MISAMIS UNIVERSITY

COLLEGE OF NURSING

IN-HOUSE REVIEW PROGRAM

NAME: ________________________________ DATE: _________

SECTION: ______________________________ SCORE: ________

EVALUATION EXAMINATION IN MEDICAL SURGICAL NURSING (PART II)

INSTRUCTIONS: This questionnaire contains 100 ITEMS. Read the questions thoroughly
and carefully then choose the LETTER of the correct answer.

SITUATION 1 - Maya, a housekeeper, 5. The nurse recognizes that additional

presents to an emergency department teaching is needed when the patient with
with an admitting diagnosis of acute asthma says:
asthma attack. The client has dyspnea, a. “I should exercise every day if my
SaO2 is 91%, and is exhibiting audible symptoms are controlled.”
wheezing and use of accessory muscles. b. “I may use over-the-counter
bronchodilator drugs occasionally if I
1. To decrease the patient’s sense of panic develop chest tightness.”
during an acute asthma attack, what is the c. “I should inform my spouse about my
best action for the nurse to do? medications and how to get help if I
a. Leave the patient alone to rest in a have a severe asthma attack.”
quiet, calm environment. d. “A diary to record my medication use,
b. Stay with the patient and encourage symptoms, peak expiratory flow rates,
slow, pursed lip breathing. and activity levels will help in adjusting
c. Reassure the patient that the attack my therapy.”
can be controlled with treatment.
d. Let the patient know that frequent SITUATION 2 - A 59-year-old client
monitoring is being done using comes to the emergency department.
measurement of vital signs and SpO2. She is newly diagnosed with
2. In what position should the nurse place emphysema. She currently smokes one
Maya to relieve her difficulty of breathing? pack of cigarettes a day and has been
a. High-Fowler’s c. Semi-Fowler’s smoking since she was 19. She presents
b. Side-lying d. Prone with symptoms of dyspnea, chronic
3. Maya is found to be allergic to Chinese cough, and sputum production.
food. Which instruction should the nurse
give the client? 6. Tobacco smoke causes defects in multiple
a. “Only eat Chinese food once per areas of the respiratory system. What is a
month.” long-term effect of smoking?
b. “Use your inhalers before eating a. Bronchospasm and hoarseness
Chinese food.” b. Decreased mucus secretions and cough
c. “Avoid Chinese food because this is a c. Increased function of alveolar
trigger for you.” macrophages
d. “Determine other causes because d. Increased risk of infection and
Chinese food wouldn’t cause such a hyperplasia of mucous glands
reaction.” 7. A client with emphysema should receive
4. When the nurse is evaluating the only 1 to 2 L/min of oxygen, if needed, or
effectiveness of therapy for a patient who he may lose his hypoxic drive. Which
has received treatment during an asthma statement is correct about hypoxic drive?
attack, which finding is the best indicator a. The client doesn’t notice that he needs
that the therapy has been effective? to breathe.
a. No wheezes are audible. b. The client breathes only when his
b. Oxygen saturation is >90%. oxygen levels climb above a certain
c. Accessory muscle use has decreased. point.
d. Respiratory rate is 16 breaths/minute. c. The client breathes only when his
oxygen levels dip below a certain point.
d. The client breathes only when his
carbon dioxide level dips below a
certain point.

