipment for chest tube insertion
d. Arrange for a portable chest x-ray examination
ANS. C – the first priority is to reinflate the lungs and stabilize respiratory status
A – this may be necessary later but is premature at this time
B – this is unnecessary; an endotracheal tube would be used for maintenance of the airway if necessary
D – this is not the priority at this time, this would be done later

26. A client is brought to the emergency room by the police after having seriously lacerated both wrists. The
initial action that the nurse will take is to:
e. Assess and treat the wound sites
f. Secure and record a detailed history
g. Encourage and assist the client to ventilate feelings
h. Administer an antianxiety agent
ANS. A – The initial action when a client has attempted suicide is to assess and treat any injuries. Although
options B, C and D may be appropriate at some point, the initial action would be to treat the wounds.

27. When assessing the nurse attempts to ventilate a patient during cardiopulmonary resuscitation, she notices
an airway obstruction. In an unresponsive adult, the most common cause of airway obstruction is;
i. The patient’s dentures
j. A foreign body
k. The tongue
l. The epiglottis
Answer: C- The patient is exhibiting signs of hypoxia; therefore the first priority is to inspect his chest for
symmetry. Unequal chest expansion indicates a possible pneumothorax and paradoxical chest movement
indicates a flail chest.

28. Sarah in the triage area of an emergency department should assign the highest priority to:
a. 4-year old with asthma who has diminished wheezing, is pale, and is very irritable
b. 1-year old who has had vomiting and diarrhea for 2 days and has a slightly depressed anterior fontanel
c. 6-year old who fell off her bicycle and has several lower extremity lacerations that require suturing
d. 7-month old who rolled off a chair onto a carpeted floor, hitting his head but not losing consciousness
TTS: PRIORITY QUESTION- ABC
ANSWER: A. a patient with a problem on the airway is still a priority, especially so that the wheezing has
diminished, which can mean that no more air enters the airway.
29. When developing a plan of care for a patient recovering from a serious thermal burn, the nurse knows that
the most important immediate goal of therapy is:
a. Planning for the patient’s rehabilitation and discharge
b. Providing emotional support to the patient and family
c. Maintaining the patient’s fluid, electrolyte, and acid-base balance
d. Preserving full range of motion in all affected joints

TTS: PRIORITY, KEY WORD

ANSWER: C – The most important immediate goal therapy for a patient with a serious thermal burn is maintain
fluid, electrolytes and acid-base balance to avoid potentially life-threatening complications, such as shock,
disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. The
other options are important aspects of care but do not take precedence over maintaining the patient’s fluid,
electrolyte, and acid-base balance.
Periop

30. The client recovering from a head injury is arousable and participating in care. The nurse determines that
the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client
doing which of the following activities?

a. Blowing the nose

b. Isometric exercises
c. Coughing vigorously
d. Exhaling during repositioning

ANSWER: D- Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of
the intracranial pressure. Some of these activities include isometric exercises, Valsalva’s maneuver, coughing,
sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the
glottis, which prevents intrathoracic pressure from rising.
31. The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect
that the client is developing meningitis as a complication of surgery if the client exhibits:
a. A negative Kernig’s sign
b. Absence of nuchal rigidity
c. A positive Brudzinski’s sign
d. A Glasgow coma scale score of 15

ANSWER: C-Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive
Brudzinski’s sign, and positive Kernig’s sign. Nuchal rigidity is characterized by a stiff neck and soreness,
which is especially noticeable when the neck is flexed. Kernig’s sign is positive when the client feels pain and
spasm of the hamstring muscles when the knee and thigh are extended from a flexed, right-angle position.
Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing
the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the
client is awake and alert, with no neurological deficits.

32. An ambulatory care nurse is preparing a list of instructions for the adult client who is being discharged after
tonsillectomy. The nurse avoids placing which of the following on the list?

a. Avoid hot fluids

b. Consume carbonated beverages and milk products
c. Avoid raw vegetables
d. Rest in bed or on a couch for 24 hours

ANSWER: B-The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice
pops to soothe the painful throat. Citrus products should be avoided because they irritate the throat. Milk and
milk products are avoided because they tend to increase mucus production. Foods that are highly seasoned
are irritating to the throat and should be avoided, and the client should be instructed to eat bland foods and
drink 2000 to 3000 mL of fluid daily unless contraindicated.

33. A client admitted to a surgical unit for possible bleeding in the cerebrum
has vital signs taken every hour to monitor to neurological status. Which of the following neurological checks
will give the nurse the best information about the extent of bleeding?

a. Pupillary checks
b. Spinal tap
c. Deep tendon reflexes
d. Evaluation of extrapyramidal motor system

Answer: A-Pupillary checks reflect function of the third cranial nerve, which stretches as it becomes displaced
by blood, tumor, etc.

Assessing for immediate postoperative complications, the nurse knows that a complication likely to occur
following unresolved atelectasis is

a. Hemorrhage
b. Infection
c. Pneumonia
d. Pulmonary embolism

Answer: C-Pneumonia is a major complication of unresolved atelectasis and must be treated along with
vigorous treatment for atelectasis. Hemorrhage and infection are not related to this condition. Pulmonary
embolism could result from deep vein thrombosis.

