Colegio San Agustin – Bacolod

College of Health and Allied Professions

Nursing Program
Critical Thinking in Nursing

1. A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy. The nurse assesses to ensure that
which of the following items are in place or maintained before sending the client for the procedure?
a. Signed consent, clear liquid restriction, Foley catheter
b. Signed consent, NPO status, IV line
c. IV line, clear liquid restriction, Foley catheter
d. IV line, NPO status, Foley catheter

2. A 56-year-old man comes to the emergency room complaining of severe vomiting and temperature of 101.3° F
(38.5° C) for 2 days. The nurse recognizes that which of the following actions is a priority?
a. Assessing the patient’s need for dietary teaching
b. Assessing the patient's fluid and electrolyte status
c. Examining the patient’s health history for allergies to antibiotics
d. Determining whether the patient has signed consent for surgery

3. What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying?
a. "Tell me about your feelings right now."
b. “When the doctor arrives, everything will be fine.”
c. "This is a bad situation, but you’ll feel better soon."
d. "Please be assured we’re doing everything we can to make you feel better."

4. Nurse Rina is performing an assessment on a client with hepatic encephalopathy and assesses for asterixis. To
appropriately test for asterixis, Nurse Rina should:
a. Asks the client to extend an arm, dorsiflex the wrist, and extend the fingers.
b. Checks the stools for clay colored pigmentation
c. Asks the client to sign his or her name on a piece of paper and looks for any deterioration in hand
deterioration in hand movements
d. Reviews laboratory serum levels of bilirubin and alkaline phophatase for elevation

5. Nurse Robin assesses the 12th cranial nerve in the client who sustained a cerebrovascular accident (CVA). To assess
this cranial nerve, Nurse Robin should ask the client to:
a. Extend the arms
b. Turn the head toward the nurse’s arm
c. Extend the tongue
d. Focus the eyes on an object held by the nurse

6. Marielle with type 2 diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic
hyperosmolar nonketotic syndrome (HHNS). Nurse Marielle develops a discharge teaching plan for the client and
identifies which of the following as the priority?
a. Exercise routines
b. Monitoring for signs of dehydration
c. Keeping follow-up appointments
d. Controlling dietary intake
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7. A nurse is reviewing assessment data on a clinic client. Which finding would be most important for the client to
modify to lessen the risk for coronary artery disease (CAD)?
a. Elevated high density lipoprotein
b. Elevated low density lipoprotein
c. Elevated triglyceride
d. Elevated serum lipase levels

Situation: Adam is a 17 year old admitted in the Emergency department- pediatric unit with a diagnosis of Asthma.
8. Upon admission Adam has theophylline, D5NSS at 115 ml/H and 40% O2 via nasal prong. What are the signs and
symptoms of theophylline toxicity that the ED nurse should monitor?
a. Tachycardia, nausea and vomiting
b. Somnolence, shortness of breath
c. Hyperthermia, flushing
d. Urinary retention, Hyperkalemia

Situation: Sussy an 8 year old girl, admitted to the pediatric unit with a diagnosis of status asthmaticus. She has
increased thick yellow green secretions. She has an allergy to penicillin and possible other allergies.
9. For which of the following symptoms would the nurse immediately call the doctor for Sussy?
a. Delayed expiratory breath sounds
b. Intercostal retractions
c. Expiratory stridor
d. Inspiratory Wheezes

10. Dr. Doctolero orders aminophylline 250mg IV in 50 ml. It would be inappropriate when administering aminophylline
to:
a. Discontinue the aminophylline if the pulse increases from 100- 130 per minute
b. Observe for nausea and vomiting
c. Stay with Sussy to observe for convulsions
d. Watch for cardiac arrhythmias

Situation: Kesha is an 8 year old girl admitted to the pediatric unit in no obvious distress for a cardiac catheterization.
The catheterization revealed aortic stenosis. As her nurse, you are unable to detect a radial pulse in the arm that was
used for the catheterization.
11. The best explanation for this finding is:
a. Aortic stenosis decreases pressure for blood flow throughout the body
b. A traumatized artery may be without a pulse for up to 24 hours.
c. Blood flow is normally reduced following a catheterization
d. The artery may be occluded due to spasm
12. Immediate nursing action should be:
a. Nothing since this is a common occurrence following catheterization
b. Have the father help warm the arm and call the doctor
c. Explain to the father the common side effects of catheterization
d. Have the father help pack arm in ice and recheck pulse every 15 minutes.