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8. When a hospitalized client with 13.Which information will the nurse include in
emphysema is receiving oxygen, the best teaching Jane with chronic bronchitis who
action by the nurse is to has a new prescription for home oxygen
a. minimize oxygen use to avoid oxygen therapy?
dependency. a. Storage of oxygen tanks will require a
b. maintain the pulse oximetry level at large space.
90% or greater. b. Travel opportunities will be limited
c. administer oxygen according to the because of the use of oxygen.
level of dyspnea. c. Oxygen flow should be increased if the
d. avoid giving oxygen at a rate of more patient has more dyspnea.
than 2 L/min. d. Oxygen use can improve the patient‘s
9. After the nurse has finished teaching a prognosis and quality of life.
client about pursed lip breathing, which 14.Exercise has which effect on patients with
indicates that more teaching is needed? emphysema?
a. The patient inhales slowly through the a. It enhances cardiovascular fitness.
nose. b. It improves respiratory muscle
b. The patient puffs up the cheeks while strength.
exhaling. c. It reduces the number of acute attacks.
c. The patient practices by blowing d. It worsens respiratory function and is
through a straw. discouraged.
d. The patient‘s ratio of inhalation to 15.Joshua, the husband of Jane, tells the
exhalation is 1:3. nurse that he and his wife have not had
10.The patient asks the nurse why he needs any sexual activity since she was
to get flu vaccines when in fact these diagnosed with chronic bronchitis because
biologicals do not cure emphysema. The she becomes too short of breath. What is
nurse responds correctly by saying: the nurse’s best response?
a. “These vaccines are recommended for a. “You need to discuss your feelings and
all clients.” needs with your wife so she knows
b. “These vaccines produce what you expect of her.”
bronchodilation and improve b. “There are other ways to maintain
oxygenation.” intimacy besides sexual intercourse
c. “These vaccines help reduce the that will not make her short of breath.”
tachypnea these clients experience.” c. “You should explore other ways to
d. “Respiratory infections can cause meet your sexual needs since your wife
severe hypoxia and lead to is no longer capable of sex.”
complications.” d. “Would you like for me to talk to you
and your wife about some
SITUATION 3 - Jane is a 35-year-old modifications that can be made to
mother of two school-age boys who maintain sexual activity?”
arrives via ambulance in the emergency
department (ED) with severe wheezing, SITUATION 4 - A nurse is caring for a 36-
dyspnea, and anxiety. She was recently year-old male client diagnosed with
diagnosed with chronic bronchitis. pneumonia. Initial assessment reveals
crackles bilaterally and an SaO2 of 85%.
11.Postural drainage with percussion and The client is coughing vigorously.
vibration is ordered twice daily for Jane.
The nurse will plan to: 16.Following assessment of a patient with
a. carry out the procedure 3 hours after pneumonia, the nurse identifies a nursing
the patient eats. diagnosis of ineffective airway clearance.
b. maintain patient in the lateral position Which information best supports this
for 20 minutes. diagnosis?
c. perform percussion before assisting the a. Weak, nonproductive cough effort
patient to the drainage position. b. Large amounts of greenish sputum
d. give the ordered albuterol (Proventil) c. Respiratory rate of 28 breaths/minute
after Jane has received the therapy. d. Resting pulse oximetry of 85%
12.Jane is placed under diuretic therapy. 17.Pulse oximetry may not be a reliable
Which reason best explains why? Reducing indicator of oxygen saturation if the
fluid volume _______________ patient has:
a. reduces oxygen demand. a. Fever c. Dehydration
b. improves client’s mobility. b. Anesthesia d. Oxygen therapy
c. reduces sputum production.
d. improves respiratory function.

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18.How does the nurse assess the patient’s 23.Following the incident, the nurse assesses
chest expansion? Manolo for which distinctive sign of flail
a. Put the palms of the hands against the chest?
chest wall. a. Severe hypotension
b. Put the index fingers on either side of b. Chest pain over ribs
the trachea. c. Absence of breath sounds
c. Place thumbs at midline of lower chest. d. Paradoxical chest movement
d. Place one hand on the lower anterior 24.The health care provider inserts a chest
chest and one hand on the upper tube in Manolo. When monitoring the
abdomen. patient after the chest tube placement, the
19.What is the initial antibiotic treatment for nurse will be most concerned about:
pneumonia based on? a. a large air leak in the water-seal
a. The severity of symptoms chamber.
b. The presence of characteristic leukocytes b. 400 mL of blood in the collection
c. Gram stains and cultures of sputum chamber.
specimens c. complaint of pain with each deep
d. History and physical examination and inspiration.
characteristic chest x-ray findings d. subcutaneous emphysema at the
20.Which statement by a patient who has insertion site.
been hospitalized for pneumonia indicates 25.A nursing aide is tending to Manolo. The
a good understanding of the discharge nurse should intervene when she observes
instructions given by the nurse? the nursing aide:
a. “I will call the doctor if I still feel tired a. looping the drainage tubing on the bed.
after a week.” b. securing the drainage container in an
b. “I will need to use home oxygen upright position.
therapy for 3 months.” c. stripping or milking the chest tube to
c. “I will continue to do the deep promote drainage.
breathing and coughing exercises at d. reminding the patient to cough and
home.” deep breathe every 2 hours.
d. “I will schedule two appointments for
the pneumonia and influenza SITUATION 6 - The nurse is taking care
vaccines.” of patients with tracheostomies.

