Multiple Choice

Question 1

The nurse assess the surgical patient the morning of the first postoperative day. Signs of a local inflammatory response that the nurse expects to find include:
A) redness and heat of the incision
B) leukocyte with elevated monocytes
C) pain and pure lent drainage of the incision
D) fever and increased pulse and respiration

Answer 1

A) redness and heat of the incision*
B) leukocyte with elevated monocytes
C) pain and pure lent drainage of the incision
D) fever and increased pulse and respiration

Question 2

A paraplegic patient is admitted to the hospital for intensive management of an open, infected pressure ulcer on the left buttock at the prominence of the is hail tuberous its. the initial assessment of the patient's pressure ulcer indicates the it is 5cm long by 2.5cm wide and 1.5cm deep. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer ulcer as:
A) stage I
B) stage II
C) stage III
D) stage IV

Answer 2

A) stage I
B) stage II
C) stage III*
D) stage IV

Question 3

Initial evidence that would indicate to the nurse that a patient is experiencing a systemic anaphylaxis to an injected allergen is the development of:
A) dyspnea
B) dilation of the pupils
C)itching and oedema at the injection site
D) a wheel and flare reaction at the injection site

Answer 3

A) dyspnea*
B) dilation of the pupils
C)itching and oedema at the injection site
D) a wheel and flare reaction at the injection site

Question 4

A patient with severe allergic reaction is treated with epinephrine. the nurse recognises that the rationale for the use of epinephrine is that epinephrine opposes the effects of:
A) histamine
B) lymphokines
C) Interleukin-2
D) lysomal enzymes

Answer 4

A) histamine*
B) lymphokines
C) Interleukin-2
D) lysomal enzymes

Question 5

It is especially important for the nurse to determine the patient’s current use of medications during the pre operative assessment because:
A) these medications may alter the patient’s perception about surgery
B) anaesthetics alter renal and hepatic function, causing toxicity by other drugs
C) other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs
D) routine medications are usually withheld the day of surgery, requiring dosage and schedule adjustments

Answer 5

A) these medications may alter the patient’s perception about surgery
B) anaesthetics alter renal and hepatic function, causing toxicity by other drugs
C) other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs*
D) routine medications are usually withheld the day of surgery, requiring dosage and schedule adjustments

Question 6

Ten minutes after a patient has received his post operative medication by IM injection, he asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to
A) offer him a urinal and position him to promote voiding
B) assist him to the bathroom and stay with him to protect him from falling
C) Tell him to hold the urine because he will be catheterised at the beginning of the surgical procedure
D) allow him to go to the bathroom because the onset of the effect of the medication takes more than 10 minutes

Answer 6

A) offer him a urinal and position him to promote voiding*
B) assist him to the bathroom and stay with him to protect him from falling
C) Tell him to hold the urine because he will be catheterised at the beginning of the surgical procedure
D) allow him to go to the bathroom because the onset of the effect of the medication takes more than 10 minutes

Question 7

When a surgical patient is transferred from the PACU to the clinical surgical unit, the first action done by the nurse is:
A) assess the patient’s pain
B) take the patient’s vital signs
C) check the rate of the IV infusion
D) check the physician’s post operative orders

Answer 7

When a surgical patient is transferred from the PACU to the clinical surgical unit, the first action done by the nurse is:
A) assess the patient’s pain
B) take the patient’s vital signs*
C) check the rate of the IV infusion
D) check the physician’s post operative orders

Question 8

Post operatively a patient is receiving low molecular weight heparin. When administering this drug, the nurse:
A) explains that the drug will help prevent clot formation in the legs
B) administers the dose with meals to prevent GI irritation and bleeding
C) Checks the results of the partial thromboplastin time before administration
D)informs the patient that the blood will be drawn every 6 hours to monitor the prothrombin time

