NCM 31112L

Midterm Exams
Rationalization
 1. Which of the following items is considered the
single most important factor in assisting the health
professional in arriving at a diagnosis or
determining the person’s needs?

a. History of present illness

b. Physical examination
c. Diagnostic test results
d. Biographical data
1. Which of the following items is considered the single most important factor in assisting the
health professional in arriving at a diagnosis or determining the person’s needs?
 a. History of present illness
The history of the present illness is the single most important factor in assisting the health
professional in arriving at a diagnosis or determining t he person’s needs.
 b. Physical examination
The physical examination is helpful but often only validates the information obtained
from the history.
 c. Diagnostic test results
Diagnostic test results can be helpful, but they often only verify rather than establish
the diagnosis.
 d. Biographical data
Biographical information puts the health history in context but does not focus the
diagnosis.
 
 2. Of the following areas for assessing the patient
profile, which should be addressed after the others?
a. Body image
b. Education
c. Occupation
d. Environment
2. Of the following areas for assessing the patient profile, which should be
addressed after the others?
a. Body image
 The patient is often less anxious when the interview progresses from
information that is less personal to information that is more personal.
b. Education
 Educational level is relatively impersonal and readily revealed by the patient.
c. Occupation
 Occupation is relatively impersonal and readily revealed by the patient.
d. Environment
 Housing, religion, and language are relatively impersonal and readily revealed
by the patient.
3. A steady state within the body is termed
 a. homeostasis
 b. constancy
 c. adaptation
 d. stress
3. A steady state within the body is termed
 a. homeostasis
 When a change occurs that causes a body function to deviate from its stable range,
processes are initiated to restore and maintain the steady state or homeostasis.
 b. constancy
 Constancy refers to the balanced internal state of the human body maintained by
physiologic and biochemical processes.
 c. adaptation
 Adaptation refers to a constant, ongoing process that requires change in structure,
function, or behavior so that the person is better suited to the environment.
 d. stress
 Stress refers to a state produced by a change in the environment that is perceived as
challenging, threatening, or damaging to the person’s dynamic balance or equilibrium.
4. An increase in the number of new cells in an organ or
tissue that is reversible when the stimulus for production of
new cells is removed is termed
 a. hyperplasia
 b. hypertrophy
 c. atrophy
 d. neoplasia
4. An increase in the number of new cells in an organ or tissue that is reversible when the
stimulus for production of new cells is removed is termed
a. hyperplasia
 Hyperplasia occurs as cells multiply and are subjected to increased stimulation
resulting in tissue mass enlargement.
b. hypertrophy
 Hypertrophy is an increase in size and bulk of tissue that does not result from an
increased number of cells.
c. atrophy
 Atrophy refers to reduction in size of a structure after having come to full maturity.
d. neoplasia
 With neoplasia, the increase in the number of new cells in an organ or tissue continues
after the stimulus is removed.
5. Which of the following statements describes accurate
information related to chronic illness?
 a. Most people with chronic conditions do not consider
themselves sick or ill.
 b. Most people with chronic conditions take on a sick role
identity.
 c. Chronic conditions do not result from injury.
 d. Most chronic conditions are easily controlled.
5. Which of the following statements describes accurate information related to chronic
illness?
a. Most people with chronic conditions do not consider themselves sick or ill.
 Although some people take on a sick role identity, most people with chronic conditions
do not consider themselves sick or ill and try to live as normal a life as is possible.
b. Most people with chronic conditions take on a sick role identity.
 Research has demonstrated that some people with chronic conditions may take on a sick
role identity, but they are not the majority.
c. Chronic conditions do not result from injury.
 Chronic conditions may be due to illness, genetic factors, or injury
d. Most chronic conditions are easily controlled.
 Many chronic conditions require therapeutic regimens to keep them under control.
6. Test for diabetic ketonuria:
 a. CBC
 b. Urinalysis
 c. Stool exam
 d. Blood exam
6. Test for diabetic ketonuria:
 a. CBC
 b. Urinalysis
 c. Stool exam
 d. Blood exam
7. The nurse will teach the client on how to wear embolic
stockings by:
 a. When standing roll the stockings from the toes up to the
thigh
 b. When dressing up
 c. Reclining position
 d. Teach the client to sit or stand up and gently roll
stockings up to the leg and thigh
7. The nurse will teach the client on how to wear embolic stockings by:
 a. When standing roll the stockings from the toes up to the thigh
 b. When dressing up
 c. Reclining position
 d. Teach the client to sit or stand up and gently roll stockings up to
the leg and thigh
8. Why do we have to give insulin for a client diagnosed with Chronic Renal
Failure?

 a. To lower the nitrogenous wastes c. To lower the

sugar level
 b. To lower the Potassium level d. To lower the BP
8. Why do we have to give insulin for a client diagnosed with Chronic
Renal Failure?

 a. To lower the nitrogenous wastes c. To lower the

sugar level
 b. To lower the Potassium level d. To lower the
BP
9. A nurse recognizes that a KVO rate IV means:

a. 7 -10 gtts per hour c. consume within 12 hours

b. 1 - 2 gtts/min ci. d. consume within 24 hours
 
9. A nurse recognizes that a KVO rate IV means:

a. 7 -10 gtts per hour c. consume within 12 hours

b. 1 - 2 gtts/min ci. d. consume within 24 hours
 
10. D5%W in Plain NSS 0.9% is:

a. Hypertonic b. Hypotonic
c. Isotonic d. Osmotic
10. D5%W in Plain NSS 0.9% is:

a. Hypertonic b. Hypotonic
c. Isotonic d. Osmotic
11. Mrs. Chua a 78-year-old client is admitted
with the diagnosis of mild chronic heart failure.
The nurse expects to hear when listening to
client’s lungs indicative of chronic heart failure
would be:
a. Stridor
b. Crackles
c. Wheezes
d. Friction rubs
 
 B. Left sided heart failure causes fluid accumulation in the capillary
network of the lung.
 Fluid eventually enters alveolar spaces and causes crackling
sounds at the end of inspiration.
12. Patrick who is hospitalized following a myocardial
infarction asks the nurse why he is taking morphine. The
nurse explains that morphine:
a. Decrease anxiety and restlessness
b. Prevents shock and relieves pain
c. Dilates coronary blood vessels
d. Helps prevent fibrillation of the heart
 
