Nursing Practice III

d) moist buccal cavity mucous membranes

NP III: DRILL 1
9. Which blood type is known as the universal donor?
1. Which of the following statements by a client indicates adequate a) O
understanding of posttest care after a femoral approach is used for b) A
cerebral angiography? c) AB
a. “I cannot move my neck.” d) B
b. “I need to wear a neck brace.”
c. “I need to keep my leg straight.” 10. A client that was started on a transfusion of packed red blood
d. “I need to keep my arm straight.” cells begins to complain of chest tightness, anxiety, and shortness
of breath. What should the nurse do first?
2. After receiving a client who has had a femoral approach for cerebral a) Check the oxygen saturation.
angiography, the nurse notices the puncture site is oozing bright red b) Check the vital signs.
blood. Which is the most appropriate action of the nurse? c) Monitor the client.
a. Document the findings. d) Stop the transfusion.
b. Apply pressure to the site.
c. Monitor for changes. 11. An elderly client admitted for dehydration and electrolyte
d. Inform the physician. imbalance states “Get these bugs off of me.” The nurse would
respond:
3. A client has had a right femoral approach for cerebral angiography. a) “I’ll just brush them away for you.”
The right groin dressing is clean, dry, and intact, with no bruising or b) “I do not see any bugs.”
swelling at the site. The nurse notices the client’s right foot has become c) “Your electrolyte imbalance is making you feel this
cool, and the pedal pulse is no longer palpable, or obtained with a way.”
doppler. Which is the most appropriate action of the nurse? d) “There are no bugs here. You are imagining
a. Monitor for changes. them.”
b. Apply pressure to the site.
c. Document the findings. 12. The physical examination and evidence collection is completed
d. Notify the physician. on a sexual assault victim. The victim is sitting motionless and
appears dazed and unaware of the surroundings. The nurse would
4. A client with which of the following conditions is at risk for developing interpret the behavior as:
a low magnesium level? a) indications of a severe mental disorder.
a) alcoholism b) normal behavior following a traumatic event.
b) pericarditis c) signs that the person should be hospitalized.
c) prostatitis d) signaling the need for suicide precautions.
d) Lymphoma
13. Common causes of hyperkalemia include the following except:* 1
5. Which of the following arterial blood gas values represents point poor urine output for days. potassium-wasting diuretics. renal
respiratory acidosis? insufficiency. administration of IV solutions with large doses of
a) pH = 7.60 , pCO2 = 38 mm Hg, HCO3 = 30 mEq/L potassium chloride in each solution. A client, 68 years old, has a
b) pH = 7.20, pCO2 = 36 mm Hg, HCO3 = 18 mEq/L calcium deficit. Her serum calcium level is 3.6mEq/L. The client’s
c) pH = 7.80, pCO2 = 32 mm Hg, HCO3 = 32 mEq/L serum calcium level is:
d) pH = 7.20 , pCO2 = 50 mm Hg, HCO3 = 24 mEq/L a) low average.
b) normal.
6. Which of the following is an appropriate diet for the client with acute c) severely low.
pancreatitis? d) slightly low.
a) low cholesterol
b) clear liquids 14. Nurse Troy writes, “Knowledge deficit regarding prevention of crisis”
c) regular on the nursing care plan of a client, an 18-year-old male with sickle
d) nothing by mouth cell anemia. After a client has been taught to avoid situations that
can precipitate a crisis, which of the following actions would indicate
7. A client is taking a full liquid diet following gastric surgery. The nurse a need for follow-up education?
evaluates the health teaching to be successful when the family brings a) applying for a driver’s permit
in which of the following for the client to eat? b) staying up until 3:00 A.M. to study for a test
a) chopped vegetables c) applying antiseptic to a cut on his finger
b) Custard d) planning a vacation at a beach resort
c) pureed fruits
d) soft cake 15. In a patient suspected of having aplastic anemia, the nurse
should plan to:
a) assess for renal disease and administer
8. While doing a physical assessment on a client, the nurse prescribed folic acid.
suspects that the client has poor nutritional status. Which of b) teach the patient which foods have a high iron
the following would confirm the nurse’s observations? content and administer prescribed iron.
a) flaccid soft muscles c) advice the client to sleep every time
b) firm, smooth pink nails d) take a thorough history of medication and
c) erect posture chemical exposures.
Nursing Practice III
b) increased blood pressure and decreased
pulse rate
16. The physician orders 25 milligrams of diphenhydramine c) negative glucose reading in nasal mucus
hydrochloride (Benadryl) prior to a blood transfusion for a patient. The d) continued unresponsiveness to verbal stimuli
nurse knows this product is often given prior to a blood transfusion
because:
a) it will make the patient drowsy, and he will sleep
during the blood transfusion. 24. Upon assessment, the nurse notes hepatomegaly, ascites,
b) it will prevent sneezing and accidental dependent edema, and jugular neck vein distention. The
dislodgement of the IV. nurse understands that which of the following mechanisms
c) it will prevent the transmission of hepatitis. accounts for these symptoms?
d) it decreases the chance of an allergic reaction to the a) backward effects of right ventricular failure
blood. b) end-stage left ventricular failure
c) end-stage cirrhosis of the liver
17. A patient asks a nurse what’s the definition of total parenteral d) backward effects of lymphatic obstruction
nutrition (TPN). The nurse responds by saying
a) “An inexpensive way to give protein and vitamins.” 25. Which of the following arterial blood gas values represents
b) “It is a convenient method of providing metabolic alkalosis?
nutrition.” a) pH = 7.20 , pCO2 = 36 mm Hg, HCO3 = 18 mEq/L
c) “An IV solution that provides adequate b) pH = 7.60 , pCO2 = 38 mm Hg , HCO3 = 30 mEq/L
nutrition.” c) pH = 7.10, pCO2 = 50 mm Hg, HCO3 = 24 mEq/L
d) “TPN is part of long-term patient care.” d) pH = 7.30, pCO2 = 50 mm Hg, HCO3 = 24 mEq/L

18. How can total parenteral nutrition (TPN) be of primary value in a 26. Which of the following arterial blood gas values represents respiratory
patient receiving chemotherapy who has stomatitis and severe alkalosis?
diarrhea? a) pH = 7.30, pCO2 = 50 mm Hg, HCO3 = 24 mEq/L
a. These symptoms will resolve if the patient b) pH = 7.20, pCO2 = 36 mm Hg, HCO3 = 18 mEq/L
does not take oral nutrition c) pH = 7.80, pCO2 = 37 mm Hg , HCO3 = 32 mEq/L
b. TPN will prevent nosocomial infections d) pH = 7.60 , pCO2 = 38 mm Hg, HCO3 = 30 mEq/L
c. It will prevent dehydration
d. It will provide nutrition 27. Which of the following is a sign or symptom of hypothyroidism?* 1
point weight gain weight loss diaphoresis palpitations Nocturia is best
19. Which of the following stages of NREM sleep is thought to restore defined as:
the body physically? a) awakening at night to urinate.
a) NREM IV b) painful and difficulty voiding.
b) REM c) total urine output of less than 30 cc/hr.
c) NREM II d) voiding more frequently than every 3 hours.
d) NREM III
28. Which of the following foods are most likely to exacerbate acute
20. The nurse should use which assessment tool to evaluate Mr. James cholecystitis?
Reid nutritional patterns? a) potatoes
a) anthropometric measurements b) bacon
b) height and weight measurements c) beans
c) lipid profile d) apples
d) hour diet recall
29. The loop diuretics such as furosemide (Lasix) and bumetanide
21. Which type of jaundice is due to increased destruction of (Bumex) can be ototoxic. This effect is enhanced when certain
erythrocytes? antibiotics are given concomitantly. An example of an antibiotic that
a) obstructive could potentiate ototoxicity is
b) hepatocellular a) a cephalosporin antibiotic such as cefoxitin (Mefoxin).
c) hemolytic b) an aminoglycoside antibiotic such as
d) Both 2 and 3 are correct gentamicin (Garamycin).
c) a beta-lactam antibiotic such as ampicillin
22. When assessing a patient admitted with a bleeding gastric (Omnipen, Polycillin).
ulcer, the nurse should expect to find which of the following stool d) a macrolide antibiotic such as azithromycin
characteristics? (Zithromax).
a) clay colored
b) black, tarry 30. What foods have the highest content of potassium and are
c) bright red included in a client’s care plan when at risk for hypokalemia?
d) coffee-ground color a) canned soups and milk
b) carrots, squash, and okra
23. The nurse is providing postoperative care to a patient who has c) potatoes, apricots, broccoli
had a craniotomy. Which of the following observations would d) whole grain products, apples
require immediate attention?
a) pale, warm skin and a temperature of 99°F 31. A patient has undergone “a classic cholecystectomy.” To
Nursing Practice III
promote comfort when coughing, the nurse should teach the overload?
patient to: a) a person who is blind and deaf
a) lean forward when coughing. b) a prisoner in solitary confinement
b) lie down on left side when coughing. c) a person with post-operative pain for three weeks
c) dangle feet on the side of the bed before d) a client in ICU for 14 days
coughing.
d) sit up and support abdomen with pillow. 39. A patient who has suicidal intentions would be experiencing which
class of crisis?
32. Which of the following nursing diagnoses is most appropriate for a) developmental crisis
the client who has recently had surgery for repair of a b) dispositional crisis
mandibular fracture? c) anticipated life transition crisis
a) impaired mobility d) psychiatric emergencies crisis
b) activity intolerance
c) imbalanced nutrition 40. Jeremiah is diagnosed as having respiratory insufficiency due to
d) bowel incontinence longstanding restrictive lung disease as a result of working in the coal
mines for 35 years. Jeremiah should be advised to prevent or control
33. Which of the following statements by a client going home after respiratory infections by:
a below the knee amputation indicates further need for teaching a) taking influenza injections and broad-
by the nurse? spectrum antibiotics as prescribed.
a) “I will only wear a residual limb sock on the b) having periodic blood studies to determine his PO2.
stump.” c) smoking low-tar cigarettes.
b) “I will perform range of motion daily.” d) taking penicillin for the rest of his life as
c) “I will change the residual limb sock weekly.” prophylaxis.
d) “I will check my stump daily for signs of
irritation.” 41. The nurse suspects that a patient with diabetes is experiencing
ketoacidosis. What manifestations is the nurse observing?
34. A patient is placed on a higher than usual dose of an opioid a) tachycardia and pale, moist skin
analgesic for pain management of osteosarcoma. He asks the b) bradycardia and dry, pale mucous
nurse if he is becoming a drug addict. An appropriate response by membranes
the nurse is: c) hypertension and dry mucous membranes
a) “Opioids have never been shown to produce d) hypotension and dry, hot, flushed skin
addiction in those who take them only for pain.”
b) “Addiction and tolerance are not the same. Your 42. Client Mel, who is 64 years old, has chronic renal failure. Nurse
body needs more medicine now and it is important not Issa observes the following measurements: BUN 64,
to undertreat your pain.” hemoglobin 8.8, creatinine 2.4, and a urine output of 250 ml over
c) “If you feel you are becoming addicted, switch your the past 24 hours compared with a 10000-ml intake. An
medicine to Tylenol.” appropriate nursing diagnosis for this set of data is:
d) “Yes, the drugs you are taking are highly
addictive, but you can be detoxed later.” a) urinary retention related to intake greater than output.
b) fluid volume excess related to inability of the kidney
35. A client who is a Jehovah’s Witness needs a transfusion of to maintain body fluid balance.
packed red blood cells but refuses the transfusion. What is the c) anemia related to impaired renal function.
appropriate response of the nurse? d) high risk for injury related to possible seizure activity.
a) Have the client sign a refusal form.
b) Lecture the client on the need for blood. 43. Dr. Yap orders 250 milliliters of packed red blood cells (RBC)
c) Give the transfusion anyhow. for a patient, you can assume that this therapy is for treatment
d) Berate the client for such beliefs. of:
a) thrombocytopenia.
36. What is the maximum amount of time that packed red blood b) anemia.
cells may be administered? c) hypoalbuminemia.
a) 3 hours d) leukopenia.
b) 5 hours
c) 2 hours 44. Mr. Roxy Aquino requires a whole blood transfusion. In order for
d) 4 hours Transfusion Services (the blood bank) to prepare the correct
product, a sample of the patient’s blood must be obtained for:
37. CJ, a patient with a serious GI illness has been receiving total a) a blood type and cross-match.
parenteral nutrition (TPN) for 2months. Today CJ reports right b) a complete blood count and differential.
upper quadrant abdominal pain radiating to the right shoulder. c) a blood culture and sensitivity.
Nurse Rome would suspect: d) a blood type and antibody screen.
a) myocardial infarction (MI).
b) pneumonia. 45. Client Haina is undergoing a paracentesis, the client suddenly
c) infection develops hypotension as the peritoneal fluid is being drained.
d) cholecystolithiasis. Which of the following is an appropriate action of nurse Shaine?
a) Monitor the blood pressure.
38. Which of the following situations is considered to be sensory b) Document the blood pressure.
Nursing Practice III
c) Slow the drainage rate.
d) Increase the drainage rate. 55. Nurse Sheandrei is teaching a nutrition course at the local retirement
center. Due to the decreased peristalsis in older adults, many
46. Which clients with the following diagnoses might warrant struggles with constipation. What recommendation Nurse
fecal occult blood testing? Sheandrei can make to help prevent this common problem?
a) cerebral bleeding a) Increase fiber intake.
b) gastrointestinal bleeding b) Take aspirin once a day.
c) vaginal bleeding c) Increase vitamin E.
d) tracheal bleeding d) Decrease water intake.

47. Which of the following statements by a client who has 56. Ms. Milleny, aged 22 is admitted with seizure activity. Her
undergone an outpatient esophagogastroduodenoscopy indicates electrolyte values are as follows: Na, 115mEq/L; K, 3.0 mEq/L;
adequate understanding of post-test instructions? Ca, 8.0 mg/dL; and Mg, 1/0 mEq/L. Which imbalances must be
a) “I will take Tylenol for a fever.” controlled to reduce her seizure activity?
b) “I will need someone to drive me home.” a) Na and Ca
c) “I can drive myself home after the test.” b) Na and K
d) “I can eat and drink right after the test.” c) K and Ca
d) Mg and K
48. A patient has problems ambulating secondary to “foot drop.” A
“foot drop” is what type of contracture? 57. The most common sign of thrombocytopenia is:
a) foot in plantar extension a) melena.
b) foot in plantar flexion b) hemarthosis.
c) ankle with twisted flexion c) hemostasis.
d) hip with a fibrotic contracture d) petechiae.

49. Venous stasis that occurs with decreased muscular contraction 58. What is the best indication that a client is not getting adequate
when a patient is on bed rest (immobility) predisposes him/her to: sleep?
a) orthostatic hypotension. a) the patient reports not sleeping well
b) respiratory acidosis. b) inability to concentrate
c) deep vein thrombosis. c) amount of time the client sleeps or doesn’t
d) decreased cardiac workload. sleep
d) general appearance
50. A nurse asks a client to describe the quality of pain currently
experienced. Which is an expected term for the client to use? 59. The physiology of sleep is complex. Which of the following is the
a) intermittent most appropriate statement in regards to this process?*
b) severe a) The RAS is partially responsible for the level of
c) stabbing consciousness of a person.
d) chronic b) The Basal metabolic rate causes the REM
sleep in most normal activities.
51. Pain in the elderly requires careful assessment because older people c) NREM refers to the cycle most patients
have which of the following characteristics? experience when in a high stimulus
a) decreased pain tolerance environment.
b) increased pain tolerance d) Ultradian rhythm occurs in a cycle longer than 24
c) are likely to experience chronic pain hours
d) experience reduced sensory perception
60. When a client is deprived of sleep, the nurse might assess such
52. Which vitamin is deficient in the diet of a client diagnosed with symptoms as:
scurvy? a) rapid respirations and inappropriateness.
a) vitamin B b) confusion and mistrust.
b) vitamin A c) decreased temperature and talkativeness.
c) vitamin C d) elevated blood pressure and confusion.
d) vitamin D
61. During a routine health exam, the client Romar asks the nurse which
53. What foods would most benefit a client with scurvy? foods he should eat on a low cholesterol diet. Which of the following
a) oranges, broccoli, liver could Nurse Matthew use as examples of foods consistent with a
b) cereal, peanut butter, fish low cholesterol diet?
c) sweet potatoes, cheese, cantaloupe a) eggs, potato chips, cottage cheese
d) cheese, grain cereal, milk b) steak, cheese, leafy vegetables
c) chicken, breads, fruits, beans
54. A patient with advanced cancer of the stomach is undergoing surgery d) liver, yogurt, bread, rice
to take out part or debulk the tumor. This is known as surgery.
a) palliative 62. Carl, an elderly client expresses difficulty sleeping because his
b) tertiary spirit is disturbed because of sin in his life. Which intervention would
c) restorative have priority?
d) curative a) Call the chaplain and schedule a visit.
Nursing Practice III
b) Ascertain what religious practice is 69. Client Denise complains of constipation. In assessing this
appropriate to the client. complaint, which is the most important question for nurse
c) Pray immediately with the client. Marie to ask?
d) Administer sleep medications as ordered. a) How often do you normally move your bowels?
b) Do you strain when you move your bowels?
63. Client Dimple, who has type I diabetes mellitus, is experiencing c) When did you move your bowels last?
nausea and vomiting. Which action indicates that she understands d) What is the consistency of the stool?
the “sick day rules” for diabetes management?
a) drinking nondiatetic ginger ale 70. Foods such as scallops, red wine, and gravies should be restricted
b) abandoning his normal meal timing in favor of getting in the diet of clients with which disease?
an extended period of sleep a) Muscular dystrophy
c) taking 2/3 of his normal insulin dose b) Gout
d) monitoring his blood glucose every 6 hours c) Rheumatoid arthritis
d) Systemic lupus erythematosus
64. A client is to undergo bone marrow transplantation (BMT) for
treatment of leukemia and is receiving pre-procedure teaching with 71. Place the phases or stages of the inflammatory response in the
regard to nutrition. Which of the following nutritional support options correct sequential order, do NOT include any phases that is
would most likely be utilized for this client? NOT part of the inflammatory process.
a) oral feedings as soon as possible following BMT to 1. The vascular phase
prevent gastroparesis 2. The prodromal phase
b) total parenteral nutrition (TPN) for a period of months 3. The incubation phase
to maintain nutritional balance 4. The initial injury
c) insertion of a PEG tube following the GMT to maintain 5. The exudate phase
nutritional balance 6. The convalescence phase
d) supplementation with enteral feedings to prevent a) 4,5,1
catabolism b) 4,1,5
c) 4,2,5
65. Junna, a client who is an intravenous drug abuser had an d) 4,2,1
appendectomy. She requests morphine sulfate for pain relief every
hour, and it is only ordered every four hours. What is the 72. Nurse Thea caring for a post-operative client who is
appropriate response of the nurse? complaining of abdominal distention and flatus. Which
a) Notify the physician of her request. intervention would Nurse Thea most likely do for this client?
b) Let her know his addiction may get worse. a) cleansing enema
c) Instruct her on possible side effects. b) A laxative
d) Tell her it is only ordered every four hours. c) A retention enema
d) A return-flow enema
66. Which statement made by a client following teaching about the
importance of using only unsaturated fats when cooking 73. Nurse Marianne is planning discharge education for your client who
indicates that information about which fats are unsaturated was has a new colostomy. Which complication of a colostomy should
understood? Nurse Marianne educate this client about?
a) “I will use palm oil when cooking.” a) Nocturnal enuresis
b) “I will use lard when cooking.” b) GI stone formation
c) “I will use olive oil when cooking.” c) A prolapsed stoma
d) “I will use butter when cooking.” d) A vitamin B12 deficiency

