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MEDICAL SURGICAL NURSING Part 1 8. Dr. Marquez orders a continuous intravenous

nitroglycerin infusion for the client suffering from
1. Mrs. Chua a 78 year old client is admitted with the myocardial infarction. Which of the following is the most
diagnosis of mild chronic heart failure. The nurse expects essential nursing action?
to hear when listening to client’s lungs indicative of a. Monitoring urine output frequently
chronic heart failure would be: b. Monitoring blood pressure every 4 hours
a. Stridor c. Obtaining serum potassium levels daily
b. Crackles d. Obtaining infusion pump for the medication
c. Wheezes 9. During the second day of hospitalization of the client
d. Friction rubs after a Myocardial Infarction. Which of the following is
2. Patrick who is hospitalized following a myocardial an expected outcome?
infarction asks the nurse why he is taking morphine. The a. Able to perform self-care activities without pain
nurse explains that morphine: b. Severe chest pain
a. Decrease anxiety and restlessness c. Can recognize the risk factors of Myocardial Infarction
b. Prevents shock and relieves pain d. Can Participate in cardiac rehabilitation walking
c. Dilates coronary blood vessels program
d. Helps prevent fibrillation of the heart 10. A 68 year old client is diagnosed with a right-sided
3. Which of the following should the nurse teach the brain attack and is admitted to the hospital. In caring for
client about the signs of digitalis toxicity? this client, the nurse should plan to:
a. Increased appetite a. Application of elastic stockings to prevent flaccid by
b. Elevated blood pressure muscle
c. Skin rash over the chest and back b. Use hand roll and extend the left upper extremity on a
d. Visual disturbances such as seeing yellow spots pillow to prevent contractions
4. Nurse Trisha teaches a client with heart failure to take c. Use a bed cradle to prevent dorsiflexion of feet
oral Furosemide in the morning. The reason for this is to d. Do passive range of motion exercise
help… 11. Nurse Liza is assigned to care for a client who has
a. Retard rapid drug absorption returned to the nursing unit after left nephrectomy.
b. Excrete excessive fluids accumulated at night Nurse Liza’s highest priority would be…
c. Prevents sleep disturbances during night a. Hourly urine output
d. Prevention of electrolyte imbalance b. Temperature
5. What would be the primary goal of therapy for a client c. Able to turn side to side
with pulmonary edema and heart failure? d. Able to sips clear liquid
a. Enhance comfort 12. A 64 year old male client with a long history of
b. Increase cardiac output cardiovascular problem including hypertension and
c. Improve respiratory status angina is to be scheduled for cardiac catheterization.
d. Peripheral edema decreased During pre cardiac catheterization teaching, Nurse
6. Nurse Linda is caring for a client with head injury and Cherry should inform the client that the primary purpose
monitoring the client with decerebrate posturing. Which of the procedure is…..
of the following is a characteristic of this type of a. To determine the existence of CHD
posturing? b. To visualize the disease process in the coronary
a. Upper extremity flexion with lower extremity flexion arteries
b. Upper extremity flexion with lower extremity c. To obtain the heart chambers pressure
extension d. To measure oxygen content of different heart
c. Extension of the extremities after a stimulus chambers
d. Flexion of the extremities after stimulus 13. During the first several hours after a cardiac
7. A female client is taking Cascara Sagrada. Nurse Betty catheterization, it would be most essential for nurse
informs the client that the following maybe experienced Cherry to…
as side effects of this medication: a. Elevate clients bed at 45°
a. GI bleeding b. Instruct the client to cough and deep breathe every 2
b. Peptic ulcer disease hours
c. Abdominal cramps c. Frequently monitor client’s apical pulse and blood
d. Partial bowel obstruction pressure

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d. Monitor clients temperature every hour male client will go home with a prescription for which
14. Kate who has undergone mitral valve replacement medication?
suddenly experiences continuous bleeding from the a. Paracetamol
surgical incision during postoperative period. Which of b. Ibuprofen
the following pharmaceutical agents should Nurse Aiza c. Nitroglycerin
prepare to administer to Kate? d. Nicotine (Nicotrol)
a. Protamine Sulfate 21. Nurse Lilly has been assigned to a client with
b. Quinidine Sulfate Raynaud’s disease. Nurse Lilly realizes that the etiology
c. Vitamin C of the disease is unknown but it is characterized by:
d. Coumadin a. Episodic vasospastic disorder of capillaries
15. In reducing the risk of endocarditis, good dental care b. Episodic vasospastic disorder of small veins
is an important measure. To promote good dental care c. Episodic vasospastic disorder of the aorta
in client with mitral stenosis in teaching plan should d. Episodic vasospastic disorder of the small arteries
include proper use of… 22. Nurse Jamie should explain to male client with
a. Dental floss diabetes that self-monitoring of blood glucose is
b. Electric toothbrush preferred to urine glucose testing because…
c. Manual toothbrush a. More accurate
d. Irrigation device b. Can be done by the client
16. Among the following signs and symptoms, which c. It is easy to perform
would most likely be present in a client with mitral d. It is not influenced by drugs
gurgitation? 23. Jessie weighed 210 pounds on admission to the
a. Altered level of consciousness hospital. After 2 days of diuretic therapy, Jessie weighs
b. Exceptional Dyspnea 205.5 pounds. The nurse could estimate the amount of
c. Increase creatine phospholinase concentration fluid Jessie has lost…
d. Chest pain a. 0.3 L
17. Kris with a history of chronic infection of the urinary b. 1.5 L
system complains of urinary frequency and burning c. 2.0 L
sensation. To figure out whether the current problem is d. 3.5 L
in renal origin, the nurse should assess whether the 24. Nurse Donna is aware that the shift of body fluids
client has discomfort or pain in the… associated with Intravenous administration of albumin
a. Urinary meatus occurs in the process of:
b. Pain in the Labium a. Osmosis
c. Suprapubic area b. Diffusion
d. Right or left costovertebral angle c. Active transport
18. Nurse Perry is evaluating the renal function of a male d. Filtration
client. After documenting urine volume and 25. Myrna a 52 year old client with a fractured left tibia
characteristics, Nurse Perry assesses which signs as the has a long leg cast and she is using crutches to ambulate.
best indicator of renal function. Nurse Joy assesses for which sign and symptom that
a. Blood pressure indicates complication associated with crutch walking?
b. Consciousness a. Left leg discomfort
c. Distension of the bladder b. Weak biceps brachii
d. Pulse rate c. Triceps muscle spasm
19. John suddenly experiences a seizure, and Nurse Gina d. Forearm weakness
notice that John exhibits uncontrollable jerking 26. Which of the following statements should the nurse
movements. Nurse Gina documents that John teach the neutropenic client and his family to avoid?
experienced which type of seizure? a. Performing oral hygiene after every meal
a. Tonic seizure b. Using suppositories or enemas
b. Absence seizure c. Performing perineal hygiene after each bowel
c. Myoclonic seizure movement
d. Clonic seizure d. Using a filter mask
20. Smoking cessation is critical strategy for the client 27. A female client is experiencing painful and rigid
with Burgher’s disease, Nurse Jasmin anticipates that the abdomen and is diagnosed with perforated peptic ulcer.