 B. Morphine is a central nervous system
depressant used to relieve the pain associated
with myocardial infarction, it also decreases
apprehension and prevents cardiogenic shock.
13. Which of the following should the nurse teach the client
about the signs of digitalis toxicity?
 a. Increased appetite
 b. Elevated blood pressure
 c. Skin rash over the chest and back
 d. Visual disturbances such as seeing yellow spots
 
 D. Seeing yellow spots and colored vision are common
symptoms of digitalis toxicity
14. Nurse Tanya teaches a client with heart failure to take
oral Furosemide in the morning. The reason for this is to
help:
 a. Retard rapid drug absorption
 b. Excrete excessive fluids accumulated at night
 c. Prevents sleep disturbances during night
 d. Prevention of electrolyte imbalance
 C. When diuretics are taken in the morning, client will
void frequently during daytime and will not need to void
frequently at night.
15. What would be the primary goal of therapy for a client
with pulmonary edema and heart failure?
 a. Enhance comfort
 b. Increase cardiac output
 c. Improve respiratory status
 d. Peripheral edema decreased
 B. The primary goal of therapy for the client with
pulmonary edema or heart failure is increasing cardiac
output. Pulmonary edema is an acute medical emergency
requiring immediate intervention.
16. Dr. Marquez orders a continuous intravenous
nitroglycerin infusion for the client suffering from
myocardial infarction. Which of the following is the most
essential nursing action?
 a. Monitoring urine output frequently
 b. Monitoring blood pressure every 4 hours
 c. Obtaining serum potassium levels daily
 d. Obtaining infusion pump for the medication
 D. Administration of Intravenous Nitroglycerin infusion
requires pump for accurate control of medication.
17. During the second day of hospitalization of the client
after a Myocardial Infarction. Which of the following is an
expected outcome?
 a. Able to perform self-care activities without pain
 b. Severe chest pain
 c. Can recognize the risk factors of Myocardial Infarction
 d. Can participate in cardiac rehabilitation walking
program
 A. By the 2nd day of hospitalization after suffering a
Myocardial Infarction, Clients are able to perform care
without chest pain
18. Nurse Liza is assigned to care for a client who has
returned to the nursing unit after left nephrectomy. Nurse
Liza’s highest priority would be…
 a. Hourly urine output
 b. Temperature
 c. Able to turn side to side
 d. Able to sips clear liquid
 A. After nephrectomy, it is necessary to measure urine output
hourly. This is done to assess the effectiveness of the remaining
kidney also to detect renal failure early.
19. A 64-year-old male client with a long history of
cardiovascular problem including hypertension and angina is to
be scheduled for cardiac catheterization. During pre-cardiac
catheterization teaching, Nurse Cherry should inform the client
that the primary purpose of the procedure is…..
 a. To determine the existence of CHD
 b. To visualize the disease process in the coronary arteries
 c. To obtain the heart chambers pressure
 d. To measure oxygen content of different heart chambers
 B. The lumen of the arteries can be assessed by cardiac
catheterization. Angina is usually caused by narrowing of
the coronary arteries.
20. During the first several hours after a cardiac
catheterization, it would be most essential for nurse Cherry
to…
 a. Elevate client’s bed at 45°
 b. Instruct the client to cough and deep breathe every 2
hours
 c. Frequently monitor client’s apical pulse and blood
pressure
 d. Monitor client’s temperature every hour
 C. Blood pressure is monitored to detect hypotension
which may indicate shock or hemorrhage. Apical pulse is
taken to detect dysrhythmias related to cardiac irritability.
21. Kate who has undergone mitral valve replacement suddenly
experiences continuous bleeding from the surgical incision during
postoperative period. Which of the following pharmaceutical agents
should Nurse Aiza prepare to administer to Kate?
 a. Protamine Sulfate
 b. Quinidine Sulfate
 c. Vitamin C
 d. Coumadin
 A. Protamine Sulfate is used to prevent continuous bleeding in
client who has undergone open heart surgery.
22. In reducing the risk of endocarditis, good dental care is
an important measure. To promote good dental care in client
with mitral stenosis in teaching plan should include proper
use of…
 a. Dental floss
 b. Electric toothbrush
 c. Manual toothbrush
 d. Irrigation device
 C. The use of electronic toothbrush, irrigation device or
dental floss may cause bleeding of gums, allowing
bacteria to enter and increasing the risk of endocarditis.
23. Among the following signs and symptoms, which would
most likely be present in a client with mitral gurgitation?
 a. Altered level of consciousness
 b. Exceptional Dyspnea
 c. Increase creatinine phosphokinase concentration
 d. Chest pain
 B. Weight gain due to retention of fluids and worsening
heart failure causes exertional dyspnea in clients with
mitral regurgitation.
24. Kris with a history of chronic infection of the urinary
system complains of urinary frequency and burning
sensation. To figure out whether the current problem is in
renal origin, the nurse should assess whether the client has
discomfort or pain in the…
 a. Urinary meatus
 b. Pain in the Labium
 c. Suprapubic area
 d. Right or left costovertebral angle
 D. Discomfort or pain is a problem that originates in the
kidney. It is felt at the costovertebral angle on the affected
side.
25. Nurse Perry is evaluating the renal function of a male
client. After documenting urine volume and characteristics,
Nurse Perry assesses which signs as the best indicator of
renal function.
 a. Blood pressure
 b. Consciousness
 c. Distension of the bladder
 d. Pulse rate
 A. Perfusion can be best estimated by blood pressure,
which is an indirect reflection of the adequacy of cardiac
output.
26. Smoking cessation is critical strategy for the client with
Burger’s disease, Nurse Jasmin anticipates that the male
client will go home with a prescription for which
medication?
 a. Paracetamol
 b. Ibuprofen
 c. Nitroglycerin
 d. Nicotine (Nicotrol)
 D. Nicotine (Nicotrol) is given in controlled and
decreasing doses for the management of nicotine
withdrawal syndrome.
27. Nurse Lilly has been assigned to a client with Raynaud’s
disease. Nurse Lilly realizes that the etiology of the disease
is unknown but it is characterized by:
 a. Episodic vasospastic disorder of capillaries
 b. Episodic vasospastic disorder of small veins
 c. Episodic vasospastic disorder of the aorta
 d. Episodic vasospastic disorder of the small arteries
 
