NP3 MS

The physician ordered: “report drainage that is cloudy and in excess of 70 mL per hour.” The nurse knows that a cloudy drainage would indicate:

A. Infection
B. Presence of debris
C. Impending hemorrhage
D. Occluded tubing

Answer: A. Infection
Rationale: Cloudy or purulent drainage from a chest tube suggests infection (e.g., empyema) and requires prompt reporting.

Which of the following is the most likely cause of impaired vitamin B12 absorption leading to pernicious anemia?

A. Decreased bile production
B. Damage to the intestinal villi
C. Absence of intrinsic factor
D. Increased gastric acid secretion

Answer: C. Absence of intrinsic factor

Rationale:
Pernicious anemia occurs when the stomach fails to produce intrinsic factor, a protein secreted by parietal cells that is necessary for vitamin B12 absorption in the ileum. Without intrinsic factor, vitamin B12 cannot be absorbed properly, leading to megaloblastic anemia.

In relation to the functions of small intestine motility, which type of contraction is primarily responsible for propelling intestinal contents toward the colon?

A. Segmentation contractions
B. Mastication
C. Mass movements
D. Intestinal peristalsis

Answer: D. Intestinal peristalsis

Rationale:
Peristalsis consists of wave-like contractions that move food forward through the gastrointestinal tract. Segmentation mainly mixes chyme, while mass movements occur in the colon.

A nurse is assessing a patient who complains of dyspepsia. Which of the following dietary intake is most likely the cause of the patient’s symptom?

A. 2 pieces of nilagang itlog for breakfast
B. Adobong tokwa with kangkong for lunch
C. 1 slice of puto and 1 piece of saging na saba for snacks
D. Dinner consisting of sisig and lechon baboy with white rice for dinner

Answer: D. Dinner consisting of sisig and lechon baboy with white rice for dinner

Rationale:
Dyspepsia is commonly triggered by fatty, spicy, and heavy meals. Sisig and lechon are high-fat foods that can delay gastric emptying and increase gastric discomfort.

In assessing the abdomen of the patient complaining of dyspepsia, which of the following is the correct order of abdominal assessment techniques that the nurse should follow?

A. Inspection, auscultation, palpation, then percussion
B. Inspection, palpation, percussion, auscultation
C. Inspection, auscultation, percussion, palpation
D. Auscultation, percussion, palpation, inspection

Answer: C. Inspection, auscultation, percussion, palpation

A nurse is preparing a client for an overnight dexamethasone suppression test as part of the diagnostic workup for Cushing’s syndrome. Which nursing action demonstrates the correct procedure for this test?

Choices:

A. Administer 8 mg dexamethasone orally at 2200 hours and obtain serum cortisol at 0800 hours
B. Give 1 mg dexamethasone intravenously at 2000 hours, then collect urine cortisol for 24 hours
C. Administer 1 mg dexamethasone orally at 2300 hours and obtain a serum cortisol level at 0800 hours the following day
D. Withhold dexamethasone and obtain baseline cortisol levels only

Answer: C. Administer 1 mg dexamethasone orally at 2300 hours and obtain serum cortisol at 0800 hours

Rationale:

The overnight dexamethasone suppression test evaluates whether cortisol production can be suppressed.

Which finding is characteristic of Osteoarthritis involving the interphalangeal joints?

Choices:

A. Soft tissue swelling with ulnar deviation
B. Bony enlargement of the distal and proximal interphalangeal joints
C. Symmetric inflammation with prolonged morning stiffness
D. Joint deformity caused by pannus formation

B. Bony enlargement of the distal and proximal interphalangeal joints

A patient with Osteoarthritis asks how to manage pain when starting a walking exercise program. Which response is most appropriate?

A. Avoid exercise when experiencing pain
B. Perform vigorous exercise daily
C. Take a prescribed analgesic before exercising to reduce discomfort
D. Limit all physical activity

C. Take a prescribed analgesic before exercising to reduce discomfort

Which individual is at greatest risk for developing Osteoarthritis (OA)?

A. 28-year-old sedentary office worker
B. 50-year-old warehouse worker with repetitive heavy lifting and previous knee injury
C. 35-year-old with autoimmune disorder and morning stiffness >1 hour
D. 42-year-old with normal weight and no trauma

B. 50-year-old warehouse worker with repetitive heavy lifting and previous knee injury

Which joint deformity is most commonly associated with Rheumatoid Arthritis?

A. Heberden’s and Bouchard’s nodes
B. Ulnar deviation and swan-neck deformity
C. Bone spur formation
D. Crepitus and cartilage thinning

B. Ulnar deviation and swan-neck deformity

In the immediate postoperative period following a Total Hip Arthroplasty, which nursing intervention is most appropriate to prevent hip dislocation?

A. Position the affected leg in full flexion while sitting upright
B. Allow the legs to be adducted together when lying in bed
C. Place an abduction splint or wedge pillow between the legs
D. Encourage internal rotation of the affected hip during repositioning

Answer: C. Place an abduction splint or wedge pillow between the legs

Rationale:

After THA, the greatest risk is hip dislocation.

The patient has a history of a bleeding disorder. Which intervention is most appropriate to prevent DVT postoperatively?

Choices:

A. Administer LMWH
B. Continuous IV anticoagulant therapy
C. Apply mechanical compression devices such as sequential compression stockings
D. Encourage complete bed rest

Answer: C

Rationale:

Because the patient has a bleeding disorder, anticoagulants may increase bleeding risk.

Which postoperative finding requires immediate notification of the surgeon?

A. Incisional pain 3/10 with movement
B. Mild edema and warmth near incision
C. Sudden “popping” sensation, acute groin pain, shortening of affected leg, and external rotation
D. Stiffness during first ambulation

Answer: C

Which statement indicates correct understanding regarding sexual activity after THA?

