MS2 Rle P1

6/1/2021 NUR 150 / MS 2 (P1 EXAM)
NUR 150 / MS 2 (P1 EXAM)
Email *
lepe.evangelista@swu.phinma.edu.ph
Name (Last Name, First Name, Middle Initial) *
EVANGELISTA, LEDELYN MARIE P.
Questions 1 to 25
Your patient has a GI tract that is functioning, but has the inability to
swallow foods. Which is the preferred method of feeding for your patient? *
A. Total Parenteral Nutrition
B. Partial Parenteral Nutrition
C. Nasogastric Feeding
D. Oral Liquid Supplementation
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6/1/2021 NUR 150 / MS 2 (P1 EXAM)
A male client with a recent history of rectal bleeding is being prepared for a
colonoscopy. How should the nurse position the client for this test initially? *
A. Lying on the right side with legs straight
B. Lying on the left side with knees bent
C. Prone with the torso elevated
D. Bent over with hands touching the floor
Which assessment data indicate to the nurse the clients gastric ulcer has
perforated? *
A. Complaints of sudden, sharp, substernal pain
B. Rigid, boardlike abdomen with rebound tenderness
C. Frequent, clay-colored, liquid stool
D. Complaints of vague abdominal pain in the right upper quadrant
Which specific data should the nurse obtain from the client who is
suspected of having peptic ulcer disease? *
A. History of side effects experienced from all medications
B. Use of non steroidal anti inflammatory drugs (NSAIDs)
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C. Any known allergies to drugs and environmental factors
D. Medical histories of at lease 3 generations
The nurse is caring for a male client postoperatively following creation of a

colostomy. Which nursing diagnosis should the nurse include in the plan of
care? *
A. Sexual Dysfunction
B. Disturbed Body Image
C. Fear related to Poor Prognosis
D. Imbalanced Nutrition: more than body requirements
Bethanechol (Urecholine) has been ordered for a client with

gastroesophageal reflux disease (GERD). The nurse should assess the client
for which of the following adverse effects? *
A. Dry oral mucosa
B. Hypertension
C. Urinary urgency
D. Constipation
Which of the following factors would most likely contribute to the

development of a client's hiatal hernia? *
A. having a sedentary desk job

6/1/2021 NUR 150 / MS 2 (P1 EXAM)
B. using laxatives frequently
C. being 40 years old
D. being 5 feet 2 inches tall and weighing 200 lbs.
Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions,
her HGB is 7.5g/dl and HCT is 27%. Her doctor determines that surgical
intervention is necessary and she undergoes partial gastrectomy.
Postoperative nursing care includes: *
A. Giving pain medication Q6H.
B. Flushing the NG tube with sterile water.
C. Positioning her in high Fowler’s position.
D. Keeping her NPO until the return of peristalsis.
Which of the following instructions should the nurse include in the teaching
plan for a client who is experiencing gastroesophageal reflux disease
(GERD)? *
A. Limit caffeine intake to two cups of coffee per day.
B. Do not lie down for 2 hours after eating.
C. Follow a low-protein diet.
D. Take medications with milk to decrease irritation.
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
The client with gastroesophageal reflux disease (GERD) complains of a

chronic cough. The nurse understands that in a client with GERD this
symptom may be indicative of which of the following conditions? *
A. development of laryngeal cancer
B. aspiration of gastric contents
C. Irritation of the esophagus
D. Esophageal scar tissue formation
The nurse has been assigned to care for a client diagnosed with peptic ulcer
disease. Which assessment data require further intervention? *
A. Bowel sour s auscultated 15 times in 1 minute
B. Belching after eating a heavy and fatty meal late at night
C. A decrease in systolic BP of 20 mm Hg from lying to sitting
D. A decreased frequency of distress located in the epigastric region
The nurse is obtaining a health history from a client who has a sliding hiatal
hernia associated with reflux. The nurse should ask the client about the
presence of which of the following symptoms? *
A. Jaundice
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B. Anorexia
C. Heartburn
D. Stomatitis
A client who has been diagnosed with gastroesophageal reflux disease