 D. Raynaud’s disease is characterized by vasospasms of
the small cutaneous arteries that involves fingers and toes.
28. Nurse Jamie should explain to male client with diabetes
that self-monitoring of blood glucose is preferred to urine
glucose testing because…
 a. More accurate
 b. Can be done by the client
 c. It is easy to perform
 d. It is not influenced by drugs
 A. Urine testing provides an indirect measure that maybe
influenced by kidney function while blood glucose testing
is a more direct and accurate measure.
29. Jessie weighed 210 pounds on admission to the hospital.
After 2 days of diuretic therapy, Jessie weighs 205.5 pounds.
The nurse could estimate the amount of fluid Jessie has
lost…
 a. 0.3 L
 b. 1.5 L
 c. 2.0 L
 d. 3.5 L
 C. One liter of fluid approximately weighs 2.2 pounds. A
4.5-pound weight loss equals to approximately 2L
 
30. Nurse Donna is aware that the shift of body fluids
associated with Intravenous administration of albumin
occurs in the process of:
 a. Osmosis
 b. Diffusion
 c. Active transport
 d. Filtration
 A. Osmosis is the movement of fluid from an area of
lesser solute concentration to an area of greater solute
concentration.
31. A female client is experiencing painful and rigid
abdomen and is diagnosed with perforated peptic ulcer. A
surgery has been scheduled and a nasogastric tube is
inserted. The nurse should place the client before surgery in
 a. Sims position
 b. Supine position
 c. Semi-fowlers position
 d. Dorsal recumbent position
 C. Semi-fowlers position will localize the spilled stomach
contents in the lower part of the abdominal cavity.
 
32. Which nursing intervention ensures adequate ventilating
exchange after surgery?
 a. Remove the airway only when client is fully conscious
 b. Assess for hypoventilation by auscultating the lungs
 c. Position client laterally with the neck extended
 d. Maintain humidified oxygen via nasal cannula
 C. Positioning the client laterally with the neck
extended does not obstruct the airway so that drainage
of secretions and oxygen and carbon dioxide exchange
can occur.
33. George who has undergone thoracic surgery has chest
tube connected to a water-seal drainage system attached to
suction. Presence of excessive bubbling is identified in
water-seal chamber, the nurse should…
 a. “Strip” the chest tube catheter
 b. Check the system for air leaks
 c. Recognize the system is functioning correctly
 d. Decrease the amount of suction pressure
 B. Excessive bubbling indicates an air leak which must
be eliminated to permit lung expansion.
34. A client who has been diagnosed of hypertension is being
taught to restrict intake of sodium. The nurse would know
that the teachings are effective if the client states that…
 a. I can eat celery sticks and carrots
 b. I can eat broiled scallops
 c. I can eat shredded wheat cereal
 d. I can eat spaghetti on rye bread
 C. Wheat cereal has a low sodium content.
35. Which of the following illnesses is the leading cause of
death in the US?
 a. Cancer
 b. Coronary artery disease
 c. Liver failure
 d. Renal failure
 
 b. Coronary artery disease
 Coronary artery disease accounts for over 50% of all
deaths in the US.
 Cancer accounts for approximately 20%.
 Liver failure and renal failure account for less than 10% of
all deaths in the US.
 
36. Which of the following conditions most commonly
results in CAD?
 a. Atherosclerosis
 b. DM
 c. MI
 d. Renal failure
 a. Atherosclerosis
 Atherosclerosis, or plaque formation, is the leading cause of CAD.
DM is a risk factor for CAD but isn't the most common cause. Renal
failure doesn't cause CAD, but the two conditions are related.
Myocardial infarction is commonly a result of CAD.
37. Atherosclerosis impedes coronary blood flow by which
of the following mechanisms?
 a. Plaques obstruct the vein
 b. Plaques obstruct the artery
 c. Blood clots form outside the vessel wall
 d. Hardened vessels dilate to allow the blood to flow
through
 
 b. Plaques obstruct the artery
 Arteries, not veins, supply the coronary arteries with oxygen and
other nutrients. Atherosclerosis is a direct result of plaque formation
in the artery. Hardened vessels can't dilate properly and, therefore,
constrict blood flow.
38. Which of the following risk factors for coronary artery
disease cannot be corrected?
 a. Cigarette smoking
 b. DM
 c. Heredity
 d. HPN
 c. Heredity
 Because "heredity" refers to our genetic makeup, it can't
be changed.
 Cigarette smoking cessation is a lifestyle change that
involves behavior modification.
 Diabetes mellitus is a risk factor that can be controlled
with diet, exercise, and medication.
 Altering one's diet, exercise, and medication can correct
hypertension.
39. Medical treatment of coronary artery disease includes
which of the following procedures?
 a. Cardiac catheterization
 b. Coronary artery bypass surgery
 c. Oral medication administration
 d. Percutaneous transluminal coronary angioplasty
 