SITUATION 5 - Manolo, a 24-year-old 26.What is included in the nursing care of the

male TV host, is admitted to the patient with a cuffed tracheostomy tube?
emergency department suffering from a a. Change the tube every 3 days.
gunshot wound. Vital signs are: blood b. Monitor cuff pressure every 8 hours.
pressure 108/55 mm Hg, heart rate 124 c. Perform mouth care every 12 hours.
beats/min, respiratory rate 36/min, d. Assess arterial blood gases every 8
temperature 38.6° C (101.4° F), and hours.
SaO2 95% on 15 L/min by a 27.During care of a patient with a cuffed
nonrebreather mask. He reports dyspnea tracheostomy, the nurse notes that the
and pain. tracheostomy tube has an inner cannula.
To care for the tracheostomy
21.Thirty minutes later, Manolo develops appropriately, what should the nurse do?
hemothorax and pneumothorax. He now a. Deflate the cuff, then remove & suction
has absent breath sounds in the right lung. inner cannula.
To promote improved ventilation and b. Remove inner cannula and replace it
perfusion, how should the nurse position per institutional guidelines.
the patient? c. Remove inner cannula if there is airway
a. On the left side obstruction.
b. On the right side d. Keep the inner cannula in place at all
c. In a reclining chair bed times to prevent dislodging the
d. Supine with the head elevated tracheostomy tube.
22.The emergency department nurse notes 28.A patient’s tracheostomy tube becomes
that the breath sounds are absent on the dislodged with vigorous coughing. What
right side. The nurse will anticipate the should be the nurse’s first action?
need for a. Attempt to replace the tube.
a. emergency pericardiocentesis. b. Notify the health care provider.
b. stabilization of the chest wall with tape. c. Place the patient in high Fowler
c. administration of an inhaled position.
bronchodilator. d. Ventilate the patient with a manual
d. insertion of a chest tube with a chest resuscitation bag until the health care
drainage system. provider arrives.

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29.An RN is observing a nursing student who 34.Which part of the eye is examined to see
is suctioning a hospitalized patient with a arterial changes caused by hypertension?
tracheostomy in place. Which action by the a. Cornea c. Retina
student requires the RN to intervene? b. Fovea d. Sclera
a. The student preoxygenates the patient 35.Which information should the nurse include
for 1 minute before suctioning. when teaching a patient with newly diagnosed
b. The student puts on clean gloves and hypertension?
uses a sterile catheter to suction. a. Dietary sodium restriction will control BP
c. The student inserts the catheter about for most patients.
5 inches into the tracheostomy tube. b. Most patients are able to control BP
d. The student applies suction for 10 through lifestyle changes.
seconds while withdrawing the c. Hypertension is usually asymptomatic
catheter. until significant organ damage occurs.
30.An 87-year-old client requires long term d. Annual BP checks are needed to monitor
ventilation therapy. he has a tracheostomy treatment effectiveness.
in place and requires frequent suctioning.
Which technique is correct? SITUATION 8 - While working at the Cardiac
a. Using intermittent suction while Unit, the nurse is tasked to take care of
advancing the catheter. patients with hypertension. Her tasks
b. Using continuous suction for no longer include delegation and prioritization of the
than 10 seconds while withdrawing the needs of the patients.
catheter.
c. Using continuous suction for no longer 36.The nurse just received the change-of-shift
than 20 seconds. report on four patients with hypertension.
d. Using continuous suction while Which patient should the nurse assess first?
advancing the catheter. a. 52-year-old with BP of 212/90 &
claudication
SITUATION 7 - Vickie, a call center b. 43-year-old with a BP of 190/102 & chest
agent, is admitted to the emergency pain
department with a high blood pressure. c. 50-year-old with a BP of 210/110 & crea
The client reports a headache and states of 1.5 mg/dL
that she is seeing double. d. 48-year-old with a BP of 200/98 whose
urine shows microalbuminuria
31.The nurse is about to measure Vicky’s 37.The nurse is reviewing the laboratory tests for
blood pressure (BP). The bell of the a patient who has recently been diagnosed
stethoscope is most commonly placed over with hypertension. Which result is most
which artery to obtain the BP? important to communicate to the health care
a. Brachial c. Radial provider?
b. Brachiocephalic d. Ulnar a. Serum creatinine of 2.6 mg/dL
32.Which action will the nurse in emergency b. Serum potassium of 3.8 mEq/L
department take in order to obtain an c. Serum hemoglobin of 14.7 g/dL
accurate baseline blood pressure (BP) for d. Blood glucose level of 98 mg/dL
a new patient? 38.Which nursing action should the nurse take
a. Obtain a BP reading in each arm. first in order to assist a patient with newly
b. Deflate cuff at rate of 5-10 mmHg/sec. diagnosed stage 1 hypertension in making
c. Have the patient sit with the feet flat needed dietary changes?
on the floor. a. Have patient record diet for 3 days.
d. Assist the patient to the supine position b. Give the patient a detailed list of low-
for BP measurements. sodium foods.
33.Vickie tells that nurse that she has no c. Teach the patient about foods that are
previous history of hypertension or other high in sodium.
health problems. After reconfirming her d. Help the patient make an appointment
BP, it is appropriate for the nurse to tell with a dietitian.
the patient that 39.The unit is very busy and short staffed. What
a. a BP recheck should be scheduled in a could be delegated to the nursing aide?
few weeks. a. Administer antihypertensive medications
b. the dietary sodium and fat content to stable patients.
should be decreased. b. Obtain orthostatic blood pressure (BP)
c. there is an immediate danger of a readings for older patients.
stroke and hospitalization will be c. Check BP readings for the patient
required. receiving IV enalapril.
d. more diagnostic testing may be needed d. Teach about home BP monitoring and
to determine the cause of the use of automatic BP monitoring
hypertension. equipment.