(GERD) complains of heartburn. To decrease the heartburn, the nurse
should instruct the client to eliminate which of the following items from the
diet? *
A. Lean beef
B. Air popped popcorn
C. Raw vegetables
D. Hot chocolate
The nurse is caring for a client with chronic gastritis. The nurse monitors the
client, knowing that this client is at risk for which of the following vitamin
deficiencies? *
A.Vitamin A
B. Vitamin B12
C. Vitamin C
D. Vitamin E
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
Before bowel surgery, Lee is to administer enemas until clear. During

administration, he complains of intestinal cramps. What do you do next? *
A. Discontinue the procedure
B. Lower the height of the enema container
C. Complete the procedure as quickly as possible
D. Continue administering the enema without making any adjustments
Alvin has a history of peptic ulcer disease and vomits coffee-ground

emesis. What does this indicate? *
A. He has fresh, active upper GI bleeding.
B. He needs immediate saline gastric lavage.
C. His gastric bleeding occurred 2 hours earlier.
D. He needs a transfusion of packed RBC’s.
The nurse is providing discharge instructions to a male client following

gastrectomy and instructs the client to take which measure to assist in
preventing dumping syndrome? *
A. Ambulate following a meal
B Eat high carbohydrate foods

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B. Eat high carbohydrate foods
C. Limit the fluid taken with meal
D. Sit in a high-Fowler’s position during meals
A male client who is recovering from surgery has been advanced from a
clear liquid diet to a full liquid diet. The client is looking forward to the diet
change because he has been “bored” with the clear liquid diet. The nurse
would offer which full liquid item to the client? *
A. Tea
B. Gelatin
C. Custard
D. Popsicle
The nurse is providing discharge instructions to a male client following

gastrectomy and instructs the client to take which measure to assist in
preventing dumping syndrome? *
A. Ambulate following a meal
B. Eat high carbohydrate foods
C. Limit the fluid taken with meal
D. Sit in a high-Fowler’s position during meals
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The nurse is caring for a female client with active upper GI bleeding due to a
peptic ulcer. What is the appropriate diet for this client during the first 24
hours after admission? *
A. Regular diet
B. Skim milk
C. Nothing by mouth
D. Clear liquids
The client being seen in a physician’s office has just been scheduled for a
barium swallow the next day. The nurse writes down which of the following
instructions for the client to follow before the test? *
A. Fast for 8 hours before the test
B. Eat a regular supper and breakfast
C. Continue to take all oral medications as scheduled.
D. Monitor own bowel movement pattern for constipation
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A nurse is inserting a nasogastric tube in an adult male client. During the

procedure, the client begins to cough and has difficulty breathing. Which of
the following is the appropriate nursing action? *
A. Quickly insert the tube
B. Notify the physician immediately
C. Remove the tube and reinsert when the respiratory distress subsides
D. Pull back on the tube and wait until the respiratory distress subsides
The client is scheduled to have an upper gastrointestinal tract series of x-

rays. Following the x-rays, the nurse should instruct the client to: *
A. administer an enema
B. take a laxative
C. take an antiemetic
D. follow a clear liquid diet
Which expected outcome should the nurse include for a client diagnosed
with peptic ulcer disease? *
A. The clients pain is controlled with the use of NSAIDs
B The client maintains lifestyle modifications

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B. The client maintains lifestyle modifications
C. The client has no signs and symptoms of hemoptysis
D. The client take s antacids with each meal
Nurse Gemma is teaching a group of middle-aged men about peptic ulcers.

When discussing risk factors for peptic ulcers, the nurse should mention: *
A. a sedentary lifestyle and smoking.
B. a history of hemorrhoids and smoking.
C. alcohol abuse and a history of acute renal failure.
D. alcohol abuse and smoking.
Questions 26 to 50
The nurse would monitor for which of the following adverse reactions to
aluminum-containing antacids such as aluminum hydroxide (Amphojel)? *
A. Diarrhea
B. Constipation
C. GI upset
D. Fluid retention
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The hospitalized client with GERD is complaining of chest discomfort that