67. Client Carl James, comes to the clinic complaining of 74. Nurse Camille is working as a wound care nurse. she measures
unexplained black and blues and bloody appearing urine. Which the size of a client’s wound and it is 3 cm deep, 2 cm long and 4
of medications is it most important to find out if the client is taking? cm wide. Nurse Camille would document the dimension of this
a) Antibiotic wound as:
b) Anticoagulant a) 12 cm
c) Antipruritic b) 6 cm
d) Antianemic c) 24 cm
d) 20 cm
68. Nurse Shainna is monitoring the effects of bronchodilators,
which of the following should be included? 75. Client Denden had a ruptured appendix and peritonitis. What type
a) Observe client for adverse effects and ensure that he of healing would be most likely for this client?
uses metered-dose inhalers correctly every hour. a) Secondary prevention healing
b) Observe client for cyanosis, rapid respiratory rate, b) Primary prevention healing
and monitor magnesium levels. c) Secondary intention healing
c) Monitor for cyanosis of lips, earlobes, nail beds d) Tertiary intention healing
and mucous membranes, and monitor theophylline
levels.
d) Be familiar with client’s VS, and monitor their bowel
sounds and respiratory effort.
76. Which of the following theories of pain are you utilizing when you
Nursing Practice III
recognize the fact that some of the factors that open this “gate” to d) “The client is having anesthesia awareness which
pain are low endorphins and anxiety and that some of the factors is not good.”
that close this “gate” to pain are decreased anxiety and fear?
a) The Specificity Theory of Pain 82. Intussusception occurs when:
b) Melzack and Wall’s theory of pain a) An ileostomy stoma retracts below the
c) The Intensive Theory of Pain abdominal surface.
d) Moritz Schiff’s theory of pain b) Lungs are infiltrated.
c) Part of the intestine slides into another part of the
77. Christine is a 20-year-old female attending college is found intestine.
unconscious in her dorm room. She has a fever and a noticeable d) The appendix ruptures.
rash. She has just been admitted to the hospital. Which of the
following tests is most likely to be performed first? 83. You are having a nice dinner in a fancy restaurant. As you are
a) Blood cultures eating, you hear the gentleman eating at the next table start to bang
b) Arterial blood gases the table, hold his throat and forceably cough. What should you
c) CT scan do?
d) Blood sugar check a) Encourage the person to continue coughing
b) Begin CPR and prepare for ACLS measures
78. Nurse Pauline routinely use the PQRST method to assess pain. c) Perform the Valsalva maneuver
The PQRST method consists of: d) Perform the Heimlich maneuver
a) Precipitating factors, the quality of the pain, the
region or area of the pain, the severity of the pain, 84. Nurse Raquel is assigned to telephone triage. A client called who was
and the pain triggers stung by a honeybee and is asking for help. The client reports pain
b) Precipitating factors, the quality of the pain, relief and localized swelling but has no respiratory distress or other
factors, the severity of the pain, and the pain triggers symptoms of anaphylactic shock. What is the appropriate initial action
c) Pain level, the quality of the pain, the region or area nurse Raquel should direct the client to perform?
of the pain, the severity of the pain, and the pain a) Taking an oral antihistamine
triggers b) Removing the stinger by scraping it
d) Pain level, the quantitative numerical pain score, c) Call Emergency and Disaster for transport and
the region or area of the pain, the severity of the assistance.
pain, and the pain triggers d) Applying a cold compress

79. The A, B, C, and Ds of a complete and comprehensive 85. Nurse Leinus is conducting nutrition counseling for a patient with
nutritional assessment includes: cholecystitis. Which of the following information is important to
a) Anthropometric data, biological data, communicate?
chemical data and dietary data a) The patient must maintain a high protein/low
b) Anthropometric data, biochemical data, carbohydrate diet.
clinical data and dietary data b) The patient should limit fatty foods.
c) Ancestral cultural data, biochemical data, clinical c) The patient must maintain a low-calorie diet.
data and dietary data d) The patient should limit sweets and sugary drinks.
d) Assessment data, biochemical data, clinical data
and dietary data 86. Client Laarni arrives at the emergency department who suffered
multiple injuries from a head-on car collision. Which of the following
80. Nurse Pauline will be administering packed red blood cells to your assessment should take the highest priority to take?
client. Which of the following principles should Nurse Pauline a) Unequal pupils
apply to this blood administration? b) A deviated trachea
a) Nurse Pauline will need the help of another nurse c) Ecchymosis in the flank area
prior to the administration of these packed red d) Irregular pulse
blood cells.
b) Nurse Pauline must ensure that the client has a patent 87. A group of people arrived at the emergency unit by a private car with
intravenous catheter that is at least 20 gauge. complaints of periorbital swelling, cough, and tightness in the
c) The unit of packed red blood cells should start no more throat. There is a strong odor emanating from their clothes. They
than 1 hour after it is picked up. report exposure to a “gas bomb” that was set off in the house. What
d) Nurse Pauline must remain with and monitor the is the priority action?
client for at least 30 minutes after the transfusion a) Direct the clients to the decontamination area
begins. b) Direct the clients to the cold or clean zone for
immediate treatment
81. Melanie, a clinical instructor, in the operating room with a student c) Immediately remove other clients and visitors from the
nurse. The client has received general anesthesia. The student area
nurse says, “Oh no, the general anesthesia is not working. The d) Instruct personnel to don personal protective
client is shaking and moving.” How should you respond to this equipment
student nurse?
a) “This often happens during stage 2 of general 88. Client Marcelo arrives in the emergency unit and reports that a
anesthesia.” concentrated household cleaner was splashed in both eyes. Which
b) "The client needs more general anesthesia.” of the following nursing actions is a priority? Examine the client's
c) “The client is having a seizure.” visual acuity
Nursing Practice III
a) Flush the eye repeatedly using sterile normal saline c) Polyphagia
b) Use Restasis (Allergan) drops in the eye d) Dehydration
c) Patch the eye
d) Instruct personnel to don personal protective equipment 95. Which of the following should the nurse implement to prepare a
client for a KUB (Kidney, Ureter, Bladder) radiography test?
89. Client Chretienne was brought to the emergency department a) Enema to be administered prior to the
after suffering a closed head injury and lacerations around the examination
face due to a hit-run accident. Client Chretienne is unconscious and b) No special orders are necessary for this
has a minimal response to noxious stimuli. Which of the following examination
assessment findings if observed after few hours, should be reported c) Medicate client with furosemide 20 mg IV 30
to the physician immediately? minutes prior to the examination
a) Withdrawal of the client in response to painful d) Client must be NPO before the examination
stimuli
b) Bruises and minimal edema of the eyelids 96. Jerald, triage nurse has these four (4) clients arrive in the
c) Drainage of a clear fluid from the client's nose emergency department within 15 minutes. Which client should the
d) Bleeding around the lacerations triage nurse send back to be seen first?
a) Lianne, an elderly client with complaints of frequent
90. Client Queen, 23-year-old male client who has had a full-thickness liquid brown colored stools
burn is being discharged from the hospital. Which information is b) Kelvin, a 2-month-old infant with a history of rolling off
most important for the nurse to provide prior to discharge? the bed and has bulging fontanelle with crying
a) How to maintain home smoke detectors c) George, a middle-aged client with intermittent pain
b) Joining a community reintegration program behind the right scapula
c) Learning to perform dressing changes d) Joshua, a teenager who got a singed beard while
d) Options available for scar removal camping

91. Client Dany has a large burned area on the right arm. The 97. Client Sheena is scheduled for a magnetic resonance imaging
burned area appears pink, has blisters, and is very painful. (MRI) scan. Which of the following is a contraindication to the
How will the nurse categorize this injury? study for this patient?
a) Full-thickness a) The patient is allergic to shellfish.
b) Partial-thickness deep b) The patient suffers from claustrophobia.
c) Full-thickness deep c) The patient takes antipsychotic medication.
d) Partial-thickness superficial d) The patient has a pac

92. A 22-year-old female named Michaela who ingested 15 tablets

of maximum strength acetaminophen 45 minutes ago is rushed NP III: DRILL 2
to the emergency department. Which of these orders should
the nurse do first? 1. When the nurse is admitting a client for surgery, which
a) Have the patient drink activated charcoal question is most useful in determining the client’s
mixed with water current nutritional status?
b) Administer acetylcysteine (Mucomyst) orally a) "How is your appetite usually?"
c) Start an IV Dextrose 5% with 0.33% normal b) "What did you eat and drink yesterday?"
saline to keep the vein open c) "Have you noticed any weight loss
d) Gastric lavage recently?"
d) "Who does most of your shopping and
93. The hospital has sounded the call for a disaster drill on the evening cooking?"
shift. Which of these clients would the nurse Mercado put first on
the list to be discharged in order to make a room available for a new 2. A client complains of severe pain 2 days after surgery.
admission? Which initial action should the nurse take after
a) An elderly client with a history of hypertension, assessing the character of the pain?
hypercholesterolemia, and lupus, and was admitted a. have the client rest
with Stevens-Johnson syndrome b. take the client’s vital signs
that morning. c. administer the prn analgesic
b) An adolescent with a positive HIV test and admitted d. document the client’s complaint
for acute cellulitis of the lower leg 48 hours ago.
c) A middle-aged client with a history of being 3. Which response should the nurse make?
ventilator dependent for over seven (7) years and a) "The surgeon will explain the procedure to
admitted with bacterial pneumonia five days ago. you since the doctor is responsible for
d) A young adult with diabetes mellitus Type 2 for over obtaining consent."
ten (10) years and admitted with b) "Your stomach is completely removed and
antibioticinduced diarrhea 24 hours ago. the esophagus is connected to the small
94. In children suspected to have a diagnosis of diabetes, which intestine."
one of the following complaints would be most likely to prompt c) "The bottom part of the stomach is
parents to take their school-age child for evaluation? removed and the remainder is attached to the
a) Weight loss small intestine."
b) Bedwetting d) The nerves that go to your stomach are cut
Nursing Practice III
and a larger opening is made for stomach complains of severe abdominal pain. Which action
emptying." should the nurse take first?
a. Have the patient ambulate in the room.
4. On the first postoperative day after an open Billroth II b. Ask the client to deep breathe and cough.
procedure a client develops hiccups, 6 on a scale of c. Administer the ordered morphine sulfate.
10 epigastric pain, and a drop in blood pressure. The d. Give the prn acetaminophen (Tylenol).
nurse's initial actions should be to:
a. assess the amount of drainage from the 11. The nurse in the ambulatory Preoperative unit
nasogastric (NG) tube. identifies that a client is more anxious than most
b. notify the client’s physician. clients. The nurse’s best intervention is to:
c. assess the abdominal dressing. a) attempt to identify the client’s concerns
d. administer the ordered Morphine Sulfate 4 b) report the client’s anxiety to the surgeon
mg IV. c) reassure the client that the surgery is
routine
5. Which information obtained in the postoperative d) provide privacy by pulling the curtain
assessment of a 32-year-old client with Peritonitis will around the client
be of most concern to the nurse?
a) Bowel sounds are decreased in all four 12. Which is an independent nursing measure that would
quadrants. be helpful in preventing the accumulation of secretions
b) Drainage from wound drains is purulent. in a client who had general anesthesia during surgery?
c) Oxygen saturation is 90%. a. postural drainage
d) Pain level is 6 on a scale of 10. b. cupping the chest
c. nasotracheal suctioning
6. On the first postoperative day after an abdomino- d. frequent changes of position
perineal resection, the Surgical nurse notes that there
is a large quantity of serous drainage on the client's 13. What is the priority nursing intervention for a client
perineal dressing. The nurse will: during the immediate postoperative period?
a. reinforce or change the dressing. a) observe for hemorrhage
b. notify the physician immediately. b) maintaining a patent airway
c. irrigate the wound drain. c) recording the intake and output
d. culture the drainage. d) checking the vital signs every 15 minutes

7. When developing the postoperative plan of care for a 14. The nurse in the postanesthesia care unit identifies
client who has had a Cystectomy and creation of a that after an abdominal cholecystectomy a client has
neobladder, which action is appropriate to include? serosanguineous drainage on the abdominal
a) Assess the stoma every hour for the first dressing. What should the nurse do?
24 hours after surgery. a. change the dressing
b) Call the surgeon if the urine appears b. reinforce the dressing
cloudy or has clots. c. apply an abdominal binder
c) Irrigate the urethral catheter with saline d. replace the tape with Montgemery traps
every 2 to 4 hours.
d) Change the ostomy bag when it is one-half 15. A client has corrective surgery for a bladder laceration.
full of urine. Which nursing intervention takes priority during this
client’s postoperative period?
8. Which information about a client on the first a) turning frequently
postoperative day after a total vaginal hysterectomy is b) raising side rails on the bed
most important to communicate to the physician? c) providing range-of-motion exercises
a. The client has hypotonic bowel sounds. d) massaging the back three times a day
b. The client complains of incisional pain with
coughing rated at 8 on a scale of 10. 16. A client is prescribed prolonged bed rest after surgery.
c. The client’s sanitary pad needs to be Which complication does the nurse expect to prevent
changed every hour. by teaching the client to avoid pressure on the
d. The client’s temperature is 100.3 degrees popliteal space?
F. a. cerebral embolism
b. pulmonary embolism
9. What should the nurse expect to see with the c. dry gangrene of a limb
discontinuation of the black tea? d. coronary vessel occlusion
a) Increased blood pressure
b) Increased urine output 17. The nurse in the postanesthesia care unit is caring for
c) Increased blood sugar a client who has received a general anesthetic. The
d) Increased heart rate nurse should notify the Physician if the:
a) client pushes the airway out
10. On the first postoperative day after a client has had an b) client has snoring respirations
open cholecystectomy, the nurse notes crackles at c) respirations of 16 breaths/min are shallow
both lung bases, a temperature of 100” F, and d) systolic blood pressure drops from 130 to
Nursing Practice III
90 mm Hg 23. A client tells the novice nurse that he has severe and
continuous scrotal pain. The nurse anticipates testing
18. After abdominal surgery a client suddenly complains for:
of numbness in the right leg and “funny feeling” in the a) testicular cancer.
toes. What should the nurse do first? b) pyelonephritis.
a. elevate the legs and tell the client to drink c) nephrolithiasis.
more fluids d) epididymitis.
b. instruct the client to remain in bed and
notify the physician 24. A novice nurse admitted a 22-year-old client is with
c. rub the client’s legs to stimulate circulation right lower quadrant abdominal pain of unknown
and cover the client with blanket etiology rated at 7 on a scale of 10. Which action will
d. tell the client about the dangers of be included in the initial plan of care?
prolonged bed rest and encourage a. Have client cough and deepbreathe q4h.
ambulation b. Apply heating pad to abdomen prn for
pain.
19. After a bilateral lumbar sympathectomy a client has a c. Teach client about a high-fiber diet.
sudden drop in blood pressure but there is no d. Place client on NPO (nothing by mouth)
evidence of bleeding. What should the nurse status.
recognize as the most likely cause of the change in
pressure? 25. A male client is brought to the emergency department
a) inadequate fluid intake with complaints of pain around his right scapula. The
b) after effects of anesthesia pain seems to occur shortly after eating. This is not the
c) increased level of epinephrine first time the client has experienced this type of pain
d) reallocation of the blood supply but the pain is worse now than ever before. What
question should the nurse ask to obtain additional
20. A 45-year-old male client with a history of blood clots information to develop a plan of care?
and degenerative joint disease in his bilateral knees is a) "Have you had nausea or vomiting
taking over-thecounter glucosamine and chondroitin recently?"
along with his prescribed warfarin. What potential b) "What type of food did you have within the
nursing diagnosis should be a priority? last 24 hours?"
a. Risk for Impaired Circulation: arterial c) "Have you noticed a significant weight gain
b. Risk for Alteration in Comfort or loss recently?"
c. Risk for Imbalanced Nutrition d) "Are you urinating less frequently than you
d. Risk for Ineffective Breathing Pattern were before?"