 c. Oral medication administration. Oral medication
administration is a noninvasive, medical treatment for
coronary artery disease. Cardiac catheterization isn't a
treatment but a diagnostic tool. Coronary artery bypass
surgery and percutaneous transluminal coronary
angioplasty are invasive, surgical treatments.
40. Prolonged occlusion of the right coronary artery
produces an infarction in which of he following areas of
the heart?
 a. Anterior
 b. Apical
 c. Inferior
 d. Lateral
 c. Inferior.
 The right coronary artery supplies the right ventricle, or
the inferior portion of the heart. Therefore, prolonged
occlusion could produce an infarction in that area.
 The right coronary artery doesn't supply the anterior
portion (left ventricle), lateral portion (some of the left
ventricle and the left atrium), or the apical portion (left
ventricle) of the heart.
41. Which individual is at greatest risk for developing
hypertension?
 a. 45-year-old African American attorney
 b. 60-year-old Asian American shop owner
 c. 40 year-old Caucasian nurse
 d. 55-year-old Hispanic teacher
 The correct answer is A: 45 year-old African American
Attorney
 The incidence of hypertension is greater among African
Americans than other groups in the US.
 The incidence among the Hispanic population is rising.
42. Which complication of cardiac catheterization should the
nurse monitor for in the initial 24 hours after the procedure?
 a. angina at rest
 b. thrombus formation
 c. dizziness
 d. falling blood pressure
 The correct answer is B: thrombus formation
 Thrombus formation in the coronary arteries is a potential
problem in the initial 24 hours after a cardiac
catheterization.
 A falling BP occurs along with hemorrhage of the
insertion site which is associated with the first 12 hours
after the procedure.
43. A client is admitted to the emergency room with renal
calculi and is complaining of moderate to severe flank pain
and nausea. The client’s temperature is 100.8 degrees
Fahrenheit. The priority nursing goal for this client is
 a. Maintain fluid and electrolyte balance
 b. Control nausea
 c. Manage pain
 d. Prevent urinary tract infection
 The correct answer is C: Manage pain
 The immediate goal of therapy is to alleviate the client’s
pain.
44. At a community health fair the blood pressure of a 62-
year-old client is 160/96. The client states “My blood
pressure is usually much lower.” The nurse should tell the
client to…
 a. go get a blood pressure check within the next 48 to 72
hours
 b. check blood pressure again in 2 months
 c. see the health care provider immediately
 d. visit the health care provider within 1 week for a BP
check
 
 The correct answer is A: go get a blood pressure check within the
next 48 to 72 hours
 The blood pressure reading is moderately high with the need to have
it rechecked in a few days. The client states it is ‘usually much
lower.’ Thus a concern exists for complications such as stroke.
However immediate check by the provider of care is not warranted.
 Waiting 2 months or a week for follow-up is too long.
45. When teaching a client with coronary artery disease
about nutrition, the nurse should emphasize
 a. Eating 3 balanced meals a day
 b. Adding complex carbohydrates
 c. Avoiding very heavy meals
 d. Limiting sodium to 7 gms per day
 
 The correct answer is C: Avoiding very heavy meals
 Eating large, heavy meals can pull blood away from the heart for
digestion and is dangerous for the client with coronary artery
disease.
46. Which of these findings indicate that a pump to deliver a
basal rate of 10 ml per hour plus PRN for pain breakthrough for
morphine drip is not working?
 a. The client complains of discomfort at the IV insertion
site
 b. The client states "I just can’t get relief from my pain."
 c. The level of drug is 100 ml at 8 AM and is 80 ml at noon
 d. The level of the drug is 100 ml at 8 AM and is 50 ml at
noon
 
 The correct answer is C: The level of drug is 100 ml at 8 AM and is
80 ml at noon The minimal dose of 10 ml per hour which would be
40 ml given in a 4-hour period. Only 60 ml should be left at noon.
 The pump is not functioning when more than expected medicine is
left in the container.
47. The nurse is giving discharge teaching to a client 7 days’ post
myocardial infarction. He asks the nurse why he must wait 6 weeks
before having sexual intercourse. What is the best response by the
nurse to this question?
 a. "You need to regain your strength before attempting such
exertion."
 b. "When you can climb 2 flights of stairs without problems, it
is generally safe.”
 c. "Have a glass of wine to relax you, then you can try to have
sex."
 d. "If you can maintain an active walking program, you will
have less risk."
 
 The correct answer is B: "When you can climb 2 flights of
stairs without problems, it is generally safe." There is a
risk of cardiac rupture at the point of the myocardial
infarction for about 6 weeks. Scar tissue should form
about that time. Waiting until the client can tolerate
climbing stairs is the usual advice given by health care
providers.
48. The nurse is preparing to administer an enteral feeding to
a client via a nasogastric feeding tube. The most important
action of the nurse is
 a. Verify correct placement of the tube
 b. Check that the feeding solution matches the dietary
order
 c. Aspirate abdominal contents to determine the amount
of last feeding remaining in stomach
 d. Ensure that feeding solution is at room temperature
 
 The correct answer is A: Verify correct placement of the
tube Proper placement of the tube prevents aspiration.
49. The nurse is caring for a client with a serum potassium
level of 3.5 mEq/L. The client is placed on a cardiac monitor
and receives 40 mEq KCL in 1000 ml of 5% dextrose in
water IV. Which of the following EKG patterns indicates to
the nurse that the infusions should be discontinued?
 a. Narrowed QRS complex
 b. Shortened "PR" interval
 c. Tall peaked T waves
 d. Prominent "U" waves
 The correct answer is C: Tall peaked T waves
 A tall peaked T wave is a sign of hyperkalemia. The health
care provider should be notified regarding discontinuing
the medication.
50. During an assessment of a client with cardiomyopathy, the nurse
finds that the systolic blood pressure has decreased from 145 to 110
mm Hg and the heart rate has risen from 72 to 96 beats per minute and
the client complains of periodic dizzy spells. The nurse instructs the
client to
 a. Increase fluids that are high in protein
 b. Restrict fluids
 c. Force fluids and reassess blood pressure
 d. Limit fluids to non-caffeine beverages
 The correct answer is C: Force fluids and reassess blood
pressure Postural hypotension, a decrease in systolic blood
pressure of more than 15 mm Hg and an increase in heart
rate of more than 15 percent usually accompanied by
dizziness indicates volume depletion, inadequate
vasoconstrictor mechanisms, and autonomic insufficiency.
51. A client has a Swan-Ganz catheter in place. The nurse
understands that this is intended to measure
 a. Right heart function
 b. Left heart function
 c. Renal tubule function
 d. Carotid artery function
 
 The correct answer is B: Left heart function
 The Swan-Ganz catheter is placed in the pulmonary artery
to obtain information about the left side of the heart. The
pressure readings are inferred from pressure
measurements obtained on the right side of the circulation.
Right-sided heart function is assessed through the
evaluation of the central venous pressures (CVP).
52. A nurse enters a client’s room to discover that the client
has no pulse or respirations. After calling for help, the first
action the nurse should take is
 a. Start a peripheral IV
 b. Initiate closed-chest massage
 c. Establish an airway
 d. Obtain the crash cart
 The correct answer is C: Establish an airway Establishing
an airway is always the primary objective in a
cardiopulmonary arrest.
53. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The
health care provider has written a new order to give metoprolol
(Lopressor) 25 mg. B.I.D. In assessing the client prior to
administering the medications, which of the following should
the nurse report immediately to the health care provider?
 a. Blood pressure 94/60
 b. Heart rate 76
 c. Urine output 50 ml/hour
 d. Respiratory rate 16
 