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A surgery has been scheduled and a nasogastric tube is 34. Nurse Lucy is planning to give pre operative teaching
inserted. The nurse should place the client before to a client who will be undergoing rhinoplasty. Which of
surgery in the following should be included?
a. Sims position a. Results of the surgery will be immediately noticeable
b. Supine position postoperatively
c. Semi-fowlers position b. Normal saline nose drops will need to be administered
d. Dorsal recumbent position preoperatively
28. Which nursing intervention ensures adequate c. After surgery, nasal packing will be in place 8 to 10
ventilating exchange after surgery? days
a. Remove the airway only when client is fully conscious d. Aspirin containing medications should not be taken 14
b. Assess for hypoventilation by auscultating the lungs days before surgery
c. Position client laterally with the neck extended 35. Paul is admitted to the hospital due to metabolic
d. Maintain humidified oxygen via nasal canula acidosis caused by Diabetic ketoacidosis (DKA). The
29. George who has undergone thoracic surgery has nurse prepares which of the following medications as an
chest tube connected to a water-seal drainage system initial treatment for this problem?
attached to suction. Presence of excessive bubbling is a. Regular insulin
identified in water-seal chamber, the nurse should… b. Potassium
a. “Strip” the chest tube catheter c. Sodium bicarbonate
b. Check the system for air leaks d. Calcium gluconate
c. Recognize the system is functioning correctly 36. Dr. Marquez tells a client that an increase intake of
d. Decrease the amount of suction pressure foods that are rich in Vitamin E and beta-carotene are
30. A client who has been diagnosed of hypertension is important for healthier skin. The nurse teaches the client
being taught to restrict intake of sodium. The nurse that excellent food sources of both of these substances
would know that the teachings are effective if the client are:
states that… a. Fish and fruit jam
a. I can eat celery sticks and carrots b. Oranges and grapefruit
b. I can eat broiled scallops c. Carrots and potatoes
c. I can eat shredded wheat cereal d. Spinach and mangoes
d. I can eat spaghetti on rye bread 37. A client has Gastroesophageal Reflux Disease (GERD).
31. A male client with a history of cirrhosis and The nurse should teach the client that after every meals,
alcoholism is admitted with severe dyspnea resulted to the client should…
ascites. The nurse should be aware that the ascites is a. Rest in sitting position
most likely the result of increased… b. Take a short walk
a. Pressure in the portal vein c. Drink plenty of water
b. Production of serum albumin d. Lie down at least 30 minutes
c. Secretion of bile salts 38. After gastroscopy, an adaptation that indicates major
d. Interstitial osmotic pressure complication would be:
32. A newly admitted client is diagnosed with Hodgkin’s a. Nausea and vomiting
disease undergoes an excisional cervical lymph node b. Abdominal distention
biopsy under local anesthesia. What does the nurse c. Increased GI motility
assess first after the procedure? d. Difficulty in swallowing
a. Vital signs 39. A client who has undergone a cholecystectomy asks
b. Incision site the nurse whether there are any dietary restrictions that
c. Airway must be followed. Nurse Hilary would recognize that the
d. Level of consciousness dietary teaching was well understood when the client
33. A client has 15% blood loss. Which of the following tells a family member that:
nursing assessment findings indicates hypovolemic a. “Most people need to eat a high protein diet for 12
shock? months after surgery”
a. Systolic blood pressure less than 90mm Hg b. “I should not eat those foods that upset me before the
b. Pupils unequally dilated surgery”
c. Respiratory rate of 4 breath/min c. “I should avoid fatty foods as long as I live”
d. Pulse rate less than 60bpm

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d. “Most people can tolerate regular diet after this type 46. Nurse Jenny is instilling an otic solution into an adult
of surgery” male client left ear. Nurse Jenny avoids doing which of
40. Nurse Rachel teaches a client who has been recently the following as part of the procedure
diagnosed with hepatitis A about untoward signs and a. Pulling the auricle backward and upward
symptoms related to Hepatitis that may develop. The b. Warming the solution to room temperature
one that should be reported immediately to the c. Pacing the tip of the dropper on the edge of ear canal
physician is: d. Placing client in side lying position
a. Restlessness 47. Nurse Bea should instruct the male client with an
b. Yellow urine ileostomy to report immediately which of the following
c. Nausea symptom?
d. Clay- colored stools a. Absence of drainage from the ileostomy for 6 or more
41. Which of the following antituberculosis drugs can hours
damage the 8th cranial nerve? b. Passage of liquid stool in the stoma
a. Isoniazid (INH) c. Occasional presence of undigested food
b. Paraoaminosalicylic acid (PAS) d. A temperature of 37.6 °C
c. Ethambutol hydrochloride (myambutol) 48. Jerry has diagnosed with appendicitis. He develops a
d. Streptomycin fever, hypotension and tachycardia. The nurse suspects
42. The client asks Nurse Annie the causes of peptic which of the following complications?
ulcer. Nurse Annie responds that recent research a. Intestinal obstruction
indicates that peptic ulcers are the result of which of the b. Peritonitis
following: c. Bowel ischemia
a. Genetic defect in gastric mucosa d. Deficient fluid volume
b. Stress 49. Which of the following compilations should the nurse
c. Diet high in fat carefully monitors a client with acute pancreatitis.
d. Helicobacter pylori infection a. Myocardial Infarction
43. Ryan has undergone subtotal gastrectomy. The nurse b. Cirrhosis
should expect that nasogastric tube drainage will be c. Peptic ulcer
what color for about 12 to 24 hours after surgery? d. Pneumonia
a. Bile green 50. Which of the following symptoms during the icteric
b. Bright red phase of viral hepatitis should the nurse expect the
c. Cloudy white client to inhibit?
d. Dark brown a. Watery stool
44. Nurse Joan is assigned to come for client who has b. Yellow sclera
just undergone eye surgery. Nurse Joan plans to teach c. Tarry stool
the client activities that are permitted during the post d. Shortness of breath
operative period. Which of the following is best
recommended for the client?
a. Watching circus
b. Bending over
c. Watching TV
d. Lifting objects
45. A client suffered from a lower leg injury and seeks
treatment in the emergency room. There is a prominent
deformity to the lower aspect of the leg, and the injured
leg appears shorter that the other leg. The affected leg is
painful, swollen and beginning to become ecchymotic.
The nurse interprets that the client is experiencing:
a. Fracture
b. Strain
c. Sprain
d. Contusion

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ANSWERS and RATIONALES for MEDICAL SURGICAL gums, allowing bacteria to enter and increasing
NURSING Part 1 the risk of endocarditis.
16. B. Weight gain due to retention of fluids and
1. B. Left sided heart failure causes fluid worsening heart failure causes exertional
accumulation in the capillary network of the dyspnea in clients with mitral regurgitation.
lung. Fluid eventually enters alveolar spaces and 17. D. Discomfort or pain is a problem that
causes crackling sounds at the end of inspiration. originates in the kidney. It is felt at the
2. B. Morphine is a central nervous system costovertebral angle on the affected side.
depressant used to relieve the pain associated 18. A. Perfusion can be best estimated by blood
with myocardial infarction, it also decreases pressure, which is an indirect reflection of the
apprehension and prevents cardiogenic shock. adequacy of cardiac output.
3. D. Seeing yellow spots and colored vision are 19. C. Myoclonic seizure is characterized by sudden
common symptoms of digitalis toxicity uncontrollable jerking movements of a single or
4. C. When diuretics are taken in the morning, multiple muscle group.
client will void frequently during daytime and 20. D. Nicotine (Nicotrol) is given in controlled and
will not need to void frequently at night. decreasing doses for the management of
5. B. The primary goal of therapy for the client with nicotine withdrawal syndrome.
pulmonary edema or heart failure is increasing 21. D. Raynaud’s disease is characterized by
cardiac output. Pulmonary edema is an acute vasospasms of the small cutaneous arteries that
medical emergency requiring immediate involves fingers and toes.
intervention. 22. A. Urine testing provides an indirect measure
6. C. Decerebrate posturing is the extension of the that maybe influenced by kidney function while
extremities after a stimulus, which may occur blood glucose testing is a more direct and
with upper brain stem injury. accurate measure.
7. C. The most frequent side effects of Cascara 23. C. One liter of fluid approximately weighs 2.2
Sagrada (Laxative) is abdominal cramps and pounds. A 4.5 pound weight loss equals to
nausea. approximately 2L.
8. D. Administration of Intravenous Nitroglycerin 24. A. Osmosis is the movement of fluid from an
infusion requires pump for accurate control of area of lesser solute concentration to an area of
medication. greater solute concentration.
9. A. By the 2nd day of hospitalization after 25. D. Forearm muscle weakness is a probable sign
suffering a Myocardial Infarction, Clients are of radial nerve injury caused by crutch pressure
able to perform care without chest pain on the axillae.
10. B. The left side of the body will be affected in a 26. B. Neutropenic client is at risk for infection
right-sided brain attack. especially bacterial infection of the
11. A. After nephrectomy, it is necessary to measure gastrointestinal and respiratory tract.
urine output hourly. This is done to assess the 27. C. Semi-fowlers position will localize the spilled
effectiveness of the remaining kidney also to stomach contents in the lower part of the
detect renal failure early. abdominal cavity.
12. B. The lumen of the arteries can be assessed by 28. C. Positioning the client laterally with the neck
cardiac catheterization. Angina is usually caused extended does not obstruct the airway so that
by narrowing of the coronary arteries. drainage of secretions and oxygen and carbon
13. C. Blood pressure is monitored to detect dioxide exchange can occur.
hypotension which may indicate shock or 29. B. Excessive bubbling indicates an air leak which
hemorrhage. Apical pulse is taken to detect must be eliminated to permit lung expansion.
dysrhythmias related to cardiac irritability. 30. C. Wheat cereal has a low sodium content.
14. A. Protamine Sulfate is used to prevent 31. A. Enlarged cirrhotic liver impinges the portal
continuous bleeding in client who has system causing increased hydrostatic pressure
undergone open heart surgery. resulting to ascites.
15. C. The use of electronic toothbrush, irrigation 32. C. Assessing for an open airway is the priority.
device or dental floss may cause bleeding of The procedure involves the neck, the anesthesia
may have affected the swallowing reflex or the

