MEDICAL SURGICAL NURSING-ANSWERS

Situation 4. Hearing, impairment appears to be common

1. A 42-year-old client admitted with an acute myocardial among elderly patients. But also occurs among children.
infarction asks to see his chart. What should the nurse do
first? 6. To assess the degree of hearing impairment of a 70-year-
old client. Which communication approach would you
a. Allow the client to view his chart initiate?
b. Contact the supervisor and physician for approval
c. Ask the client if he has concerns about his care a. Use verbal communication and observe the response
d. Tell the client that he isn't permitted to view his chart. b. Give message to client in writing
c. Asks a family member about the client's
2. A registered nurse who works in the preoperative area d. Post a sign "Patient deaf"
of the operating room notices that a client is scheduled for
a partial mastectomy and axillary lymph node removal the 7. While you are mating your routine rounds you were told
following week. The nurse should make sure, that the that there is a client in the 1CU who is in respirator and
client is well educated about her surgery by: who lip-reads. To establish relationship with him,
communication is best accomplished by:
a. taking with the nursing staff at the physician's office to find
out what the client has been taught and her level of a. Speaking slowly but aloud
understanding b. Writing messages
b. making sure that the post-anesthesia recovery unit nurses c. Gesturing while speaking
know what to teach the patient before discharge d. Using simple "charade" approach or strategy
c. providing all of the preoperative teaching before surgery
d. having the post-operative nurses teach the patient because 8. One of your client's has just undergone an ear surgery.
she'll be too anxious before surgery Which of the following would be inappropriate in planning
for his care?
3. A male client brings a list of his prescribed medications
to the clinic. During the initial assessment, he tells the a. Administration of anti-emetics and analgesics as ordered
nurse that he has been experiencing delayed ejaculation. b. Daily irrigation of the ear canal
Which drug class is associated with this problem? c. Walking with assistance at least 24 hours after operation
d. Teaching the patient to avoid sneezing, coughing and nose
a. Anticoagulants blowing
b. Antibiotics
c. Antihypertensive 9. Which of the following conditions would an irrigation of
d. Steroids the ear canal be appropriate intervention?
Situation: Larry was admitted at Manila Doctor's Hospital
because of a second-degree burn wound. a. Foreign body in the ear canal
b. Serious otitis
4. Before debriding a second-degree burn wound in the left c. Impacted cerumen
lower leg, the nurse should do which of the following? d. Tympanic membrane perforation

a. Apply Lindane (Kwell) to the affected area 10. Children who have undetected hearing loss are likely to
b. Medicate the client with narcotic analgesic exhibit which of the following:
c. Administer acylovir (Zovirax) IV
d. Apply a topical antimicrobial ointment a. Indifference and lack of interest in the environment
b. Hyperactivity
5. Larry’s anterior trunk, both front upper extremities, c. An increased interest in reading
both lower extremities sustained second and third degree d. Hand gestures while speaking
burn. Estimate the total percentage of body surface area Situation 9. One of the main fools of the nursing profession is
burned using the Rule of Nines. the use of therapeutic communication. The following situation
would require you of your communication skills.
a. 60%
b. 63% 11. A patient who is diagnosed to have terminal illness tells
c. 62% you. "I’m really scared. Am I dying?" What could be your
d. 61% most appropriate response?
a. "Tell me about what you think." d. "Let us asks your doctor about your operation."
b. "I'm sure you are scared; other clients in your situation feel
the same way." 16. The nurse is caring for a client whose arterial blood
c. "You should be careful not to let your family know you're gases indicate metabolic acidosis. The nurse knows that of
scared" the following, the least likely to cause metabolic acidosis is:
d. "Why are you scared?"
a. cardiac arrest
12. The nurse assessing a male client who has been b. Diabetic ketoacidosis
admitted for treatment of alcoholism. Which question by c. decreased serum potassium level
the nurse is least appropriate? d. renal failure

