Ivy G.

Sudaria
BSN 4-2

CASE SCENARIO: The nurse supervisor is observing the staff nurses in their hospital
to see how the quality of care is provided in preparation for their ISO accreditation.

1. Hygiene is a highly personal matter determined by individual values and

practices. THERAPEUTIC BATHS are given for physical effects, such as to
soothe irritated skin or to treat an area (e.g., the perineum). A nurse is giving a
bed bath to a client who is on strict bed rest. To increase venous return, the
nurse bathes the client’s extremities by using:
A. Firm circular strokes from proximal to distal areas
B. Short, patting strokes from distal to proximal areas
C. Smooth, light strokes back and forth from proximal to distal areas
D. Long, firm strokes from distal to proximal areas
RATIONALE: When the extremities are bathed, long, firm strokes in the direction of
venous flow encourage venous return. On the face, circular strokes are utilized. Short,
patting strokes and light strokes are inconvenient for the client and do not encourage
venous return.

2. Part of hygiene measures is mouth care by brushing the teeth thoroughly after meals
and at bedtime. When performing oral care on a comatose client the nurse should:
A. Apply lemon glycerin to the client’s lips at least every 2 hours
B. Brush the teeth with the client lying supine
C. Place the client in a side-lying position, with the head of the bed lowered
D. Clean the client’s mouth with hydrogen peroxide
RATIONALE: To facilitate oral hygiene and protect the patient's airway, the nurse
should keep the patient on his side with his head lower than his stomach
CASE SCENARIO: Nurse Sarah, a newly hired nurse, is asked to take over an absent
nurse in another unit. She will take care of clients with various conditions.

3. Clients with acid-base imbalance are usually being scheduled for blood to be drawn
from the radial artery for an arterial blood gas (ABG) determination. Before the blood
is drawn, an Allen’s test is performed to determine the adequacy of blood supply in
ULNAR ARTERY. The respiratory therapist is doing the Allen’s test erroneously if
he performs which of the following?
A. Applies direct pressure over the client’s ulnar and radial arteries
simultaneously
B. While applying pressure, he asks the client to open and close the hand
repeatedly
C. Releases pressure from the ulnar artery while compressing the radial
artery and assesses the color of the extremity distal to the pressure point
D. Withdraws blood if the pinkness of the hand returns within 9 seconds
RATIONALE: If pinkness fails to return within 6 seconds, the ulnar artery is insufficient,
indicating that the radial artery should not be used for obtaining a blood specimen.

4. In hyperventilation, rapid respirations may cause the blowing off of CO2, leading to a
decrease in carbonic acid that could predispose the accumulation of base without a
comparable loss of base in the body fluids. Nurse Sarah reviews an ABG result of
her patient hooked to a mechanical ventilator and notes the following: pH-7.45,
PCO2 of 30 mmHg, and HCO3 of 22mEq/L. Nurse Sarah analyzes these results as
indicating:
A. Metabolic acidosis, compensated
B. Metabolic alkalosis, uncompensated
C. Respiratory alkalosis, compensated
D. Respiratory acidosis, uncompensated
RATIONALE: Respiratory alkalosis is a disturbance in acid and base balance due to
alveolar hyperventilation. Alveolar hyperventilation leads to a decreased partial pressure
of arterial carbon dioxide (PaCO2). In turn, the decrease in PaCO2 increases the ratio
of bicarbonate concentration to PaCO2 and, thereby, increases the pH level; thus the
descriptive term respiratory alkalosis.
5. A bronchoscopy is usually ordered for direct visual examination of the larynx,
trachea and bronchi with a BRONCHOSCOPE. Nurse Sarah is caring for a client
after a bronchoscopy and biopsy. Which of the following signs if noted in the client
should be reported immediately to the physician?
A. Blood-streaked sputum C. Hematuria
B. Dry cough D. Bronchospasm – when airways (bronchial tubes)
go into spasm and contract
RATIONALE: The most common complication during this procedure is bleeding form
the biopsy site.

6. If a client’s complaint is related to a certain respiratory disorder, an initial

radiographic diagnostic procedure being ordered is CHEST X-RAY, which provides
information regarding the anatomical location and appearance of the lungs. Nurse
Sarah is caring for a female client. Which of the following actions is the most
essential that nurse Sarah must ensure prior to Chest x-ray?
A. Remove all accessories and other metal objects from the chest area.
B. Assess the client’s ability to inhale and hold breath.
C. Ask about the first day of the last menstruation.
D. Ask the ability to hold arms above the head.
RATIONALE: The nurse should inquire about the client's pregnancy status first,
because pregnant women should not be exposed to radiation.

7. In obtaining sputum sample, ask the client to breathe deeply and then cough up 1 to
2 teaspoons (4 to 10 mL) of sputum. Nurse Sarah is preparing to obtain a sputum
specimen from a client. Which of the following nursing actions will facilitate obtaining
the specimen?
A. Limiting fluids
B. Having the client take three deep breaths
C. Asking the client to spit into the collection container
D. Asking the client to obtain the specimen after eating
RATIONALE: To obtain a sputum specimen, the client should rinse his or her mouth to
remove any potential contaminants, breathe deeply, and cough into a sputum specimen
container. To obtain sputum, the client should be urged to cough rather than spit.
Sputum can be thinned with fluids or a respiratory therapy like nebulized saline or water
inhalation. The best time to collect a specimen is when you first wake up in the morning.

