Anxiety Nitroglycerin: Myocardial Infarction

1.
Which of the following actions is the first priority of care

for a client exhibiting signs and symptoms of coronary artery
disease?
1. Decrease anxiety
2. Enhance myocardial oxygenation
3. Administer sublingual nitroglycerin
4. Educate the client about his symptoms
2. Medical treatment of coronary artery disease includes

which of the following procedures?
1. Cardiac catheterization
2. Coronary artery bypass surgery
3. Oral medication therapy
4. Percutaneous transluminal coronary angioplasty
3. Which of the following is the most common symptom

of myocardial infarction (MI)?
1. Chest pain
2. Dyspnea
3. Edema
4. Palpitations
4. Which of the following symptoms is the most likely origin

of pain the client described as knifelike chest pain that
increases in intensity with inspiration?
1. Cardiac
2. Gastrointestinal
3. Musculoskeletal
4. Pulmonary
5. Which of the following blood tests is most indicative of

cardiac damage?
1. Lactate dehydrogenase
2. Complete blood count (CBC)
3. Troponin I
4. Creatine kinase (CK)
6. What is the primary reason for administering morphine to

a client with an MI?
1. To sedate the client
2. To decrease the client’s pain
3. To decrease the client’s anxiety
4. To decrease oxygen demand on the client’s heart
7. Which of the following conditions is most commonly

responsible for myocardial infarction?
1. Aneurysm
2. Heart failure
3. Coronary artery thrombosis
4. Renal failure
8. Which of the following complications is indicated by a third

heart sound (S3)?
1. Ventricular dilation
2. Systemic hypertension
3. Aortic valve malfunction
4. Increased atrial contractions
9. After an anterior wall myocardial infarction, which of the
following problems is indicated by auscultation of crackles in
the lungs?
1. Left-sided heart failure

2. Pulmonic valve malfunction
3. Right-sided heart failure
4. Tricupsid valve malfunction
10. What is the first intervention for a client experiencing MI?
1. Administer morphine
2. Administer oxygen
4. Obtain an ECG
11. Which of the following classes of medications protects the

ischemic myocardium by blocking catecholamines and
sympathetic nerve stimulation?
1. Beta-adrenergic blockers
2. Calcium channel blockers
3. Narcotics
4. Nitrates
12. What is the most common complication of an MI?
1. Cardiogenic shock
2. Heart failure
3. arrhythmias
4. Pericarditis
13. With which of the following disorders is jugular vein

distention most prominent?
1. Abdominal aortic aneurysm

2. Heart failure
3. MI
4. Pneumothorax
14. Toxicity from which of the following medications may

cause a client to see a green-yellow halo around lights?
1. Digoxin
2. Furosemide (Lasix)
3. Metoprolol (Lopressor)
4. Enalapril (Vasotec)
15. Which of the following symptoms is most commonly

associated with left-sided heart failure?
1. Crackles
2. Arrhythmias
3. Hepatic engorgement
4. Hypotension
16. In which of the following disorders would the nurse

expect to assess sacral edema in a bedridden client?
1. Diabetes
2. Pulmonary emboli
3. Renal failure
17. Which of the following symptoms might a client with

right-sided heart failure exhibit?
1. Adequate urine output
2. Polyuria
3. Oliguria
4. Polydipsia
18. Which of the following classes of medications maximizes

cardiac performance in clients with heart failure by increasing
ventricular contractility?
3. Diuretics
4. Inotropic agents
19. Stimulation of the sympathetic nervous system produces

which of the following responses?
1. Bradycardia
2. Tachycardia
3. Hypotension
4. Decreased myocardial contractility
20. Which of the following conditions is most closely
associated with weight gain, nausea, and a decrease in urine
output?
1. Angina pectoris
2. Cardiomyopathy
3. Left-sided heart failure
21. Which of the following heart muscle diseases is unrelated

to other cardiovascular disease?
1. Cardiomyopathy
2. Coronary artery disease
3. Myocardial infarction
4. Pericardial effusion
22. Which of the following types of cardiomyopathy can be

associated with childbirth?
1. Dilated
2. Hypertrophic
3. Myocarditis
4. Restrictive
23. Septal involvement occurs in which type of

cardiomyopathy?
1. Congestive
2. Dilated
3. Hypertrophic
4. Restrictive
24. Which of the following recurring conditions most

commonly occurs in clients with cardiomyopathy?
1. Heart failure
2. Diabetes
3. MI
4. Pericardial effusion
25. Dyspnea, cough, expectoration, weakness, and edema are

classic signs and symptoms of which of the following
conditions?
1. Pericarditis
2. Hypertension
3. MI
4. Heart failure
26. In which of the following types of cardiomyopathy does

cardiac output remain normal?
1. Dilated
2. Hypertrophic
3. Obliterative
4. Restrictive
27. Which of the following cardiac conditions does a fourth

heart sound (S4) indicate?
1. Dilated aorta
2. Normally functioning heart
3. Decreased myocardial contractility
4. Failure of the ventricle to eject all of the blood during systole
28. Which of the following classes of drugs is most widely

used in the treatment of cardiomyopathy?
1. Antihypertensives
4. Nitrates
29. If medical treatments fail, which of the following invasive

procedures is necessary for treating cardiomyopathy?
2. Coronary artery bypass graft (CABG)
3. Heart transplantation
4. Intra-aortic balloon pump (IABP)
30. Which of the following conditions is associated with a

predictable level of pain that occurs as a result of physical or
emotional stress?
1. Anxiety
2. Stable angina
3. Unstable angina
4. Variant angina
31. Which of the following types of angina is most closely
related with an impending MI?
1. Angina decubitus
2. Chronic stable angina
3. Nocturnal angina
4. Unstable angina
32. Which of the following conditions is the predominant

cause of angina?
1. Increased preload
2. Decreased afterload
3. Coronary artery spasm
4. Inadequate oxygen supply to the myocardium
33. Which of the following tests is used most often to

diagnose angina?
1. Chest x-ray
2. Echocardiogram
4. 12-lead electrocardiogram (ECG)
34. Which of the following results is the primary treatment
goal for angina?
1. Reversal of ischemia
2. Reversal of infarction
3. Reduction of stress and anxiety
4. Reduction of associated risk factors
35. Which of the following interventions should be the first

priority when treating a client experiencing chest pain while
walking?
1. Sit the client down

2. Get the client back to bed
3. Obtain an ECG
36. Myocardial oxygen consumption increases as which of the

following parameters increase?
1. Preload, afterload, and cerebral blood flow

2. Preload, afterload, and renal blood flow
3. Preload, afterload, contractility, and heart rate.
4. Preload, afterload, cerebral blood flow, and heart rate.
37. Which of the following positions would best aid breathing

for a client with acute pulmonary edema?
1. Lying flat in bed

2. Left side-lying
3. In high Fowler’s position
4. In semi-Fowler’s position
38. Which of the following blood gas abnormalities is initially

most suggestive of pulmonary edema?
1. Anoxia
2. Hypercapnia
3. Hyperoxygenation
4. Hypocapnia
39. Which of the following is a compensatory response

to decreased cardiac output?
1. Decreased BP
2. Alteration in LOC
3. Decreased BP and diuresis
4. Increased BP and fluid retention
40. Which of the following actions is the appropriate initial

response to a client coughing up pink, frothy sputum?
1. Call for help

2. Call the physician
3. Start an I.V. line
4. Suction the client
41. Which of the following terms describes the force against

which the ventricle must expel blood?
1. Afterload
2. Cardiac output
3. Overload
4. Preload
42. Acute pulmonary edema caused by heart failure is usually
a result of damage to which of the following areas of the
heart?
1. Left atrium
2. Right atrium
3. Left ventricle
4. Right ventricle
43. An 18-year-old client who recently had an URI is admitted

with suspected rheumatic fever. Which assessment findings
confirm this diagnosis?
1. Erythema marginatum, subcutaneous nodules, and fever

2. Tachycardia, finger clubbing, and a load S3
3. Dyspnea, cough, and palpitations
4. Dyspnea, fatigue, and syncope
44. A client admitted with angina complains of severe chest

pain and suddenly becomes unresponsive. After establishing
unresponsiveness, which of the following actions should the
nurse take first?
1. Activate the resuscitation team
2. Open the client’s airway
3. Check for breathing
4. Check for signs of circulation
45. A 55-year-old client is admitted with an acute inferior-

wall myocardial infarction. During the admission interview, he
says he stopped taking his metoprolol (Lopressor) 5 days ago
because he was feeling better. Which of the following nursing
diagnoses takes priority for this client?
1. Anxiety
2. Ineffective tissue perfusion; cardiopulmonary
3. Acute pain
4. Ineffective therapeutic regimen management
46. A client comes into the E.R. with acute shortness of breath
and a cough that produces pink, frothy sputum. Admission
assessment reveals crackles and wheezes, a BP of 85/46, a HR
of 122 BPM, and a respiratory rate of 38 breaths/minute. The
client’s medical history included DM, HTN, and heart failure.
Which of the following disorders should the nurse suspect?
1. Pulmonary edema
2. Pneumothorax
3. Cardiac tamponade
4. Pulmonary embolus
47. The nurse coming on duty receives the report from the
nurse going off duty. Which of the following clients should
the on-duty nurse assess first?
1. The 58-year-old client who was admitted 2 days ago with heart
failure, BP of 126/76, and a respiratory rate of 21 breaths a
minute.
2. The 88-year-old client with end-stage right-sided heart failure,
BP of 78/50, and a DNR order.
3. The 62-year-old client who was admitted one day ago
with thrombophlebitis and receiving IV heparin.
4. A 76-year-old client who was admitted 1 hour ago with new-
onset atrial fibrillation and is receiving IV diltiazem (Cardizem).
48. When developing a teaching plan for a client with

endocarditis, which of the following points is most essential
for the nurse to include?
1. “Report fever, anorexia, and night sweats to the physician.”
2. “Take prophylactic antibiotics after dental work and invasive
procedures.”
3. “Include potassium rich foods in your diet.”
4. “Monitor your pulse regularly.”
49. A nurse is conducting a health history with a client with a

primary diagnosis of heart failure. Which of the following
disorders reported by the client is unlikely to play a role in
exacerbating the heart failure?
1. Recent URI
2. Nutritional anemia
3. Peptic ulcer disease
4. A-Fib
50. A nurse is preparing for the admission of a client with

heart failure who is being sent directly to the hospital from
the physician’s office. The nurse would plan on having which
of the following medications readily available for use?
1. Diltiazem (Cardizem)
2. Digoxin (Lanoxin)
3. Propranolol (Inderal)
4. Metoprolol (Lopressor)
51. A nurse caring for a client in one room is told by another

nurse that a second client has developed severe pulmonary
edema. On entering the 2nd client’s room, the nurse would
expect the client to be:
1. Slightly anxious
2. Mildly anxious
3. Moderately anxious
4. Extremely anxious
52. A client with pulmonary edema has been on diuretic

therapy. The client has an order for
additional furosemide (Lasix) in the amount of 40 mg IV push.
Knowing that the client also will be started
on Digoxin (Lanoxin), a nurse checks the client’s most recent:
1. Digoxin level
2. Sodium level
3. Potassium level
4. Creatinine level
53. A client who had cardiac surgery 24 hours ago has a urine
output averaging 19 ml/hr for 2 hours. The client received a
single bolus of 500 ml of IV fluid. Urine output for the
subsequent hour was 25 ml. Daily laboratory results indicate
the blood urea nitrogen is 45 mg/dL and the serum creatinine
is 2.2 mg/dL. A nurse interprets the client is at risk for:
1. Hypovolemia
2. UTI
3. Glomerulonephritis
4. Acute renal failure
54. A nurse is preparing to ambulate a client on the 3rd day

after cardiac surgery. The nurse would plan to do which of the
following to enable the client to best tolerate the
ambulation?
1. Encourage the client to cough and deep breathe

