COMPETENCY OPTIMIZING REVIEW (CORe) GUIDED NLE REVIEW DIAGNOSTIC EXAMINATION III SITUATION: PAIN

1. Nursing interventions can greatly help a patient experiencing pain. As a nurse, you decided to utilize the cognitive and behavioral interventions. Which of the following is not related to cognitive-behavioral pain management? a. Asking the patient to do deep breathing exercise because it reduces muscle tension b. Asking the patient to sit comfortably and meditate. c. Distracting the attention of the patient away from the painful sensation. d. Give patient a back rub because it makes the patient relax and may lessen pain sensation. ANSWER: D Cognitive-behavioral interventions include deep breathing exercises, music, guided imagery, biofeedback, distraction, therapeutic touch, meditation, hypnosis and humor. Physical interventions include cutaneous stimulation, massage, heat and cold application, TENS, acupuncture and acupressure. Therefore, choice D is not included in cognitivebehavioral intervention. Reference: Medical-Surgical Nursing by Joyce Black, 8th edition, p. 379-382. 2. You have decided to use hypnosis in relieving the clients pain. To reduce pain, you induce the patient to a hypnotic state by following a certain procedure. Which of the following is not included in the procedure? a. Anesthesia and analgesia for superficial and deep sensation. b. Body disorientation and dissociation. c. Assess the clients energy field. d. Suggestion to alter the character of the pain or ones attitude to it ANSWER: C Options A, B, and D are procedures included in induction of hypnotic state. Choice C is included in therapeutic touch. Therapeutic touch has three steps: center or focus client on meditative state, assess client energy field, use hands to rearrange the clients energy field. Reference: Medical-Surgical Nursing by Joyce Black, 8th edition, p.381. 3. Nurse Isabelle is assessing a client for pain. If the client denies having pain, Nurse Hannah will consider monitoring the clients vital signs for sympathetic responses to pain, such as: a. Increased blood pressure, increased pulse, increased respiratory rate b. Decreased blood pressure, decreased pulse, increased respiratory rate c. Increased blood pressure, decreased pulse, increased respiratory rate

d. Decreased blood pressure, decreased pulse, decreased respiratory rate ANSWER: A The sympathetic nervous system controls blood pressure, pulse, and respiration and is stimulated during pain.These responses are short lived as the body adapts to stress. Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition Page 273 4. Nurse Hannah is teaching a client with cancer about opioid management for intractable pain and tolerance related side effects. Nurse Hannah should prepare the client for which side effect that is most likely to persist during longterm use of opioids? a. Sedation b. Constipation c. Urinary retention d.Respiratory depression ANSWER: B The client should be prepared to implement measures for constipation which is the most likely persistent side effect related to opioid use. Tolerance to opiate narcotics is common, and the client may experience less sedation and respiratory depression as analgesic use continues. Opioids increase the tone in the urinary bladder sphincter, which causes retention but may subside. Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition 5. Two patients are hospitalized with the same diagnosis, but one is 23 years old, with acute recent pain from an injury, and the other is 64 years old, with pain of long-standing duration of several years. The difference in anticipated assessment is which of the following? a. Acute pain for young patients is more intense at the same level, but these patients experience few changes in vital signs. b.Young patients with acute pain exhibit fewer changes in vital signs but still report true levels of pain at levels 8 to 10. c.Older adult patients with chronic pain exhibit increased changes in vital signs and report levels lower than reality. d.Older adult patients with chronic pain usually report lower levels of pain much less severe than they really are. ANSWER: D Older adult patients with chronic pain do not report pain as severe at the same level as younger patients for several reasons. For example, older adult patients believe that pain comes with old age, or they do not want to bother the staff. Chronic pain of long standing frequently does not change vital sign normal values. Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition 268 6. A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (of a 0-10 scale) and requests something for pain that will work quickly. The best way for the nurse to document this information is as

a. Breakthrough pain b. Neuropathic pain c. Somatic pain d. Referred pain ANSWER: A Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue. Reference: Sharon Lewis. Medical Surgical Nursing 7th edition Page 132 7. The nurse asks the patient, What does the pain feel like? The nurse is trying to identify which pain factor? a. Aggravating b. Characteristics c. Duration d. Onset ANSWER: B The characteristics of pain identify whether the pain is sharp, dull, throbbing, electric shock, tingling, pins and needleshow pain feels. Reference: Rick Daniels. Contemporary Medical Surgical Nursing 2nd edition 8. The nurse is providing care to a client who is experiencing pain. Which statement is true about pain? a. The nurse is the best judge of a clients pain. b. Clients with severe tissue damage will experience more pain than those with less damage. c. Most complaints of pain are psychological. d. Addiction is unlikely when analgesics are carefully administered and closely monitored. ANSWER: D There are common myths surrounding pain. One myth is that the nurse is the best judge of a clients pain. The fact is, the client is the best judge of the severity of pain. Another myth is clients with severe tissue damage will experience more pain that those with less damage. The fact is that the perception of pain does not depend upon the degree of tissue damage. Another myth is that most complaints of pain are psychological. The fact is pain is a perception that is honestly reported by clients. Addiction is unlikely when analgesics are carefully administered and closely monitored is true about pain. Reference: Sue Delaune. Fundamentals of Nursing 4th edition 9. A client says that inserting an intravenous line causes pain. This type of well-localized pain is considered to be: a. Cutaneous pain b. Somatic pain c. Visceral pain d. Referred pain ANSWER: A Cutaneous pain is caused by the stimulation of the cutaneous nerve endings in the skin, and it results in a welllocalized sensation. Somatic pain is not well-localized and originates in tendons, ligaments, and nerves. Visceral pain is discomfort in internal organs and is less localized. Referred pain is pain that originates in the internal organs but is felt at the spot where the organs were located during fetal development. Reference: Sue Delaune. Fundamentals of Nursing 4th edition

10. The nurse, providing pain medication to a client, realizes that all of the following are true about pain, except: a. There are two known endogenous analgesia systems in humans b. Internal organs are very sensitive to distension c. Ischemic pain onsets rapidly in an active muscle d. Transmission of visceral pain impulses is faster than impulses from cutaneous pain ANSWER: D Cutaneous pain impulses travel faster than visceral pain impulses. There are two known endogenous analgesia systems in humans. Internal organs are very sensitive to distention. Ischemic pain does have a rapid onset in an active muscle. Reference: Sue Delaune. Fundamentals of Nursing 4th edition 11. A client, recovering from a hysterectomy, has PCA (patientcontrolled analgesia) prescribed. To reduce her anxiety regarding receiving adequate pain relief, the most appropriate statement for the nurse to provide is: a. PCA is almost always effective. b. The clients comfort level will be assessed frequently. c. Additional medication by IM injection will be available. d. Most pain management therapies are better than frequent IM injections. ANSWER: B The nurse should instruct the client that the clients comfort level will be assessed frequently for adequate pain control. The nurse should not tell the client that PCA is almost always effective. The client should not need additional medication with a PCA. The nurse should also not tell the client that most pain management therapies are better than frequent intramuscular injections. Reference: Sue Delaune. Fundamentals of Nursing 4th edition 12. A client is grimacing and with fists clenched states, Im in excruciating pain. Which of these entries indicates correct documentation of the clients affect? a. Client is angry. c. Client states, Im in excruciating pain. Grimacing, clenched fists noted. b. Client is in a hostile mood. d. Client is uncooperative during the assessment process. ANSWER: C The pain assessment is to include pain intensity and quality. Pain is subjective and therefore is whatever the client states it is. Documentation require the use of quotations when describing the clients pain level if no scale is being used. Reference: Sue Delaune. Fundamentals of Nursing 4th edition 13. Which of these data provide the most accurate information about the pain a client is experiencing? a. Objective changes in vital signs such as increased respiratory rate, heart rate, and blood pressure b. The amount of tissue damage actually occurring or already present c. Facial expressions and level of mobility d. Self-report