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inflammation may have closed in on the airway 49. D. A client with acute pancreatitis is prone to
leading to ineffective air exchange. complications associated with respiratory
33. A. Typical signs and symptoms of hypovolemic system.
shock includes systolic blood pressure of less 50. B. Liver inflammation and obstruction block the
than 90 mm Hg. normal flow of bile. Excess bilirubin turns the
34. D. Aspirin containing medications should not be skin and sclera yellow and the urine dark and
taken 14 days before surgery to decrease the frothy.
risk of bleeding.
35. A. Metabolic acidosis is anaerobic metabolism
caused by lack of ability of the body to use
circulating glucose. Administration of insulin
corrects this problem.
36. D. Beta-carotene and Vitamin E are antioxidants
which help to inhibit oxidation. Vitamin E is
found in the following foods: wheat germ, corn,
nuts, seeds, olives, spinach, asparagus and other
green leafy vegetables. Food sources of beta-
carotene include dark green vegetables, carrots,
mangoes and tomatoes.
37. A. Gravity speeds up digestion and prevents
reflux of stomach contents into the esophagus.
38. B. Abdominal distension may be associated with
pain, may indicate perforation, a complication
that could lead to peritonitis.
39. D. It may take 4 to 6 months to eat anything, but
most people can eat anything they want.
40. D. Clay colored stools are indicative of hepatic
obstruction
41. D. Streptomycin is an aminoglycoside and
damage on the 8th cranial nerve (ototoxicity) is a
common side effect of aminoglycosides.
42. D. Most peptic ulcer is caused by Helicopter
pylori which is a gram negative bacterium.
43. D. 12 to 24 hours after subtotal gastrectomy
gastric drainage is normally brown, which
indicates digested food.
44. C. Watching TV is permissible because the eye
does not need to move rapidly with this activity,
and it does not increase intraocular pressure.
45. A. Common signs and symptoms of fracture
include pain, deformity, shortening of the
extremity, crepitus and swelling.
46. C. The dropper should not touch any object or
any part of the client’s ear.
47. A. Sudden decrease in drainage or onset of
severe abdominal pain should be reported
immediately to the physician because it could
mean that obstruction has been developed.
48. B. Complications of acute appendicitis are
peritonitis, perforation and abscess
development.

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MEDICAL SURGICAL NURSING Part 2 c. Protects the client’s head from injury
d. Attempt to insert a tongue depressor between the
1. A client is scheduled for insertion of an inferior vena client’s teeth
cava (IVC) filter. Nurse Patricia consults the physician 8. A client has undergone right pneumonectomy. When
about withholding which regularly scheduled medication turning the client, the nurse should plan to position the
on the day before the surgery? client either:
a. Potassium Chloride a. Right side-lying position or supine
b. Warfarin Sodium b. High fowlers
c. Furosemide c. Right or left side lying position
d. Docusate d. Low fowler’s position
2. A nurse is planning to assess the corneal reflex on 9. Nurse Jenny should caution a female client who is
unconscious client. Which of the following is the safest sexually active in taking Isoniazid (INH) because the drug
stimulus to touch the client’s cornea? has which of the following side effects?
a. Cotton buds a. Prevents ovulation
b. Sterile glove b. Has a mutagenic effect on ova
c. Sterile tongue depressor c. Decreases the effectiveness of oral contraceptives
d. Wisp of cotton d. Increases the risk of vaginal infection
3. A female client develops an infection at the catheter 10. A client has undergone gastrectomy. Nurse Jovy is
insertion site. The nurse in charge uses the term aware that the best position for the client is:
“iatrogenic” when describing the infection because it a. Left side lying
resulted from: b. Low fowler’s
a. Client’s developmental level c. Prone
b. Therapeutic procedure d. Supine
c. Poor hygiene 11. During the initial postoperative period of the client’s
d. Inadequate dietary patterns stoma. The nurse evaluates which of the following
4. Nurse Carol is assessing a client with Parkinson’s observations should be reported immediately to the
disease. The nurse recognize bradykinesia when the physician?
client exhibits: a. Stoma is dark red to purple
a. Intentional tremor b. Stoma is oozes a small amount of blood
b. Paralysis of limbs c. Stoma is lightly edematous
c. Muscle spasm d. Stoma does not expel stool
d. Lack of spontaneous movement 12. Kate which has diagnosed with ulcerative colitis is
5. A client who suffered from automobile accident following physician’s order for bed rest with bathroom
complains of seeing frequent flashes of light. The nurse privileges. What is the rationale for this activity
should expect: restriction?
a. Myopia a. Prevent injury
b. Detached retina b. Promote rest and comfort
c. Glaucoma c. Reduce intestinal peristalsis
d. Scleroderma d. Conserve energy
6. Kate with severe head injury is being monitored by the 13. Nurse KC should regularly assess the client’s ability to
nurse for increasing intracranial pressure (ICP). Which metabolize the total parenteral nutrition (TPN) solution
finding should be most indicative sign of increasing adequately by monitoring the client for which of the
intracranial pressure? following signs:
a. Intermittent tachycardia a. Hyperglycemia
b. Polydipsia b. Hypoglycemia
c. Tachypnea c. Hypertension
d. Increased restlessness d. Elevate blood urea nitrogen concentration
7. A hospitalized client had a tonic-clonic seizure while 14. A female client has an acute pancreatitis. Which of
walking in the hall. During the seizure the nurse priority the following signs and symptoms the nurse would
should be: expect to see?
a. Hold the clients arms and leg firmly a. Constipation
b. Place the client immediately to soft surface b. Hypertension

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c. Ascites 22. The nurse is assessing a client with pleural effusion.

d. Jaundice The nurse expect to find:
15. A client is suspected to develop tetany after a a. Deviation of the trachea towards the involved side
subtotal thyroidectomy. Which of the following b. Reduced or absent of breath sounds at the base of the
symptoms might indicate tetany? lung
a. Tingling in the fingers c. Moist crackles at the posterior of the lungs
b. Pain in hands and feet d. Increased resonance with percussion of the involved
c. Tension on the suture lines area
d. Bleeding on the back of the dressing 23. A client admitted with newly diagnosed with
16. A 58 year old woman has newly diagnosed with Hodgkin’s disease. Which of the following would the
hypothyroidism. The nurse is aware that the signs and nurse expect the client to report?
symptoms of hypothyroidism include: a. Lymph node pain
a. Diarrhea b. Weight gain
b. Vomiting c. Night sweats
c. Tachycardia d. Headache
d. Weight gain 24. A client has suffered from fall and sustained a leg
17. A client has undergone for an ileal conduit, the nurse injury. Which appropriate question would the nurse ask
in charge should closely monitor the client for the client to help determine if the injury caused
occurrence of which of the following complications fracture?
related to pelvic surgery? a. “Is the pain sharp and continuous?”
a. Ascites b. “Is the pain dull ache?”
b. Thrombophlebitis c. “Does the discomfort feel like a cramp?”
c. Inguinal hernia d. “Does the pain feel like the muscle was stretched?”
d. Peritonitis 25. The Nurse is assessing the client’s casted extremity
18. Dr. Marquez is about to defibrillate a client in for signs of infection. Which of the following findings is
ventricular fibrillation and says in a loud voice “clear”. indicative of infection?
What should be the action of the nurse? a. Edema
a. Places conductive gel pads for defibrillation on the b. Weak distal pulse
client’s chest c. Coolness of the skin
b. Turn off the mechanical ventilator d. Presence of “hot spot” on the cast
c. Shuts off the client’s IV infusion 26. Nurse Rhia is performing an otoscopic examination
d. Steps away from the bed and make sure all others on a female client with a suspected diagnosis of
have done the same mastoiditis. Nurse Rhia would expect to note which of
19. A client has been diagnosed with glomerulonephritis the following if this disorder is present?
complains of thirst. The nurse should offer: a. Transparent tympanic membrane
a. Juice b. Thick and immobile tympanic membrane
b. Ginger ale c. Pearly colored tympanic membrane
c. Milk shake d. Mobile tympanic membrane
d. Hard candy 27. Nurse Jocelyn is caring for a client with nasogastric
20. A client with acute renal failure is aware that the tube that is attached to low suction. Nurse Jocelyn
most serious complication of this condition is: assesses the client for symptoms of which acid-base
a. Constipation disorder?
b. Anemia a. Respiratory alkalosis
c. Infection b. Respiratory acidosis
d. Platelet dysfunction c. Metabolic acidosis
21. Nurse Karen is caring for clients in the OR. The nurse d. Metabolic alkalosis
is aware that the last physiologic function that the client 28. A male adult client has undergone a lumbar puncture
loss during the induction of anesthesia is: to obtain cerebrospinal fluid (CSF) for analysis. Which of
a. Consciousness the following values should be negative if the CSF is
b. Gag reflex normal?
c. Respiratory movement a. Red blood cells
d. Corneal reflex b. White blood cells