A. Resume as soon as pain decreases; any position is acceptable
B. “Sexual activity is generally allowed after 3 to 6 months, and the supine position is recommended to avoid hip flexion and adduction.”
C. Avoid sexual activity permanently
D. Resume within 1 week

B. “Sexual activity is generally allowed after 3 to 6 months, and the supine position is recommended to avoid hip flexion and adduction.”

The admitting nurse understands that in pneumothorax, air accumulates abnormally in the:

A. Pulmonary vascular system
B. Pleural space
C. Lung tissues
D. Thoracic cavity

Answer: B. Pleural space
Rationale: Pneumothorax is the presence of air in the pleural space, leading to loss of negative intrapleural pressure and lung collapse.

What is the most common initial clinical manifestation of Rheumatoid Arthritis?

A. Asymmetric joint pain worsening with activity
B. Symmetric joint pain with prolonged morning stiffness lasting more than 1 hour
C. Sudden severe pain in one large joint
D. Evening stiffness only

B. Symmetric joint pain with prolonged morning stiffness lasting more than 1 hour

Which of the following best describes the autoimmune pathophysiology of Rheumatoid Arthritis (RA)?

A. Degeneration of articular cartilage due to mechanical wear and tear leading to joint space narrowing and osteophyte formation
B. Autoimmune inflammation originating in synovial tissue leading to pannus formation that erodes cartilage and bone

C. Loss of bone density from estrogen deficiency causing microfractures and vertebral collapse
D. Degeneration of articular cartilage due to aging with decreased synovial fluid production

B. Autoimmune inflammation originating in synovial tissue leading to pannus formation that erodes cartilage and bone

Upon auscultation of the abdomen, the nurse noted 6 bowel sounds within 20 seconds. How should this finding be interpreted?

A. Hypoactive bowel sounds
B. Normal bowel sounds
C. Hyperactive bowel sounds
D. Absent bowel sounds

Answer: B. Normal bowel sounds

Rationale:
Normal bowel sounds occur approximately 5–30 sounds per minute. Six sounds in 20 seconds equals about 18 sounds per minute, which is normal.

In verifying the placement of a newly inserted nasogastric tube before initiating feeding, what is the BEST way to confirm that the tube is correctly placed in the stomach?

A. The client is able to speak normally and is not coughing
B. A radiograph confirms placement of the tube in the stomach
C. The pH of the aspirate obtained is less than 5
D. A “whooshing” sound is heard over the epigastrium when air is injected through the tube

Answer: B. A radiograph confirms placement of the tube in the stomach

Rationale:
X-ray confirmation is the gold standard for verifying NG tube placement. Air insufflation is no longer considered reliable.

The patient is diagnosed with open pneumothorax. The nurse knows that this occurs when?

A. The chest wall wound is large enough to allow air to pass freely in and out.
B. There is a buildup of positive pressure occurring with each inspiration and the air is trapped.
C. There is a rupture of air-filled bleb or blister on the surface of the lung.
D. There is a presence of bronchopleural fistula.

Answer: A. The chest wall wound is large enough to allow air to pass freely in and out.
Rationale: An open pneumothorax (“sucking chest wound”) allows free movement of air between the atmosphere and pleural space through a chest wall defect.

Feature	Closed Pneumothorax	Open Pneumothorax
Chest wall	Intact	Open wound
Air entry	From lung	From outside atmosphere
Sound	None externally	“Sucking” sound
Main issue	Lung collapse	Air shunting through chest wound

When the nurse checked the water-sealed drainage, she observed that the water level does not fluctuate simultaneously with the client’s breathing. The nurse interprets this observation as:

A. An abnormal occurrence suggesting problem with the system’s patency
B. Normal but may require water to be added to the suction control chamber
C. Emergent requiring immediate reporting to the physician
D. Expected with the client’s current condition

Answer: A. An abnormal occurrence suggesting problem with the system’s patency
Rationale: Normally, tidaling (fluctuation) occurs with respiration. Absence may indicate obstruction, lung re-expansion, or system issue that requires assessment.

The nurse identifies presence of chest tubes. Which of the following nursing interventions will the nurse consider as APPROPRIATE?

1. Secure a loop of the drainage tubing to the sheet or groin of the client

2. Encourage deep breathing exercises (DBE) and coughing as needed

3. Maintain the collection apparatus below the chest

4. When turning client, ensure chest tube and drainage tubing are not occluded under the client

5. Clamp the chest tube to practice pleural training

A. 1, 2, 3, and 5 only
B. 3, 4 only
C. 2, 3, 4 only
D. ALL OF THE ABOVE

Answer: C. 2, 3, 4 only
Rationale:

• (2) Correct – promotes lung expansion

• (3) Correct – prevents backflow into pleural space

• (4) Correct – avoids kinking or occlusion

• (1) Incorrect – tubing should be secured properly but not looped to groin (risk of dislodgement)

• (5) Incorrect – routine clamping is contraindicated (risk of tension pneumothorax)

Which nursing observations would MOST likely predispose the client to develop venous thrombosis in the lower extremity?

A. Drinking coffee at least 3 to 5 cups in a day
B. Refusing to get out of bed
C. Taking soft diet only
D. Requesting for analgesics frequently

Answer: B. Refusing to get out of bed

Rationale:
Immobility (bed rest) is the strongest risk factor for venous stasis, which leads to deep vein thrombosis (DVT). Lack of muscle contraction reduces venous return.

The patient was prescribed to have antiembolism stockings. The nurse assesses the patient knows its purpose when she states:

1. It promotes venous return

2. It strengthens muscle tone

3. It prevents pooling of blood in the extremities

A. 1 & 2
B. 1 & 3
C. 2 & 3
D. 1, 2 & 3

Answer: B. 1 & 3

Rationale:
Antiembolism stockings work by promoting venous return and preventing venous stasis (blood pooling). They do NOT strengthen muscle tone.

The nurse assesses the client for Homan’s sign. Which of the following is the CORRECT instruction of the nurse?