ANSWER: D Although many factors contribute to individual responses to pain, the nurses primary consideration when assessing pain is that the client is the only authority about the existence and nature of his or her pain. Reference: Lois White. Foundations of Nursing 3rd edition 14. To obtain the most complete assessment data about a patients chronic pain pattern, the nurse asks the patient a. Can you describe where your pain is the worst? b. What is the intensity of your pain on a scale of 0 to 10? c. Would you describe your pain as aching, throbbing, or sharp? d. Can you describe your daily activities in relation to your pain? ANSWER: D The assessment of chronic pain should focus on the impact of the pain on patient function and daily activities. The other questions are also appropriate to ask, but will not give as complete information. Reference: Sharon Lewis. Medical Surgical Nursing 7th edition Page 134 15. A 29-year-old woman tells the nurse that she has excruciating pain in her back. Which of the following would be an appropriate response by the nurse to her statement? a. How does your family react to your pain? b. That must be terrible. You probably pinched a nerve. c. Ive had back pain myself and it can be excruciating. d. How would you say the pain affects your ability to do your daily activities? ANSWER: D The symptom of pain is difficult to quantify because of individual interpretation. With pain, avoid adjectives and ask how it affects daily activities. Reference: Carolyn Jarvis. Physical examination and health assessment. 5th edition page 77 SITUATION: FLUID AND ELECTROLYTES 16. When the nurse hangs an IV bag with Na+, K+, and Cl-, he is aware that ____ are being administered. a. Nutrients b. Electrolytes c. Enzymes d. Vitamins ANSWER: B C Sodium, potassium, and chlorides are electrolytes. A Nutrients are organic or inorganic substances found in food. B Enzymes are biologic catalysts that speed up chemical reaction D Vitamins are organic substances that cannot be manufactured by the body and is needed in small quantities to catalyze metabolic processes. Reference: Kozier, B. et. al. (2008). Fundamentals of Nursing: Concepts, Process and Practice. 8th edition. New Jersey: Prentice Hall. 17. The nurse is aware that extracellular fluid osmolarity is primarily maintained by: a. Chloride b. Magnesium c. Potassium d. Sodium ANSWER: D D Osmalarity is a term that describes concentration of solution and is measured in milliosmoles per liter (mOsm/L).

Sodium as the primary extracellular electrolyte controls the osmolarity of the extracellular fluid, either too much or too little. A, B, C Although other electrolytes affect the fluid osmolarity, extracellular fluid osmolarity is mannily maintained by sodium. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 253. 18. Both the intracellular and extracellular fluids are made up of many different electrolytes, but the most abundant intracellular positively charged electrolyte is: a. Calcium. b. Chloride c. Potassium d. Sodium ANSWER: C C K+ is the most abundant electrolyte in the cell. A Chloride is a negatively charged ion B, D Potassium and calcium are both positively charged ion but sodium is the most abundant References: Kozier, B. et. al. (2008). Fundamentals of Nursing: Concepts, Process and Practice. 8th edition. New Jersey: Prentice Hall. Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 261. 19. The nurse clarifies that fluid balance is mainly monitored in the body by two systems, which are the: a. Circulatory and renal c. Renal and gastrointestinal b. Respiratory and circulatory. d. Hepatic and lymphatic ANSWER: A A The monitoring of basic fluid balance in the body is done by the renal and circulatory systems. B, C, D Although the systems are interconnected, the circulatory and renal systems play the major role in the fluid balance. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 250, 252. 20. A client in chronic renal failure has a serum potassium level of 5.0 mEq/L. Which of the following interventions is most appropriate at this time? a. Preparing to administer I.V. potassium c. Preparing to administer ion exchange resin b. Immediately notify the doctor d. Continuing to monitor the client ANSWER: D The client's potassium level is normal. The nurse would continue monitoring the client without notifying the health care provider. B there is no need to notify the health care provider, potassium level is normal. C - Administering an ion exchange resin would be appropriate for hyperkalemia, which is indicated by a serum potassium level greater than 5.5 mEq/L. A - Administering I.V. potassium would be appropriate for hypokalemia, which is indicated by a serum potassium level less than 3.5 mEq/L. NV of K+ 3.5-5.6 mEq/L

Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 266 21. Nurse Hannah who is caring for a client with hypocalcemia would expect to note which of the following changes on the ECG strip? a. Prolonged QT interval b. Widened T wave c. Prominent U wave d. Shortened ST segment ANSWER: A Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. B & D - A shortened ST segment and a widened T wave occur with hypercalcemia. C - Prominent U waves occur with hypokalemia. Reference: Bare, B.G. and Smeltzer, S.C. Brunner & Suddarths Textbook of Medical-Surgical Nursing. 12th Edition, Vol. 1. Page 285 SITUATION: HEMATOLOGIC PROBLEMS 22. Nurse Isabela is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? a. Eggs. b. Lettuce. c. Citrus fruits. d. Cheese. ANSWER: A One of the microcytic, hypochromic anemias is iron deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ meats, shellfish, shrimp and tuna, enriched, whole grain, and fortified cereals and breads, legumes nuts, dried fruits and beans, oatmeal and sweet potatoes,. Dark green, leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a god source of calcium. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.1050 23. The nurse implements which of the following for the client who is starting a schilling test? a. Administering methylcellulose (Citrucel). c. Maintaining nothing by-mouth (NPO) status. b. Starting a 24-to-48 hour urine specimen collection. d. Starting a 72-hour stool specimen collection. ANSWER: B Urinary B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-48 hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of nonradioactive B12. In a healthy state of absorption, excess B12 is excreted in the urine; in a malabsorptive state or when the IF Is missing, B12 is excreted in feces. Citrucel is a bulk forming agent. Laxatives interfere with the absorption of B12. Client should be NPO for 8-12 hours before the test but is not NPO during the test. Stool collection is not needed. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.1053

24. The nurse should be alert to monitor which of the following physiologic functions in a client diagnosed with aplastic anemia? a. Bleeding tendencies. b. Intake and output. c. Peripheral sensation. d. Bowel function. ANSWER: A Aplastic anemia decreases the bone marrow production of RBCs, white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the clients intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.1036 25. Nurse Mish is teaching a client with polycythemia vera about the potential complications of this disease. Which manifestations should the nurse include in the clients teaching plan? i. Hearing loss. iii. Headache. v. Gout. ii. Visual disturbance. iv. Orthopnea. vi. Weight loss. a. ii, iii, iv, v b. i, ii, v, vi c. iii, iv, v, vi d. i, ii, iii, vi ANSWER: A Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful, swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.1066 26. When assessing an older adult male client, which blood value indicates that the client is experiencing normal changes associated with aging? a. Hemoglobin = 13.0 g/dL c. Prothrombin time (PT) = 14 seconds b. Platelet count = 100,000/mm3 d. White blood cell count = 5,000/mm3 ANSWER: A Hemoglobin levels in men and women fall after middle age. Therefore, this hemoglobin value would just be considered part of the aging process. Platelet counts and blood-clotting times are not age-related. Therefore, this platelet count and PT are elevated because of some other reason. The WBC count listed is normal. Reference: Ignatavicius. Ignatavicius: Medical-Surgical Nursing, 6th Edition 27. The client has a decreased serum iron level. Which intervention will the nurse implement first? a. Dietary consult c. Cardiac assessment