34. A client is recovering well 24 hours after cranial surgery but is fatigued. The neurosurgeon advances the
client from nothing by mouth (NPO) status to clear liquids. The nurse interprets that which of the following data
is the least reliable in determining the client’s readiness to take in fluids?

a. Presence of bowel sounds

b. Appetite
c. Absence of nausea
d. Presence of swallow reflex

ANSWER: B-To begin and tolerate oral intake after cranial or any other type of surgery, the client must have
bowel sounds. The client also must have intact swallow and gag reflexes and should be free of nausea and
vomiting. The client is likely to be easily fatigued, which may decrease appetite. Thus, appetite is the least
reliable indicator regarding when intake should be started.

35. A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and
does not seem to be progressing as quickly as the client of family hoped. The nurse plans to implement which
of the following approaches as the most helpful to the client and family at this time?

a. Emphasize progress in a realistic manner

b. Inform the client and family of standardized goals of care
c. Set high goals to give the client something to “aim for”
d. Tell the family to be extremely optimistic with the client

ANWER: A- The most helpful approach by the nurse is to emphasize progress that is being made in a realistic
manner. The nurse does not offer false hope but does provide factual information in a clear and positive
manner. The nurse encourages the family to be realistic in their expectations and attitudes as well. The plan of
care should be individualized for each client.
36. A nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a
total knee replacement. The nurse includes in the plan of care to assess the client’s neurovascular status by
monitoring:

a. The range of motion at the left knee when a continuous passive motion machine is used
b. The pain level and cognitive level of the client
c. Blood pressure and respiratory rate
d. Capillary refill sensation, color and pulse of the left foot

ANSWER: D-The nurse would check capillary refill, sensation, color, and pulse of the affected extremity in a
neurovascular assessment. Blood pressure and respiratory rate may be components of the nursing
assessment but are not specific to neurovascular status. Monitoring the pain level and cognitive level also is
unrelated to neurovascular status. Range of motion is related to musculoskeletal status, not neurovascular
status.
37. What is the responsibility of the nurse in obtaining an informed consent during surgery?
a. Describing in a clear and simply stated manner what the surgery will involve
b. Explaining the benefits, alternatives, and possible risks and complications of surgery
c. Using the nurse/client relationship to persuade the client to sign the operative permit
d. Providing the informed consent for surgery and witnessing the client’s signature
Answer: D – The nurse’s responsibility in obtaining an informed consent for surgery is providing the client with
the consent form and witnessing the client’s signature.
Answers A and B are the responsibility of the physician, not the nurse.
Answer C is incorrect because the nurse-client relationship should never be used to persuade the client to sign
a permit for surgery or other medical treatments.

38. The nurse is constructing a nursing care plan for a client post-operative open cholecystectomy. Which
nursing diagnosis would be the priority for this client?
a. Risk for ineffective airway clearance
b. Activity intolerance
c. Risk for urinary retention
d. Acute pain
Answer: A – Airway clearance is the priority. After gallbladder surgery, clients can have respiratory problems
because the location of the incision is in the proximity of the diaphragm.
Answer B, C and D can also occur but not the priority.

39. The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the
nurse most likely place the client for surgery on this area?
a. Lithotomy
b. Sim’s
c. Prone
d. Trendelenburg

Answer: D – the Trendelenburg position is used for surgeries on the lower abdomen and pelvis. This position
helps to displace intestines into the upper abdomen and out of the surgical area.
A - Reserved for vaginal, perineal, and some rectal surgeries.
B - Used for renal surgery.
C - Used for back surgery and some rectal surgeries.

40. When preparing a client for magnetic resonance imaging, the nurse should implement which of the
following?
a. Obtain informed consent and administer atropine 0.4mg
b. Scrub the injection site for 15 minutes
c. Remove any jewelry and inquire about metal implants
d. Assess for allergies to seafood or iodine
Answer: C – An MRI uses a powerful magnetic force; therefore, any metal or jewelry should be removed before
this test. Answers A, B, and D are not appropriate for this test. Answer D would be appropriate if a dye were
used with iodine, for example, with an intravenous pyelogram.

41. Which of the following is the primary responsibility of the nurse before surgical operation?
a. Taking the vital signs
b. Obtaining the permit
c. Explaining the procedure
d. Checking the lab works
Answer: A – primary responsibility of the nurse is to take the vital signs before any surgery. The actions in
answers B, C and D are the responsibility of the doctor and, therefore, are incorrect for this question

42. What is the most appropriate nursing action if the client’s mother is a Jehovah’s Witness and refuses to
sign the blood permit?
a. Give the blood without permission
b. Encourage the mother to reconsider
c. Explain the consequences without permission
d. Notify the physician of the mother’s refusal
Answer: D – it the client’s mother refuses the blood transfusion, the doctor should be notified. Because the
client is a minor, the court might order treatment. Answer A is incorrect because of the legal standing of the
mother. Answer B and C are incorrect because it is not the primary responsibility of the nurse to encourage the
mother to consent or explain the consequences.

43. The nurse is caring for a client following a modified radical mastectomy. Which assessment finding would
indicate that the client is experiencing a complication related to the surgery?
a. Sanguineous drainage in the Jackson-Pratt drain
b. Pain at the incision sited
c. Complaints of decreased sensation at the operative site.
d. Arm edema on the operative side
Answer: D – Lymphedema is a complication following a mastectomy and ca occur immediately post operatively
A, B, C – expected outcomes
SOURCE: Saunders Comprehensive Review for NCLEX, 3rd Edition. pp. 603, 610

44. A client undergoes a thyroidectomy and the nurse monitors the client for signs of damage to the
parathyroid glands post operatively. Which of the following findings would indicate damage to the parathyroid
glands?
a. Hoarseness
b. Tingling around the mouth
c. Respiratory distress
d. Neck pain

Answer: B - The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery.
Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for
complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are
signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek’s and Trousseau’s
signs. Hoarseness and neck pain are expected findings postoperatively. Respiratory distress indicates a
complication but is not a sign of damage to the parathyroid glands.