A. Have the client push each foot hard against the mattress
B. Tell the client to sit on bed and point to her toes
C. Ask the client to contract her tight muscles
D. Instruct the client to extend her legs and flex each foot toward the head

Answer: D. Instruct the client to extend her legs and flex each foot toward the head

Rationale:
Homan’s sign is elicited by dorsiflexion of the foot (flexing toward the head) with the leg extended, although it is no longer a reliable diagnostic test.

Which client’s response suggest a positive Homan’s sign?

A. Inability of the client to bend her knees
B. Sudden numbness while extending the foot
C. Tingling sensation throughout the affected leg
D. Sharp, immediate calf pain in the legs

Answer: D. Sharp, immediate calf pain in the legs

Rationale:
A positive Homan’s sign is indicated by pain in the calf upon dorsiflexion of the foot, suggesting possible DVT (though not definitive).

Answer: D. Sharp, immediate calf pain in the legs

Rationale:
A positive Homan’s sign is indicated by pain in the calf upon dorsiflexion of the foot, suggesting possible DVT (though not definitive).

Based on the findings, the client has been diagnosed with thrombophlebitis. Which of the following nursing action must be AVOIDED?

A. Elevating the client’s leg
B. Massaging the affected leg
C. Applying ice compress to the affected leg
D. Ambulating at least twice each shiftg.

Answer: B. Massaging the affected leg

Rationale:
Massage is strictly contraindicated in thrombophlebitis/DVT because it can dislodge the clot and cause pulmonary embolism, which is life-threatenin

nurse is developing a Teaching Plan for Isabel, an 18-year-old with Bronchial Asthma. She has an order for discharge. Which part of the teaching plan should be given PRIORITY?

A. Quick relief medicines as ordered
B. Avoid contact with fur-bearing pets
C. Avoid going to malls
D. Wash bed sheets in warm water

Answer: A. Quick relief medicines as ordered

Rationale: Airway and breathing take priority. The client must know how and when to use quick-relief medications (rescue inhalers) to manage acute asthma attacks and prevent respiratory distress. The other options are important preventive measures but are not the highest priority.

Mr. Gilbert is for postural drainage. The nurse should position the client’s head at ______________.

A. No greater than a 25 degree downward angle
B. A 30 degree lateral angle for 25 minutes
C. 25 degree at lateral angle
D. A 30 degree downward angle for 25 minutes

Answer: D. A 30 degree downward angle for 25 minutes

Nurse Beth is teaching Michel, an asthmatic, on how to use the Spirometer. She should instruct the client to have the mouthpiece ________________.

A. Place into the mouth and have regular breathing
B. Place into the mouth and have a fast deep breath
C. Place into the mouth and inhale slowly
D. Place into the mouth and exhale slowly

Answer: C. Place into the mouth and inhale slowly

Rationale: The client should place the mouthpiece in the mouth, seal the lips around it, and inhale slowly and deeply. Slow inhalation promotes lung expansion and helps prevent atelectasis.

Nurse Beth is teaching a client on how to use a metered-dose inhaler to prevent an asthmatic attack while in the hospital. She should instruct the client to do the following EXCEPT.

A. Keep the head of the bed at 15 degree angle
B. Do oral care after use of the inhaler
C. Use the inhaler before she take her meals
D. Use the inhaler as ordered

Answer: A. Keep the head of the bed at 15 degree angle

Rationale: A client should be in an upright or semi-Fowler’s position

You are conducting health-teaching sessions to clients with cardiovascular disorders. Client Pedro asks you this question: “Tell me, Nurse, what I should do with my Hypertension?” The best response of a Nurse is ____________.

A. “Comply with your diet, lifestyle and exercise”
B. “Strictly follow your prescribed daily exercise and smoking cessation”
C. “Comply with your diet, lifestyle modification and prescribed medicines”
D. “Include garlic in your meals with regulation of alcohol consumption”

Answer: C. “Comply with your diet, lifestyle modification and prescribed medicines”

The patient asks you, “What do you think of my surgeon?” You answered: “Hmmmmm… he is not really the best one and he seems not to care for patients…” As a result, the patient switches to another surgeon. The latter may have grounds to sue you for _____________.

A. Slander
B. Invasion of privacy
C. Malpractice
D. Libel

Answer: A. Slander

Rationale: Slander is spoken defamation that damages a person’s reputation. The nurse’s verbal statement about the surgeon influenced the patient’s decision.

According to the Joint Commission, the most frequently cited factor in sentinel (unanticipated) events that leads to a patient’s serious physical or psychological injury is ______________________.

A. Confusion within the health team
B. Miscommunication among health team members
C. Incompetence by a team member
D. Policy changes are not followed by adequate and consistent staff education

Answer: B. Miscommunication among health team members

Rationale: The Joint Commission identifies communication failure as the most common root cause of sentinel events.

A Nurse researcher is using ACCU-CHEK monitoring kit to test presence of Diabetes Mellitus among her study subjects. How do you classify this type of measurement?

A. Microbial
B. Cytological
C. Physiological
D. Chemical

Answer: D. Chemical

Rationale: Blood glucose testing (ACCU-CHEK) measures chemical levels in the blood (glucose concentration), making it a chemical measurement.

Nurse Joan wanted to conduct a study using quasi-experimental design. This design will need a __________.

A. Retrospective evaluation
B. Field setting for the study
C. Comparable group
D. Manipulation of the dependent variable

Answer: C. Comparable group

Rationale: Quasi-experimental designs require a comparison or non-equivalent group, but may lack randomization.

Nurse Tessie respects cultural practices integration in her nursing care plan. Which of the following nursing action is MOST representative of the culturally competent nurse?

A. Help patient Kian to learn and understand the language
B. Explain and validate health knowledge and beliefs of Patient Kian with that of the hospital
C. Help Patient Kian identify ways to relate more to the culture where they now resides
D. Ask patient Kian to help Nurse Tessie in knowing more the culture of his origin

Answer: D. Ask patient Kian to help Nurse Tessie in knowing more the culture of his origin

Rationale: Culturally competent care is patient-centered and respectful, promoting mutual learning. Asking the patient about their culture reflects cultural humility and respect, not assimilation or judgment.