Answer 8

Post operatively a patient is receiving low molecular weight heparin. When administering this drug, the nurse:
A) explains that the drug will help prevent clot formation in the legs
B) administers the dose with meals to prevent GI irritation and bleeding
C) Checks the results of the partial thromboplastin time before administration
D)informs the patient that the blood will be drawn every 6 hours to monitor the prothrombin time

Question 9

The patient is very anxious about the source of the bleeding and asks the nurse whether it is possible to find the cause. The nurse's response is based on the knowledge that the diagnostic test which  can most accurately identify the source of the bleeding is:
A) an endoscopy
B) an angiography 
C) a gastric analysis
D) barium contrast studies

Answer 9

The patient is very anxious about the source of the bleeding and asks the nurse whether it is possible to find the cause. The nurse's response is based on the knowledge that the diagnostic test which  can most accurately identify the source of the bleeding is:
A) an endoscopy*
B) an angiography 
C) a gastric analysis
D) barium contrast studies

Question 10

A dark skinned person has been admitted to the hospital on severe respiratory distress. To assess for cyanosis in the patient, the nurse knows that:
A) cyanosis in patients with dark skin can be seen only in the sclera
B) it is not possible to assess abnormal colour changes in patients with dark skin
C) cyanosis can be seen in the lips and mucous membranes of patients with dark skin
D) cyanosis will blanch out with direct pressure to the soles of the feet in dark skinned patients

Answer 10

A) cyanosis in patients with dark skin can be seen only in the sclera
B) it is not possible to assess abnormal colour changes in patients with dark skin
C) cyanosis can be seen in the lips and mucous membranes of patients with dark skin*
D) cyanosis will blanch out with direct pressure to the soles of the feet in dark skinned patients

Question 11

The best example of nursing documentation of a normal assessment of the skin is:
A) ‘skin warm and dry; tutor good; nails flat and pink; old surgical scars noted on the abdomen’
B) ‘history of allergic rashes; skin very fair with numerous freckles, warm and intact; no lesions noted’
C)’brown skin, slightly moist and warm; tugor immediate return; no lesions noted. States no problem with skin.’
D) ‘no history of skin problems; skin intact, pink temperature consistent over body; no lesions except brown moles.”

Answer 11

The best example of nursing documentation of a normal assessment of the skin is:
A) ‘skin warm and dry; tutor good; nails flat and pink; old surgical scars noted on the abdomen’
B) ‘history of allergic rashes; skin very fair with numerous freckles, warm and intact; no lesions noted’
C)’brown skin, slightly moist and warm; tugor immediate return; no lesions noted. States no problem with skin.’
D) ‘no history of skin problems; skin intact, pink temperature consistent over body; no lesions except brown moles.”*

Question 12

During application of a wet dressing to the skin of a patient with impetigo, it is most important for the nurse to:
A) use cool solutions to deride the lesion
B) use clean gloves to prevent the spread of infect to others
C) use sterile gloves and dressings to prevent infection of the lesions
D) apply a prescribed topical antibiotic ointment before the application of the dressings

Answer 12

During application of a wet dressing to the skin of a patient with impetigo, it is most important for the nurse to:
A) use cool solutions to deride the lesion
B) use clean gloves to prevent the spread of infect to others*
C) use sterile gloves and dressings to prevent infection of the lesions
D) apply a prescribed topical antibiotic ointment before the application of the dressings

Question 13

A patient is scheduled for an outpatient ultrasound of the gallbladder. the nurse instructs the patient that the evening before the test it will be necessary for her to
A) eat a high fat evening meal
B) drink a liquid barium contrast medium
C) use enemas until the return is clear of stool
D) take nothing by mouth for 8 hours before the test

Answer 13

A patient is scheduled for an outpatient ultrasound of the gallbladder. the nurse instructs the patient that the evening before the test it will be necessary for her to
A) eat a high fat evening meal
B) drink a liquid barium contrast medium
C) use enemas until the return is clear of stool
D) take nothing by mouth for 8 hours before the test*