45. A nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week’s time. The client
has a history of arthritis and has been taking acetylsalicylic acid (aspirin, ASA). The nurse determines that the
client needs additional teaching and the client states:
a. “I need to continue to take the aspirin prescribed until the day of surgery
b. “Aspirin can cause bleeding after surgery.”
c. “Aspirin can cause my ability to clot blood to abnormal.”
d. “I need to discontinue the aspirin 48 hours before the scheduled surgery.”
ANSWER A. Anti-coagulants alter normal clotting factors and increase the risk of bleeding after surgery.
Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours
before surgery.

46. A nurse in a surgical unit receives a postoperative client from the post-anesthesia care unit (PACU). After
the initial assessment of the client, the nurse plans to continue with postoperative assessment activities:
a. Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and
then every hour as needed
b. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours as needed
c. Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed.
d. Every hour for 2 hours, and then every 4 hours as needed
ANSWER B - When the postoperative client arrives from the PACU, an initial assessment is performed.
Common time frames for continuing postoperative assessment activities are every 15 minutes the first hour,
every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed.
C and D - Identify time frames that are too infrequent and will not provide adequate assessment of the
postoperative client.
A - Identifies close timeframes that are unnecessary.
47. Before undergoing a subtotal thyroidectomy, a client receives Lugol’s solution and propylthiouracil. The
nurse would expect the maximum effect of both agents to occur:
a. In a few days
b. In 3 to 4 months
c. Immediately
d. In 1 to 2 weeks
Answer: D - Potassium iodide reduces the vascularity of the thyroid gland and is used to prepare the gland for
surgery. It reaches its maximum effect in 1 to 2 weeks. PTU blocks the conversion of thyroxine to
triiodothyronine, the more biologically active the thyroid hormone. PTU effects are also seen in 1 to 2 weeks.

Fluids and elec

48. Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the
following?
a. Muscle weakness
b. Tremors
c. Diaphoresis
d. Constipation
Answer: A. - Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and
face are findings associated with hyperkalemia, which is transient and occurs from transient
hypoaldosteronism when the adenoma is removed. B, C, D. - Tremors, diaphoresis, and constipation aren't
seen in hyperkalemia.
49. What does a positive Chvostek's sign indicate?
a. Hypocalcemia
b. Hyponatremia
c. Hypokalemia
d. Hypermagnesemia
Answer: A. - Chevostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the
temple. If the client's facial muscles twitch, it indicates hypocalcemia.
B. Hyponatremia is indicated by weight loss, abdominal cramping, muscle weakness, headache, and postural
hypotension. C. Hypokalemia causes paralytic ileus and muscle weakness. D. Clients with hypermagnesemia
exhibit a loss of deep tendon reflexes, coma, or cardiac arrest.

50. The client has the following ABG values: pH of 7.34, PaO2 of 80 mmHg, PaCO2 of 49 mmHg, HCO3 of 24
mEq/L. Based on these results, which of the following would the nurse do?
a. Administer low-flow oxygen
b. Encourage the client to cough and breath deeply
c. Instruct the client to breathe slowly into a paper bag
d. Do nothing because these ABG values are within normal limits
Answer: B. - The ABG results indicate respiratory acidosis requiring improved ventilation and increased oxygen
to lungs. Coughing and deep breathing can accomplish this.
A. - The nurse would administer high oxygen levels because client does not have COPD.
C. - Breathing into a paper bag is appropriate for a client hyperventilating and experiencing respiratory
alkalosis.
D. - Some action is necessary, because the ABG results are not within normal limits.

51. Which of the following would the nurse expect the physician to order for the client diagnosed with metabolic
acidosis?
a. Potassium
b. Sodium bicarbonate
c. Serum sodium level
d. Bronchodilator
Answer: B. - Metabolic acidosis results from excessive absorption or retention of acid or excessive excretion of
bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to treat documented metabolic
acidosis.
A, C, D. - Potassium, serum sodium determinations and bronchodilator would be inappropriate physician
orders for this client.

52. Which of the following would the nurse suspect if the client’s ECG waveform showed a shortened QT
interval and bradycardia?
a. Hypercalcemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypokalemia
Answer: A. - An ECG waveform showing a shortened QT interval and bradycardia suggest hypercalcemia.
B. - The ECG pattern typically associated with hyperkalemia reveals tall-tented T waves, a prolonged PR
interval and QRS duration, absent P waves, and ST depression.
C. - The ECG associated with hypocalcemia typically shows a prolonged QT interval.
D. - With hypokalemia, the ECG reveals a flattened T wave, prominent U wave, depressed ST segment, and
prolonged PR interval.

53. Which assessment data should the nurse anticipate when admitting a client with an extracellualr fluid
excess?
a. Elevated hematocrit
b. Rapid, thready pulse
c. Distended jugular veins
d. Increased serum sodium
Answer. C – Because of fluid overload in the intravascular space, the neck veins become visibly distended.
A and B – Occurs with a fluid deficit
D – If sodium causes the fluid retention, its concentration is unchanged; if fluid is retained independently of
sodium, its concentration will be decreased.