 The correct answer is A: Blood pressure 94/60 Both medications
decrease the heart rate. Metoprolol affects blood pressure.
Therefore, the heart rate and blood pressure must be within normal
range (HR 60-100; systolic B/P over 100) in order to safely
administer both medications.
54. A client has been taking furosemide (Lasix) for the past
week. The nurse recognizes which finding may indicate the
client is experiencing a negative side effect from the
medication?
 a. Weight gain of 5 pounds
 b. Edema of the ankles
 c. Gastric irritability
 d. Decreased appetite
 
 The correct answer is D: Decreased appetite Lasix causes a loss of
potassium if a supplement is not taken. Signs and symptoms of
hypokalemia include anorexia, fatigue, nausea, decreased GI
motility, muscle weakness, dysrhythmias.
55. The nurse is caring for a client with a venous stasis ulcer.
Which nursing intervention would be most effective in
promoting healing?
 a. Apply dressing using sterile technique
 b. Improve the client’s nutrition status
 c. Initiate limb compression therapy
 d. Begin proteolytic debridement
 
 The correct answer is B: Improve the client’s nutrition status. The
goal of clinical management in a client with venous stasis ulcers is
to promote healing. This only can be accomplished with proper
nutrition. The other answers are correct, but without proper
nutrition, the other interventions would be of little help.
56. The client has ST segment depression on his 12-lead
ECG. The nurse determines that this would indicate the
following:
 a. necrosis
 b. injury
 c. ischemia
 d. nothing significant
 c. ischemia
 Depressed ST segment and inverted T-waves represent myocardial
ischemia. Injury has a ST segment elevation
57. Trousseau’s sign is associated with which electrolyte
imbalance?
 a. hyponatremia
 b. hypocalcemia
 c. hypernatremia
 d. hypercalcemia
 
 
 b. hypocalcemia
 Trousseau’s sign is a carpal pedal spasm elicited when a blood
pressure cuff is inflated on the arm of a patient with hypocalcemia.
58. A 76-year-old man enters the ER with complaints of back
pain and feeling fatigued. Upon examination, his blood
pressure is 190/100, pulse is 118, and hematocrit and
hemoglobin are both low. The nurse palpates the abdomen
which is soft, non-tender and auscultates an abdominal pulse.
The most likely diagnosis is:
 a. Buerger’s disease
 b. CHF
 c. Secondary hypertension
 d. Aneurysm
 
 d. Aneurysm
 The symptoms exhibited by the client are typical of an abdominal
aortic aneurysm. The most significant sign is the audible pulse in
the abdominal area. If hemorrhage were present, the abdomen
would be tender and firm.
59. Nurse Fiona is caring a patient with Raynaud’s disease.
Which of the following outcomes concerning medication
regimen is of highest priority?
 a. Controlling the pain once vasospasm occur
 b. Relaxing smooth muscle to avoid vasospasms
 c. Preventing major disabilities that may occur
 d. Avoiding lesions on the feet
 
 b. Relaxing smooth muscle to avoid vasospasms
 The major task of the health care team is to medicate the client
drugs that produce smooth muscle relaxation, which will decrease
the vasospasm and increase the arterial flow to the affected part. The
drugs used are calcium antagonists.
60. Dianne Hizon is a 27-year-old woman who has been
admitted to the ER due to severe vomiting. Her ABG values
are pH= 7.50, PaCO2= 85, HCO3= 31, and SaO2= 93%. The
nurse interpretation of this ABG analysis is:
 a. respiratory acidosis
 b. respiratory alkalosis
 c. metabolic acidosis
 d. metabolic alkalosis
 d. metabolic alkalosis
 Ms. Hizon’s pH is above 7.45, which makes it alkalotic,
and her bicarbonate is high which is also makes it basic.
Thus, the diagnosis is metabolic alkalosis.
61. A 47-year-old man with liver failure who has developed
ascites. The nurse understands that ascites is due to:
 a. dehydration
 b. protein deficiency
 c. bleeding disorders
 d. vitamin deficiency
 b. protein deficiency
 Protein deficiency allows fluid to leak out of the vascular system
and third space into the tissues and spaces in the body such as the
peritoneal space. Bleeding tendencies, dehydration and vitamin
deficiency can occur but don’t cause ascites.
62. A 48-year-old woman presents to the hospital
complaining of chest pain, tachycardia and dyspnea. On
exam, heart sounds are muffled. Which of the following
assessment findings would support a diagnosis of cardiac
tamponade?
 a. A deviated trachea
 b. Absent breath sounds to the lower lobes
 c. Pulse 40 with inspiration
 d. Blood pressure 140/80
 
 c. Pulse 40 with inspiration
 Paradoxical pulse is a hallmark symptom of cardiac tamponade. As
pressure is exerted on the left ventricle from fluid, the natural
increase in pressure from the right ventricle during inspiration
creates even more pressure, diminishing cardiac output.
63. The proper way to open an envelope-wrapped sterile
package after removing the outer package or tape is to open
the first position of the wrapper:
 a. away from the body
 b. to the left of the body
 c. to the right of the body
 d. toward the body
 a. away from the body
 When opening an envelope-wrapped sterile package, reaching
across the package and using the first motion to open the top cover
away from the body eliminates the need to later reach across the
steri9le field while opening the package. To remove equipment from
the package, opening the first portion of the package toward, to the
left, or to the right of the body would require reaching across a
sterile field.
64. Assessment of a client with possible thrombophlebitis to
the left leg and a deep vein thrombosis is done by pulling up
on the toes while gently holding down on the knee. The
client complains of extreme pain in the calf. This should be
documented as:
 a. positive tourniquet test
 b. positive homan’s sign
 c. negative homan’s sign
 d. negative tourniquet test
 b. positive homan’s sign
 Pain in the calf while pulling up on the toes is abnormal and
indicates a positive test. If the client feels nothing or just feels like
the calf muscle is stretching, it is considered negative. A tourniquet
test is used to measure for varicose veins.
65. A client with congestive heart failure has digoxin
(Lanoxin) ordered every day. Prior to giving the medication,
the nurse checks the digoxin level which is therapeutic and
auscultates an apical pulse. The apical pulse is 63 bpm for 1
full minute. The nurse should:
 a. Hold the Lanoxin
 b. Give the half dose now, wait an hour and give the other
half
 c. Call the physician
 d. Give the Lanoxin as ordered
 