a. "How much do you think?" 17. The nurse is caring for a client who is receiving IV
b. "What other drugs do you use?" . fluids, Which observation the nurse makes best indicates
c. "How is your general health?" that the IV has infiltrated?
d. "Why do you drink so much?"
a. Pain at the site
13. A 58-year-old male client tells the office nurse that his b. A change in flow rate
wife does not let him change his colostomy bag himself. c. Coldness around the insertion site
Which response by the nurse indicates as understanding of d. Redness around the insertion site
the situation?
18 A 27 y.o adult is admitted for treatment of Crohn's
a. "Your wife's need to help you is a reality you should accept" disease. Which information is most significant when the
b. "Do you think your wife might benefit from counseling?" nurse assesses nurtritional health?
c. "You feel you need privacy when changing your
colostomy?" a. Anthropometric measurements
d. "Have you discussed the situation with your doctor?" b. bleeding gums
c. dry skin
14. An 87 year old widow was hospitalized for treatment of d. facial rubor
chronic renal disease. She lives with her daughter and son-
in-law and their family, who are very supportive. She is 19. ASA (aspirin) is being administered to a client. The
now ready for discharge. The doctor has ordered high nurse understands that the most common mechanism of
carbohydrates, low-protein, low sodium diet for her and action for nonnarcotic analgesic is their ability to:
the family has asked for assistance in planning low-sodium
diet meals. Which of the following choices best reflects the a. Inhibit prostaglandin systhesis
pre-discharge information the nurse should provide for the b. After pain perception in the cerebellum
client's family regarding low-sodium diet? c. Directly affect the central nervous system
d. Target the pain-producing effect of kinins
a. Avoid canned and processed foods, do not use salt
replacements substitute herbs and replaces for salt in cooking 20. The nurse caring for an adult client who is receiving
and when seasoning foods, call a dietitian for help. TPN will need to be monitored for which of the following
b. Use potassium salts in place of table salt when coking and metabolic complications?
seasoning foods, read the labels on packaged foods to
determine sodium content, and avoid snacks food a. Hypoglycemia and Hypercalcemia
c. Limit milk and dairy products, cook separate meals that are b. Hyperglycemia and Hypokalemia
low in sodium and encourage increased fluid intake c. Hyperglycemia and Kyperkalemia
d. Avoid eating in a restaurant, soak vegetables well before d. Hyperkalemia and Hypercalcemia
cooking to remove sodium, omit all canned foods, and remove
salt shakes from table. 21. Total parenteral nutrition is ordered for an adult.
Which nutrient is not likely to be in the solution?
15. You are encouraging your patient for major cancer
operation to verbalize her fears. She remarked," I am a. Dextrose 10%
afraid to do". Your appropriate response is b. Trace minerals
c. Amino acids
a. "I know how you feel about your condition". d. Non of the above
b. "Don't worry, you are in good hands."
c. "Let me call a chaplain to see you." 22. A man has sprained his ankle. The physician would
order cold applied to the injured area to. b. air embolus
c. head injury
a. Reduce the body's temperature d. thrombophlebitis
b. Increase circulation to the area
c. Aid in absorbing the edema 29. The nurse enter a room and finds a fire. Which is the
d. Relieve pain and control bleeding. best initial action?

23. An adult is to have a tepid sponge bath to lower his a. Evacuate any people in the room, beginning with the most
fever. What temperature should the nurse make the ambultory and ending with the least mobile
water? b. activating the fire alarm or call the operator, depending on
the institutions system
a. 65 F c. get a fire extinguisher and put out the fire
b. 90 F d. close all the windows and doors and turn off any oxygen or
c. 110 F electricity appliance.
d. 105 F
30. The nurse is to open a sterile package from central
24. An adult has chronic lower back pain and receives hot supply. Which is the correct direction to open the first lap?
pack three times a week. The nurse knows that the
treatment is given for which of the following reasons? a. Toward the nurse
b. Away from the nurse
a. To help remove debris from the wound c. To the nurse's left or right hand
b. To keep the client warm and raise his temperature d. It does not matter as long as the nurse touches only the
c. To improve the client's general circulation outside edge
d. To relieve muscle spasm and promote muscle relaxation
31. The nurse knows which of the following is the proper
25. A patient classification system where patients minimal technique for medical asepsis?
theraphy and less frequent observation
a. gloving for all the client contact
a. minimal care (category 1) b. changing hospital linens weekly
b. moderate care (category 2) c. using your hands to turn off the faucet after handwashing
c. maximum care (category 3) d. gowning to care for a 1 year old child w/ infections
d. intensive care (category 4) diarrhea

26. The nurse is to apply a dressing to a stage II pressure 32. An adult ha a left, above the knee amputation two
ulcer. Which of the following dressing is best? weeks ago. The nurse places him in a prone position tree
times a day because
a. Dry gauze dressing
b. wet gauze dressing a. Prevents pressure ulcer on the sacrum
c. wet to dry dressing b. helps the prosthesis to fit correctly
d. moisture vapor permeable dressing c. prevents flexion constractures
d. allow better blood flow to the heart
27. The client has been placed in the trendelenburg
position. The nurse knows the effects of this position to the 33. A woman is to have a pelvic exam. Which of the
client include which of the following. following should the nurse have the client do first?