54. The nurse is aware that fluid can most accurately be assessed by:

a. A change in body weight

b. The presence of dry skin
c. A decrease in blood pressure
d. An altered general appearance

Answer. A – Dehydration is most readily and accurately measured by serial assessments of body weight; 1 liter
of fluid weighs 2.2 pounds
B – Although dry skin may be associated with dehydration, it also is associated with aging
C – Although hypovolemia will eventually result in a decrease in blood pressure, it is not an accurate, reliable
assessment because there are many other causes of hypotension
D – This is too general and not an accurate assessment to determine fluid volume deficit.

55. The most important electrolyte of intracellular fluid is:

a. Sodium
b. Calcium
c. Chloride
d. Potassium

Answer. D – The concentration of potassium is greater inside the cell and is important in establishing a
membrane potential, a critical factor in the cell’s ability to function.
A – Sodium is the most abundant cat ion of the extra cellular compartment
B – Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones.
C – Chloride is an extra cellular anion

56. When teaching a client diagnosed with hypokalemia, which of the following foods should the nurse instruct
the client to increase?

a. Whole grains and nuts

b. Milk products and green, leafy vegetables
c. Pork products and canned-vegetables
d. Orange juice and bananas

Answer: D. - The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice
and bananas are high in potassium, along with raisins, avocados, beans and potatoes.
A. - Whole grains nuts would be encouraged for the client with hypomagnesemia
B. - Milk products and green, leafy vegetables are good sources of calcium for the client with hypocalcemia
C. - Pork products and canned vegetables are high in sodium and are encouraged for the client with
hyponatremia

57. Which of the following interventions is most appropriate for the client who is hyperventilating and develops
respiratory alkalosis?
a. Administer low-flow oxygen therapy
b. Prepare to administer sodium bicarbonate
c. Encourage the client to breathe in and out of a paper bag
d. Administer sodium chloride intravenously

Answer: C. - The client who is hypoventilating and subsequently develops respiratory alkalosis is losing too
much carbon dioxide. Measures that results in the retention of carbon dioxide are needed. Breathing in and out
of a paper bag helps reverse hyperventilations and encourages slow, deep breathing to retain carbon dioxide
and reverse respiratory alkalosis.
A. - Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis
B. - Administering sodium bicarbonate is appropriate for treating metabolic acidosis
D. - Administering sodium chloride is appropriate for metabolic alkalosis

58. Which of the following does the nurse document when the client diagnosed with hypocalcemia develops a
carpopedal spasm after the blood pressure cuff is inflated?

a. Positive trousseau sign

b. Positive chvostek sign
c. Paresthesia
d. Tetany

Answer: A. - In a client with hypocalcemia, a positive Trousseau sign refers to carpopedal spasm that develops
usually within 2 to 5 minutes after applying and inflating a BP cuff to about 20 mmHg higher that systolic
pressure on the upper arm. This spasm occurs as the blood supply to ulnar nerve is obstructed.
B. - The Chvostek sign refers to twitching of the facial nerve when tapping below the ear lobe.
C. - Paresthesia refers to numbness or tingling.
D. - Tetany is clinical manifestation of hypocalcemia manifested as tingling in tips of fingers, around mouth, and
spasms of muscles in extremities and face.

60. Which of the following clinical manifestations would the nurse expect to assess in the client with
hypernatremia?

a. Muscle weakness and paresthesia

b. Fruity breath and Kussmaul breathing
c. Muscle twitching and tetany
d. Tented skin turgor and thirst

Answer: D. Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. typically, the
client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy, and
restlessness.
A. Muscle weakness and paresthesia are associated with hypokalemia
B. Fruity breath and Kussmaul breathing are assoictaed with diabetic ketoacidosis
C. muscle twitching and tetany may be seen with hypocalcemia or hyperphosphatemia

61. For the client diagnosed with hypomagnesimia, which of the following nursing interventions would be
appropriate?
a. Instruct the client on the importance of preventing infection
b. Avoid using a too tight tourniquet when drawing blood
c. Teach the client importance of early ambulation
d. Institute seizure precautions to prevent injury

Answer: D. - Instituing seizure precautions is an appropriate intervention, because the client with
hypomagnesemia is at risk for seizure.
A. Hypophospatemia may produce changes in granulocytes, which would require the nurse to instruct the
client about measures to prevent infection.
B. Avoiding the use of a tight tourniquet when drawing blood helps prevent pseudohyperkalemia.
C. Early ambulation is recommended to reduce calcium loss from bones during hospitalization

62. Which of the following would the nurse identify as the major electrolyte responsible for determining the
concentration of the extracellular fluid?
a. Potassium
b. Phosphate
c. Chloride
d. Sodium

Answer: D. - Sodium is the electrolyte whose level is the primary determinant of the extracellular fluid
concentration. A, B. Potassium (a cation) and phosphate (an anion) are the major electrolytes in the
intracellular fluid.
C. Sodium, a cation (ex: positively charged ion), chloride, an anion (ex: negatively charged ion), are the major
electrolytes in the extracellular fluid.