8. Incentive spirometers measure the flow of air inhaled through the mouthpiece. It is
used to improve pulmonary ventilation. Nurse Sarah is conducting preoperative
teaching with a client about the use of an incentive spirometer in the postoperative
period. Nurse Sarah would include which piece of information in discussion with the
client?
A. Keep a loose seal between the lips and the mouthpiece
B. Inhale as rapidly as possible
C. After maximum inspiration, hold the breath for 15 seconds and exhale
D. The best results are achieved when the head of the bed is elevated 45 to
90 degrees
RATIONALE: When sitting up or with the head of the bed elevated 45 to 90 degrees,
the best results are obtained. The client should assume the semi-or Fowler's high
Fowler's position for optimal lung expansion with the incentive spirometer. While the
client inhales slowly, with a continuous flow through the unit, the mouthpiece should be
covered entirely and tightly. Hold your breath for 5 seconds before slowly exhaling.

9. Post-abdominal surgery clients are encouraged to do deep breathing and coughing

exercises to prevent ATELECTASIS, which is the most common post-operative
complication that develops during 1 to 2 days postoperative period from the collapse
of the alveoli with retained mucous secretions. Nurse Sarah must include all of the
following proper instructions in deep breathing and coughing exercises to post-
operative clients except:
A. Instruct the client that a sitting position gives the best lung expansion
B. Instruct the client to breathe deeply 3 times, inhaling through the nostrils
and exhaling slowly through pursed lips.
C. Instruct the client that the third breath should be held for 3 seconds; then
the client should cough deeply 3 times.
D. The client should perform this exercise at least twice every shift.
RATIONALE: Inhale deeply and cough forcefully. If you cough up mucus, wipe it away
with a tissue. Repeat the coughing until no more mucous remains. If you have a lot of
mucus, you may need to take a break to avoid becoming too exhausted.
10. In doing the pursed-lip breathing, purse your lips as if about to whistle, and breathe
out slowly and gently, making a slow 'WHOOSHING' sound without puffing the
cheeks. This creates a resistance to air flowing out of the lungs. Nurse Sarah
instructs a client to use the pursed-lip method of breathing and the client asks about
the purpose of this type of breathing. Nurse Sarah responds, knowing that the
primary purpose of pursed-lip breathing is to:
A. Promote oxygen intake
B. Strengthen the diaphragm
C. Promote carbon dioxide elimination
D. Strengthen the intercostal muscles
RATIONALE: For patients with obstructive pulmonary disease, pursed-lip breathing
allows for maximum expiration. By boosting airway pressure and keeping air
passageways open during exhalation, this form of breathing allows for improved
expiration.

11. The nurse must ensure chest physiotherapy every after nebulization by percussing
over the thorax to loosen secretions in the affected area of the lungs. It is important
in loosening and mobilizing secretions. A nurse orientee states imperfectly to nurse
Sarah the proper way of doing chest physiotherapy (CPT) during their post-
conference if she specifies:
A. “I should place a layer of gown between the hands and the client’s skin”.
B. “I should perform this in the morning on rising, 1 hour before meals, or 2 to
3 hours after meals”.
C. “If the client is receiving a tube feeding, finish the feeding and begin doing
the CPT in high fowlers’ position”.
D. “I must stop CPT if pain occurs”.
RATIONALE: If the client is being fed through a tube, stop it and aspirate for residuals
before starting CPT.

12. Chest tubes may be inserted to drain fluid or air from any of the three compartments
of the thorax. The pleural space, located between the visceral
and parietal pleura, normally contains 20ml or less of fluid, which helps lubricate the
visceral and parietal pleura. Nurse Sarah has assisted a physician with the insertion
of a chest tube. Nurse Sarah monitors the client and notes fluctuation of the fluid
level in the water seal chamber after the tube is inserted. Based on this assessment,
which of the following actions would be most appropriate?
 A. Inform the physician
B. Encourage the client to deep breathe
C. Continue to monitor, for this is an expected finding – fluctuation in Chest
tube is normal
D. Reinforce the occlusive dressing
RATIONALE: The presence of fluid level variation in the water seal chamber shows the
presence of a patent drainage system.

13. Surgical incision of the chest wall almost always causes some degree of
pneumothorax (air accumulating in the pleural space) or hemothorax (buildup of
serous fluid or blood in the pleural space). Air and fluid collect in the pleural space,
restricting lung expansion and reducing gas exchange. Nurse Sarah is caring for a
client with a chest tube. Nurse Sarah turns the client to the side, and the chest tube
accidentally disconnects. The initial nursing action is to:
A. Call the physician
B. Place the tube in a bottle of sterile water
C. Immediately replace the chest tube system
D. Place a sterile dressing over the disconnection site
RATIONALE: The end of the tube is placed in a bottle of sterile water positioned below
the level of the chest if the chest drainage system is disconnected. If the system breaks
or cracks, or if the collection chamber is full, it is replaced. Placing a sterile dressing
over the disconnection site will not prevent complications resulting from the
disconnection.