Julie, 28 years old with Diabetes Mellitus, received insulin at 6 AM. After 2 hours, she has cold clammy perspiration, chills, and abdominal discomfort. Which PRIORITY nursing action should the nurse perform?

A. Give her biscuit to eat
B. Do urine testing for sugar
C. Provide her warm blanket
D. Take blood pressure and put her on bed rest

Answer: A. Give her biscuit to eat

Rationale: The patient is showing signs of hypoglycemia (insulin reaction). The priority is to give fast-acting carbohydrates immediately to prevent worsening hypoglycemia and possible loss of consciousness.

Mr. Dencio, 58 years old, refuses oxygen therapy despite encouragement. He is aware of the benefits. Which should be given priority?

A. Ask the opinion of the wife
B. Conduct consensus building
C. Let the attending physician decide on the necessity of the treatment
D. Respect the decision of the client

Answer: D. Respect the decision of the client

Rationale: A competent adult client has the right to refuse treatment, even if it is beneficial. This respects autonomy and informed refusal.

You are taking care of Mr. Dencio who is on the last cycle of radiation therapy for lung cancer. You should instruct him to:

A. Brush teeth and gums vigorously after meals
B. Wait one hour after treatment before eating
C. Use mouthwash containing alcohol every 2 hours
D. Avoid drinking hot fluids

Answer: D. Avoid drinking hot fluids

Rationale: Radiation therapy can cause mucositis and oral irritation. Hot fluids may worsen inflammation. Gentle oral care is recommended; alcohol-based mouthwash and vigorous brushing are avoided.

The following are relevant data in a client with anemia EXCEPT:

A. Alcohol intake
B. Fatigue and weakness
C. Dietary intake
D. Episodes of bleeding

Answer: A. Alcohol intake

Rationale: Fatigue, diet, and bleeding are directly related to anemia assessment. Alcohol intake is not a primary focus in anemia history.

A client with congenital heart disease is suffering from thickening of the skin under his fingers due to chronic hemoglobin desaturation. Which term should the nurse use?

A. Peripheral cyanosis
B. Pallor of the finger tips
C. Peripheral neuropathy
D. Clubbing of the fingers

Answer: D. Clubbing of the fingers

Rationale: Chronic hypoxia causes digital clubbing, commonly seen in congenital heart disease and lung disorders.

A client is on a diuretic therapy. Expected entry in patient’s chart should include the following EXCEPT:

A. Serum electrolytes monitored
B. Intake and output recorded
C. Lasix administered at 8 o’clock in the evening
D. Weight is taken before drug is given

Answer: C. Lasix administered at 8 o’clock in the evening

Rationale: Diuretics are usually given in the morning to prevent nocturia and sleep disturbance.

Based on your knowledge, Patient Maya, who has a history of cardiac illness, should not be given an enema before surgery. Which of the following reasons inhibits the order of enema for Patient Maya? Enema____________

Answer: B. Produces vagal stimulation that is dangerous to cardiac patient

Rationale: Enema administration can stimulate the vagus nerve, which may lead to bradycardia, hypotension, or dysrhythmias. This is especially dangerous in patients with cardiac illness, making it contraindicated or used with caution.

At what stage of pain mechanism do you classify this pain?

A. Perception
B. Modulation
C. Transmission
D. Transduction

Answer: A. Perception

Rationale:
Pain perception is the stage where the brain becomes consciously aware of pain. Since the patient reports feeling pain even while asleep (post-op pain still being processed by the CNS), this reflects the brain’s interpretation and awareness of pain stimuli, which is perception.

A. Perception (CORRECT)

• Pain becomes consciously experienced

• Occurs in the thalamus and cerebral cortex

• Patient can say: “I feel pain” even during sleep or after surgery

B. Modulation

• Pain is suppressed or amplified

• Happens in the spinal cord (descending pathways)

• Involves endorphins, serotonin

❌ Wrong because this is about pain control, not awareness

C. Transmission

• Pain signal moves from spinal cord → brain

• Involves A-delta and C fibers

❌ Wrong because this is just signal movement, not feeling pain

D. Transduction

• Pain starts at injury site

• Tissue damage → chemicals released (prostaglandins, bradykinin)

❌ Wrong because this is the starting point of pain

When a client complains of pain less than 6 months, it is called ____________.

A. Chronic pain
B. Persistent pain
C. Acute pain
D. Intermittent pain

Answer: C. Acute pain

Rationale:
Acute pain is typically short-term, usually less than 6 months, and is associated with injury, surgery, or illness. It has a sudden onset and is expected to resolve as healing occurs.

In order for the nurse to recall the location of pain, he has to ____________.

A. Ask for onset and duration
B. Mark the painful area in a body diagram
C. Ask for facial expression
D. Ask verbal description using pain intensity scale

Answer: B. Mark the painful area in a body diagram

Rationale:
A body pain diagram (pain map) allows the nurse to accurately document and later recall the exact location, distribution, and pattern of pain, making assessment more precise.

An example of a drug therapy to relieve moderate pain is ____________.

A. Codeine
B. Demerol
C. Methadone
D. Morphine sulfate

Answer: A. Codeine

Rationale:
Codeine is an opioid used for mild to moderate pain. Stronger opioids like morphine, methadone, and meperidine (Demerol) are used for moderate to severe pain.

When a client is on prolonged pain therapy, the nurse should watch for ____________.

A. Tolerance to drug
B. Allergic reaction to drug
C. Drug resistance
D. Addiction to drug

Answer: A. Tolerance to drug

Rationale:
With prolonged opioid use, patients may develop tolerance, meaning they need higher doses to achieve the same pain relief effect. This is a common and expected physiological adaptation.