b. Family assessment d. Administration of vitamin K ANSWER: A Diets can alter cell quality and affect blood clotting. Diets low in iron can cause anemia and decrease the function of all red blood cells. The stem does not say that the hemoglobin is low enough to affect the cardiac function. Family assessment may be important in finding out any genetic or family lifestyle causes of the low serum iron level. However, the first intervention that the nurse can take is to have the clients dietary habits evaluated and changed so that the iron levels can increase. Vitamin K is involved with clotting, not iron stores. Reference: Ignatavicius. Ignatavicius: Medical-Surgical Nursing, 6th Edition 28. A client with iron deficiency anemia has been taught proper diet. Which food choice indicates understanding of dietary teaching? a. Chicken b. Oranges c. Steak d. Tomatoes ANSWER: C The treatment of iron deficiency anemia involves increasing the oral intake of iron from food sources. Foods high in iron include red meat, organ meat, kidney beans, leafy green vegetables, and raisins. Reference: Ignatavicius. Ignatavicius: Medical-Surgical Nursing, 6th Edition 29. A client is admitted to the hospital with a medical diagnosis of anemia. When assessing the client, the nurse should expect which symptom? a. Difficulty with breathing c. Heart rate of 45 beats/min b. Blood pressure of 150/70 mm Hg d. Skin flushed and warm ANSWER: A Anemia is a reduction in the number of RBCs, amount of hemoglobin, or hematocrit level. Tissue oxygenation depends on RBCs. Typical symptoms of anemic clients include dyspnea, increased somnolence, tachycardia, and pallor. A client who is anemic tends to have a lower blood pressure, increased heart rate, and skin that is pale and cool to touch. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition 30. A 17-year-old client with edematous lymph nodes and headaches is diagnosed with leukemia. The nurse suspects that this client most likely has: a. Chronic myeloid leukemia (CML). c. Chronic lymphocytic leukemia (CLL). b. Acute myeloid leukemia (AML). d. Acute lymphocytic leukemia (ALL). Answer: D Lymphocytic leukemias infiltrate the spleen, lymph nodes, CNS, and other tissues. Acute lymphoblastic leukemia is the most common type of leukemia in children. Reference: Lemone-Burke Medical Surgical Nursing 4th edition 31. When a nurse suspects a client is having a transfusion reaction, which action must the nurse take immediately? a. Call the blood bank or laboratory and report findings. c. Continue to observe the client closely.

b. Call the physician and report findings. d. Stop the infusion. ANSWER: D If a client experiences and symptoms of a transfusion reaction, the infusion is stopped immediately and the physician is notified. Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition 32. Which of the following medications or solutions may be administered with a blood transfusion? a. Intravenous (IV) antibiotics c. Lactated Ringers solution b. Calcium or potassium d. 0.9% sodium chloride (normal saline) ANSWER: D Blood is administered with 0.9% sodium chloride solution since other solutions cause the blood to clot. Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition 33. A new nurse in orientation prepares to administer heparin. Which action of this nurse would indicate a need for further instruction? a. Using ice on the site before and after administration b. Do not give intramuscular c. Cleansing, but not rubbing, the desired injection site d. Aspirating to be certain the needle is not in a blood vessel ANSWER: D After inserting the needle of the syringe into the injection site, heparin should never be aspirated, but slowly injected. Other options are correct steps. Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition 34. The nurse evaluates the understanding of the predischarge client receiving warfarin. Which comment indicates further teaching is needed? a. I should avoid the use of laxatives and mineral oil. b. I should eat lots of dark green leafy vegetables in increase my vitamin K1. c. If I have episodes of gastrointestinal illnesses, I should report these to my doctor. d. I understand the importance of keeping all of my appointments for blood tests. ANSWER: B Vitamin K1 should not be increased or decreased. Warfarin is known for highest adverse drug interactions of all groups. Consult the doctor before taking any OTC drugs. Option C: Gastrointestinal illness may present with bleeding. Option D: Client will need to report frequently for blood tests. Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition SITUATION: RESPIRATORY PROBLEMS 35. Nurse Julienne can increase the ventilatory efficiency of a client with COPD by positioning the client as follows: a. High fowlers b. Prone c. Sitting up and leaning slightly forward d. Trendelenburg ANSWER: C

The position that allows for the greatest amount of lung expansion is siitng up and leaning slightly forward. This position can be facilitated by allowing the client to rest his or her arms on a bedside table. The position that also facilitates lung expansion, but not to the same degree, is high fowlers. Both the prone and the trendelenburg position tend to decrease full lung expansion due to increased pressure of abdominal contents on the diaphragm. Reference Kozier and Erbs Fundamentals of Nursing 8th edition Page 1132 36. Nurse Mian recognizes that pattern of pulmonary dysfunction reflected by increased total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV) is characteristic of: a. Restrictive lung disease c. Vascular lung disease b. Obstructive lung disease d. A combination of restrictive and obstructive lung disease ANSWER: B Increased lung volumes (TLC, FRC, RV) and decreased airflow vital capacity (VC) and forced expiratory volume in 1 second (FEV1)- are functional problems consistent with obstructive lung disease. In restrictive lung disease, volumes generally decreased. Vascular lung disease has no effect on ventilator capacity but directly affects diffusion of gases; that is, pulmonary infarction decreases blood flow to the lungs, so some alveoli that are ventilated are no longer perfused. Restrictive lung disease is incorrect Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition Page 491 37. Which statement by the nurse correctly describes a wheeze? a. A high-pitched crowing sound produced by edema in the trachea b. A sound that is rarely considered pathological c. A medium-pitched sonorous soundby airflow in obstructed bronchi d. A high-pitched musical sound produced by airflow in narrowed bronchioles ANSWER: D A wheeze is a high-pitched, musical chest sound produced by airflow in narrowed bronchioles. It is primarily an expiratory sound and is always, not rarely, considered pathological. Rhonchi are medium-pitched sonorous sounds produced by airflow obstruction in larger airways. Stridor is highpitched crowing sound on inspiration and is due to an upper airway obstruction, such as edema, adhesions or tracheal hypertrophy. Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition 38. Nursing actions that will facilitate medical therapy for a client with COPD include: a. Limiting fluid intake to prevent volume overload and right-sided heart failure b. Oral and endotracheal suctioning as necessary c. Instructing the client in deep breathing and coughing techniques and pursed lip exhalations d. Maintenance of bed rest and activity restrictions to reduce acidosis