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40.Which manifestation is an indication that a SITUATION 10 - A nurse is performing an
patient is having a hypertensive assessment with a client who is suspected
emergency? to have a peripheral arterial disease (PAD).
a. Symptoms of a stroke with an elevated
BP 46.The patient at the clinic says, “I have always
b. A systolic BP >200 and a diastolic BP taken an evening walk, but lately my leg
>120 cramps and hurts after just a few minutes of
c. A sudden rise in BP accompanied by walking. The pain goes away after I stop
neurologic impairment walking, though.” The nurse should
d. A severe elevation of BP that occurs a. palpate the dorsalis pedis and posterior
over several days or weeks tibial pulses.
b. check for the presence of tortuous veins
SITUATION 9 - Fredo, 56-year-old client on the legs.
presents with reports of a persistent, c. ask about any skin color changes that
chronic cough unrelieved by sinus and occur in response to cold.
cold medications or antacids. On d. assess for unilateral swelling, redness, and
assessment, the nurse notes that the tenderness of either leg.
client’s blood pressure is 164/98 mm Hg, 47.The nurse performing an assessment with a
pulse 96 beats/min, and respirations patient who has chronic peripheral artery
22/min. CT scan results indicate a 5-cm disease (PAD) of the legs and an ulcer on the
enlargement of the ascending aorta. left great toe would expect to find
a. a positive Homans‘ sign.
41.A patient has a 5-cm abdominal aortic b. swollen, dry, scaly ankles.
aneurysm (AAA) that was discovered c. prolonged capillary refill in all the toes.
during a CT scan. When obtaining a d. a large amount of drainage from ulcer.
nursing history from the patient, it will be 48.For a client with severe PAD, the nurse should
most important to ask about all of the expect that the client may sleep most
following symptoms, EXCEPT: comfortably in which of the following
a. back or lumbar pain. positions?
b. difficulty swallowing. a. Affected limb hanging from bed
c. abdominal tenderness. b. Affected limb elevated on pillows
d. changes in bowel habits. c. Head of bed raised on blocks
42.Which sound is distinctly heard on d. Side-lying recumbent position
auscultation over the abdominal region of 49.When teaching the patient with PAD about
a patient with AAA? modifying risk factors associated with the
a. Bruit c. Dullness condition, what should nurse emphasize?
b. Crackles d. Friction rubs a. Amputation is the ultimate outcome if the
43.Upon seeing the CT scan results, Fredo’s patient does not alter lifestyle behaviors.
aneurysm is uniform in shape and shows a b. Modifications will reduce the risk of other
circumferential dilation of the artery. This atherosclerotic conditions such as stroke.
type of aneurysm is classified by the nurse c. Risk-reducing behaviors initiated after
as: angioplasty can stop the progression of
a. False aneurysm the disease.
b. Pseudoaneurysm d. Maintenance of normal body weight is the
c. Saccular aneurysm most important factor in controlling
d. Fusiform aneurysm arterial disease.
44.Which symptom usually signifies rapid 50.In evaluating the patient outcomes following
expansion and impending rupture of an teaching for a patient with chronic peripheral
abdominal aortic aneurysm? artery disease (PAD), the nurse determines a
a. Abdominal pain need for further instruction when the patient
b. Absent pedal pulses says,
c. Angina a. “I will have to buy some loose clothing that
d. Lower back pain does not bind across my legs or waist.”
45.A patient with a small AAA is not a good b. “I will use a heating pad on my feet at
surgical candidate. What should the nurse night to increase the circulation and
teach the patient is one of the best ways warmth in my feet.”
to prevent expansion of the lesion? c. “I will walk to the point of pain, rest, and
a. Avoid strenuous physical exertion. walk again until I develop pain for a half
b. Control hypertension with prescribed hour daily.”
therapy. d. “I will change my position every hour and
c. Comply with prescribed anticoagulant avoid long periods of sitting with my legs
therapy. down.”
d. Maintain a low-calcium diet to prevent
calcification of the vessel.