14. If there is no fluctuation noted in the water seal chamber, the doctor will order chest
radiograph to determine whether the lung has reexpanded, as supported by
increased breath sounds upon chest auscultation. Nurse Sarah is assisting a
physician with the removal of a chest tube. Nurse Sarah will appropriately instruct
the client to:
A. Stay very still
B. Inhale and exhale quickly
C. Exhale slowly
D. Deep breathe, exhale, and bear down
RATIONALE: When the chest tube is removed, the client is asked to perform the
Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly
withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask
the client to take a deep breath and hold the breath while the tube is removed

15. In Metered Dose Inhaler (MDI), patients should wait 20-30 seconds before taking
another dose of bronchodilator. Disinfect the metered-dose inhaler mouthpieces
weekly by soaking for 20 minutes in one pint of water with 2 ounces of vinegar
added. Nurse Sarah has an order to give a client Albuterol (Ventolin) two puffs, and
Budesonide (Fulmicort), two puffs, by MDI. Nurse Sarah administers the medication
by giving the:
A. Budesonide first and then the Albuterol
B. Albuterol first and then the Budesonide
C. Alternating a single puff of each, beginning with the Budesonide
D. Alternating a single puff of each, beginning with the Albuterol
RATIONALE: Administer the bronchodilator (Albuterol) first and the corticosteroid
(Budesonide) second. This will allow for the widening of the air passages by the
bronchodilator, making the corticosteroids more effective.

16. The nasal cannula (nasal prongs) is the most common and inexpensive device used
to administer oxygen. It delivers a relatively low concentration of oxygen (24% to
45%) at flow rates of 2 to 6 L/min. Effective oxygen concentration can be delivered
to nose breathers with the use of a nasal cannula. An oxygen delivery system is
prescribed for a client with Chronic Obstructive Pulmonary Disease (COPD) to
deliver a precise oxygen concentration. Which of the following types of oxygen
delivery systems would Nurse Sarah anticipates to be prescribed?
A. Venturi mask - C. Face tent
B. Aerosol mask D. Tracheostomy collar
RATIONALE: The Venturi mask delivers the most accurate oxygen concentration. It is
the best oxygen delivery system for the client with chronic airflow limitation because it
delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy
collar are also high-flow oxygen delivery systems but most often are used to administer
high humidity.
17. A simple face mask is used to deliver oxygen concentrations from 40% to 60% at
liter flows of 5 to 8 L/min, respectively for short-term oxygen therapy or to deliver
oxygen in an emergency. A minimal flow rate of 5L/min is needed to prevent the
rebreathing of exhaled air. Nurse Sarah is caring for a client with emphysema. The
client is receiving oxygen. Nurse Sarah assesses the oxygen flow rate to ensure that
it does not exceed:
A. 1L/min C. 6L/min
B. 2L/min D. 10L/min
RATIONALE: Oxygen is used cautiously & should not exceed 2 L/min. The respiratory
drive in emphysema is activated by low oxygen levels rather than high carbon dioxide
levels, as it is in a normal respiratory system, due to the long-term hypercapnia.

18. Suctioning is a sterile procedure performed to maintain a patent airway. It involves

the removal of respiratory secretions that accumulate in the tracheobronchial airway
when the client is unable to expectorate secretions. Which nursing action by nurse
Sarah is essential to prevent hypoxemia during tracheal suctioning on her patient?
A. Removing oral and nasal secretions.
B. Encouraging the client to deep breath and cough to facilitate removal of
upper-airway secretions.
C. Administering 100% oxygen to reduce the effects of airway obstruction
during suctioning.
D. Auscultating the lungs to determine the baseline data to assess the
effectiveness of suctioning.
RATIONALE: The administration of 100% oxygen helps prevent a decrease in arterial
oxygen levels during the suctioning procedure.

19. The endotracheal tube needs to be moved to the opposite side of the mouth to
prevent pressure and necrosis of the lips and mouth area, nerve damage and
cleaning of the mouth, and this should be done by two health care providers. Nurse
Sarah is caring for a client immediately after removal of the endotracheal tube
following radical neck dissection. Nurse Sarah reports which of the following signs
immediately if experienced by the client?
A. Stridor
B. Occasional pink-tinged sputum
C. Respiratory rate 24 breaths per minute
 D. A few basilar crackles on right
RATIONALE: Stridor is immediately reported to the physician by the nurse. When a
stethoscope is placed over the trachea, a high-pitched, coarse sound is detected. The
presence of stridor implies airway edema, putting the client at danger of airway
blockage.

20. Tracheostomy tubes have an outer cannula that is inserted into the trachea and a
flange that rests against the neck and allows the tube to be secured in place with
tape or ties. Nurse Sarah is changing the tapes on a tracheostomy tube. The client
coughs and the tube is dislodged. The initial nursing action is to:
A. Cover the tracheostomy site with a sterile dressing to prevent infection
B. Call the physician to reinsert the tube
C. Grasp the retention sutures to spread the opening
D. Call the respiratory therapy department to reinsert the tracheostomy
RATIONALE: If the tube is dislodged accidentally, the initial nursing action is to grasp
the retention sutures and spread the opening. If agency policy permits, the nurse then
attempts immediately to replace the tube.