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c. Insulin 36. A client with peptic ulcer is being assessed by the

d. Protein nurse for gastrointestinal perforation. The nurse should
29. A client is suspected of developing diabetes monitor for:
insipidus. Which of the following is the most effective a. (+) guaiac stool test
assessment? b. Slow, strong pulse
a. Taking vital signs every 4 hours c. Sudden, severe abdominal pain
b. Monitoring blood glucose d. Increased bowel sounds
c. Assessing ABG values every other day 37. A client has undergone surgery for retinal
d. Measuring urine output hourly detachment. Which of the following goal should be
30. A 58 year old client is suffering from acute phase of prioritized?
rheumatoid arthritis. Which of the following would the a. Prevent an increase intraocular pressure
nurse in charge identify as the lowest priority of the plan b. Alleviate pain
of care? c. Maintain darkened room
a. Prevent joint deformity d. Promote low-sodium diet
b. Maintaining usual ways of accomplishing task 38. A Client with glaucoma has been prescribed with
c. Relieving pain miotics. The nurse is aware that miotics is for:
d. Preserving joint function a. Constricting pupil
31. Among the following, which client is autotransfusion b. Relaxing ciliary muscle
possible? c. Constricting intraocular vessel
a. Client with AIDS d. Paralyzing ciliary muscle
b. Client with ruptured bowel 39. When suctioning an unconscious client, which
c. Client who is in danger of cardiac arrest nursing intervention should the nurse prioritize in
d. Client with wound infection maintaining cerebral perfusion?
32. Which of the following is not a sign of a. Administer diuretics
thromboembolism? b. Administer analgesics
a. Edema c. Provide hygiene
b. Swelling d. Hyperoxygenate before and after suctioning
c. Redness 40. When discussing breathing exercises with a
d. Coolness postoperative client, Nurse Hazel should include which
33. Nurse Becky is caring for client who begins to of the following teaching?
experience seizure while in bed. Which action should the a. Short frequent breaths
nurse implement to prevent aspiration? b. Exhale with mouth open
a. Position the client on the side with head flexed c. Exercise twice a day
forward d. Place hand on the abdomen and feel it rise
b. Elevate the head 41. Louie, with burns over 35% of the body, complains of
c. Use tongue depressor between teeth chilling. In promoting the client’s comfort, the nurse
d. Loosen restrictive clothing should:
34. A client has undergone bone biopsy. Which nursing a. Maintain room humidity below 40%
action should the nurse provide after the procedure? b. Place top sheet on the client
a. Administer analgesics via IM c. Limit the occurrence of drafts
b. Monitor vital signs d. Keep room temperature at 80 degrees
c. Monitor the site for bleeding, swelling and hematoma 42. Nurse Trish is aware that temporary heterograft (pig
formation skin) is used to treat burns because this graft will:
d. Keep area in neutral position a. Relieve pain and promote rapid epithelialization
35. A client is suffering from low back pain. Which of the b. Be sutured in place for better adherence
following exercises will strengthen the lower back c. Debride necrotic epithelium
muscle of the client? d. Concurrently used with topical antimicrobials
a. Tennis 43. Mark has multiple abrasions and a laceration to the
b. Basketball trunk and all four extremities says, “I can’t eat all this
c. Diving food”. The food that the nurse should suggest to be
d. Swimming eaten first should be:
a. Meat loaf and coffee

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b. Meat loaf and strawberries

c. Tomato soup and apple pie
d. Tomato soup and buttered bread
44. Tony returns form surgery with permanent
colostomy. During the first 24 hours the colostomy does
not drain. The nurse should be aware that:
a. Proper functioning of nasogastric suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery
45. When teaching a client about the signs of colorectal
cancer, Nurse Trish stresses that the most common
complaint of persons with colorectal cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits
46. Louis develops peritonitis and sepsis after surgical
repair of ruptures diverticulum. The nurse in charge
should expect an assessment of the client to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds
47. Immediately after liver biopsy, the client is placed on
the right side, the nurse is aware that that this position
should be maintained because it will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary ducts
c. Position with greatest comfort
d. Promote circulating blood volume
48. Tony has diagnosed with hepatitis A. The information
from the health history that is most likely linked to
hepatitis A is:
a. Exposed with arsenic compounds at work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants
49. Nurse Trish is aware that the laboratory test result
that most likely would indicate acute pancreatitis is an
elevated:
a. Serum bilirubin level
b. Serum amylase level
c. Potassium level
d. Sodium level
50. Dr. Marquez orders serum electrolytes. To determine
the effect of persistent vomiting, Nurse Trish should be
most concerned with monitoring the:
a. Chloride and sodium levels
b. Phosphate and calcium levels
c. Protein and magnesium levels
d. Sulfate and bicarbonate levels

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MEDICAL SURGICAL NURSING Part 2 c. Protects the client’s head from injury
d. Attempt to insert a tongue depressor between
1. A client is scheduled for insertion of an inferior vena the client’s teeth
cava (IVC) filter. Nurse Patricia consults the physician 8. A client has undergone right pneumonectomy. When
about withholding which regularly scheduled turning the client, the nurse should plan to position
medication on the day before the surgery? the client either:
a. Potassium Chloride a. Right side-lying position or supine
b. Warfarin Sodium b. High fowlers
c. Furosemide c. Right or left side lying position
d. Docusate d. Low fowler’s position
2. A nurse is planning to assess the corneal reflex on 9. Nurse Jenny should caution a female client who is
unconscious client. Which of the following is the sexually active in taking Isoniazid (INH) because the
safest stimulus to touch the client’s cornea? drug has which of the following side effects?
a. Cotton buds a. Prevents ovulation
b. Sterile glove b. Has a mutagenic effect on ova
c. Sterile tongue depressor c. Decreases the effectiveness of oral
d. Wisp of cotton contraceptives
3. A female client develops an infection at the catheter d. Increases the risk of vaginal infection
insertion site. The nurse in charge uses the term 10. A client has undergone gastrectomy. Nurse Jovy is
“iatrogenic” when describing the infection because it aware that the best position for the client is:
resulted from: a. Left side lying
a. Client’s developmental level b. Low fowler’s
b. Therapeutic procedure c. Prone
c. Poor hygiene d. Supine
d. Inadequate dietary patterns 11. During the initial postoperative period of the client’s
4. Nurse Carol is assessing a client with Parkinson’s stoma. The nurse evaluates which of the following
disease. The nurse recognize bradykinesia when the observations should be reported immediately to the
client exhibits: physician?
a. Intentional tremor a. Stoma is dark red to purple
b. Paralysis of limbs b. Stoma is oozes a small amount of blood
c. Muscle spasm c. Stoma is lightly edematous
d. Lack of spontaneous movement d. Stoma does not expel stool
5. A client who suffered from automobile accident 12. Kate which has diagnosed with ulcerative colitis is
complains of seeing frequent flashes of light. The following physician’s order for bed rest with
nurse should expect: bathroom privileges. What is the rationale for this
a. Myopia activity restriction?
b. Detached retina a. Prevent injury
c. Glaucoma b. Promote rest and comfort
d. Scleroderma c. Reduce intestinal peristalsis
6. Kate with severe head injury is being monitored by the d. Conserve energy
nurse for increasing intracranial pressure (ICP). 13. Nurse KC should regularly assess the client’s ability to
Which finding should be most indicative sign of metabolize the total parenteral nutrition (TPN)
increasing intracranial pressure? solution adequately by monitoring the client for
a. Intermittent tachycardia which of the following signs:
b. Polydipsia a. Hyperglycemia
c. Tachypnea b. Hypoglycemia
d. Increased restlessness c. Hypertension
7. A hospitalized client had a tonic-clonic seizure while d. Elevate blood urea nitrogen concentration
walking in the hall. During the seizure the nurse 14. A female client has an acute pancreatitis. Which of
priority should be: the following signs and symptoms the nurse would
a. Hold the clients arms and leg firmly expect to see?
b. Place the client immediately to soft surface a. Constipation