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SITUATION 11 - Liro, a 65-year-old client SITUATION 12 – Nurse Sharon is working in
with a diagnosis of deep vein thrombosis a Coronary Care Unit providing care to
(DVT) and thrombophlebitis of the left patients with angina and myocardial
lower extremity is admitted to a medical- infarction (MI).
surgical unit. Reported symptoms
include left calf pain and tenderness with 56.Upon reading the chart of one of her patients,
a sudden onset of swelling in the affected Nurse Sharon read a history of acute coronary
extremity. syndrome. This means that Nurse Sharon’s
patient:
51.To monitor for the progression of the DVT, a. experienced an increased supply and a
the nurse should decreased demand of myocardial oxygen
a. place the client in the knee-chest supply.
position. b. went through an abrupt interruption of
b. measure, record, and compare right oxygen supply to the heart muscle.
and left calf and thigh circumferences. c. had an irreversible condition attributed to
c. perform passive range of motion in the tissue necrosis.
affected leg. d. survived a fatal heart attack secondary to
d. encourage the client to walk to the the presence of an atherosclerosis.
point of pain, rest, and then walk again 57.Which of the following is NOT a risk factor for
until the point of pain. MI?
52.The provider has ordered thigh-high a. Female gender c. Diabetes mellitus
compression stockings to prevent chronic b. Cocaine use d. Recent divorce
venous insufficiency. The nurse should 58.The nurse is reading the laboratory tests of
instruct the client to the patient and confirms cardiac damage has
a. massage both legs firmly with lotion transpired upon seeing an increased level of:
prior to applying the stockings. a. CK-MB c. Myoglobin
b. apply the stockings in the morning b. Troponin I d. LDH
upon awakening. 59.What is the primary reason for administering
c. roll the stockings down to the knees if morphine to a client with a myocardial
they will not stay up on the thighs. infarction?
d. remove the stockings while out of bed a. To sedate the client
for 1 hr four times a day to allow the b. To decrease the client’s pain
legs to rest. c. To decrease the client’s anxiety
53.The health care provider has prescribed d. To decrease the oxygen demand on the
bed rest with the feet elevated for a client’s heart
patient admitted to the hospital with deep 60.Nurse Sharon finds a female client who had
vein thrombosis. The best method for the MI slumped on the side rails of the bed and
nurse to use in elevating the patient‘s feet unresponsive to shaking or shouting. Which
is to should be Nurse Sharon’s next action?
a. place the patient in the Trendelenburg a. Call for help and note the time.
position. b. Clear the airway.
b. place two pillows under the calf of the c. Give two sharp thumps to the precordium,
affected leg. and check the pulse.
c. elevate the bed at the knee & put d. Administer two quick blows.
pillows under feet.
d. put one pillow under thighs and two SITUATION 13 - A patient is admitted to the
pillows under legs. Coronary Care unit for signs and symptoms
54.What is the most important measure in the of angina.
treatment of venous stasis ulcers?
a. Elevation of the limb 61.Which information given by a patient
b. Elastic compression stockings admitted with chronic stable angina will help
c. Application of moist dressings the nurse confirm this diagnosis?
d. Application of topical antibiotics a. The patient rates the pain at a level 3 to 5
55.The nurse teaches the patient with any (0 to 10 scale).
venous disorder that the best way to b. The patient states that the pain “wakes me
prevent venous stasis and increase venous up at night.”
return is to: c. The patient says that the frequency of the
a. walk. pain has increased over the last few
b. sit with legs elevated. weeks.
c. frequently rotate ankles. d. The patient states that the pain is resolved
d. wear elastic stockings. after rest.