63. Which if the following would the nurse anticipate administering for the client with a potassium level of 6.2
mEq/L?

a. Potassium supplements
b. Kayexalate
c. Calcium gluconate
d. Sodium tablets
Answer: B. - The client’s potassium level is elevated and therefore Kayexalate would be ordered to help
reduced the potassium level. Kayexalate is a cation-exchange resin, which can be given orally, by nasograstric
tube, or by retention enema. Potassium is drawn from the bowel and excreted through the feces.
A. C. and D. - Because the client’s potassium level is already elevated, potassium supplements would not be
given. Neither calcium gluconate nor sodium tables would address the client’s elevated potassium level.

64. A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to
assess:
a. Trousseau's sign
b. Homans' sign
c. Hegar's sign
d. Goodell's sign
Answer: A. - This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes
Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure).
B. - Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis.
C. - Hegar's sign (softening of the uterine isthmus).
D. - Goodell's sign (cervical softening) are probable signs of pregnancy.

65. A client with atrial fibrillation who is receiving maintenance therapy of Warfarin sodium (Coumadin) has a
prothrombin time of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following
order?
a. Adding a dose of heparin sodium
b. Holding the next dose of warfarin
c. Increasing the next dose of warfarin
d. Administering the next dose of warfarin

ANSWER: B -The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds
(female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35
seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not
receive further doses at this time.

66. The nurse checks the laboratory result for a serum digoxin level that was determined for a client earlier in
the day and notes that the result is 2.4 ng/ml. Which of the following is the most important action on the part of
the nurse?

a. Notify the physician

b. Check the client’s last pulse rate
c. Record the normal value on the client’s flow sheet
d. Administer the next dose of the medication as scheduled

ANSWER: A - The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL. A level of 2.4 ng/mL exceeds the
therapeutic range and indicates toxicity. The most important action is to notify the physician, who may give
further orders about holding further doses of digoxin. Option 3 is incorrect because the level is not normal. The
next dose should not be administered because the serum digoxin level exceeds the therapeutic range.
Checking the client’s last pulse rate is not incorrect but may have limited value in this situation. Depending on
the time that has elapsed since the last assessment, a current assessment of the client’s status may be more
useful.
Endo

67. If you are the nurse who is assigned to perform a room assignments for the day. Which client should be
assigned to a private room if only one is available?
a. The client with Cushing’s disease
b. The client with diabetes
c. The client with acromegaly
d. The client with myxedema

Answer: A – the client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of
cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses no risk to
other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others.
The client in answer D has hyperthyroidism or myxedema, and poses no risk to others or himself.

68. In a 28 year old female client who’s been successfully treated for Cushing’s syndrome, the nurse would
expect a decline in:
a. Serum glucose level
b. Hair loss
c. Bone mineralization
d. Menstrual flow
Answer: A - Hyperglycemia which develops from glucocorticoid excess, is a manifestation of Cushing’s
syndrome. With successful treatment of the disorder, the serum glucose level declines. Hirsutism is common in
Cushing’s syndrome” therefore, with successful treatment, abnormal excessive hair growth also declines.
Osteoporosis occurs in Cushing syndrome: therefore, with successful treatment, bone mineralization
increases. Amenorrhea develops in Cushing’s syndrome. With successful treatment, the client experiences a
return of menstrual flow, not a decline.

69. Which nursing action is most appropriate for a client with acute pancreatitis?
a. Withholding all oral intake, as ordered, to decrease pancreatic secretions
b. Administering morphine, as prescribed, to relieve severe pain
c. Limiting I.V. fluids, as ordered, to decrease cardiac workload
d. Keeping the client supine or flat position to increase comfort
Answer: A- The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen
pancreatitis. Typically, this client requires a nasogastric tube to decompress the stomach and GI tract. Although
pancreatitis may cause considerable pain, it's treated with I.M. meperidine (Demerol), not morphine, which
may worsen pain by inducing spasms of the pancreatic and biliary ducts. Pancreatitis places the client at risk
for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs
fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees
flexed.

70. A 71 year old client is admitted with hyperosmolar hyperglycemic non-ketotic syndrome(HHNS). Which
laboratory finding would the nurse expect n this client?
a. Arterial ph of 7.25
b. Plasma bicarbonate level of 12 mEq/L
c. Blood glucose level of 1,300 mg/dl
d. Blood urea nitrogen level of 15 mg/dl
Answer: C - HHNS occurs most frequent in older clients. It can occur in clients with either type 1 or 2 diabetes
mellitus but occurs most frequently in those with type 2. the blood glucose level rises to above 600 mg/dl in
response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of excess
glucose by eliminating it urine. Initially, the client produces large quantities of urine. If fluid intake isn’t
increased at this time, the client becomes dehydrated, causing BUN level to rise. Arterial PH and plasma
bicarbonate level typically remain within normal limits. PH-7.35-7.45, HCo3-22-26, blood glucose 70-110 mg/dl,
BUN-10-20 mg/dl

71. Hydrocortisone given IV is the proper treatment for which of the following disease?
a. Addison’s disease
b. Cushing’s disease
c. Hyperthyroidism
d. Hypoparathyroidism
Answer: A – IV hydrocortisone is the proper treatment for Addison’s disease because it replaces the
glucocorticoid deficiency. Cushing’s syndrome has excessive amounts of glucocorticoids. Hyperthryroidism
and hypoparathyroidism have different treatment modalities.

72. A client is being treated for adrenal crisis ( Addisonian crisis). Which laboratory values are most important
to monitor?
a. Serum bicarbonate and sodium
b. Serum glucose and ketones
c. Serum sodium and potassium
d. Serum calcium and magnesium
Answer: C – If steroid replacement therapy is inadequate, sodium loss and potassium retention persist. If the
steroid dose is too high, sodium and water are retained, and large amount of potassium are excreted. Steroid
replacement can affect glucose, but the replacement doesn’t have as great an impact on ketones, bicarbonate,
calcium, or magnesium as it does on sodium and potassium.