21. Another female client with multiple lumbar muscle 26. The nurse is managing acute pain exercised by the
strains is looking at using alternative therapies to older adult client during the first 24 hours after
reduce the pain. The client seeks advice from Nurse admission to the hospital. The nurse should ensure
Jane as to what type of alterative therapy would that:
provide the best pain relief. How should the nurse a. pain medication is ordered via the
respond? intramuscular route
a) "I have seen many individuals with your b. an order for meperidine (Demerol) is
type of pain be relieved of pain through the secured for pain reliefan order for meperidine
use of acupuncture." (Demerol) is secured for pain relief
b) "These types of therapies are more than c. patient-controlled analgesia is avoided in
just therapies; they are really a mind over this population
matter type of event or game." d. ordered PRN analgesics are administered
c) "Some of my other clients swear by on a scheduled basis
magnet therapy to reduce pain as it is very
small and very easy to use." 27. The nurse is working with an elderly female with
d) "You need to choose the alternative complaints of abdominal pain and nausea and
therapy that is right for you based on vomiting. While assessing the abdomen, the nurse
research that supports the intervention." notes the shape is round and the abdomen sags. From
analyzing these data, what condition should the nurse
22. Which action indicates that the new RN needs more expect?
instruction? a) Possible small bowel obstruction
a. The new RN listens for bowel sounds only b) Constipation
at the right lower quadrant. c) Nothing, normal aging process
b. The new RN performs abdominal palpation d) Peptic ulcer
before auscultating the abdomen.
c. The new RN checks for rebound 28. A client with intractable pain in the upper torso is
tenderness at the end of the examination. admitted to the hospital. The nurse understands that
d. The new RN asks the client to bend the the client may be candidate for surgery to control the
knees during the examination. pain. Which surgery should the nurse expect to
schedule?
Nursing Practice III
a. rhizotomy d) difficulty breathing
b. rhinotomy
c. cordotomy 36. Immediately after receiving spinal anesthesia a client
d. chonderectomy experiences hypotension as a result of postural
changes. To what physiologic change does the nurse
29. A client with an inflamed sciatic nerve is to have a attribute the change in BP?
conventional transcutaneous electrical nerve a. dilation of blood vessels
stimulation (TENS) device applied to the painful nerve b. decreased response of chemoreceptors
pathway. When operating the TENS unit, which c. decreased strength of cardiac contractions
nursing action is appropriate? d. interruption of cardiac accelerator
a) maintain the same dial settings every day pathways
b) turn the machine on several times a day
for 10 to 20 minutes 37. What should the nurse teach a client to do to minimize
c) adjust the TENS dial until the client orthostatic hypotension?
experiences relief of pain a) wear support hose continuously
d) apply the color-coded electrodes b) lie down for 30 minutes after taking
anywhere it is comfortable for the client medication
c) avoid tasks that require high energy
30. The response to the drug is described as a (n): expenditures
a. allergic response d) sit on the edge of the bed a short time
b. synergistic response before arising
c. paradoxical response
d. hypersusceptibility response 38. A 35-year-old executive secretary is hospitalized for
treatment of severe hypertension. The physician
31. Kris is further being treated for hypertension reports orders captopril (Capoten) and alprazolam (Xanax).
having a persistent hacking cough. The nurse explains The client quickly finds fault with the therapeutic
that this may be a side effect associated with: regimen and nursing care. The nurse identifies that
a) ACE inhibitors this behavior is probably a manifestation of the client’s:
b) thiazide diuretics a. denial of illness
c) calcium channel blockers b. fear of the health problem
d) Angiotensin receptor blockers c. response to cerebral anorexia
d. reaction to hypertensive medications
32. What should the nurse assess to determine if a client
is experiencing the therapeutic effect of valsartan 39. The Physician scheduled for an exercise
(Diovan), an Angiotensin II receptor blocking agent? electrocardiogram (stress test). What information
a. lipid profile should the nurse include when explaining the value of
b. apical pulse this test? Exercise stress testing is a:
c. urinary output a) definitive method to diagnose the cause of
d. blood pressure chest pain
b) diagnostic modality of minimal value in
33. To assess the effectiveness of a vasodilator planning treatment of angina
administered to a client, what should the nurse c) noninvasive means of assessing
assess? cardiovascular conduction and function
a) pulse rate d) minimally invasive manner of assessing a
b) breath sounds body’s reaction to increase in exercise
c) cardiac output
d) blood pressure 40. Which physiologic effect of nicotine should the nurse
explain to the group?
34. When teaching a client with heart disease about risk a. constriction of the superficial vessels,
factors, what should the nurse tell the client about dilating the deep vessels
cholesterol? Cholesterol: b. constriction of the peripheral vessels,
a. causes an increase in serum HDL increasing the force of flow
b. can be found in both plant and animal c. dilation of the superficial vessels with
sources constriction of the collateral circulation
c. should be eliminated because it causes the d. dilation of the peripheral vessels, causing
disease process a reflex dilation of visceral vessels
d. decrease when unsaturated fats are
substituted for saturated fat 41. A Nurse in a Special Health program department is
assessing the skin of a client with a history of chronic
35. Nifepidine (Procardia XL) 90 mg is prescribed for a venous insufficiency. The nurse understands that the
client with Hypertension. The nurse should instruct the darkening of tissue results from the breakdown of
client to notify the Physician if the client experiences: Haemoglobin with subsequent formation of:
a) blurred vision a) heme
b) dizziness on rising b) ferric chloride
c) excessive urination c) ferrous sulphide
Nursing Practice III
d) insoluble amino acids by:
a. oxygen
42. A client is admitted with chest pain unrelieved by b. lactic acid
Nitroglycerin, an elevated temperature, decreased c. calcium ions
blood, and diaphoresis. A Myocardial Infarction is d. carbon dioxide
diagnosed. Which is the most accurate explanation for
one of these clinical indicators based on the nurse’s 49. What explanation should the nurse give the client?
understanding of the disease process? Tidal volume is the amount of air:
a. parasympathetic reflexes from the a) exhaled forcibly after a normal expiration
infracted myocardium cause diaphoresis b) exhaled after there is a normal inspiration
b. inflammation in the myocardium causes a c) inspired forcibly above a normal inspiration
rise in the systemic body temperature d) trapped in the alveoli that cannot be
c. catecholamines released at the site of the exhaled
infarction cause intermittent localized pain
d. constriction of central and peripheral blood 50. The nurse is teaching Edwin deepbreathing exercises.
vessels causes a decreased in blood The nurse understands that air rushes into the alveoli
pressure as a result of which change in pressure?
a. increasing alveolar pressure
43. Which clinical indicator of this complication should the b. elevated diaphragmatic pressure
nurse expect to identify when assessing the client? c. rising pressure in the pleural space
a) pitting edema of the lower leg d. lowered pressure within the chest activity
b) ecchymotic areas of the extremity
c) intermittent claudication of the leg 51. Edwin is scheduled for a pulmonary function test. The
d) localized warmth of the lower extremity nurse explains that during the test one of the
instructions the respiratory therapist will give the client
44. When caring for a client with chronic occlusive arterial is to breathe normally. What is being measuring when
disease, what precipitating cause is the nurse most the client follows these directions?
likely to identify for development of ulceration and a) tidal volume
gangrenous lesions? b) vital capacity
a. emotional stress, which is shortlived c) expiratory reserve
b. poor hygiene and limited protein intake d) inspiratory reserve
c. stimulants such as coffee, tea, or cola
drinks 52. The nurse notes that Edwin’s Hemoglobin level is
d. trauma from mechanical, chemical, or decreasing and is concerned about tissue hypoxia. An
thermal sources increase in what diagnostic test result indicates an
acceleration in O2 dissociation from haemoglobin? a.
45. Nurse Benjie observes an anxious client pH b. po2 c. pco2 d. HCO3 What nursing action will
hyperventilating after learning that his wife met an limit hypoxia when suctioning a client’s airway?
accident and intervenes to prevent: a) lubricate the catheter with saline
a) cardiac arrest b) use a sterile suction catheter each time
b) carbonic acid deficit c) apply suction only after catheter is inserted
c) reduction in serum pH d) limit suctioning with catheter to 30 seconds
d) excess oxygen saturation
53. The nurse repositions a client to which of the following
46. Nurse Benjie admitted another client with an arterial position who is diagnosed with emphysema to
blood gas report indicates the client’s pH is 7.25, Pco2 facilitate maximum air exchange?
is 35 mm Hg, and HCO3 is 20 mEq/L. Which a. supine
disturbance does the nurse identify based on these b. orthopneic
results? c. Low-Fowler’s
a. metabolic acidosis d. Semi-Fowler’s
b. metabolic alkalosis
c. respiratory acidosis 54. The nurse must be alert for signs of respiratory
d. respiratory alkalosis acidosis in the client with Emphysema. In addition to a
long-term problem with O2 maintenance, what
47. A client arterial blood gas report indicates the pH is problem does this client have?
7.52, Pco2 is 32 mm Hg, and HCO3 is 24 mEq/L. What a) CO2 retention
imbalance does Nurse Benjie identify as a possible b) localized tissue necrosis
cause of these results? c) increased respiratory rate
a) airway obstruction d) saturated haemoglobin molecules
b) inadequate nutrition
c) prolonged gastric suction 55. A client diagnosed with a spontaneous Pneumothorax.
d) excessive mechanical ventilation Which physiologic effect of a spontaneous
Pneumothorax should the nurse include in a teaching
48. Nurse Benjie understands that in the absence of plan for the client?
pathology, a client’s respiratory center is stimulated a. the heart and great vessels shift to the
Nursing Practice III
affected side into the client’s room and tell them about the
b. there is greater negative pressure within diet
the chest cavity
c. inspired air will move from the lung into the 62. Which of the following client data indicate that the
pleural space nurse should check with the Physician before giving
d. the other lung will collapse if not treated the Capoten?
immediately A) The client’s blood pressure is 128/82 mm
Hg.
56. A client is admitted with suspected atelectasis. Which b) The client’s serum potassium level is 5.6
clinical indicator does the nurse expect to identify mg/dL.
when assessing the client? c) The client has an elevated blood urea
a) slow, deep respirations nitrogen and creatinine.
b) diminished breath sounds d) The client has lung crackles in both bases.
c) a dry, unproductive cough
d) a normal oral temperature 63. The physician prescribes Cholestyramine (Questran)
for a client with Hyperlipidemia. Which instructions
57. Nurse Romeo is attending the client on his first 24 should the nurse include in the client’s teaching plan?
hours after insertion of chest tubes, and assessing the a. “Increase your intake of fiber and fluid”
function of a three chamber, closed-chest drainage b. “Take the medication before you go to bed”
system. He notes that the water in the underwater seal c. “Check your pulse before taking the
tube is not fluctuating. What initial action should the medication”
Nurse Romeo take? d. “Contact your doctor if your skin or sclera
a. inform the physician turn yellow”
b. take the client’s vital signs
c. check whether the tube is kinked 64. When teaching a client with cardiac problem who must
d. turn the client to the unaffected side limit saturated fats in the diet, the nurse should stress
the importance of increasing the intake of:
58. A client is admitted to the unit of Nurse Romeo with a) enriched whole milk
acute Pulmonary Edema. Which rapidly acting diuretic b) red meats, such as beef
that can be administered intravenously should the c) vegetables and whole grains
nurse anticipate that the physician will order? d) liver and other glandular organ meats
a) Furosemide (Lasix)
b) Chlorothiazide (Diuril) 65. What statement by the client validates the need for
c) Chlorthalidone (Hygroton) additional education?
d) Spironolactone (Aldactone) a. "I can take ibuprofen routinely as long as I
don’t take it with caffeine."
59. She is being instructed on the use of antiembolism b. "I will reduce the amount of nicotine in my
stockings. The nurse should teach the client that the system daily until there is none."
stockings should be: c. "I need to learn how to read labels to
a. alternately kept on 2 hours and off 2 hours calculate carbohydrates and fat."
b. worn only at night when activity is lessened d. "I need to go shopping for shoes with a
c. put on before getting out of bed in the closed toe to protect my feet."
morning
[Link] in place until the physician advises 66. Nurse Teresa has also a client 54-year-old woman has
otherwise recently been diagnosed with type 2 diabetes. She has
a history of hypertension and obesity. The nurse is
60. Which is one of the more common complications of preparing to educate the client on how to reduce the
Myocardial Infarction identified by the nurse in the effects of diabetes and reduce the incidence of
coronary care unit? complications. What should the nurse stress with the
a) Dysrhythmia client?
b) hypokalemia a) Weight reduction
c) anaphylactic shock b) Blood pressure control
d) cardiac enlargement c) Foot care
d) Self-injection technique
61. A 2-g sodium diet is prescribed for a male client with
severe Hypertension. The client does not like the diet, 67. The nurse notes all of the following laboratory values
and the nurse hears him requesting to the spouse to when reviewing the chart for a client with a 20-year
“Bring in some good home-cooked food.” What is the history of diabetes. Which one is of most concern?
most effective nursing intervention? a. Hemoglobin A1C 6.9%
a. call in the dietitian for client teaching b. Hemoglobin 11.0 g/dL
b. wait for the client’s family and discuss the c. Urine protein level 3+
diet with the client and family d. Urine specific gravity 1.005
c. tell the client what the use of salt is
forbidden, because it will raise the BP 68. A nursing student is shadowing a nurse who is
d. catch the family members before they go providing education on atherosclerosis to a client with
Nursing Practice III
recently diagnosed type 1 diabetes and no significant sugar substitutes. The client is overweight and knows
cardiovascular history. After the nurse is finished that she needs to reduce her calorie intake to reduce
providing the education, the nursing student requests the weight and help prevent complications associated
from the nurse a rationale for why this particular client with diabetes. The client asks which sugar substitute
received education on Atherosclerosis without would assist in meeting her goal. What sugar
indication of the condition. What statement by the substitute should the nurse suggest?
nurse best fits the rationale for the education? a. Fructose
a) In type 1 diabetes, ketones are a by- b. Sucrose
product of fat metabolism that increases the c. Sucralose
osmotic pressure, leading to increase in fluid d. Sorbitol
loss.
b) In type 1 diabetes, stress is the major 72. A novice nurse is preparing to administer insulin to a
cause of the body switching to fat metabolism client with a blood sugar level of 124 mg/dL. The
that leads to plaque buildup in the vascular student compares the result to the medication record
system. and physician's order and notes that the client is
c) In type 1 diabetes, when fat is used as the ordered NovoLog insulin. The novice nurse draws the
primary source of energy, the body lipid level appropriate amount of insulin and then goes to the
can increase greatly, leading to plaque client's room to administer the injection. The meal tray
buildup. is due in 30 minutes. What should the novice nurse do
d) In type 1 diabetes, the lack of insulin next?
prevents the body from adequate protein a) Administer the insulin immediately to
synthesis, leading to increased destruction of coincide the onset with the time of the meal.
proteins. b) Hold the medication until the tray is in front
of the client, because onset is 5 minutes.
69. Another 65-year-old man is being tested for Diabetes c) Give the insulin immediately after the client
Mellitus. Today the client is to have a 2-hour has finished the entire meal.
postprandial glucose test. The client was given a d) Administer the insulin because the blood
regular meal and 2 hours later the result was 210 glucose is high enough to prevent
mg/dL. According to the result what should the nurse hypoglycemia.
expect?
a. The result is above the standard cut off for 73. An individual was recently diagnosed with type 1
diabetes diagnosis; therefore the client is diabetes. Nurse Roxas is providing education on what
considered diabetic and will need follow-up is termed "survival skills." Which of the following skills
care. should the nurse make a priority when teaching the
b. The result is normal for the age of the client?
client, so the client is not diagnosed with a. Insulin self-injection technique
diabetes but will need follow-up care. b. Treatment of hypoglycemia
c. Because the result is only slightly higher c. Sick day management
than normal, a retest maybe ordered with d. Basic dietary information Larger than
attention paid to the lunch to make sure that normal amounts of acetoacetic acid have
no caffeine is on the tray. been entering the blood as one of the blood
d. Because the result was lower than what is as one of the indirect results of a client’s
expected for his age, the client is questioned insulin deficiency.
regarding participation in a strenuous activity
before the test. 74. The nurse understands the chemical mainly
responsible for buffering acetoacetic acid is: a)
70. A middle-age male client has recently been diagnosed potassium b) bicarbonate c) carbon dioxide d) sodium
with diabetes mellitus. He has been started on insulin chloride Which of the following physician's orders
and has been attending diabetes education classes. should the nurse implement first?
During the class, the client asks whether drinking a. Obtain a chest x-ray study.
alcohol would be possible "with the new diabetes stuff" b. Insert a retention catheter.
because he has heard there is sugar in alcoholic c. Measure blood urea nitrogen and
drinks. What is the nurse's best response? creatinine.
a) Alcohol is a fast-acting sugar that will d. Start a normal saline infusion at 200 mL/hr.
increase your blood sugar rapidly." An older female client is being seen for
b) "The calories from alcohol must be figured recent history of diarrhea and vomiting.
into the daily plan to prevent weight gain."
c) "Alcohol does not require insulin for 75. The client states that she has had at least two
absorption so hypoglycemia may be a episodes of vomiting with more episodes of diarrhea
problem." within the last few days. The nurse suspects
d) "Alcohol can impair the client’s ability to dehydration. Where should the nurse test skin turgor
recognize and treat hypoglycemia." on this client?
a) Lower forearm
71. A female client with diabetes mellitus begins a b) Top of the sternum
discussion with the diabetes nurse Roxas regarding c) Forehead
Nursing Practice III
d) Abdomen c. Lorazepam (Ativan) 0.5 mg PO
d. Calcium carbonate (Tums) 500 mg PO
76. A client is admitted with dehydration as a result of
prolonged water diarrhea. Which intervention ordered 83. Sarah is completing her charting with a client with
by the physician should the nurse question? acute renal failure (ARF) has a nursing diagnosis of
a. parenteral albumin Imbalanced Nutrition: Less Than Body Requirements
b. psyllium (Metamucil) related to anorexia. Which of the following
c. potassium supplements interventions will be included in the plan of care?
d. half normal saline a) Keep fresh water at the bedside.
b) Administer prn antiemetics before meals.
77. Which intervention will be included in the initial plan of c) Offer high-calorie snacks at frequent
care? intervals.
a) Bed rest d) Have family members bring food from
b) Private room home.
c) Fluid restriction
d) Oxygen administration 84. One of the clients in the ward developed renal failure.
The dialysis team is discussing whether peritoneal
78. Which information about a client with renal dialysis should be started for a client with chronic
insufficiency who is to have an intravenous pyelogram kidney disease. Which information about the client
with contrast infusion is of most concern to nurse indicates that hemodialysis may be a better option?
Gloria ? a. The client has insulin-dependent diabetes.
a. The client’s serum potassium level is 5 b. The client has severe rheumatoid arthritis.
mg/dL. c. The client has a history of coronary artery
b. The client has poor skin turgor and dry oral disease.
mucosa. d. The client has poor compliance with
c. The client has had insulindependent dietary restrictions.
diabetes for 20 years.
d. The client takes acetaminophen (Tylenol) 85. What is the earliest symptom of chronic renal failure?
for occasional headaches. a) Increased BUN
b) Oliguria
79. Sarah is preparing the client for possible discharge. c) Polyuria
Which statement by a client after receiving teaching d) Pruritus
about prevention of urinary tract infections (UTIs)
indicates that the teaching has been effective? 86. Which statement by a client who has received
a) "I will drink at least a quart of water or other teaching about oral herpes simplex lesions indicates
fluids every day." that more teaching is necessary?
b) "I will plan to take a quick bath after sexual a. "I will take all of the antibiotics that the
intercourse." doctor ordered for me."
c) "I will have cranberry juice every morning b. "I can make a salt-water solution to rinse
for breakfast." my mouth."
d) "I will need to give up drinking coffee or c. "I will avoid sharing my dishes with family
cola beverages." members."
d. "I can use an over-the-counter medication
80. Which clinical manifestation noted by nurse Sarah to numb the sores."
during the assessment of a client with a urinary tract
infection (UTI) will be of most concern? 87. A 37-year-old female client is admitted in the ward with
a. Temperature of 102.8 degrees F complaints of unilateral anterior neck pain and fever.
b. Pain with voiding rated at 8 on a scale of During the assessment, the nurse learns that she has
10 recently recovered from a bacterial respiratory
c. Cloudy-appearing urine infection. The nurse anticipates that the Physician will
d. Urge incontinence diagnose her with which type of Thyroiditis?
a) Acute thyroiditis
81. Which of the following Physician's orders should nurse b) Subacute granulomatous thyroiditis
Sarah implement first for the client admitted with a c) Subacute lymphocytic thyroiditis
urinary tract infection, flank pain, and fever? d) Chronic thyroiditis
a) Gentamicin (Garamycin) 80 mg IV
b) Acetaminophen (Tylenol) 600 mg PO 88. What clinical indicator is important for the nurse to
c) Urine for culture and sensitivity assess when a client undergoes a submucosal
d) Flat plate x-ray study of the abdomen resection (SMR) for a deviated septum?
a. occipital headache
82. Sarah is checking the medications of the clients. b. periorbital crepitus
Which of the following medications ordered for a client c. expectoration of blood
with acute renal failure should the nurse question? d. changes in vocalization
a. Mannitol (Osmitrol) 12.5 mg IV
b. Milk of Magnesia 30 mL PO 89. The nurse must establish and maintain an airway in a
Nursing Practice III
client who has experienced a neardrowning in the labelled Heparin sodium 20,000 units =1ml. Using a
ocean. For which potential danger should the nurse tuberculin syringe how much would the nurse
assess the client? administer?
a) alkalosis a) 1 ml
b) renal failure b) 0.9 ml
c) hypervolemia c) 2 ml
d) pulmonary edema d) 2.9 ml

90. The nurse uses abdominal-thoracic thrusts (Heimlich 96. The client develop Cardiac Arrhythmias and the
maneuver) when an older adult in a senior center Physician prescribed Atropine 0.3mg to be
chokes on a piece of meat. Which volume of air is the administered by IV bolus. The vial of Atropine is
basis for the efficacy of the abdominal thrusts labelled 600mcg=1ml. How many ml should the nurse
(Heimlich maneuver) to expel a foreign object in the draw into the syringe?
larynx? a. 1 ml
a. tidal b. 2 ml
b. residual c. 0.5 ml
c. vital capacity d. 1.5 ml
d. inspiratory reserve
97. The patient is receiving a Total Parenteral Nutrition
91. When caring for a client with a portable wound (TPN) at a rate of 65ml / hour via an electronic infusion
drainage system, the nurse understands that the device . The drop factor of the infusion set is 60 drops
principle behind its functioning is: per ml. What is the total amount of the TPN solution
a) the lumen diameter will determine the rate that the patient will receive in 24 hours?
fluid flow a) 1,500 ml
b) gravity causes liquids to flow down a b) 1,560 ml
pressure c) 1.600 ml
gradient d) 1,660 ml
c) siphonage causes fluids to flow from one
level to a lower one 98. The Nurse is caring for a patient whose IV has
d) fluids flow from an area of higher pressure been regulated to deliver 35 drops per minute of
to one of lower pressure D5NSS. The drop factor of the infusion set is 15 drops
/ ml. The nurse recognizes that the amount absorbed
92. Which of the following assessment data would most in one hour will be how many ml?
likely be related to a client’s current complaint of stress a. 120 ml
incontinence? b. 130 ml
a. The client’s intake of 2 to 3 L of fluid per c. 140 ml
day d. 150 ml
b. The client’s history of three full-term
pregnancies
c. The client’s age of 45 year NP III: DRILL 3
d. The client’s history of competitive
swimming 1. A client who crashed her motorcycle suffered a tibial
fracture that required casting. Approximately 5 hours
93. The primary goal of nursing care for a client with stress later, the client begins to complain of increasing pain
incontinence is to: distal to the left tibial fracture despite the morphine
a) Help the client adjust to the frequent injection administered 30 minutes previously. The
episodes of incontinence nurse’s next action should be to assess for which of
b) Eliminate all episodes of incontinence the following? Presence of a distal pulse Pain with a
c) Prevent the development of urinary tract pain rating scale Vital sign changes Potential for drug
infections tolerance*
d) Decrease the number of incontinence a. Presence of a distal pulse
episodes b. Pain with a pain rating scale
c. Vital sign changes
94. The Physician has prescribed Lente Human Insulin ( d. Potential for drug tolerance
Humulin L ) 36 units subcutaneously once a day. The
available s in a vial labelled Humulin L -100 units per 2. After surgery, Gina returns from the Post-anesthesia
ml. Using a tuberculin syringe the nurse should Care Unit (Recovery Room) with a nasogastric tube in
administer how many ml? place following a gall bladder surgery. She continues
a. 1 ml to complain of nausea. Which action would the nurse
b. 2 ml take?*
c. 0.26 ml a. Call the physician immediately.
d. 0.36 ml b. Administer the prescribed antiemetic.
c. Check the patency of the nasogastric tube
95. The physician prescribed Heparin Sodium 18,000 for any obstruction.
units subcutaneously. The available vial is that is d. Change the patient’s position.
Nursing Practice III
b. Monitor for increased intracranial
3. A 60-year-old male client comes into the emergency pressure.
department with complaints of crushing substernal c. Observe frequently for hypervigilance.
chest pain that radiates to his shoulder and left arm. d. Offer the client food every three to four
The admitting diagnosis is acute myocardial infarction hours.
(MI). Immediate admission orders include oxygen by
nasal cannula at 4L/minute, blood work, a chest 9. The client diagnosed with Addison’s disease is
radiograph, a 12-lead electrocardiogram (ECG) and 2 admitted to the emergency department after a day at
mg of morphine sulfate given intravenously. The nurse the lake. The client is lethargic, forgetful, and weak.
should first:* Which intervention should be the emergency
a. order the chest radiograph department nurse’s first action?*
b. obtain a 12 lead ECG a. Start an IV with an 18-gauge needle and
c. administer the morphine infuse NS rapidly.
d. obtain a blood work b. Have the client wait in the waiting room
until a bed is available.
4. Intervention for a pt. who has swallowed a Muriatic c. Perform a complete head-to-toe
Acid includes all of the following except* assessment.
a. administering an irritant that will stimulate d. Collect urinalysis and blood samples for a
vomiting CBC and calcium level.
b. aspirating secretions from the pharynx if
respirations are affected 10. Which equipment must be immediately brought to the
c. neutralizing the chemical client’s bedside when a code is called for a client who
d. washing the esophagus with large has experienced a cardiac arrest?*
volumes of water via gastric lavage a. A ventilator.
b. A crash cart.
5. After you managed to stabilize the respiratory function c. A gurney.
of your burn patient, your next goal is to prevent this d. Portable oxygen.
you have to replace the lost fluid and electrolytes. In
starting fluid replacement therapy, the total volume 11. A client is concerned about contacting malaria while
and rate of IV fluid replacement are gauged by the visiting relatives in Southeast Asia. The nurse explains
patient’s response and by the patient’s response and that the best way to prevent malaria is to avoid:*
by the resuscitation formula. In determining the a. Mosquito bites
adequacy of fluid resuscitation, it is essential for you b. Undercooked food
to monitor the:* c. Untreated water
a. urine output d. Overpopulated areas
b. blood pressure
c. intracranial pressure 12. To prevent a valsalva maneuver in a client recovering
d. cardiac output from an acute myocardial infarction, the nurse would*
a. Assist the client to use the bedside
6. You are a nurse in the emergency department and it commode
is during the shift that Mr. CT is admitted in the area b. Administer stool softeners every day as
due to a fractured skull from a motor accident. You ordered
scheduled him for surgery under which classification?* c. Administer antidysrhythmics prn as
a. Urgent ordered
b. Emergent d. Maintain the client on strict bed rest
c. Required
d. Elective 13. After the acute phase of congestive heart failure, the
nurse should expect the dietary management of the
7. Lucky was in a vehicular accident where he sustained client to include the restriction of:*
injury to his left ankle. In the Emergency room, you a. Magnesium
noticed anxious he looks. You establish rapport with b. Sodium
him and to reduce his anxiety, you initially:* c. Potassium
a. Identify yourself and state your purpose in d. Calcium
being with the client
b. Take him to the radiology section for x-ray 14. A patient with angina pectoris is being discharged
of affected extremity home with nitroglycerine tablets. Which of the
c. Talk to the physician for an order of valium following instructions does the nurse include in the
d. Do inspection and palpation to check teaching?*
extent of his injuries a. “When your chest pain begins, lie down,
and place one tablet under your tongue. If the
8. The client diagnosed with a mild concussion is being pain continues, take another tablet in 5
discharged from the emergency department. Which minutes.”
discharge instruction should the nurse teach the b. “Place one tablet under your tongue. If the
client’s significant other?* pain is not relieved in 15 minutes, go to the
a. Awaken the client every two hours. hospital.”
Nursing Practice III
c. “Continue your activity, and if the pain does
not go away in 10 minutes, begin taking the 21. Nurse Rozeth teaches a client with heart failure to take
nitro tablets one every 5 minutes for 15 oral Furosemide in the morning. The reason for this is
minutes, then go lie down.” to help… *
d. “Place one Nitroglycerine tablet under the a. Retard rapid drug absorption
tongue every five minutes for three doses. b. Excrete excessive fluids accumulated at
Go to the hospital if the pain is unrelieved. night
c. Prevents sleep disturbances during night
15. A client with chronic heart failure has been placed on d. Prevention of electrolyte imbalance
a diet restricted to 2000mg. of sodium per day. The
client demonstrates adequate knowledge if behaviors 22. What would be the primary goal of therapy for a Kelvin,
are evident such as not salting food and avoidance of a client with pulmonary edema and heart failure?*
which food?* a. Enhance comfort
a. Whole milk b. Increase cardiac output
b. Canned sardines c. Improve respiratory status
c. Plain nuts d. Peripheral edema decreased
d. Eggs
23. Dr. Marquez orders a continuous intravenous
16. Mr. Ong is admitted to the hospital with a diagnosis of nitroglycerin infusion for the client suffering from
Left-sided CHF. In the assessment, the nurse should myocardial infarction. Which of the following is the
expect to find:* most essential nursing action?*
a. Crushing chest pain a. Monitoring urine output frequently
b. Dyspnea on exertion b. Monitoring blood pressure every 4 hours
c. Extensive peripheral edema c. Obtaining serum potassium levels daily
d. Jugular vein distention d. Obtaining infusion pump for the medication

