1. A female client is admitted with a diagnosis of acute renal failure. She is

• A female client is admitted with a diagnosis of acute renal failure. She is

awake, alert, oriented, and complaining of severe back pain, nausea and vomiting and abdominal cramps. Her vital signs are blood pressure 100/70 mm Hg, pulse 110, respirations 30, and oral temperature 100.4°F (38°C). Her electrolytes are sodium 120 mEq/L, potassium 5.2 mEq/L; her urinary output for the first 8 hours is 50 ml. The client is displaying signs of which electrolyte imbalance?

• Hyponatremia
• Hyperkalemia
• Hyperphosphatemia
• Hypercalcemia

• Assessing the laboratory findings, which result would the nurse most likely

expect to find in a client with chronic renal failure?

• BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, creatinine 0.5 to 1.5 mg/dl
• Decreased serum calcium, blood pH 7.2, potassium 6.5 mEq/L
• BUN 15 mg/dl, increased serum calcium, creatinine l.0 mg/dl
• BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, pH 7.35, decreased serum

calcium

• Treatment with hemodialysis is ordered for a client and an external shunt is

created. Which nursing action would be of highest priority with regard to the external shunt?

• Heparinize it daily.
• Avoid taking blood pressure measurements or blood samples from the

affected arm.

• Change the Silastic tube daily.
• Instruct the client not to use the affected arm.

• Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign

prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching?

• TURP is the most common operation for BPH.
• Explain the purpose and function of a two-way irrigation system.
• Expect bloody urine, which will clear as healing takes place.
• He will be pain free.

• Roxy is admitted to the hospital with a possible diagnosis of appendicitis. On

physical examination, the nurse should be looking for tenderness on palpation at McBurney‟s point, which is located in the

• left lower quadrant
• left upper quadrant
• right lower quadrant
• right upper quadrant

• Mr. Valdez has undergone surgical repair of his inguinal hernia. Discharge

teaching should include

• telling him to avoid heavy lifting for 4 to 6 weeks
• instructing him to have a soft bland diet for two weeks
• telling him to resume his previous daily activities without limitations
• recommending him to drink eight glasses of water daily

• A 30-year-old homemaker fell asleep while smoking a cigarette. She

sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned?

A. 18%

B. 22%

C. 31%

D. 40%

• Nursing care planning is based on the knowledge that the first 24-48 hours

post-burn are characterized by:

• An increase in the total volume of intracranial plasma
• Excessive renal perfusion with diuresis
• Fluid shift from interstitial space
• Fluid shift from intravascular space to the interstitial space

• If a client has severe bums on the upper torso, which item would be a

primary concern?

• Debriding and covering the wounds
• Administering antibiotics
• Frequently observing for hoarseness, stridor, and dyspnea
• Establishing a patent IV line for fluid replacement

• Contractures are among the most serious long-term complications of severe

burns. If a burn is located on the upper torso, which nursing measure would be least effective to help prevent contractures?

• Changing the location of the bed or the TV set, or both, daily
• Encouraging the client to chew gum and blow up balloons
• Avoiding the use of a pillow for sleep, or placing the head in a position of

hyperextension

• Helping the client to rest in the position of maximal comfort

• An adult is receiving Total Parenteral Nutrition (TPN). Which of the following

assessment is essential?

• evaluation of the peripheral IV site
• confirmation that the tube is in the stomach
• assess the bowel sound
• fluid and electrolyte monitoring

• Which drug would be least effective in lowering a client‟s serum potassium

level?

• Glucose and insulin
• Polystyrene sulfonate (Kayexalate)
• Calcium glucomite
• Aluminum hydroxide

• A nurse is directed to administer a hypotonic intravenous solution. Looking

at the following labeled solutions, she should choose

• 0.45% NaCl
• 0.9% NaCl

C. D5W

D. D5NSS

• A patient is hemorrhaging from multiple trauma sites. The nurse expects

that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms EXCEPT

• hypertension
• oliguria

• tachycardia
• tachypnea

• Maria Sison, 40 years old, single, was admitted to the hospital with a

diagnosis of Breast Cancer. She was scheduled for radical mastectomy. Nursing care during the preoperative period should consist of

• assuring Maria that she will be cured of cancer
• assessing Maria‟s expectations and doubts
• maintaining a cheerful and optimistic environment
• keeping Maria‟s visitors to a minimum so she can have time for herself

• Maria refuses to acknowledge that her breast was removed. She believes

that her breast is intact under the dressing. The nurse should

• call the MD to change the dressing so Kathy can see the incision
• recognize that Kathy is experiencing denial, a normal stage of the grieving

process

• reinforce Kathy‟s belief for several days until her body can adjust to stress of

surgery.

• remind Kathy that she needs to accept her diagnosis so that she can begin

rehabilitation exercises.

• A chemotherapeutic agent 5FU is ordered as an adjunct measure to surgery.

Which of the ff. statements about chemotherapy is true?

• it is a local treatment affecting only tumor cells
• it affects both normal and tumor cells
• it has been proven as a complete cure for cancer
• it is often used as a palliative measure.

• Which is an incorrect statement pertaining to the following procedures for

cancer diagnostics?

• Biopsy is the removal of suspicious tissue and the only definitive method to

diagnose cancer

• Ultrasonography detects tissue density changes difficult to observe by X-ray

via sound waves.

• CT scanning uses magnetic fields and radio frequencies to provide cross-

sectional view of tumor

• Endoscopy provides direct view of a body cavity to detect abnormality.