SITUATION: Proper food and nutrition are important factors that contribute to fast
recovery and rehabilitation of patients. As such, meeting the nutritional needs of
patients must be a major part of the nursing care plan.
21. Barium swallow is an examination of the upper GI tract under fluoroscopy after the
client drinks barium sulfate. The client being seen in a physician’s office has just
been scheduled for a barium swallow the next day. The nurse writes down which of
the following instructions for the client to follow before the test?
A. Fast for 8 hours before the test
B. Eat a regular supper and breakfast
C. Continue to take all oral medications as scheduled
D. Monitor own bowel movement pattern for constipation
RATIONALE: The client should fast for 8 to 12 hours before the test, depending on
physician instructions. A barium swallow is an x-ray study that uses a substance called
barium for contrast to highlight abnormalities in the gastrointestinal tract
22. Upper gastrointestinal fiberoscopy is usually being done for patients with chief
complaint of melena and other signs and symptoms related to upper gastrointestinal
bleeding. Following sedation, an endoscope is passed down the esophagus to view
the esophagus, stomach and duodenum; issue specimens can be obtained. The
client has undergone esophagogastroduodenoscopy. The nurse places highest
priority on which of the following items as part of the client’s care plan?
A. Assessing for the return of the gag reflex
B. Giving warm gargles for a sore throat
C. Monitoring for temperature -
D. Monitoring complaints of heartburn
RATIONALE: The nurse places highest priority on assessing for return of the gag reflex.
This examination focuses on the client's airway.
23. Clients whose gastrointestinal tracts are severely dysfunctional or non-functional and
are unable to process nutrients normally require Total Parenteral Nutrition (TPN)
administered through a central vein, such as subclavian vein. The nurse is caring for
a client who is receiving total parenteral nutrition (TPN) via a central line. Which
nursing intervention specifically would provide assessment data related to the most
common complication related to TPN?
A. Weighing the client daily – fluid volume overload
B. Monitoring intake and output - fluid volume overload
C. Monitoring the temperature - infection
D. Monitoring the serum blood urea nitrogen – renal function
RATIONALE: Probably the most prevalent problem linked with complete parenteral
feeding is infection.
24. When TPN is anticipated for an extended period (greater than 4 weeks), a more
permanent catheter, such as peripherally inserted central catheter line, a tunnelled
catheter, or an implanted vascular access device is used. A nurse is preparing to
change the TPN solution bag and tubing. The client’s central venous line is located
in the right subclavian vein. The nurse asks the client to do who of the following most
essential items during the tubing change?
A. Take a deep breath, hold it, and bear down.
B. Exhale slowly and evenly.
C. Turn the head to the right.
D. Breathe normally.
RATIONALE: The client should be asked to perform the Valsalva maneuver during
tubing changes. This helps avoid air embolism during tube changes. The nurse asks the
client to take a deep breath. hold it. and bear down

25. A client on TPN is usually being monitored for blood glucose levels every 4-6 hours
to monitor for possible complication signs of hyperglycemia or hypoglycemia. A
nurse is making initial rounds at the beginning of the shift. The TPN bag of an
assigned client is empty. Which of the following solutions readily available on the
nursing unit should the nurse hang until another TPN solution is mixed and delivered
to the nursing unit?
A. 5% dextrose in water
B. 5% dextrose in 0.9% sodium chloride
C. 5% dextrose in Ringers lactate
D. 10% dextrose in water
RATIONALE: The client is at risk for hypoglycemia; therefore the solution containing the
highest amount of glucose should be hung until the new PN solution becomes available.
Because PN solutions contain high glucose concentrations, the 10% dextrose in water
solution is the best of the choices presented

26. A stroke patient suffering from dysphagia is usually being given a bolus feeding
through the use of nasogastric tube, this feeding resembles a normal feeding pattern
which consists of 300 to 400 mL of formula every 3 to 6 hours. A nurse is inserting a
nasogastric tube in an adult client. During the procedure, the client begins to cough
and has difficulty of breathing. Which of the following is the most appropriate nursing
action?
A. Remove the tube and reinsert when the respiratory distress subsides
B. Pull back on the tube and wait until the respiratory distress subsides
C. Quickly insert the tube
D. Notify the physician immediately
RATIONALE: The client is at risk for hypoglycemia; therefore the solution containing the
highest amount of glucose should be hung until the new PN solution becomes available.
Because PN solutions contain high glucose concentrations, the 10% dextrose in water
solution is the best of the choices presented
27. Nasogastric tubes are used for feeding clients who have adequate gastric emptying,
and who require short-term feedings. They are not advised for feeding clients
without intact gag and cough reflexes since the risk of accidental placement of the
tube into the lungs is much higher in those clients. The nurse checks for residual
before administering a bolus tube feeding to a client with nasogastric tube and
obtains a residual amount of 150 mL. What is the appropriate action for the nurse to
take?
A. Hold the feeding.
B. Reinstill the amount and continue with administering the feeding.
C. Elevate the client’s head at least 45 degrees and administer the feeding.
D. Discard the residual amount and proceed with administering the feeding.
RATIONALE: Unless specifically indicated, residual amounts greater than 100 mL
require holding the feeding, but this is individualized and each agency's policy should be
checked