2. Premedicate the client with an analgesic
3. Provide the client with a walker
4. Remove telemetry equipment because it weighs down the
hospital gown.
55. A client’s electrocardiogram strip shows atrial and
ventricular rates of 80 complexes per minute. The PR interval
is 0.14 second, and the QRS complex measures 0.08 second.
The nurse interprets this rhythm is:
1. Normal sinus rhythm

2. Sinus bradycardia
3. Sinus tachycardia
4. Sinus dysrhythmia
56. A client has frequent bursts of ventricular tachycardia on

the cardiac monitor. A nurse is most concerned with this
dysrhythmia because:
1. It is uncomfortable for the client, giving a sense of impending

doom.
2. It produces a high cardiac output that quickly leads to cerebral
and myocardial ischemia.
3. It is almost impossible to convert to a normal sinus rhythm.
4. It can develop into ventricular fibrillation at any time.
57. A home care nurse is making a routine visit to a client
receiving digoxin (Lanoxin) in the treatment of heart failure.
The nurse would particularly assess the client for:
1. Thrombocytopenia and weight gain

2. Anorexia, nausea, and visual disturbances
3. Diarrhea and hypotension
4. Fatigue and muscle twitching
58. A client with angina complains that the angina pain is

prolonged and severe and occurs at the same time each day,
most often in the morning, On further assessment a nurse
notes that the pain occurs in the absence of precipitating
factors. This type of anginal pain is best described as:
1. Stable angina
2. Unstable angina
3. Variant angina
4. Nonanginal pain
59. The physician orders continuous intravenous nitroglycerin

infusion for the client with MI. Essential nursing actions
include which of the following?
1. Obtaining an infusion pump for the medication
2. Monitoring BP q4h
3. Monitoring urine output hourly
4. Obtaining serum potassium levels daily
60. Aspirin is administered to the client experiencing an MI

because of its:
1. Antipyretic action
2. Antithrombotic action
3. Antiplatelet action
4. Analgesic action
61. Which of the following is an expected outcome for a

client on the second day of hospitalization after an MI?
1. Has severe chest pain

2. Can identify risks factors for MI
3. Agrees to participate in a cardiac rehabilitation walking
program
4. Can perform personal self-care activities without pain
62. Which of the following reflects the principle on which a
client’s diet will most likely be based during the acute phase
of MI?
1. Liquids as ordered
2. Small, easily digested meals
3. Three regular meals per day
4. NPO
63. An older, sedentary adult may not respond to emotional

or physical stress as well as a younger individual because of:
1. Left ventricular atrophy

2. Irregular heartbeats
3. Peripheral vascular occlusion
4. Pacemaker placement
64. Which of the following nursing diagnoses would be

appropriate for a client with heart failure? Select all that
apply.
1. Ineffective tissue perfusion related to decreased peripheral

blood flow secondary to decreased cardiac output.
2. Activity intolerance related to increased cardiac output.
3. Decreased cardiac output related to structural and functional
changes.
4. Impaired gas exchange related to decreased sympathetic
nervous system activity.
65. Which of the following would be a priority nursing

diagnosis for the client with heart failure and pulmonary
edema?
1. Risk for infection related to stasis of alveolar secretions

2. Impaired skin integrity related to pressure
3. Activity intolerance related to pump failure
4. Constipation related to immobility
66. Captopril may be administered to a client with HF because

it acts as a:
1. Vasopressor
2. Volume expander
3. Vasodilator
4. Potassium-sparing diuretic
67. Furosemide is administered intravenously to a client with
HF. How soon after administration should the nurse begin to
see evidence of the drugs desired effect?
1. 5 to 10 minutes
2. 30 to 60 minutes
3. 2 to 4 hours
4. 6 to 8 hours
68. Which of the following foods should the nurse teach a

client with heart failure to avoid or limit when following a 2-
gram sodium diet?
1. Apples
2. Tomato juice
3. Whole wheat bread
4. Beef tenderloin
69. The nurse finds the apical pulse below the 5th intercostal
space. The nurse suspects:
1. Left atrial enlargement

2. Left ventricular enlargement
3. Right atrial enlargement
4. Right ventricular enlargement
70. Which of the following arteries primarily feeds the

anterior wall of the heart?
1. Circumflex artery
2. Internal mammary artery
3. Left anterior descending artery
4. Right coronary artery
1. Dr. Jones prescribes albuterol sulfate (Proventil)

for a patient with newly diagnose asthma. When
teaching the patient about this drug, the nurse
should explain that it may cause:
A. Nasal congestion
B. Nervousness
C. Lethargy
D. Hyperkalemia
2. Miriam, a college student with acute rhinitis sees

the campus nurse because of excessive nasal
drainage. The nurse asks the patient about the
color of the drainage. In acute rhinitis, nasal
drainage normally is:
A. Yellow
B. Green
C. Clear
D. Gray
3. A male adult patient hospitalized for treatment

of a pulmonary embolismdevelops respiratory
alkalosis. Which clinical findings commonly
accompany respiratory alkalosis?
A. Nausea or vomiting
B. Abdominal pain or diarrhea
C. Hallucinations or tinnitus
D. Lightheadedness or paresthesia
4. Before administering ephedrine, Nurse Tony

assesses the patient’s history. Because of
ephedrine’s central nervous system (CNS) effects,
it is not recommended for:
A. Patients with an acute asthma attack
B. Patients with narcolepsy
C. Patients under age 6
D. Elderly patients
5. A female patient suffers adult respiratory

distress syndrome as a consequence of shock. The
patient’s condition deteriorates rapidly, and
endotracheal intubation and mechanical
ventilation are initiated. When the high-pressure
alarm on the mechanical ventilator, alarm sounds,
the nurse starts to check for the cause. Which
condition triggers the high-pressure alarm?
A. Kinking of the ventilator tubing

B. A disconnected ventilator tube
C. An endotracheal cuff leak
D. A change in the oxygen concentration without
resetting the oxygen level alarm
6. A male adult patient on mechanical ventilation is

receiving pancuroniumbromide (Pavulon), 0.01
mg/kg I.V. as needed. Which assessment finding
indicates that the patient needs
another pancuronium dose?
A. Leg movement
B. Finger movement
C. Lip movement
D. Fighting the ventilator
7. On auscultation, which finding suggests a

right pneumothorax?
A. Bilateral inspiratory and expiratory crackles

B. Absence of breaths sound in the right thorax
C. Inspiratory wheezes in the right thorax
D. Bilateral pleural friction rub.
8. Rhea, confused and short breath, is brought to

the emergency department by a family member.
The medical history reveals chronic bronchitis and
hypertension. To learn more about the current
respiratory problem, the doctor orders a chest x-
ray and arterial blood gas (ABG) analysis. When
reviewing the ABG report, the nurses sees many
abbreviations. What does a lowercase “a” in ABG
value present?
A. Acid-base balance
B. Arterial Blood
C. Arterial oxygen saturation
D. Alveoli
9. A male patient is admitted to the healthcare

facility for treatment of chronic obstructive
pulmonary disease. Which nursing diagnosis is
most important for this patient?
A. Activity intolerance related to fatigue

B. Anxiety related to actual threat to health status
C. Risk for infection related to retained secretions
D. Impaired gas exchange related to airflow obstruction
10. Nurse Ruth assessing a patient for tracheal

displacement should know that the trachea will
deviate toward the:
A. Contralateral side in a simple pneumothorax
B. Affected side in a hemothorax
C. Affected side in a tension pneumothorax
D. Contralateral side in hemothorax
11. After undergoing a left pneumonectomy, a

female patient has a chest tube in place for
drainage. When caring for this patient, the nurse
must:
A. Monitor fluctuations in the water-seal chamber

B. Clamp the chest tube once every shift
C. Encourage coughing and deep breathing
D. Milk the chest tube every 2 hours
12. When caring for a male patient who has just

had a total laryngectomy, the nurse should plan to:
A. Encourage oral feeding as soon as possible

B. Develop an alternative communication method
C. Keep the tracheostomy cuff fully inflated
D. Keep the patient flat in bed
13. A male patient has a sucking stab wound to the
chest. Which action should the nurse take first?
A. Drawing blood for a hematocrit and hemoglobin level

B. Applying a dressing over the wound and taping it on
three sides
C. Preparing a chest tube insertion tray
D. Preparing to start an I.V. line
14. For a patient with advanced chronic obstructive

pulmonary disease(COPD), which nursing action
best promotes adequate gas exchange?
A. Encouraging the patient to drink three glasses of fluid

daily
B. Keeping the patient in semi-Fowler’s position
C. Using a high-flow venture mask to deliver oxygen as
prescribe
D. Administering a sedative, as prescribe
15. A male patient’s X-ray result reveals bilateral

white-outs, indicating adult respiratory distress
syndrome (ARDS). This syndrome results from:
A. Cardiogenic pulmonary edema
B. Respiratory alkalosis
C. Increased pulmonary capillary permeability
D. Renal failure
16. For a female patient with chronic obstructive

pulmonary disease, which nursing intervention
would help maintain a patent airway?
A. Restricting fluid intake to 1,000 ml per day

B. Enforcing absolute bed rest
C. Teaching the patient how to perform controlled
coughing
D. Administering prescribe sedatives regularly and in
large amounts
17. Nurse Lei caring for a client with

a pneumothorax and who has had a chest tube
inserted notes continues gentle bubbling in the
suction control chamber. What action is
appropriate?
A. Do nothing, because this is an expected finding
B. Immediately clamp the chest tube and notify the
physician
C. Check for an air leak because the bubbling should be
intermittent
D. Increase the suction pressure so that the bubbling
becomes vigorous
18. Nurse Maureen has assisted a physician with

the insertion of a chest tube. The nurse monitors
the client and notes fluctuation of the fluid level in
the water seal chamber after the tube is inserted.
Based on this assessment, which action would be
appropriate?
A. Inform the physician

B. Continue to monitor the client
C. Reinforce the occlusive dressing
D. Encourage the client to deep breathe
19. Nurse Reynolds caring for a client with a chest

tube turns the client to the side, and the chest tube
accidentally disconnects. The initial nursing action
is to:
A. Call the physician

B. Place the tube in bottle of sterile water
C. Immediately replace the chest tube system
D. Place a sterile dressing over the disconnection site
20. A nurse is assisting a physician with the

removal of a chest tube. The nurse should instruct
the client to:
A. Exhale slowly
B. Stay very still
C. Inhale and exhale quickly
D. Perform the Valsalva maneuver
21. While changing the tapes on

a tracheostomy tube, the male client coughs and
tube is dislodged. The initial nursing action is to:
A. Call the physician to reinsert the tube