 d. Give the Lanoxin as ordered
 The Lanoxin should be held for a pulse of 60 bpm. Nurses cannot
arbitrarily give half of a dose without a physician’s order. Unless
specific parameters are given concerning pulse rate, most resources
identify 60 as the reference pulse.
66. Hyperkalemia can be treated with administration of 50%
dextrose and insulin. The 50% dextrose:
 a. causes potassium to be excreted
 b. causes potassium to move into the cell
 c. causes potassium to move into the serum
 d. counteracts the effects of insulin
 
 d. counteracts the effects of insulin
 The 50% dextrose is given to counteract the effects of insulin.
Insulin drives the potassium into the cell, thereby lowering the
serum potassium levels. The dextrose doesn’t directly cause
potassium excretion or any movement of potassium.
67. Chvostek’s sign is associated with which electrolyte
imbalance?
 a. hypocalcemia
 b. hypokalemia
 c. hyponatremia
 d. hypophosphatemia
 a. hypocalcemia
 Chvostek’s sign is a spasm of the facial muscles elicited by tapping
the facial nerve and is associated with hypocalcemia. Clinical signs
of hypokalemia are muscle weakness, leg cramps, fatigue, nausea
and vomiting. Muscle cramps, anorexia, nausea and vomiting are
clinical signs of hyponatremia. Clinical manifestations associated
with hypophosphatemia include muscle pain, confusion, seizures
and coma.
68. What laboratory test is a common measure of the renal
function?
 a. CBC
 b. BUN/Crea
 c. Glucose
 d. Alanine amino transferase (ALT)

 
 b. BUN/Crea
 The BUN is primarily used as indicator of kidney function because
most renal diseases interfere with its excretion and cause blood
vessels to rise. Creatinine is produced in relatively constant
amounts, according to the amount of muscle mass and is excreted
entirely by the kidneys making it a good indicator of renal function.
69. Nurse Edward is performing discharge teaching for a
newly diagnosed diabetic patient scheduled for a fasting
blood glucose test. The nurse explains to the patient that
hyperglycemia is defined as a blood glucose level above:
 a. 100 mg/dl
 b. 120 mg/dl
 c. 130 mg/dl
 d. 150 mg/dl
 b. 120 mg/dl
 Hyperglycemia is defined as a blood glucose level greater than 120
mg/dl. Blood glucose levels of 120 mg/dl, 130 mg/dl and 150 mg/dl
are considered hyperglycemic. A blood glucose of 100 mg/dl is
normal.
70. Hazel Murray, 32 years old complains of abrupt onset of
chest and back pain and loss of radial pulses. The nurse
suspects that Mrs. Murray may have:
 a. Acute MI
 b. CVA
 c. Dissecting abdominal aorta
 d. Dissecting thoracic aneurysm
 d. Dissecting thoracic aneurysm
 A dissecting thoracic aneurysm may cause loss of radical pulses and
severe chest and back pain. An MI typically doesn’t cause loss of
radial pulses or severe back pain. CVA and dissecting abdominal
aneurysm are incorrect responses.
71. Nurse Alexandra is establishing a plan of care for a client
newly admitted with SIADH. The priority diagnosis for this
client would be which of the following?
 a. Fluid volume deficit
 b. Anxiety related to disease process
 c. Fluid volume excess
 d. Risk for injury
 c. Fluid volume excess
 SIADH results in fluid retention and hyponatremia.
Correction is aimed at restoring fluid and electrolyte
balance. Anxiety and risk for injury should be addressed
following fluid volume excess.
72. Nursing management of the client with a UTI should
include:
 a. Taking medication until feeling better
 b. Restricting fluids
 c. Decreasing caffeine drinks and alcohol
 d. Douching daily
 c. Decreasing caffeine drinks and alcohol
 Caffeine and alcohol can increase bladder spasms and mucosal
irritation, thus increase the signs and symptoms of UTI.
 All antibiotics should be taken completely to prevent resistant
strains of organisms.
73. Felicia Gomez is 1 day postoperative from coronary
artery bypass surgery. The nurse understands that a
postoperative patient who’s maintained on bed rest is at high
risk for developing:
 a. angina
 b. arterial bleeding
 c. deep vein thrombosis (DVT)
 d. dehiscence of the wound
 c. deep vein thrombosis (DVT)
 DVT, is the most probable complication for postoperative patients
on bed rest. Options A, B and D aren’t likely complications of the
post-operative period.
74. The physician ordered a low-sodium diet to the client.
Which of the following food will the nurse avoid to give to
the client?
 a. Orange juice
 b. Whole milk
 c. Ginger ale
 d. Black coffee
 B. Whole milk should be avoided to include in the client’s
diet because it has 120 mg of sodium in 8 0z of milk.
75. The physician prescribed digoxin 0.125 mg PO qd to a
client and instructed the nurse that the client is on high-
potassium diet. High potassium foods are recommended in
the diet of a client taking digitalis preparations because a low
serum potassium has which of the following effects?
 a. Potentiates the action of digoxin
 b. Promotes calcium retention
 c. Promotes sodium excretion
 d. Puts the client at risk for digitalis toxicity
 D. Potassium influences the excitability of nerves and
muscles. When potassium is low and the client is on
digoxin, the risk of digoxin toxicity is increased.
76. A client is placed on digoxin; high potassium foods are
recommended in the diet of the client. Which of the
following foods will the nurse give to the client?
 a. Whole grain cereal, orange juice, and apricots
 b. Turkey, green bean, and Italian bread
 c. Cottage cheese, cooked broccoli, and roast beef
 d. Fish, green beans and cherry pie
 