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b. Hypertension d. Corneal reflex

c. Ascites 22. The nurse is assessing a client with pleural effusion.
d. Jaundice The nurse expect to find:
15. A client is suspected to develop tetany after a a. Deviation of the trachea towards the involved
subtotal thyroidectomy. Which of the following side
symptoms might indicate tetany? b. Reduced or absent of breath sounds at the
a. Tingling in the fingers base of the lung
b. Pain in hands and feet c. Moist crackles at the posterior of the lungs
c. Tension on the suture lines d. Increased resonance with percussion of the
d. Bleeding on the back of the dressing involved area
16. A 58 year old woman has newly diagnosed with 23. A client admitted with newly diagnosed with
hypothyroidism. The nurse is aware that the signs Hodgkin’s disease. Which of the following would the
and symptoms of hypothyroidism include: nurse expect the client to report?
a. Diarrhea a. Lymph node pain
b. Vomiting b. Weight gain
c. Tachycardia c. Night sweats
d. Weight gain d. Headache
17. A client has undergone for an ileal conduit, the nurse 24. A client has suffered from fall and sustained a leg
in charge should closely monitor the client for injury. Which appropriate question would the nurse
occurrence of which of the following complications ask the client to help determine if the injury caused
related to pelvic surgery? fracture?
a. Ascites a. “Is the pain sharp and continuous?”
b. Thrombophlebitis b. “Is the pain dull ache?”
c. Inguinal hernia c. “Does the discomfort feel like a cramp?”
d. Peritonitis d. “Does the pain feel like the muscle was
18. Dr. Marquez is about to defibrillate a client in stretched?”
ventricular fibrillation and says in a loud voice 25. The Nurse is assessing the client’s casted extremity
“clear”. What should be the action of the nurse? for signs of infection. Which of the following findings
a. Places conductive gel pads for defibrillation on is indicative of infection?
the client’s chest a. Edema
b. Turn off the mechanical ventilator b. Weak distal pulse
c. Shuts off the client’s IV infusion c. Coolness of the skin
d. Steps away from the bed and make sure all d. Presence of “hot spot” on the cast
others have done the same 26. Nurse Rhia is performing an otoscopic examination
19. A client has been diagnosed with glomerulonephritis on a female client with a suspected diagnosis of
complains of thirst. The nurse should offer: mastoiditis. Nurse Rhia would expect to note which
a. Juice of the following if this disorder is present?
b. Ginger ale a. Transparent tympanic membrane
c. Milk shake b. Thick and immobile tympanic membrane
d. Hard candy c. Pearly colored tympanic membrane
20. A client with acute renal failure is aware that the d. Mobile tympanic membrane
most serious complication of this condition is: 27. Nurse Jocelyn is caring for a client with nasogastric
a. Constipation tube that is attached to low suction. Nurse Jocelyn
b. Anemia assesses the client for symptoms of which acid-base
c. Infection disorder?
d. Platelet dysfunction a. Respiratory alkalosis
21. Nurse Karen is caring for clients in the OR. The nurse b. Respiratory acidosis
is aware that the last physiologic function that the c. Metabolic acidosis
client loss during the induction of anesthesia is: d. Metabolic alkalosis
a. Consciousness 28. A male adult client has undergone a lumbar puncture
b. Gag reflex to obtain cerebrospinal fluid (CSF) for analysis.
c. Respiratory movement

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Which of the following values should be negative if b. Basketball

the CSF is normal? c. Diving
a. Red blood cells d. Swimming
b. White blood cells 36. A client with peptic ulcer is being assessed by the
c. Insulin nurse for gastrointestinal perforation. The nurse
d. Protein should monitor for:
29. A client is suspected of developing diabetes a. (+) guaiac stool test
insipidus. Which of the following is the most b. Slow, strong pulse
effective assessment? c. Sudden, severe abdominal pain
a. Taking vital signs every 4 hours d. Increased bowel sounds
b. Monitoring blood glucose 37. A client has undergone surgery for retinal
c. Assessing ABG values every other day detachment. Which of the following goal should be
d. Measuring urine output hourly prioritized?
30. A 58 year old client is suffering from acute phase of a. Prevent an increase intraocular pressure
rheumatoid arthritis. Which of the following would b. Alleviate pain
the nurse in charge identify as the lowest priority of c. Maintain darkened room
the plan of care? d. Promote low-sodium diet
a. Prevent joint deformity 38. A Client with glaucoma has been prescribed with
b. Maintaining usual ways of accomplishing task miotics. The nurse is aware that miotics is for:
c. Relieving pain a. Constricting pupil
d. Preserving joint function b. Relaxing ciliary muscle
31. Among the following, which client is autotransfusion c. Constricting intraocular vessel
possible? d. Paralyzing ciliary muscle
a. Client with AIDS 39. When suctioning an unconscious client, which
b. Client with ruptured bowel nursing intervention should the nurse prioritize in
c. Client who is in danger of cardiac arrest maintaining cerebral perfusion?
d. Client with wound infection a. Administer diuretics
32. Which of the following is not a sign of b. Administer analgesics
thromboembolism? c. Provide hygiene
a. Edema d. Hyperoxygenate before and after suctioning
b. Swelling 40. When discussing breathing exercises with a
c. Redness postoperative client, Nurse Hazel should include
d. Coolness which of the following teaching?
33. Nurse Becky is caring for client who begins to a. Short frequent breaths
experience seizure while in bed. Which action should b. Exhale with mouth open
the nurse implement to prevent aspiration? c. Exercise twice a day
a. Position the client on the side with head d. Place hand on the abdomen and feel it rise
flexed forward 41. Louie, with burns over 35% of the body, complains of
b. Elevate the head chilling. In promoting the client’s comfort, the nurse
c. Use tongue depressor between teeth should:
d. Loosen restrictive clothing a. Maintain room humidity below 40%
34. A client has undergone bone biopsy. Which nursing b. Place top sheet on the client
action should the nurse provide after the procedure? c. Limit the occurrence of drafts
a. Administer analgesics via IM d. Keep room temperature at 80 degrees
b. Monitor vital signs 42. Nurse Trish is aware that temporary heterograft (pig
c. Monitor the site for bleeding, swelling and skin) is used to treat burns because this graft will:
hematoma formation a. Relieve pain and promote rapid
d. Keep area in neutral position epithelialization
35. A client is suffering from low back pain. Which of the b. Be sutured in place for better adherence
following exercises will strengthen the lower back c. Debride necrotic epithelium
muscle of the client? d. Concurrently used with topical antimicrobials
a. Tennis

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43. Mark has multiple abrasions and a laceration to the 50. Dr. Marquez orders serum electrolytes. To determine
trunk and all four extremities says, “I can’t eat all this the effect of persistent vomiting, Nurse Trish should
food”. The food that the nurse should suggest to be be most concerned with monitoring the:
eaten first should be: a. Chloride and sodium levels
a. Meat loaf and coffee b. Phosphate and calcium levels
b. Meat loaf and strawberries c. Protein and magnesium levels
c. Tomato soup and apple pie d. Sulfate and bicarbonate levels
d. Tomato soup and buttered bread
44. Tony returns form surgery with permanent
colostomy. During the first 24 hours the colostomy
does not drain. The nurse should be aware that:
a. Proper functioning of nasogastric suction
b. Presurgical decrease in fluid intake
c. Absence of gastrointestinal motility
d. Intestinal edema following surgery
45. When teaching a client about the signs of colorectal
cancer, Nurse Trish stresses that the most common
complaint of persons with colorectal cancer is:
a. Abdominal pain
b. Hemorrhoids
c. Change in caliber of stools
d. Change in bowel habits
46. Louis develops peritonitis and sepsis after surgical
repair of ruptures diverticulum. The nurse in charge
should expect an assessment of the client to reveal:
a. Tachycardia
b. Abdominal rigidity
c. Bradycardia
d. Increased bowel sounds
47. Immediately after liver biopsy, the client is placed on
the right side, the nurse is aware that that this
position should be maintained because it will:
a. Help stop bleeding if any occurs
b. Reduce the fluid trapped in the biliary ducts
c. Position with greatest comfort
d. Promote circulating blood volume
48. Tony has diagnosed with hepatitis A. The information
from the health history that is most likely linked to
hepatitis A is:
a. Exposed with arsenic compounds at work
b. Working as local plumber
c. Working at hemodialysis clinic
d. Dish washer in restaurants
49. Nurse Trish is aware that the laboratory test result
that most likely would indicate acute pancreatitis is
an elevated:
a. Serum bilirubin level
b. Serum amylase level
c. Potassium level
d. Sodium level