B. Grasp the retention sutures to spread the opening
C. Call the respiratory therapy department to reinsert the
tracheotomy
D. Cover the tracheostomy site with a sterile dressing to
prevent infection
22. Nurse Oliver is caring for a client immediately

after removal of the endotracheal tube. The nurse
reports which of the following signs immediately if
experienced by the client?
A. Stridor
B. Occasional pink-tinged sputum
C. A few basilar lung crackles on the right
D. Respiratory rate 24 breaths/min
23. An emergency room nurse is assessing a male

client who has sustained a blunt injury to the chest
wall. Which of these signs would indicate the
presence of a pneumothorax in this client?
A. A low respiratory rate

B. Diminished breath sounds
C. The presence of a barrel chest
D. A sucking sound at the site of injury
24. Nurse Reese is caring for a client hospitalized

with acute exacerbation of chronic obstructive
pulmonary disease. Which of the following would
the nurse expect to note on assessment of this
client?
A. Hypocapnia
B. A hyperinflated chest noted on the chest x-ray
C. Increased oxygen saturation with exercise
D. A widened diaphragm noted on the chest x-ray
25. An oxygen delivery system is prescribed for a

male client with chronic obstructive pulmonary
disease to deliver a precise oxygen concentration.
Which of the following types of
oxygen delivery systems would the nurse
anticipate to be prescribed?
A. Face tent
B. Venturi mask
C. Aerosol mask
D. Tracheostomy collar
26. Blessy, a community health nurse is conducting

an educational session with community members
regarding tuberculosis. The nurse tells the group
that one of the first symptoms associated with
tuberculosis is:
A. Dyspnea
B. Chest pain
C. A bloody, productive cough
D. A cough with the expectoration of mucoid sputum
27. A nurse performs an admission assessment on

a female client with a diagnosis of tuberculosis. The
nurse reviews the result of which diagnosis test
that will confirm this diagnosis?
A. Bronchoscopy
B. Sputum culture
C. Chest x-ray
D. Tuberculin skin test
28. A nurse is caring for a male client with
emphysema who is receiving oxygen. The nurse
assesses the oxygen flow rate to ensure that it
does not exceed:
A. 1 L/min
B. 2 L/min
C. 6 L/min
D. 10 L/min
29. A nurse instructs a female client to use the

pursed-lip method of breathing and the client asks
the nurse about the purpose of this type of
breathing. The nurse responds, knowing that the
primary purpose of pursed-lip breathing is to:
A. Promote oxygen intake

B. Strengthen the diaphragm
C. Strengthen the intercostal muscles
D. Promote carbon dioxide elimination
30. A nurse is caring for a male client with acute

respiratory distress syndrome. Which of the
following would the nurse expect to note in the
client?
A. Pallor
B. Low arterial PaO2
C. Elevated arterial PaO2
D. Decreased respiratory rate
31. A nurse is preparing to obtain a sputum

specimen from a male client. Which of the following
nursing actions will facilitate obtaining the
specimen?
A. Limiting fluid
B. Having the client take deep breaths
C. Asking the client to spit into the collection container
D. Asking the client to obtain the specimen after eating
32. Nurse Joy is caring for a client after a

bronchoscopy and biopsy. Which of the following
signs, if noticed in the client, should be reported
immediately to the physician?
A. Dry cough
B. Hematuria
C. Bronchospasm
D. Blood-streaked sputum
33. A nurse is suctioning fluids from a male client

via a tracheostomy tube. When suctioning, the
nurse must limit the suctioning time to a maximum
of:
A. 1 minute
B. 5 seconds
C. 10 seconds
D. 30 seconds
34. A nurse is suctioning fluids from a female client

through an endotracheal tube. During the
suctioning procedure, the nurse notes on the
monitor that the heart rate is decreasing. Which if
the following is the appropriate nursing
intervention?
A. Continue to suction
B. Notify the physician immediately
C. Stop the procedure and reoxygenate the client
D. Ensure that the suction is limited to 15 seconds
35. A male adult client is suspected of having a

pulmonary embolus. A nurse assesses the client,
knowing that which of the following is a common
clinical manifestation of pulmonary embolism?
A. Dyspnea
B. Bradypnea
C. Bradycardia
D. Decreased respirations
36. A slightly obese female client with a history

of allergy-induced asthma, hypertension, and
mitral valve prolapse is admitted to an acute care
facility for elective surgery. The nurse obtains a
complete history and performs a thorough physical
examination, paying special attention to the
cardiovascular and respiratory systems. When
percussing the client’s chest wall, the nurse
expects to elicit:
A. Resonant sounds.
B. Hyperresonant sounds.
C. Dull sounds.
D. Flat sounds.
37. A male client who weighs 175 lb (79.4 kg) is

receiving aminophylline (Aminophyllin) (400 mg in
500 ml) at 50 ml/hour. The theophylline level is
reported as 6 mcg/ml. The nurse calls the
physician who instructs the nurse to change the
dosage to 0.45 mg/kg/hour. The nurse should:
A. Question the order because it’s too low.

B. Question the order because it’s too high.
C. Set the pump at 45 ml/hour.
D. Stop the infusion and have the laboratory repeat the
theophylline measurement.
38. The nurse is teaching a male client with chronic
bronchitis about breathing exercises. Which of the
following should the nurse include in the teaching?
A. Make inhalation longer than exhalation.

B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.
39. Which phrase is used to describe the volume of

air inspired and expired with a normal breath?
A. Total lung capacity

B. Forced vital capacity
C. Tidal volume
D. Residual volume
40. A male client abruptly sits up in bed, reports

having difficulty breathing and has an arterial
oxygen saturation of 88%. Which mode of
oxygen delivery would most likely reverse the
manifestations?
A. Simple mask
B. Non-rebreather mask
C. Face tent
D. Nasal cannula
41. A female client must take streptomycin for

tuberculosis. Before therapy begins, the nurse
should instruct the client to notify the physician if
which health concern occurs?
A. Impaired color discrimination

B. Increased urinary frequency
C. Decreased hearing acuity
D. Increased appetite
42. A male client is asking the nurse a question

regarding the Mantoux test for tuberculosis. The
nurse should base her response on the fact that
the:
A. Area of redness is measured in 3 days and determines

whether tuberculosis is present.
B. Skin test doesn’t differentiate between active and
dormant tuberculosis infection.
C. Presence of a wheal at the injection site in 2 days
indicates active tuberculosis.
D. Test stimulates a reddened response in some clients
and requires a second test in 3 months.
43. A female adult client has a tracheostomy but

doesn’t require continuous mechanical ventilation.
When weaning the client from
the tracheostomytube, the nurse initially should
plug the opening in the tube for:
A. 15 to 60 seconds.
B. 5 to 20 minutes.
C. 30 to 40 minutes.
D. 45 to 60 minutes.
44. Nurse Oliver observes constant bubbling in the

water-seal chamber of a closed chest drainage
system. What should the nurse conclude?
A. The system is functioning normally

B. The client has a pneumothorax.
C. The system has an air leak.
D. The chest tube is obstructed.
45. A black client with asthma seeks emergency

care for acute respiratory distress. Because of this
client’s dark skin, the nurse should assess for
cyanosis by inspecting the:
A. Lips.
B. Mucous membranes.
C. Nail beds.
D. Earlobes.
46. For a male client with an endotracheal (ET)

tube, which nursing action is most essential?
A. Auscultating the lungs for bilateral breath sounds

B. Turning the client from side to side every 2 hours
C. Monitoring serial blood gas values every 4 hours
D. Providing frequent oral hygiene
47. The nurse assesses a male client’s respiratory
status. Which observation indicates that the client
is experiencing difficulty breathing?
A. Diaphragmatic breathing
B. Use of accessory muscles
C. Pursed-lip breathing
D. Controlled breathing
48. A female client is undergoing a complete

physical examination as a requirement for college.
When checking the client’s respiratory status, the
nurse observes respiratory excursion to help
assess:
A. Lung vibrations.
B. Vocal sounds.
C. Breath sounds.
D. Chest movements.
49. A male client comes to the emergency

department complaining of sudden onset
of diarrhea, anorexia, malaise, cough, headache,
and recurrent chills. Based on the client’s history
and physical findings, the physician suspects
legionnaires’ disease. While awaiting diagnostic
test results, the client is admitted to the facility and
started on antibiotic therapy. What is the drug of
choice for treating legionnaires’ disease?
A. Erythromycin (Erythrocin)
B. Rifampin (Rifadin)
C. Amantadine (Symmetrel)
D. Amphotericin B (Fungizone)
50. A male client with chronic obstructive

pulmonary disease (COPD) is recovering from
a myocardial infarction. Because the client is
extremely weak and can’t produce an effective
cough, the nurse should monitor closely for:
A. Pleural effusion.
B. Pulmonary edema.
C. Atelectasis.
D. Oxygen toxicity.
51. The nurse in charge is teaching a client with
emphysema how to perform pursed-lip breathing.
The client asks the nurse to explain the purpose of
this breathing technique. Which explanation should
the nurse provide?
A. It helps prevent early airway collapse.

B. It increases inspiratory muscle strength.
C. It decreases use of accessory breathing muscles.
D. It prolongs the inspiratory phase of respiration.
52. After receiving an oral dose of codeine for an

intractable cough, the male client asks the nurse,
“How long will it take for this drug to work?” How
should the nurse respond?
A. In 30 minutes
B. In 1 hour
C. In 2.5 hours
D. In 4 hours
53. A male client suffers adult respiratory distress

syndrome as a consequence of shock. The client’s
condition deteriorates rapidly, and endotracheal
(ET) intubation and mechanical ventilation are
initiated. When the high-pressure alarm on
the mechanical ventilator sounds, the nurse starts
to check for the cause. Which condition triggers the
high-pressure alarm?
A. Kinking of the ventilator tubing

B. A disconnected ventilator tube
C. An ET cuff leak
D. A change in the oxygen concentration without
resetting the oxygen level alarm
54. A female client with chronic obstructive

pulmonary disease (COPD) takes anhydrous
theophylline, 200 mg P.O. every 8 hours. During a
routine clinic visit, the client asks the nurse how
the drug works. What is the mechanism of action of
anhydrous theophylline in treating a nonreversible
obstructive airway disease such as COPD?
A. It makes the central respiratory center more sensitive

to carbon dioxide and stimulates the respiratory drive.
B. It inhibits the enzyme phosphodiesterase, decreasing
degradation of cyclic adenosine monophosphate, a
bronchodilator.
C. It stimulates adenosine receptors, causing
bronchodilation.
D. It alters diaphragm movement, increasing chest
expansion and enhancing the lung’s capacity for gas
exchange.
55. A male client with pneumococcal pneumonia is

admitted to an acute care facility. The client in the
next room is being treated for
mycoplasmal pneumonia. Despite the different
causes of the various types of pneumonia, all of
them share which feature?
A. Inflamed lung tissue

B. Sudden onset
C. Responsiveness to penicillin.
D. Elevated white blood cell (WBC) count
56. A client with Guillain-Barré syndrome develops

respiratory acidosis as a result of reduced alveolar
ventilation. Which combination of arterial blood gas
(ABG) values confirms respiratory acidosis?
A. pH, 5.0; PaCO2 30 mm Hg

B. pH, 7.40; PaCO2 35 mm Hg
C. pH, 7.35; PaCO2 40 mm Hg
D. pH, 7.25; PaCO2 50 mm Hg
57. A male client admitted to an acute care facility

with pneumonia is receiving supplemental oxygen,
2 L/minute via nasal cannula. The client’s history
includes chronic obstructive pulmonary disease
(COPD) and coronary artery disease. Because of
these history findings, the nurse closely monitors
the oxygen flow and the client’s respiratory status.
Which complication may arise if the client receives
a high oxygen concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis
58. At 11 p.m., a male client is admitted to the
emergency department. He has a respiratory rate
of 44 breaths/minute. He’s anxious, and wheezes
are audible. The client is immediately given oxygen
by face mask and methylprednisolone (Depo-
medrol) I.V. At 11:30 p.m., the client’s arterial
blood oxygen saturation is 86% and he’s still
wheezing. The nurse should plan to administer:
A. Alprazolam (Xanax).
B. Propranolol (Inderal)
C. Morphine.
D. Albuterol (Proventil).
59. After undergoing a thoracotomy, a male client

is receiving epidural analgesia. Which assessment
finding indicates that the client has developed the
most serious complication of epidural analgesia?
A. Heightened alertness
B. Increased heart rate
C. Numbness and tingling of the extremities
D. Respiratory depression
60. The nurse in charge formulates a nursing
diagnosis of Activity intolerance related to
inadequate oxygenation and dyspnea for a client
with chronic bronchitis. To minimize this problem,
the nurse instructs the client to avoid conditions
that increase oxygen demands. Such conditions
include:
A. Drinking more than 1,500 ml of fluid daily.

