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St. Paul University Dumaguete
College of Nursing
Nursing Local Board Review 2021
MEDICAL SURGICAL NURSING
SENSORY: Eye and Ear Disorders
1. The health care provider places an ear wick in the external ear canal and prescribes antibiotic otic
drops for a patient with external otitis. After the nurse does patient teaching about the disorder,
which patient statement indicates that more instruction is needed?
a. “I may use aspirin or acetaminophen (Tylenol) for pain relief.”
b. “I should clean my ear canal daily with a cotton-tipped applicator.”
c. “I may use warm compresses to the outside of my ear for comfort.”
d. “I should apply the eardrops to the cotton wick in my ear canal.”
2. A patient with chronic otitis media is scheduled for a tympanoplasty. Preoperatively the nurse
teaches the patient that postoperative expectations include
a. avoidance of coughing or blowing the nose.
b. the need for prolonged bed rest.
c. keeping the head elevated.
d. continuous antibiotic irrigation of the ear canal.
3. A patient with otosclerosis has a stapedectomy for treatment of hearing loss. Two days after the
surgery, the patient tells the nurse, “I do not hear as well now as I did right after the surgery.”
Which response by the nurse is most appropriate?
a. “You may have a different kind of hearing loss that is not related to the otosclerosis.”
b. “The dressing over your incision most likely is decreasing your hearing in that ear.”
c. “Postoperative accumulation of fluid and blood in your middle ear will temporarily decrease your
hearing.”
d. “I will let the health care provider know about this because you could have a fistula or other
complication of the surgery.”
4. A patient with Ménière’s disease is admitted with vertigo, nausea, and vomiting. Which nursing
intervention will be included in the care plan?
a. Encourage oral fluids to 3000 ml daily.
b. Change the patient’s position every 2 hours.
c. Keep the head of the bed elevated 30 degrees.
d. Keep the patient’s room darkened.
5. The priority nursing diagnosis for a patient with Ménière’s disease who is experiencing an acute
attack is
a. risk for falls related to dizziness.
b. impaired verbal communication related to tinnitus.
c. self-care deficit: bathing and hygiene related to vertigo.
d. imbalanced nutrition: less than body requirements related to nausea.
6. When watching a patient self-administer eardrops, the home heath nurse observes all the
following actions by the patient. Which patient action indicates a need for more teaching?
a. The patient gets the eardrops out of the refrigerator just before administering the drops.
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b. The patient lies down before and for 2 minutes after administering the drops.
c. The patient holds the tip of the dropper 1 cm above the ear while administering the drops.
d. The patient leaves the ear wick in place while administering the drops.
7. A 78-year-old patient is hospitalized with a fractured femur. During the nursing assessment, the
patient repeatedly asks the nurse to “speak up so that I can hear you.” The best action by the
nurse is to
a. increase the volume of the nurse’s voice.
b. speak normally but more slowly.
c. over enunciate while speaking.
d. use more facial expressions when talking.
8. An older adult patient with presbycusis is fitted with binaural hearing aids. Which information
will the nurse include when teaching the patient how to use the hearing aids?
a. Experiment with volume and hearing ability in a quiet environment initially.
b. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.
c. Keep the volume low on the hearing aids for the first week while adjusting to them.
d. Add the second hearing aid after making the initial adjustment to the first hearing aid.
9. The nurse at the outpatient surgery unit obtains all of this information about a patient who is
scheduled for cataract extraction and implantation of an intraocular lens. Which information has
the most immediate implications for the patient’s care?
a. The patient has not eaten anything for 8 hours.
b. The patient takes 3 antihypertensive medications.
c. The patient has had blurred vision for several years.
d. The patient gets nauseated with general anesthesia.
10. The nurse obtains all these data when assessing a patient who has left-sided labyrinthitis. Which
information should be reported immediately to the health care provider?
a. The patient states, “My ears are really ringing.”
b. The patient has jerking eye movements.
c. The patient complains about a stiff neck.
d. The patient’s hearing is decreased on the left.