feels like heartburn following a meal. After administering an ordered
antacid, the nurse encourages the client to lie in which of the following
positions? *
A. Supine with the head of the bed flat
B. On the stomach with the head flat
C. On the left side with the head of the bed elevated 30 degrees
D. On the right side with the head of the bed elevated 30 degrees.
The nurse is doing an admission assessment on a client with a history of

duodenal ulcer. To determine whether the problem is currently active, the
nurse would assess the client for which of the following most frequent
symptom(s) of duodenal ulcer? *
A. Pain that is relieved by food intake
B. Pain that radiated down the right arm
C. Nausea and vomiting
D. Weight loss
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
Trent has been diagnosed with appendicitis. He develops a fever,

hypotension and tachycardia. The nurse suspects which of the following
complications? *
A. Intestinal obstruction
B. Peritonitis
C. Bowel ischemia
D. Deficient fluid volume
A client with irritable bowel syndrome is being prepared for discharge.

Which of the following meal plans should the nurse give the client? *
A. Low fiber, low-fat
B. High fiber, low-fat
C. Low fiber, high-fat
D. High-fiber, high-fat
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
Angelo is being admitted to a hospital unit complaining of severe pain in the

lower abdomen. Admission vital signs reveal an oral temperature of 38 C.
Signs and symptoms include pain in the RLQ of the abdomen that may be
localize at McBurney’s point. To relieve pain, Angelo should assume which
position? *
A. Prone
B. Supine, stretched out
C. Sitting
D. Lying with legs drawn up
A nurse is monitoring a client admitted to the hospital with a diagnosis of

appendicitis. The client is scheduled for surgery in 2 hours. The client begins
to complain of increased abdominal pain and begins to vomit. On
assessment the nurse notes that the abdomen is distended and the bowel
sounds are diminished. Which of the following is the most appropriate
nursing intervention? *
A. Administer Dilaudid
B. Notify the physician
C. Call and ask the operating room team to perform the surgery as soon as possible
D. Reposition the client and apply a heating pad on a warm setting to the client’s
abdomen.
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
When preparing a male client, age 51, for surgery to treat appendicitis, the
nurse formulates a nursing diagnosis of Risk for infection related to
inflammation, perforation, and surgery. What is the rationale for choosing
this nursing diagnosis? *
A. Obstruction of the appendix may increase venous drainage and cause the
appendix to rupture.
B. Obstruction of the appendix reduces arterial flow, leading to ischemia,

inflammation, and rupture of the appendix.
C. The appendix may develop gangrene and rupture, especially in a middle-aged

client.
D. Infection of the appendix diminishes necrotic arterial blood flow and increases
venous drainage.
The nurse is performing a colostomy irrigation on a male client. During the

irrigation, the client begins to complain of abdominal cramps. What is the
appropriate nursing action? *
A. Notify the physician
B. Stop the irrigation temporarily
C. Increase the height of the irrigation
D. Medicate for pain and resume the irrigation
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The client with GERD complains of a chronic cough. The nurse understands
that in a client with GERD this symptom may be indicative of which of the
following conditions? *
A. Development of laryngeal cancer
B. Irritation of the esophagus
C. Esophageal scar tissue formation
D. Aspiration of gastric contents
When teaching an elderly client how to prevent constipation, which of the

following instructions should the nurse include? *
A. “Drink 6 glasses of fluid each day.”
B. “Avoid grain products and nuts.”
C. “Add at least 4 grams of bran to your cereal each morning.”
D. “Be sure to get regular exercise.”
After a subtotal gastrectomy, care of the client’s nasogastric tube and

drainage system should include which of the following nursing
interventions? *
A. Irrigate the tube with 30 ml of sterile water every hour, if needed.