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ANSWERS and RATIONALES for MEDICAL SURGICAL manipulation that can interfere with circulation and
NURSING Part 2 promote venous stasis.
18. D. For the safety of all personnel, if the defibrillator
1. B. In preoperative period, the nurse should consult paddles are being discharged, all personnel must
with the physician about withholding Warfarin stand back and be clear of all the contact with the
Sodium to avoid occurrence of hemorrhage. client or the client’s bed.
2. D. A client who is unconscious is at greater risk for 19. D. Hard candy will relieve thirst and increase
corneal abrasion. For this reason, the safest way to carbohydrates but does not supply extra fluid.
test the cornel reflex is by touching the cornea 20. C. Infection is responsible for one third of the
lightly with a wisp of cotton. traumatic or surgically induced death of clients with
3. B. Iatrogenic infection is caused by the heath care renal failure as well as medical induced acute renal
provider or is induced inadvertently by medical failure (ARF)
treatment or procedures. 21. C. There is no respiratory movement in stage 4 of
4. D. Bradykinesia is slowing down from the initiation anesthesia, prior to this stage, respiration is
and execution of movement. depressed but present.
5. B. This symptom is caused by stimulation of retinal 22. B. Compression of the lung by fluid that accumulates
cells by ocular movement. at the base of the lungs reduces expansion and air
6. D. Restlessness indicates a lack of oxygen to the brain exchange.
stem which impairs the reticular activating system. 23. C. Assessment of a client with Hodgkin’s disease
7. C. Rhythmic contraction and relaxation associated most often reveals enlarged, painless lymph node,
with tonic-clonic seizure can cause repeated banging fever, malaise and night sweats.
of head. 24. A. Fractured pain is generally described as sharp,
8. A. Right side lying position or supine position permits continuous, and increasing in frequency.
ventilation of the remaining lung and prevent fluid 25. D. Signs and symptoms of infection under a casted
from draining into sutured bronchial stump. area include odor or purulent drainage and the
9. C. Isoniazid (INH) interferes in the effectiveness of oral presence of “hot spot” which are areas on the cast
contraceptives and clients of childbearing age should that are warmer than the others.
be counseled to use an alternative form of birth 26. B. Otoscopic examnation in a client with mastoiditis
control while taking this drug. reveals a dull, red, thick and immobile tymphanic
10. B. A client who has had abdominal surgery is best membrane with or without perforation.
placed in a low fowler’s position. This relaxes 27. D. Loss of gastric fluid via nasogastric suction or
abdominal muscles and provides maximum vomiting causes metabolic alkalosis because of the
respiratory and cardiovascular function. loss of hydrochloric acid which is a potent acid in the
11. A. Dark red to purple stoma indicates inadequate body.
blood supply. 28. A. The adult with normal cerebrospinal fluid has no
12. C. The rationale for activity restriction is to help red blood cells.
reduce the hypermotility of the colon. 29. D. Measuring the urine output to detect excess
13. A. During Total Parenteral Nutrition (TPN) amount and checking the specific gravity of urine
administration, the client should be monitored samples to determine urine concentration are
regularly for hyperglycemia. appropriate measures to determine the onset of
14. D. Jaundice may be present in acute pancreatitis diabetes insipidus.
owing to obstruction of the biliary duct. 30. B. The nurse should focus more on developing less
15. A. Tetany may occur after thyroidectomy if the stressful ways of accomplishing routine task.
parathyroid glands are accidentally injured or 31. C. Autotransfusion is acceptable for the client who is
removed. in danger of cardiac arrest.
16. D. Typical signs of hypothyroidism includes weight 32. D. The client with thromboembolism does not have
gain, fatigue, decreased energy, apathy, brittle nails, coolness.
dry skin, cold intolerance, constipation and 33. A. Positioning the client on one side with head flexed
numbness. forward allows the tongue to fall forward and
17. B. After a pelvic surgery, there is an increased chance facilitates drainage secretions therefore prevents
of thrombophlebitits owing to the pelvic aspiration.

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34. C. Nursing care after bone biopsy includes close

monitoring of the punctured site for bleeding,
swelling and hematoma formation.
35. D. Walking and swimming are very helpful in
strengthening back muscles for the client suffering
from lower back pain.
36. C. Sudden, severe abdominal pain is the most
indicative sign of perforation. When perforation of
an ulcer occurs, the nurse maybe unable to hear
bowel sounds at all.
37. A. After surgery to correct a detached retina,
prevention of increased intraocular pressure is the
priority goal.
38. A. Miotic agent constricts the pupil and contracts
ciliary muscle. These effects widen the filtration
angle and permit increased out flow of aqueous
humor.
39. D. It is a priority to hyperoxygenate the client before
and after suctioning to prevent hypoxia and to
maintain cerebral perfusion.
40. D. Abdominal breathing improves lungs expansion
41. C. A Client with burns is very sensitive to
temperature changes because heat is loss in the
burn areas.
42. A. The graft covers the nerve endings, which reduces
pain and provides framework for granulation
43. B. Meat provides proteins and the fruit proteins
vitamin C that both promote wound healing.
44. C. This is primarily caused by the trauma of intestinal
manipulation and the depressive effects anesthetics
and analgesics.
45. D. Constipation, diarrhea, and/or constipation
alternating with diarrhea are the most common
symptoms of colorectal cancer.
46. B. With increased intraabdominal pressure, the
abdominal wall will become tender and rigid.
47. A. Pressure applied in the puncture site indicates
that a biliary vessel was puncture which is a common
complication after liver biopsy.
48. B. Hepatitis A is primarily spread via fecal-oral route.
Sewage polluted water may harbor the virus.
49. B. Amylase concentration is high in the pancreas and
is elevated in the serum when the pancreas becomes
acutely inflamed and also it distinguishes
pancreatitis from other acute abdominal problems.
50. A. Sodium, which is concerned with the regulation of
extracellular fluid volume, it is lost with vomiting.
Chloride, which balances cations in the extracellular
compartments, is also lost with vomiting, because
sodium and chloride are parallel electrolytes,
hyponatremia will accompany.