Question 14

Following diagnostic testing, a patient with recurring heartburn and indigestion is diagnosed with a hiatal hernia. the nurse explains to the patient that this condition involves
A) extension of the esophagus through the diaphragm
B) displacement of the duodenum through the stomach to the esophagus
C) twisting of the stomach around the esophagus, occluding the esphagus
D) protrusion of the stomach into the esophagus through the opening in the diaphragm

Answer 14

Following diagnostic testing, a patient with recurring heartburn and indigestion is diagnosed with a hiatal hernia. the nurse explains to the patient that this condition involves
A) extension of the esophagus through the diaphragm
B) displacement of the duodenum through the stomach to the esophagus
C) twisting of the stomach around the esophagus, occluding the esphagus
D) protrusion of the stomach into the esophagus through the opening in the diaphragm *

Question 15

A patient with upper gastrointestinal bleeding is diagnosed with a duodenal ulcer following an endoscopy, with a histology of a mucosal specimen is positive for Helibactor pylori. When the nurse administers antibiotic therapy for the H.pylori, the patient asks if ulcers are caused by infection. The best response the nurse includes in the information is that:
A) H.pylori is strongly associated with gastric ulcers but is rarely present in those with duodenal ulcers
B) although H.pylori is believed to be a cause of gastritis, it’s role in the development of ulcers is not known
C) because most of the population is infected with H.pylori, it is believed that other factors are responsible for ulcer development
D) infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier

Answer 15

A patient with upper gastrointestinal bleeding is diagnosed with a duodenal ulcer following an endoscopy, with a histology of a mucosal specimen is positive for Helibactor pylori. When the nurse administers antibiotic therapy for the H.pylori, the patient asks if ulcers are caused by infection. The best response the nurse includes in the information is that:
A) H.pylori is strongly associated with gastric ulcers but is rarely present in those with duodenal ulcers
B) although H.pylori is believed to be a cause of gastritis, it’s role in the development of ulcers is not known
C) because most of the population is infected with H.pylori, it is believed that other factors are responsible for ulcer development
D) infection with this bacteria in combination with other factors is believed to be a major cause of breakdown of the gastric mucosal barrier*

Question 16

A 78 year old patient is transferred to the hospital from a nursing home upon developing abdominal pain and watery, incontinent diarrhoea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficult. In planning care for the patient, the nurse recognises that a priority nursing goal is to:
A) maintain normal nutritional intake
B) prevent transmission of the microorganism to others
C) Premote relief of abdominal pain with comfort measures
D) control the diarrhoea with administration of antidiarreal drugs

Answer 16

A 78 year old patient is transferred to the hospital from a nursing home upon developing abdominal pain and watery, incontinent diarrhoea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficult. In planning care for the patient, the nurse recognises that a priority nursing goal is to:
A) maintain normal nutritional intake*
B) prevent transmission of the microorganism to others
C) Premote relief of abdominal pain with comfort measures
D) control the diarrhoea with administration of antidiarreal drugs

Question 17

While obtaining a nursing history from a patient with inflammatory bowl disease, the nurse recognises that the patient most likely has ulcerative colitis rather than Crohn's disease when the patient reports experiencing:
A) weigh loss
B) bloody diarrhoea
C) abdominal pain and cramping
D) the onset of the disease at age 20

Answer 17

While obtaining a nursing history from a patient with inflammatory bowl disease, the nurse recognises that the patient most likely has ulcerative colitis rather than Crohn's disease when the patient reports experiencing:
A) weigh loss
B) bloody diarrhoea*
C) abdominal pain and cramping
D) the onset of the disease at age 20

Question 18

An 81 year old patient has large bowel obstruction that occurred as a result of a fecal impact ion. During nursing assessment of the patient, a finding by the nurse that is consistent with a large bowel obstruction includes:
A) metabolic alkalosis
B) referred pain to the back
C) rapid onset of copious vomiting
D) greatly increased abdominal distention