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B. Reposition the tube if it is not draining well
C. Monitor the client for nausea and vomiting, and abdominal distention
D. Turn the machine to high suction of the drainage is sluggish on low suction.
While caring for a client with peptic ulcer disease, the client reports that he
has been nauseated most of the day and is now feeling lightheaded and
dizzy. Based upon these findings, which nursing actions would be most
appropriate for the nurse to take? Select all that apply. *
A. Administering an antacid hourly until nausea subsides.
B. Monitoring the client’s vital signs
C. Notifying the physician of the client’s symptoms
D. Initiating oxygen therapy
E. Reassessing the client on an hour
How does exercise helps manage IBS? *
A. It increases peristalsis.
B. It decreases peristalsis.
C. It decreases intestinal motility.
D. It relieves abdominal pain.
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
A 70-year-old client visits the clinic and complains of minor soiling with
occasional urgency and loss of control. Further assessment reveals that the
client has poor control of flatus. Based on the presenting symptoms, you
suspect that the client may have: *
A. Peptic ulcer disease
B. Constipation
C. Irritable bowel syndrome
D. Fecal incontinence
Hypokalemia can occur rapidly in an elderly person who experiences

diarrhea. The nurse should immediately report to the physician a critical
potassium level of: *
A. 3.0 mEq/L
B. 4.0 mEq/L
C. 4.5 mEq/L
D. 5.0 mEq/L
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
A patient with IBS asks, “How can I manage abdominal discomfort?” Your
best response would be: *
A. “It is best managed by eating dry crackers.”
B. “Some patients maintain an antidepressant drugs.”
C. “You will be the one to choose what is best for you.”
D. “Abdominal pain can be reduced by avoiding carbonated beverages.”
Nursing suggestions to help a person break the constipation habit include

all of the following except: *
A. A low-residue, bland diet.
B. A fluid intake of at least 2 L/day.
C. Establishing a regular schedule of exercise.
D. Establishing a regular time for daily elimination.
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A 20 year old college student was rushed to the ER of VSMMC after he

fainted during their ROTC drill. He complained of severe right iliac pain.
Upon palpation of his abdomen, the student jerks even on slight pressure.
Blood test was ordered. Diagnosis is acute appendicitis. Pre-anesthetic med
of Demerol and atrophine sulfate were ordered to : *
A. Allay anxiety and apprehension
B. Reduce pain
C. Prevent vomiting
D. Relax abdominal muscle
When preparing to teach a client with colostomy how to irrigate his

colostomy, the nurse should plan to perform the procedure: *
A. When the client would have normally had a bowel movement
B. After the client accepts he had a bowel movement
C. Before breakfast and morning care
D. At least 2 hours before visitors arrive
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The client has been admitted with a diagnosis of acute pancreatitis. The
nurse would assess this client for pain that is: *
A. Severe and unrelenting, located in the epigastric area and radiating to the
back.
B. Severe and unrelenting, located in the left lower quadrant and radiating to the
groin.
C. Burning and aching, located in the epigastric area and radiating to the umbilicus.
D. Burning and aching, located in the left lower quadrant and radiating to the hip.
A 20 year old college student was rushed to the ER of VSMMC after he

fainted during their ROTC drill. He complained of severe right iliac pain.
Upon palpation of his abdomen, the student jerks even on slight pressure.
Blood test was ordered. Diagnosis is acute appendicitis. Stat appendectomy
was indicated. Pre op care would include all of the following except? *
A. Consent signed by the father
B. Enema STAT
C. Skin prep of the area including the pubis
D. Remove the jewelries
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In a client with diarrhea, which outcome indicates that fluid resuscitation is

successful? *
A. The client passes formed stools at regular intervals
B. The client reports a decrease in stool frequency and liquidity
C. The client exhibits firm skin turgor
D. The client no longer experiences perianal burning.
Which of the following best describes the method of action of medications,

such as ranitidine (Zantac), which are used in the treatment of peptic ulcer
disease? *
A. Neutralize gastric acid
B. Reduce gastric acid secretions
C. Stimulate gastrin release
D. Protect the mucosal barrier
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Which of the following are considered as the risk factors of irritable bowel
syndrome? Select all that apply. *
A. Gastric resection
B. Stress
C. Spicy foods
D. Celiac disease
E. Enteritis
F. Smoking
Questions 51 to 100
A client who is recuperating from a spinal cord injury at the T4 level wants to
use a wheelchair. In preparation for this activity the client should be taught:
*
Balancing exercises to promote equilibrium.
Push-ups to strengthen arm muscles.
Quadriceps-setting exercises to maintain muscle tone.
Leg lifts to prevent hip contractures.
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
A nurse would question an order to irrigate the ear canal in which of the
following circumstances? *
Perforated tympanic membrane
. Ear pain
Otitis externa
Hearing loss
A client who has Guillain-Barre syndrome asks, "Will I ever got better?" The
most appropriate answer by the nurse would be: *
"We are doing everything we can to provide the best care."
"You'll notice your strength will improve each day."
"Your chances for recovery are very good but recovery is slow".
"You seem concerned about getting better. What do you think?"
After cataract surgery, a client is taught how to self-administer eyedrops