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MEDICAL SURGICAL NURSING Part 3 7. A client has undergone with penile implant. After 24
hrs of surgery, the client’s scrotum was edematous
1. Marco who was diagnosed with brain tumor was and painful. The nurse should:
scheduled for craniotomy. In preventing the a. Assist the client with sitz bath
development of cerebral edema after surgery, the b. Apply war soaks in the scrotum
nurse should expect the use of: c. Elevate the scrotum using a soft support
a. Diuretics d. Prepare for a possible incision and drainage.
b. Antihypertensive 8. Nurse hazel receives emergency laboratory results for
c. Steroids a client with chest pain and immediately informs the
d. Anticonvulsants physician. An increased myoglobin level suggests
2. Halfway through the administration of blood, the which of the following?
female client complains of lumbar pain. After a. Liver disease
stopping the infusion Nurse Hazel should: b. Myocardial damage
a. Increase the flow of normal saline c. Hypertension
b. Assess the pain further d. Cancer
c. Notify the blood bank 9. Nurse Maureen would expect the a client with mitral
d. Obtain vital signs. stenosis would demonstrate symptoms associated
3. Nurse Maureen knows that the positive diagnosis for with congestion in the:
HIV infection is made based on which of the a. Right atrium
following: b. Superior vena cava
a. A history of high risk sexual behaviors. c. Aorta
b. Positive ELISA and western blot tests d. Pulmonary
c. Identification of an associated opportunistic 10. A client has been diagnosed with hypertension. The
infection nurse priority nursing diagnosis would be:
d. Evidence of extreme weight loss and high a. Ineffective health maintenance
fever b. Impaired skin integrity
4. Nurse Maureen is aware that a client who has been c. Deficient fluid volume
diagnosed with chronic renal failure recognizes an d. Pain
adequate amount of high-biologic-value protein 11. Nurse Hazel teaches the client with angina about
when the food the client selected from the menu common expected side effects of nitroglycerin
was: including:
a. Raw carrots a. high blood pressure
b. Apple juice b. stomach cramps
c. Whole wheat bread c. headache
d. Cottage cheese d. shortness of breath
5. Kenneth who has diagnosed with uremic syndrome 12. The following are lipid abnormalities. Which of the
has the potential to develop complications. Which following is a risk factor for the development of
among the following complications should the nurse atherosclerosis and PVD?
anticipates: a. High levels of low density lipid (LDL)
a. Flapping hand tremors cholesterol
b. An elevated hematocrit level b. High levels of high density lipid (HDL)
c. Hypotension cholesterol
d. Hypokalemia c. Low concentration triglycerides
6. A client is admitted to the hospital with benign d. Low levels of LDL cholesterol.
prostatic hyperplasia, the nurse most relevant 13. Which of the following represents a significant risk
assessment would be: immediately after surgery for repair of aortic
a. Flank pain radiating in the groin aneurysm?
b. Distention of the lower abdomen a. Potential wound infection
c. Perineal edema b. Potential ineffective coping
d. Urethral discharge c. Potential electrolyte balance
d. Potential alteration in renal perfusion

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14. Nurse Josie should instruct the client to eat which of 21. Which of the following signs and symptoms would
the following foods to obtain the best supply of Nurse Maureen include in teaching plan as an early
Vitamin B12? manifestation of laryngeal cancer?
a. dairy products a. Stomatitis
b. vegetables b. Airway obstruction
c. Grains c. Hoarseness
d. Broccoli d. Dysphagia
15. Karen has been diagnosed with aplastic anemia. The 22. Karina a client with myasthenia gravis is to receive
nurse monitors for changes in which of the following immunosuppressive therapy. The nurse understands
physiologic functions? that this therapy is effective because it:
a. Bowel function a. Promotes the removal of antibodies that
b. Peripheral sensation impair the transmission of impulses
c. Bleeding tendencies b. Stimulates the production of acetylcholine at
d. Intake and out put the neuromuscular junction.
16. Lydia is scheduled for elective splenectomy. Before c. Decreases the production of autoantibodies
the clients goes to surgery, the nurse in charge final that attack the acetylcholine receptors.
assessment would be: d. Inhibits the breakdown of acetylcholine at the
a. signed consent neuromuscular junction.
b. vital signs 23. A female client is receiving IV Mannitol. An
c. name band assessment specific to safe administration of the
d. empty bladder said drug is:
17. What is the peak age range in acquiring acute a. Vital signs q4h
lymphocytic leukemia (ALL)? b. Weighing daily
a. 4 to 12 years. c. Urine output hourly
b. 20 to 30 years d. Level of consciousness q4h
c. 40 to 50 years 24. Patricia a 20 year old college student with diabetes
d. 60 60 70 years mellitus requests additional information about the
18. Marie with acute lymphocytic leukemia suffers from advantages of using a pen like insulin delivery
nausea and headache. These clinical manifestations devices. The nurse explains that the advantages of
may indicate all of the following except these devices over syringes includes:
a. effects of radiation a. Accurate dose delivery
b. chemotherapy side effects b. Shorter injection time
c. meningeal irritation c. Lower cost with reusable insulin cartridges
d. gastric distension d. Use of smaller gauge needle.
19. A client has been diagnosed with Disseminated 25. A male client’s left tibia was fractured in an
Intravascular Coagulation (DIC). Which of the automobile accident, and a cast is applied. To assess
following is contraindicated with the client? for damage to major blood vessels from the fracture
a. Administering Heparin tibia, the nurse in charge should monitor the client
b. Administering Coumadin for:
c. Treating the underlying cause a. Swelling of the left thigh
d. Replacing depleted blood products b. Increased skin temperature of the foot
20. Which of the following findings is the best indication c. Prolonged reperfusion of the toes after
that fluid replacement for the client with blanching
hypovolemic shock is adequate? d. Increased blood pressure
a. Urine output greater than 30ml/hr 26. After a long leg cast is removed, the male client
b. Respiratory rate of 21 breaths/minute should:
c. Diastolic blood pressure greater than 90 a. Cleanse the leg by scrubbing with a brisk
mmhg motion
d. Systolic blood pressure greater than 110 b. Put leg through full range of motion twice
mmhg daily
c. Report any discomfort or stiffness to the
physician

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d. Elevate the leg when sitting for long periods of cause of tonic clonic seizures in adults more the 20
time. years?
27. While performing a physical assessment of a male a. Electrolyte imbalance
client with gout of the great toe, Nurse Vivian should b. Head trauma
assess for additional tophi (urate deposits) on the: c. Epilepsy
a. Buttocks d. Congenital defect
b. Ears 34. What is the priority nursing assessment in the first 24
c. Face hours after admission of the client with thrombotic
d. Abdomen CVA?
28. Nurse Katrina would recognize that the a. Pupil size and papillary response
demonstration of crutch walking with tripod gait was b. cholesterol level
understood when the client places weight on the: c. Echocardiogram
a. Palms of the hands and axillary regions d. Bowel sounds
b. Palms of the hand 35. Nurse Linda is preparing a client with multiple
c. Axillary regions sclerosis for discharge from the hospital to home.
d. Feet, which are set apart Which of the following instruction is most
29. Mang Jose with rheumatoid arthritis states, “the only appropriate?
time I am without pain is when I lie in bed perfectly a. “Practice using the mechanical aids that you
still”. During the convalescent stage, the nurse in will need when future disabilities arise”.
charge with Mang Jose should encourage: b. “Follow good health habits to change the
a. Active joint flexion and extension course of the disease”.
b. Continued immobility until pain subsides c. “Keep active, use stress reduction strategies,
c. Range of motion exercises twice daily and avoid fatigue.
d. Flexion exercises three times daily d. “You will need to accept the necessity for a
30. A male client has undergone spinal surgery, the quiet and inactive lifestyle”.
nurse should: 36. The nurse is aware the early indicator of hypoxia in
a. Observe the client’s bowel movement and the unconscious client is:
voiding patterns a. Cyanosis
b. Log-roll the client to prone position b. Increased respirations
c. Assess the client’s feet for sensation and c. Hypertension
circulation d. Restlessness
d. Encourage client to drink plenty of fluids 37. A client is experiencing spinal shock. Nurse Myrna
31. Marina with acute renal failure moves into the should expect the function of the bladder to be
diuretic phase after one week of therapy. During this which of the following?
phase the client must be assessed for signs of a. Normal
developing: b. Atonic
a. Hypovolemia c. Spastic
b. renal failure d. Uncontrolled
c. metabolic acidosis 38. Which of the following stage the carcinogen is
d. hyperkalemia irreversible?
32. Nurse Judith obtains a specimen of clear nasal a. Progression stage
drainage from a client with a head injury. Which of b. Initiation stage
the following tests differentiates mucus from c. Regression stage
cerebrospinal fluid (CSF)? d. Promotion stage
a. Protein 39. Among the following components thorough pain
b. Specific gravity assessment, which is the most significant?
c. Glucose a. Effect
d. Microorganism b. Cause
33. A 22 year old client suffered from his first tonic- c. Causing factors
clonic seizure. Upon awakening the client asks the d. Intensity
nurse, “What caused me to have a seizure? Which of
the following would the nurse include in the primary