ANSWER: C Deep breathing, coughing, and pursed lip exhalations are all techniques that the nurse can teach the client to improve ventilation. Adequate fluid intake is essential for keeping sputum liquefied; however, very hot and very cold drinks should be avoided because they may cause bronchospasm. Clients with COPD also need to be taught to avoid exposure to infections, early signs of infection, and the need to seek medical intervention promptly should symptoms occur. Options B and D are not indicated in the clients therapy Reference: Brunner and Suddarths Medical Surgical Nursing 12th edition Page 615-619 39. Upon percussion, the nurse elicits a flat sound over the clients right lung. She notes an abnormal percussion sound in the assessment sheet. What could be the possible pathology underlying the assessment? a. Lobar pneumonia b. Pleural effusion c. Pneumothorax d. Bronchitis ANSWER: B Rationale: Resonance is the normal lung percussion sound. Flatness can be heard over the thigh. With client who has large pleural effusion, flatness can be heard during percussion. Hyperresonance is indicative of emphysema or pneumothorax. With bronchitis, a resonance might be heard. Reference: Med-surgical Nursing, Brunner and Suddarths, p. 574 40. After the tracheostomy care, tube should be secured properly. How will the nurse secure the tracheostomy tube? a. Take the tape around the back of the patients neck and thread it through the opposite opening of the outer cannula. b. Take the tape around the back of the patients neck and thread it through the opposite, on the clients gown. c. Take the tape around the back of the patients neck and thread it through the opposite, on the clients bed. d. Take the tape around the back of the patients neck and thread it through the opposite opening of the inner cannula. ANSWER: A Tracheostomy tube should not be thread anywhere. It should be secured around the clients neck where both ends meet on one side of the neck. This provides a double thickness security to avoid dislodgement of the tube by a forceful cough. Reference: Med-surgical Nursing, Brunner and Suddarths, p. 740 41. A client has undergone right pneumonectomy. When turning the client, the nurse should plan to position the client either: a. Right side-lying position or supine c. Right or left side lying position b. High fowlers d. Low fowlers position ANSWER: A Right side lying position or supine position permits ventilation of the remaining lung and prevent fluid from draining into sutured bronchial stump. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.758

42. George who has undergone thoracic surgery has chest tube connected to a water-seal drainage system attached to suction. Presence of excessive bubbling is identified in water-seal chamber, the nurse should: a. Strip the chest tube catheter c. Recognize the system is functioning correctly b. Check the system for air leaks d. Decrease the amount of suction pressure ANSWER: B Excessive bubbling indicates an air leak which must be eliminated to permit lung expansion. Option B will not address the problem in the situation. Nurse should never adjust the suction pressure without any doctors order. There is no alarm system attached to chest tube drainage. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p. 758-764 43. An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? a. Help the client to determine ways to increase his fluid intake. b. Obtain an appointment for the client to see an ear, nose, and throat specialist. c. Schedule an appointment with an allergist to determine if the client is allergic to the cat. d. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen. ANSWER: A The nurse should suggest creative methods to increase the intake of fluids (A), such as having disposable fruit juices readily available. Clients with COPD should have at least three liters of fluids a day. These clients often reduce fluid intake because of shortness of breath. (B) is not indicated. These symptoms are not indicative of an allergy (C). Many elderly depend on their pets for socialization and self-esteem. Humidified oxygen will not relieve these symptoms and increased oxygen levels will stifle the COPD client's trigger to breathe (D). Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.680 44. Nurse Minda is assessing a 60-year old client with chronic obstructive pulmonary disease. The client weighs 200lb and is 6 feet tall. Nurse Minda should expect to document the clients chest as: a. Barrel-shaped. c. Normal for the clients age, height, and weight. b. Muscular. d. Showing the effects of long-term use of bronchodilators. ANSWER: A This client has a barrel chest. The anterior-posterior diameter of the chest is larger than the transverse diameter, as is characteristic of the client with chronic obstructive pulmonary disease, although the client maybe muscular, the barrel chest is not associated with the clients age, height, or weight. Use of bronchodilators will not change the shape of the clients chest.

Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.569-570 45. A patient in respiratory distress is admitted to the medical unit at the hospital. During the initial assessment of the patient, Nurse Daniel should: a. Obtain a comprehensive health history to determine the extent of any prior respiratory problems. b. Complete a full physical examination to determine the systemic effect of the respiratory distress. c. Delay the physical assessment and ask family members about any history of respiratory problems. d. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress. ANSWER: D Rationale: When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the patients history of medical problems, the patient is the best informant for these data. Reference: Sharon Lewis. Medical Surgical Nursing 7th edition Page 517 46. The client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse? a. Decreased level of consciousness c. Increased temperature b. Tachycardia d. Slowed respiratory rate ANSWER: B An increased heart rate may indicate that the client is developing a pneumothorax or hypoxia. Although it is important to note immediately if the client is experiencing a decreased level of consciousness, increased temperature, or slowed respiratory rate, none of these are as indicative of a life-threatening a complication as tachycardia. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition 47. A client tells the nurse he has a "cold" every spring that lasts for a few weeks. The nurse suspects that the client is experiencing: a. Atrophic rhinitis b. Allergic rhinitis c. Vasomotor rhinitis d. Acute viral rhinitis ANSWER: B Rhinitis, inflammation of the nasal cavities, is the most common upper respiratory disorder. Rhinitis may be either acute or chronic. Acute viral rhinitis is the common cold. Allergic rhinitis, or hay fever, results from a sensitivity reaction to allergens such as plant pollens. It tends to occur seasonally. The etiology of vasomotor rhinitis is unknown. Although its manifestations are similar to those of allergic rhinitis, it is not linked to allergens. Atrophic rhinitis is characterized by changes in the mucous membrane of the nasal cavities. Reference: Lemone-Burke. Medical Surgical Nursing 4th edition

48. A client says, "My nose is always congested and it just seems to get worse with the nasal spray I've been using." The nurse realizes that this client is describing: a. A side effect of the nasal spray. c. An acute sinus infection that needs to be treated with antibiotics. b. An incorrect use of the nasal spray. d. Rebound nasal congestion. ANSWER: D Chronic use of nasal sprays may lead to rhinitis medicamentosa, a rebound phenomenon of drug-induced nasal irritation and inflammation. The nasal spray is being used correctly. The worsening nasal congestion is not considered a side effect. No other signs indicate that the client has a bacterial sinus infection. Reference: Lemone-Burke. Medical Surgical Nursing 4th edition 49. The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the nurses first action should be to a. Have the patient use the incentive spirometer. c. Splint the patients chest during coughing. b. Medicate the patient with the ordered morphine. d. Assist the patient to sit up at the bedside. ANSWER: B A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given. Reference: Sharon Lewis Medical Surgical Nursing 7th edition Page 591-594 50. A female client with asthma tells Nurse Isabel that her asthma is exacerbated by fresh fruit. Nurse Isabel realizes that the classification of this trigger is: a. Pharmacologic b. Psychosocial c. Emotional stress d. Exposure to an allergen ANSWER: A Common pharmacologic triggers include aspirin and other NSAIDs, sulfites (which are used as preservatives in wine, beer, fresh fruits, and salad), and beta-blockers. Reference: Lemone-Burke Medical Surgical Nursing 4th edition 51. Which statement indicates that the client understands teaching about the use of his long-acting beta2 agonist medication? a. I will not have to take this medication every day. b. I will take an extra dose of this medication when I have an asthma attack. c. I will take this medication daily to prevent an acute attack. d. I will eventually be able to stop using this medication. ANSWER: C