before discharge. The nurse approves the technique when the client : *
Squeezes the eye shut after instilling the eyedrops
Raises the upper eyelid with gentle traction
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Places the drops on the cornea of the eye.
Holds the dropper tip above the eye.
While assessing a client with Parkinson's disease , the nurse identifies

bradykinesia when the client exhibits: *
An intention tremor
A lack of spontaneous movement
Muscle flaccidity
Paralysis of the limbs
The husband of a client with aphasia as a result of a brain attack (CVA) asks
whether his wife's speech will ever return. The nurse should respond: *
"It should return to normal in two or three months."
"You will have to ask your physician".
"It is hard to say how much improvement will occur."
"This will probably be the extent of her speech from now on."
During the immediate post-trauma period after injury to the frontal lobe of
the brain, the nurse should pace a client in the: *
Low-fowler's position
Trendelenburg position
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Side-lying position
Supine position
After a left cataract extraction, a client complains of severe discomfort in

the operated eye. The nurse recognizes that this is a problem that may be
caused by: *
Expected postoperative discomfort
Hemorrhage into the eye.
Pressure on the eye from the protective shield
Isolation related to sensory deprivation
Which of the following clinical manifestations suggest Amyotrophic Lateral

Sclerosis (ALS)? *
Involuntary contraction of the facial muscles causing sudden closing of the eye or
twitching of the mouth
Tremor, rigidity, bradykinesia (abnormally slow movements), and postural

instability
Paralysis of the facial muscles, increased lacrimation (tearing), and painful

sensations in the face, behind the ear, and in the eye
Fatigue, progressive muscle weakness, cramps, fasciculations (twitching), and

incoordination
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A lumbar puncture is performed on a child suspected of having bacterial

meningitis. CSF is obtained for analysis. A nurse reviews the results of the
CSF analysis and determines that which of the following results would verify
the diagnosis? *
Clear CSF, decreased pressure, and elevated protein
Cloudy CSF, elevated protein, and decreased glucose
Clear CSF, elevated protein, and decreased glucose
Cloudy CSF, decreased protein, and decreased glucose
A client who has had a retinal detachment has a scleral buckling procedure
to attempt to reattach the retina. Before the client is discharged home, the
nurse should: *
Reassure the client that the glasses worn before surgery can still be worn.
Explain to the client that reading will help strengthen the eye muscles.
Tell the client that usual activities can be resumed within two weks.
Instruct the client to wear dark glasses after the patch is removed.
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The nurse has notes that the physician has a diagnosis of presbycusis on the
client’s chart. The nurse plans care knowing the condition is: *
Nystagmus that occurs with aging
Tinnitus that occurs with aging
A sensorineural hearing loss that occurs with aging
A conductive hearing loss that occurs with aging.
A client is admitted to the hospital after sustaining a head injury. The most
reliable sign that this client is experiencing an increase in intracranial
pressure would be a slowly: *
Increasing diastolic blood pressure
Narrowing pulse pressure
Rising respiratory rate
Decreasing level of consciousness
Nursing interventions to treat a musculoskeletal injury may include cold or

heat therapy. Cold therapy decreases pain by which of the following
actions? *
Numbs the nerves and dilates the vessels