73. Which of the following statements describing urinary incontinence in the elderly is true?
a. Urinary incontinence is a normal part of aging
b. Urinary incontinence isn't a disease
c. Urinary incontinence in the elderly can't be treated
d. Urinary incontinence is a disease
Answer: B- Urinary incontinence isn't a normal part of aging nor is it a disease. It may be caused by confusion,
dehydration, fecal impaction, restricted mobility, or other causes. Certain medications, including diuretics,
hypnotics, sedatives, anticholinergics, and antihypertensive, may trigger urinary incontinence. Most clients with
urinary incontinence can be treated; some can be cured.

74. Which nursing diagnosis is most appropriate for a client with Addison's disease?
a. Risk for infection
b. Excessive fluid volume
c. Urinary retention
d. Hypothermia
Answer: A - Addison's disease decreases the production of all adrenal hormones, compromising the body's
normal stress response and increasing the risk of infection. In Addison’s there is a decrease in cortisol which
assists in adaptation to stress, the body then lowers resistance to stress. Other appropriate nursing diagnoses
for a client with Addison's disease include Deficient fluid volume and Hyperthermia. Urinary retention isn't
appropriate because Addison's disease causes polyuria.

75. Which of the following would indicate that a client has developed water intoxication secondary to treatment
for diabetes insipidus?
a. Confusion and seizures
b. Sunken eyeballs and spasticity
c. Flaccidity and thirst
d. Tetany and increased blood urea nitrogen (BUN) levels.
Answer: A - Classic signs of water intoxication include confusion and seizures, both of which are caused by
cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid
volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.
76. A client has just been diagnosed with type 1 diabetes mellitus. Which comment by the client correlates best
with this disorder?
a. “I was thirsty all the time. I just couldn’t get enough to drink.”
b. “It seemed like I had no appetite. I had to make myself eat.”
c. “I had a cough and cold that just didn’t seem to go away.”
d. “I noticed I had pain when I went to the bathroom.”
Answer: A - the classic s/s of diabetes mellitus are polydipsia, polyuria, and polyphagia. Decreased appetite,
lingering cold and cough, and pain on urination are unrelated to DM.
B- decreased appetite reflects a GI disorder,
C- cough and cold indicate upper respiratory disease
D- pain with urination suggests UTI

77. Which outcome would indicate successful treatment of diabetes insipidus?

a. Fluid intake of less than 2,500 ml in 24 hours
b. Urine output of more than 200 ml/hr
c. Blood pressure of 90/50
d. Pulse rate of 126 beats/minute
Answer: A - DI is characteritized by polyuria( u/o to 8 L/day). Constant thirst, and an unusually high oral take of
fluids. Treatment with the appropriate drug should decrease urine output and oral fluid intake. Fluid intake of
less than 2,500 ml in 24 hours would indicate that treatment has been effective.
B- A urine output 200 ml/ hour indicates continuing polyuria.
C and D- signs of compensation for continued fluid deficit, suggesting that treatment hasn’t been effective

78. A nurse administered NPH insulin to a client with Diabetes mellitus at 7 am. At what time would the nurse
expect the client to be at greatest risk for a hypoglycemic reaction?
a. 10 am
b. Noon
c. 4 pm
d. 10 pm
Answer: C - NPH is intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the
nurse administered NPH insulin at 7 am, the client s at greatest risk for hypoglycemia from 3 to 7 pm

79. Which instruction should be included in the teaching plan for a client requiring insulin?
a. Administer insulin
b. Administer insulin at a 45-degree angle into a deltoid muscle
c. Shake the vial of insulin vigorously before withdrawing the medication
d. Draw up clear insulin first when mixing two types of insulin in one syringe

Answer: D - When mixing types of insulin, the client should draw the clear(regular) insulin into the syringe first
to avoid contamnatng the regular/clear insulin. The daily insulin dose typically is administered before, not after,
the first meal of the day and a 90-degree angle to fatty tissue. If cloudy, NPH, or insulin must be administered,
the client should gently roll the vial between the palm of her hands before withdrawing the medication, rather
than shaking the vial vigorously.

80. A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented; has
hot, dry skin; and has the following vital signs: temperature 38.1 degrees Celsius, heart rate of 116 beats/min
and blood pressure of 108/70 mmHg. Based on these assessment findings, which nursing diagnosis takes
highest priority?
a. Deficient fluid volume related to osmotic diuresis
b. Decreased cardiac output related to osmotic diuresis
c. Imbalanced Nutrition; less than body requirements related to insulin deficiency
d. Ineffective thermoregulation related to dehydration
Answer: A - A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient
fluid volume is prioritized than from decreased cardiac output because his blood pressure is normal. Although
the clients serum glucose level is elevated, food isn’t a priority because fluids and insulin should be
administered to lower the serum glucose level. Therefore, a diagnosis of imbalanced nutrition; less than body
requirements isn’t appropriate. a temperature of 38.1 isn’t life threatening, eliminating ineffective regulation as
the top priority

81. For the first 72 hours after thyroidectomy surgery, a nurse would assess a client for Chvostek’s and
Trousseau’s signs because they indicate:
a. Hypocalcemia
b. Hpercalcemia
c. Hypokalemia
d. Hyperkalemia
Answer: A - Due to accidental of removal or damage to the parathyroid gland. The client with hypocalcemia will
exhibit a positive Chvostek’s indicated by facial spasms and Trouseau’s sign indicated by carpal spasms when
a BP cuff is inflated on the upper arm.