a. increase blood flow to the feet a. Remove all her clothes and her socks and shoes
b. decrease blood pressure b. go to the bahtroom and void saving a sample
c. increase pressure on the diaphragm c. assume a lithotomy position on the exam table
d. decrease intracranial pressure d. assemble all the equipments needed for the examination

28. A man who has been in an MVA is going into shock. 34. An adult is supine. Which of the ff. can the nurse to to
Before placing the client in a modified trendelenburg prevent external rotation of the legs?
position, the nurse should assess the client for:
a. put a pillow under the clients lower legs
a. long bone fracture b. place a pillow directly under the client knee
c. use a trochanter rool alongside the client's upper thighs
d. lower the client's legs so that they ae below hips. b. Scatter rugs
c. Snack tables
35. The nurse prepares to palpate a clients maxillary d. Diet high in fat
sinues. For this procedure, where should the nurse place
the hands? 41. A patient who has kaposis sarcoma has all of the
following nursing diagnoses. To which one should the
a. On the bridge of the nose nurse give priority?
b. below the eyebrows
c. below the cheekbones a. Altered thought processes related to lesions
d. over the temporal area b. Altered with maintenance related to non compliance
c. Defensive coping related to loss of boundaries
36. A client who receives general anesthesia returns from d. Hopelessness, related to inability to control disease process
surgery. Postoperatively, which nursing diagnosis takes
highest priority for this client? 42. Which of the following statements, if made by a patient
who has had a basal cell carcinoma removed, would
a. Pain related to the surgery indicate to the nurse the need for further instruction?
b. Fluid volume deficit related to fluid and blood loss from
surgery a. "I will use sunscreen with at least a sun protection factor
c. Impared physical mobility related to surgery (SPF) of 15.”
d. Risk for aspiration related to anesthesia b. "I will use tanning booths rather than sunbathing from now
on."
37. After a client receives an IM injection, he complains of c. "I will stay out of the sun between 10:00 AM and 2:00 PM"
a burning pain in the injection site. Which nursing action d. "I will wear a broad - brimmed heat when I am in the sun"
whould be best to take at this time?
43. A patient who has a diagnosis is metastatic cancer of
a. apply a cold compress to decrease swelling the kidney is told by the physician that the kidney needs to
b. apply a warm compress to dilate the blood vessels be removed. The patient asks the nurse. "What should I
c. Massage the area to promote absorption of the drug do?" Which of the following responses by the nurse would
d. Instruct the client to tighten his gluteal muscles to enhance be most therapeutic?
absorption of the drug
a. "Let's talk about your options."
38. A patient classification system where patients need b. "You need to follow the doctor's advice."
close attention and complete care in most activities and c. "What does your family want you to do."
requires frequent and complex treatments and d. "I wouldn't have the surgery done without a second opinion.
medications
44. Which of the following conditions, reported to a nurse
a. Minimal Care (category 1) by a 20 year old male patient, would indicate a risk for
b. Moderate Care (category 2) development of testicular cancer?
c. Maximum Care (category 3)
d. Intensive Care (category 4) a. Genital Herpes
b. Undescended testicle
39. An observation consistent with complete-airway c. Measles
obstruction is: d. Hydrocele