This medication will help prevent an acute asthma attack because it is long acting. The client will take this medication every day for best effect. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his daily medications. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition 52. The client has been diagnosed with chronic obstructive pulmonary disease (COPD). Nurse Allan is attempting to determine if the clients self-image has suffered as a result of his diagnosis. What is Nurse Allans priority line of questioning? a. Whether the earning power of the clients household has decreased b. Whether the client has experienced difficulty quitting smoking c. Whether the client has a fulfilling relationship with his wife d. Whether the client has changed his hobbies to accommodate his disease ANSWER: A Economic status may be affected by COPD through changes in income and health insurance coverage. If the client is the head of the household, severe COPD may require role changes that have a negative impact on self-image. If the client is experiencing difficulty in quitting smoking, his self-image will probably not be altered as much as it would be related to income. The client may be experiencing difficulty with his marital relationship, but it probably will not be causing changes in his self-image. Although the client may have had to change his hobbies to accommodate the disease, it probably will not have affected his self-image adversely. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition 53. A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy. Following the bronchoscopy, Nurse Isabel should: a. Check vital signs every 15 minutes for 2 hours. c. Keep the patient NPO until the gag reflex returns. b. Place the patient on bed rest for at least 4 hours. d. Elevate the head of the bed to 80 to 90 degrees. ANSWER: C Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Vital signs are monitored immediately after the procedure but should not need to be obtained every 15 minutes for 2 hours. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowlers position. Reference: Sharon Lewis. Medical Surgical Nursing 7th edition Page 528 54. A patient with COPD has a barrel chest. The nurse would expect the chest x-ray report to indicate that there is: a. Overinflation of the alveoli. c. Fluid in the alveoli. b. Consolidation of lung tissue. d. Air in the pleural space. ANSWER: A

A barrel chest results from lung hyperinflation and is a common finding in patients with COPD. Consolidation, fluid, and air in the pleural space all would indicate that intervention is needed. Reference: Sharon Lewis. Medical Surgical Nursing 7th edition page 511, 521 55. Surgical clients who have chronic respiratory diseases are most likely to develop which postoperative complication? a. Atelectasis b. Stroke c. Hypovolemic shock d. Myocardial infarction ANSWER: A Client with chronic respiratory problems, such as asthma and COPD, impair the clients gas exchange and increase the clients risk associated with inhalation anesthetic agents. It is because of these factors that the client is more likely to develop atelectasis and pneumonia. Reference: Lois White. Foundations of Nursing 3rd edition 56. A 16-year-old asthma patient has an intravenous infusion of theophylline. Which of the following lab results indicates that the theophylline is at therapeutic levels? a. 1 to 9 mcg/mL b. 10 to 20 mcg/mL c. 21 to 30 mcg/mL d. 25 to 32 mcg/mL ANSWER: B From 1 to 9 mcg/mL is not at a therapeutic level. A therapeutic level of theophylline is between 10 and 20 mcg/mL. Greater than 20 mcg/mL is a toxic level of theophylline. Reference: Rick Daniels. Contemporary Medical Surgical Nursing 2nd edition 57. The nurse is assessing a patient with asthma. The patients breath sounds initially had wheezing but are diminishing until no audible sounds heard. This has occurred because: a. Swelling has increased and blocked airways. c. The patient used an inhaler. b. The attack has passed. d. No mucus is present. ANSWER: A This patient needs to be evaluated immediately and receive prompt treatment to reduce the airway obstruction and reverse inflammation. Reference: Rick Daniels. Contemporary Medical Surgical Nursing 2nd edition 58. The client is prescribed two inhalant medications. One is a bronchodilator and the other is a corticosteroid. The nurse believes that the client understands proper self-administration when the client relates which of the following statements? a. I can use the inhalers as often as necessary. b. I should first take the steroid and then the bronchodilator. c. I should first take the bronchodilator and then the steroid. d. It really doesnt matter which one I use first. ANSWER: C If both bronchodilators and steroids are ordered by inhaler, the client should be instructed to use bronchodilator first

then the steroid inhaler. If the bronchioles are dilated first, more tissue is exposed for the steroid drugs to act upon. Reference: Kozier and erbs Fundamentals of Nursing 8th edition 59. The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client is developing pulmonary edema after observing which change in the client? a. Bradycardia c. Cough with pink frothy sputum b. Increased urination d. Increased sleepiness ANSWER: C Pulmonary edema in a client with heart failure is the accumulation of fluid in the alveoli characterized by increased rales, tachypnea, tachycardia, pink frothy sputum, decreased SO2 and PO2. The client presents with acute restlessness and anxiety. Urine output is generally decreased in heart failure clients; increased urinary output is usually caused by diuretic therapy Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Pages 542. 60. A patient is to receive oxygen via nasal cannula. It is important for the nurse to: a. Check that the flow meter is at 15 L/min. c. Make sure the patient performs oral hygiene hourly. b. Keep oxygen tubing and prongs clean. d. Make sure the reservoir bag is inflated. ANSWER: B The maximum amount of oxygen administered via nasal cannula is 6 L/min; 15 L/min is the amount used for a nonrebreather mask. The nonrebreather masks reservoir bag should be inflated; a nasal cannula does not have a bag. Oral hygiene should be performed every two to three hours. A nasal cannula and oxygen tubing should be kept clean and changed if contaminated. Reference: Rick Daniels. Contemporary Medical Surgical Nursing 2nd edition 61. A patient has been smoking for the last 40 years and has a history of emphysema. Which of the following findings would the nurse not expect to find? a. Decreased forced vital capacity (FVC) c. Increased forced expiratory volume (FEV1) b. Increased anterior-posterior chest diameter d. Pursed lip breathing ANSWER: C The FEV1 does not increase; it decreases. The FVC does decrease, and the patient can exhibit increased anteriorposterior chest diameter and pursed lip breathing. Reference: Rick Daniels. Contemporary Medical Surgical Nursing 2nd edition SITUATION: CARDIOVASCULAR PROBLEMS 62. The pumping action of the heart is accomplished by the rhythmic contraction and relaxation of its muscular wall. What change occurs during systole?

a. The chambers of the heart become smaller as the blood is ejected b. The heart chambers fill with blood in preparation for subsequent ejection. c. The heart chamber of the heart becomes bigger as it receives blood d. The myocardium becomes thinner as it blood enter the chamber. ANSWER: A As the blood coming from the systemic circulation enters the inferior and superior vena cava, the atrium will receive the blood which makes the myocardium thin and enlarged. This occurs during diastole when the heart relaxes as the chamber of the heart is filled with blood. During systole or contraction, the heart become smaller as the blood is ejected to the circulation. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.786 63. Cardiac conduction system generates and transmits electrical impulses that stimulate contraction of the myocardium. Impulses come from two specialized electrical cells. What are the physiologic characteristics of the electrical cell? a. Automaticity, excitability, potentiality c. Conductivity, potentiality, refractivity b. Automaticity, conductivity, refractivity d. Automaticity, conductivity, excitability ANSWER: D The two specialized electrical cells are the purkinje cells and the nodal cell that is physiologically characterized by its automaticity, conductivity, and excitability. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.786 64. A normal age-related change in older adults that makes them susceptible to cardiovascular disease is: a. Increasing cardiac output c. Stiff peripheral vessels b. An increase in stroke volume d. Oxygen capacity improvement ANSWER: C As adults age, their peripheral vessels become stiff, their oxygen capacity and stroke volume are reduced, and their aorta thickens and calcifies. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol 1. Page 191-193. 65. Murmurs that indicate heart disease are often accompanied by other symptoms such as: a. Dyspnea on exertion b. Subcutaneous emphysema c. Thoracic petechiae d. Periorbital edema ANSWER: A Murmur that indicates heart disease is often accompanied by dyspnea on exertion which is a hallmark of heart failure. Other indicators are tachycardia, syncope and chest pain. B Subcutaneous emphysema, curs when gas or air is present in the subcutaneous layer of the skin and can result from puncture of parts of the respiratory or gastrointestinal systems. C Thoracic petechiae may be a sign of fat embolism syndrome