11. A patient schedules annual testing for glaucoma with the ophthalmologist. Which information
will be included when teaching the patient about routine glaucoma testing?
a. The test involves reading a Snellen chart at a distance of 20 feet.
b. Application of a Tono-pen to the cornea of the eye will be needed.
c. The examination includes checking the pupil’s reaction to a bright light.
d. Cycloplegic medications are used to allow visualization of the retina.
12. Which assessment information obtained by the nurse when performing an eye examination for a
68-year-old patient indicates that more extensive examination of the eyes is needed?
a. The patient has persistent photophobia.
b. The sclerae are light yellow.
c. The pupil recovers slowly after being stimulated by a penlight.
d. There is a whitish gray ring encircling the periphery of the iris.
13. When performing an eye examination, the nurse will assess for accommodation by
a. touching the patient’s pupil with a small piece of sterile cotton and watching for a blink reaction.
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b. observing the pupils when the patient focuses on a close object and then on a distant object.
c. shining a light into the patient’s eye and watching the pupil response in the opposite eye.
d. covering one eye for 1 minute and noting the pupil reaction when the cover is removed.
14. A nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes from
ultraviolet light because ultraviolet sunlight exposure is associated with the development of
a. glaucoma.
b. exophthalmos.
c. anisocoria.
d. cataracts.
15. Assessment of a patient’s visual acuity reveals that the left eye can see at 20 feet what a person
with normal vision can see at 40 feet and the right eye can see at 20 feet what a person with
normal vision can see at 50 feet. The nurse records these findings as visual acuity
a. OS 20/40; OD 20/50.
b. OU 20/40; OS 50/20.
c. OD 20/40; OS 20/50.
d. OU 40/20; OD 50/20.
16. The nurse in the eye clinic is examining a 44-year-old patient who says “I see small spots that
move around in front of my eyes.” Which action will the nurse take first?
a. Have the ophthalmologist evaluate the patient immediately for possible eye damage.
b. Explain that “floaters” are a normal part of aging and do not require follow-up.
c. Use an ophthalmoscope to examine the posterior chamber and retina of the patient’s eyes.
d. Inform the patient that these spots are common and can be surgically removed if they are
bothersome.
16. When assessing a sedated patient, the nurse notes that the patient blinks only five or six times a
minute. The nurse should plan to
a. notify the health care provider immediately.
b. use artificial tears every hour.
c. apply patches to the eyes.
d. check the pupil response to light.
17. When obtaining a health history from a 52-year-old patient, which patient statement will be of
most concern to the nurse?
a. “My vision seems blurry now when I read.”
b. “I have noticed that my eyes are drier now.”
c. “It is hard for me to see when I drive at night.”
d. “The middle part of my vision is decreased.”
18. The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a new
patient at the eye clinic. Which information given by the patient will have the most implications
for the patient’s treatment?
a. “I use aspirin when I have a sinus headache.”
b. “I have not had an eye examination for at least 10 years.”
c. “I take metoprolol (Lopressor) daily for angina.”
d. “I have had frequent episodes of conjunctivitis.”
19. The nurse working in the outpatient clinic receives a new order to check the visual acuity for a
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patient. The nurse will need to obtain a (an)
a. Snellen chart.
b. ophthalmoscope.
c. penlight.
d. Amsler grid.