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Situation: Stan aged 88 years old is admitted to the hospital with prostatic hypertrophy. He tells you during your
morning rounds that he was not voided since last night.

13. After assessing Stan and determining his bladder is distended, what is your most appropriate action?
a. Encourage use of urinal
b. Force fluids to induce voiding
c. Assist her into a warm shower
d. Apply pressure over the pubic area

14. Stan undergoes a suprapubic prostatectomy. What is the most appropriate action by the nurse to prevent secondary
bladder infection?
a. Observe for signs of uremia
b. Attach the catheter to suction
c. Clamp off the connection tubing
d. Change the dressings frequently

15. Stan complains of pain in the operative site. What is the most appropriate initial response by the nurse?
a. Administer the prescribed analgesic
b. Encourage intake of fluids to dilute urine
c. Inspect the drainage tubing for occlusion
d. Measure the record and vital signs before administering an analgesic

16. An indwelling catheter is removed after a prostatectomy and the patient is experiencing urinary frequency and
dribbling. Which if these statements would alleviate the patient’s anxiety concerning this situation?
a. Complete urinary control may never return
b. Dribbling will always be a problem
c. Urinary control will return slowly
d. A urinary bag may give you more security

17. What action should you take when performing tracheal suctioning?
a. Preoxygenate before suctioning
b. Apply negative pressure as the catheter is being inserted
c. Be sure the cuff of the tracheostomy is inflated during suctioning
d. Instill acetylcysteine into the tracheostomy prior to suctioning to loosen secretions

18. Treatment for Cushing’s syndrome may involve removal of one of the adrenal glands, which may cause a temporary
state of which of the following condition?
a. Hyperkalemia
b. Adrenal insufficiency
c. Excessive adrenal hormone
d. SIADH

19. Which of the following nursing interventions should be performed for a client with Cushing’s syndrome?
a. Suggest clothing or bedding that is cool and comfortable
b. Suggest consumption of high carbohydrate and low protein foods
c. Explain that physical changes are a result of excessive corticosteroids
d. Explain the rationale for increasing fluid intake in time of illness, increased stress, and very hot weather
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20. Jim’s mother is a nurse. Postoperatively, she notices that his ventilator is making him hyperventilate. She questions
if Jim is going to respiratory alkalosis. An appropriate response is
a. No, prolonged expiration is a relaxation technique used to reduce stress
b. Yes, this will keep Jim from becoming combative as he wakes up
c. Yes, this helps reduce the brain swelling
d. No, it can cause acidosis, which makes his blood vessel constrict

21. A patient received NPH Humulin insulin at 7:30am. At which time of the day would the nurse be alert to the
potential for a hypoglycemic reaction?
a. After breakfast
b. At midnight
c. Before bedtime
d. Before supper

22. A client asks what diabetes mellitus does to the body overtime. Which of the following condition is a common
chronic complication of diabetes mellitus?
a. Multiple sclerosis
b. Diabetic ketoacidosis
c. Cardiovascular disease
d. Hyperosmolar hyperglycemic nonketotic syndrome

23. Which of the following observations indicates that the closed chest drainage is functioning properly?
a. Absence of bubbling in the suction control bottle
b. The fluctuating movement of fluid in the long tube of the water-seal bottle during inspiration
c. Intermittent bubbling through the long tube of the suction control bottle
d. Less than 25ml drainage bottle

24. A client with pleural effusion has a chest tube inserted and connected to a closed chest drainage system. Which of
the following findings would require immediate nursing intervention?
a. Continuous bubbling in the drainage chamber
b. Straw colored drainage in the tubing
c. Tenderness at the insertion site
d. Movement of fluid in the tubing during the respiratory cycle

25. Claudine reviewed the client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which
of the following would Nurse Claudine note in the ECG as the result of the laboratory value?
a. Elevated T waves
b. Absent P waves
c. Elevated ST segment
d. U waves

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26. You are caring for a group of clients you reviewed the laboratory test results and nptes a sodium level of 130 mEq/L
on one client’s laboratory report. You understand that which is at most risk for the development of a sodium value
at this level?
a. The client who is taking diuretics
b. The client who is taking sodium with renal failure
c. The client with renal failure
d. the client with hyperaldosteronism