28. Obtaining capillary blood glucose by skin puncture is an alternative for self-
management of diabetes mellitus. The procedure is less painful than venipuncture,
and the ease of the skin puncture method makes it possible for patients to perform
this procedure. A diabetes nurse educator is providing health teaching regarding the
proper method of blood glucose determination through skin puncture. The nurse
needs to reinforce the teaching if the client identifies which of the following
statements?
A. “I should perform hand hygiene before the procedure”.
B. “I should clean the site with antiseptic swab, and allow it to dry
completely”.
C. “I should wipe away the first droplet of blood with cotton ball”.
D. “I should select the central tip of the finger which has more dense blood
supply”.
RATIONALE:

29. A stoma is the surgical creation of an opening into the colon that allows for drainage
of fecal matter from the colon to the outside of the body. The nurse is assessing a
stoma prolapse in a client with colostomy. The nurse would observe which of the
following if the stoma prolapsed occurred?
 A. Sunken and hidden stoma
B. Dark- and bluish-colored stoma
C. Narrowed and flattened stoma
D. Protruding stoma
RATIONALE: A prolapsed stoma is one in which the bowel protruded through the
stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the
stoma would be associated with dusky or bluish color. A stoma with a narrowed opening
at the level of the skin or fascia is said to be stenosis.

30. Patients with colostomy must be instructed to avoid foods that cause excess gas
formation and odor. The client with a new colostomy is concerned about the odor
from stool in the ostomy drainage bag. The nurse teaches the client to include which
of the following foods in the diet to reduce odor?
A. Yogurt C. Cucumbers
B. Broccoli D. Eggs
RATIONALE: The client should be taught to include deodorizing foods in the diet, such
a beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas
forming food as well. Broccoli, cucumbers, and eggs are gas forming foods.
31. The normal stool of patients with an ileostomy is liquid. The client has just had
surgery to create an ileostomy. The nurse assesses the client in the immediate post-
operative period for which of the following most frequent complication of this type of
surgery?
A. Intestinal obstruction
B. Fluid and electrolyte imbalance
C. Malabsorption of fat
D. Folate deficiency
RATIONALE: Fluid and electrolyte imbalance A major complication that occurs most
frequent following an ileostomy is fluid and electrolyte imbalance. The client requires
constant monitoring of intake and output to prevent this from happening. Losses require
replacement by intravenous infusion until the client can tolerate a diet orally
32. Cleansing enemas uses a variety of solutions. Hypotonic solutions (e.g tap water)
exert osmotic pressure, which draws fluid from the interstitial space into the colon. A
client has an order for “enemas until clear” before major bowel surgery. After
preparing the equipment and solution, the nurse assists the client into which of the
following positions to administer the enema?
A. Right side-lying with the head of the bed elevated 45 degrees.
B. Left-lateral sim’s position
C. Right-lateral sim’s position
D. Left side-lying with the head of the bed elevated 45 degrees.
RATIONALE: The left lateral sim’s position is the most appropriate position for giving an
enema because of the anatomical characteristics of the colon and this eases the
passage and flow of fluid into the rectum.

33. In carminative enema, the solution is instilled into the rectum releases gas, which in
turn distends the rectum and the colon, thus stimulating peristalsis. For an adult, 60-
180 ml of fluid is instilled. A nurse has administered approximately half of a high
cleansing enema when the client complains of pain and cramping. Which nursing
action is the most appropriate?
A. Discontinuing the enema and notifying the physician.
B. Raising the enema bag so that the solution can be completed quickly.
C. Clamping the tubing for 30 seconds and restarting the flow at a slower
rate.
D. Reassuring the client and continuing the flow.
RATIONALE: The enema fluid should be administered slowly. If the client complains of
fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate.
Although client reassurance is important, continuing the flow is inappropriate. Slow
enema administration and stopping the flow temporarily, if necessary, decrease the
likelihood of intestinal spasm and premature ejection of the solution. The higher the
solution container is held above the rectum, the faster the flow and the greater the force
in the rectum; this could increase cramping
CASE SCENARIO: Nurse July is assigned to patient SM who undergone Open-Heart
Surgery. The patient’s central venous catheter is hooked to a central venous pressure
monitor.

34. In measuring the CVP, the zero point on the manometer needs to be at the level of
the phlebostatic axis. The client needs to be supine, with the head of bed at 45
degrees. To measure the CVP of patient S.M., nurse July should manipulate the 3
way stopcock to which of the following?
A. Turn the 3 way stopcock OFF to the patient
B. Turn the 3 way stopcock ON to the patient and ON to the manometer
C. Turn the 3 way stopcock ON to the saline solution and ON to the
manometer
D. Turn the 3 way stopcock ON to the saline solution and ON to the patient
RATIONALE:
35. The Einthoven's triangle was derived from Willem Einthoven a Dutch doctor and
physiologist who invented the first practical electrocardiogram. It refers to an
imaginary inverted equilateral triangle centered on the chest and the points being the
standard leads on the arms and legs. Patient SM suddenly complains of severe
chest pain, nurse July immediately hooked her to the cardiac monitor. Nurse July is
correct in placing the 3 leads if:
A. The white lead is placed on the right arm, the black lead is at the
left arm, and the red lead is placed on the left leg
B. The white lead is placed on the left arm, the black lead is at the left
arm, and the red lead is placed on the left leg
C. The white lead is placed on the right leg, the black lead is at the
right arm, and the red lead is placed on the left arm
D. The white lead is placed on the right arm, the black lead is at the
left arm, and the red lead is placed on the right leg