B. Being overweight.
C. Eating a high-protein snack at bedtime.
D. Eating more than three large meals a day.
1. An 18-year-old client is admitted with a closed

head injury sustained in a MVA. His intracranial
pressure (ICP) shows an upward trend. Which
intervention should the nurse perform first?
1. Reposition the client to avoid neck flexion

2. Administer 1 g Mannitol IV as ordered
3. Increase the ventilator’s respiratory rate to 20
breaths/minute
4. Administer 100 mg of pentobarbital IV as ordered.
2. A client with a subarachnoid hemorrhage is
prescribed a 1,000-mg loading dose of Dilantin IV.
Which consideration is most important when
administering this dose?
1. Therapeutic drug levels should be maintained between

20 to 30 mg/ml.
2. Rapid Dilantin administration can cause cardiac
arrhythmias.
3. Dilantin should be mixed in dextrose in water before
administration.
4. Dilantin should be administered through an IV catheter
in the client’s hand.
3. A client with head trauma develops

a urine output of 300 ml/hr, dry skin, and dry
mucous membranes. Which of the following
nursing interventions is the most appropriate to
perform initially?
1. Evaluate urine specific gravity

2. Anticipate treatment for renal failure
3. Provide emollients to the skin to prevent breakdown
4. Slow down the IV fluids and notify the physician
4. When evaluating an ABG from a client with a

subdural hematoma, the nurse notes the PaCO2 is
30 mm Hg. Which of the following responses best
describes this result?
1. Appropriate; lowering carbon dioxide (CO2) reduces

intracranial pressure (ICP).
2. Emergent; the client is poorly oxygenated.
3. Normal
4. Significant; the client has alveolar hypoventilation.
5. A client who had a transsphenoidal

hypophysectomy should be watched carefully for
hemorrhage, which may be shown by which of the
following signs?
1. Bloody drainage from the ears

2. Frequent swallowing
3. Guaiac-positive stools
4. Hematuria
6. After a hypophysectomy, vasopressin is given IM
for which of the following reasons?
1. To treat growth failure

2. To prevent syndrome of inappropriate antidiuretic
hormone (SIADH)
3. To reduce cerebral edema and lower intracranial
pressure
4. To replace antidiuretic hormone (ADH) normally
secreted by the pituitary.
7. A client comes into the ER after hitting his head

in an MVA. He’s alert and oriented. Which of the
following nursing interventions should be done
first?
1. Assess full ROM to determine extent of injuries

2. Call for an immediate chest x-ray
3. Immobilize the client’s head and neck
4. Open the airway with the head-tilt-chin-lift maneuver
8. A client with a C6 spinal injury would most likely

have which of the following symptoms?
1. Aphasia
2. Hemiparesis
3. Paraplegia
4. Tetraplegia
9. A 30-year-old was admitted to the progressive

care unit with a C5 fracturefrom a motorcycle
accident. Which of the following assessments
would take priority?
1. Bladder distension
2. Neurological deficit
3. Pulse ox readings
4. The client’s feelings about the injury
10. While in the ER, a client with C8 tetraplegia

develops a blood pressure of 80/40, pulse 48, and
RR of 18. The nurse suspects which of the following
conditions?
1. Autonomic dysreflexia
2. Hemorrhagic shock
3. Neurogenic shock
4. Pulmonary embolism
11. A client is admitted with a spinal cord injury at

the level of T12. He has limited movement of his
upper extremities. Which of the following
medications would be used to control edema of
the spinal cord?
1. Acetazolamide (Diamox)
2. Furosemide (Lasix)
3. Methylprednisolone (Solu-Medrol)
4. Sodium bicarbonate
12. A 22-year-old client with quadriplegia is

apprehensive and flushed, with a blood pressure of
210/100 and a heart rate of 50 bpm. Which of the
first?
1. Place the client flat in bed

2. Assess patency of the indwelling urinary catheter
3. Give one SL nitroglycerin tablet
4. Raise the head of the bed immediately to 90 degrees
13. A client with a cervical spine injury has

Gardner-Wells tongs inserted for which of the
following reasons?
1. To hasten wound healing

2. To immobilize the cervical spine
3. To prevent autonomic dysreflexia
4. To hold bony fragments of the skull together
14. Which of the following interventions describes

an appropriate bladder program for a client in
rehabilitation for spinal cord injury?
1. Insert an indwelling urinary catheter to straight

drainage
2. Schedule intermittent catheterization every 2 to 4
hours
3. Perform a straight catheterization every 8 hours while
awake
4. Perform Crede’s maneuver to the lower abdomen
before the client voids.
15. A client is admitted to the ER for head trauma is

diagnosed with an epidural hematoma. The
underlying cause of epidural hematoma is usually
related to which of the following conditions?
1. Laceration of the middle meningeal artery

2. Rupture of the carotid artery
3. Thromboembolism from a carotid artery
4. Venous bleeding from the arachnoid space
16. A 23-year-old client has been hit on the head

with a baseball bat. The nurse notes clear fluid
draining from his ears and nose. Which of the
first?
1. Position the client flat in bed

2. Check the fluid for dextrose with a dipstick
3. Suction the nose to maintain airway patency
4. Insert nasal and ear packing with sterile gauze
17. When discharging a client from the ER after a
head trauma, the nurse teaches the guardian to
observe for a lucid interval. Which of the following
statements best described a lucid interval?
1. An interval when the client’s speech is garbled

2. An interval when the client is alert but can’t recall
recent events
3. An interval when the client is oriented but then
becomes somnolent
4. An interval when the client has a “warning” symptom,
such as an odor or visual disturbance.
18. Which of the following clients on the rehab unit

is most likely to develop autonomic dysreflexia?
1. A client with a brain injury

2. A client with a herniated nucleus pulposus
3. A client with a high cervical spine injury
4. A client with a stroke
19. Which of the following conditions indicates that
spinal shock is resolving in a client with C7
quadriplegia?
1. Absence of pain sensation in chest

2. Spasticity
3. Spontaneous respirations
4. Urinary continence
20. A nurse assesses a client who has episodes of

autonomic dysreflexia. Which of the following
conditions can cause autonomic dysreflexia?
1. Headache
2. Lumbar spinal cord injury
3. Neurogenic shock
4. Noxious stimuli
21. During an episode of autonomic dysreflexia in

which the client becomes hypertensive, the nurse
should perform which of the following
interventions?
1. Elevate the client’s legs
2. Put the client flat in bed
3. Put the client in the Trendelenburg’s position
4. Put the client in the high-Fowler’s position
22. A client with a T1 spinal cord injury arrives at

the emergency department with a BP of 82/40,
pulse 34, dry skin, and flaccid paralysis of the
lower extremities. Which of the following
conditions would most likely be suspected?
1. Autonomic dysreflexia
2. Hypervolemia
3. Neurogenic shock
4. Sepsis
23. A client has a cervical spine injury at the level

of C5. Which of the following conditions would the
nurse anticipate during the acute phase?
1. Absent corneal reflex

2. Decerebrate posturing
3. Movement of only the right or left half of the body
4. The need for mechanical ventilation
24. A client with C7 quadriplegia is flushed and

anxious and complains of a pounding headache.
Which of the following symptoms would also be
anticipated?
1. Decreased urine output or oliguria

2. Hypertension and bradycardia
3. Respiratory depression
4. Symptoms of shock
25. A 40-year-old paraplegic must perform

intermittent catheterization of the bladder. Which
of the following instructions should be given?
1. “Clean the meatus from back to front.”

2. “Measure the quantity of urine.”
3. “Gently rotate the catheter during removal.”
4. “Clean the meatus with soap and water.”
26. An 18-year-old client was hit in the head with a
baseball during practice. When discharging him to
the care of his mother, the nurse gives which of the
following instructions?
1. “Watch him for keyhole pupil the next 24 hours.”

2. “Expect profuse vomiting for 24 hours after the
injury.”
3. “Wake him every hour and assess his orientation to
person, time, and place.”
4. “Notify the physician immediately if he has a
headache.”
27. Which neurotransmitter is responsible for may

of the functions of the frontal lobe?
1. Dopamine
2. GABA
3. Histamine
4. Norepinephrine
28. The nurse is discussing the purpose of an

electroencephalogram (EEG) with the family of a
client with massive cerebral hemorrhage and loss
of consciousness. It would be most accurate for the
nurse to tell family members that the test
measures which of the following conditions?
1. Extent of intracranial bleeding

2. Sites of brain injury
3. Activity of the brain
4. Percent of functional brain tissue
29. A client arrives at the ER after slipping on a

patch of ice and hitting her head. A CT scan of the
head shows a collection of blood between
the skulland dura mater. Which type of head injury
does this finding suggest?
1. Subdural hematoma
2. Subarachnoid hemorrhage
3. Epidural hematoma
4. Contusion
30. After falling 20’, a 36-year-old man sustains a
C6 fracture with spinal cord transaction. Which
other findings should the nurse expect?
1. Quadriplegia with gross arm movement and

diaphragmatic breathing
2. Quadriplegia and loss of respiratory function
3. Paraplegia with intercostal muscle loss
4. Loss of bowel and bladder control
31. A 20-year-old client who fell approximately 30’

is unresponsive and breathless. A cervical spine
injury is suspected. How should the first-responder
open the client’s airway for rescue breathing?
1. By inserting a nasopharyngeal airway

2. By inserting a oropharyngeal airway
3. By performing a jaw-thrust maneuver
4. By performing the head-tilt, chin-lift maneuver
32. The nurse is caring for a client with a T5

complete spinal cord injury. Upon assessment, the
nurse notes flushed skin, diaphoresis above the T5,
and a blood pressure of 162/96. The client reports
a severe, pounding headache. Which of the
following nursing interventions would be
appropriate for this client? Select all that apply.
1. Elevate the HOB to 90 degrees