Situation: A nurse is watching his son’s baseball when a pitch hits the batter a 20 year old in the middle of his chest and
he collapses.
27. Paramedics defibrillated the injured player three times and are unsuccessful. Which medication should you
administer next?
a. Sodium bicarbonate
b. Lidocaine (Xylocaine)
c. Epinephrine
d. Bretyllium (Bretylol)

28. A client has a diagnosis of a stroke versus a transient ischemic attack (TIA). Which of the following statements shows
the difference between a TIA and a stroke?
a. TIAs typically resolve in 24 hours
b. TIAs may be hemorrhage
c. TIAs may cause a permanent motor deficit
d. TIAs may predispose the client to a myocardial inferction (MI)

29. For Mrs. Torre who is having an episode of acute narrow angle glaucoma, you would expect to give which of the
following medications?
a. Acetazolamide (Diamox)
b. Atropine
c. Furosemide (Lasix)
d. Urokinase (Abhokinase)

30. Aling Yayay has been diagnosed with cataract. What would you expect for Aling Yayay to report which of the
following?
a. Decreased color perception
b. Loss of peripheral vision
c. Halos around light
d. Headaches

31. After instilling Isopto Atropine eye drops, the nurse would anticipate instructing the client to
a. Hold pressure on inner canthus for one minute
b. Keep eyes opened blinking frequently to disperse medication
c. Roll eyes in all directions to enhance action of the medication
d. Close eyes tightly to prevent leakage of medication

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32. Dingdong was diagnosed with Meniere’s Disease. What drug would you expect to be given to Dingdong?
a. Antihypertensive
b. Antibiotics
c. Vasoconstrictor
d. Diuretics

33. You would question an order to irrigate the ear canal in which of the following circumstances?
a. Ear pain
b. Hearing loss
c. Otitis externa
d. Perforated tympanic membrane

34. A client who is diagnosed with a myocardial infarction is admitted to the coronary care unit with orders for bed rest
and medication for chest pain. Within an hour after admission, the nurse finds the client walking around the unit.
The nurse best initial best response would be;
a. “Tell me what you are doing out of bed.”
b. “It must be frustrating to be confined in bed.”
c. “You need to rest; therefore, you should get back to bed.”
d. Please get back in bed immediately. The doctor wants you to rest.”

35. The wife of a client who has had emergency coronary artery bypass surgery asks why her husband has a dressing on
his left leg. The nurse explains that:
a. This is the access site for the heart lung machine
b. A filter is inserted in the leg to prevent embolization.
c. The saphenous vein was used to bypass the coronary artery.
d. The arteries in distal extremities are examined during surgery.

36. The nurse is discussing discharge instructions with a client who has had coronary bypass surgery and his wife. The
client states, “My wife is afraid to have sex with me. When will it be safe to have sex again?” The most appropriate
response by the nurse would be:
a. “You should wait at least six weeks, but check with your doctor.”
b. You will need to talk that over with your doctor before you leave.”
c. “When you feel you have recovered enough to resume sexual activity.”
d. “As soon as you can climb one flight of stairs without fatigue or discomfort.”

37. While obtaining a health history the nurse would expect a 78-year-old client admitted to the hospital with chronic
heart failure to report a:
a. Tingling in the hands and arms.
b. Feeling of being “bloated” after eating.
c. Need to use three pillows at night to sleep
d. Swelling of the ankles more apparent in the morning than at night

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38. Before having sclerotherapy for varicose veins, a female client who states she is fearful of chemical injection ask the
nurse to explain what would be involved if she insisted on a ligation and stripping to correct the problem. The nurse
should explain that this surgery involves:
a. Removing the dilated saphenous veins
b. Cleaning out plaque from within the vessels
c. Anastomosing superficial veins to deep veins
d. Placing an umbrella filter in the large affected veins.

39. After a long history of recurrent thrombophlebitis in extensive varicose veins of the lower extremities, surgical
intervention is suggested to the client. When ask about the procedure, the nurse should explain that this surgery
involves:
a. Removing the dilated superficial vein
b. Bypassing the varicosities with artificial veins
c. Stripping the cholesterol deposits from the vein
d. Creating fistulas between superficial and deep veins.