 A. These foods are high in potassium
77. The nurse encourages the client to wear compression
stockings. What is the rationale behind in using compression
stockings?
 a. Compression stockings promote venous return
 b. Compression stockings divert blood to major vessels
 c. Compression stockings decreases workload on the heart
 d. Compression stockings improve arterial circulation
 A. Compression stockings promote venous return and
prevent peripheral pooling.
78. The client is transferred from the operating room to recovery
room after an open-heart surgery. The nurse assigned is taking the
vital signs of the client. The nurse notified the physician when the
temperature of the client rises to 38.8 ºC or 102 ºF because
elevated temperatures:
 a. May be a forerunner of hemorrhage
 b. Are related to diaphoresis and possible chilling
 c. May indicate cerebral edema
 d. Increase the cardiac output
 D. The temperature of 102 ºF (38.8ºC) or greater lead to
an increased metabolism and cardiac workload.
79. The nurse is reviewing the laboratory results of the
client. In reviewing the results of the RBC count, the nurse
understands that the higher the red blood cell count, the:
 a. Greater the blood viscosity
 b. Higher the blood pH
 c. Less it contributes to immunity
 d. Lower the hematocrit
 A. Viscosity, a measure of a fluid’s internal resistance to
flow, is increased as the number of red cells suspended in
plasma.
80. A 55-year-old client is admitted with chest pain that radiates to the neck,
jaw and shoulders that occurs at rest, with high body temperature, weak with
generalized sweating and with decreased blood pressure. A myocardial
infarction is diagnosed. The nurse knows that the most accurate explanation
for one of these presenting adaptations is:
 a. Catecholamine released at the site of the infarction causes intermittent
localized pain
 b. Parasympathetic reflexes from the infarcted myocardium causes
diaphoresis
 c. Constriction of central and peripheral blood vessels causes a decrease in
blood pressure
 d. Inflammation in the myocardium causes a rise in the systemic body
temperature
 
 D. Temperature may increase within the first 24 hours and
persist as long as a week.
81. A 38-year-old client with severe hypertension is
hospitalized. The physician prescribed a Captopril (Capoten)
and Alprazolam (Xanax) for treatment. The client tells the
nurse that there is something wrong with the medication and
nursing care. The nurse recognizes this behavior is probably a
manifestation of the client’s:
 a. Reaction to hypertensive medications.
 b. Denial of illness.
 c. Response to cerebral anoxia.
 d. Fear of the health problem.
 
 D. Clients adapting to illness frequently feel afraid and
helpless and strike out at health team members as a way of
maintaining control or denying their fear.
82. The nurse is reviewing the client’s chart about the
ordered medication. The nurse must observe for signs of
hyperkalemia when administering:
 a. Furosemide (Lasix)
 b. Hydrochlorothiazide (HydroDIURIL)
 c. Metolazone (Zaroxolyn)
 d. Spironolactone (Aldactone)
 D. Aldactone is a potassium-sparing diuretic;
hyperkalemia is an adverse effect.
83. A client is taking nitroglycerine tablets; the nurse should
teach the client the importance of:
 a. Increasing the number of tablets if dizziness or
hypertension occurs
 b. Limiting the number of tablets to 4 per day
 c. Making certain the medication is stored in a dark
container
 d Discontinuing the medication if a headache develops
 
 C. Nitroglycerine is sensitive to light and moisture ad
must be stored in a dark, airtight container.
84. The client with an acute myocardial infarction is
hospitalized for almost one week. The client experiences
nausea and loss of appetite. The nurse caring for the client
recognizes that these symptoms may indicate the:
 a. Adverse effects of spironolactone (Aldactone)
 b. Adverse effects of digoxin (Lanoxin)
 c. Therapeutic effects of propranolol (Indiral)
 d. Therapeutic effects of furosemide (Lasix)
 B. Toxic levels of Lanoxin stimulate the medullary
chemoreceptor trigger zone, resulting in nausea and
subsequent anorexia.
85. Which of the following is the most important electrolyte
of intracellular fluid?
 a. Potassium
 b. Sodium
 c. Chloride
 d. Calcium
 A. The concentration of potassium is greater inside the cell
and is important in establishing a membrane potential, a
critical factor in the cell’s ability to function.
 
86. Which of the following client has a high risk for
developing hyperkalemia?
 a. Crohn’s disease
 b. End-Stage renal disease
 c. Cushing’s syndrome
 d. Chronic heart failure
 
 B. The kidneys normally eliminate potassium from the
body; hyperkalemia may necessitate dialysis.
 87. The nurse is reviewing the laboratory result of the client. The client’s serum potassium
level is 5.8 mEq/L. Which of the following is the initial nursing action?
 a. Call the cardiac arrest team to alert them
 b. Call the laboratory and repeat the test
 c. Take the client’s vital signs and notify the physician
 d. Obtain an ECG strip and have lidocaine available
  
 C. Vital signs monitor cardiorespiratory status;
hyperkalemia causes serious cardiac dysrhythmias.
 88. Potassium chloride, 20 mEq, is ordered and to be added in the IV solution of a client in
a diabetic ketoacidosis. The primary reason for administering this drug is:
 a. Replacement of excessive losses
 b. Treatment of hyperpnea
 c. Prevention of flaccid paralysis
 d. Treatment of cardiac dysrhythmias
  
 A. Once treatment with insulin for diabetic ketoacidosis is
begun, potassium ions reenter the cell, causing
hypokalemia; therefore, potassium, along with the
replacement fluid, is generally supplied.
 89. The nurse is reviewing the laboratory result of the client. An arterial blood gas report
indicates the client’s pH is 7.20, PCO2 35 mmHg and HCO3 is 19 mEq/L. The results are
consistent with:
 a. Metabolic acidosis
 b. Metabolic alkalosis
 c. Respiratory acidosis
 d. Respiratory alkalosis
  