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Promotes circulation and reduces muscle spasms
Promotes analgesia and circulation
Causes local vasoconstriction and prevents edema or muscle spasm
A client is admitted to the hospital with weakness in the right extremities

and a slight speech problem. Vital signs are normal. During the first 24
hours, the nurse should give priority to: *
Checking the client's temperature
Obtaining a urine specimen from the client.
Evaluating the client's motor status
Monitoring the client's blood pressure.
The nurse is aware that the teaching about myasthenic and cholinergic
crises is understood when a client who has been diagnosed with
myasthenia gravis states that a symptom common to both is: *
diarrhea
difficulty breathing
abdominal cramping
salivation
After cataract surgery, a client complains of feeling nauseated. The nurse

should: *
Explain that this is expected following surgery

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Administer the antiemetic drug as ordered.
Give the client some crackers to eat.
Instruct the client to deep-breathe until the nausea subsides.
A female client is admitted to the hospital with a diagnosis of Guillain-Barre

syndrome. The nurse inquires during the nursing admission interview if the
client has a history of: *
Meningitis during the last five (5 years
Respiratory or gastrointestinal infection during the previous month.
Seizures or trauma to the brain
Back injury or trauma to the spinal cord
A female client is admitted to the facility for investigation of balance and

coordination problems, including possible Ménière’s disease. When
assessing this client, the nurse expects to note: *
Vertigo, tinnitus, and hearing loss.
Vertigo, pain, and hearing impairment.
Vertigo, blurred vision, and fever.
Vertigo, vomiting, and nystagmus
Osteomyelitis most commonly results from which of the following

mechanisms? *
Surgery
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IV drug use
Trauma
.Immune suppression
While performing the history and physical examination of a client with

Parkinson's disease , the nurse should assess the client for: *
A low-pitched , monotonous voice
Hyperextension of the neck
A recent increase in appetite and weight gain
Frequent bouts of diarrhea
The most significant initial nursing observations that should be made about
a client who is suspected of having myasthenia gravis , include the: *
Capacity to smile and close the eyelids.
Degree of anxiety and concern about the suspected diagnosis
Ability to chew and speak distinctly
Effectiveness of respiratory exchange and ability to swallow.
A client with Meniere’s disease is experiencing severe vertigo. Which

instruction would the nurse give to the client to assist in controlling the
vertigo? *
Increase sodium in the diet
Avoid sudden head movements

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Avoid sudden head movements
. Increase fluid intake to 3000 ml a day
Lie still and watch the television
When assisting the family to help an aphasic member regain as much

speech function as possible, the nurse should instruct them to: *
Encourage the client to speak while being patient with all attempts.
Give positive reinforcement for correct communication
Tell the client to use the correct words when speaking
Speak louder than usual during visits.
During the neurological assessment of a client with a tentative diagnosis of

Guillain-Barre syndrome, the nurse should expect that the client will
manifest: *
Diminished visual acuity
Pronounced muscular atrophy
Impairment in cognitive reasoning
Increased muscular weakness
On the evening before discharge from the hospital, a client has a

hypertensive crisis and a brain attack (CVA). Initially the nurse should place
the client in a: *
High Fowler's position

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Supine position
Side-lying position
Slight Trendelenburg position
While walking in the hall a hospitalized client has a tonic-clonic seizure.

During the seizure the nurse's priority should be to: *
Hold the client's arms and legs firmly.
Move the client immediately to a soft surface.
Attempt to insert an airway between the client's teeth.
Protect the client's head from injury.
The nurse is aware that a client with a spinal cord injury is developing
autonomic dysreflexia when the client has: *
Flaccid paralysis and numbness.
Absence of sweating and pyrexia
Escalating tachycardia and shock
Paroxysmal hypertension and bradycardia.
A client is being prepared for discharge from an ambulatory surgical unit

following a cataract removal with an intraocular lens implant. The statement
by the client that suggests to the nurse that discharge teaching was
effective would be: *
"I can't expect to see bright flashes of light for awhile."