40. A 55 year old bank teller, with a history of occasional pain in the left foot when walking, has now developed pain at
rest. The left foot is cyanotic, numb and painful. The suspected cause is arteriosclerosis. The nurse should teach the
client that the pain in the foot is more likely to decrease if he:
a. Keeps the left foot cool
b. Crosses his legs with the left one on top
c. Complies with the prescribed exercise program
d. Keeps the left foot elevated at a 30 degree angle

41. Six hours after a femoral-popliteal bypass graft, the client’s blood pressure becomes severely elevated. The nurse
should notify the physician primarily because the client’s:
a. Hypervolemia needs to be corrected immediately
b. Blood pressure could cause the graft to occlude
c. Intraabdominal pressure could compromise the viability of the graft.
d. Cardiovascular status could precipitate a cerebrovascular accident.

42. The nurse is aware that during the early postoperative period after open heart surgery adequate oxygenation is
essential because:
a. Clients have closed chest drainage in place
b. Hypoxia can precipitate respiratory alkalosis
c. Hypoxia can stimulate dangerous dysrhythmias
d. An increased respiratory rate adds to post operative pain.

43. A client who is taking an oral hypoglycemic daily for type two diabetes develops the flu and is concerned about the
need for special care. The nurse should advise the client to:
a. Avoid food, drink clear liquids, take a daily temperature, and stay in bed
b. Skip the oral hypoglycemic pill, drink plenty of fluids and stay in bed.
c. Eat as much as possible, increase fluid intake, and call the office again the next day.
d. Take the oral hypoglycemic pill, drink warm fluids, and perform a serum glucose test AC and HS.

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44. When teaching a client about the expected outcomes after the intravenous administration of furosemide, the nurse
would include which outcome?
a. Increased blood pressure.
b. Increased urine output.
c. Pain
d. Decreased PVCs.

45. Of all the following controllable risk factors for coronary artery disease (CAD) appears most closely linked to the
development of the disease?
a. Age
b. Medication usage
c. High cholesterol level
d. Gender

46. Altepace recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the
first 6 hours after onset of MI to:
a. Control chest pain
b. Reduce coronary artery vasospasm.
c. Control the dysrhythmias associated with MI.
d. Revascularized the blocked coronary artery.

47. Contraindications to the administration of t-PA include which of the following?

a. Age greater than 60 years.
b. History of cerebral hemorrhage
c. History of heart failure
d. Cigarette smoking.

48. In which of the following positions should the nurse place a client with suspected heart failure?
a. Low fowler’s position
b. Sim’s position
c. High Fowler’s position
d. Trendelenburg position

49. To help maintain a normal blood serum level of potassium, the client receiving a loop diuretic should be encourage
to eat such foods as bananas, orange juice and ?
a. Spinach
b. Skimmed milk
c. Baked chicken
d. Brown rice

50. Peripheral blood flow is dependent on which of the following variables?

a. Blood viscosity and diameter of vessels.
b. Diameter and resistance of vessels.
c. Force of contraction of the heart and resistance of vessels.
d. Pressure differences in the arterial and venous systems and resistance.

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51. The nurse has been assigned to a client with Buerger’s disease. Which of the following anatomic areas are most
often affected by this vascular condition?
a. Hands and fingers
b. Lower legs and feet
c. Head and neck
d. Lower back

52. The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge.
Which of the following foods should be included in the diet?
a. Eggs
b. Lettuce
c. Citrus fruits
d. Cheese

53. When determining the parent’s compliance with treatment for their toddler who has recurrent otitis media, which
of the following measures would the nurse expect the parents to describe?
a. Cleaning the child’s ear canals with hydrogen peroxide
b. Administering continuous, small-dose antibiotic therapy.
c. Instilling ear drops regularly to prevent cerumen accumulation.
d. Holding the child upright when feeding with a bottle.

54. A child diagnosed with tetralogy of Fallot becomes upset, crying and thrashing around when a blood specimen is
obtained. The child’s color becomes blue and the respiratory rate increases to 44 breaths/ minute?
a. Obtain an order for sedation for the child
b. Assess for an irregular heart rate and rhythm
c. Explain to the child that it will only hurt for a short time.
d. Place the child in a knee-to-chest position.