The patient admitted in the unit with a urinary condition asked you, the nurse, where in the kidney does urine get formed. You answer them correctly by stating that urine is produced in the:

A. Glomerulus
B. Proximal convoluted tubule
C. Loop of Henle
D. Nephron

Answer: D. Nephron

Rationale: The nephron is the functional unit of the kidney where urine is formed

Explanation of Choices:

A. Glomerulus – Site of filtration only, not the entire urine formation process.

B. Proximal convoluted tubule – Site of major reabsorption.

C. Loop of Henle – Concentrates urine through water and electrolyte regulation.

D. Nephron – Correct. Urine formation (filtration, reabsorption, and secretion) occurs throughout the nephron.

A client was assigned to your unit after abdominal surgery. You asked the patient during your morning rounds about the passage of flatus. The patient answered, “Yes, flatus has passed earlier this morning.” In anticipation of defecation, which of the following instructions are most important for you, the nurse, to give to this client?

A. Please call the nurse if you need to go to the bathroom.

B. If you feel the urge to have a bowel movement, please call for assistance before getting up to the toilet. When having a bowel movement, be sure to breathe out to prevent straining. Do not hold your breath.

C. To prevent the Valsalva maneuver, contract the stomach muscles while holding your breath and push. This will assist in the passage of the stool and will decrease the amount of time required to have a bowel movement.

D. Your bowels will be moving soon. Please report any abdominal pain.

Answer: B. If you feel the urge to have a bowel movement, please call for assistance before getting up to the toilet. When having a bowel movement, be sure to breathe out to prevent straining. Do not hold your breath.

Rationale: Following abdominal surgery, straining during defecation can stress the surgical site. The nurse should teach the client to avoid the Valsalva maneuver and ask for assistance when ambulating.

One of the elderly patients assigned to you in the ward has been complaining of increasing trips to the bathroom to urinate. Her estimated coffee intake is 3 cups every day. What is the best explanation you can provide to this patient?

A. The increased urine production is most likely due to a urinary tract infection.

B. Coffee is causing the increased urination due to your increased fluid intake. This is completely normal and nothing to be concerned about.

C. Coffee is causing the increased urination. Coffee contains caffeine that causes diuresis, or increased urine formation. Simply decreasing the number of cups of coffee you drink each day, and limiting the consumption of caffeinated beverages to the morning hours, should help decrease your trips to the bathroom.

D. Drinking coffee increases the circulating plasma in the body and this increases the urine formation. Simply decreasing the number of cups of coffee you are drinking should help.

Answer: C. Coffee is causing the increased urination. Coffee contains caffeine that causes diuresis, or increased urine formation. Simply decreasing the number of cups of coffee you drink each day, and limiting the consumption of caffeinated beverages to the morning hours, should help decrease your trips to the bathroom.

Rationale: Caffeine is a mild diuretic that increases urine production. Elderly clients may experience urinary frequency due to caffeine intake, especially if consumed throughout the day.

You are beginning your shift for the day. You start by assessing a client that has a Foley catheter connected to a collection bag. Which of the following is the best routine catheter care action to take while caring for this client?

A. Encourage increased oral fluid intake and observe for any opacity in the urine suggesting bacterial infection.

B. Carefully wash the perineal area with soap and water after each bowel movement.

C. Avoid touching the tip of the spigot to any surfaces when emptying the collection bag.

D. Encourage the client to drink at least 2000 mL each day and carefully wash the perineal area, with soap and water, at least twice daily and with each bowel movement.

Answer: D. Encourage the client to drink at least 2000 mL each day and carefully wash the perineal area, with soap and water, at least twice daily and with each bowel movement.

PNLE Tip: Foley care = Closed system + Perineal care + Adequate fluids.

A client of yours read the term activities of daily living. Which of the following statements best describes Instrumental Activities of Daily Living (IADL)?

A. Activities that are usually performed in the course of a normal day. These activities include ambulating, eating, dressing, bathing, brushing the teeth, and grooming.

B. Activities that assist the client in recognizing and managing stress. These activities include facilitating interpersonal relationships, allowing adequate time for rest, and providing regular, nutritious meals.

C. Activities that allow the client to be independent in society. These activities include shopping, preparing meals, paying bills, and taking medications appropriately.

D. Activities that support the effectiveness of direct care interventions. These activities include checking equipment, directing the maintenance of the client’s room, and managing the supply of materials needed for client care.

Answer: C. Activities that allow the client to be independent in society. These activities include shopping, preparing meals, paying bills, and taking medications appropriately.

Rationale: IADLs are more complex skills necessary for independent living within the community.

The relative of an immobile client asked about the complications of immobility. Which of the following are complications of immobility?

I. Primary osteoporosis

II. Foot drop

III. Urinary stasis

IV. Pressure ulcer

A. I

B. I, II, III, IV

C. I, II, IV

D. II, III, IV

Answer: D. II, III, IV

Rationale: Immobility causes muscle atrophy, contractures, foot drop, urinary stasis, constipation, atelectasis, and pressure ulcers. It causes secondary osteoporosis, not primary osteoporosis.

Best definition of palliative care

A. Care for terminally ill clients
B. Symptom management for a client when a disease no longer responds to cure-focused treatment
C. Aggressive cure-focused disease treatment and management
D. Comfort care

Answer: B. Symptom management for a client when a disease no longer responds to cure-focused treatment

Rationale: Palliative care is an approach that focuses on symptom control, comfort, and quality of life when cure is no longer the goal. It is not limited to end-of-life but is commonly used in advanced illness.

PNLE Tip: Palliative care = “No cure focus, only comfort + symptom control.”

Best intervention for nausea in palliative care

A. Educate the patient and family in the use of prescribed antiemetics; oral care every 2–4 hours; clear liquids and ice chips; avoid coffee, milk, citrus juices
B. Administer additional pain medication
C. Provide education regarding oral care and antiemetics
D. Take a detailed medical history to determine cause of nausea

Answer: A. Educate the patient and family in the use of prescribed antiemetics; oral care every 2–4 hours; clear liquids and ice chips; avoid coffee, milk, citrus juices

Common symptoms in terminally ill clients

A. Hunger, thirst, fatigue, diarrhea
B. Dehydration, nausea, effective breathing, adequate nutrition
C. Discomfort, nausea, ineffective breathing, fatigue
D. Urinary continence, thirst, dehydration, diarrhea

Answer: C. Discomfort, nausea, ineffective breathing, fatigue

You are planning care for patient Alvida with a history of PVD with symptoms of claudication. The focus of your nursing care should be directed in avoiding which of the following scenarios?