2. Loosen constrictive clothing
3. Use a fan to reduce diaphoresis
4. Assess for bladder distention and bowel impaction
5. Administer antihypertensive medication
6. Place the client in a supine position with legs elevated
33. The client with a head injury has been urinating

copious amounts of dilute urine through the Foley
catheter. The client’s urine output for the previous
shift was 3000 ml. The nurse implements a new
physician order to administer:
1. Desmopressin (DDAVP, Stimate)

2. Dexamethasone (Decadron)
3. Ethacrynic acid (Edecrin)
4. Mannitol (Osmitrol)
34. The nurse is caring for the client in the ER
following a head injury. The client momentarily lost
consciousness at the time of the injury and then
regained it. The client now has lost consciousness
again. The nurse takes quick action, knowing this is
compatible with:
1. Skull fracture
2. Concussion
3. Subdural hematoma
4. Epidural hematoma
35. The nurse is caring for a client who suffered

a spinal cord injury 48 hours ago. The nurse
monitors for GI complications by assessing for:
1. A flattened abdomen
2. Hematest positive nasogastric tube drainage
3. Hyperactive bowel sounds
4. A history of diarrhea
36. A client with a spinal cord injury is prone to

experiencing autonomic dysreflexia. The nurse
would avoid which of the following measures to
minimize the risk of recurrence?
1. Strict adherence to a bowel retraining program

2. Limiting bladder catheterization to once every 12
hours
3. Keeping the linen wrinkle-free under the client
4. Preventing unnecessary pressure on the lower limbs
37. The nurse is planning care for the client in

spinal shock. Which of the following actions would
be least helpful in minimizing the effects of
vasodilation below the level of the injury?
1. Monitoring vital signs before and during position

changes
2. Using vasopressor medications as prescribed
3. Moving the client quickly as one unit
4. Applying Teds or compression stockings.
38. The nurse is caring for a client admitted with

spinal cord injury. The nurse minimizes the risk of
compounding the injury most effectively by:
1. Keeping the client on a stretcher
2. Logrolling the client on a firm mattress
3. Logrolling the client on a soft mattress
4. Placing the client on a Stryker frame
39. The nurse is evaluating neurological signs of

the male client in spinal shock following spinal cord
injury. Which of the following observations by the
nurse indicates that spinal shock persists?
1. Positive reflexes
2. Hyperreflexia
3. Inability to elicit a Babinski’s reflex
4. Reflex emptying of the bladder
40. A client with a spinal cord injury suddenly

experiences an episode of autonomic dysreflexia.
After checking the client’s vital signs, list in order
of priority, the nurse’s actions (Number 1 being the
first priority and number 5 being the last priority).
1. Check for bladder distention

2. Raise the head of the bed
3. Contact the physician
4. Loosen tight clothing on the client
5. Administer an antihypertensive medication
41. A client is at risk for increased ICP. Which of

the following would be a priority for the nurse to
monitor?
1. Unequal pupil size

2. Decreasing systolic blood pressure
3. Tachycardia
4. Decreasing body temperature
42. Which of the following respiratory patterns

indicate increasing ICP in the brain stem?
1. Slow, irregular respirations

2. Rapid, shallow respirations
3. Asymmetric chest expansion
4. Nasal flaring
43. Which of the following nursing interventions is

appropriate for a client with an ICP of 20 mm Hg?
1. Give the client a warming blanket
2. Administer low-dose barbiturate
3. Encourage the client to hyperventilate
4. Restrict fluids
44. A client has signs of increased ICP. Which of

the following is an early indicator of deterioration
in the client’s condition?
1. Widening pulse pressure

2. Decrease in the pulse rate
3. Dilated, fixed pupil
4. Decrease in LOC
45. A client who is regaining consciousness after a

craniotomy becomes restless and attempts to pull
out her IV line. Which nursing intervention protects
the client without increasing her ICP?
1. Place her in a jacket restraint

2. Wrap her hands in soft “mitten” restraints
3. Tuck her arms and hands under the draw sheet
4. Apply a wrist restraint to each arm
46. Which of the following describes decerebrate
posturing?
1. Internal rotation and adduction of arms with flexion of

elbows, wrists, and fingers
2. Back hunched over, rigid flexion of all four extremities
with supination of arms and plantar flexion of the feet
3. Supination of arms, dorsiflexion of feet
4. Back arched; rigid extension of all four extremities.
47. A client receiving vent-assisted mode

ventilation begins to experience cluster breathing
after recent intracranial occipital bleeding. Which
action would be most appropriate?
1. Count the rate to be sure the ventilations are deep

enough to be sufficient
2. Call the physician while another nurse checks the vital
signs and ascertains the patient’s Glasgow Coma score.
3. Call the physician to adjust the ventilator settings.
4. Check deep tendon reflexes to determine the best
motor response
48. In planning the care for a client who has had a
posterior fossa (infratentorial) craniotomy, which
of the following
is contraindicated when positioning the client?
1. Keeping the client flat on one side or the other

2. Elevating the head of the bed to 30 degrees
3. Log rolling or turning as a unit when turning
4. Keeping the head in neutral position
49. A client has been pronounced brain dead.

Which findings would the nurse assess? Check all
that apply.
1. Decerebrate posturing
2. Dilated nonreactive pupils
3. Deep tendon reflexes
4. Absent corneal reflex
50. A 23-year-old patient with a recent history of

encephalitis is admitted to the medical unit with
new onset generalized tonic-clonic seizures. Which
nursing activities included in the patient’s care will
be best to delegate to an LPN/LVN whom you are
supervising?
1. Document the onset time, nature of seizure activity,

and postictal behaviors for all seizures.
2. Administer phenytoin (Dilantin) 200 mg PO daily.
3. Teach patient about the need for good oral hygiene.
4. Develop a discharge plan, including physician visits
and referral to the EpilepsyFoundation.
1. An agitated, confused female client arrives in the

emergency department. Her history includes type
1 diabetes mellitus, hypertension, and angina
pectoris. Assessment reveals pallor, diaphoresis,
headache, and intense hunger. A
stat blood glucose sample measures 42 mg/dl, and
the client is treated for an acute hypoglycemic
reaction. After recovery, the nurse teaches the
client to treat hypoglycemia by ingesting:
A. 2 to 5 g of a simple carbohydrate.
B. 10 to 15 g of a simple carbohydrate.
C. 18 to 20 g of a simple carbohydrate.
D. 25 to 30 g of a simple carbohydrate.
2. A female adult client with a history of chronic

hyperparathyroidism admits to being
noncompliant. Based on initial assessment findings,
the nurse formulates the nursing diagnosis of Risk
for injury. To complete the nursing diagnosis
statement for this client, which “related-to” phrase
should the nurse add?
A. Related to bone demineralization resulting in

pathologic fractures
B. Related to exhaustion secondary to an accelerated
metabolic rate
C. Related to edema and dry skin secondary to fluid
infiltration into the interstitial spaces
D. Related to tetany secondary to a decreased serum
calcium level
3. Nurse Joey is assigned to care for a

postoperative male client who has diabetes
mellitus. During the assessment interview, the
client reports that he’s impotent and says he’s
concerned about its effect on his marriage. In
planning this client’s care, the most appropriate
intervention would be to:
A. Encourage the client to ask questions about personal

sexuality.
B. Provide time for privacy.
C. Provide support for the spouse or significant other.
D. Suggest referral to a sex counselor or other
appropriate professional.
4. During a class on exercise for diabetic clients, a

female client asks the nurse educator how often to
exercise. The nurse educator advises the clients to
exercise how often to meet the goals of planned
exercise?
A. At least once a week

B. At least three times a week
C. At least five times a week
D. Every day
5. Nurse Oliver should expect a client
with hypothyroidism to report which health
concerns?
A. Increased appetite and weight loss

B. Puffiness of the face and hands
C. Nervousness and tremors
D. Thyroid gland swelling
6. A female client
with hypothyroidism (myxedema) is
receiving levothyroxine (Synthroid), 25 mcg P.O.
daily. Which finding should nurse Hans recognize
as an adverse drug effect?
A. Dysuria
B. Leg cramps
C. Tachycardia
D. Blurred vision
7. A 67-year-old male client has been complaining

of sleeping more, increased urination, anorexia,
weakness, irritability, depression, and
bone pain that interferes with her going outdoors.
Based on these assessment findings, nurse Richard
would suspect which of the following disorders?
A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism
8. When caring for a male client

with diabetes insipidus, nurse Juliet expects to
administer:
A. vasopressin (Pitressin Synthetic).

B. furosemide (Lasix).
C. regular insulin.
D. 10% dextrose.
9. The nurse is aware that the following is the most

common cause of hyperaldosteronism?
A. Excessive sodium intake

B. A pituitary adenoma
C. Deficient potassium intake
D. An adrenal adenoma
10. A male client with type 1 diabetes mellitus has

a highly elevated glycosylated hemoglobin (Hb)
test result. In discussing the result with the client,
nurse Sharmaine would be most accurate in
stating:
A. “The test needs to be repeated following a 12-hour

fast.”
B. “It looks like you aren’t following the prescribed
diabetic diet.”
C. “It tells us about your sugar control for the last 3
months.”
D. “Your insulin regimen needs to be altered
significantly.”
11. Following a unilateral adrenalectomy, nurse

Betty would assess for hyperkalemia shown by
which of the following?
A. Muscle weakness
B. Tremors
C. Diaphoresis
D. Constipation
12. Nurse Louie is developing a teaching plan for a

male client diagnosed with diabetes insipidus. The
nurse should include information about which
hormone lacking in clients with diabetes insipidus?
A. antidiuretic hormone (ADH).

B. thyroid-stimulating hormone (TSH).
C. follicle-stimulating hormone (FSH).
D. luteinizing hormone (LH).
13. Early this morning, a female client had a

subtotal thyroidectomy. During evening rounds,
nurse Tina assesses the client, who now has
nausea, a temperature of 105° F (40.5° C),
tachycardia, and extreme restlessness. What is the
most likely cause of these signs?
A. Diabetic ketoacidosis
B. Thyroid crisis
C. Hypoglycemia
D. Tetany
14. For a male client with hyperglycemia, which

assessment finding best supports a nursing
diagnosis of Deficient fluid volume?
A. Cool, clammy skin

B. Distended neck veins
C. Increased urine osmolarity
D. Decreased serum sodium level
15. When assessing a male client with

pheochromocytoma, a tumor of the adrenal
medulla that secretes excessive catecholamine,
nurse April is most likely to detect:
A. a blood pressure of 130/70 mm Hg.