36. Pulse oximetry is a noninvasive test that registers the saturation of the client’s
hemoglobin. As nurse July made her rounds for 12NN, she noticed that the SaO2 is
recorded as 90% on the pulse oximeter hooked on patient SM’s finger. Which of the
following actions should you expect that nurse July will do initially?
 A. Immediately press the call light and call for the code blue
B. Check the client status and sensor placement
C. Transfer the sensor to other location such as the earlobe or forehead
D. Continue monitoring as the SaO2 reading is within normal limits

37. Cardiac catheterization involves insertion of catheter into the heart and surrounding
vessels. It obtains information about the structure and performance of the heart
valves and circulatory system. Patient SM is now scheduled for cardiac
catheterization using a radiopaque dye due to persistence of chest heaviness.
Which of the following assessments is most critical before the procedure?
A. Intake and output C. Height and weight
B. Baseline peripheral pulse rates D. Allergy to shellfish

38. Cardiac catheterization is an invasive diagnostic procedure which imposes that the
nurse must monitor vital signs and cardiac rhythm for dysrhythmia at least every 30
minutes for 2 hours initially. Nurse July now receives patient SM from the
catheterization laboratory. In the first few hours after cardiac catheterization, which
nursing measure would be most essential?
A. Checking pedal pulse in the extremity used for the cut-down
B. Encouraging the client to cough and deep breathe hourly
C. Keeping the client sedated to maintain the pressure dressing
D. Monitoring the client’s urine output

CASE SCENARIO: Patient EA, a 35-year old female was brought to the emergency
room due to a decrease in the level of consciousness. In the assessment made by
nurse PM his VS revealed the following: HR=135, RR= 29, BP=80/50, T=35.9 0C. He is
pale-looking, profusely sweating and cold to touch. An IV insertion was immediately
ordered by the resident doctor.

39. Intravenous therapy provides a vascular route to sustain clients who are unable to
take substances orally to replace water, electrolytes, and nutrients more rapidly.
Patient EA is hypovolemic, and plasma expanders are not available. Nurse PM
anticipates that which of the following solutions available on the nursing unit will be
prescribed by the physician?
A. 5% dextrose in water
B. 0.9% sodium chloride
C. 0.45% sodium chloride
D. 5% dextrose in 0.45% sodium chloride

40. In adding of medication to an intravenous line, the expiry date of the medication and
solution should be assessed, and the medication must be ensured that it can be
mixed in soft plastic because some medications absorb into the soft plastic and
should be mixed only in glass. Nurse PM has an order to hang an IV bag of 1L 5%
dextrose in water with 20 mEq KCl. Nurse PM should plan to do which of the
following immediately after injecting the potassium chloride into the port of the IV
bag?
A. Attach the tubing to the client
B. Check the solution for yellowish discoloration
C. Rotate the bag gently
D. Place the time tape on the IV
41. Immunocompromised clients have a high risk to develop infection which occurs from
the entry of microorganisms into the body through the venipuncture site. Patient EA
has a 1L bag of 5% dextrose in 0.9% NaCl hung at 3PM. Nurse PM is making
rounds at 3:45PM finds the client to be complaining of a pounding headache and to
be dyspneic, experiencing chills, apprehensive, and with increased pulse rate. The
IV bag has 400 mL remaining. Nurse PM should take which of the following actions
first?
A. Sit the client up in bed C. Slow the IV infusion
B. Call the physician D. Remove the IV catheter
CASE SCENARIO: Nurse Marica is a medical-surgical nurse taking care of patient CKD
who is suffering from Chronic Renal Failure. Two units of packed red blood cells were
ordered to be transfused for 4-6 hours each unit.

42. Before blood transfusion, the recipient’s ABO type and Rh type are identified. An
antibody screen is done to determine the presence of antibodies other than anti-A
and anti-B. Crossmatching is done, in which donor red blood cells are combined with
recipient’s serum and Coomb’s serum; crossmatch is compatible if no red blood cell
clumping occurs. Nurse Marica measured the temperature of patient CKD before
hanging the packed red blood cells and it was found to be 100.6 0F orally. Nurse
Marica must do which of the following as the most appropriate nursing action?
A. Administer diphenhydramine as ordered and begin the transfusion
B. Administer two tablets of paracetamol and begin the transfusion
C. Begin the transfusion as prescribed
D. Delay hanging the blood and notify the physician

43. Blood products should be infused through administration sets designed specifically
for blood; use straight tubing blood administration set that contains an in-line blood
filter designed to trap fibrin clots and other debris that accumulate during blood
storage. Nurse Marica overhears a physician stating that another client is in
hypovolemic shock and requires plasma expansion. Nurse Marica anticipates
receiving an order to transfuse which of the following blood products to this client?
A. Cryoprecipitate C. Albumin
B. Packed red blood cells D. Platelets

CASE SCENARIO: Ms. GS is a newly hired staff nurse in the emergency room. She
enrolled herself to Basic Life Support (BLS) and Advance Cardiac Life Support (ACLS)
certification as these are required for the said position.