A. Oxygen demand by the muscle exceeds the supply.
B. Oxygen demand and supply of the working muscle are in balance.
C. Oxygen supply exceeds the demand of the working muscle.
D. Oxygen is absent.

Answer: A

Rationale: Intermittent claudication in PVD occurs when there is insufficient arterial blood flow, meaning oxygen supply cannot meet muscle demand. This leads to ischemic pain during activity. Nursing care focuses on improving perfusion and preventing ischemia.

You are reviewing the labs of Alvida. You note which of the following common abnormal laboratory results associated with PVD?

A. High serum calcium level
B. High serum lipid levels
C. Low serum potassium level
D. Low serum lipid levels

Answer: B

Rationale:

PVD is primarily caused by atherosclerosis, which is strongly linked to hyperlipidemia (high cholesterol and triglycerides). Fat deposits narrow arteries → reduced blood flow.

PNLE Tip:

PVD = “Fat clogs the vessel” → HIGH lipids

You are assessing Alvida’s lower extremities. Which finding is expected in PVD?

A. Hairy legs
B. Mottled skin
C. Pink, cool skin
D. Warm, moist skin

✅

Answer: B

Rationale:

PVD causes decreased arterial perfusion, leading to:

• Mottling

• Pallor

• Cool extremities

• Hair loss (not increased hair)

Answer: B

Rationale:

PVD causes decreased arterial perfusion, leading to:

• Mottling

• Pallor

• Cool extremities

• Hair loss (not increased hair)

Morgan is a few days post–abdominal aortic aneurysm (AAA) repair. Based on the chart findings below, which should be emphasized in discharge teaching?

1. Smokes 4 cigars a month

2. BP 150/76–170/98 mm Hg, HR 90–100 bpm, RR 12–18, Temp 99.9°F (37.8°C)

3. +1 bilateral ankle edema

A. Food intake
B. Fluid volume
C. Skin integrity
D. Tissue perfusion

Answer: D. Tissue perfusion

Rationale: After AAA repair, the priority is preventing complications related to vascular disease and impaired perfusion. The patient has hypertension and smoking history, both major risks for poor arterial circulation and graft complications. Tissue perfusion is the key focus to prevent rupture, thrombosis, and ischemia.

PNLE Tip:

AAA care priority = “Perfusion first (BP control + circulation monitoring)”

Yasopp, a 54 year old client was admitted in the emergency department. On assessment, it was revealed he has severe back pain, Grey Turner’s sign, nausea, BP of 90/40, HR of 128 bpm, and RR of 28 cpm. As Yasopp’s nurse, you should first do which of the following actions:

A. Assess the urine output.

B. Place a large bore I.V.

C. Position onto the left side.

D. Insert a nasogastric tube.

Answer: B. Place a large-bore IV

Rationale: Signs indicate possible AAA rupture with hypovolemic shock (Grey Turner’s sign = retroperitoneal bleeding). Immediate priority is to establish rapid IV access for fluid and blood replacement.

Arlong, one of the patients assigned to you, complains of sudden, severe pain in his back and chest, accompanied by SOB. He describes the pain sensation as “as if something was tearing inside”. The physician suspects that he is experiencing a dissecting aortic aneurysm. The code cart is brought into Arlong’s room because you know that one of the complications of dissecting aneurysm is:

A. Cardiac tamponade.

B. Stroke.

C. Pulmonary edema.

D. Myocardial infarction.

Answer: A. Cardiac tamponade

Rationale: Aortic dissection can extend and rupture into the pericardial sac causing cardiac tamponade, a rapidly fatal complication requiring emergency intervention.

Tashigi reports worsening chronic bronchitis. Which instruction should be reinforced?

A. Increase amount of bedrest
B. Increase fluid intake
C. Decrease caloric intake
D. Reduce home oxygen use

Answer: B. Increase fluid intake

Rationale: In chronic bronchitis, secretions are thick and difficult to expectorate. Adequate hydration helps thin mucus, making it easier to cough out and improving airway clearance.

Expected finding in chronic bronchitis

A. Minimal sputum with cough
B. Pink, frothy sputum
C. Barrel chest
D. Stridor on expiration

Answer: A. Minimal sputum with cough

Rationale:

• Chronic bronchitis = productive cough with mucus

• Pink frothy sputum = pulmonary edema

• Barrel chest = emphysema

• Stridor = upper airway obstruction

🧠

PNLE Tip:

COPD:

• Chronic bronchitis = “Blue bloater, lots of mucus”

• Emphysema = barrel chest

Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child’s history, the nurse considers which information to be most important?

A. A fever that started 3 days ago

B. Lack of interest in food

C. A recent episode of pharyngitis

D. Vomiting for 2 days

Correct Answer: C. A recent episode of pharyngitis

A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever.

The nurse is aware that the most common assessment finding in a child with ulcerative colitis is:

A. Intense abdominal cramps

B. Profuse diarrhea

C. Anal fissures

D. Abdominal distention

Correct Answer: B. Profuse diarrhea

The most common assessment finding in a child with ulcerative colitis is profuse diarrhea. The main symptom of ulcerative colitis is bloody diarrhea, with or without mucus. Other symptoms include blood in the toilet, on toilet paper, or in the stool.

When developing a plan of care for a hospitalized child, nurse Mary knows that children in which age group is most likely to view illness as a punishment for misdeeds?