82. On a medical-surgical floor, the nurse is caring for a cluster of clients who have been diagnosed with
diabetes mellitus. Which client should the nurse assess first?
a. An 80-year old client with a blood glucose level of 350 mg/dl
b. A 20 year old client with a blood glucose level of 70 mg/dl
c. A 60 year old client experiencing nausea and vomiting
d. A 55 year old client complaining of chest pressure
Answer: D - The nurse should assess the client with chest pressure first because he might be experiencing a
myocardial infarction. Chest pressure may indicate tissue ischemia that brought about lactic acid build up
causing the pressure or discomfort. The blood glucose levels in A and B are abnormal, but not life threatening:
therefore, those clients don’t require immediate attention. After assessing the client with chest pressure, the
nurse should assess the client experiencing nausea and vomiting

83. The nurse is assigned to a 40-yr old client who has a diagnosis of chronic pancreatitis. The nurse reviews
the laboratory results, anticipating a laboratory report that indicates a serum amylase level of:

a. 45 units/L
b. 100 units/L
c. 300 units/L
d.500 units/L

ANSWER: C -The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise
in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value
may exceed five times the normal value. Options A and B are within normal limits. Option D is an extremely
elevated level seen in acute pancreatitis.
84. What laboratory finding is the primary diagnostic indicator for pancreatitis?
a. Elevated blood urea nitrogen (BUN)
b. Elevated serum lipase
c. Elevated aspartate aminotransferase (AST)
d. Increased lactate dehydrogenase (LD)

ANSWER: B - Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is
produced solely by the pancreas.
A - A client's BUN is typically elevated in relation to renal dysfunction.
C - The AST, in relation to liver dysfunction.
D - LD, in relation to damaged cardiac muscle
85. A nurse is caring for client with pheochromocytoma. The client asks for a snack and something warm to
drink. The most appropriate choice for this client to meet nutritional needs would be which of the following?
a. Crackers with cheese and tea
b. Graham crackers and warm milk
c. Toast with peanut butter and cocoa
d. Vanilla wafers and coffee with cream and sugar

ANSWER: B- The client with pheochromocytoma needs to be provided with a diet high in vitamins, minerals,
and calories. Of particular importance are the foods or beverages that contain caffeine, such as cocoa, coffee,
tea, or colas. These foods are prohibited because they can precipitate a hypertensive crisis.

86. A nurse is performing an assessment on a client with pheochromocytoma. Which of the following
assessment data would indicate a potential complication associated with this disorder?
a. A coagulation time of 5 minutes
b. A blood urea nitrogen level of 20 mg/dl
c. A urinary output of 50 ml per hour
d. A heart rate that is 90 beats/min and irregular

ANSWER: D- The complications associated with pheochromocytoma include hypertensive retinopathy and
nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke,
renal failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a
dysrhythmia. A urinary output of 50 mL/hr is an adequate output. A blood urea nitrogen level of 20 mg/dL is a
normal finding. A coagulation time of 5 minutes is normal.

87. A nurse is preparing to provide instructions to a client with Addison’s disease regarding diet therapy. The
nurse knows that which of the following diets most likely would be prescribed for this client?

a. High fat intake

b. Low protein intake
c. Normal sodium intake
d. Low carbohydrate intake

ANSWER: C- A high-complex carbohydrate and high-protein diet will be prescribed for the client with Addison’s
disease. To prevent excess fluid and sodium loss, the client is instructed to maintain a normal salt intake daily
(3 g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever,
vomiting, or diarrhea. A high-fat diet is not prescribed.

88. A nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an
understanding of the treatment for this disorder?

a. “I take oral insulin instead of shots”

b. “By taking these medications, I am able to eat more.”
c. “When I become ill, I need to increase the number of pills I take.”
d. “The medications I’m taking help release the insulin I already make.”

ANSWER: D- Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral
hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given
during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the
insulin by digestion. Options A, B, and C are incorrect.

89. A nurse is providing discharge instructions to a client who has Cushing’s syndrome. Which client statement
indicates that instructions related to dietary management are understood?

a. “I can eat foods that have a lot of potassium in them.”

b. “I will need to limit the amount of protein in my diet.”
c. “I am fortunate that I can eat all the salty foods I enjoy.”
d. “I am fortunate that I do not need to follow any special diet.”

ANSWER: A- A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a
client with Cushing’s syndrome. Such a diet promotes weight loss, reduction of edema and hypertension,
control of hypokalemia, and rebuilding of wasted tissue.

90. A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for
a hypoglycemic reaction to occur is:

a. 2 to 4 hours after administration

b. 4 to 12 hours after administration
c. 16 to 18 hours after administration
d. 18 to 24 ours after administration

ANSWER: B- NPH is an intermediate-acting insulin. The onset of action is 1.5 hours, it peaks in 4 to 12 hours,
and its duration of action is 24 hours. Hypoglycemic reactions most likely occur during peak time.

91. A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet.
Which statement, if made by the client, indicates a need for further teaching?
a. “I need to drink diet soft drinks.”
b. “I will eat a balanced meal plan.”
c. “I need to purchase special diabetic foods.”
d. “I’ll snack on fruits instead of cake.”