Answer 18

An 81 year old patient has large bowel obstruction that occurred as a result of a fecal impact ion. During nursing assessment of the patient, a finding by the nurse that is consistent with a large bowel obstruction includes:
A) metabolic alkalosis
B) referred pain to the back
C) rapid onset of copious vomiting
D) greatly increased abdominal distention*

Question 19

During the initial postoperative assessment of a patient’s stoma formed with a transverse colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding. The most appropriate interpretation of this finding by the nurse is that there is

a. A viable stoma with high vascularity
b. Obstruction of the stoma with venous congestion
c. Inadequate blood supply to the stoma, caused by edema
d. An abnormal stomal condition that should be reported to the surgeon

Answer 19

During the initial postoperative assessment of a patient’s stoma formed with a transverse colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding. The most appropriate interpretation of this finding by the nurse is that there is

a. A viable stoma with high vascularity*
b. Obstruction of the stoma with venous congestion
c. Inadequate blood supply to the stoma, caused by edema
d. An abnormal stomal condition that should be reported to the surgeon

Question 20

A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of her ileostomy, the nurse informs the patient that she should

a. Restrict fluid intake to prevent constant liquid drainage from the stoma.
b. Change the pouch every day to prevent leakage of contents onto the skin
c. Maintain as normal a diet as possible, avoiding foods that cause gas or diarrhoea
d. Irrigate the ileostomy daily or every other day to avoid having to wear a drainage appliance

Answer 20

A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of her ileostomy, the nurse informs the patient that she should

a. Restrict fluid intake to prevent constant liquid drainage from the stoma.
b. Change the pouch every day to prevent leakage of contents onto the skin
c. Maintain as normal a diet as possible, avoiding foods that cause gas or diarrhoea*
d. Irrigate the ileostomy daily or every other day to avoid having to wear a drainage appliance

Question 21

When the nurse applies a painful stimuli to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. The nurse interprets this finding as

a. Decorticate posturing indicating an interruption of voluntary motor tracts.
b. Decerebrate posturing indicating an interruption of voluntary motor tracts.
c. Decorticate posturing indicating a distruption of motor fibers in the midbrain and brainstem
d. Decerebrate posturing indicating indicating a distruption of motor fibers in the midbrain and brainstem

Answer 21

When the nurse applies a painful stimuli to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. The nurse interprets this finding as

a. Decorticate posturing indicating an interruption of voluntary motor tracts.
b. Decerebrate posturing indicating an interruption of voluntary motor tracts.
c. Decorticate posturing indicating a distruption of motor fibers in the midbrain and brainstem
d. Decerebrate posturing indicating indicating a distruption of motor fibers in the midbrain and brainstem*

Question 22

When assessing a patient with a neurologic disorder using the Glasgow Coma Scale, the nurse is obtaining information related to the

a. Level of consciousness
b. Presence of cerebral edema.
c. Presence of corneal and pupillary reflexes.
d. Integrated functions of the cerebral cortex.

Answer 22

When assessing a patient with a neurologic disorder using the Glasgow Coma Scale, the nurse is obtaining information related to the

a. Level of consciousness*
b. Presence of cerebral edema.
c. Presence of corneal and pupillary reflexes.
d. Integrated functions of the cerebral cortex.

Question 23

A 68 year old man has had several transient ischemic attacks (TIA’s) with temporary hemiparesis and dysarthria that have lasted up to an hour. The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour, explaining that permanent disability from a stoke may be reduce if therapy is initiated within 3 hours with use of

a. Intravenous heparin
b. Transluminal angioplasty
c. A surgical endarterectomy
d. Tissue plasminogen activator (TPA)

Answer 23

A 68 year old man has had several transient ischemic attacks (TIA’s) with temporary hemiparesis and dysarthria that have lasted up to an hour. The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour, explaining that permanent disability from a stoke may be reduce if therapy is initiated within 3 hours with use of

a. Intravenous heparin
b. Transluminal angioplasty
c. A surgical endarterectomy
d. Tissue plasminogen activator (TPA)*