17. Which meal would indicate the client understands the 24. After mitral valve replacement, client Wennar
discharge teaching concerning the recommended diet suddenly experiences continuous bleeding from the
for coronary artery disease?* surgical incision during postoperative period. As a
a. Baked fish, steamed broccoli, and garden nurse, which of the following pharmaceutical agents
salad. should you prefer to administer to Wennar?*
b. Enchilada dinner with fried rice and refried a. Protamine Sulfate
beans. b. Quinidine Sulfate
c. Tuna salad sandwich on white bread and c. Vitamin C
whole milk. d. Coumadin
d. Fried chicken, mashed potatoes, and
gravy. 25. Smoking cessation is critical strategy for the client with
Burgher’s disease, Nurse Phoebe anticipates that the
18. A 78-year old client is admitted to general ward with male client will go home with a prescription for which
the diagnosis of mild chronic heart failure. Nurse medication?*
Trisha expects to hear when listening to client’s lungs a. Paracetamol
indicative of chronic heart failure would be:* b. Ibuprofen
a. Stridor c. Nitroglycerin
b. Crackles d. Nicotine (Nicotrol)
c. Wheezes
d. Friction rubs 26. Nurse Airrah is aware that the shift of body fluids
associated with Intravenous administration of albumin
19. Joshua is a 42-year old business man who is occurs in the process of:*
hospitalized following a myocardial infarction. He asks a. Osmosis
the nurse why he is taking morphine. The nurse b. Diffusion
explains that morphine:* c. Active transport
a. Decrease anxiety and restlessness d. Filtration
b. Prevents shock and relieves pain
c. Dilates coronary blood vessels 27. To ensure adequate ventilating exchange post
d. Helps prevent fibrillation of the heart operatively, which nursing intervention should be
implemented?*
20. Nurse Romar is assigned to the client diagnose with a. Remove the airway only when client is fully
Chronic Kidney Disease. Which of the following should conscious
nurse Romar teach the client about the signs of b. Assess for hypoventilation by auscultating
digitalis toxicity?* the lungs
a. Increased appetite c. Position client laterally with the neck
b. Elevated blood pressure extended
c. Skin rash over the chest and back d. Maintain humidified oxygen via nasal
d. Visual disturbances such as seeing yellow canula
spots
Nursing Practice III
28. George who has undergone thoracic surgery has rheumatoid arthritis. Which of the following would the
chest tube connected to a water-seal drainage system nurse in charge identify as the lowest priority of the
attached to suction. Presence of excessive bubbling is plan of care?*
identified in water-seal chamber, the nurse should…* a. Prevent joint deformity
a. “Strip” the chest tube catheter b. Maintaining usual ways of accomplishing
b. Check the system for air leaks task
c. Recognize the system is functioning c. Relieving pain
correctly d. Preserving joint function
d. Decrease the amount of suction pressure
36. Nurse Jarius is caring for client who begins to
29. Sheena is a client who has been diagnosed of experience seizure while in bed. Which action should
hypertension. Her nurse Leinus instructed her to Nurse Jarius implement to prevent aspiration?*
restrict intake of sodium. Nurse Leinus would know a. Position the client on the side with head
that the teachings are effective if the client states flexed forward
that…* b. Elevate the head
a. I can eat celery sticks with peanut butter c. Use tongue depressor between teeth
b. I can eat buttered scallops and muscles d. Loosen restrictive clothing
c. I can eat shredded wheat cereal
d. I can eat spaghetti on white bread 37. A client has undergone surgery for retinal detachment.
Which of the following goal should be prioritized?*
30. Nurse Laarni is performing an assessment of her a. Prevent an increase intraocular pressure
client’s stoma d uring the initial postoperative period. b. Alleviate pain
Nurse Laarni evaluates which of the following c. Maintain darkened room
observations should be reported immediately to the d. Promote low-sodium diet
physician?*
a. Stoma is dark red to purple 38. A Client with glaucoma has been prescribed with
b. Stoma is oozes a small amount of blood miotics. The nurse is aware that miotics is for:*
c. Stoma is lightly edematous a. Constricting pupil
d. Stoma does not expel stool b. Relaxing ciliary muscle
c. Constricting intraocular vessel
31. Roan is 58 year old woman has newly diagnosed with d. Paralyzing ciliary muscle
hypothyroidism. Nurse Elvi is aware that the signs and
symptoms of hypothyroidism include:* 39. When suctioning an unconscious client, which nursing
a. Diarrhea intervention should the nurse prioritize in maintaining
b. Vomiting cerebral perfusion?*
c. Tachycardia a. Administer diuretics
d. Weight gain b. Administer analgesics
c. Provide hygiene
32. Nurse Jamielyn is caring for clients in the Operating d. Hyperoxygenate before and after
Room. Nurse Jamielyn is aware that the last suctioning
physiologic function that the client loss during the
induction of anesthesia is:* 40. Nurse Lee is caring for a client who has just had a
a. Consciousness splenectomy. When planning care in the immediate
b. Gag reflex postoperative period Nurse Lee should avoid using
c. Respiratory movement which position?*
d. Corneal reflex a. Left side lying
b. Semi-Fowler’s
33. Nurse Mico is caring for Faye, a client with nasogastric c. Right side lying
tube that is attached to low suction. Nurse Mico d. Supine
assesses the client for symptoms of which acid-base
disorder?* 41. Nurse Neil is caring for a client who is being transfused
a. Respiratory alkalosis for severe gastrointestinal bleeding. Nurse Neil can
b. Respiratory acidosis decrease the danger of hypothermia by:*
c. Metabolic acidosis a. administering blood with normal saline
d. Metabolic alkalosis b. administering blood products through a
central line
34. Danny admitted to female medical ward and is c. giving only packed cells
suspected of developing diabetes insipidus. Which of d. warming blood to body temperature before
the following is the most effective assessment?* administering
a. Taking vital signs every 4 hours
b. Monitoring blood glucose 42. Client Hershey is suffering from congestive heart
c. Assessing ABG values every other day failure and is receiving spironolactone (Aldactone).
d. Measuring urine output hourly Which of the following is least appropriate for her
nurse to teach the client Hershey about this
35. A 58-year-old client is suffering from acute phase of medication?*
Nursing Practice III
a. Use calcium-based salt substitutes c. No physical preparation is needed before
b. Swelling and tenderness of the breasts the test
may occur with longterm therapy d. A nuclear medication is administered by
c. Take the medicine in the morning if the radiology department 24 hours before the
possible test
d. Include high-potassium foods in the diet to Option 5
decrease the possibility of hypokalemia
47. The nurse finds a client who has been diagnosed with
43. The nurse is assessing a client following hemodialysis. a peptic ulcer surrounded by papers from his briefcase
Which of the following findings indicates the treatment and arguing on the telephone with a coworker. The
was effective?* nurse’s response to observing these actions should be
a. hypertension based on knowledge that:*
b. fluid volume decrease a. involvement with his job will keep the client
c. hyperkalemia from becoming bored
d. cardiac dysrhythmias b. a relaxed environment will promote ulcer
healing
44. A client with deep vein thrombosis is started is started c. not keeping up with his job will increase the
on heparin therapy. Which nursing action is not client’s stress level
indicated during heparin administration?* d. setting limits on the client’s behavior is an
a. Having vitamin K available if bleeding important nursing responsibility
occurs
b. Observing for hematomas at IV puncture 48. Which of the following systems would be indicative of
sites the dumping syndrome*
c. Suggesting that the client use a soft a. Hunger
bristled toothbrush b. Vomiting
d. Using an IV control device for drug c. Diaphoresis
administration d. Heartburn

45. Jeremiah is a 37-year-old man whose secondary 49. During the client’s dialysis, the nurse observes that the
hypertension has not responded to lifestyle solution draining from the abdomen is consistently
medications over the last 5 weeks is admitted to bloodtinged. The client has a permanent peritoneal
undergo treatment in an effort to bring the catheter in place. Which interpretation of this
hypertension under control. During the hospitalization observation would be correct?*
he is being treated using the stepped-care approach. a. Bleeding is expected with permanent
The medications which are pat of his therapy are peritoneal catheter.
furosemide (Lasix) and quinipril hydrochloride b. Bleeding indicates abdominal blood vessel
(accupril) What types of information should the nurse damage
include in the discharge plan for this client?* c. Bleeding can indicate kidney damage
a. Cholesterol restriction, weight reduction, d. Bleeding is caused by too-rapid infusion
limited activity, drug use and drug use and of the dialysate
side effects
b. Potassium restriction, increased activity, 50. Of the following nursing interventions for catheter
drug use and self-blood pressure monitoring care, which should have the highest priority?*
c. Sodium restriction, increased activity, drug a. Cleansing the area around the urethral
action, tobacco avoidance and reduced meatus
stress b. Clamping the catheter periodically to
d. Magnesium restriction, drug use and side maintain muscle tone
effects, limited alcohol intake, and rest c. Irrigating the catheter with several ounces
periods of normal saline solution
d. Changing the location where the catheter
46. Christian, age 55 years, is admitted to the oncology is taped to the client’s leg
ward. Brian has a history of weight loss, has a
persistent cough that has increased, and has had Lysis - splitting Genesis - formation Deep breathing exercise -
bloodtinged sputum for 2 weeks. He has a smoked up 4 secs inhale using nose -7 secs hold breath-8 secs exhale
to two packs of cigarettes a day for 20 years. He is an using mouth
accountant and had delayed seeking medical attention
until his work load was lighter. His chest radiograph
revealed a mass in the right lung. He is being admitted
for further evaluation and treatment. An MRI
evaluation is scheduled. You prepare Mr. Christian for
this study by telling him that:*
a. He will have to take laxatives before the
study
b. A dye will be injected into his veins just
before the test
Nursing Practice III
C. Presence of lochia rubra
PRE INTENSIVE EXAM TOPRANK D. Increase in perineal pain sensation

1. A patient who has terminal cancer has an order for morphine 8. A nurse is counseling a parent of a six- month – old
sulfate (MS Contin) tablets every 8 to 12 hrs p.r.n. for moderate infant about beginning solid foods in the infant’s diet.
pain or morphine sulfate injections of 10 to 12 mg every four Which of the following foods should the nurse
hours p.r.n. intramuscularly for severe pain. The patient has recommend be introduced initially?
been receiving MS Contain p.o. every 12 hours but is A. Poached egg
experiencing breakthrough pain after about 10 hours. Which of B. Strained peaches
the following nursing action is most appropriate. C. Pureed peas
a. Administer injectable morphine sulfate, 12 D. Rice cereal
mg, IM, p.r.n.
b. Administer the MS Contain, po, every 12 9. A nurse observes a nurse’s aide taking all of the
hours following measures when caring for a patient in the
c. Administer the MS Contain, po, every 10 postoperative period following a pneumonectomy.
hours Which measures would require immediate intervention
d. Withhold the pain medications and notify the by the nurse?
physician A. Assisting the patient to ambulate in the hall
B. Positioning the patient on the unoperated
side
C. Placing elastic stockings on the patient’s
2. Which of the following outcomes observed by the nurse legs
during the drain cycle of peritoneal dialysis should be reported D. Splinting the patient’s chest during
immediately to the physician? coughing
A. Clear yellow output
B. Cloudy output 10. Which of the following pulmonary findings would a
C. Patient complaint of slight cramping nurse expect to assess in a patient who has lower lobe
D. A drain output of 50 cc less than instilled pneumonia?
A. Paradoxical chest movement
3. Which of the following conditions would a nurse recognize as B. Eupnea
contributing to the development of respiratory alkalosis? C. Bronchial breath sounds
A. Chronic obstructive pulmonary disease (COPD) D. Kussmaul respirations
B. Episodes of hyperventilation 11. A nurse would assess a patient who has peripheral
C. Frequent loose stools vascular disease of which of the following venous
D. Hiatal hernia insufficiencies?
A. Paresthesias
4. When planning preoperative care for a child suspected of B. Bounding pedal pulses
having Wilms tumor, the nurse should recognize that which of C. Intermittent claudication
the following interventions places the child at risk for D. Edematous ankles
complications?
A. Palpating the child’s abdomen every eight hours 12. A young boy who is receiving chemotherapy
B. Measuring the child’s temperature rectally develops alopecia and says to the nurse, “I’ve lost all
C. Monitoring the child’s blood pressure ever four my hair.” Which of the following responses would be
hours appropriate for the nurse to make to the child?
D. Monitoring the child’s intake and output A. “Did you know that because your hair fell
out, we know that the medicine is working to
5. Which of the following comments by a patient should indicate make you better
to a nurse that the patient has ideas of reference? B. “Would you like to see some pictures of
A. “Those other nurses are talking about me” famous men who are bald?”
B. “The nurse explained how my medication works” C. “it’s hard to look different from the way you
C. “Do all the nurse here have a college degree?” used to look.”
D. “Will a nurse lead group therapy today?” D. “You can wear a baseball cap until your hair
grows back.”
6. Which of the following conditions would a nurse recognize as
contributing to the development of respiratory acidosis? 13. A patient expresses many physical complaints
A. Emphysema during the first two weeks on the alcohol rehabilitation
B. Hyperventilation unit. The results of physical examination have been
C. Diarrhea negative. The patient frequently approaches staff
D. Achalasia members to request medication for her discomfort.
Based on the patient’s behavior, which of the following
7. A woman who is 24- hours postpartum and who has an interpretations is correct?
episiotomy would be instructed to report which of the following A. The patient is trying to make the staff feel
findings immediately? guilty
A. Decrease in urine output B. The patient is attempting to relive her
B. Absence of a daily bowel movement anxiety
Nursing Practice III
C. The patient is experiencing organic pain from B. Place the patient’s head between his legs
alcohol withdrawal C. Pinch the nose and have the patient lean
D. The patients is using a more mature way of meeting forward
her needs than alcohol. D. Place warm compresses on the patient’s
nasal bridge
14. Which of the following foods should be removed from the
dietary tray of a patient who has hepatic encephalopathy? 21. Which of the following questions is most important
A. Pasta for a nurse to ask when taking a history from a patient
B. Spinach who presents with symptoms of peripheral arterial
C. Fresh fruit occlusive disease?
D. Eggs A. “Do your legs hurt while walking?”
B. “Do you notice swelling in your legs at
15. A patient who had a tonsillectomy reports spitting up night?”
copious amounts of blood at home 10 days after the operation. C. “Do you have calf pain when you flex your
Which of the following actions would the nurse instruct the foot?”
patient to take first? D. “Do you feet feel warm after exercise?”
A. Take nothing by mouth and go to the emergency
room 22. When assessing a woman who is six days
B. Gargle with warm saline solution postpartum following a vaginal delivery, a nurse would
C. Drink ice cold water expect to describe the lochia in which of the following
D. Apply direct pressure to the carotid artery ways?
A. Red in color with occasional small clots
16. Which of the following behaviors would indicated the B. Brown in color without clots
greatest improvement in a patient who was admitted to the C. Pink in color with occasional small clots
hospital with a diagnosis of hyperactivity. D. White in color without clots
A. The patient completes an assigned task
B. The patient frequently apologizes for his behavior 23. A patient who has hyperthyroidism is taking
C. The patient takes naps during the day patient on methimazole (Tapazole) and attends the clinic
the unit regularly. To evaluate the effectiveness of Tapazole
D. The patient on the unit therapy, the nurse should consider which of the
following questions?
17. When admitting a four – day – old Hispanic infant to the A. Has the patient’s vision improved?
pediatric unit, the nurse notes irregular bluish discoloration over B. Has the patient’s appetite improved?
the infant’s sacrum and buttocks. The nurse should recognize C. Has the patient’s need for sleep
that this is a decreased?
A. sign of child abuse and is reportable. D. Has the patient’s pulse rate decreased?
B. manifestation of a rare bleeding disorder
C. normal variation in the skin assessment of a 24. To which of the following nursing diagnosis would a
newborn nurse give priority when caring for a patient who has
D. Result of a traumatic birth injury. septic shock?
A. Initiating a bowel program
18. The nurse assessing a toddler who has an acute upper B. Encouraging deep breathing
respiratory infection notes that the child has been vomiting. The C. Increasing sensory stimulation
nurse correctly interprets the vomiting as. D. Promoting fluid intake
A. an indication that the child also has a
gastrointestinal infection 25. Which of these findings should a nurse expect to
B. a sign that the child is unable to mobilize secretions identify when assessing a patient who is receiving
in the lungs radiation therapy for cancer of the esophagus?
C. a common manifestation of respiratory illness in A. Peripheral neuropathy
young children B. Gingival hyperplasia
D. a common manifestation of respiratory illness in C. Alopecia
young children D. Hypersalivation