A. Infancy

B. Preschool age

C. School age

D. Adolescence

Correct Answer: B. Preschool age

Preschool-age children are most likely to view illness as a punishment for misdeeds.

female child, age 6, is brought to the health clinic for a routine checkup. To assess the child’s vision, the nurse should ask:

A. “Do you have any problems seeing different colors?”

B. “Do you have trouble seeing at night?”

C. “Do you have problems with glare?”

D. “How are you doing in school?”

Correct Answer: D. “How are you doing in school?”

A child’s poor progress in school may indicate a visual disturbance

5-year-old girl Hannah is recently diagnosed with Kawasaki disease. Apart from the identified symptoms of the disease, she may also likely develop which of the following?

A. Sepsis

B. Meningitis

C. Mitral valve disease

D. Aneurysm formation

Correct Answer: D. Aneurysm formation

Kawasaki disease is a rare childhood illness that affects the blood vessels. 20% to 25% of children can develop aneurysm formation if not intervened. Treatment depends on the degree of the disease but is often immediate treatment with IV gamma globulin or aspirin.

When creating a teaching program for the parents of Jessica who is diagnosed with pulmonic stenosis (PS), Nurse Alex would keep in mind that this disorder involves which of the following?

A. A single vessel arising from both ventricles

B. Obstruction of blood flow from the left ventricle

C. Obstruction of blood flow from the right ventricle

D. Return of blood to the heart without entry to the left atrium

Correct Answer: C. Obstruction of blood flow from the right ventricle.

PS refers to an obstruction of blood flow from the right ventricle.

Which of the following would Nurse Tony suppose to regard as a cardinal manifestation or symptom of digoxin toxicity to his patient Clay diagnosed with heart failure?

A. Headache

B. Respiratory distress

C. Extreme bradycardia

D. Constipation

Correct Answer: C. Extreme bradycardia

Extreme bradycardia is a cardinal sign of digoxin toxicity.

is considered as the bluntly rounded portion of the heart.

A. Base

B. Pericardium

C. Aorta

D. Apex

Correct Answer: D. Apex

Option A: The larger, flat portion at the opposite is the base.

Option B: The pericardium is also called the pericardial sac.

Option C: The aorta is the largest artery that carries blood from the left ventricle to the body.

Which of the following disorders leads to cyanosis from deoxygenated blood entering the systemic arterial circulation?

A. Aortic stenosis (AS)

B. Coarctation of aorta

C. Patent ductus arteriosus (PDA)

D. Tetralogy of Fallot

Correct Answer: D. Tetralogy of Fallot

Betty is a 9-year-old girl diagnosed with cystic fibrosis. Which of the following must Nurse Archie keep in mind when developing a care plan for the child?

A. Pulmonary secretions are abnormally thick.

B. Elevated levels of potassium are found in sweat.

C. CF is an autosomal dominant hereditary disorder.

D. Obstruction of the endocrine glands occurs.

Correct Answer: A. Pulmonary secretions are abnormally thick.

CF is identified by abnormally thick pulmonary secretions.

Alice is rushed to the emergency department during an acute, severe prolonged asthma attack and is unresponsive to usual treatment. The condition is referred to as which of the following?

A. Status asthmaticus

B. Reactive airway disease

C. Intrinsic asthma

D. Extrinsic asthma

Correct Answer: A. Status asthmaticus

Status asthmaticus is an acute, prolonged, severe asthma attack that is unresponsive to usual treatment

A patient is on postoperative day 4 following a major exploratory laparotomy. During a severe bout of coughing, the patient screams, "Something just popped open!" Nurse Bianca rushes in and observes that the abdominal incision has separated, and a loop of pink, moist bowel is protruding completely outside the abdominal cavity. What is the nurse's immediate sequence of actions?

A. Place the patient perfectly flat on their back, manually push the bowel gently back into the cavity, and apply a tight abdominal binder.

B. Place the patient in a High-Fowler's position, cover the bowel with a dry, sterile abdominal pad, and call the surgeon.

C. Place the patient in a low Fowler's position with knees bent, and cover the protruding bowel with sterile dressings soaked in warm, sterile saline.

D. Instruct the patient to bear down slightly, assess the bowel for necrosis, and obtain a set of vital signs before intervening.

Correct Answer: C. Place the patient in a low Fowler’s position with knees bent, and cover the protruding bowel with sterile dressings soaked in warm, sterile saline.

Rationale:
This is evisceration, a surgical emergency. The nursing priorities are:

1. Reduce tension on the abdominal incision (low Fowler’s, knees bent).

2. Protect exposed organs with warm sterile saline-soaked dressings.

3. Notify the surgeon immediately.

Never attempt to push the bowel back

Nurse Bianca is preparing discharge education for a patient recovering from a pelvic fracture. The patient is at extreme risk for developing a Deep Vein Thrombosis (DVT) and secondary Pulmonary Embolism (PE). Which specific instruction provided by the nurse is essential for preventing this vascular complication?*

A. "If your calves feel tight or cramped, ask your spouse to firmly massage the muscles to promote blood flow."

B. "When sitting in a chair, cross your legs at the ankles to prevent fluid from pooling in your feet."

C. "Place a firm, rolled pillow directly under your knees when lying in bed to completely relax your legs."

D. "Ensure you drink plenty of oral fluids to prevent dehydration, which makes your blood thicker and more prone to clotting."

Correct Answer: D. “Ensure you drink plenty of oral fluids to prevent dehydration, which makes your blood thicker and more prone to clotting.”

Rationale:
Adequate hydration reduces blood viscosity and helps prevent venous stasis and clot formation.

Right Lower Lobe Pneumonia: Best position to improve oxygenation?

A. Lying on the right side (Right Lateral Decubitus).

B. Lying on the left side (Left Lateral Decubitus).

C. Strictly in a prone position flat on the abdomen.

D. Lying flat on the back with the head extended (Supine).

B. Left lateral decubitus (left side down).

A patient with a femur fracture develops sudden dyspnea, chest pain, and petechiae on the chest and neck. What is the most likely complication?