20. A patient being admitted to the hospital has an eye patch in place and tells the nurse “I had a
recent eye injury, so I need to wear this patch for a few weeks.” Which nursing diagnosis will the
nurse include in the plan of care?
a. Ineffective denial related to inability to admit the impact of the eye injury
b. Risk for falls related to current decrease in stereoscopic vision
c. Disturbed body image related to eye trauma and need to wear eye patch
d. Impaired physical mobility related to inability to see surroundings
21. The nurse is assessing a 48-year-old patient for presbyopia. Which equipment will the nurse need
to obtain prior to the examination?
a. Snellen chart
b. Jaeger chart
c. Penlight
d. Tono-pen
22. When the nurse is taking a health history of a new patient at the ear clinic, the patient states, “I
always sleep with the radio on.” Which response by the nurse is most appropriate?
a. “Are you ever dizzy when you are lying down?”
b. “Do you grind your teeth at night?”
c. “Have you noticed any ringing in your ears?”
d. “What time do you usually fall asleep?”
23. An 87-year-old patient has marked bilateral presbycusis. In performing a Rinne test on the
patient, the nurse would anticipate that the patient
a. lateralizes the sound when a tuning fork is placed on the forehead.
b. hears best when the tuning fork is placed next to the ear canal.
c. hears the tuning fork better when it is placed on the mastoid bone.
d. hears the sound equally well in both ears when the fork is placed midline on the skull.
24. The nurse notes all these assessment data when examining a patient’s auditory canal andtympanic
membrane. Which one is of most concern?
a. Cerumen is present in the auditory canal.
b. The tympanum is bluish-tinged.
c. There is a cone of light visible.
d. The skin in the ear canal is dry and scaly.
25. When taking a health history from a new patient in the outpatient clinic, which information may
indicate the need to perform a focused hearing assessment?
a. The patient has a 20-year history of rheumatoid arthritis.
b. The patient uses acetaminophen (Tylenol) frequently.
c. The patient takes atenolol (Tenormin) to prevent angina.
d. The patient had a scalp laceration about a year ago.
26. When assessing the activity-exercise pattern of a patient with chronic vertigo syndrome, the
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nurse notes that the patient states, “I love to run for exercise, and I usually run five or six times a
week, but now I feel dizzy when I run.” Which action should be included in the plan of care?
a. Teaching the patient about the need to avoid activities that cause dizziness
b. Having the patient try running more in the early part of the day
c. Encouraging the patient to try riding a bicycle instead of running
d. Developing an exercise program that gradually increases time spent running
27. The nurse is observing a student who is preparing to perform an ear examination of a 24-year-old
patient. The nurse will need to intervene if the student
a. pulls the auricle of the ear down and backward.
b. chooses a speculum smaller than the ear canal.
c. stabilizes the hand holding the otoscope on the patient’s head.
d. stops inserting the otoscope after observing impacted cerumen.
28. Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse
analyzes the test results as documented in the client’s chart and understands that normal intraocular
pressure is:
a. 2 to 3 mm Hg
b. 10 to 21 mm Hg
c. 22 to 30 mm Hg
d. 31 to 35 mm Hg
29. The nurse notes that the physician has documented a diagnosis of presbycusis on the client’s
chart. The nurse plans care knowing that the condition is:
a. Tinnitus that occurs with aging
b. Nystagmus that occurs with aging
c. A conductive hearing loss that occurs with aging
d. A sensorineural hearing loss that occurs with aging
30. A client with Meniere’s disease is experiencing severe vertigo. Which instruction should the
nurse give to the client to assist in controlling the vertigo?
a. Increase sodium in the diet
b. Lie still and watch the television.
c. Avoid sudden head movements
d. Increase fluid intake to 3000 mL a day.
31. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination
of the tympanic membrane, which of the following would the nurse expect to observe?
a. A pink-colored tympanic membrane
b. A pearly colored tympanic membrane
c. A transparent and clear tympanic membrane
d. A red, dull, thick, and immobile tympanic membrane
32. The client is diagnosed with a disorder involving inner ear. Which of the following is the most
common client complaint associated with a disorder involving this part of the ear?