6/1/2021 NUR 150 / MS 2 (P1 EXAM)
"I'll call the surgeon if the analgesic doesn't relieve the pain."
"I can't wait until I get home to wash my hair."
"I'm driving home since I feel so good."
A client asks for an explanation about glaucoma. The nurse explains that
with glaucoma there is: *
A separation of the neural retina from the pigmented retina
A curvature of the cornea that becomes unequal
An opacity of the crystalline lens or its capsule
An increase in the pressure within the eyeball.
During a hearing assessment, the nurse notes that the sound lateralizes to
the clients left ear with the Weber test. The nurse analyzes this result as: *
A conductive hearing loss in the right ear
A normal finding
A sensorineural or conductive loss
The presence of nystagmus
A female client with a suspected brain tumor is scheduled for computed

tomography (CT). What should the nurse do when preparing the client for
this test? *
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
Immobilize the neck before the client is moved onto a stretcher

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Immobilize the neck before the client is moved onto a stretcher.
Place a cap on the client’s head.
Administer a sedative as ordered.
An older adult has cataracts in both eyes. The left cataract is scheduled to
be extracted in several days. The nurse should plan to instruct the client
that: *
"Both eyes will be bandaged for 24 hours after surgery."
"You may have to remain on bed rest for three to four days after your surgery."
"You must remember to take deep breaths and cough several times an hour."
"At night you will be wearing a hard patch over your operated eye for a month or
so."
During the first week after a spinal cord injury at the T3 level, a male client
and the nurse identify a short term goal. An appropriate short-term goal for
this client would be, "The client will: *
Carry out personal hygiene activities."
Perform independent ambulation."
Understand his limitations".
Consider lifestyle changes."
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
When assisting a client who has myasthenia gravis with a bath, the nurse
notices that the client's arms become weaker with sustained movement.
The nurse should: *
Gradually increase the client's activity level each day.
Continue the bath while supporting the client's arms.
Encourage the client to rest for short periods of time.
Administer a dose of pyridostigmine bromide (Mestinon)
Pathophysiologic changes seen with osteoarthritis includes: *
The formation of bony spurs at the edges of the joint surfaces.
Joint cartilage degeneration.
All of the above.
Narrowing of the joint space.
A client with gout is encouraged to increase fluid intake. Which of the

following statements best explains why increased fluids are encouraged for
gout? *
.Fluids increase calcium absorption.
Fluids provide a cushion for weakened bones

6/1/2021 NUR 150 / MS 2 (P1 EXAM)
Fluids provide a cushion for weakened bones.
Fluids decrease inflammation.
.Fluids promote the excretion of uric acid.
The nurse is teaching a female client with multiple sclerosis. When teaching
the client how to reduce fatigue, the nurse should tell the client to: *
Rest in an air-conditioned room.
Take a hot bath.
Avoid naps during the day.
Increase the dose of muscle relaxants.
When obtaining the nursing history from a client who has open-angle
(chronic) glaucoma, a complaint that the nurse should expect is: *
Flashes of light
Intolerance to light
Loss of peripheral vision
Seeing floating specks
A client who has sustained a severe head injury in a diving accident remains
unconscious. In addition, the nurse observes bleeding from the left ear, as
well as rhinorrhea. The nurse is aware that the drainage from the ear and
nose indicates: *
Contusion
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
Concussion
Nose fracture
Basilar fracture
A client whose vertebral column at the level of T6 and T7 was completely

crushed and whose left leg was traumatically amputated above the knee is
admitted to the ICU . When performing an assessment, the nurse would
expect to find that the client was experiencing: *
Difficulty breathing
Spastic paralysis of the arms and legs.
Pain in the residual limb
Pain at the level of compression
After an automobile accident, a client complains of seeing frequent flashes

of light. The nurse should suspect: *
A cerebral concussion
Scleroderma
A detached retina
Acute glaucoma
When assessing the progress of a client being treated for myasthenia

gravis, the nurse would expect: *
partial improvement of muscle strength with mild exercise.

6/1/2021 NUR 150 / MS 2 (P1 EXAM)
fluctuating weakness of muscles innervated by the cranial nerves
little or no change in muscle strength regardless of therapy initiated
dramatic worsening in muscle strength with anticholinesterase drugs
Postoperative nursing assessment for a patient who has had a

mastoidectomy should include observing for: *
Olfactory paralysis
Optic paralysis
Facial paralysis
Oculomotor paralysis
A male client with Bell’s Palsy asks the nurse what has caused this problem.
The nurse’s response is based on an understanding that the cause is: *
Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia
Unknown, but possibly includes ischemia, viral infection, or an autoimmune