A. Anaphylaxis
B. Pulmonary embolism
C. Fat Embolism Syndrome (FES)
D. Opioid overdose

C. Fat Embolism Syndrome (FES)

Rationale:

Fat Embolism Syndrome (FES) occurs when fat droplets from a fractured long bone (especially the femur) enter the bloodstream and travel to the lungs and brain. It commonly presents with:

• Respiratory distress

• Neurologic changes

• Petechial rash (especially chest, neck, axilla, conjunctiva)

Twenty minutes after induction of general anesthesia, the patient develops rapidly increasing CO₂, tachycardia, and muscle rigidity. What is the priority intervention?

A. Preparing cooling blankets and antipyretics
B. Preparing dantrolene sodium for administration
C. Increasing IV fluids rapidly
D. Repositioning the patient to improve ventilation

Answer: B. Preparing dantrolene sodium for administration

Rationale:

The patient is experiencing malignant hyperthermia, a life-threatening reaction to certain anesthetics.

Nurse Eli is assigned to care for Mrs. Santos, a 30-year-old patient who just returned to the post-anesthesia care unit (PACU) after a cesarean section.

What is the appropriate postoperative positioning for this patient?

A. Assist the patient to a semi-Fowler’s position immediately to facilitate breathing

B. Allow the patient to sit up as soon as she feels comfortable to prevent hypotension

C. Keep the patient flat in bed with the head of the bed at 0 degrees and allow small, gentle movements of the extremities

D. Elevate the head of the bed to 30 degrees and place a pillow under the knees

D. Elevate the head of the bed to 30 degrees and place a pillow under the knees

Which assessment finding indicates a life-threatening asthma exacerbation?

A. Wheezing audible upon auscultation and difficulty breathing
B. Absent wheezing and inability to speak more than a few words
C. Mild cough with pink sputum, RR 22, SpO₂ 95%
D. Wheezing only on auscultation, mild dyspnea, full sentences, SpO₂ 90%

Answer: B. Absent wheezing upon auscultation and inability to speak more than a few words

Which of these is the greatest risk factor for the development and progression of COPD?

A. History of hypertension and hyperlipidemia increasing cardiovascular strain
B. Previous acute COPD exacerbations, indicating chronic airway vulnerability
C. Long-term cigarette smoking with additional environmental exposures
D. Sedentary lifestyle and poor dietary habits leading to decreased pulmonary reserve

Answer: C. Long-term cigarette smoking with additional environmental exposures

Which breathing technique should the nurse recommend as most effective for COPD patients?

A. Diaphragmatic breathing – breathing deeply into the abdomen while lying flat
B. Pursed-lip breathing – inhaling through the nose and exhaling slowly through pursed lips
C. Shallow thoracic breathing – taking rapid, small breaths to conserve energy
D. Inspiratory hold technique – holding breath for several seconds before exhaling

Answer: B. Pursed-lip breathing – inhaling through the nose and exhaling slowly through pursed lips

Which nursing recommendation is most appropriate to help him cope with activity intolerance?

A. Encourage him to complete all tasks at once to build endurance
B. Perform activities only when feeling completely rested, regardless of schedule
C. Restrict all activity and remain in bed to prevent dyspnea
D. Pace activities throughout the day and use assistive devices as needed to conserve energy

Answer: D. Pace activities throughout the day and use assistive devices as needed to conserve energy

Which set of symptoms best indicates fluid volume deficit (FVD)?

A. BP 88/54 mmHg, bounding pulses, crackles in lungs, peripheral edema

B. BP 150/90 mmHg, jugular vein distention, peripheral edema, pulmonary crackles

C. BP 88/54 mmHg, dry mucous membranes, poor skin turgor, dizziness, tachycardia

D. BP 88/54 mmHg, dry mucous membranes, crackles in lungs, peripheral edema

Answer: C. BP 88/54 mmHg, dry mucous membranes, poor skin turgor, dizziness, tachycardia

FVD = “Dry and Empty”

Which intervention most effectively manages severe fluid overload in heart failure?

A. Administer oral potassium supplement
B. Give a beta-blocker
C. Administer a loop diuretic (e.g., furosemide) intravenously
D. Start isotonic saline infusion

Answer: C. Administer a loop diuretic (e.g., furosemide) intravenously to promote rapid diuresis

PNLE Tip: Heart Failure Fluid Management

If you see:

• Crackles

• Edema

• Weight gain

• Dyspnea

Think:
➡ Diuretics

Which nursing intervention is most appropriate to relieve orthopnea related to heart failure?

A. Encourage sleeping flat in bed
B. Assist him to sit upright only during the day
C. Position the patient in semi-Fowler’s position (head of bed 30–45°)
D. Place patient in Trendelenburg position

Answer: C. Position the patient in semi-Fowler’s position (head of bed at 30–45°)

How can a nurse most safely help reduce peripheral edema?

A. Encourage barefoot walking frequently
B. Elevate legs when resting and apply compression stockings as prescribed
C. Administer extra IV fluids
D. Place patient in Trendelenburg position

Answer: B. Elevate the legs when resting and apply compression stockings as prescribed

Which statement demonstrates appropriate patient education regarding spironolactone therapy?

A. “You can eat bananas and avocados freely because they are healthy foods.”
B. “Take an additional dose if you notice swelling in your legs.”
C. “Avoid foods high in potassium and salt substitutes containing potassium.”
D. “Monitoring potassium levels is unnecessary as long as you feel well.”

Answer: C. “Avoid foods high in potassium and salt substitutes containing potassium.”

Which condition represents the most dangerous complication of hyperkalemia?

A. Muscle cramps
B. Difficulty breathing
C. Increased bleeding
D. Cardiac dysrhythmias

Answer: D. Cardiac dysrhythmias

Rationale:

Potassium plays a major role in cardiac conduction.

Severe hyperkalemia can cause:

• Peaked T waves

• Bradycardia

• Heart block

• Ventricular fibrillation

• Cardiac arrest- most life theat