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62.There are different types of angina. What 68.During the assessment, the nurse identifies
is another term used for variant angina? crackles in the lungs and an S3 heart sound.
a. Unstable c. Prinzmetal Which complication of MI should the nurse
b. Preinfarction d. Angina at rest suspect and further investigate?
63.When a patient reports chest pain, why a. Pericarditis
must unstable angina be identified and b. Heart failure
rapidly treated? c. Ventricular aneurysm
a. The pain may be severe and disabling. d. Papillary muscle dysfunction
b. ECG changes and dysrhythmias may 69.After a myocardial infarction (MI), serum
occur during an attack. glucose levels and free fatty acid production
c. Atherosclerotic plaque deterioration both increase. What type of physiologic
may cause complete thrombus of the changes are these?
vessel lumen. a. Electrophysiologic c. Mechanical
d. Spasm of a major coronary artery may b. Hematologic d. Metabolic
cause total occlusion of the vessel with 70.A patient who survived MI is exhibiting
progression to MI. anxiety while being taught about possible
64.When instructing the patient with angina lifestyle changes. The nurse evaluates that
about taking sublingual nitroglycerin the anxiety is relieved when the patient
tablets, what should the nurse teach the states
patient? a. “I’m going to take this recovery one step
a. To lie or sit and place one tablet under at a time.”
the tongue when chest pain occurs b. “I feel much better and am ready to get
b. To take the tablet with a large amount on with my life.”
of water so it will dissolve right away c. “How soon do you think I will be able to
c. That if one tablet does not relieve the go back to work?”
pain in 15 minutes, the patient should d. “I know you are doing everything
go to the hospital possible to save my life.”
d. That if the tablet causes dizziness and
a headache, stop the medication and SITUATION 15 - Heart failure is the
call the doctor or go to the hospital inability of the heart to maintain adequate
65.A client with angina reports not being able circulation to meet tissue needs for oxygen
to make all of the lifestyle changes and nutrients. Heart failure occurs when
recommended. Which of the following the heart muscle is unable to pump
changes should the nurse suggest the effectively, resulting in inadequate cardiac
client work on first? output, myocardial hypertrophy, and
a. Diet modification pulmonary/systemic congestion.
b. Relaxation exercises
c. Smoking cessation 71.Prior to diagnosis of heart failure, a nurse is
d. Taking omega-3 capsules auscultating the chest of a patient for heart
sounds. To auscultate for S3 or S4 gallops in
SITUATION 14 - Eduardo, a 52-year-old the mitral area, the nurse listens with the
politician is admitted to the emergency a. bell of the stethoscope with the patient in
department with severe chest pain right the left lateral position.
after delivering a public speech. Upon b. bell of the stethoscope with the patient
evaluation of his chest pain, Eduardo has sitting and leaning forward.
no abnormal serum cardiac markers 4 c. diaphragm of the stethoscope with the
hours after the onset of pain. patient in a reclining position.
d. diaphragm of the stethoscope with the
66.On what basis would the nurse suspect MI? patient lying flat on the left side.
a. He has pale, cool, clammy skin. 72.While assessing a patient who was admitted
b. He reports nausea and vomited once at with heart failure, the nurse notes that the
home. patient has jugular venous distention (JVD)
c. He says he is anxious and has a feeling when lying flat in bed. Which action should
of impending doom. the nurse take next?
d. He reports he has had no relief of the a. Use a ruler to measure the level of the
pain with rest or position change. JVD.
67.What noninvasive diagnostic test can be b. Document this finding in the patient‘s
used to differentiate angina from other record.
types of chest pain? c. Observe for JVD with the head at 30
a. 12-lead ECG degrees.
b. Exercise stress test d. Have the patient perform the Valsalva
c. Coronary angiogram maneuver.
d. Echocardiogram