a. Loud crowing when attempting to speak 45. A client has been diagnosed as having bladder cancer,
b. Inability to cough and a cystectomy and an ileal conduit are scheduled.
c. Wheezes on auscultation Preoperatively, the nurse plans to:
d. Gradual
a. Limit fluid intake for 24 hours
40. The nurse assesses the client's home environment for b. Teach muscle tightening exercises
the safe use crutches. Which one of the following would c. Teach the procedure for irrigation of the stoma
pose the greatest hazard to the client's safe use of crutches d. Provide cleansing enemas and laxatives as ordered
at home?
46. To gain access to a vein and an artery, an external
a. A 4-year old cocker spaniel shunt may be used for clients who require hemodialysis.
The most serious problem with an external shunt is.
 c. Adjust the TENS dial until the client perceives pain relief
a. Septicemia and comfort
b. Clot-formation d. Apply the color-coded electrodes anywhere it is
c. Exsanguination comfortable for the client
d. Sclerosis of vessels
53. Although no cause has been determined for
47. A client has been diagnosed as having bladder cancer, scleroderma, it is thought to be caused by:
and a cystectomy and an ileal conduit are scheduled.
Preoperatively, the nurse plans to: a. Autoimmunity
b. Ocular motility
a. Limit fluid intake for 24 hours c. Increased amino acid metabolism
b. Teach the procedure for irrigation of the stoma d. Defective sebaceous gland formation
c. Teach muscle-tightening exercises
d. Provide cleansing enemas and laxatives as ordered 54. The nurse must help the client with pemphigus vulgaris
deal with the resulting:
48. Intramedullary nailing is used in the treatment of:
a. Infertility
a. Slipped epiphysis of the femur b. Paralysis
b. Fracture of shaft of the femur c. Skin lesions
c. Fracture of the neck of the femur d. Impaired digestion
d. Intertrochanteric fracture of the femur
55. The nurse should explain to the client with psoriasis
49. The nurse should know that, following a fracture of the that treatment usually involves:
neck of the femur, the desirable position for the
a. Avoiding exposure to the sum
a. Internal rotation with extension of the knee b. Topical application of steroids
b. Internal rotation with flexion of the knee and hip c. Potassium permanganate baths
c. External rotation with flexion of the knee and hip d. Debridement of necrotic plaques
d. External rotation with extension of the knee and hip
56. The nurses should assess a client with psoriasis
50. A client with myasthenia gravis has been receiving
Neostigmine (Prostigmin). This drug acts by: a. Pruritic lesions
b. Multiple petechiae
a. Stimulating the cerebral cortex c. Shiny, scaly lesions
b. Blocking the action of cholinesterase d. Erythematous macules
c. Replacing deficient neurotransmitters
d. Accelerating transmission along neural swaths 57. A urine specimen for ketones should be removed from
a client's retention catheter by:
51. A client with myasthenia gravis ask the nurse why the
disease has occurred. The nurse bases the reply on the a. Disconnecting the catheter and draining it into a clean
knowledge that there is: container
b. Cleansing the drainage valve and removing it from the
a. A genetic in the production acetylcholine catheter bag
b. A reduced amount of neurotransmitter acetylcholine c. Wiping the catheter with alcohol and draining it into a
c. A decreased number of functioning acetylcholine receptor sterile test tube
sites d. Using a sterile syringe to remove it from clamped, cleansed
d. An inhibition of the enzyme ACHE leaving the end plates catheter
folded
58. Following an abdominal cholecystectomy, the nurse
52. A client with an inflamed sciatic nerve is to have a should assess for signs of respiratory complications
conventional transcutaneous electrical nerve stimulation because the:
(TENS) device applied to the painful nerve pathway. When
operating the TENS unit the nurse should a. Incision is in close proximity to the diaphragm
b. Length of time required for surgery is prolonged
a. Maintain the same dial setting everyday c. Client's resistance is lowered because of bile in the blood
b. Turn the machine several times a day for 10 to 20 minutes d. Bloodstream is invaded by microorganisms from the biliary
tract bleeding. The nurse recognizes that this is most likely
caused by:
59. The nurse assess the client with cholecystitis for the
development of obstructive jaundice, which would be a. An inadequate fluid intake
evidenced by: b. The after effects of anesthesia
c. A reallocation of the blo6d supply
a. Inadequate absorption of fat-soluble K d. An increased level of epinephrine
b. Light amber urine, dark brown stools, yellow skin
c. Dark-colored urine, clay colored stools, itchy skin 66. The occurrence of chronic illness is greatest in:
d. Straw-colored urine, putty-colored stools, yellow sclerae
a. Older adult
60. A client with cholelithiasis experience discomfort after b. Adolescents
ingesting fatty foods because. c. Young children
d. Middle-aged adults
a. Fatty foods are hard to digest
b. Bile flow into the intestine is obstructed 67. A client with full-thickness burns on the chest has a
c. The liver is manufacturing inadequate bile skin graft. During the 1s124 hours after a skin graft, care
d. There is inadequate closure of the Ampulla of Vater of the donor site includes immediately reporting.