 A. A low pH and bicarbonate level are consistent with
metabolic acidosis.
 90. Postural Hypotension is…
 a. A drop in systolic pressure less than 10 mmHg when patient changes position from lying
to sitting.
 b. A drop in systolic pressure greater than 10 mmHg when patient changes position from
lying to sitting
 c. A drop in diastolic pressure less than 10 mmHg when patient changes position from
lying to sitting
 d. A drop in diastolic pressure greater than 10 mmHg when patient changes position from
lying to sitting
  
 B. A drop in systolic pressure greater than 10 mmHg when
patient changes position from lying to sitting
 Postural hypotension is exhibited by a drop of systolic BP
when client changes position from lying to sitting or
standing.
 91. Which of the following measures will not help correct the patient’s condition.
 a. Offer large amount of oral fluid intake to replace fluid lost
 b. Give enteral or parenteral fluid
 c. Frequent oral care
 d. Give small volumes of fluid at frequent interval
  
 A. Offer large amount of oral fluid intake to replace fluid
lost
 The patient will not tolerate large amount of oral fluid due
to incessant vomiting.
92. After nursing intervention, you will expect the patient to
have...
 1. Maintain body temperature at 36.5 C
 2. Exhibit return of BP and Pulse to normal
 3. Manifest normal skin turgor of skin and tongue
 4. Drinks fluids as prescribed

a. 1,3
b. 2,4
c. 1,3,4
d. 2,3,4
 D. 2,3,4
 Client need not maintain a temperature of 36.5 C. As long
as the client will exhibit absence of fever or hypothermia,
Nursing interventions are successfully carried out.
93. A nurse is caring for an infant that has recently been
diagnosed with a congenital heart defect. Which of the
following clinical signs would most likely be present?
 a. Slow pulse rate
 b. Weight gain
 c. Decreased systolic pressure
 d. Irregular WBC lab values
 b. Weight gain
Anoxia or venous congestion of the bowel may result in
malabsorption; peripheral anoxia and acidosis may lead to
inefficient utilization of nutrients
94. A patient has recently experienced a (MI) within the last
4 hours. Which of the following medications would most
like be administered?
 a. Streptokinase
 b. Atropine
 c. Acetaminophen
 d. Coumadin
 a. Streptokinase
 A Trombolytic medication used to breakdown clots in
cases of MI.
 Used to dissolve blood clots that have formed in the blood
vessels immediately after symptoms of heart attack occurs
to improve patient’s survival
95. Ana’s postoperative vital signs are: a blood pressure of
80/50 mm Hg, a pulse of 140, and respirations of 32.
Suspecting shock, which of the following orders would the
nurse question?
 a. Put the client in modified Trendelenburg’s position
 b. Administer oxygen at 100%
 c. Monitor urine output every hour
 d. Administer Demerol 50mg IM q4h
 
 Answer: (D) Administer Demerol 50mg IM q4h
 This is a synthetic opioid pain medication
 Administering Demerol, which is a narcotic analgesic, can
depress respiratory and cardiac function and thus not
given to a patient in shock. What is needed is promotion
for adequate oxygenation and perfusion. All the other
interventions can be expected to be done by the nurse.
96. After surgery, Gina returns from the Post- Anesthesia
Care Unit (Recovery Room) with a nasogastric tube in place
following a gall bladder surgery. She continues to complain
of nausea. Which action would the nurse take?
 a. Call the physician immediately
 b. Administer the prescribed antiemetic
 c. Check the patency of the nasogastric tube for any
obstruction
 d. Change the patient’s position
 
 Answer: (C) Check the patency of the nasogastric tube for
any obstruction.
 Nausea is one of the common complaints of a patient after
receiving general anesthesia. But this complaint could be
aggravated by gastric distention especially in a patient
who has undergone abdominal surgery. Insertion of the
NGT helps relieve the problem. Checking on the patency
of the NGT for any obstruction will help the nurse
determine the cause of the problem and institute the
necessary intervention.
97. A client returns from the recovery room at 9AM alert and
oriented, with an IV infusing. His pulse is 82, blood pressure
is 120/80, respirations are 20, and all are within normal range.
At 10 am and at 11 am, his vital signs are stable. At noon,
however, his pulse rate is 94, blood pressure is 116/74, and
respirations are 24. What nursing action is most appropriate?
 a. Notify his physician
 b. Take his vital signs again in 15 minutes
 c. Take his vital signs again in an hour
 d. Place the patient in shock position
 Answer: (B) Take his vital signs again in 15 minutes.
 Monitoring the client’s vital signs following surgery gives
the nurse a sound information about the client’s condition.
Complications can occur during this period as a result of
the surgery or the anesthesia or both. Keeping close track
of changes in the VS and validating them will help the
nurse initiate interventions to prevent complications from
occurring.
98. Which of the ff. statements by the client to the nurse
indicates a risk factor for CAD?
 a. “I exercise every other day.”
 b. “My father died of Myasthenia Gravis.”
 c. “My cholesterol is 180.”
 d. “I smoke 1 1/2 packs of cigarettes per day.”
 Answer: (D) “I smoke 1 1/2 packs of cigarettes per day.”
 Smoking has been considered as one of the major
modifiable risk factors for coronary artery disease.
Exercise and maintaining normal serum cholesterol levels
help in its prevention.
99. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor
knowledge regarding this drug?
 a. It has positive inotropic and negative chronotropic effects
 b. The positive inotropic effect will decrease urine output
 c. Toxicity can occur more easily in the presence of
hypokalemia, liver and renal problems
 d. Do not give the drug if the apical rate is less than 60 beats
per minute.
 Answer: (B) The positive inotropic effect will decrease
urine output
 Inotropic effect of drugs on the heart causes increase force
of its contraction. This increases cardiac output that
improves renal perfusion resulting in an improved urine
output.
100. Valsalva maneuver can result in bradycardia. Which of
the following activities will not stimulate Valsalva’s
maneuver?
 a. Use of stool softeners
 b. Enema administration
 c. Gagging while tooth brushing
 d. Lifting heavy objects
 Answer: (A) Use of stool softeners.
 Straining or bearing down activities can cause vagal
stimulation that leads to bradycardia. Use of stool
softeners promote easy bowel evacuation that prevents
straining or the valsalva maneuver.
 End of Rationale 

GOOD LUCK FUTURE RN’s