55. A 29 year old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her
49 year old sister was recently diagnosed with the disease. After gathering information about the client’s history of
sun exposure, the nurse’s best response would be to explain that:
a. Some melanomas have a familial component and she should seek medical advice.
b. Her personal risk is low because most melanomas occur at age 60 or later.
c. Her personal risk is low because melanoma does not have a familial component.
d. She should not worry because she did not experience severe sunburn as a child.

56. Which of the following factors can cause hepatitis A?

a. Contact with infected blood
b. Blood transfusion with infected blood.
c. Eating contaminated shellfish
d. Sexual contact with an infected person.

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57. To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge
instruction?
a. Lie down after meals to promote digestion.
b. Avoid coffee and alcoholic beverages.
c. Take antacids with meals
d. Limit fluid intake with meals

58. A client is scheduled to undergo a left hemicolectomy for a colorectal cancer. The physician prescribes Phenobarbital
(Luminmal), 100mg IM 60 mins before surgery for sedation. Which statement accurately describes administration of
Phenobarbital?
a. The preferred route for administration for this drug is IM.
b. This drug can be mixed and given with other medications
c. This drug should be used within 24 hours after opening
d. This drug should be injected into a large muscle mass.

59. When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
a. Administering an analgesic once per shift, as prescribed, to prevent addiction.
b. Positioning the client on the side with the knees flexed.
c. Encouraging frequent visits from family and friends.
d. Administering frequent oral feedings.

60. The nurse should expect to administer which vaccine to the client after a spleenectomy?
a. Recombivax HB
b. Attenuvax
c. Pneumovax 23
d. Tetanus toxoid

61. The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin
K absorption caused by the hepatic disease?
a. Dyspnea and fatigue
b. Ascites and orthopnea
c. Purpura and petechiae
d. Gynecomastia and testicular atrophy

62. Why are antacids administered regularly, rather than as needed, to treat peptic ulcer diseases?
a. To keep gastric pH at 3.0 to 3.5
b. To promote client compliance
c. To maintain regular bowel pattern
d. To increase pepsin activity

63. A client Is receiving a course of chemotherapy on an outpatient basis for the diagnosis of lung cancer. Which home
care instruction should the nurse provide to the client?
a. A bathroom can be shared with any member of the family.
b. Urinary and bowel excreta are not considered contaminated.
c. Disposable plates and plastic utensils must be used during the entire course of chemotherapy.
d. Contaminated linens should be washed separately and then washed a second time, if necessary.

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64. The home care nurse visits a client with bowel cancer who recently received a course of chemotherapy. The client
has developed stomatitis, and the nurse provides instructions to the client about the care to the mouth. The nurse
determines that the client needs further instructions if the client states the need to:
a. Eat foods without spices.
b. Maintain a diet of soft foods
c. Drink juices that are not citrus
d. Take foods and liquids that are hot.

65. The nurse provides instructions to the client who received cryosurgery for a local stage 0 cervical tumor. The nurse
tells the client:
a. To avoid tub baths
b. To call the physician if a watery discharge occurs.
c. That pain indicates a complication of the procedure
d. To call the physician if the discharge remains odorous after 1 week.

66. The home care nurse is caring for a client with acute cancer pain. The most appropriate assessment of the client’s
pain should include which of the following?
a. The client’s pain rating
b. The nurse’s impression of the client’s pain
c. Verbal and non-verbal clues from the client
d. Pain relief after appropriate nursing intervention.

67. A client has terminal cancer and is using opioid analgesics for pain relief. The client is concerned about becoming
addicted to the pain medication. The home care nurse allays the client’s anxiety by:
a. Encouraging the client to hold off as long as possible between doses of pain medication.
b. Telling the client to take lower doses of medication even though the pain is not well controlled.
c. Explaining to the client that addiction that the fears are justified but should be of no concern during the final
stages of care
d. Explaining to the client that addiction rarely occurs in individuals who are taking medication to relieve pain.

68. A client with cancer is placed on permanent parenteral nutrition as a means of providing nutrition. The nurse
includes psychosocial support when planning care for this client because:
a. Death is imminent.
b. Parenteral nutrition requires disfiguring surgery for permanent port implantation.
c. The client will need to adjust the idea of living without eating by the usual route.
d. Nausea and vomiting occur regularly with this type of treatment and will prevent the client from
participating in social activity.

69. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary
teaching focusing on foods high in vitamin that may be lacking in a vegan diet?
a. Vitamin A
b. Vitamin B12
c. Vitamin C
d. Vitamin E

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70. When assessing a client who is experiencing pain, the nurse should be alert for a sign of an involuntary reaction to
pain, which is:
a. Crying
b. Splinting
c. Perspiring
d. Grimacing

71. In the evaluation of the condition of a client with burns of the upper body, an assessment that would indicate
potential respiratory obstruction is:
a. Deep breathing
b. Pink-tinged, frothy sputum
c. Hoarse quality of the voice
d. Rapid abdominal breathing

72. The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full-
thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from
recording:
a. Weights every day
b. Urinary output every hour
c. Blood pressure every 15 minutes
d. Extent of peripheral edema every 4 hours

73. When a female client who has partial-thickness burns on her chest, abdomen, and right leg from a fire at her
workplace arrives in the emergency room the nurse's first responsibility should be to:
a. Carefully remove all of the client's clothing
b. Evaluate whether heat inhalation had occurred
c. Apply sterile saline dressings on all burned surfaces
d. Determine the extent of the burns, using the rule of nines

74. The nurse is caring for a client immediately after an abdominal aortic aneurysm repair. Vital signs are: blood
pressure 100/70, pulse 120, respirations 24, urine output 75 cc during the past 3 hours. Which of the following
would be a priority nursing action(s) for this client?
a. Weigh the client.
b. Obtain an EKG.
c. Decrease the rate of the IV fluids and start nasal oxygen.
d. Maintain bedrest and evaluate for a decrease in CVP readings.

75. The clinic nurse returns a phone call from a diabetic client who has been vomiting for 24 hours. It is MOST important
for the nurse to instruct the client to
a. take only half of her regular insulin dose.
b. attempt to maintain her regular diabetic diet.
c. limit intake of sweets and sugar.
d. drink liquids as often as possible.

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76. The nurse is caring for a patient admitted to the unit 3 days ago with second- and third-degree burns over 30% of
her body. It would be MOST important for the nurse to report which of the following observations to the next shift?
a. CVP reading of 12 cm water pressure.
b. General muscle weakness and lethargy.
c. Heart rate of 100 beats per minute.
d. Systolic blood pressure of 105.

77. Which of the following statements, if made by the nurse, is accurate about the exercise program required for a
patient with rheumatoid arthritis?
a. "If you are having a 'bad' day, postpone your exercises until the next day."
b. "Passive exercises are better for you than active exercises."
c. "When inflammation is severe, decrease the number of repetitions of the exercise."
d. "You can substitute your normal household tasks for your exercises to provide variety."

78. Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis?
a. Provide support to flexed joints with pillows and pads.
b. Position her on her abdomen several times a day.
c. Massage the inflamed joints with creams and oils.
d. Assist her with heat application and ROM exercises.

79. A client is diagnosed with lung cancer and undergoes a pneumonectomy. In the immediate postoperative period,
which of the following nursing assessments is MOST important?
a. Presence of breath sounds bilaterally.
b. Position of the trachea in the sternal notch.
c. Amount and consistency of sputum.
d. Increase in the pulse pressure.
80. A client develops severe, crushing chest pain radiating to the left shoulder and arm. Which of the following PRN
medications should the nurse administer?
a. Diazepam (Valium) PO.
b. Meperidine (Demerol) IM.
c. Morphine sulfate IV.
d. Nitroglycerine (Nitrostat) SL.

81. A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities. Which of the
following nursing observations would indicate a therapeutic response to therapy for the edema?
a. Serum potassium 4.0 mEq/L.
b. Plasma glucose 140 mg/dL.
c. Increased specific gravity of the urine.
d. Weight loss of 5 lb over last two days.

82. The nurse is caring for patients in an acute care facility. The nurse would identify which of the following patients as
a likely candidate for developing acute renal failure?
a. A young female with recent ileostomy due to ulcerative colitis.
b. A middle-aged male with elevated temperature and chronic pancreatitis.
c. A teenager in hypovolemic shock following a crushing injury to the chest.
d. Child with compound fracture of the right femur and massive laceration of the left arm.