61. The chief complaint in a client with Vincent's Angina a. Small amount of yellowish green oozing
is: b. A moderate area of serosanguinous oozing
c. Epithelialization under the non-adherent dressing
a. Chest pain d. Separation of the edges of the non-adherent dressing
b. Shortness of breath
c. Shoulder discomfort 68. During peritoneal dialysis the nurse observes that
d. Bleeding oral ulcerations drainage of dialysate from the peritoneal cavity has ceased
before the required amount has drained out The nurse
should assist the client to:

62. Clients with fractured mandibles usually have them a. Turn from side to side
immobilized with wires. The life-threatening problem that b. Drink 8 ounces of water
can develop postoperatively is: c. Deep breathe and cough
d. Periodically rotate the catheter
a. Infection
b. Vomiting 69. A client has ear surgery. An early response that may be
c. Osteomyelitis associated with possible damage to the motor branch of the
d. Bronchospasm facial nerve is:

63. As a result of fractured ribs, the client may develop: a. A bitter metallic state
b. Dryness of the lips and mouth
a. Scoliosis c. A sensation of pain behind the ear
b. Paradoxical respiration d. An inability to wrinkle the forehead
c. Obstructive lung-disease
d. Hernation of the diaphragm 70. After a prostatectomy, a client complains of painful
bladder spasms. To limit these spasms the nurse should:
64. A client has a bone marrow aspiration performed,
immediately after the procedure, the nurse should: a. Administer a narcotic every 4 hours
b. irrigate the Foley catheter with 60 ml of normal saline
a. Position the client on the affected side c. Encourage the client not to contract his muscles as if he
b. Begin frequent monitoring of vital signs were voiding
c. Cleanse the site with an antiseptic solution d. Advance the catheter to relieve the pressure against the
d. Briefly apply pressure over the aspiration site prostatic fossa

65. Following a bilateral lumbar sympathectomy a client 71. After 1 week a client with acute renal failure moves,
has a sudden drop in blood pressure but no. evidence of into the diuretic phase. During this phase the client must
be carefully assessed for signs of:
 correct?
a. Hypovolemia
b. Hyperkalemia a. The anal area is washed at a separate time
c. Metabolic acidosis b. The foreskin is retracted and the area beneath the foreskin
d. Chronic renal failure is cleansed
c. The foreskin should not be retracted except by a physician
72. The nurse checks for hypocalcemia by placing a blood d. The scrotum is carefully washed with sterile normal saline
pressure cuff on a client's arm and inflating it. After about
3 minutes the client develops carpopedial spasm. The 78. A female nurse is assigned to obtain a history from &
nurse records this finding as a positive: client with a urinary tract problem an sexual dysfunction.
Which of the following statements might place the client
a. Homan's sign more at ease and willing to give a. history of his problem?
b. Romberg sign
c. Chvostek's skin a. "When dud you first notice this problem?
d. Trosseau's sign b. "Why do you think you have a problem?"
c. "Do you think you sexual dysfunction is psychological?"
73. A client is scheduled for a below-the-knee amputation d. "Does your sexual dysfunction seem to be related to your
of the right leg. Legally, the client may not sign the urinary tract problem?"
operative consent if:
79. A client is scheduled for an ultrasound examination of
a. Ambivalent feelings regarding operation are present the prostate. To describe the procedure to the client, the
b. Any sedative type of medication has recently been nurse should plan to relate that:
administration
c. A discussion of alternative with 2 physicians have not been a. The procedure is performed using a cystoscope
performed and recorded b. A probe will be inserted into the rectum
d. A complete history and physical have not been performed c. A flat disk is placed on the abdomen
d. This procedure uses x-rays to produce a visual image
74. The nurse is assigned to check a client's continuous
bladder irrigation. Which one of the following solution is 80. To effectively teach men the importance of testicular
normally used for continuous or intermittent bladder and self-examination, the nurse should know that testicular
catheter irrigations? carcinoma:

a. Hydrogen peroxide a. Rarely metastasizes

b. Bacteriostatic water b. Has a high incidence of early metastasis
c. Sterile normal saline c. Cannot be detected by laboratory tests
d. Plain water d. Must first be biopsied to confirm the diagnosis

75. When continuous bladder irrigation is used following 81. A nurse is assigned to instruct a client in the method of
prostate surgery, the rate of flow is adjusted: testicular self-examination. The instruction should include
mention that the best time to perform this task is:
a. To run at 60 drops per minutes
b. According to the client's oral intake a. Immediately after getting out of bed in the morning
c. To maintain an output of 500 ml every 8 hours b. Immediately before going to bed
d. To keep the drainage to light pink c. In the morning after breakfast
d. After a warm bath or shower
76. The nurse is assigned to teach a class in health
behaviors to young man. Which of the following can be 82. Mr. Dorn has vasectomy. He asks the nurse why he just
stated as a probably cause of cancer of the penis? use a method of birth control because today he, had a
sterilization procedure. The most correct answer is:
a. A diet high in acidic foods
b. Poor personal hygiene a. The sperm count will not be negative until his testosterone
c. Exercise level decrease
d. Circumcision b. Some minor surgery usually is necessary to ensure
sterilization
77. The nurse is assigned to give perineal care to an c. Some live sperm will be present in the ejaculatory fluid for
uncircumcised male client. Which of the following is a period of time
d. Even though a vasectomy is performed, a condom is still
recommended for 1 to 2 years a. Ask the client to void prior to inserting the suppository
b. Lubricate the tip of the suppository with petroleum jelly
83. A client is scheduled for a cystectomy and asks the c. Insert the applicator tip gently and with an upward and
nurse what the physician will be able to see during the forward motion
procedure. The most correct reply is the: d. Insert the applicator approximately ½ inch and depress the
plunger
a. Kidney and ureters
b. Bladder and rectum 89. The nurse is assigned to give Ms. Milton perineal care.
c. Prostate and ureters When cleansing the perineum, the cotton ball or wash
d. Urethra and bladder cloth is gently directed:

84. A client is scheduled for a cystectomy and asks the a. Side to side across the labia majora
nurse what the physician will be able to see during the b. Downward from the pubic area to the anus
procedure. The most correct reply is the: c. Upward from the anus to the pubic area
d. Prom the urinary meatus to the vagina
a. Kidney and ureters
b. Bladder and rectum 90. The nurse is assigned to administer a vaginal irrigation
c. Prostate and ureters (douche). Which of the following is correct?
d. Urethra and bladder
a. The irrigation is best administered with the client standing
85. Nurse assistant attending a nursing conference hears in a bathtub
that one of her clients has hydrocele. She asks the nurse b. Before inserting, the nozzle is lubricated with petroleum
how this condition is treated. The most common response jelly
is: c. The temperature of the solution should be between 80°F and
84°F
a. Usually the problem requires more medical or surgical d. The nozzle is inserted downward and backward within the
intervention vagina
b. Surgery may be necessary to correct the problem
c. Wearing a scrotal support usually corrects She problem 91. The nurse is assigned to teach health-seeking behaviors
d. Drug therapy usually helps control the collection of fluid to young women. One topic the nurse plans to includes is
the importance of the Pap test, which is used mainly to
86. The nurse is participating in a health class for young detect:
women. One subject is cancer of the ovary. Which of the
following statements is correct? a. Ovarian cyst
b. Patency of the fallopian tube
a. Early symptoms of cancer of the ovary are vague c. Cervical cancer
b. This type of cancer has a high cure rate d. Uterine infections
c. Chemotherapy is not used for treating ovarian cancer
d. The most prominent early symptoms is an irregular 92. The physician asks the nurse to position a client for a
menstrual cycle vaginal examination. Which of the following position is
normally used for this type of examination?
87. The nurse is asked to discuss the signs and symptoms
of vaginitis caused by the fungus candida albicans with a. Lithotomy position
Ms. Barrows. Which one of the following is a usual sign b. Sim's position
and symptoms of this infection? c. Dorsal recumbent position
d. Left lateral position
a. Pain high in the abdomen
b. Intensive vaginal and perineal itching 93. Ms. Hull has had an electrocauterization of her cervix
c. Decrease in urinary output for chronic cervicitis. Following the procedure the nurse
d. High fever should instruct Ms. Hull to:

88. The nurse prepares to give Ms. Edwards a vaginal a. Douche the next day to remove debris and blood cloth
suppository, which is inserted by means of a special b. Avoid straining and heavy lifting until the physician permits
applicator supplied with the drug. Which one of the this activity
following is correct? c. Stay in bed for the next 5 days
d. Return in bed for the next 5 days leg. Which of the following nursing actions is correct when
applying the warm moist compress? The nurse:
94. The nursing assistant is assigned to give Ms. Bailey,
who has had an abdominal hysterectomy, a sitz bath. She a. Heats the water to 120°F
is instructed to use the special sitz bath tub. She asks the b. Uses a sterile technique
nurse why the regular bath tub cannot be used. The most c. Inspect the skin every 4 hours
correct reply is based on the fact that a regular bath tab: d. Covers the wet gauze with a towel