19. A patient in the recovery room complains of incisional pain. 26. When taking the history of a patient who has
Which of the following nursing interventions would be most multiple myeloma, a nurse would expect the patient to
appropriate? report which of the following symptoms?
A. Give meperidine (Demero) 50 mg, MI, as ordered A. Back pain
B. Encourage deep breathing exercises B. Blurred vision
C. Place the patient in a prone position C. Hair loss
D. Give acetaminophen (Tylenol), two tablets as D. Cloudy urine
ordered
27. A nurse would recognize that adolescents perceive
20. Which of the following nursing measures would be most which of the following issues as being a priority?
appropriate in the care of a patient who has acute epistaxis? A. Nutrition
A. Tilt the patient’s head back B. Safety
Nursing Practice III
C. Education C. The woman has a blood pressure of 124/80
D. Privacy mm Hg, compared with 90/60 mm Hg a month
ago
28. A seven- year- old girls is to begin her first immunization D. The woman has gained three pounds (1.4
schedule. According to recommended guidelines, which of the kgs) during the past month
following vaccines is not needed?
A. Polio 35. Which of the following responses of a female patient
B. Measles who is codependent and has low self- esteem indicates
C. Pertussis that nursing interventions have been successful?
D. Mumps A. The patient encourages her 16- year- old
daughter to prepare her own breakfast.
29. An elderly widow who has dementia of the Alzheimer type B. The patient regularly prepares
says to the nurse who offers her breakfast, “Oh no, honey. I refreshments for her reading club.
have to wait until my husband gets here.” The nurse should say C. The patient refuses help from her child with
to the woman. meal preparation.
A. “Your husband died six year ago. Let me put milk D. The patient seeks other family member’s
on your cereal for you.” approval prior to preparing meals.
B. “I’ve told you several times that your husband is
dead. It’s time to eat now.” 36. A four- month- old infant who has acquired immune
C. “You’re going to have to wait a long time. Your food deficiency syndrome (AIDS) and is living with the
will get cold.” biological mother would receive the injectable form of
D. “Why do you think he’s alive? Why can’t you just eat polio vaccine for which of the following reasons?
your breakfast?” A. Improve absorption
B. Improved immunity
30. Which of the following findings would a nurse identify as C. Decreased viral shedding
indicative of septic shock in a patient? D. Decreased risk of anaphylaxis
A. Bradycardia
B. Flushed appearance 37. Which of the following parameters should be given
C. Cool, clammy skin priority when caring for a patient with hypoadrenalism
D. S3 gallop (Addison’s disease)?
A. Evaluating pulmonary function
31. The nurse should instruct a patient who is to receive digoxin B. Monitoring blood sugar
(Lanoxin) to report development of which of the following side C. Measuring blood pressure
effects? D. Assessing neurological status
A. Ringing in the ears
B. Loss of appetite 38. Which of the following comments, if made by the
C. Signs of bruising spouse of a patient who has been newly diagnosed with
D. Sensitivity to sunlight schizophrenia, would indicate that the spouse has a
correct understanding of the disorder?
32. A 16- year- old female who has cystic fibrosis and is sexually A. “I can’t wait for these illness- related
active asks a nurse, “Can I get pregnant?” The nurse’s problems to disappear”
response would be based on the understanding that cystic B. “My spouse and I will need ongoing
fibrosis psychiatric support in the community.”
A. causes sterility in females C. “I’ll be glad when my spouse becomes the
B. leads to a higher incidence of spontaneous abortion person I married again.”
C. may result in problems with infertility in females D. “My spouse will no longer live with me
D. does not affect the reproductive system because permanent hospitalization is
necessary.”
33. Which of the following instructions should a nurse give to a
patient who has history of venous leg ulcers in order to prevent 39. A physician has written all of the following orders for
recurrence? a patient who has a diagnosis of septic shock. Which
A. “Sit with your legs dependent whenever possible” order should the nurse carry out first?
B. “Use warm compresses on your legs in the evening” A. Obtain culture specimens
C. “Examine your legs for areas of redness every day” B. Initiate antibiotic therapy
D. “Keep your legs flexed when standing for long C. Insert indwelling urinary (Foley) catheter
periods” D. Apply antiembolism stockings

34. A woman, who is 30 weeks pregnant and attending the 40. A child presents with periorbital edema,
prenatal clinic, has symptoms of pregnancy- induced dark colored urine and decreased urine output. A
hypertension. Which of the following findings is indicative of this priority question for the nurse to ask when obtaining the
condition? history from the parent is.
A. The woman has been getting short of breath when A. “Has your child been diagnosed recently
climbing the second flight of stairs to her family’s with strep throat?”
apartment. B. “Does you child get short of breath when
B. The woman has had a craving for salty foods lately playing?”
Nursing Practice III
C. “Is there any history of liver disease in the family?” folic acid. Which of the following foods would a nurse
D. “Does your child seem to be more tired than usual?” encourage the child to eat?
A. Peas
41. When assessing a 14- year- old girl who has mittelschmerz, B. Spinach
a nurse would expect the girl to have which of the following C. Squash
symptoms? D. Carrots
A. Nausea and vomiting
B. Heavy menstrual flow 48. Which of the following instructions regarding skin
C. Low- grade fever and malaise care should a nurse give to a patient who is receiving
D. Lower abdominal pain radiation therapy?
A. “Cover the irradiated area with a light gauze
42. A 30- year- old primigravida at 38 weeks gestation is dressing.”
admitted to the hospital in labor. The woman and her husband B. “Rinse the irradiated area with normal
both attended education- for – childbirth classes. In the labor saline solution.
room, the husband is timing the frequency of his wife’s C. “Apply petroleum- based ointment to the
contractions. If he is timing the frequency accurately, he is treatment area.”
nothing the time from D. “Use a mild soap to cleanse the affected
A. the beginning of one contraction to the beginning of area.”
the next contraction
B. the beginning of one contraction to the end of that 49. The family you are caring for had difficult labor and
contraction an unexpected cesarean delivery. They voice their
C. the end of one contraction to the beginning of the displeasure with the way the situation was handled and
next contraction are threatening to sue. As the nurse caring for this
D. the end of one contraction to the peak of the next family, you will
contraction A. carefully document your care on the
patient’s chart
43. Because a woman is planning to breast- feed her infant, B. delegate routine care to other personnel
measures to prevent her nipples from becoming sore are C. go into the room only when called, to allow
discussed with her. Which of the following comments, if made for privacy
by the woman, would indicate that she under stood the D. contact the hospital legal advisor prior to
instructions? giving care
A. “I’ll use a nipple shield with every other breastfeed
during my first postpartum week.” 50. An infant born at 34 weeks gestation is at risk for
B. “I’ll cleanse my nipples with soap and water before respiratory synctial virus (RSV). When teaching the
each feeding.” family about health care promotion, what primary
C. “I’ll expose my nipples to the air several times a recommendation should the nurse make to the
day.” parents?
D. “I’ll apply an antiseptic cream to my nipples after A. “Avoid group settings of other children if at
each feeding.” all possible.”
B. “Limit visitation of the infant by anyone who
44. Which of the following laboratory result, if identified in a has a cold.”
patient who is experiencing vomiting and diarrhea, is most C. “Use good hand washing techniques.”
suggestive of hypovolemic shock? D. “Keep the baby out of drafts.”
A. Potassium, 5.6 mEq/ L
B. Hematocrit, 58% SITUATION: Diabetes mellitus is an endocrine
C. Hemoglobin, 11g/dL condition characterized by relative or absolute
D. Calcium, 6 mEq/ L insulin deficiency. Moreover, cycles of
hypoglycemia and hyperglycemia accompanies the
45. Nursing care for a patient who has polycythemia vera would disorder. Lifestyle modification and compliance to
focus on preventing medications and other treatments are necessary to
A. dysrhythmias improve patient’s prognosis.
B. hypotension
C. thrombosis 51. The nurse provides information to another diabetic
D. decubitus ulcers patient named Freda who is taking insulin, about the
signs of hypoglycemia. Which of the following signs
46. Which of the following concepts should a nurse emphasize should the nurse exclude in the information?
when conducting a community education program on reducing a. Body malaise
the risk of rape? b. Increasing agitation
A. Rape rarely occurs in rural areas c. Cool clammy skin
B. The very young and the very old are usually safe d. Increased
from rape e. urinary output
C. People who walk in groups are less likely to be
raped. 52. Freda is ordered to receiveHumulin Regular insulin
D. Rape is a response to sexual need. 8 units subcutaneously at 7:30 AM. The nurse would be
47. A child who has sickle cell disease should eat foods rich in most alert to signs of hypoglycemia at what time during
Nursing Practice III
the day? 58. Another client is brought to the ER in an
a. 9:30 AM to 11:30 AM unresponsive state, and a diagnosis of hyperglycemic
b. 11:30 AM to 1:30 PM hyperosmolar nonketotic syndrome (HHNKS) is made.
c. 1:30 PM to 3:30 PM The nurse would immediately prepare to initiate which
d. 3:30 PM to 5:30 PM of the following anticipated physician’s orders? (2)
a. Endotracheal intubation
53. A nurse knows that which of the following foods/ drinks can b. 100 units of NPH insulin
be given to Freda to raise her blood glucose level at a sooner c. Intravenous infusion of normal saline
time if ever she suffers from hypoglycemia? d. Intravenous infusion of sodium bicarbonate
a. Crackers
b. Apple juice 59. The nurse caring for these patients with DKA and
c. Chocolate bar HHNKS is preparing a plan of care. She chooses the
d. Milkshake priority nursing diagnosis which is:
a. Deficient fluid volume
54. Suppose Freda’s blood glucose level rises to 200 mg/dL, b. Dysfunctional family processes
and the doctor ordered her to receive 30 units of NPH insulin at c. Imbalanced nutrition: more than body
7:00 AM. Knowing that NPH insulin peaks at a specified time requirements
interval following administration, the nurse is expected to feed d. Knowledge deficit: disease process and
Freda at? treatment
a. 8:00 AM
b. 11:00 AM 60. The home care nurse is developing a plan of care
c. 3:00 PM for the patient with type 1 diabetes mellitus who has
d. 7:00 PM also developed gastroenteritis. To maintain food and
fluid intake, the nurse plans to:
55. A nurse is teaching a Freda about general hygienic a. Offer water only until the client is able to
measures for foot and nail care. Which instructions should the tolerate solid foods.
nurse provide to her? b. Withhold all fluids until vomiting has ceased
1 Wear knee-high hose to prevent edema. for at least 4 hours.
2 Soak and wash the feet daily using cool water. c. Encourage the client to take 8 to 12 ounces
3 Use commercial removers for corns or calluses. of fluid every hour while awake.
4 Use OTC preparations to treat ingrown nails. d. Maintain a clear liquid diet for at least 5 days
5 Apply lanolin or baby oil if dryness is noted along the feet. before advancing to solids to allow
6 Pat the feet dry thoroughly after washing and dry well between inflammation of the bowel to dissipate.
toes.
a. 1, 3, 6 SITUATION: Jean is a nurse assigned in the
b. 3, 5 neurologic ward of La Trinidad Doctor’s Hospital.
c. 5, 6 She is expected to be knowledgeable and
d. 2, 5, 6 dexterous in holistic care of patients with different
neurologic conditions.
SITUATION: Diabetes mellitus (DM), if improperly managed
may lead to numerous complications. Type I DM results to 61. Jean is performing a physical assessment on a
diabetic ketoacidosis while Type II DM leads to male client to test his reflexes. What action would the
Hyperglycemic Hyperosmolar Nonketotic Syndrome nurse take to assess the pharyngeal reflex?
(HHNKS). The following questions apply. a. Ask the client to swallow
b. Ask the client to extend the neck
56. Lourdes, a patient with a diagnosis of diabetic ketoacidosis c. Ask the client to speak while palpating his
is being treated in the emergency room. Which finding would a Adam’s apple
nurse expect to note as confirming this diagnosis? d. Stimulate the back of the throat
a. Increase in respiration and increase in pH
b. Decrease in respiration and increase in pH 62. Nurse Jean is conducting a routine examination of
c. Elevated blood glucose level and low plasma motor reflexes to another patient. Using a reflex
bicarbonate level hammer, she was able to elicit an ankle reflex. She
d. Elevated blood glucose level and high plasma noted that the reflex was more brisk than average. She
bicarbonate level will determine a grade of?
a. 4+
57. Lourdes’ initial blood glucose level was 950 mg/dL. A b. 3+
continuous intravenous infusion of regular insulin is initiated, c. 2+
along with intravenous rehydration with normal saline. The d. 1+
serum glucose level is now 240 mg/dL. The nurse would next
prepare to administer: 63. Jean is caring for a client with a head injury. She is
a. Ampule of 50% dextrose aware that Glasgow Coma Scale (GCS) is vital in
b. NPH insulin subcutaneously patient assessment. She correctly identifies the best
c. Intravenous fluids containing 5% dextrose parameters of GCS as:
d. Phenytoin (Dilantin) for prevention of seizures a. E4, V5, M6
b. E5, V4, M6
Nursing Practice III
c. E5, V6, M4 The nurse developing a plan of care for this patient
d. E4, V6, M5 should incorporate which intervention in the plan?
a. Change the client’s positions slowly.
64. She is now monitoring the client for decerebrate posturing. b. Assess the client for decreased sensation
Which of the following is characteristic of this type of posturing? to touch. c. Assess the client for decreased
a. Flexion of the extremities sensation to vibration.
b. Extension of the extremities d. Inform the client about loss of motor function
c. Upper extremity extension with lower extremity and decreased pain sensation.
flexion
d. Upper extremity flexion with lower extremity 70. The nurse caring for patients with spinal cord
extension injuries should be familiar that the standard
pharmacologic treatment for spinal cord injuries,
65. Jean is assessing a client with a brainstem injury. In addition regardless of the cause or type is:
to performing the Glasgow Coma Scale, she plans to: a. High-dose IV Azathioprine
a. Perform arterial blood gases. b. High-dose IV Solu-Medrol
b. Assist with a lumbar puncture. c. High-dose IV Immunoglobulin
c. Perform a pulmonary wedge pressure. d. High-dose IV Tegretol
d. Check cranial nerve functioning and respiratory rate
and rhythm. SITUATION:Electrical burns causes 10% lethality
and leads to formation of entrance and exit wounds.
SITUATION:Spinal cord injury (SCI) is primarily an injury of Moreover, electrical burns from 1000V or more
young adult males and 50% of those injured are between leads to spinal cord injury. The nurse caring for
16 and 30 years of age. Motor vehicle crashes accounts for patients with spinal cord injury must be well versed
48% or reported cases of SCI. Other causes of SCI include in anticipating and managing life threatening
falls (23%), gunshot wounds (14%), recreational sporting complications of the condition.
activities (9%), and other events (4%).
71. The nurse is caring for a patient with a T3 spinal
66. A patient was rushed into the ER after sustaining multiple cord injury who also has spinal shock. The nurse
traumatic injuries after being involved in a car crash. The doctor performs an assessment on the client, knowing that
confirmed C4 spinal cord injury after series of imaging studies. which assessment will provide the best information
The nurse assess the patient and notes intact motor and about spinal shock?
sensory function below C4 level. She knows that the patient a. Hypertension, Bradycardia, Bradypnea
sustained: b. Hypotension, Tachycardia, Tachypnea
a. Incomplete spinal cord injury c. Hypotension, Bradycardia, Tachypnea
b. Complete spinal cord injury d. Hypertension, Tachycardia, Bradypnea
c. Circumferential spinal cord injury
d. Impartial spinal cord injury 72. The nurse anticipates that the most likely
intravenous (IV) fluid to be prescribed for the patient
67. The American Spinal Injury Association (ASIA) provides would be:
classification of SCI according to degree of motor and sensory a. Dextran
function present after injury. The nurse correctly interprets ASIA b. 0.9% normal saline
impairment scale B as: c. 5% dextrose in water
a. Motor function is preserved below the neurologic d. 5% dextrose in 0.9% normal saline
level, and atleast half of key muscles below the
neurologic level have a muscle grade of 3 or greater 73. To determine whether the patient is recovering from
b. Motor function is preserved below the neurologic spinal shock, which assessment finding would she
level, and more than half of key muscles below the monitor?
neurologic level have a muscle grade of less than 3 a. Reflexes
c. Sensory but no motor function is preserved below b. Pulse rate
the neurologic level and includes sacral segments S4- c. Temperature
S5 d. Blood pressure
d. No motor or sensory function is preserved in the
sacral segments S4-S5 74. After the patient’s spinal shock resolved, she
developed autonomic dysreflexia. The nurse includes
68. The patient also manifests ipsilateral paralysis with which intervention in the plan to prevent autonomic
ipsilateral loss of touch, pressure and vibration and contralateral dysreflexia (hyperreflexia)?
loss of pain and temperature. The nurse is aware that the a. Administer dexamethasone (Decadron) as
patient was accurately diagnosed by the doctor if he wrote what per the physician’s prescription.
medical diagnosis in the chart? b. Assist the client to develop a daily bowel
a. Central Cord Syndrome (CCS) routine to prevent constipation.
b. Brown-Sequard Syndrome (BSS) c. Teach the client that this condition is
c. Anterior Cord Syndrome (ACS) relatively minor with few symptoms.
d. Arnold-Chiari Syndrome d. Assess vital signs and observe for
hypotension, tachycardia, and tachypnea.
69. Another patient was diagnosedwith anterior cord syndrome.
Nursing Practice III
75. If preventive measures initiated by the nurse are ineffective, working in National Kidney and Transplant Institute
and the patient experiences severe pounding headache with (NKTI). She is assigned to care for patient with
hypertension, the nurse anticipates the doctor to prescribe: different renal problems.
a. Sympathomimetic drugs
b. Corticosteroids 81. Nurse Sarah interviews a client named Alben. He
c. Neuromuscular junction (NMJ) blockers claimed that he developed acute renal failure (ARF)
d. Ganglionic blocking agents after sustaining multiple physical injuries from a
vehicular accident eight weeks ago. Nurse Sarah
SITUATION: Myasthenia Gravis is a neuromuscular disease interprets that this type of renal failure is due to:
characterized by weakness and abnormal fatigue of the a. Prerenal cause
voluntary muscles. This is caused by insufficient secretion of b. Postrenal cause
acetylcholine, excessive secretion of cholinesterase, and c. Intrarenal cause
unresponsiveness of muscle fibers to acetylcholine. d. Extrarenal cause