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40. A 65 year old female is experiencing flare up of d. elder abuse

pruritus. Which of the client’s action could aggravate 48. Nurse Anna is aware that early adaptation of client
the cause of flare ups? with renal carcinoma is:
a. Sleeping in cool and humidified environment a. Nausea and vomiting
b. Daily baths with fragrant soap b. flank pain
c. Using clothes made from 100% cotton c. weight gain
d. Increasing fluid intake d. intermittent hematuria
41. Atropine sulfate (Atropine) is contraindicated in all 49. A male client with tuberculosis asks Nurse Brian how
but one of the following client? long the chemotherapy must be continued. Nurse
a. A client with high blood Brian’s accurate reply would be:
b. A client with bowel obstruction a. 1 to 3 weeks
c. A client with glaucoma b. 6 to 12 months
d. A client with U.T.I c. 3 to 5 months
42. Among the following clients, which among them is d. 3 years and more
high risk for potential hazards from the surgical 50. A client has undergone laryngectomy. The immediate
experience? nursing priority would be:
a. 67-year-old client a. Keep trachea free of secretions
b. 49-year-old client b. Monitor for signs of infection
c. 33-year-old client c. Provide emotional support
d. 15-year-old client d. Promote means of communication
43. Nurse Jon assesses vital signs on a client undergone
epidural anesthesia. Which of the following would
the nurse assess next?
a. Headache
b. Bladder distension
c. Dizziness
d. Ability to move legs
44. Nurse Katrina should anticipate that all of the
following drugs may be used in the attempt to
control the symptoms of Meniere’s disease except:
a. Antiemetics
b. Diuretics
c. Antihistamines
d. Glucocorticoids
45. Which of the following complications associated with
tracheostomy tube?
a. Increased cardiac output
b. Acute respiratory distress syndrome (ARDS)
c. Increased blood pressure
d. Damage to laryngeal nerves
46. Nurse Faith should recognize that fluid shift in an
client with burn injury results from increase in the:
a. Total volume of circulating whole blood
b. Total volume of intravascular plasma
c. Permeability of capillary walls
d. Permeability of kidney tubules
47. An 83-year-old woman has several ecchymotic areas
on her right arm. The bruises are probably caused
by:
a. increased capillary fragility and permeability
b. increased blood supply to the skin
c. self inflicted injury

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ANSWERS and RATIONALES for MEDICAL SURGICAL 15. C. Aplastic anemia decreases the bone marrow
NURSING Part 3 production of RBC’s, white blood cells, and platelets.
The client is at risk for bruising and bleeding
1. C. Glucocorticoids (steroids) are used for their anti- tendencies.
inflammatory action, which decreases the 16. B. An elective procedure is scheduled in advance so
development of edema. that all preparations can be completed ahead of
2. A. The blood must be stopped at once, and then time. The vital signs are the final check that must be
normal saline should be infused to keep the line completed before the client leaves the room so that
patent and maintain blood volume. continuity of care and assessment is provided for.
3. B. These tests confirm the presence of HIV antibodies 17. A. The peak incidence of Acute Lymphocytic
that occur in response to the presence of the human Leukemia (ALL) is 4 years of age. It is uncommon
immunodeficiency virus (HIV). after 15 years of age.
4. D. One cup of cottage cheese contains approximately 18. D. Acute Lymphocytic Leukemia (ALL) does not cause
225 calories, 27 g of protein, 9 g of fat, 30 mg gastric distention. It does invade the central nervous
cholesterol, and 6 g of carbohydrate. Proteins of system, and clients experience headaches and
high biologic value (HBV) contain optimal levels of vomiting from meningeal irritation.
amino acids essential for life. 19. B. Disseminated Intravascular Coagulation (DIC) has
5. A. Elevation of uremic waste products causes irritation not been found to respond to oral anticoagulants
of the nerves, resulting in flapping hand tremors. such as Coumadin.
6. B. This indicates that the bladder is distended with 20. A. Urine output provides the most sensitive
urine, therefore palpable. indication of the client’s response to therapy for
7. C. Elevation increases lymphatic drainage, reducing hypovolemic shock. Urine output should be
edema and pain. consistently greater than 30 to 35 mL/hr.
8. B. Detection of myoglobin is a diagnostic tool to 21. C. Early warning signs of laryngeal cancer can vary
determine whether myocardial damage has depending on tumor location. Hoarseness lasting 2
occurred. weeks should be evaluated because it is one of the
9. D. When mitral stenosis is present, the left atrium has most common warning signs.
difficulty emptying its contents into the left ventricle 22. C. Steroids decrease the body’s immune response
because there is no valve to prevent back ward flow thus decreasing the production of antibodies that
into the pulmonary vein, the pulmonary circulation is attack the acetylcholine receptors at the
under pressure. neuromuscular junction
10. A. Managing hypertension is the priority for the 23. C. The osmotic diuretic mannitol is contraindicated in
client with hypertension. Clients with hypertension the presence of inadequate renal function or heart
frequently do not experience pain, deficient volume, failure because it increases the intravascular volume
or impaired skin integrity. It is the asymptomatic that must be filtered and excreted by the kidney.
nature of hypertension that makes it so difficult to 24. A. These devices are more accurate because they are
treat. easily to used and have improved adherence in
11. C. Because of its widespread vasodilating effects, insulin regimens by young people because the
nitroglycerin often produces side effects such as medication can be administered discreetly.
headache, hypotension and dizziness. 25. C. Damage to blood vessels may decrease the
12. A. An increased in LDL cholesterol concentration has circulatory perfusion of the toes, this would indicate
been documented at risk factor for the development the lack of blood supply to the extremity.
of atherosclerosis. LDL cholesterol is not broken 26. D. Elevation will help control the edema that usually
down into the liver but is deposited into the wall of occurs.
the blood vessels. 27. B. Uric acid has a low solubility, it tends to
13. D. There is a potential alteration in renal perfusion precipitate and form deposits at various sites where
manifested by decreased urine output. The altered blood flow is least active, including cartilaginous
renal perfusion may be related to renal artery tissue such as the ears.
embolism, prolonged hypotension, or prolonged 28. B. The palms should bear the client’s weight to avoid
aortic cross-clamping during the surgery. damage to the nerves in the axilla.
14. A. Good source of vitamin B12 are dairy products
and meats.

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29. A. Active exercises, alternating extension, flexion, 45. D. Tracheostomy tube has several potential
abduction, and adduction, mobilize exudates in the complications including bleeding, infection and
joints relieves stiffness and pain. laryngeal nerve damage.
30. C. Alteration in sensation and circulation indicates 46. C. In burn, the capillaries and small vessels dilate,
damage to the spinal cord, if these occurs notify and cell damage cause the release of a histamine-
physician immediately. like substance. The substance causes the capillary
31. A. In the diuretic phase fluid retained during the walls to become more permeable and significant
oliguric phase is excreted and may reach 3 to 5 liters quantities of fluid are lost.
daily, hypovolemia may occur and fluids should be 47. A. Aging process involves increased capillary fragility
replaced. and permeability. Older adults have a decreased
32. C. The constituents of CSF are similar to those of amount of subcutaneous fat and cause an increased
blood plasma. An examination for glucose content is incidence of bruise like lesions caused by collection
done to determine whether a body fluid is a mucus of extravascular blood in loosely structured dermis.
or a CSF. A CSF normally contains glucose. 48. D. Intermittent pain is the classic sign of renal
33. B. Trauma is one of the primary cause of brain carcinoma. It is primarily due to capillary erosion by
damage and seizure activity in adults. Other the cancerous growth.
common causes of seizure activity in adults include 49. B. Tubercle bacillus is a drug resistant organism and
neoplasms, withdrawal from drugs and alcohol, and takes a long time to be eradicated. Usually a
vascular disease. combination of three drugs is used for minimum of 6
34. A. It is crucial to monitor the pupil size and papillary months and at least six months beyond culture
response to indicate changes around the cranial conversion.
nerves. 50. A. Patent airway is the most priority; therefore
35. C. The nurse most positive approach is to encourage removal of secretions is necessary.
the client with multiple sclerosis to stay active, use
stress reduction techniques and avoid fatigue
because it is important to support the immune
system while remaining active.
36. D. Restlessness is an early indicator of hypoxia. The
nurse should suspect hypoxia in unconscious client
who suddenly becomes restless.
37. B. In spinal shock, the bladder becomes completely
atonic and will continue to fill unless the client is
catheterized.
38. A. Progression stage is the change of tumor from the
preneoplastic state or low degree of malignancy to a
fast growing tumor that cannot be reversed.
39. D. Intensity is the major indicative of severity of pain
and it is important for the evaluation of the
treatment.
40. B. The use of fragrant soap is very drying to skin
hence causing the pruritus.
41. C. Atropine sulfate is contraindicated with glaucoma
patients because it increases intraocular pressure.
42. A. A 67 year old client is greater risk because the
older adult client is more likely to have a less-
effective immune system.
43. B. The last area to return sensation is in the perineal
area, and the nurse in charge should monitor the
client for distended bladder.
44. D. Glucocorticoids play no significant role in disease
treatment.

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