B. a blood glucose level of 130 mg/dl.
C. bradycardia.
D. a blood pressure of 176/88 mm Hg.
16. A male client is admitted for treatment of the
syndrome of inappropriate antidiuretic hormone
(SIADH). Which nursing intervention is
appropriate?
A. Infusing I.V. fluids rapidly as ordered

B. Encouraging increased oral intake
C. Restricting fluids
D. Administering glucose-containing I.V. fluids as ordered
17. A female client has a serum calcium level of 7.2

mg/dl. During the physical examination, nurse
Noah expects to assess:
A. Trousseau’s sign.
B. Homans’ sign.
C. Hegar’s sign.
D. Goodell’s sign.
18. Which outcome indicates that treatment of a

male client with diabetes insipidus has been
effective?
A. Fluid intake is less than 2,500 ml/day.
B. Urine output measures more than 200 ml/hour.
C. Blood pressure is 90/50 mm Hg.
D. The heart rate is 126 beats/minute.
19. Jemma, who weighs 210 lb (95 kg) and has

been diagnosed with hyperglycemia tells the nurse
that her husband sleeps in another room because
her snoring keeps him awake. The nurse notices
that she has large hands and a hoarse voice. Which
of the following would the nurse suspect as a
possible cause of the client’s hyperglycemia?
A. Acromegaly
B. Type 1 diabetes mellitus
C. Hypothyroidism
D. Deficient growth hormone
20. Nurse Kate is providing dietary instructions to a

male client with hypoglycemia. To control
hypoglycemic episodes, the nurse should
recommend:
A. Increasing saturated fat intake and fasting in the
afternoon.
B. Increasing intake of vitamins B and D and taking iron
supplements.
C. Eating a candy bar if lightheadedness occurs.
D. Consuming a low-carbohydrate, high protein diet and
avoiding fasting.
21. An incoherent female client with a history

of hypothyroidism is brought to the emergency
department by the rescue squad. Physical and
laboratory findings reveal hypothermia,
hypoventilation, respiratory acidosis,
bradycardia, hypotension, and nonpitting edema of
the face and pretibial area. Knowing that these
findings suggest severe hypothyroidism, nurse
Libby prepares to take emergency action to prevent
the potential complication of:
A. Thyroid storm.
B. Cretinism.
C. myxedema coma.
D. Hashimoto’s thyroiditis.
22. A male client with type 1 diabetes mellitus asks
the nurse about taking an oral antidiabetic agent.
Nurse Jack explains that these medications are
only effective if the client:
A. prefers to take insulin orally.

B. has type 2 diabetes.
C. has type 1 diabetes.
D. is pregnant and has type 2 diabetes.
23. When caring for a female client with a history

of hypoglycemia, nurse Ruby should avoid
administering a drug that may potentiate
hypoglycemia. Which drug fits this description?
A. sulfisoxazole (Gantrisin)
B. mexiletine (Mexitil)
C. prednisone (Orasone)
D. lithium carbonate (Lithobid)
24. After taking glipizide (Glucotrol) for 9 months,

a male client experiences secondary failure. Which
of the following would the nurse expect the
physician to do?
A. Initiate insulin therapy.

B. Switch the client to a different oral antidiabetic agent.
C. Prescribe an additional oral antidiabetic agent.
D. Restrict carbohydrate intake to less than 30% of the
total caloric intake.
25. During preoperative teaching for a female client

who will undergo subtotal thyroidectomy, the nurse
should include which statement?
A. “The head of your bed must remain flat for 24 hours

after surgery.”
B. “You should avoid deep breathing and coughing after
surgery.”
C. “You won’t be able to swallow for the first day or two.”
D. “You must avoid hyperextending your neck after
surgery.”
26. Nurse Ronn is assessing a client with possible
Cushing’s syndrome. In a client with Cushing’s
syndrome, the nurse would expect to find:
A. Hypotension.
B. Thick, coarse skin.
C. Deposits of adipose tissue in the trunk and
dorsocervical area.
D. Weight gain in arms and legs.
27. A male client with primary diabetes insipidus is

ready for discharge on desmopressin (DDAVP).
Which instruction should nurse Lina provide?
A. “Administer desmopressin while the suspension is

cold.”
B. “Your condition isn’t chronic, so you won’t need to
wear a medical identification bracelet.”
C. “You may not be able to use desmopressin nasally if
you have nasal discharge or blockage.”
D. “You won’t need to monitor your fluid intake and
output after you start taking desmopressin.”
28. Nurse Wayne is aware that a positive
Chvostek’s sign indicate?
A. Hypocalcemia
B. Hyponatremia
C. Hypokalemia
D. Hypermagnesemia
29. In a 29-year-old female client who is being

successfully treated for Cushing’s syndrome, nurse
Lyzette would expect a decline in:
A. Serum glucose level.

B. Hair loss.
C. Bone mineralization.
D. Menstrual flow.
30. A male client has recently undergone surgical

removal of a pituitary tumor. Dr. Wong
prescribes corticotropin (Acthar), 20 units I.M.
q.i.d. as a replacement therapy. What is the
mechanism of action of corticotropin?
A. It decreases cyclic adenosine monophosphate (cAMP)
production and affects the metabolic rate of target
organs.
B. It interacts with plasma membrane receptors to inhibit
enzymatic actions.
C. It interacts with plasma membrane receptors to
produce enzymatic actions that affect protein, fat, and
carbohydrate metabolism.
D. It regulates the threshold for water resorption in the
kidneys.
31. Capillary glucose monitoring is being performed

every 4 hours for a female client diagnosed
with diabetic ketoacidosis. Insulin is administered
using a scale of regular insulin according to glucose
results. At 2 p.m., the client has a capillary glucose
level of 250 mg/dl for which he receives 8 U of
regular insulin. Nurse Vince should expect the
dose’s:
A. Onset to be at 2 p.m. and its peak to be at 3 p.m.

B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. Onset to be at 4 p.m. and its peak to be at 6 p.m.
32. A female client with Cushing’s syndrome is

admitted to the medical-surgical unit. During the
admission assessment, nurse Tyzz notes that the
client is agitated and irritable, has poor memory,
reports loss of appetite, and appears disheveled.
These findings are consistent with which problem?
A. Depression
B. Neuropathy
C. Hypoglycemia
D. Hyperthyroidism
33. Nurse Ruth is assessing a client after a

thyroidectomy. The assessment reveals muscle
twitching and tingling, along with numbness in the
fingers, toes, and mouth area. The nurse should
suspect which complication?
A. Tetany
B. Hemorrhage
C. Thyroid storm
D. Laryngeal nerve damage
34. After undergoing a subtotal thyroidectomy, a

female client develops hypothyroidism. Dr. Smith
prescribes levothyroxine (Levothroid), 25 mcg P.O.
daily. For which condition is levothyroxine the
preferred agent?
A. Primary hypothyroidism
B. Graves’ disease
C. Thyrotoxicosis
D. Euthyroidism
35. Which of these signs suggests that a male

client with the syndrome of inappropriate
antidiuretic hormone (SIADH) secretion is
experiencing complications?
A. Tetanic contractions
B. Neck vein distention
C. Weight loss
D. Polyuria
36. A female client with a history of
pheochromocytoma is admitted to the hospital in
an acute hypertensive crisis. To reverse
hypertensive crisis caused by pheochromocytoma,
nurse Lyka expects to administer:
A. phentolamine (Regitine).
B. methyldopa (Aldomet).
C. mannitol (Osmitrol).
D. felodipine (Plendil).
37. A male client with a history of hypertension is

diagnosed with primary hyperaldosteronism. This
diagnosis indicates that the client’s hypertension is
caused by excessive hormone secretion from which
of the following glands?
A. Adrenal cortex
B. Pancreas
C. Adrenal medulla
D. Parathyroid
38. Nurse Troy is aware that the most appropriate
for a client with Addison’s disease?
A. Risk for infection

B. Excessive fluid volume
C. Urinary retention
D. Hypothermia
39. Acarbose (Precose), an alpha-glucosidase

inhibitor, is prescribed for a female client with type
2 diabetes mellitus. During discharge planning,
nurse Pauleen would be aware of the client’s need
for additional teaching when the client states:
A. “If I have hypoglycemia, I should eat some sugar, not

dextrose.”
B. “The drug makes my pancreas release more insulin.”
C. “I should never take insulin while I’m taking this
drug.”
D. “It’s best if I take the drug with the first bite of a
meal.”
40. A female client whose physical findings suggest
a hyperpituitary condition undergoes an extensive
diagnostic workup. Test results reveal a pituitary
tumor, which necessitates
a transsphenoidal hypophysectomy. The
evening before the surgery, nurse Jacob reviews
preoperative and postoperative instructions given
to the client earlier. Which postoperative
instruction should the nurse emphasize?
A. “You must lie flat for 24 hours after surgery.”

B. “You must avoid coughing, sneezing, and blowing your
nose.”
C. “You must restrict your fluid intake.”
D. “You must report ringing in your ears immediately.”
41. Dr. Kennedy prescribes glipizide (Glucotrol), an

oral antidiabetic agent, for a male client with type 2
diabetes mellitus who has been having trouble
controlling the blood glucose level through diet and
exercise. Which medication instruction should the
nurse provide?
A. “Be sure to take glipizide 30 minutes before meals.”
B. “Glipizide may cause a low serum sodium level, so
make sure you have your sodium level checked monthly.”
C. “You won’t need to check your blood glucose level
after you start taking glipizide.”
D. “Take glipizide after a meal to prevent heartburn.”
42. For a diabetic male client with a foot ulcer, the

physician orders bed rest, a wet-to-dry dressing
change every shift, and blood glucose monitoring
before meals and bedtime. Why are wet-to-dry
dressings used for this client?
A. They contain exudate and provide a moist wound

environment.
B. They protect the wound from mechanical trauma and
promote healing.
C. They debride the wound and promote healing by
secondary intention.
D. They prevent the entrance of microorganisms and
minimize wound discomfort.
43. When instructing the female client diagnosed
with hyperparathyroidism about diet, nurse Gina
should stress the importance of which of the
following?
A. Restricting fluids
B. Restricting sodium
C. Forcing fluids
D. Restricting potassium
44. Which nursing diagnosis takes highest priority

for a female client with hyperthyroidism?
A. Risk for imbalanced nutrition: More than body

requirements related to thyroid hormone excess
B. Risk for impaired skin integrity related to edema, skin
fragility, and poor wound healing
C. Body image disturbance related to weight gain and
edema
D. Imbalanced nutrition: Less than body requirements
related to thyroid hormone excess
45. A male client with a tentative diagnosis of
hyperosmolar hyperglycemic nonketotic syndrome
(HHNS) has a history of type 2 diabetes that is
being controlled with an oral diabetic
agent, tolazamide (Tolinase). Which of the
following is the most important laboratory test for
confirming this disorder?
A. Serum potassium level

B. Serum sodium level
C. Arterial blood gas (ABG) values
D. Serum osmolarity
46. A male client has just been diagnosed with type

1 diabetes mellitus. When teaching the client and
family how diet and exercise affect insulin
requirements, Nurse Joy should include which
guideline?
A. “You’ll need more insulin when you exercise or

increase your food intake.”
B. “You’ll need less insulin when you exercise or reduce
your food intake.”
C. “You’ll need less insulin when you increase your food
intake.”
D. “You’ll need more insulin when you exercise or
decrease your food intake.”
47. Nurse Noemi administers glucagon to her

diabetic client, then monitors the client for adverse
drug reactions and interactions. Which type of drug
interacts adversely with glucagon?
A. Oral anticoagulants
B. Anabolic steroids
C. Beta-adrenergic blockers
D. Thiazide diuretics
48. Which instruction about insulin administration

should nurse Kate give to a client?
A. “Always follow the same order when drawing the

different insulins into the syringe.”
B. “Shake the vials before withdrawing the insulin.”
C. “Store unopened vials of insulin in the freezer at
temperatures well below freezing.”
D. “Discard the intermediate-acting insulin if it appears
cloudy.”
49. Nurse Perry is caring for a female client with

type 1 diabetes mellitus who exhibits confusion,
light-headedness, and aberrant behavior. The client
is still conscious. The nurse should first administer:
A. I.M. or subcutaneous glucagon.