44. Defibrillation is an asynchronous countershock used to terminate pulseless

ventricular tachycardia or ventricular fibrillation. During the defibrillation, be sure that
no one is touching the bed or the client when delivering the countershock. Ms. GS is
preparing to defibrillate a client in ventricular fibrillation during the return
demonstration. Ms. GS places the paddles correctly on the client’s chest if:
 A. The first paddle is placed on the left sternum at 2 nd intercostal space, and
the second on the right anterior axillary line at 5 th intercostal space.
B. The first paddle is placed on the right sternum at 2 nd intercostal space, and
the second on the left anterior axillary line at 5 th intercostal space.
C. The first paddle is placed on the right sternum at 5th intercostal space,
and the second on the left anterior axillary line at 2nd intercostal space.
D. The first paddle is placed on the left sternum at 5th intercostal space, and
the second on the right anterior axillary line at 5 th intercostal space.

45. Cardioversion involves the delivery of a “timed” electrical current to terminate a

tachydysrhythmia. In cardioversion, the defibrillator is set to synchronize with the
ECG on a cardiac monitor so that the electrical impulse discharges during ventricular
depolarization (QRS complex. A lower amount of energy is used than with
defibrillation. If the defibrillator were not synchronized, it would discharge on the T
wave and cause ventricular fibrillation. Ms. GS is evaluating a client’s response to
cardioversion on their return demonstration. Which of the following observations
would be of highest priority to the nurse?
A. Oxygen flow rate C. Blood pressure
B. Status of airway D. Level of consciousness

CASE SCENARIO: Student nurse GH is a sophomore student. She is reviewing the

important concepts about proper food and nutrition for their upcoming preliminary
examination.

46. Nutrition is the sum of all interactions between an organism and the food it
consumes. Nutrients are organic and inorganic substances found in foods that are
required for body functioning. GH is taking care of a bulimic client who stated that
she is overweight. Upon assessment, GH determined that her BMI is 17.5. This
means that the patient’s BMI is considered a/an:
 A. Normal weight C. Overweight
B. At risk D. Underweight

47. Low-purine diet is used to treat gout. Purine is a precursor for uric acid that forms
stones and crystals. In developing a dietary plan for patients with gout, GH must
plan to include which item on a list of foods to be avoided?
A. Liver C. Carrots
B. Chocolate D. Broccoli

48. Enteral feedings are administered through nasogastric and small-bore feeding tubes,
or through gastrostomy or jejunostomy tubes. It is used for clients with swallowing
problems, burns, major trauma, or severe malnutrition. A client who recently has
been started on enteral feedings begins to complain of abdominal cramping,
followed by the passage of two liquid stools. Student nurse GH notes that the client
has abdominal distention as well. GH reviews the nutritional content on the label of
the can of feeding to see if it has which of the following ingredients?
A. Maltose C. Sucrose
B. Lactose D. Fructose

CASE SCENARIO: BJ has recently passed the board exam and was assigned to the
medical ward of Sulu Medical Center. As a competent nurse, it is essential that she
knows the basic procedure when providing care for the patient.

49. Some urine examinations require collection of all urine produced and voided over a
specific period of time, ranging from 1 to 2 hours to 24 hours. Urine osmolality is a
measure of the solute concentration of urine that is a more exact measurement of
urine concentration than specific gravity. The physician has ordered a 24-hour urine
specimen. After explaining the procedure to the client, nurse BJ collects the first
specimen. This specimen is then:
A. Tested, then discarded
B. Placed in a separate container and later added to the collection
C. Discarded, then the collection begins
 D. Saved as part of the 24-hour collection

50. Renal biopsy is the insertion of a needle into the kidney to obtain a sample of tissue
for examination. During the procedure, the client must be placed on prone with pillow
under the abdomen and shoulders. Nurse BJ is caring for the client who has had a
renal biopsy. Which of the following interventions would nurse BJ avoid in the care of
the client after this procedure?
A. Encouraging fluids to at least 3L in the first 24 hours
B. Administering narcotics as needed
C. Testing serial samples with dipsticks for occult blood
D. Ambulating the client in the room and hall for short distances

51. Intravenous pyelogram is performed to identify abnormalities in the renal system. It

is vital to inform the client about possible throat irritation, flushing of the face,
warmth, or a salty taste during the test. The client is scheduled for intravenous
pyelogram. Before the test the priority action of nurse BJ would be to:
A. Administer an oral preparation of radiopaque dye
B. Restrict fluids
C. Determine history of allergies
D. Administer a sedative

52. Renal angiography involves the injection of a radiopaque dye through a catheter for
examination of the renal artery. Inform the client about the possible burning feeling
or the feeling of heat along the vessel when dye is injected. Nurse BJ is caring for
the client who has undergone renal angiography using the left femoral artery for
access. Nurse BJ evaluates that the client is experiencing a complication of the
procedure if which of the following observations is made?
A. Urine output 50 mL/hour
B. Absence of hematoma in the left groin
 C. Blood pressure 110/74 mmHg
D. Pallor and coolness of the left leg

CAE SCENARIO: Nurse AB is assigned to take care of a group of elderly patients. Pain
and urinary incontinence are their common concerns. Nurse AB should be able to
address their concerns in a holistic manner.