76. Edrophonium (Tensilon) 2 mg is administered IV to confirm 82. Nurse Sarah noticed that Alben’s doctor wrote in his
the diagnosis of myasthenia gravis. Which of the following progress notes that Alben is on the oliguric phase of
indicates that the client has this condition? acute renal failure. Nurse Sarah monitors him for which
a. Joint pain following the administration of the following?
b. Feeling of faintness, dizziness, hypotension, and a. Hypernatremia, Hypokalemia and CNS
signs of flushing depression
c. A decrease in muscle strength within 30 to 60 b. Pulmonary edema and ECG changes
seconds after the administration c. Kussmaul’s respiration, acidosis and
d. An increase in muscle strength within 30 to 60 hypotension
seconds after the administration d. Urine with high specific gravity and low
sodium concentration
77. In caring for a client with myasthenia gravis, the nurse
should be alert for which of the following manifestations of 83. The doctor ordered for close monitoring of Alben’s
myasthenic crisis? serum electrolyte levels. The result revealed that he has
1 Bradycardia a serum potassium level of 6.8 mEq/L. Nurse Sarah
2 Increased diaphoresis would plan which of the following as a priority action?
3 Decreased lacrimation a. Allow an extra 500 mL fluid intake to dilute
4 Bowel and bladder incontinence the electrolyte concentration.
5 Absent cough and swallow reflex b. Encourage increased intake of fruits and
6 Sudden marked rise in blood pressure vegetables in the diet.
a. 1, 2, 3, 6 c. Place the client on a cardiac monitor.
b. 3, 4, 5, 6 d. Check the sodium and magnesium level.
c. 2, 4, 5, 6
d. 1, 2, 5, 6 84. Patient Alben exhibited an unexpected increase in
urinary output to about 150ml/hr after a week. Nurse
78. The doctor ordered for the client to take pyridostigmine Sarah knows that he has entered the third phase of
(Mestinon). The nurse assesses the client for side effects of the acute renal failure. Nursing actions throughout this
medication and asks the client about the presence of: phase include observation for signs and symptoms of:
a. Mouth ulcers a. Hypervolemia, hypokalemia, and
b. Muscle cramps hypernatremia.
c. Feelings of depression b. Hypovolemia, hyperkalemia and
d. Muscle weakness hyponatremia
c. Hypovolemia, hypokalemia and
79. The client suddenly experiences a prolonged period of hyponatremia
weakness, and the physician prescribes an Edrophonium d. Hypervolemia, hyperkalemia, and
(Tensilon) test. A test dose is administered and the client hypernatremia.
becomes weaker. The nurse interprets this test result as:
a. Normal 85. Nurse Sarah makes a nursing care plan for patient
b. Positive Alben this time. She knows that among the following
c. Myasthenic crisis nursing diagnoses, she will prioritize?
d. Cholinergic crisis a. Altered renal tissue perfusion
b. Fluid volume deficit
80. The physician confirmed that the client is in a cholinergic c. Fluid Volume excess
crisis. Which of the following medications would the nurse d. Activity intolerance
expect the physician to order?
a. Pyridostigmine SITUATION: The use of renal replacement therapies
b. Neostigmine becomes necessary when the kidneys can no
c. Atropine longer remove wastes, maintain electrolyte and
d. Pilocarpine fluid balance such as in End-Stage Renal Disease
(ESRD). The main renal replacement therapies
SITUATION: Nurse Sarah is a certified nephrology nurse include various types of dialysis and kidney
Nursing Practice III
transplantation. diagnosed with nephrotic syndrome. She will
expect the patient to manifest the following apart from:
86. Nurse develops a care plan for a patient named Vinci, who a. Hyperlipidemia
has chronic renal failure. He is receiving hemodialysis via an b. Hematuria
arteriovenous (AV) fistula in the right arm. Nurse Sarah includes c. Hypoalbuminemia
which interventions in the plan, to ensure protecting the AV d. Albuminuria
fistula apart from?
a. Palpate for bruit and auscultate for thrills every 4 92. Nurse Alexis accurately incorporates these
hours. interventions in the plan of care apart from:
b. Check for bleeding and infection at hemodialysis a. Monitoring patient’s urine for specific gravity
needle insertion sites. and albumin
c. Instruct the client not to carry heavy objects or b. Preparing a regular diet with added salt is
anything that compresses the extremity. the child is in remission
d. Instruct the client not to sleep in a position that c. Monitoring for vital signs, I & O, and daily
places his or her body weight on top of the extremity. weights
d. Monitoring the patient closely for signs of
87. During the dialysis, Vinci suddenly develops restlessness, infection
nausea and vomiting, and fluctuating level of consciousness.
Nurse Sarah is abreast with the disease process if she assumes 93. Suppose the child developed massive edema,
that her patient’s signs and symptoms subsisted as a result of: nurse Alexis will anticipate the doctor to order:
a. High levels of serum sodium, potassium, a. Fresh frozen plasma
magnesium and phosphorus b. Packed RBC
b. Fluid accumulation and increased intracranial c. Cryoprecipitate
pressure d. Human albumin
c. Rapid cerebral fluid shifts
d. Multiple organ failure 94. Nurse Alexis is caring for another pediatric patient
showing signs of bruising, anuria, and seizures. She
88. Four days after, Vinci is again scheduled for hemodialysis correctly anticipates the medical diagnosis of this new
this morning, and is due to receive a daily dose of enalapril patient to be:
(Vasotec). Nurse Sarah plans to administer this medication: a. Acute Glomerulonephritis
a. During dialysis b. Good Pasture Syndrome
b. Just before dialysis c. Hemolytic-Uremic Syndrome
c. The day after dialysis d. Nephritic Syndrome
d. Upon return from dialysis
95. Nurse Alexis went to the laboratory to follow-up the
89. Patient Vinci is prescribed to be on a fluid restriction atmost result of serum diagnostic studies done for the patient.
1500 mL per day. Nurse Sarah best plans to assist him with The result should reveal:
maintaining the restriction by: a. Decreased hemoglobin and hematocrit
a. Removing the water pitcher from the bedside level
b. Using mouthwash with alcohol for mouth care b. Elevated hemoglobin and hematocrit level
c. Prohibiting beverages with sugar to minimize thirst c. Elevated BUN but decreased serum
d. Asking the client to calculate the IV fluids into the creatinine level
total daily allotment d. Decreased BUN but elevated serum
creatinine level
90. Nutrition and fluid therapy are essential to minimize Vinci’s
uremic symptoms and fluid and electrolyte imbalance. Nurse SITUATION: Mang Palos is a 58-year old with a
Sarah has an accurate understanding of the goals of long-standing history of alcoholism. He started
management for patients with chronic renal failure if she binge drinking since he was 22 years old. On Friday
incorporates in the plan pf care the following interventions apart the 13th, he was admitted to the hospital with
from: ascites and difficulty of breathing. The doctor’s
a. Protein intake restriction to about 1.2-1.3g/kg ideal tentative medical diagnosis was liver cirrhosis.
body weight per day
b. Sodium restriction to 2-3g/day 96. The nurse performs which intervention as a priority
c. Keeping interdialytic weight gain under 2.0 kg measure to assist Mang Palos with breathing?
d. An amount equal to the daily urine output plus a. Repositions side to side every 2 hours
500mL/day is the ideal fluid restriction b. Elevates the head of the bed 60 degrees
c. Auscultates the lung fields every 4 hours
SITUATION: Microorganisms mutated and developed d. Encourages deep breathing exercises
resistance to most antibiotics over time. A number of renal every 2 hours
disorders caused by gram-positive bacteria (GABHS) pose
a threat to vulnerable children and to the population in 97. To confirm the doctor’s tentative diagnosis, he
general. The following questions apply. scheduled Mang Palos to have a liver biopsy. Before
the procedure, it is most important for the nurse to
assess MangPalost’:
[Link] Alexis is assigned to care for a pediatric patient a. Tolerance for pain
Nursing Practice III
b. Allergy to iodine or shellfish C. Grounding pad is connected to grounding
c. History of nausea and vomiting cable properly placed under the patent’s
d. Ability to lie still and hold the breath buttocks
D. Electro cautery pencil is made easily
98. Since liver biopsy may pose a risk to the patient, the nurse available each time the surgeon uses it
is aware that what additional precautions must she observe
prior to the procedure? 3. The surgeon passed the specimen to the scrub
a. Check liver function test result nurse. Which of the following is the correct action of the
b. Check coagulation test result scrub nurse?
c. Check BUN & serum Creatinine levels A. Place specimen in a basin moistened with
d. Check patient’s lipid profile saline solution
B. Wipe specimen with sponge
99. Two days after admission, series of laboratory tests are C. Wipe specimen with surgical sponge (OS)
ordered and the nurse discovers that Mang Palos’ serum D. Pass the specimen to the circulating nurse
ammonia is very high. The doctor confirmed that Mang
Palos’ condition progressed to hepatic encephalopathy 4. The surgeon asked a suture to close the peritoneum.
secondary to chronic liver cirrhosis. Sooner, Mang Palos Which of the following should have been done by the
begins to experience a tonic-clonic seizure. The nurse scrub nurse before suture is handed to the surgeon?
should take which of the following actions? A. Specimen passed to the circulating nurse
1 Restrain the client. B. Needle holder passed to the surgeon
2 Turn the client to the side. C. Needle mounted on the needle holder
3 Maintain the client’s airway. D. “Surgical count” completed
4 Place a padded tongue blade into the client’s mouth.
5 Loosen any restrictive clothing that the client is wearing. 5. The surgeon tells the scrub nurse that the procedure
6 Protect the client from injury, and guide the client’s done was total abdominal hysterectomy with bilateral
movements. sphingo oophorectomy. The scrub nurse understands
a. 1,2,5,6 that the specimen she received would consist of which
b. 3,4,5,6 of the following organs?
c. 2,3,4,5 A. Right and left ovaries, uterus, a fallopian
d. 2,3,5,6 100. tube
B. Uterus, fallopian tube, ovary, and urinary
100. The nurse is assisting the Mang Palos to fill out the bladder
dietary menu. The nurse advises the client to avoid which C. Uterus, right and left fallopian tubes, and
of the following entree items that could aggravate the ovaries
client’s condition? D. Uterus, urinary bladder, two ovaries, right
a. Soybean curd and left fallopian tubes
b. Tomato soup
c. Fresh fruit plate Situation: Jasmine is working in the cardiac unit with a
d. Vegetable salad nurse floater. Together, they made their rounds while
Kristine assessed the nurse’s knowledge on the
commonly used cardiac drugs.
REFRESHER PRE BOARD EXAMINATION
NP III: CARE OF CLIENT WITH PHYSIOLOGIC AND 6. Jasmine asked the floater why nitroglycerin is given
PSYCHOSOCIAL INTERACTION PART A: to a client with angina. The correct response of the
nurse is that nitroglycerine:
A. increases preload
B. increases afterload
Situation: Florenda, 52 years old, was transported to the
C. dilates the veins
Operating Room for Total Abdominal Hysterectomy
D. constricts the arteries
1. The scrub nurse ensures that aseptic technique is maintained
7. Being new in the cardiac unit, Jasmine emphasized
throughout the procedure. When she serves the right gloves to
to the floater that the long standing hallmark in nursing
the surgeon, which of the following is the correct technique to
intervention for clients taking Digoxin (Lanoxin) is:
be followed by the scrub nurse?
A. Take the apical pulse for one full minute
A. Keep thumbs away from the cuff
B. Monitor intake and output hourly
B. Pick up the gloves and place the palm towards you
C. Check the blood pressure reading with the
C. Maintain fingers of the gloves facing you
same BP apparatus
D. Slide the gloves by holding under the glove cuff and
D. Palpate the radial pulse for one full minute
spread to create wide opening
8. Jasmine tests the floater’s readiness for the
2. The surgeon uses electrosurgical equipment to cauterize
assignment by asking this question “When you find a
blood vessels. Which of the following nursing activity should
client in cardiac arrest, which of the following drugs
have been done by the circulating nurse to ensure safety?
would you be ready to administer?” The correct answer
A. Correctly drape electro cautery cable and cord
of the nurse floater is:
B. Electro cautery equipment is placed appropriately
A. Atropine sulfate
at the back of the surgeon
Nursing Practice III
B. Lidocaine 2% identified by the nurse. The following are acceptable
C. Morphine sulfate indicators of excess fluid volume, EXCEPT:
D. Epinephrine A. Intake and output record
B. Compliance to sodium restriction
9. One of the hypertensive clients assigned to the nurse floater C. Vital signs reading
is on Captopril (Capoten), an Angiotensin Converting Enzyme D. Weight changes
(ACE) Inhibitor. Which of the following nursing interventions
should be included in the plan of care? Situation: Conrado sought admission for acute gout of
A. Monitor sugar level the right foot. Nurse Karmela was in-charge of the
B. Observe complete bed rest client. 16. Nurse Karmela performs initial assessment.
C. Measure intake and output carefully Which of the following types of joint pain supports the
D. Monitor for bruising, petechiae, or bleeding physician’s diagnosis?
A. Bilateral
10. The nurse floater is instructing one of her clients on B. Symmetrical
Clopidogrel bisulfate (Plavix). Which of the following indicates C. Polyarticular
that her client understands the effect of the drug? D. Monoarticular
A. “I should slow down on my carbohydrate intake.”
B. “I should take liberal amount of fluid while on this 17. Which of the following examinations would the
drug.” nurse expect to be ordered?
C. “I should use caution in taking over the counter A. Bone marrow aspiration
drugs that might cause bleeding.” B. Knee-jerk examination
D. “I may gain weight while on this drug.” C. Synovial fluid analysis
D. Bone density
Situation: Virgilio, 40 years old, was admitted for check- up.
He was diagnosed with essential hypertension a year ago. 18. The client is for 24- hour urine collection for uric acid
Upon admission, his blood pressure is 170/90, slightly determination. To have a reliable result, the nurse
dysneic, dizzy and with blurred vision. anticipates which diet prescription prior to the
examination?
11. The admitting nurse understands that increased diastolic
pressure indicates which of the following?
A. Generalized vasoldilation
B. Loss of elasticity of the aorta and arteries 19. During the acute attack, the pain of the affected foot
C. Increased peripheral resistance and increased can be so intense that even the weight of the linen can
workload of the left ventricle be unbearable. The MOST appropriate nursing
D. Widening of the lumen of the arteries intervention is to:
A. Apply splint on the affected
12. Virgilio has been taking Atenolol (Tenormin) 50 mg. orally B. Place a foot cradle on the bed
once daily. The nurse understands that the specific action is to C. Elevate the affected foot
block: D. Apply bandage around the affected foot
A. Beta receptor stimulation of the heart
B. Effects of the angiotensin II on receptors 20. Colchicine is prescribed during the acute attack
C. Calcium entry into the myocardium cells phase. Nurse Karmela is aware that the action of the
D. Alpha receptors in vascular smooth muscle drug is to:
A. Provide fast symptomatic relief
13. Hydrochlorothiazide (Hytaz) 12.5mg 1 tablet orally once B. Lower serum uric acid
daily has been prescribed for the client. The specific action of C. Block the conduction of pain sensation
this thiazide diuretic is to: D. Interfere with the inflammation response of
A. Promote excretion of sodium and chloride be uric acid crystals in the joints
decreasing absorption in the distal tubule
B. Increase osmotic draw of the urine inhibiting water Situation: Henry, 65 year old underwent Transurethral
re absorption Prostatectomy (TURP). He was admitted to the Post
C. Inhibit sodium and chloride re-absorption in the Anesthesia Care Unit (PACU). The following questions
ascending loop of Henle apply.
D. Inhibit sodium- potassium exchange in the distal
tubule 21. The Operating Room (OR) nurse endorsed the
ongoing intravenous infusion of Dextrose 5% Ringer’s
14. From the results of the laboratory test prescribed by the Lactate, 500ml, running at 40ml per hour at the level of
physician, which of the following will the nurse consider as an 300ml. The nurse who received the client in PACU at
indication of impaired renal function? Elevated levels of; 1500H,would expect the present infusion to be
A. Creatinine consumed at:
B. Hematocrit A. 2400H
C. Potassium B. 0100H
D. Total Cholesterol C. 2200H
D. 0300H
15. “Risk for excess fluid volume” is a nursing diagnosis
Nursing Practice III
22. The client has an indwelling triple catheter to continuous in periorbital fluid?
bladder irrigation (CBI) with Normal Saline Solution (NSS) A. Cover eyes
infusing at 200ml per hour. After four hours, the nurse emptied B. Administer artificial tears as prescribed
the drainage bag and obtained and output of 1,080 ml. Which C. Elevate head at 45 degrees
of the following will the nurse record as the client’s urinary D. Use cool moist eye compress
output?
A. 180ml 29. The client is scheduled for subtotal thyroidectomy.
B. 1,080 ml Strong iodine solution is prescribed. The nurse
C. 800ml prepares to administer the medication knowing that
D. 280ml therapeutic effect of the medication is to:
A. increase thyroid hormone
23. The surgeon’s order reads: “Maintain traction on the B. replace the thyroid hormone
indwelling triple lumen catheter.” Which of the following is the C. suppress thyroid hormone production
MOST appropriate action of the nurse? D. prevent oxidation of iodide
A. Tape the catheter to the abdomen and keep client
in supine position 30. Following thyroidectomy, the nurse notes the very
B. Pull the catheter taut and tape to the thigh weak and hoarse voice of the client. Which nursing
alternately every 6 hours intervention is most appropriate at this time?
C. Instruct the client to keep both legs together and A. Caution the client not to force herself to talk
extended all the time B. Notify the surgeon immediately
D. Pull the catheter taut, tape to one thigh and keep C. Reassure the client this is usually a
the leg extended all the time temporary condition
D. Offer the client warm NSS gargle
24. The nurse understands that Normal Saline Solution (NSS)
is used for CBI to prevent which of the following? Situation: Nurse Remy is assigned in the pediatric ward.
A. Later intoxication She was in charge of a 20 month-old child, Jayson,
B. Elevation of specific urine gravity diagnosed with intussusception 31. Nurse Remy is
C. Dehydration reviewing the chart of Jayson. What will she expect to
D. Formation of stones read as symptoms of her client?
A. Foul-smelling, watery stool
25. The nurse assigned to the client monitored and maintained B. Nausea and vomiting
the CBI rate of NSS at 200 ml per hour. This intervention is C. Projectile vomiting
critical because it: D. Crampy and intermittent severe abdominal
A. Washes out remaining fragments of stones pain
B. Avoids postoperative infection
C. Decreases bleeding and keep the bladder free from 32. A nursing student was with Nurse Remy. She wants
blood clot to fully understand the case and so she asks the nurse
D. Maintains adequate hydration. to describe the case. The appropriate definition of
intussusception is the:
Situation: The nurse is assigned to admit a 27 year old female A. herniation of the small intestine into the
patient with protruding eyeballs and an enlarged neck. abdominal opening
Physician’s diagnosis is Grave’s disease. B. telescoping of bowel into the adjacent
segment
26. The nurse performs initial assessment and confers with the C. Mechanical obstruction from the
medical resident. Which of the following will the nurse consider inadequate motility of the small intestine
as the correct description of Grave’s disease? D. protrusion of the bowel through an
A. Antibodies bind to TSH receptors causing increased abdominal opening
thyroid hormone
B. Multiple thyroid nodules resulting in thyroid hyper 33. Nurse Remy prepares for the insertion of
function nasogastric tube (NGT). She understands that the
C. Increased in thyroid secretion of T3 cause unknown primary indication of NGT in Jayson’s case is for:
D. Uncontrolled secretion of T3 and T4 form benign A. irrigation
thyroid tumor B. feeding
C. medication administration
27. During the interview, nurse found out that the client takes D. decompression
Prophylthiouracil (Prophyl-Thracil) daily. Which of the following
is the specific action of this drug? 34. While making her rounds, Jayson’s mother showed
A. Beta-adreneric blocking drug nurse Remy the child’s brown stool. What is the
B. Decreases blood flow to the thyroid gland appropriate action of the nurse?
C. Destroys thyroid cells A. bring the stool to the laboratory
D. Blocks thyroid hormone production B. instruct the mother to dispose the stool
properly
28. The nurse identified the nursing diagnosis “Disturbed C. document the characteristics of the stool
sensory perception related to exophthalmus.” Which of the D. reports the passage of stool to the physician
following nursing interventions is intended to promote decrease
Nursing Practice III
35. Nurse Remy reviewed a certain literature where the Situation: Statistics from nursing research show that
classical triad of pain, palpable sausage-shaped abdominal structured health teaching programs have resulted in
mass and currant jelly-like stool occurred only in 15% of modified client behavior and improved health status.
children when they are seen initially. Which of the following is
nurse Remy’s correct interpretation of this finding, if there are
60 sick children as the population? 41. Nurses are aware that normal aging affects the
A. The classic triad of symptoms was observed in 9 changes in client’s cognition. Therefore, when teaching
out of 60 sick children a 72 year old diabetic client how to administer insulin,
B. Approximately 15 sick children experienced the the nurse should:
classic triad of symptoms A. demonstrate faster because the client tires
C. When seen initially, 30 sick children did not show easily
any of the symptoms B. present all information at one time
D. Among the 60 children, there were 25 who showed C. demonstrate by using audio visual
the classic triad of symptoms technology
D. frequently repeat information for
Situation: The primary goal of nursing research is to develop a reinforcement
scientific knowledge base for nursing practice. Nursing
research includes all students concerning nursing practice, 42. Considering the sensory changes in the elderly,
nursing education, and nursing administration. which of the following techniques would be most helpful
to enhance client’s recall?
36. Researcher Bea conducted a research of the effect of using A. use of colors to emphasize data and dose
an agent in giving oral hygiene in the nursing care of the acutely B. use properly labeled individual containers
ill surgical patients. In this type of study, it necessary to: C. highlight date and dose
A. conduct a pilot study D. label all medications with number in bold ink
B. administer treatment
C. conduct interview 43. When teaching a client drug self-administration,
D. develop a questionnaire which of the following behaviors reflect that the client is
not ready to learn?
37. Of the following listed designs below, which one would allow A. Arranges the medication in the container
the researcher to have the most confidence that the oral care provided for
with agent is effective in helping acutely ill surgical client attain B. Hears without reaction
health outcome? C. Agrees to schedule of teaching
A. One-shot case study D. Notes medication, dose and time
B. Non-equivalent control group design
C. Post-test only control group design 44. Modifying the teaching program because the
D. One-group pre-test post-test group design learner has difficulty in comprehending involves which
appropriate nursing action?
38. A team of researchers conducted a study on the relationship A. postponing the teaching until client’s
of the completed surgical cases and the extent of performance condition improves
of standard competencies among level 3 nursing students B. contacting family members to assist in the
assigned in the Operating Room, in correlational study, the goal development to learn
researcher examines the: C. changing the terms in the teaching
A. questionnaire used to collect data from large pamphlet so that the learner can understand it
samples D. altering the content of the program
B. difference between two correlated groups
C. relationship between or among two or more 45. Nursing actions that can be used to motivate clients
variables learn the health programs include all of the following
D. cause and effect relationship except:
A. negative criticism is emphasized at once
39. The statistical tool that is used in determining the magnitude B. the establishment of realistic goals based
and direction of the relationship between two variables is: on individual client needs
A. Test of relationship C. creation of a conducive atmosphere for
B. Analysis of variance client’s privacy
C. Pearson r coefficient of correlation D. feedback when a client has been
D. Spearman rho coefficient of correlation unsuccessful