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83. A client has been diagnosed with metastatic cancer with a poor prognosis. Recently, the client has complained of
increased pain, is less communicative, very irritable, and anorexic. Which of the following nursing goals should be a
priority at this time?
a. Encourage client to talk about the possibility of dying.
b. Provide pain assessment and effective pain management.
c. Manage nutrition and hydration.
d. Verify that the physician has discussed the prognosis with the family.

84. The nurse is caring for a 67-year-old man following a cardiac catheterization. Two hours after the procedure, the
nurse checks the patient's insertion site in the antecubital space, and the patient complains that his hand is numb.
The nurse should:
a. change the position of his hand.
b. check his grip strength in both hands.
c. notify the physician.
d. instruct the patient to exercise his fingers.

85. The nurse is caring for a client with cirrhosis. Which manifestations indicate deficient vitamin-K absorption caused
by this liver disease?
a. Dyspnea and fatigue
b. Ascites and orthopnea
c. Purpura and petechiae
d. Gynecomastia and testicular atrophy

86. A client reports sharp pain in the right side of the chest and difficulty of breathing and has a respiratory rate of 40
breaths/minute. Which goal should the nurse consider the top priority?
a. Maintenance of adequate circulatory volume.
b. Maintenance of effective respirations.
c. Anxiety reduction
d. Pain reduction

87. What should the nurse do first for a client with a sucking stab wound to the chest?
a. Draw blood for hematocrit and hemoglobin levels.
b. Apply a dressing, taped on three sides.
c. Prepare a chest-tube insertion tray.
d. Prepare to start an I.V. line.

88. A client is admitted with a cervical spine injury caused by a diving accident. When planning this client's care, the
nurse should give which nursing diagnosis the highest priority?
a. Impaired physical mobility
b. Ineffective breathing pattern
c. Sensory or perceptual alterations
d. Dressing or grooming self-care deficit

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89. A client seeks care for severe pain in the right upper quadrant of the abdomen, which is accompanied by nausea and
vomiting. The physician make a diagnosis of acute cholecystitis and cholelithiasis. For this client, which nursing
diagnosis should receive top priority?
a. Pain related to biliary spasms
b. Knowledge deficit related to prevention of recurrence
c. Anxiety related to unknown outcome of hospitalization.
d. Altered nutrition: less than body requirements related to biliary inflammation.

90. A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared to a control time of 11
seconds. Which drug should the nurse expect to administer?
a. Spironolactone (Aldactone)
b. Phytonadione (Mephyton)
c. Furosemide (Lasix)
d. Warfarin (Coumadin)

91. After a surgical procedure for cancer of the pancreas a client is to receive the following intravenous fluids over 24
hours: 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is
ordered every 8 hours. The nurse calculates that the client’s IV fluid intake for 24 hours will be:
a. 3150 ml
b. 3200 ml
c. 3650 ml
d. 3750 ml

92. An elderly client is diagnosed as having acute renal failure secondary to dehydration, and the physician orders an IV
infusion of 50% glucose and regular insulin. The nurse understands that this is ordered for a client in renal failure to:
a. Prevent cardiac arrest
b. Increase urinary output
c. Prevent respiratory acidosis
d. Decrease serum calcium levels

93. Clients with insulin dependent diabetes mellitus may experience a fluid imbalance. The primary fluid shift that
occurs in diabetes mellitus is:
a. Intravascular to interstitial because of glycosuria
b. Extracellular to interstitial because of hypoproteinemia
c. Intracellular to intravascular as a result of hyperosmolarity
d. Intracellular to intravascular as a result of increased hydrostatic pressure

94. An adult comes to the clinic because she has a productive cough. She smokes two packs of cigarettes a day and has a
family history of lung cancer and emphysema. Using the principles of health promotion, the nurse would make what
interpretation of the client's behavior?
a. She is using denial to deal with being at high risk for lung cancer.
b. Not assuming self-responsibility for her health.
c. Exhibiting a laissez-faire attitude toward smoking and her risk of cancer.
d. Demonstrating passive suicidal tendencies.

Critical Thinking in Nursing

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95. The finding that would most significantly indicate that a client is hypertensive is:
a. An extended Korotkoff's sound
b. A regular pulse of 92 beats per minute
c. A systolic blood pressure ranging from 140 to 150 mm Hg
d. A diastolic blood pressure that remains greater than 90 mm Hg

96-100

Critical Thinking in Nursing