D Periorbital edema Edematous swelling of the eyelids in association with local injury, allergic reactions, hypoproteinemia, trichinosis, and myxedema Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 2. Page 2083-2084 66. Which of the following interventions are a priority during exacerbation of left-sided heart failure? 1. Metered dose inhaler of albuterol 3. Oxygen 5. Incentive spirometer 2. High-fowlers position 4. IV fluids 6. Diuretics a. 2, 3, 6 b. 2, 3, 4 c. All except 1 d. All of the above ANSWER: A Nursing interventions that are a priority for a client with acute exacerbation of left-sided heart failure including having the client assume a high-fowlers position, oxygen and diuretics to reduce fluid retention. Albuterol is used for a client with asthma. IV fluid flush would be harmful for a client experiencing respiratory distress from left-sided heart failure Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition Page 953-957 67. Nitroglycerine is prescribed to a patient with angina. As part of the discharge planning, you will provide health teachings on the proper use of NTG. Which statement by the client will help you determine that additional health teaching is needed? a. I should place my NTG tablet on my buccal pouch. b. I should crush NTG tablet if the pain is severe. c. My mouth should be moist d. I should keep my tongue still and swallow my saliva as NTG tablet dissolves. ANSWER: D NTG tablet must be place under the tongue or in the cheek because these areas have too many blood vessels. The mouth should be moist so NTG will dissolve easily and fast. If the patient has a severe chest pain, tablet can crushed or chew for faster absorption. Tongue should be keep still and do not swallow until NTG tablet is completely dissolved. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p. 870 68. Which of the following should the nurse include in the plan of care for a client following a coronary angiogram? a. Vigorous leg exercises c. Encourage fluids b. Immediate cardiac stress test d. Activity restriction for 4 to 6 weeks ANSWER: C The clients leg on the side where the cardiologist entered the femoral artery needs to remain still for a period of time after the procedure (usually 2 to 4 hours) in order to allow the arterial site to seal. A cardiac stress test would not be indicated because angiogram provides a more definitive diagnostic work-up. ! 4 to 6 weeks activity restriction may be indicated after a large MI, but not for a simple coronary angiogram, after which the client can begin walking hours

later. The client should be encouraged to drink fluids to protect the kidney from contrast dye. Reference: Brunner and Suddarths Medical Surgical Nursing 11th edition Page 814 69. Proper care of CVP insertion is a must because this is directly inserted to the blood stream. What nursing intervention is not needed to prevent infection? a. Dressing must be checked and kept dry at all times. c. Dressing must be air occlusive. b. Use sterile technique in changing the dressing of the catheter. d. Observe the dressing for any discharge. ANSWER: D A, B and C are correct answers that can prevent infection. Option D is part of nursing intervention but it cannot prevent infection because it is assessment. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p.818 70. Alteplase recombinant (TPA), a thrombolytic enzyme, is administered during the first 6 hours following onset of MI to: a. Control chest pain c. Control the dysrhythmia associated with MI b. Reduce coronary artery vasospasm d. Revascularize the blocked coronary artery ANSWER: D Rationale: Alteplase recombinant (TPA), a thrombolytic agent administered IV, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours following onset of myocardial infarction. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p. 1003, 2212 71. A client who suffered a myocardial infarction was admitted in the ED. What would be your priority nursing diagnosis during the first 24 hours following an MI? a. Impaired gas exchange b. High risk for infection c. Fluid volume deficit d. Constipation ANSWER: A Impaired gas exchange related to poor oxygenation and dysrhythmia is a major problem immediately following MI therapy is directed toward improving CO and decreasing myocardial workload. Reference: Medical-Surgical by Brunner and Suddarths, 11th edition, p. 883 72. A clients heart rate and rhythm is regular. What does the nurse assume from this finding? a. The coronary arteries have no atherosclerosis. b. Blood pressure is stable. c. Conductivity of the cells in the heart is normal. d. Automaticity of the cells in the conduction system is normal. ANSWER: D Automaticity refers to the ability of cardiac cells to initiate an impulse spontaneously and repetitively. The initiation of an impulse in response to a stimulus refers to excitability. The transmission of electrical impulses that are received

refers to the property of conductivity. The response to a stimulus only after repolarization refers to refractoriness. Blood pressure may or may not be stable with a regular heart rate, because there are other influences. There is no determination that can be made about the coronary arteries, but it may be assumed that the cells in the conduction system are receiving adequate blood flow. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition page 706 73. The client presents with a heart rate of 40 beats/min. The nurse expects that an electrophysiological study may determine an alteration in which structure? a. Sinoatrial (SA) node b. Bachmanns bundle c. Bundle of His d. Purkinje fibers ANSWER: A The SA node is composed of pacemaker cells that normally initiate electrical impulses at a rate of 60 to 100 beats/min. Altered function of the SA node may result in slow or rapid heart rates. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition page 710 74. A clients heart disease has resulted in a reduction of stroke volume. Which compensatory mechanism is expected? a. Increased blood pressure c. Increased heart rate b. Decreased mean arterial pressure d. Decreased respiratory rate ANSWER: C Cardiac output is equal to stroke volume multiplied by the heart rate. When stroke volume decreases, the heart rate increases to compensate. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition page 75. The nurse has administered a drug that causes vasoconstriction. Which finding indicates an expected response? a. Increased diastolic blood pressure c. Increased systolic blood pressure b. Decreased heart rate d. Increased mean arterial pressure ANSWER: A Diastolic pressure is determined by the amount of vasoconstriction in the periphery. An increase in peripheral vascular resistance increases diastolic pressure. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition page 709 76. To auscultate for S3 or S4 gallops in the mitral area, Nurse Hannah listens with the: a. Diaphragm of the stethoscope with the patient in a reclining position. b. Diaphragm of the stethoscope with the patient lying flat on the left side. c. Bell of the stethoscope with the patient in the left lateral position. d. Bell of the stethoscope with the patient sitting and leaning forward. ANSWER: C Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds

associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as S1 and S2. Reference: Sharon Lewis. Medical-Surgical Nursing, 7th Edition Page 750-751 77. When auscultating over the patients abdominal aorta, Nurse Hannah hears a humming sound. She documents this finding as a: a. Thrill b. Bruit c. Heave d. Murmur ANSWER: B A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. Heaves are sustained lifts over the precordium that can be observed or palpated. A murmur is the sound caused by turbulent blood flow through the heart. Reference: Sharon Lewis. Medical-Surgical Nursing, 7th Edition Page 748, 750 78. When auscultating an adult clients heart sound, at which location will S1 be heard the loudest? a. Left midclavicular line at the fifth intercostal space b. Right sternal border at the third intercostal space c. Left sternal border at the fifth intercostal space d. Right midclavicular line at the fifth intercostal space ANSWER: A S1 is the sound produced by the atrioventricular (AV) valves closing. The apex of the heart is located lower on the left chest wall than the base of the heart. The loudest sounds can be heard over the apex of the heart. The sound is audible at the left sternal boarder, but would not be as loud. This sound would not normally be audible on the right midclavicular line at the fifth intercostal space, not at the right sternal border. Reference: Lemone-Burke Medical Surgical Nursing 4th edition pain? 79. Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest a. Sinus tachycardia b. Inverted T wave c. ST-segment elevation d. Frequent PACs ANSWER: C Rationale: The patient is likely to be experiencing an ST-segment elevation myocardial infarction (STEMI) and immediate therapy with PCI or fibrinolytic medications is indicated to minimize the amount of myocardial damage. The other ECG changes also suggest a need for therapy, but not as rapidly. Reference: Sharon Lewis. Medical-Surgical Nursing, 7th Edition Page 802 80. Nurse Lemuel suspects myocardial infarction to a client based on which laboratory value? a. Troponin T = 0.8 ng/mL c. CK creatine kinase = 180 units/L b. Myoglobin = 85 mcg/L d. HDL = 60 mg/dL ANSWER: A