53. Urinary catheterization is the introduction of a catheter into the urinary bladder. For
adult female clients, use a 22-cm catheter; for adult male clients, a 40-cm catheter is
used. Nurse AB is inserting an indwelling urinary catheter into a male client. As the
catheter is inserted into the urethra, urine begins to flow into the tubing. At this point,
nurse BJ:
A. Immediately inflates the balloon
B. Withdraws the catheter approximately 1 inch and inflates the balloon
C. Inserts the catheter until resistance is met and inflates the balloon
D. Inserts the catheter 2.5 to 5 cm and inflates the balloon

54. Nurses in a health care facility or clients in the home setting can use commercially
prepared kits to test abnormal constituents in the urine. Urine specific gravity is an
indicator of urine concentration, or the amount of solutes present in the urine. Nurse
AB has an order to obtain a urinalysis from a client with an indwelling catheter. The
nurse avoids which of the following, which could contaminate the specimen?
A. Clamping the tubing of the drainage bag
B. Aspirating a sample from the port on the drainage bag
C. Wiping the port with an alcohol swab before inserting the syringe
D. Obtaining the specimen from the urinary drainage bag

55. An irrigation is a flushing or washing-out with a specified solution. The CLOSED

method is the preferred technique for catheter or bladder irrigation because it is
associated with a lower risk of urinary tract infection. A client has had a
 Transurethral Resection of the Prostate (TURP). What is the most important nursing
intervention that must be observed by nurse BJ in the first 24 hours?
A. Assess urinary output
B. Irrigate the bladder every 2 hours
C. Assess for haemorrhage
D. Force fluids

56. Benign Prostatic Hyperplasia (BPH) is the slow enlargement of the prostate gland,
which causes narrowing of the urethra and results in partial or complete obstruction.
The client with BPH undergoes a transurethral resection of the prostate.
Postoperatively, the client is receiving continuous bladder irrigations (CBI). Nurse BJ
assesses the client for signs of transurethral resection syndrome. Which of the
following assessment data would indicate the onset of this syndrome?
A. Bradycardia and confusion
B. Tachycardia and diarrhea
C. Decreased urinary output and bladder spasms
D. Increased urinary output and anemia

CASE SCENARIO: Nurse Kris is assigned to patient AT, a 65 year old male, diagnosed
with Chronic Renal Failure for 1 year and undergoes hemodialysis 3x/week via a left
AVF.

57. Internal arteriovenous fistula provides the access of choice for chronic dialysis
patients. The fistula is created surgically by anastomosis of a large artery and a
large vein in the arm. Its maturity takes about 6-12 weeks and it is required before
the fistula can be used so that the engorged vein can be punctured with a large-bore
needle for the dialysis procedure. Nurse Kris is assessing the patency of an
arteriovenous fistula in the left arm of patient AT. Which finding indicates that the
fistula is patent?
A. Absence of bruit on auscultation of the fistula
B. Palpation of a thrill over the fistula
C. Presence of a radial pulse in the left wrist
 D. Capillary refill less than 3 seconds in the nail beds of the fingers on the left
hand

58. Internal arteriovenous graft is used primarily for chronic dialysis patients who do not
have adequate ________ for the creation of a fistula. An artificial graft made of
Gore-Tex is used to create an artificial vein for blood flow. Patient AT has a left arm
fistula and is at risk for steal syndrome. Nurse Kris assesses patient AT for which of
the following manifestations?
A. Warmth, redness, and pain in the left hand
B. Pallor, diminished pulse, and pain in the left hand
C. Edema and reddish discoloration of the left arm
D. Aching pain, pallor, and edema of the left arm

59. Hemodialysis is the movement of dissolved particles from one fluid compartment into
another across a semipermeable membrane. Knowing that patient AT is at risk for
disequilibrium syndrome, nurse Kris assesses the client during hemodialysis for:
A. Hypertension, tachycardia, and fever
B. Hypotension, bradycardia, and hypothermia
C. Restlessness, irritability, and generalized weakness
D. Headache, deteriorating level of consciousness, and twitching

CASE SCENARIO: Nurse KE is assigned at the emergency room. Patient KK, a 76-year
old female, came in due to a chief complaint of difficulty of breathing. Latest laboratory
exams revealed: K=7.8, Crea=3.6, BUN=145, Na=160. The doctor immediately ordered
for Emergency Tenchkhoff catheter insertion instead of the Femoral catheter insertion.
60. Peritoneal dialysis works on the principles of diffusion and osmosis, and the dialysis
occurs via the transfer of fluid and solute from the bloodstream through the
peritoneum. Nurse KE is reviewing the list of components consisted in the peritoneal
dialysis solution with the client. Patient KK asks the nurse about the purpose of the
glucose contained in the solution. The nurse bases the response knowing that the
glucose:
A. Prevents excess glucose from being removed from the client
B. Decreases the risk of peritonitis
C. Prevents disequilibrium syndrome
D. Increases osmotic pressure to produce ultrafiltration