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73.Which initial physical assessment finding 78.The nurse caring for a client with heart
would the nurse expect to be present in a failure discusses the importance of
patient with acute left-sided heart failure? restricting sodium in the diet. Which
a. Bubbling crackles and tachycardia statement made by the client indicates
b. Hepatosplenomegaly and tachypnea that he needs further teaching?
c. Peripheral edema and cool, diaphoretic a. "I should avoid grilling hamburgers."
skin b. "I must cut out bacon and canned
d. Frothy blood-tinged sputum and foods."
distended jugular veins c. "I shouldn't put the salt shaker on the
74.The nurse enters the room of the client table anymore."
diagnosed with congestive heart failure. d. "I should avoid lunch meats but may cook
The client is lying in bed gasping for my own turkey."
breath, is cool and clammy, and has buccal 79.A client admitted for heart failure has a
cyanosis. Which intervention would the priority problem of Excess Fluid Volume
nurse implement first? related to compromised regulatory
a. Sponge the client’s forehead. mechanisms. Which of these assessment
b. Obtain a pulse oximetry reading. data obtained the day after admission is
c. Take the client’s vital signs. the best indicator that the treatment has
d. Assist the client to a sitting position. been effective?
75.The nurse determines that treatment of a. The client has a diuresis of 400 mL in
heart failure has been successful when the 24 hours.
patient experiences b. The client's blood pressure is 122/84
a. weight loss and diuresis. mm Hg.
b. warm skin and less fatigue. c. The client has an apical pulse of 82
c. clear lung sounds and decreased HR. beats/min.
d. absence of chest pain and improved d. The client's weight decreases by 2.5
level of consciousness (LOC). kg.
80.The nurse is providing discharge teaching
SITUATION 16 - The nurse is giving to the client with heart failure, focusing on
health education to a number of patients when to seek medical attention. Which
with heart failure in the medical surgical statement by the client indicates
unit. She focuses her teachings on understanding of the teaching?
lifestyle modifications. a. "I will call the provider if I have a
cough lasting 3 or more days."
76.Which nursing intervention for a client b. "I will report to the provider weight
admitted today with heart failure will loss of 2 to 3 pounds in a day."
assist the client to conserve energy? c. "I will try walking for 1 hour each
a. Client ambulates around the nursing day."
unit with a walker. d. "I should expect occasional chest
b. The nurse monitors the client's pulse pain."
and blood pressure frequently.
c. The nurse obtains a bedside commode SITUATION 27– The nurse works in an
before administering furosemide. eye center and caters to clients with
d. The nurse returns the client to bed various eye problems.
when he becomes tachycardic
77.Which intervention will best assist the 81.Children often experience visual
client with acute pulmonary edema in impairments. Refractive errors affect the
reducing anxiety and dyspnea? child’s visual activity. The main refractive
a. Monitor pulse oximetry and cardiac error seen in children is myopia. The nurse
rate and rhythm. explains to the child’s parents that myopia
b. Reassure the client that his distress may also be described as:
can be relieved with proper a. Cataracts c. Nearsightedness
intervention. b. Farsightedness d. Lazy eye
c. Place the client in high Fowler's 82.Which instruction given to a client after
position with the legs down. cataract surgery is inappropriate?
d. Ask a family member to remain with a. “Avoid bending and straining.”
the client. b. “Avoid salty foods.”
c. “Don’t drive or sleep on the affected
side.”
d. “Don’t use make-up on the affected
eye.”