Question 24

When taking a patient history during assessment of the musculoskeletal system, the nurse identifies an increase risk for the patient who reports a family history of

a. Osteoporosis
b. Osteomalacia
c. Osteomyelitis
d. Bony tuberculosis

Answer 24

When taking a patient history during assessment of the musculoskeletal system, the nurse identifies an increase risk for the patient who reports a family history of

a. Osteoporosis
b. Osteomalacia
c. Osteomyelitis
d. Bony tuberculosis

Question 25

A patient is admitted to the emergency department, with possible fractures of the bones of the left lower extremity. Prior to initiating treatment for the patient, it is most important for the nurse to

a. Spint the lower leg
b. Elevate the injured leg
c. Check neurovascular status distal to the injury
d. Assess the patient’s tetanus immunisation status

Answer 25

A patient is admitted to the emergency department, with possible fractures of the bones of the left lower extremity. Prior to initiating treatment for the patient, it is most important for the nurse to

a. Spint the lower leg
b. Elevate the injured leg
c. Check neurovascular status distal to the injury*
d. Assess the patient’s tetanus immunisation status

Question 26

A Braden and Norton scales are used in the clinical area to:
A) assess the skin in patient’s to identify any pressure areas
B) assess the patient’s own physical ability to take care of skin
C) assess the pressure ulcer once developed
D) assess the wound care of patients with pressure ulcers

Answer 26

A Braden and Norton scales are used in the clinical area to:
A) assess the skin in patient’s to identify any pressure areas*
B) assess the patient’s own physical ability to take care of skin
C) assess the pressure ulcer once developed
D) assess the wound care of patients with pressure ulcers

Question 27

A patient is ordered 2L of O2 therapy, what would be best delivery device for administering this amount of oxygen and what % of O2 is the patient receiving?
A) 21% O2 via a Hudson mask
B) 24% O2 via a Hudson mask
C) 24% O2 via Nasal prongs
D) 36% O2 via a Hudson mask

Answer 27

A patient is ordered 2L of O2 therapy, what would be best delivery device for administering this amount of oxygen and what % of O2 is the patient receiving?
A) 21% O2 via a Hudson mask
B) 24% O2 via a Hudson mask
C) 24% O2 via Nasal prongs*
D) 36% O2 via a Hudson mask

Question 28

When using the AORC Observation Chart, observations falling in which colour box according to the escalation protocol necessitates activating a medical emergency?
A) orange
B) blue
C) purple
D) yellow

Answer 28

When using the AORC Observation Chart, observations falling in which colour box according to the escalation protocol necessitates activating a medical emergency?
A) orange
B) blue
C) purple*
D) yellow

Question 29

Watson's theory of Caring defines health as being a unity of mind, body and what?
A) caring
B) spirit
C) environment
D) soul

Answer 29

Watson's theory of Caring defines health as being a unity of mind, body and what?
A) caring
B) spirit*
C) environment
D) soul

Question 30

Oesophageal Varices are-
A) formed as a direct result of liver dysfunction increasing splanchnic pressure in the GIT
B) formed as a direct result of liver dysfunction decreasing the formation of essential clotting factors such as Factor VII and XI
C) formed as direct result of liver dysfunction resulting in raised oesophageal venous pressure
D) formed as a direct result of liver dysfunction reducing portal vein and intrahepatic resistance.

Answer 30

Oesophageal Varices are-
A) formed as a direct result of liver dysfunction increasing splanchnic pressure in the GIT
B) formed as a direct result of liver dysfunction decreasing the formation of essential clotting factors such as Factor VII and XI
C) formed as direct result of liver dysfunction resulting in raised oesophageal venous pressure*
D) formed as a direct result of liver dysfunction reducing portal vein and intrahepatic resistance.