40. A researcher conducted a study on assessment of the Situation: Integral to quality management in the
psychosocial problems of cancer patients in Metro Manila. Operating Room is the observance of the basic
Which of the following instruments was used to collect data from principles and practices to establish and maintain
large samples? a sterile field by the sterile team involved in the
A. Descriptive statistics surgical intervention.
B. Inferential statistics
C. Questionnaire and interview 46. Once a scrubbed personnel dons a sterile gown and
D. Controlled laboratory setting gloves, he/she is considered “sterile”. This connotes
that he/she can:
Nursing Practice III
A. assist in positioning the client for surgery 51. Nurse Lulu reads the chart and finds out that NGT
B. touch sterile instrument on the sterile field placement was ordered for her patient. Nurse Lulu
C. hand suture as needed to the scrub performs the procedure correctly if she does the
D. “prep” the surgical site following except:
A. Tilts the patient’s nose upward before
47. The assistant surgeon accidentally contaminated his gloves inserting the tube.
while adjusting the retractor. As a perioperative nurse you know B. Asks the patient to swallow when the tube
that there are two methods that the surgeon can choose from. is in the nasopharynx.
What are these methods? C. Prepare the patient NPO 6-8 hours prior to
1. Change the contaminated gloves by the closed glove the insertion.
technique D. Apply water soluble lubricant at the tip of
2. Change the contaminated gloves using the open glove the tube.
technique
3. One member of the surgical sterile team is to glove the 52. After the procedure, the nurse checks if the tube is
assistant surgeon properly placed. She is correct of she states that the
4. The circulating nurse the sterile gloves to the assistant most accurate method of checking tube placement is:
surgeon A. pH measurement of the aspirate
A. 3 and 4 B. Air auscultation
B. 1 and 2 C. Visual assessment of the aspirate
C. 1 and 3 D. X-ray visualization
D. 2 and 3
53. Patient Zyra was about to take her lunch. Before the
48. The scrub nurse aids the assistant surgeon apply the sterile administration of osteorized food, the tube must be
drape. The scrub nurse understands that once the drapes are irrigated. Nurse Lulu has an accurate understanding of
positioned over the prepped incision site, the drapes must not the situation if she uses this fluid in tube irrigation:
be: A. Bottled water
A. marked B. Tap water
B. folded C. Normal saline solution
C. aligned D. D5LRs
D. moved
54. Enteral feeding poses patients receiving it to various
49. You are circulating in an Exploratory Laparotomy for a complications. Appropriate interventions must done for
ruptured appendicitis. The scrub nurse asks for “normal saline the following except:
solution (NSS) wash”. You immediately opened one liter of NSS A. Diarrhea
and began to pour to the sterile basin of the scrub nurse. Before B. Pasty, unformed stool
you can empty the NSS container, the scrub nurse signal you C. Constipation
“enough”. What is your appropriate action with the remaining D. Hyperglycemia
NSS?
A. Discard the remaining NSS 55. Zyra who was in NGT was prescribed a timed-
B. Pour the remaining NSS to another sterile basin in release tablet. What action of the nurse indicates the
the back table she had an accurate understanding of the situation
C. Cover the remaining NSS bottle aseptically right upon giving the drug?
away A. Powderized the tablet and dissolve in water.
D. Transfer the remaining NSS to smaller sterile B. Give it as prescribed.
container C. Call the physician to change the medication
D. Consult the pharmacist for an alternative
50. Immediately before opening and presenting any sterile item form of the drug.
to the sterile field, the circulating nurse should inspect for which
of the following indicators? Situation: Mr. John Skarner, a 57 year-old lawyer was
1. Package integrity confined after complaining persistent and productive
2. Date when manufactures cough accompanied by shortness of breath. History
3. Sterilization indicator was taken and it revealed that he started smoking at the
4. Expiration date age of 15 and was able to consume 10 cigarettes in a
5. Purchase price day.
6. Device specification
A. 1,2,3,5 56. Based on the situation, how many pack years does
B. All of these Mr. Skarner have?
C. 1,3,4 only A. 42 years
D. 1,2,3,6 B. 28years
C. 21 years
Situation: Zyra, a 32 year old woman was rushed to the nearest D. 36 years
community hospital after obtaining burns in the anterior chest,
both upper extremities and half of her face. Nurse Lulu was 57. The patient was diagnosed of Chronic Bronchitis
assigned to her. has a correct understanding of the situation if she states
that Chronic bronchitis is the presence of cough and
Nursing Practice III
sputum production for how long? 63. As you make your rounds, you noticed that there
A. at least 2 months in each 3 consecutive years are implants in the patient’s bed. Initially, what should
B. at least 3 months in each 2 consecutive years the nurse do?
C. more or less 3 months in each 3 consecutive year A. Pick up the implants using a gloved hand
D. more than 3 months in a year and place it in the trash bin.
B. Call the attention of the maintenance and
58. One night, the patient prompted the nurse because of let him dispose of the implants.
difficulty in breathing. The patient requested the nurse to raise C. Pick up the implants using long forceps
the oxygen level from what is being prescribed. The nurse has and place it in a lead container.
an accurate understanding of the situation if she does what D. Have the patient pick the implants and
action? insert it back.
A. Follow the client’s wish to facilitate breathing.
B. Discontinue the oxygen therapy because the patient 64. Another patient was also admitted in the same ward
is no longer responsive to it. and diagnosed of stage 3 lung cancer. He was advised
C. Give the client expectorant immediately to expel to undergo chemotherapy. The following statements
retained secretions. indicate that the patient has an accurate understanding
D. Maintain the regulation and assess for other regarding the effects of chemotherapy except:
potential problems. A. I will use soft-bristled toothbrush for my oral
care.
B. Imgonna eat nutritious foods like fresh fruits
59. Mr. Skarner was ordered for a postural drainage. The and vegetables.
patient asked the nurse when it will be done. The nurse is C. I prefer artificial rather than fresh flowers in
correct if she stated that CPT is best performed: my room.
A. Early in the morning before breakfast. D. I should avoid engaging in contact sports.
B. In the morning after eating merienda.
C. In the afternoon before dinner. 65. The patient started to worry why his hair had started
D. Thirty minutes after the patient took his lunch. to fall off. You came off with a diagnosis of body image
disturbance. The patient asked if his hair would grow
60. You noticed that the patient still have productive cough. back. The nurse has a correct understanding of the
Which method is best used for assessing breath sounds? situation if she stated that:
A. Palpation A. “Hair loss is temporary and it will grow back
B. Auscultation right after the treatment.”
C. Percussion B. “Your hair will never grow back and wearing
D. Inspection of wigs is recommended for life.”
C. “Your hair will grow back some time after
Situation: Cancer is one of the leading causes of disability and the therapy but it is not the same as before.”
death worldwide. Various treatments and medical regimen have D. “Worrying is the cause of hair loss and not
been discovered to halt or minimize the progression of the said the treatment so stop worrying.”
disease.
Situation: Diabetes Mellitus is one of the leading
61. A patient who was admitted in the oncology ward had his debilitating diseases in the world. It is related to
chart placed in the station. As the nurse browses the chart, she sedentary lifestyle, improper diet and genetics.
notices TIS, N0, and M0 written on the patient’s diagnosis. She
correctly interprets the data if she states that TIS, N0, M0 66. Nurse Annie was assigned in the Diabetes enter.
means : She is aware that insulin is mainly responsible for
A. No evidence of primary tumor, Regional lymph node controlling the levels of glucose in the blood. Insulin is
can’t be assessed and distant metastasis produced by what cell?
B. Primary Tumor can’t be assessed, No regional A. Alpha-cells
lymph node metastasis and distant metastasis can’t be B. Beta-cells
assessed C. Delta-cells
C. Carcinoma in situ, No regional lymph node D. Goblet cells
metastasis and no distant metastasis
D. Tumor less than 2 cm, One regional node 67. A type I DM client experiences Diabetic
involvement and distant metastasis can’t be assessed Ketoacidosis. Based on your knowledge, the acid-base
balance most likely seen in the patient is:
62. Tristana, a 38 year old woman was also admitted in the A. Metabolic acidosis
ward. She was diagnosed of having stage 2 cervical cancer and B. Respiratory alkalosis
was scheduled a radiation therapy specifically cervical C. Metabolic alkalosis
implants. Which of the following room locations is best for D. Respiratory acidosis
patient Tristana?
A. Near the nurses’ station 68. A type II DM client is asking the nurse what is the
B. Away from the hallway best time to buy shoes. The nurse is correct if she
C. Somewhere near the ward exit replied:
D. In front of the ward’s common rest room A. Morning
B. Anytime of the day will do
Nursing Practice III
C. Time is not a relevant factor C. She drank too much coffee during breakfast
D. Late in the afternoon D. She is anxious about the surgery.

69. The nurse is instructing a diabetic client about foot care. The Situation: Sterilization is the process of removing all
patient needs no further instruction if he states the following living microorganisms. To be free of all living
except: microorganisms is sterility.
A. “I will walk barefooted in the house to promote
circulation”. 76. There are three general types of sterilization used
B. “ I’m gonna avoid soaking my feet in the water for in the hospital. Which is not included?
long time”. A. Steam sterilization
C. “I will cut my toe nails straight”. B. Chemical sterilization
D. “I will eat nutritious food recommended by my C. Dry heat sterilization
dietician”. D. Sterilization by boiling

70. A client is taking Glyburide (Micronase) for her type II DM. 77. Autoclave on steam under pressure is the most
Which statement from the patient would alert the nurse? common method of sterilization in the hospital. The
A. The client stays up late when he overtimes at work. nurse knows that the temperature and time is set to the
B. I limit my alcohol intake up to 2 glasses everytime optimum level to destroy not only the microorganism,
we have a night out. but also the spores. Which of the following is the ideal
C. I do not recommend this drug to my pregnant setting of the autoclave machine?
diabetic friends. A. 10,0000C for 1 hour
D. I usually experience headache after taking this B. 5,0000C for 30 minutes
medication. C. 370C for 15 minutes
D. 1210C for 15 minutes
Situation: In the OR, there are safety protocols that should be
followed. The OR nurse should be well versed with all these to 78. It is important that before a nurse prepares the
safeguard the safety and quality of patient delivery outcome. material to be sterilized a chemical indicator strip,
preferably a Muslin Sheet, should be placed above the
71. Which of the following should be given highest priority when package. What is the color of the stripe produced after
receiving patient in the OR? autoclaving?
A. Assess level of consciousness A. Black
B. Verify patient identification and informed consent B. Blue
C. Gray
C. Assess vital signs D. Purple
D. Check for jewelry, gown, manicure and dentures
79. Chemical indicators communicate that:
72. Surgeries like I and D (Incision and Drainage) and A. The items are sterile.
debridement are relatively short procedures but considered B. The items have undergone sterilization
“dirty cases.” When are these procedures best scheduled? process but not necessarily sterile.
A. Last case C. The items are disinfected.
B. In between cases D. The items have undergone disinfection
C. According to the availability of the anesthesiologist process but not necessarily disinfected
D. According to the surgeon’s preference
80. If a nurse will sterilize a heat and moisture label
73. Katarina, an active cheerleader complains flashes of lights instruments, it is according to AORN recommendation
appearing and a shadow covering the upper vision of her left to use which of the methods of sterilization?
eye. You suspect that Katarina sustained A. Ethylene oxide gas
a: A. Retinal Detachment B. Autoclaving
B. Glaucoma C. Flash sterilizer
C. Cataract D. Alcohol immersion Situation: Nurses hold a
D. Macular degeneration variety of roles when providing care to a peri-
operative patient.
74. Based on the situation, you plan to position the client on:
A. Side-lying on the affected eye 81. Which of the following role would be the
B. Lateral on the affected eye responsibility of the scrub nurse?
C. Dependent position on the area affected A. Assess the readiness of the client prior to
D. Independent position on the side affected the surgery
B. Ensure that the airway is adequate
75. As you prepare the patient for surgery, you noticed that the C. Account for the number of sponges,
patient is fidgeting, going in and out of his bed and frequently needles, supplies used during the surgical
asks about the procedure. These behaviors of the patient most procedure
likely suggest? D. Evaluate the type of anesthesia appropriate
A. The patient does not have enough sleep last night. for the surgical client
B. Client is pressed between financial burden and
family responsibilities. 82. As a peri-operative nurse, how can you best meet
Nursing Practice III
the safety need of the client after administering pre-operative b. Progressing as nurse-generalist in a
narcotic? multitude of choice-practice settings to that of
A. Put side rails up and ask the client not to get out of expert nurse practitioner also in choice-
bed practice-settings
B. Send the client to OR with the family c. Avoiding personal and professional
C. Assist client to get up to go to the comfort room stagnation by updating and upgrading one’s
D. Obtain consent form self
d. Constantly upgrading one’s self through
83. It is the responsibility of the pre-op nurse to do skin prep for advanced technological means and strategies
patients undergoing surgery. If hair at the operative site is not
shaved, what should be done to make suturing easy and lessen 88. It is important to remember that while RNs value
the chance of incision infection? “job tenure” because the years in service spell variety
A. Draped of experiences in nursing practice, it is far more
B. Pulled valuable to consider that tenure-years are nothing if
C. Clipped these are not parallel with one’s personal-professional
D. Shampooed growth and maturity. This implies:
a. Simply earning years of job-related service
84. It is also the nurse’s function to determine when infection until we retire from service.
has developed in the surgical incision. The perioperative nurse b. Extending assistance to our less-fortunate
should observe for what signs of impending infection? fellow nurses.
A. Localized heat and redness c. Progressive upgrading of competencies in
B. Serosanguinous exudates and skin blanching terms of knowledge, skills, attitudes, and
C. Separation of the incision values as professional nurse.
D. Blood clots and scar tissue are visible d. Volunteering our services wherever
needed.
85. Which of the following nursing interventions is done when
examining the incision wound and changing dressing? 89. We often give our best in caring but despite all
A. Observe the dressing, and type and odor of efforts, the reality of facing death is inevitable. Our
drainage if any brand and core values of nursing will always extend
B. Get patient’s consent beyond the ordinary levels of promotive, preventive,
C. Wash hands curative, and rehabilitative care. This culturally-bound,
D. Request the client to expose the incision wound Filipino values of nursing likewise needs to be nurtured:
A. Psychological care
Situation: Enrolling as nursing students taught you what the B. Emotional care
nursing profession has in store for you and to recognize that C. Spiritual care
each one came from different environs, different influences, D. Relational care
different past and present. As you journey through nursing, you
saw yourselves transform “from the person you were” to the 90. It is important to not only enrich one’s mind with
“aspiring nurse” you have become. Now that you have progressive technical upgrades but equip one’s self
graduated and now taking your Nurse Licensure Examination with holistic personal and professional development
(NLE) there is only the “YOU, who is the nurse.” believing that:
A. we are also God’s angels of mercy on earth
86. As an aspirant, a beginning nurse practitioner after your B. we may also find real holism in the service
basic nursing education, the “YOU, who is a professional nurse” we render
means: C. we and the beneficiaries of our care are
a. I have simply fine tuned myself, my needs, made up of body, soul, and spirit and each
my wants, my idiosyncrasies, to fit in the component do have health needs intertwined
profession of nursing. D. should we encounter terminal patients, we
b. The I in me and the nurse in me are two may understand how to support them to their
distinct identities that even my patients have dying stage
to learn to respect.
c. I have simply retained my former self but Situation: Nurse Jade is in charge of a client who was
acquired the knowledge, skills, attitudes, and admitted for management of acute episodes of
values expected of a nurse. cholecystitis.
d. The person I am and the professional nurse I
aspire to be have now developed into one 91. Nurse Jade did her admission assessment. She
Filipino Nurse. We are one and the same understands that the pain is characterized as:
identity. A. Tenderness that is generalized in the upper
epigastric area
87. As you progress in developing your nursing competencies, B. Tenderness and rigidity at the left epigastric
you have to thread a career-path according to the culture and area radiating to the back
design of Philippine Nursing. This means: C. Tenderness and rigidity of the upper right
a. Serving in other countries and learning new and abdomen radiating to the midsternal area
modern ways of doing nursing and sharing these back D. Pain of the left upper quadrant radiating to
in the Philippines. the left shoulder
Nursing Practice III
B. Putting the client in semi-Fowler’s position
92. To confirm the diagnosis of cholecystitis, the attending all the time
physician ordered the procedure that can detect gallstones as C. Taking cough med q4 hours round the clock
small as 1 to 2 cm and inflammation. Nurse Jade would prepare D. Utilizing the purse-lip technique of
the client for which specific diagnostic procedure? breathing
A. cholangiography
B. gall bladder series 98. The physician prescribes oral penicillin 500 mg
C. oral cholecystogram every six hours for seven days. On the fifth day, before
D. ultrasonography Kikay administers the first dose for the day, she
computed for the total amount in the milligrams of the
93. The diagnosis was confirmed as cholecystitis with oral penicillin that has been received by the client.
gallstones. The doctor prepared the client for the removal of his Which of the following is the correct amount?
gallbladder. The client asks the nurse: “How will this procedure a. 2,500 mg
affect my digestion?” The nurse’s most correct response would b. 15,000 mg
be: c. 10,000 mg
A. c. “Your body system will adjust in due time.” d. 8,000 mg
B. “The removal of the gallbladder usually interferes
with digestion but can be remedied by dietary 99. Standard precaution dictates that the nurse
modifications.” observes which of the following when caring for a client
C. “The removal of the gallbladder would significantly with streptococcal pneumonia?
interfere only with the digestion of fatty food.” A. Use of face mask
D. “The removal of gallbladder does not usually B. Use of sterile gloves
interfere with digestion.” C. Observe two-feet distance when giving
care
94. While reviewing the laboratory findings of the client, Nurse D. Use clean gloves
Jade found out that which findings are elevated?
1. white blood cell count 100. Sputum cultures are to be obtained to establish the
2. total serum bilirubin client’s specific antibiotic treatment. Kikay would BEST
3. alkaline phosphate collect the specimen:
4. red blood cell count A. Early in the morning
5. cholesterol B. Early morning after an antiseptic gargle
6. serum amylase C. After brushing the client’s teeth
A. 3,5,6 D. Anytime of the day after a warm salt
B. 1,2,6 solution gargle
C. 1,2,3
D. 2,3,4 PNLE NURSING PRACTICE III

95. A T-tube was inserted and the doctor ordered: “Monitor the
amount, color, consistency and odor of drainage.” Which of the 1. The nurse is going to replace the Pleur-O-Vac
following procedures can the nurse perform without the doctor’s attached to the client with a small, persistent left upper
order? lobe pneumothorax with a Heimlich Flutter Valve.
A. clamping Which of the following is the best rationale for this?
B. emptying A. Promote air and pleural drainage
C. aspirating B. Prevent kinking of the tube
D. irrigating C. Eliminate the need for a dressing
D. Eliminate the need for a water-seal
Situation: Alfonsus sought hospital confinement for pleuritic drainage
pain, fever, and cough. The attending physician had a chest x- Answer: D. The Heimlich flutter valve has a one-way
ray taken STAT. Result revealed presence of lung infiltrates. valve that allows air and fluid to drain. Underwater seal
The client was assigned to Kianne the staff nurse. drainage is not necessary. This can be connected to a
drainage bag for the patient’s mobility. The absence of
96. When Kikay performed chest auscultation, she observed a long drainage tubing and the presence of a one-way
short discreet bubbling sounds over the lower region of the right valve promote effective therapy
lung. Which of the following abnormal findings will Kikay
consider? 2. The client with acute pancreatitis and fluid volume
A. Friction rub deficit is transferred from the ward to the ICU. Which of
B. Murmur the following will alert the nurse?
C. Wheezes A. Decreased pain in the fetal position
D. Crackles B. Urine output of 35mL/hr C. CVP of 12
mmHg
97. Kikay put her priority nursing diagnosis as “Ineffective D. Cardiac output of 5L/min
airway clearance related to increased secretions and ineffective
coughing.” Which nursing intervention would be considered to Answer: C. C = the normal CVP is 0-8 mmHg. This
facilitate coughing with the LEAST discomfort? value reflects hypervolemia. The right ventricular
A. Splinting chest wall with pillow when coughing function of this client reflects fluid volume overload, and
Nursing Practice III
the physician should be notified.
3. The nurse in the morning shift is making rounds in the ward. 8. The nurse is going to insert a Miller-Abbott tube to
The nurse enters the client’s room and found the client in the client. Before insertion of the tube, the balloon is
discomfort condition. The client complains of stiffness in the tested for patency and capacity and then deflated.
joints. To reduce the early morning stiffness of the joints of the Which of the following nursing measure will ease the
client,the nurse can encourage the client to: insertion to the tube?
A. Sleep with a hot pad A. Positioning the client in Semi-Fowler’s
B. Take to aspirins before arising, and wait 15 minutes position
before attempting locomotion B. Administering a sedative to reduce anxiety
C. Take a hot tub bath or shower in the morning C. Chilling the tube before insertion
D. Put joints through passive ROM before trying to D. Warming the tube before insertion
move them actively Answer: C. Chilling the tube before insertion assists in
Answer: C. A hot tub bath or shower in the morning helps many relieving some of the nasal discomfort. Water-soluble
patients limber up and reduces the symptoms of early morning lubricants along with viscous lidocaine (Xylocaine) may
stiffness. Cold and ice packs are used to a lesser degree, also be used. It is usually only lightly lubricated before
though some clients state that cold decreases localized pain, insertion
particularly during acute attacks.
9. The physician ordered a low-sodium diet to the client.
4. The nurse is planning of care to a client with peptic ulcer Which of the following food will the nurse avoid to give
disease. To avoid the worsening condition of the client, the to the client?
nurse should carefully plan the diet of the client. Which of the A. Orange juice.
following will be included in the diet regime of the client? B. Whole milk.
A. Eating mainly bland food and milk or dairy products C. Ginger ale.
B. Reducing intake of high-fiber foods D. Black coffee.
C. Eating small, frequent meals and a bedtime snack Answer: B. Whole milk should be avoided to include in
D. Eliminating intake of alcohol and coffee the client’s diet because it has 120 mg of sodium in 8
Answer: D. These substances stimulate the production of 0z of milk
hydrochloric acid, which is detrimental in peptic ulcer disease.
10. Mr. Bean, a 70-year-old client is admitted in the
5. The physician has given instruction to the nurse that the client hospital for almost one month. The nurse understands
can be ambulated on crutches, with no weight bearing on the that prolonged immobilization could lead to decubitus
affected limb. The nurse is aware that the appropriate crutch ulcers. Which of the following would be the least
gait for the nurse to teach the client would be: appropriate nursing intervention in the prevention of
A. Tripod gait decubitus?
B. Two-point gait A. Giving backrubs with alcohol
C. Four-point gait B. Use of a bed cradle
D. Three-point gait C. Frequent assessment of the skin
Answer: D. The three-point gait is appropriate when weight D. Encouraging a high-protein diet
bearing is not allowed on the affected limb. The swing-to and Answer: A. Alcohol is extremely drying and contributes
swing-through crutch gaits may also be used when only one leg to skin break down. An emollient lotion should be used.
can be used for weight bearing
11. The physician prescribed digoxin 0.125 mg PO qd
6. The client is transferred to the nursing care unit from the to a client and instructed the nurse that the client is on
operating room after a transurethral resection of the prostate. high-potassium diet. High potassium foods are
The client is complaining of pain in the abdomen area. The recommended in the diet of a client taking digitalis
nurse suspects of bladder spasms, which of the following is the preparations because a low serum potassium has
best nursing action to minimize the pain felt by the client? which of the following effects?
A. Advising the client not to urinate around catheter A. Potentiates the action of digoxin
B. Intermittent catheter irrigation with saline B. Promotes calcium retention
C. Giving prescribed narcotics every 4 hour C. Promotes sodium excretion
D. Repositioning catheter to relieve pressure D. Puts the client at risk for digitalis toxicity
Answer: A. The client needs to be told before surgery that the Answer: D. Potassium influences the excitability of
catheter causes the urge to void. Attempts to void around the nerves and muscles. When potassium is low and the
catheter cause the bladder muscles to contract and result in client is on digoxin, the risk of digoxin toxicity is
painful spasms. increased.