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83.If a patient is told to be legally blind, this 89.While caring for Liza’s husband who has
patient is: otosclerosis, which finding would the nurse
a. having errors of refraction thus expect in the patient’s history and
preventing him from seeing things physical?
even at a closer distance. a. A strong family history of the disease
b. seeing at no more than 20 ft what b. Symptoms of sensorineural hearing
normally should be seen at a distance loss
of 200 ft. c. A positive Rinne test and lateralization
c. experiencing both nearsightedness to the good or better ear on Weber
and farsightedness. testing
d. required to have constant supervision d. An immediate and consistent
to prevent all sorts of falls and improvement in hearing at the time of
injuries. surgical treatment
84.A 19-year-old male client arrived via 90.A nurse should question an order to
ambulance to the emergency room irrigate the ear canal in which
following a motorcycle accident. He is circumstance?
comatose. His face has evidence of dried a. Ear pain
blood. On assessment, the nurse notes an b. Hearing loss
obvious injury to his left eye. The c. Otitis externa
preferred positioning for a client with an d. Perforated tympanic membrane
obvious eye injury is:
a. Reclining to control bleeding SITUATION 19 - A nurse performs a
b. Any position in which the client is Rinne test during physical assessment
comfortable of a client. The client indicates that the
c. Side-lying, either left or right sound is louder when the vibrating
d. Sitting with head support tuning fork is placed against the
85.Keratitis is the inflammation of which part mastoid bone than when held closely to
of the eye? the ear.
a. Cornea c. Retina
b. Conjunctiva d. Eyelid 91.What conclusion should the nurse make
about these results?
SITUATION 28 - Liza was seen in her a. This represents an expected finding.
audiologist’s office for a routine ear b. The client may have a sensorineural
examination. Her last examination was deficit.
5 years ago. c. This is evidence of a conductive
hearing loss.
86.The nurse suspects Liza has presbycusis d. The client has an inflammation of the
when she says she has: mastoid.
a. ringing in the ears. 92.A nurse is discussing weight loss with an
b. a sensation of fullness in the ears. obese individual with Ménière’s disease.
c. difficulty understanding the meaning Which suggestion by the nurse is most
of words. important?
d. a decrease in the ability to hear high- a. Limit intake to nine hundred calories a
pitched sounds. day.
87.Liza also has external otitis. To properly b. Enroll in an exercise class at the local
instill drops in Liza’s ears, which method high school.
should be done by the nurse? c. Get involved in diversionary activities
a. Pulling the pinna down and back when there is an urge to eat.
b. Pulling the pinna up and back d. Keep a diary of all foods eaten each
c. Pulling the tragus up and back day, making certain to list everything.
d. Separating the palpebral fissures with 93.A dietary modification for a patient with
a clean gauze Ménière’s disease would be:
88.When teaching Liza to use a hearing aid, a. a decrease in sodium intake to 1,500
where does the nurse encourage the mg daily.
patient to initially use the aid? b. fluid restriction to 2.0 L/day.
a. Outdoors, where sounds are distinct c. an increase in calcium to 1.0 g/day.
b. At social functions, where d. an increase in vitamin C to 1.5 g/day.
simultaneous conversations take place 94.The most popular surgical procedure used
c. In a quiet, controlled environment to to treat this disease is:
experiment with tone and volume a. endolymphatic sac decompression.
d. In public areas such as malls or b. labyrinthectomy.
stores, where others will not notice its c. middle ear perfusion.
use d. vestibular nerve section.

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95.A client is scheduled for the most popular d. Small, superficial white nodules along
surgery to treat Ménière syndrome. What the lid margin
expected outcome of the procedure should 98.A patient is found to need corrective
be included in preoperative teaching? lenses. Which diagnostic test was most
a. Absence of pain likely used to determine this finding?
b. Decreased cerumen a. computed tomography (CT) scan
c. Loss of sense of smell b. tonometry
d. Permanent irreversible deafness c. refractometry
d. response to atropine eye drops
SITUATION 20 – Assessment of the 99.A patient with a sore throat is complaining
sensory system may be as simple as of “trouble with hearing.” The nurse
determining a patient’s acuity or as realizes that this patient might be
complex as collecting complete experiencing:
subjective and objective data pertinent a. a sinus infection.
to the corresponding system. b. infected tonsils.
c. a middle ear infection.
96.While exiting a burning building, a d. an inner ear infection.
patient’s eyebrows and lashes were 100. Which finding related to primary open-
burned. The nurse recognizes that this angle glaucoma would the nurse expect to
patient might experience: find when reviewing a patient's history and
a. wound infections. physical examination report?
b. fluid and electrolyte imbalance. a. Absence of pain or pressure
c. foreign bodies in the eyes. b. Blurred vision in the morning
d. itchiness as the hair grows back. c. Seeing colored halos around lights
97.A patient has ptosis resulting from d. Eye pain accompanied with nausea and
myasthenia gravis. Which assessment vomiting
finding would the nurse expect to see in
this patient?
a. Redness and swelling of the
conjunctiva
b. Drooping of the upper lid margin in one
or both eyes
c. Redness, swelling, and crusting along
the lid margins

END OF EXAMINATION

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