Normal levels are troponin T <0.2 ng/mL; myoglobin <90 mcg/L; CK = 30-135 units/L (females), 55-170 units/L (males); HDL = 55-60 mg/dL (females), 5-50 mg/dL (males). Troponin T and CK levels are elevated. CK is nonspecific for cardiac damage; CK-MB is specific for cardiac muscle; troponin T is specific for cardiac necrosis and acute myocardial infarction (MI). Reference: Sharon Lewis. Medical-Surgical Nursing, 7th Edition Page 81. A client postmyocardial infarction is placed on a beta blocker. Which statement best indicates that the client understands the action of this medication? a. It will decrease my blood pressure. c. I will take this medication at the first indication of chest pain. b. It will make me urinate more. d. This will help prevent cardiac disease. ANSWER: A Beta blockers slow the heart rate and decrease blood pressure. Beta blockers will not make the client urinate more, and they will not prevent cardiac disease. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition page SITUATION: PERIOPERATIVE NURSING 82. The following refers to the definition of perioperative nursing except: a. Period in the health care continuum that focuses merely on the time of surgery until the recovery of the patient b. The total surgical episode. c. The period in the health care continuum that includes the time before the surgery, the time spent during the actual surgical procedure, and after the surgery is completed. d. Care that range from home, through surgery and surgery, and back to home again. ANSWER: A The definition of perioperative nursing starts from before the time of the surgery which is the preoperative nursing; the time spent during the actual surgical procedure intraoperative nursing, and after the surgery, which is the post operative surgery. Choices B, C, and D are correct answer. A is also correct but because of the word merely or only, it became wrong. Perioperative nursing does not focus only on the time of surgery but even before the actual operation. Reference: Medical-Surgical Nursing by Joyce M. Black, 8th edition, p. 184 83. A nurse works collaboratively during the perioperative period. Which of the following would be the nurses and the surgeons role when obtaining the informed consent? a. The nurse is responsible for placing the informed consent form on the chart, for the physician to witness b. The nurse may serve as a witness to the clients signature after the physician has given the consent form to the client. c. The nurse may serve as witness that the client has been informed by the physician before the surgery is performed. d. The nurse has no duties in obtaining the consent form if the client has signed it in front of the physician.

ANSWER: B The surgeon has the ultimate responsibility for obtaining the informed consent from the patient, which includes the risks, benefits, and possible complication of all proposed surgical procedures. A witness verifies that the consent was signed without coercion after the surgeon explained the details of the procedure. The witness may be physician, nurses, other facility employees, or family members as established by policy. Reference: Operating Room Technique by Nancymarie Phillips, 11th edition, p. 45 84. Principles of sterile technique include all of the following except: a. Only sterile items are used inside the sterile field b. The circulating nurse can have a direct contact with the sterile field. c. Only the top of a sterile, draped table is considered sterile. d. Gowns are considered sterile only from the chest to the level of the sterile field in the front, and from 2 inches above the elbows to the cuffs on the sleeves. ANSWER: B Option A, C, and D are principles of sterile technique. Option B can be a correct statement but because circulating nurse belongs to unsterile group inside the OR, circulating nurse cannot directly be in contact with the sterile field. He must wear gloves and use long forceps and carefully observed sterile techniques in collaboration with the other member of the team. Circulating nurse cant be sterile because of his role inside the OR and a circulating nurse only wears scrub suit and other attire but not a gown. Reference: Operating Room Technique by Nancymarie Phillips, 11th edition, p. 45 85. You are inside the operating room as a scrub nurse. The nurse knows that the gloves and gowns are used to exclude the skin as a possible contaminant and that these create barriers between the sterile and unsterile field. Which of the following statements below should be best observed by the nurse when donning gloves? a. With the left hand, pick up the right glove by grasping the fingers, lifting straight up, and placing on the right palm thumb side down. b. Pick up the right glove with the left hand covered with cuff by grasping the fingers, lifting straight up, and placing on the right palm side down. c. Use a skin-to-skin, glove-to-glove technique. d. Put bare hand inside the cuff. ANSWER: B Option A and B is almost the same but if you would look closely to choice B, it is the correct answer because gloving by closed technique should not expose your hand out of the cuff of gowns sleeve. Option C and D applies to open gloving technique whereas skin-to-skin and glove-to-glove is use. One should grasp the inner edge of one glove, whether left or right is first, and put the bare hand inside the gloves taking care not to touch the inner aspect of the wrapper or the sterile exterior of the glove. With the sterile gloved fingers of the other hand pick up the other glove, touching the inner aspect gloves edge.

Reference: Operating Room Technique by Nancymarie Phillips, 11th edition, p. 280 86. A circulating nurse is about to pour a solution into an empty basin. The nurse proceeds with caution and properly executes her task when she does which of the following to avoid contamination? a. Reaches across the table so pouring could be easier and less chances of contaminating the top of the table. b. Set the basin or medicine cup at the center of the table so as not to shove the basin. c. Stand as close as possible to the table so it is more comfortable and accident during can be minimized. d. Hold only the lip of the bottle over the basin when pouring. ANSWER: D The nurse should only hold the lip of the bottle over the basin when pouring the solution to avoid reaching over a sterile field. This also made choice A wrong, across or reaching over breaks the aseptic technique. Choice B is incorrect because the basin or the medicine cup should be placed at the edge of the table, again to avoid reaching over the sterile field. Option D is the correct answer. It means that only the lip of the bottle is over the basin, thus you dont need to get near and reach your arm across the aseptic field. Reference: Operating Room Technique by Nancymarie Phillips, 11th edition, p. 280 87. Grasya is diagnosed with cholecystitis and she is experiencing severe pain. The doctor explained to her that she will need to undergo what category of surgery based on urgency? a. Emergent b. Urgent c. Required d. Elective ANSWER: B In urgent surgery, patient requires prompt attention. Surgery is indicated within 24 to 30 hours, sample cases are kidney or ureteral stones and acute gallbladder infections. Option A patient requires immediate attention; disorder may be life-threatening and the surgery must not be delayed. Examples cases are severe bleeding, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds and extensive burns. Option C patient needs to have surgery and plan within a few weeks or months. Example cases are prostatic hyperplasia without bladder obstruction, thyroid disorders and cataracts. Option D failure to have surgery is not catastrophic. Sample cases are repair of scars, simple hernia, and vaginal repair. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol. 1. Page 402 88. An informed consent has to be obtained from a patient who is about to undergo surgery. Who among the members of the surgical team has the responsibility to explain the procedure and obtain informed consent? a. Scrub Nurse b. Circulating Nurse c. Surgeon d. Anesthesiologist ANSWER: C