7. A client is diagnosed with peptic ulcer. The nurse caring for 12. The nurse is caring for a client who is transferred
the client expects the physician to order which diet? from the operating room for pneumonectomy. The
A. NPO nurse knows that immediately following
B. Small feedings of bland food pneumonectomy; the client should be in what position?
C. A regular diet given frequently in small amounts A. Supine on the unaffected side
D. Frequent feedings of clear liquids B. Low-Fowler’s on the back
Answer; B. Bland feedings should be given in small amounts on C. Semi-Fowler’s on the affected side
a frequent basis to neutralize the hydrochloric acid and to D. Semi-Fowler’s on the unaffected side
prevent overload Answer: C. This position allows maximum expansion,
Nursing Practice III
ventilation, and perfusion of the remaining lung. After the surgery he was transferred to the nursing care
unit. The nurse assigned to him knows that 72 hours
13. A client is placed on digoxin, high potassium foods are after the procedure the client should be positioned
recommended in the diet of the client. Which of the following properly to prevent contractures. Which of the following
foods willthe nurse give to the client? is the best position to the client?
A. Whole grain cereal, orange juice, and apricots A. Side-lying, alternating left and right sides
B. Turkey, green bean, and Italian bread B. Sitting in a reclining chair twice a day
C. Cottage cheese, cooked broccoli, and roast beef C. Lying on abdomen several times daily
D. Fish, green beans and cherry pie D. Supine with stump elevated at least 30
Answer: C. This position allows maximum expansion, degrees
ventilation, and perfusion of the remaining lung. Answer: C. At about 48-72 hours, the client must be
turned onto the abdomen to prevent flexion
14. The nurse is assigned to care to a client who undergone contractures.
thyroidectomy. What nursing intervention is important during
the immediate postoperative period following a thyroidectomy? 19. A client is scheduled to have an inguinal
A. Assess extremities for weakness and flaccidity herniorraphy in the outpatient surgical department. The
B. Support the head and neck during position changes nurse is providing health teaching about post surgical
C. Position the client in high Fowler’s care to the client. Which of the following statement if
D. Medicate for restlessness and anxiety made by the client would reflect the need for more
Answer: B. Stress on the suture line should be avoided. Prevent teaching?
flexion or hyperextension of the neck, and provide a small pillow A. “I should call the physician if I have a cough
under thehead and neck. Neck muscles have been affected or cold before surgery
during a thyroidectomy, support essential for comfort and B. “I will be able to drive soon after surgery”
incisional support. C. “I will not be able to do any heavy lifting for
3-6 weeks after surgery”
15. What would be the recommended diet the nurse will D. “I should support my incision if I have to
implement to a client with burns of the head, face, neck and cough or turn”
anterior chest? Answer: B. The client should not drive for 2 weeks after
A. Serve a high-protein, high-carbohydrate diet surgery to avoid stress on the incision. This reflects a
B. Encourage full liquid diet need for additional teaching.
C. Serve a high-fat diet, high-fiber diet
D. Monitor intake to prevent weight gain 20. Ms Jones is brought to the emergency room and is
Answer: A. A positive nitrogen balance is important for meeting complaining of muscle spasms, numbness, tremors
metabolic needs, tissue repair, and resistance to infection. and weakness in the arms and legs. The client was
Caloric goals may be as high as 5000 calories per day. diagnosed with multiple sclerosis. The nurse assigned
to Ms. Jones is aware that she has to prevent fatigue to
16. A client with multiple fractures of both lower extremities is the client to alleviate the discomfort. Which of the
admitted for 3 days ago and is on skeletal traction. The client is following teaching is necessary to prevent fatigue?
complaining of having difficulty in bowel movement. Which of A. Avoid extremes in temperature
the following would be the most appropriate nursing B. Install safety devices in the home
intervention? C. Attend support group meetings
A. Administer an enema D. Avoid physical exercise
B. Perform range-of-motion exercise to all extremities Answer: A. Extremes in heat and cold will exacerbate
C. Ensure maximum fluid intake (3000ml/day) symptoms. Heat delays transmission of impulses and
D. Put the client on the bedpan every 2 hours increases fatigue.
Answer: C. The best early intervention would be to increase
fluid intake, because constipation is common when activity is 21. Mr. Stewart is in sickle cell crisis and complaining
decreased or usual routines have been interrupted. pain in the joints and difficulty of breathing. On the
assessment of the nurse, his temperature is 38.1 ºC.
17. John is diagnosed with Addison’s disease and admitted in The physician ordered Morphine sulfate via
the hospital. What would be the appropriate nursing care for patient controlled analgesia (PCA), and oxygen at
John? 4L/min. A priority nursing diagnosis to Mr. Stewart is
A. Reducing physical and emotional stress risk for infection. A nursing intervention to assist in
B. Providing a low-sodium diet preventing infection is:
C. Restricting fluids to 1500ml/day A. Using standard precautions and medical
D. Administering insulin-replacement therapy asepsis
Answer: A. Because the client’s ability is to react to stress is B. Enforcing a “no visitors” rule
decreased, maintaining a quiet environment becomes A C. Using moist heat on painful joints
nursing priority. Dehydration is a common problem in Addison’s D. Monitoring a vital signs every 2 hour
disease, so close observation of the client’s hydration level is Answer: A. Vigilant implementation of standard
crucial. To promote optimal hydration and sodium intake, fluid precautions and medical asepsis is an effective means
intake is increased, particularly fluid containing electrolytes, of preventing infection
such as broths, carbonated beverages, and juices.
22. Mrs. Maupin is a professor in a prestigious
18. Mr. Smith is scheduled for an above-the-knee amputation. university for 30 years. After lecture, she experience
Nursing Practice III
blurring of vision and tiredness. Mrs. Maupin is brought to the D. Increasing fluid intake
emergency department. On assessment, the nurse notes that Answer: A. Placing food in the unaffected side of the
the blood pressure of the client is 139/90. Mrs. Maupin has been mouth assists in the swallowing process because the
diagnosed with essential hypertension and placed on client has sensation on that side and will have more
medication to control her BP. Which potential nursing diagnosis control over the swallowing process.
will be a priority for discharge teaching?
A. Sleep Pattern disturbance 28. Following nephrectomy, the nurse closely monitors
B. Impaired physical mobility the urinary output of the client. Which assessment
C. Noncompliance finding is an early indicator of fluid retention in the
D. Fluid volume excess postoperative period?
Answer: C. Noncompliance is a major problem in the A. Periorbital edema
management of chronic disease. In hypertension, the client B. Increased specific gravity of urine
often does not feel ill and thus does not see a need to follow a C. A urinary output of 50mL/hr
treatment regimen. D. Daily weight gain of 2 lb or more
Answer: D. Daily weights are taken following
23. Following a needle biopsy of the kidney, which assessment nephrectomy. Daily increases of 2 lb or more are
is an indication that the client is bleeding? indicative of fluid retention and should be reported to
A. Slow, irregular pulse the physician. Intake and output records may also
B. Dull, abdominal discomfort reflect this imbalance.
C. Urinary frequency
D. Throbbing headache
Answer: B. An accumulation of blood from the kidney into the 29. A nurse is completing an assessment to a client
abdomen would manifest itself with these symptoms with cirrhosis. Which of the following nursing
assessment is important to notify the physician?
24. A client with acute bronchitis is admitted in the hospital. The A. Expanding ecchymosis
nurse assigned to the client is making a plan of care regarding B. Ascites and serum albumin of 3.2 g/dl
expectoration of thick sputum. Which nursing action is most C. Slurred speech
effective? D. Hematocrit of 37% and hemoglobin of
A. Place the client in a lateral position every 2 hour 12g/dl
B. Splint the patient’s chest with pillows when Answer: A. Clients with cirrhosis have already
coughing coagulation due to thrombocytopenia and vitamin K
C. Use humified oxygen deficiency. This could be a sign of bleeding
D. Offer fluids at regular intervals
Answer: D. Fluids liquefy secretions and therefore make it 30. Mr. Park is 32-year-old, a badminton player and has
easier to expectorate a type 1 diabetes mellitus. After the game, the client
complains of becoming diaphoretic and light-
25. The nurse is going to assess the bowel sound of the client. headedness. The client asks the nurse how to avoid this
For accurate assessment of the bowel sound, the nurse should reaction. The nurse will recommend to:
listen for at least: A. Allow plenty of time after the insulin
A. 5 minutes injection and before beginning the match
B. 60 seconds B. Eat a carbohydrate snack before and during
C. 30 seconds the badminton match
D. 2 minutes C. Drink plenty of fluids before, during, and
Answer: D. Physical assessment guidelines recommend after bed time
listening for atleast 2 minutes in each quadrant (and up to 5 D. Take insulin just before starting the
minutes, not at least 5 minutes). badminton match
Answer: B. Exercise enhances glucose uptake, and the
26. The nurse encourages the client to wear compression client is at risk for an insulin reaction. Snacks with
stockings. What is the rationale behind in using compression carbohydrates will help.
stockings?
A. Compression stockings promote venous return 31. A client is rushed to the emergency room due to
B. Compression stockings divert blood to major serious vehicle accident. The nurse is suspecting of
vessels head injury. Which of the following assessment findings
C. Compression stockings decreases workload on the would the nurse report to the physician?
heart A. CVP of 5mmHa
D. Compression stockings improve arterial circulation B. Glasgow Coma Scale score of 13
Answer: A. Compression stockings promote venous C. Polyuria and dilute urinary output
return and prevent peripheral pooling. D. Insomnia
Answer: C. These are symptoms of diabetes insipidus.
27. Mr. Whitman is a stroke client and is having difficulty in The patient can become hypovolemic and vasopressin
swallowing. Which is the best nursing intervention is most likely may reverse the Polyuria.
to assist the client?
A. Placing food in the unaffected side of the mouth 32. Mrs. Moore, 62-year-old, with diabetes is in the
B. Increasing fiber in the diet emergency department. She stepped on a sharp sea
C. Asking the patient to speak slowly shells while walking barefoot along the beach. Mrs.
Nursing Practice III
Moore did not notice that the object pierced the skin until later Answer: D. If infected, the sex partner must be
that evening. What problem does the client most probably evaluated and treated
have?
A. Nephropathy 38. A client with AIDS is admitted in the hospital. He is
B. Macroangiopathy receiving intravenous therapy. While the nurse is
C. Carpal tunnel syndrome assessing the IV site, the client becomes confused and
D. Peripheral neuropathy restless and the intravenous catheter becomes
Answer: D. Peripheral neuropathy refers to nerve damage of disconnected and minimal amount of the client’s blood
the hands and feet. The client did not notice that the object spills onto the floor. Which action will the nurse take to
pierced the skin. remove the blood spill?
A. Promptly clean with a 1:10 solution of
33. A client with gangrenous foot has undergone a below-knee household bleach and water
amputation. The nurse in the nursing care unit knows that the B. Promptly clean up the blood spill with full-
priority nursing intervention in the immediate post operative strength antimicrobial cleaning solution
care of this client is: C. Immediately mop the floor with boiling
A. Elevate the stump on a pillow for the first 24 hours water
B. Encourage use of trapeze D. Allow the blood to dry before cleaning to
C. Position the client prone periodically decrease the possibility of cross-
D. Apply a cone-shaped dressing contamination
Answer: A. The elevation of the stump on a pillow for the first Answer: A. A 1:10 solution of household bleach and
24 hours decreases edema and increases venous return. water is recommended by the Centers for Disease
Control and Prevention to kill the human
34. A client with a diagnosis of gastric ulcer is complaining of immunodeficiency virus (HIV).
syncope and vertigo. What would be the initial nursing
intervention by the nurse? 39. Before surgery, the physician ordered pentobarbital
A. Monitor the client’s vital signs sodium (Nembutal) for the client to sleep. The night
B. Keep the client on bed rest before the scheduled surgery, the nurse gave the pre-
C. Keep the patient on bed rest medication. One hour later the client is still unable to
D. Give a stat dose of Sucralfate (Carafate) sleep. The nurse review the client’s chart and note the
Answer: B. The priority is to maintain client’s safety. With physician’s prescription with an order to repeat. What
syncope and vertigo, the client is at high risk for falling. should the nurse do next?
A. Rub the client’s back until relaxed
35. After a right lower lobectomy on a 55-year-old client, which B. Prepare a glass of warm milk
action should the nurse initiate when the client is transferred C. Give the second dose of pentobarbital
from the post anesthesia care unit? sodium
A. Notify the family to report the client’s condition D. Explore the client’s feelings about surgery
B. Immediately administer the narcotic as ordered Answer: D. Given the data, presurgical anxiety is
C. Keep client on right side supported by pillows suspected. The client needs an opportunity to talk about
D. Encourage coughing and deep breathing every 2 concerns related to surgery before further actions
hours (which may mask the anxiety).
Answer: D. Coughing and deep breathing are essential for re-
expansion of the lung 40. The nurse on the night shift is making rounds in the
nursing care unit. The nurse is about to enter to the
36. The nurse is providing a discharge instruction about the client’s room when a ventilator alarm sounds, what is
prevention of urinary stasis to a client with frequent bladder the first action the nurse should do?
infection. Which of the following will the nurse include in the A. Assess the lung sounds
instruction? B. Suction the client right away
A. Drink 3-4 quarts of fluid every day C. Look at the client
B. Empty the bladder every 2-4 hours while awake D. Turn and position the client
C. Encourage the use of coffee, tea, and colas for their Answer: C. A quick look at the client can help identify
diuretic effect the type and cause of the ventilator alarm.
D. Teach Kegel exercises to control bladder flow Disconnection of the tube from the ventilator,
Answer:B. Avoiding stasis of urine by emptying the bladder bronchospasm, and anxiety are some of the obvious
every 2-4 hours will prevent overdistention of the bladder and reasons that could trigger an alarm.
future urinary tract infections.
41. What effective precautions should the nurse use to
37. A male client visits the clinic for check-up. The client tells control the transmission of methicillin-resistant
the nurse that there is a yellow discharge from his penis. He Staphylococcus aureus (MRSA)?
also experiences a burning sensation when urinating. The A. Use gloves and handwashing before and
nurse is suspecting of gonorrhea. What teaching is necessary after client contact
for this client? B. Do nasal cultures on healthcare providers
A. Sex partner of 3 months ago must be treated C. Place the client on total isolation
B. Women with gonorrhea are symptomatic D. Use mask and gown during care of the
C. Use a condom for sexual activity MRSA client
D. Sex partner needs to be evaluated Answer: A. Contact isolation has been advised by the
Nursing Practice III
Centers for Disease Control and Prevention (CDC) to control medications, poor dentition, or indigestion, the bruises
transmission of MRSA, which includes gloves and may be attributed to ataxia, frequent falls, vertigo, or
handwashing. medication.

42. The postoperative gastrectomy client is scheduled for 46. A nurse is providing a discharge instruction to the
discharge. The client asks the nurse, “When I will be allowed to client about the self-catheterization at home. Which of
eat three meals a day like the rest of my family?”. The the following instructions would the nurse include?
appropriate nursing response is: A. Wash the catheter with soap and water after
A. “You will probably have to eat six meals a day for each use
the rest of your life.” B. Lubricate the catheter with Vaseline
B. “Eating six meals a day can be a bother, can’t it?” C. Perform the Valsalva maneuver to promote
C. “Some clients can tolerate three meals a day by the insertion
time they leave the hospital. Maybe it will be a little D. Replace the catheter with a new one every
longer for you.” 24 hour
D. “ It varies from client to client, but generally in 6-12 Answer: A. The catheter should be washed with soap
months most clients can return to their previous meal and water after withdrawal and placed in a clean
patterns” container. It can be reused until it is too hard or too soft
Answer:D. In response to the question of the client, the nurse for insertion. Self-care, prevention of complications,
needs to provide brief, accurate information. Some clients who and cost-effectiveness are important in home
have had gastrectomies are able to tolerate three meals a day management.
before discharge from the hospital. However, for the majority of
clients, it takes 6-12 months before their surgically reduced 47. The nurse in the nursing care unit is assigned to
stomach has stretched enough to accommodate a larger meal care to a client who is Immunocompromised. The client
tells the nurse that his chest is painful and the blisters
43. A male client with cirrhosis is complaining of belly pain, are itchy. What would be the nursing intervention to this
itchiness and his breasts are getting larger and also the client?
abdomen. The client is so upset because of the discomfort and A. Call the physician
asks the nurse why his breast and abdomen are getting larger. B. Give a prn pain medication
Which of the following is the appropriate nursing response? C. Clarify if the client is on a new medication
A. “How much of a difference have you noticed” D. Use gown and gloves while assessing the
B. “It’s part of the swelling your body is experiencing” lesions
C. “It’s probably because you have been less Answer: D. The client may have herpes zoster
physically active” D. “Your liver is not destroying (shingles), a viral infection. The nurse should use
estrogen hormones that all men produce” standard precautions in assessing the lesions.
Answer: A. This allows the client to elaborate his concern and Immunocompromised clients are at risk for infection.
provides the nurse a baseline of assessment
48. A client is admitted and has been diagnosed with
bacterial (meningococcal) meningitis. The infection
44. A client is diagnosed with detached retina and scheduled control registered nurse visits the staff nurse caring to
for surgery. Preoperative teaching of the nurse to the client the client. What statement made by the nurse reflects
includes: an understanding of the management of this client?
A. No eye pain is expected postoperatively A. speech pattern may be altered
B. Semi-fowler’s position will be used to reduce B. Respiratory isolation is necessary for 24
pressure in the eye. hours after antibiotics are started
C. Eye patches may be used postoperatively C. Perform skin culture on the macular popular
D. Return of normal vision is expected following rash
surgery D. Expect abnormal general muscle
Answer: C. Use of eye patches may be continued contractions
postoperatively, depending on surgeon preference. This is Answer: B. After a minimum of 24 hours of IV
done to achieve >90% success rate of the surgery. antibiotics, the client is no longer considered
communicable. Evaluation of the nurse’s knowledge is
45. A 70-year-old client is brought to the emergency department needed for safe care and continuity of care
with a caregiver. The client has manifestations of anorexia,
wasting of muscles and multiple bruises. What nursing 49. A 18-year-old male client had sustained a head
interventions would the nurse implement? injury from a motorbike accident. It is uncertain whether
A. Talk to the client about the caregiver and support the client may have minimal but permanent disability.
system The family is concerned regarding the client’s difficulty
B. Complete a gastrointestinal and neurological accepting the possibility of long term effects. Which
assessment nursing diagnosis is best for this situation?
C. Check the lab data for serum albumin, hematocrit A. Nutrition, less than body requirements
and hemoglobin B. Injury, potential for sensory-perceptual
D. Complete a police report on elder abuse alterations
Answer: B. Assessment and more data collection are needed. C. Impaired mobility, related to muscle
The client may have gastrointestinal or neurological problems weakness
that account for the symptoms. The anorexia could result from D. Anticipatory grieving, due to the loss of
Nursing Practice III
independence
Answer: D. Stem of the question supports this choice by stating
that the client has difficulty accepting the potential disability.

50. A client with AIDS is scheduled for discharge. The client tells
the nurse that one of his hobbies at home is gardening. What
will be the discharge instruction of the nurse to the client
knowing that the client is prone to toxoplasmosis?
A. Wash all vegetables before cooking
B. Wear gloves when gardening
C. Wear a mask when travelling to foreign countries
D. Avoid contact with cats and birds
Answer: B. Toxoplasmosis is an opportunistic infection and a
parasite of birds and mammals. The oocysts remain infectious
in moist soil for about 1 ye