B. I.V. bolus of dextrose 50%.
C. 15 to 20 g of a fast-acting carbohydrate such as
orange juice.
D. 10 U of fast-acting insulin.
50. For the first 72 hours after thyroidectomy

surgery, nurse Jamie would assess the female
client for Chvostek’s sign and Trousseau’s sign
because they indicate which of the following?
A. Hypocalcemia
B. Hypercalcemia
C. Hypokalemia
D. Hyperkalemia
1. A male client has an abnormal result on a
Papanicolaou test. After admitting, he read his
chart while the nurse was out of the room, the
client asks what dysplasia means. Which definition
should the nurse provide?
A. Presence of completely undifferentiated tumor cells

that don’t resemble cells of the tissues of their origin
B. Increase in the number of normal cells in a normal
arrangement in a tissue or an organ
C. Replacement of one type of fully differentiated cell by
another in tissues where the second type normally isn’t
found
D. Alteration in the size, shape, and organization of
differentiated cells
2. For a female client with newly diagnosed cancer,

the nurse formulates a nursing diagnosis
of Anxiety related to the threat of death secondary
to cancer diagnosis. Which expected outcome
would be appropriate for this client?
A. “Client verbalizes feelings of anxiety.”
B. “Client doesn’t guess at prognosis.”
C. “Client uses any effective method to reduce tension.”
D. “Client stops seeking information.”
3. A male client with a cerebellar brain tumor is

admitted to an acute care facility. The nurse
formulates a nursing diagnosis of Risk for injury.
Which “related-to” phrase should the nurse add to
complete the nursing diagnosis statement?
A. Related to visual field deficits

B. Related to difficulty swallowing
C. Related to impaired balance
D. Related to psychomotor seizures
4. A female client with cancer is scheduled for

radiation therapy. The nurse knows that radiation
at any treatment site may cause a certain adverse
effect. Therefore, the nurse should prepare the
client to expect:
A. hair loss.
B. stomatitis.
C. fatigue.
D. vomiting.
5. Nurse April is teaching a client who suspects that

she has a lump in her breast. The nurse instructs
the client that a diagnosis of breast cancer is
confirmed by:
A. breast self-examination.
B. mammography.
C. fine needle aspiration.
D. chest X-ray.
6. A male client undergoes a laryngectomy to treat

laryngeal cancer. When teaching the client how to
care for the neck stoma, the nurse should include
which instruction?
A. “Keep the stoma uncovered.”

B. “Keep the stoma dry.”
C. “Have a family member perform stoma care initially
until you get used to the procedure.”
D. “Keep the stoma moist.”
7. A female client is receiving chemotherapy to

treat breast cancer. Which assessment finding
indicates a fluid and electrolyte imbalance induced
by chemotherapy?
A. Urine output of 400 ml in 8 hours

B. Serum potassium level of 3.6 mEq/L
C. Blood pressure of 120/64 to 130/72 mm Hg
D. Dry oral mucous membranes and cracked lips
8. Nurse April is teaching a group of women to

perform breast self-examination. The nurse should
explain that the purpose of performing the
examination is to discover:
A. cancerous lumps.
B. areas of thickness or fullness.
C. changes from previous self-examinations.
D. fibrocystic masses.
9. A client, age 41, visits the gynecologist. After
examining her, the physician suspects cervical
cancer. The nurse reviews the client’s history for
risk factors for this disease. Which history finding
is a risk factor for cervical cancer?
A. Onset of sporadic sexual activity at age 17

B. Spontaneous abortion at age 19
C. Pregnancy complicated with eclampsia at age 27
D. Human papillomavirus infection at age 32
10. A female client is

receiving methotrexate (Mexate), 12 g/m2 I.V., to
treat osteogenic carcinoma.
During methotrexate therapy, the nurse expects
the client to receive which other drug to protect
normal cells?
A. probenecid (Benemid)
B. cytarabine (ara-C, cytosine arabinoside [Cytosar-U])
C. thioguanine (6-thioguanine, 6-TG)
D. leucovorin (citrovorum factor or folinic acid
[Wellcovorin])
11. The nurse is interviewing a male client about
his past medical history. Which preexisting
condition may lead the nurse to suspect that a
client has colorectal cancer?
A. Duodenal ulcers
B. Hemorrhoids
C. Weight gain
D. Polyps
12. Nurse Amy is speaking to a group of women

about early detection of breast cancer. The average
age of the women in the group is 47. Following the
American Cancer Society guidelines, the nurse
should recommend that the women:
A. perform breast self-examination annually.

B. have a mammogram annually.
C. have a hormonal receptor assay annually.
D. have a physician conduct a clinical examination every
2 years.
13. A male client with a nagging cough makes an
appointment to see the physician after reading that
this symptom is one of the seven warning signs of
cancer. What is another warning sign of cancer?
A. Persistent nausea
B. Rash
C. Indigestion
D. Chronic ache or pain
14. For a female client newly diagnosed with

radiation-induced thrombocytopenia, the nurse
should include which intervention in the plan of
care?
A. Administering aspirin if the temperature exceeds 102°

F (38.8° C)
B. Inspecting the skin for petechiae once every shift
C. Providing for frequent rest periods
D. Placing the client in strict isolation
15. Nurse Lucia is providing breast cancer

education at a community facility. The American
Cancer Society recommends that women get
mammograms:
A. yearly after age 40.

B. after the birth of the first child and every 2 years
thereafter.
C. after the first menstrual period and annually
thereafter.
D. every 3 years between ages 20 and 40 and annually
thereafter.
16. Which intervention is appropriate for the nurse

caring for a male client in severe pain receiving a
continuous I.V. infusion of morphine?
A. Assisting with a naloxone challenge test before

therapy begins
B. Discontinuing the drug immediately if signs of
dependence appear
C. Changing the administration route to P.O. if the client
can tolerate fluids
D. Obtaining baseline vital signs before administering the
first dose
17. A 35 years old client with ovarian cancer is
prescribed hydroxyurea(Hydrea), an antimetabolite
drug. Antimetabolites are a diverse group of
antineoplastic agents that interfere with various
metabolic actions of the cell. The mechanism of
action of antimetabolites interferes with:
A. cell division or mitosis during the M phase of the cell

cycle.
B. normal cellular processes during the S phase of the
cell cycle.
C. the chemical structure of deoxyribonucleic acid (DNA)
and chemical binding between DNA molecules (cell cycle–
nonspecific).
D. one or more stages of ribonucleic acid (RNA)
synthesis, DNA synthesis, or both (cell cycle–
nonspecific).
18. The ABCD method offers one way to assess skin

lesions for possible skin cancer. What does the A
stand for?
A. Actinic
B. Asymmetry
C. Arcus
D. Assessment
19. When caring for a male client diagnosed with a

brain tumor of the parietal lobe, the nurse expects
to assess:
A. short-term memory impairment.

B. tactile agnosia.
C. seizures.
D. contralateral homonymous hemianopia.
20. A female client is undergoing tests for multiple

myeloma. Diagnostic study findings in multiple
myeloma include:
A. a decreased serum creatinine level.

B. hypocalcemia.
C. Bence Jones protein in the urine.
D. a low serum protein level.
21. A 35 years old client has been
receiving chemotherapy to treat cancer. Which
assessment finding suggests that the client has
developed stomatitis (inflammation of the mouth)?
A. White, cottage cheese–like patches on the tongue

B. Yellow tooth discoloration
C. Red, open sores on the oral mucosa
D. Rust-colored sputum
22. During chemotherapy, an oncology client has a

nursing diagnosis of impaired oral mucous
membrane related to decreased nutrition and
immunosuppression secondary to the cytotoxic
effects of chemotherapy. Which nursing
intervention is most likely to decrease the pain of
stomatitis?
A. Recommending that the client discontinue

chemotherapy
B. Providing a solution of hydrogen peroxide and water
for use as a mouth rinse
C. Monitoring the client’s platelet and leukocyte counts
D. Checking regularly for signs and symptoms of
stomatitis
23. What should a male client over age 52 do to

help ensure early identification of prostate cancer?
A. Have a digital rectal examination and prostate-specific

antigen (PSA) test done yearly.
B. Have a transrectal ultrasound every 5 years.
C. Perform monthly testicular self-examinations,
especially after age 50.
D. Have a complete blood count (CBC) and blood urea
nitrogen (BUN) and creatinine levels checked yearly.
24. A male client complains of sporadic

epigastric pain, yellow skin, nausea, vomiting,
weight loss, and fatigue. Suspecting gallbladder
disease, the physician orders a diagnostic workup,
which reveals gallbladder cancer. Which nursing
diagnosis may be appropriate for this client?
A. Anticipatory grieving
B. Impaired swallowing
C. Disturbed body image
D. Chronic low self-esteem
25. A male client is in isolation after receiving an

internal radioactive implant to treat cancer. Two
hours later, the nurse discovers the implant in the
bed linens. What should the nurse do first?
A. Stand as far away from the implant as possible and

call for help.
B. Pick up the implant with long-handled forceps and
place it in a lead-lined container.
C. Leave the room and notify the radiation therapy
department immediately.
D. Put the implant back in place, using forceps and a
shield for self-protection, and call for help.
26. Jenny, with advanced breast cancer is

prescribed tamoxifen (Nolvadex). When teaching
the client about this drug, the nurse should
emphasize the importance of reporting which
adverse reaction immediately?
A. Vision changes
B. Hearing loss
C. Headache
D. Anorexia
27. A female client with cancer is being evaluated

for possible metastasis. Which of the following is
one of the most common metastasis sites for
cancer cells?
A. Liver
B. Colon
C. Reproductive tract
D. White blood cells (WBCs)
28. A 34-year-old female client is requesting

information about mammograms and breast
cancer. She isn’t considered at high risk for breast
cancer. What should the nurse tell this client?
A. She should have had a baseline mammogram before

age 30.
B. She should eat a low-fat diet to further decrease her
risk of breast cancer.
C. She should perform breast self-examination during the
first 5 days of each menstrual cycle.
D. When she begins having yearly mammograms, breast
self-examinations will no longer be necessary.
29. Nurse Brian is developing a plan of care for

marrow suppression, the major dose-limiting
adverse reaction to floxuridine (FUDR). How long
after drug administration does bone marrow
suppression become noticeable?
A. 24 hours
B. 2 to 4 days
C. 7 to 14 days
D. 21 to 28 days
30. The nurse is preparing for a female client for

magnetic resonance imaging (MRI) to confirm or
rule out a spinal cord lesion. During the MRI scan,
which of the following would pose a threat to the
client?
A. The client lies still.
B. The client asks questions.
C. The client hears thumping sounds.
D. The client wears a watch and wedding band.
31. Nina, an oncology nurse educator, is speaking

to a women’s group about breast cancer. Questions
and comments from the audience reveal a
misunderstanding of some aspects of the disease.
Various members of the audience have made all of
the following statements. Which one is accurate?
A. Mammography is the most reliable method for

detecting breast cancer.
B. Breast cancer is the leading killer of women of
childbearing age.
C. Breast cancer requires a mastectomy.
D. Men can develop breast cancer.
32. Nurse Mary is instructing a premenopausal

woman about breast self-examination. The nurse
should tell the client to do her self-examination:
A. at the end of her menstrual cycle.
B. on the same day each month.
C. on the 1st day of the menstrual cycle.
D. immediately after her menstrual period.
33. Nurse Kent is teaching a male client to perform

monthly testicular self-examinations. Which of the
following points would be appropriate to make?
A. Testicular cancer is a highly curable type of cancer.