It is the surgeons responsibility to explain the procedure and obtain the informed consent. Surgeon must provide a clear and simple explanation of what the surgery will entail. Reference: Bare, B.G. and Smeltzer, S.C. (2004). Brunner & Suddarths Textbook of Medical-Surgical Nursing. 10th Edition, Vol 1. Page 402 Black, J.M. and Hawks J. H. (2008) Medical-Surgical Nursing. Clinical Management for Positive Outcomes. 8th Edition. Vol. 1. Page 198 Perry, A.G. and Potter, P.A. (2005). Fundamentals of Nursing. 6th Edition. Vol. 2. Page 1610 89. The PACU nurse is evaluating the patient for possible transfer to the surgical unit. Which of the following assessment findings would prevent the patients transfer? a. Blood pressure is 126/78 mm Hg c. Pulse oximeter reading is 80% b. Pulse rate is 82 beats per minute d. Respirations are 15 per minute ANSWER: C The pulse oximeter reading should be 95% to 100%. The patient should not be transferred from the recovery room until the vital signs are stable, respiratory and circulatory functions are adequate, pain is minimal, he or she is easily wakened, no complications are experienced, and the gag reflex is present. A Value is still within the normal range (100/60 140/90 mm Hg) B Value is still within the normal range (60-100 beats per minute) D Value is still within the normal range (12-20 breaths per minute) Reference: Kozier, B. et. al. (2008). Fundamentals of Nursing: Concepts, Process and Practice. 8th edition. New Jersey: Prentice Hall. 90. Exploratory laparotomy procedure requires continuously available warm normal saline for irrigation. The perioperative nurse should pour the needed amount of saline into a sterile container. If the saline solution is not fully consumed, the remaining solution should be: a. Returned to the warmer for reuse when needed. c. Left uncapped and poured again as needed. b. Recapped and poured again as needed. d. Discarded and a new bottle opened each time more is needed ANSWER: D The entire contents of the liquid container should be poured into a sterile receptacle on the sterile field. Any remaining fluids would need to be discarded. The edge of a container is considered contaminated after the cap has been removed. Reference: Operating Room Technique by Nancymarie Phillips, 11th edition, p. 280 91. A patient has been intubated and is to be moved from supine position on the transportation vehicle to prone position on the OR bed. To ensure adequate ventilation, chest rolls must be placed: a. Perpendicular to the patient's spine across the nipple line and iliac crest. b. Lengthwise from the acromioclavicular joint to the iliac crest.

c. Along the patient's lateral chest wall from the nipple line to midthigh. d. From the rib cage to the greater trochanter. ANSWER: A Chest rolls from the shoulder to the iliac crest are needed so that chest expansion is not compromised. The weight of the abdomen will fall away from the diaphragm and keep pressure off the vena cava and abdominal aorta. Reference: Operating Room Technique by Nancymarie Phillips, 11th edition, p. 510 92. Surgery is almost completed for an obese client with diabetes, and the surgeon prepares to close a large abdominal incision. What should the scrub nurse have ready for the surgeon? a. Steri-strips b. Absorbable sutures c. Retention sutures d. Surgical glue ANSWER: C The obese client with diabetes is at high risk for poor wound healing. Retention sutures would be appropriate to reduce the risk of dehiscence or evisceration. Reference: Ignatavicius: Medical-Surgical Nursing, 6th Edition Page 93. Preoperatively a client is given meperidine (Demerol) and hydroxyzine pamoate (vistaril). The vistaril is given to: a. Inhibit peristalsis c. Limit the development of dysrhythmias b. Promote unconsciousness d. Reduce the amount of needed narcotics ANSWER: D Hydroxyzine pamoate (vistaril) is an anxiolytic drug. It is also used as an adjunctive pre and postoperative medication to permit reduction in narcotic dosage. Reference: Adrienne Woods. Nurses Drug Handbook. Page 680 94. On the fifth postoperative day, a client has had abdominal surgery complains of a giving sensation around the wound when walking about. After assessing the client back in bed, the nurse notes that the dressing covering the incision is sutured with clear, pink drainage. The nurse should suspect: a. Late hemorrhage b. Dehiscence c. Infection d. Evisceration ANSWER: B Dehiscence is a partial or total separation of the superficial layers of the wound. The strength of the tissues and extent of separation determine whether or not the wound must be reclosed. Evisceration is the protrusion of viscera through the full thickness of the abdominal incision. An evisceration requires immediate reclosure of the incision. Reference: Berry and Kohns Operating Room Technique. 6th edition Page 598 95. The best indication that a client has recovered fully from general anesthesia is: a. The blood oxygen level is normal c. The client is awake and oriented b. The client is able to lift legs off the bed d. The blood pressure and pulse is normal

ANSWER: C General anesthesia results in an unconscious, immobile, quiet patient who does not recall the procedure. Being wake and oriented means the general anesthesia has completely wear off. Reference: Berry and Kohns Operating Room Technique. 6th edition Page 598 96. A 42-year-old patient is recovering from anesthesia in the PACU. On admission to the PACU the blood pressure (BP) was 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to a. Administer oxygen therapy at 100% per mask. c. Increase the rate of the IV fluid replacement. b. Notify the anesthesia care provider (ACP) immediately. d. Continue to take vital signs every 15 minutes. Answer: D A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and highconcentration oxygen administration. Reference: Sharon Lewis. Medical Surgical Nursing 7th edition Page 386 97. To avoid the above legal risk in a publication, to whom should the nurse obtain a permission to use quotations in the study? a. Copyright holder b. Editor of the book c. Publishing company d. The author ANSWER: A Philippine copyright law is enshrined in the Intellectual Property Code of the Philippines, officially known as Republic Act No. 8293. The law is partly based on United States copyright law and the principles of the Berne Convention for the Protection of Literary and Artistic Works. The holder of the copyright is the person whom Gwen should ask the permission. It is not the editor or the publishing company or even the author if the copyright is not awarded to her or if she is not the one whos holding the right. In choosing an answer, we should be specific. Reference: Philippine National library, Philippine constitution, Approved: June 6, 1997 98. Which sampling method allows the use of any group of research subject? a. Quota b. Purposive c. Snowball d. Convenience ANSWER: D Convenience sampling or an accidental sampling entails using the most conveniently available people as study participants. Quota sampling Snowball sampling or network or chain sampling is a variant of convenient sampling where early sample members are asked to refer other people who meet the eligibility criteria. Purposive sampling is based on the belief that researchers knowledge about the population can be used to hand-pick sample members.

Nursing Research by Denise F. Polit, 8th edition, p. 339-347 99. The nurse researcher utilized the snowball sampling, in which he can easily get a sample through the help of the seeds. Seeds in snowball sampling refer to: a. Samples from population strata. b. Sample selected by the researcher with set of criteria. c. Early sample members who can refer other people who meet eligibility criteria. d. Subjects purposely selected and believed to be knowledgeable about the issues under the study. ANSWER: C Accidental samples fall under convenient sample while option B is a quota sampling and option D is purposively sampling. Seeds are early sample members who were asked to refer other people, who meet eligibility criteria which is known to be snowball sampling or networking. Nursing Research by Denise F. Polit, 8th edition, p. 339-347 100. Differentiate between a longitudinal and cross-sectional study: a. A longitudinal study looks back at subjects, a cross-sectional study looks forward b. A longitudinal study follows subjects over a period of time, in the future; a cross-sectional study examines subjects at one point in time c. A longitudinal study is conducted looking at before and after an intervention; a cross-sectional study looks at one aspect only d. The sample from a cross-sectional study comes from a crosssection of subjects from several separate cities; a longitudinal study includes subjects in neighboring cities ANSWER: B These terms refer to time frames: cross-sectional study examines subjects at one point in time. Longitudinal studies follow the subjects over a period of time in the future. Reference: Polit and Beck. Nursing Reseach. 8th edition Page 206-208