a. Is more slippery and is dangerous when used for surgical 100. Ms. Betty Lynch, age 29, holes that she has recently
clients developed a skin problem and makes an appointment to be
b. Cannot supply water that is of the desired temperature for seen in a clinic specializing diagnosis of psoriasis is made
this procedure by the physician. When examining Mr. Lynch's skin for
c. Applies heat to the legs and alters the desired effect of heat areas of psoriasis, the nurse should look for:
directed to the pelvic region
d. Cannot be kept as clean as a special sitz bath tub a. Weeping lesions on the trunk of the body
b. Patches of redness covered with silvery scales
95. Which of the following solutions would be best for the c. Areas of redness surrounded by crusts
nurse to use when cleaning the inner cannula of a d. A rash characterized by raised, pus-filled lesions
tracheostomy tube?
101. Before being discharged, Mr. Heywood must be
a. IsopropyI alcohol taught principles f good body mechanics. The nurse would
b. Sodium hydrochloride be correct in telling Mr. Heywood that when he picks up
c. Hydrogen peroxide something, he should:
d. Providone-iodine
a. Flex both his knees
96. The nurse observes that the client's knee is swollen and b. Keep his feet together
painful. Consequently; which one of the following nursing c. Lift with arms extended
measures should be carried out? d. Bend from the waist

a. Perform passive range of motion during each shift 102. The nurse applies a commercially made hot moist
b. Help to change positions to achieve comfort pack, called a hydrocollator, to the client's lower back. To
c. Ambulate with him at frequent intervals reduce the potential for a thermal injury the nurse should
d. Encourage quadriceps setting exercises plan to:

97. If Ms. Drake tells the nurse her feet are cold. Which of a. Wrap the pack in several thick towels
the following nursing action would be best b. Rub skin lotion over the back area
c. Place a pillow between hint and the back
a. Apply a hot water bottle d. Position the client on rubber ring
b Use an electric heating pad
c. Wrap them in a warm blanket 103. Which one of the following observations would most
d. Elevate her feet on a stool indicate to the nurse that the skin over Mr. Heywood's
coccyx is becoming impaired? The skin:
98. Which of the following would indicate to the nurse that
the stationary thrombus in Ms. Fleming suddenly a. Looks shiny over boy prominences
develops? b. Appears red when pressure in relieved
a. Chest pains c. Feels cool and clammy
b. Leg cramps d. Is moist and warm
c. Numbness in the foot
d. Swelling of the knee 104. Before turning Mr. Heywood to wash his back, which
instruction should the nurse provide to minimize his
discomfort?
99. Following a total abdominal hysterectomy Ms. Sara
Fleming develops a slightly elevated temperature and a. "Hold your breath as you are turning."
swelling in the right call of her leg. The physician b. "Move your upper body first then legs."
prescribes warm moist compresses for the client's affected c. "Curl up in a ball before you move."
d. "Avoid twisting your body while moving."
 b. Supine extended
105. Which of the following should the nurse use to c. On his back with his legs elevated
provide support to Mr. Heywood's spine? d. On his side with his neck

a. A sheep skin pad 111. During a farming accident Mr. Steve Rumsey's arm
b. An air mattress gets caught in a corn auger. His lower left arm and band
c. A bed board are crushed. Which of the following assessments would the
d. A foam square nurse typically find when the paramedics bring Mr.
Rumsey to the hospital in shock? The client would have:
106. Mr. Heywood is to remain in bed for the time being.
Which position would the nurse find gives Mr. Heywood a. Decreased heart rate
the most comfort? b. Decreasing blood pressure
c. Increasing bowel sounds
a. On his back with the head and knees elevated d. Increasing urine output
b. On his side with hips and legs straight
c. On his abdomen with his head to the side 112. Ms. Angela Freeman has acute low back pain. She'
d. On his back with his head and knees straight has pelvic-belt traction, which she uses intermittently
throughout the day. When the nurse helps Ms. Freeman
107. Mr. Heywood is receiving 10 mg of Diazepam apply the pelvic traction, it would be best to place the top
(Vatium) orally t.i.d. Besides diminishing anxiety, the of the belt:
nurse explains that this medication is also used to:
a. Just below the ribcage
a. Reduce emotional depression b. Even with her waistline
b. Relax skeletal muscles c. Level with the iliac crest
c. Promote restful sleep d. Where it is most comfortable
d. Relieve inflammation
113. Ms. Rizal has acute rheumatoid arthritis. Her hands
108. Mr. Barry Heywood, a construction worker, has been and spine are involved. When the nurse admits Ms. Rizal
experiencing periodic bouts of law back pain. Now, in is most likely to tell the nurse that the first symptoms that
addition to the pain that radiates into his buttocks, he has caused her to seek health care was:
some numbness and tingling in his legs. The physician
suspects that Mr. Heywood has a herniated intervertebral a. Stiff, sore joints
disk in the lumbar spine. While assessing the disk to b. Generalized fatigue
indicate that the pain is increased when: c. Stabbing hand pain
d. Disuse of fingers
a. Eating
b. Sneezing 114. Before Ms. Elkins leaves the emergency department,
c. Resting the nurse demonstrates hew to apply the roller bandage.
d. Urinating She is told to remove it for approximately 20 minutes and
re-apply it three times a day. It is essential that the nurse
109. Mr. Rumsey, who has not regained consciousness, tells Ms. Elkins to loosen-the bandage if:
rushed to surgery where his arm is amputated above the
elbow. When Mr. Rumsey reacts from the anesthesia, he a. Her toes feel fairly warm
sees that his forearm is missing. He screams obscenities b. Her ankle feels painful
and sobs uncontrollably. Which of the following is the best c. Her toes appear swollen
action the nurse can take at this time? d. She wears a cotton sock