ANSWER: C- It is important to emphasize to the client and family that they are not eating a diabetic diet but
rather a balanced meal plan. Adherence to nutrition principles is an important component of diabetic
management and an individualized meal plan should be developed for the client. It is not necessary for the
client to purchase special dietetic foods.
92. A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should assess the client for
a hypoglycemic reaction at:
a. 10:00 am
b. 11:00 am
c. 5:00 pm
d. 11:00 pm

ANSWER: C- NPH is an intermediate-acting insulin. The onset of action is 3 to 4 hours, it peaks in 4 to 12

hours, and its duration of action is 16 to 20 hours. Hypoglycemic reactions most likely occur during peak time.

93. The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative
teaching instructions should include which most important statement?
a. “Your hair will need to be shaved.”
b. “Deep breathing and coughing will be needed after surgery.”
c. “Brushing your teeth will not be permitted for at least 2 weeks following surgery.”
d. “ You will receive spinal anesthesia.”

ANSWER: C- Based on the location of the surgical procedure, spinal anesthesia would not be used.
Additionally, the hair would not be shaved. Although coughing and deep breathing are important, specific to this
procedure is avoiding brushing the teeth to prevent disruption of the surgical site.

94. A nurse caring for a client with Addison’s disease would expect to note which of the following on
assessment of the client?

a. Obesity
b. Edema
c. Hypotension
d. Hirsutism

ANSWER: C- Common manifestations of Addison’s disease include postural hypotension from fluid loss,
syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and
irritability. Options A, B, and D are not specific to this disorder.

95. A nurse is assessing a client with a diagnosis of goiter. Which of the following would the nurse expect to
note during the assessment of the client?
a. Client complains of slow wound healing
b. Client complains of chronic fatigue
c. An enlarged thyroid gland
d. The presence of heart damage

ANSWER: C- An enlarged thyroid gland develops in the client with goiter because an excessive amount of
thyroxine occurs in the thyroid gland, causing it to enlarge. Slow wound healing occurs with zinc deficiency.
Chronic fatigue occurs with iron deficiency. Heart damage occurs with selenium deficiency. Additionally, heart
damage would not likely be noted during the nursing assessment. Further diagnostic tests in addition to the
assessment would be necessary to determine heart damage.

96. The nurse is caring for a client following thyroidectomy. The nurse notes that calcium gluconate is
prescribed for the client. The nurse determines that thus medication has been prescribed to:

a. Treat thyroid storm

b. Prevent cardiac irritability
c. Stimulate release of parathyroid hormone
d. Treat hypocalcemic tetany

ANSWER: D- Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally
removed during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and
tingling around the mouth, fingertips or toes, muscle spasms, or twitching, the physician is notified immediately.
Calcium gluconate should be kept at the bedside.

97. The client with type 1 diabetes mellitus is to begin an exercise program and the nurse is providing
instructions to the client regarding the program which of the following does the nurse include in the teaching
plan?

a. Exercise is best performed during peak times of insulin

b. Administer insulin after exercising
c. Take a blood glucose test before exercising
d. Try to exercise prior to mealtime

ANSWER: C- A blood glucose test performed before exercising provides the client with information regarding
the need to consume a snack prior to exercising. Exercising during the peak times of insulin or prior to
mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed.

98. The nurse is preparing to administer an IV insulin injection. The vial of regular insulin has been refrigerated.
On inspection of the vial, the nurse finds that the medication is frozen. The nurse should:

a. Wait for the insulin to thaw at room temperature

b. Check the temperature settings of the refrigerator
c. Discard the insulin and obtain another vial
d. Rotate the vial between the hands until the medication becomes liquid.

ANSWER: C- Insulin should not be frozen. If the nurse notes that the vial of insulin is frozen, the insulin is
discarded and a new vial is obtained. Options A, B, and D are incorrect actions.

99. A nurse is assessing the learning readiness of a client newly diagnosed with diabetes mellitus. Which client
behavior indicates to the nurse that the client is not ready to learn?

a. The client complains of fatigue whenever the nurse plans a teaching session
b. The client asks if the spouse can attend the teaching session
c. The client asks for written materials about diabetes mellitus before class
d. The client ask appropriate questions about what will be taught

ANSWER: A- Physical symptoms can interfere with an individual’s ability to learn and can also indicate to the
teacher that the student lacks motivation to learn if the symptoms repeatedly recur when teaching is initiated.
Options B, C, and D identify active client participation in learning.

100. A young male client with type 1 diabetes mellitus tells the nurse that he might lose his job because he
has been having frequent hypoglycemic reactions. His boss thinks that he is drunk during these episodes, and
that he has been drinking on the job. Which action by the nurse would best assist this client to meet his needs?

a. Contact the local employment office to help him find another job
b. Ask the client if he indeed has been drinking at work
c. Examine factors with the client that may be causing frequent hypoglycemic episodes
d. Ask the client what he does to treat his hypoglycemia

ANSWER: C- Hypoglycemic reactions present as adrenergic symptoms of tremor, shakiness and nervousness,
which are comparative or alike to the signs of alcohol intoxication. The best strategy to assist the client to meet
his needs is to decrease the episodes of hypoglycemia by first identifying and then eliminating those factors
that precipitate this event. Options A and B are inappropriate. Option D is not directly related to the subject of
the question.