B. Testicular cancer is very difficult to diagnose.
C. Testicular cancer is the number one cause of cancer
deaths in males.
D. Testicular cancer is more common in older men.
34. Rhea, has malignant lymphoma. As part of her

chemotherapy, the physician prescribes
chlorambucil (Leukeran), 10 mg by mouth daily.
When caring for the client, the nurse teaches her
about adverse reactions to chlorambucil, such as
alopecia. How soon after the first administration of
chlorambucil might this reaction occur?
A. Immediately
B. 1 week
C. 2 to 3 weeks
D. 1 month
35. A male client is receiving the cell cycle–

nonspecific alkylating agent thiotepa (Thioplex), 60
mg weekly for 4 weeks by bladder instillation as
part of a chemotherapeutic regimen to
treat bladder cancer. The client asks the nurse how
the drug works. How does thiotepa exert its
therapeutic effects?
A. It interferes with deoxyribonucleic acid (DNA)

replication only.
B. It interferes with ribonucleic acid (RNA) transcription
only.
C. It interferes with DNA replication and RNA
transcription.
D. It destroys the cell membrane, causing lysis.
36. The nurse is instructing the 35 year old client to
perform a testicular self-examination. The nurse
tells the client:
A. To examine the testicles while lying down

B. That the best time for the examination is after a
shower
C. To gently feel the testicle with one finger to feel for a
growth
D. That testicular self-examination should be done at
least every 6 months
37. A female client with cancer is receiving

chemotherapy and develops thrombocytopenia. The
nurse identifies which intervention as the highest
priority in the nursing plan of care?
A. Monitoring temperature
B. Ambulation three times daily
C. Monitoring the platelet count
D. Monitoring for pathological fractures
38. Gio, a community health nurse, is instructing a
group of female clients about breast self-
examination. The nurse instructs the client to
perform the examination:
A. At the onset of menstruation

B. Every month during ovulation
C. Weekly at the same time of day
D. 1 week after menstruation begins
39. Nurse Cindy is caring for a client who has

undergone a vaginal hysterectomy. The nurse
avoids which of the following in the care of this
client?
A. Elevating the knee gatch on the bed

B. Assisting with range-of-motion leg exercises
C. Removal of antiembolism stockings twice daily
D. Checking placement of pneumatic compression boots
40. Mina, who is suspected of an ovarian tumor is

scheduled for a pelvic ultrasound. The nurse
provides which preprocedure instruction to the
client?
A. Eat a light breakfast only

B. Maintain an NPO status before the procedure
C. Wear comfortable clothing and shoes for the procedure
D. Drink six to eight glasses of water without voiding
before the test
41. A male client is diagnosed as having a

bowel tumor and several diagnostic tests are
prescribed. The nurse understands that which test
will confirm the diagnosis of malignancy?
A. Biopsy of the tumor

B. Abdominal ultrasound
C. Magnetic resonance imaging
D. Computerized tomography scan
42. A female client diagnosed with multiple

myeloma and the client asks the nurse about the
diagnosis. The nurse bases the response on which
description of this disorder?
A. Altered red blood cell production
B. Altered production of lymph nodes
C. Malignant exacerbation in the number of leukocytes
D. Malignant proliferation of plasma cells within the bone
43. Nurse Bea is reviewing the laboratory results of

a client diagnosed with multiple myeloma. Which of
the following would the nurse expect to note
specifically in this disorder?
A. Increased calcium
B. Increased white blood cells
C. Decreased blood urea nitrogen level
D. Decreased number of plasma cells in the bone marrow
44. Vanessa, a community health nurse conducts a

health promotion program regarding testicular
cancer to community members. The nurse
determines that further information needs to be
provided if a community member states that which
of the following is a sign of testicular cancer?
A. Alopecia
B. Back pain
C. Painless testicular swelling
D. Heavy sensation in the scrotum
45. The male client is receiving external radiation

to the neck for cancer of the larynx. The most likely
side effect to be expected is:
A. Dyspnea
B. Diarrhea
C. Sore throat
D. Constipation
46. Nurse Joy is caring for a client with an internal

radiation implant. When caring for the client, the
nurse should observe which of the following
principles?
A. Limit the time with the client to 1 hour per shift

B. Do not allow pregnant women into the client’s room
C. Remove the dosimeter badge when entering the
client’s room
D. Individuals younger than 16 years old may be allowed
to go in the room as long as they are 6 feet away from
the client
47. A cervical radiation implant is placed in the

client for treatment of cervical cancer. The nurse
initiates what most appropriate activity order for
this client?
A. Bed rest
B. Out of bed ad lib
C. Out of bed in a chair only
D. Ambulation to the bathroom only
48. A female client is hospitalized for insertion of

an internal cervical radiation implant. While giving
care, the nurse finds the radiation implant in the
bed. The initial action by the nurse is to:
A. Call the physician

B. Reinsert the implant into the vagina immediately
C. Pick up the implant with gloved hands and flush it
down the toilet
D. Pick up the implant with long-handled forceps and
place it in a lead container.
49. The nurse is caring for a female client

experiencing neutropenia as a result of
chemotherapy and develops a plan of care for the
client. The nurse plans to:
A. Restrict all visitors

B. Restrict fluid intake
C. Teach the client and family about the need for hand
hygiene
D. Insert an indwelling urinary catheter to prevent skin
breakdown
50. The home health care nurse is caring for a male

client with cancer and the client is complaining of
acute pain. The appropriate nursing assessment of
the client’s pain would include which of the
following?
A. The client’s pain rating

B. Nonverbal cues from the client
C. The nurse’s impression of the client’s pain
D. Pain relief after appropriate nursing intervention
51. Nurse Melinda is caring for a client who is

postoperative following a pelvic exenteration and
the physician changes the client’s diet from NPO
status to clear liquids. The nurse makes which
priority assessment before administering the diet?
A. Bowel sounds
B. Ability to ambulate
C. Incision appearance
D. Urine specific gravity
52. A male client is admitted to the hospital with a

suspected diagnosis of Hodgkin’s disease. Which
assessment findings would the nurse expect to
note specifically in the client?
A. Fatigue
B. Weakness
C. Weight gain
D. Enlarged lymph nodes
53. During the admission assessment of a 35 year
old client with advanced ovarian cancer, the nurse
recognizes which symptom as typical of the
disease?
A. Diarrhea
B. Hypermenorrhea
C. Abdominal bleeding
D. Abdominal distention
54. Nurse Kate is reviewing the complications of

colonization with a client who has microinvasive
cervical cancer. Which complication, if identified by
the client, indicates a need for further teaching?
A. Infection
B. Hemorrhage
C. Cervical stenosis
D. Ovarian perforation
55. Mr. Miller has been diagnosed with bone

cancer. You know this type of cancer is classified
as:
A. sarcoma.
B. lymphoma.
C. carcinoma.
D. melanoma.
56. Sarah, a hospice nurse visits a client dying of

ovarian cancer. During the visit, the client
expresses that “If I can just live long enough to
attend my daughter’s graduation, I’ll be ready to
die.” Which phrase of coping is this client
experiencing?
A. Anger
B. Denial
C. Bargaining
D. Depression
57. Nurse Farah is caring for a client following a

mastectomy. Which assessment finding indicates
that the client is experiencing a complication
related to the surgery?
A. Pain at the incisional site
B. Arm edema on the operative side
C. Sanguineous drainage in the Jackson-Pratt drain
D. Complaints of decreased sensation near the operative
site
58. The nurse is admitting a male client with

laryngeal cancer to the nursing unit. The nurse
assesses for which most common risk factor for
this type of cancer?
A. Alcohol abuse
B. Cigarette smoking
C. Use of chewing tobacco
D. Exposure to air pollutants
59. The female client who has been receiving

radiation therapy for bladdercancer tells the nurse
that it feels as if she is voiding through the vagina.
The nurse interprets that the client may be
experiencing:
A. Rupture of the bladder
B. The development of a vesicovaginal fistula
C. Extreme stress caused by the diagnosis of cancer
D. Altered perineal sensation as a side effect of radiation
therapy
60. The client with leukemia is receiving busulfan

(Myleran) and allopurinol (Zyloprim). The nurse
tells the client that the purpose if the allopurinol is
to prevent:
A. Nausea
B. Alopecia
C. Vomiting
D. Hyperuricemia

Anxiety Nitroglycerin: Myocardial Infarction

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1.

Which of the following actions is the first priority of care

2. Medical treatment of coronary artery disease includes

3. Which of the following is the most common symptom

4. Which of the following symptoms is the most likely origin

5. Which of the following blood tests is most indicative of

6. What is the primary reason for administering morphine to

7. Which of the following conditions is most commonly

8. Which of the following complications is indicated by a third

1. Left-sided heart failure

10. What is the first intervention for a client experiencing MI?

11. Which of the following classes of medications protects the

12. What is the most common complication of an MI?

13. With which of the following disorders is jugular vein

1. Abdominal aortic aneurysm

14. Toxicity from which of the following medications may

15. Which of the following symptoms is most commonly

16. In which of the following disorders would the nurse

17. Which of the following symptoms might a client with

18. Which of the following classes of medications maximizes

19. Stimulation of the sympathetic nervous system produces

21. Which of the following heart muscle diseases is unrelated

22. Which of the following types of cardiomyopathy can be

23. Septal involvement occurs in which type of

24. Which of the following recurring conditions most

25. Dyspnea, cough, expectoration, weakness, and edema are

26. In which of the following types of cardiomyopathy does

27. Which of the following cardiac conditions does a fourth

28. Which of the following classes of drugs is most widely

29. If medical treatments fail, which of the following invasive

30. Which of the following conditions is associated with a

32. Which of the following conditions is the predominant

33. Which of the following tests is used most often to

35. Which of the following interventions should be the first

1. Sit the client down

36. Myocardial oxygen consumption increases as which of the

1. Preload, afterload, and cerebral blood flow

37. Which of the following positions would best aid breathing

1. Lying flat in bed

38. Which of the following blood gas abnormalities is initially

39. Which of the following is a compensatory response

40. Which of the following actions is the appropriate initial

1. Call for help

41. Which of the following terms describes the force against

43. An 18-year-old client who recently had an URI is admitted

1. Erythema marginatum, subcutaneous nodules, and fever

44. A client admitted with angina complains of severe chest

45. A 55-year-old client is admitted with an acute inferior-

48. When developing a teaching plan for a client with

49. A nurse is conducting a health history with a client with a

50. A nurse is preparing for the admission of a client with

51. A nurse caring for a client in one room is told by another

52. A client with pulmonary edema has been on diuretic

54. A nurse is preparing to ambulate a client on the 3rd day

1. Encourage the client to cough and deep breathe

1. Normal sinus rhythm

56. A client has frequent bursts of ventricular tachycardia on

1. It is uncomfortable for the client, giving a sense of impending

1. Thrombocytopenia and weight gain

58. A client with angina complains that the angina pain is

59. The physician orders continuous intravenous nitroglycerin

60. Aspirin is administered to the client experiencing an MI

61. Which of the following is an expected outcome for a