a. Leave the room until he has worked through his anger 115. The x-ray reveals that the bones are intact. The
b. Stay with him quietly in the room at his bedside physician tells Ms. Elkins that she has severely sprained
c. Tell him to get control of himself ankle. The physician directs the nurse to wrap Ms. Elkins
d. Call the hospital chaplain for him foot with an elastic roller bandage referred to by some as
an Ace bandage. Where should the nurse begin applying
110. In what position should the nurse place Mr. Rumsey the bandage?
while continuing with his assessment and care?
a. Below the knee
a. Prone b. Above the knee
c. Across the phalanges d. Facial flushing and twitching
d. At the metatarsals

116. Following an injury in which Ms. Leona Elkins while

climbing stairs, she experiencing immediate swelling of her 121. The doctor orders MAFENIDE for application over
ankle and pain on movement. Her physician has sent her the bum area. The nurse understands that one
to the hospital for x-ray. Which on of the following nursing disadvantage of this drug is that:
measures would be most helpful for relieving the swelling
while preparing to obtain the x-ray of Ms. Elkin's lower a. It causes lactic acidosis
leg? b. It must be constantly applied
c. It has minimal eschar penetration
a. Dangle the foot d. It is bacteriostatic
b. Elevate the foot
c. Exercise the foot SITUATION: MARK Lester had been diagnosed with Stage 1
d. Immobilize the foot bronchogenic cancer. He had undergone lobectomy on the left
lower lung. A two-bottle drainage system is inserted.
SITUATION: Mr. Ramos was barbecuing outdoors when the
gas tank exploded. He sustained second degree and third 122. The patient is placed on bed post-operatively in what
degree burns of the anterior portion of BOTH arms, the upper position?
half of his anterior trunk and the anterior and posterior
portions of his left lower extremity. a. Prone
b. Trendelenburg
117. The BEST initial management of burns that can be c. Right side
employed at the scene is generally which of the following: d. Left side

a. Pour cold water over the burned areas 123 Water-seal chest drainage involves attaching the chest
b. Apply clean dressing to the affected area tube to a:
c. Rinse the area with mild soap and water
d. Apply tomato juice and ointment over the area a. Suction machine directly
b. Rubber tube/glass tube that is submerged underwater
118. At the emergency room, the nurse assessed the extent c. Rubber tube that is left open to air
of the burn on the patient's body. Based on the rules of d. A closed drainage bottle with sterile water and no external
nine. Which of the following is the BEST estimate of the opening
burn?
124. If the nurse sees fluid moving up and down during
a. 36% inspiration and expiration on the water seal bottle, she
b. 45% should:
c. 27%
d. 54% a. Do nothing as this is expected
b. Immediately check the bottle for leaks
119. Which one of the following .blood value c. Call the physician immediately and damp the chest tube
determinations is most likely be useful to evaluate the d. Cover the wound with wet sterile gauze and send someone
adequacy of the fluid replacement? to calf the physician

a. Creatinine levels 125. If the nurse sees vigorous and continuous bubbling in
b. Blood urea nitrogen the second bottle, she should:
c. Hematocrit level
d. C02 tension a. Momentarily clamp the tube to note for air leak
b. Administer oxygen to the patient
120. The nurse is administering the prescribed IVF. When c. Attempt to change a new bottle
she evaluated the patient, she suspected fluid overload d. Pull the chest tube out to remove the air leak
because of which finding?
126. If the tube accidentally displaces from the chest of the
a. Dark and scant urine output patient, the nurse should do which action first?
b. Moist rates
c. Bradycardia and hypotension
a. Clamp the tube with the use of forceps c. Attempt to reinsert the tube
b. Obtain a new set of tubing and submerge the tube on the d. Apply vaselinized gauze to the opening
water