problem
Primarily genetic in origin, triggered by exposure to neurotoxins
Primary genetic in origin, triggered by exposure to meningitis
The nurse might expect a client with multiple sclerosis to complain about
the most common initial symptom, which is: *
Diarrhea
Headaches
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
Visual disturbances
Skin infections
The nurse in the neurologic clinic assesses for damage to the

glossopharyngeal (ninth cranial) and vagus (tenth cranial) nerve by testing
the client's ability to: *
swallow
smell
shrug
smile
A nurse is planning care for a child with acute bacterial meningitis. Based on
the mode of transmission of this infection, which of the following would be
included in the plan of care? *
Maintain neutropenic precautions
Maintain respiratory isolation precautions for at least 24 hours after the initiation
of antibiotics
Maintain enteric precautions
No precautions are required as long as antibiotics have been started
6/1/2021 NUR 150 / MS 2 (P1 EXAM)
After surgery to repair a retinal detachment, the client returns to the post
anesthesia care unit with the affected eye patched. During the first four
hours after surgery, the nurse should notify the physician if the client: *
Has not voided
Becomes confused and restless.
Cannot open the eye.
Complains of sharp pain in the eye.
The nurse identifies that a client exhibits the characteristic gait associated
with Parkinson's disease. When recording on the client's chart, the nurse
should describe this gait as: *
Scissoring
Ataxic
Shuffling
Spastic
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6/1/2021 NUR 150 / MS 2 (P1 EXAM)

NUR 150 / MS 2 (P1 EXAM)

Name (Last Name, First Name, Middle Initial) *

EVANGELISTA, LEDELYN MARIE P.

A. Total Parenteral Nutrition

B. Partial Parenteral Nutrition

D. Oral Liquid Supplementation

A. Lying on the right side with legs straight

B. Lying on the left side with knees bent

C. Prone with the torso elevated

D. Bent over with hands touching the floor

A. Complaints of sudden, sharp, substernal pain

B. Rigid, boardlike abdomen with rebound tenderness

C. Frequent, clay-colored, liquid stool

D. Complaints of vague abdominal pain in the right upper quadrant

A. History of side effects experienced from all medications

B. Use of non steroidal anti inflammatory drugs (NSAIDs)

C. Any known allergies to drugs and environmental factors

D. Medical histories of at lease 3 generations

The nurse is caring for a male client postoperatively following creation of a

B. Disturbed Body Image

C. Fear related to Poor Prognosis

D. Imbalanced Nutrition: more than body requirements

Bethanechol (Urecholine) has been ordered for a client with

A. Dry oral mucosa

Which of the following factors would most likely contribute to the

A. having a sedentary desk job

B. using laxatives frequently

C. being 40 years old

D. being 5 feet 2 inches tall and weighing 200 lbs.

A. Giving pain medication Q6H.

B. Flushing the NG tube with sterile water.

C. Positioning her in high Fowler’s position.

D. Keeping her NPO until the return of peristalsis.

A. Limit caffeine intake to two cups of coffee per day.

B. Do not lie down for 2 hours after eating.

C. Follow a low-protein diet.

D. Take medications with milk to decrease irritation.

The client with gastroesophageal reflux disease (GERD) complains of a

A. development of laryngeal cancer

B. aspiration of gastric contents

C. Irritation of the esophagus

D. Esophageal scar tissue formation

A. Bowel sour s auscultated 15 times in 1 minute

B. Belching after eating a heavy and fatty meal late at night

C. A decrease in systolic BP of 20 mm Hg from lying to sitting

D. A decreased frequency of distress located in the epigastric region

A client who has been diagnosed with gastroesophageal reflux disease

B. Air popped popcorn

Before bowel surgery, Lee is to administer enemas until clear. During

A. Discontinue the procedure

B. Lower the height of the enema container

C. Complete the procedure as quickly as possible

D. Continue administering the enema without making any adjustments

Alvin has a history of peptic ulcer disease and vomits coffee-ground

A. He has fresh, active upper GI bleeding.

B. He needs immediate saline gastric lavage.

C. His gastric bleeding occurred 2 hours earlier.

D. He needs a transfusion of packed RBC’s.