a. Pruritus
b. Tinnitus
c. Hearing loss
d. Burning in the ear
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33. The nurse has notes that the physician has a diagnosis of presbycusis on the clients chart, The
nurse plans care knowing the condition is:
a. Tinnitus that occurs with aging
b. A sensorineural hearing loss that occurs with aging
c. Nystagmus that occurs with aging
d. A conductive hearing loss that occur with aging
34. Always assess the patient with an ophthalmic problem for:
a. Pupillary reactions
b. Visual acuity
c. Intraocular pressure
d. Confrontation visual fields
35. During an assessment of hearing, the nurse would expect to find normal finding of:
a. absent cone of light
b. midline tone heard in both ears
c. Bluish purple tympanic membrane
d. All of the above
e. None of the above
36. Which is not an age related changes in the auditory system?
a. drier cerumen
b. auditory nerve degeneration
c. tinnitus in both ears
d. Atrophy of the tympanic membrane
37. A complete eye examination yields a result that a client is color blind. The nurse interprets that
which of the following structures of the eye is affected?
a. Rods
b. Cones
c. Iris
d. Lens
38. A client is experiencing a dysfunction of the rods in the eye. The nurse interprets that this client
will most likely exhibit which of the following disturbances in vision?
a. Near sightedness
b. Far sightedness
c. Night blindness
d. Color blindness
39. A client with increased intraocular pressure is experiencing excessive production of aqueous
humor of the eye in relation to the speed of outflow. The nursE interprets that the part of the eye
responsible for the production of of aqueous humor is the:
a. Anterior chamber
b. Ciliary body
c. Posterior chamber
d. Trabecular meshwork
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40. A nurse is listening to a physician explain the results of an eye examination to a client. The
physician states that the client has glaucoma due to a congenitally narrow anterior chamber angle,
which suddenly has become blocked at the base of the iris. The nurse interprets that the physician is
describing which of the following types of glaucoma?
a. Primary open angle glaucoma
b. Low tension glaucoma
c. Angle closure glaucoma
d. Secondary glaucoma
41. A nurse is told that a client with glaucoma has experienced vision loss as a result of obstruction
to aqueous humor flow by the trabecular meshwork. The nurse interprets that this client is suffering
from:
a. Primary open angle glaucoma
b. Low tension glaucoma
c. Angle closure glaucoma
d. Secondary glaucoma
42. The result of a clients eye examination indicate that the client has an abnormal shape to the
curvature of the retina, which is impairing the ability to see [Link] nurse determines that the
client has which of the following eye condition?
a. Myopia
b. Astigmatism
c. Hyperopia
d. Presbyopia
43. A client who is experiencing visual difficulties has been told that a previous vision test showed
that the light rays entering the eye are falling in front of the retina. The nurse interprets that this client
is experiencing which of the following visual disturbances?
a. Myopia
b. Astigmatism
c. Hyperopia
d. Presbyopia
44. During the early postoperative period, the client who has had a cataract extraction complains of
nausea and severe eye pain over the operative site. The initial nursing action is to:
a. Call the physician
b. Turn the client on his or her operative side.
c. Reassure the client that this is normal
d. Administer the prescribed pain medication and antiemetic.
45. In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eye
drops. The nurse administers the eye drops, knowing that the purpose of this medication is to:
a. Produce miosis of the operative eye
b. Provide lubrication to the operative eye.
c. Dilate the pupil of the operative eye
d. Constrict the pupil of the operative eye.
46. The nurse is performing an admission assessment on a client with a diagnosis of detached retina.
Which of the following is associated with this eye disorder?
a. Total loss of vision
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b. A yellow discoloration of the sclera
c. Pain in the affected eye
d. A sense of a curtain falling across the field of vision
47. A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She
calls the emergency department frantic and screaming for help. The nurse should instruct the woman
to take which immediate action?
a. Call the physician
b. Come to the emergency room
c. Irrigate the eyes with water
d. Irrigate the eyes with diluted hydrogen peroxide
48. In a patient who has a hemorrhage in the posterior cavity of the eye, the nurse knows that blood
is accumulating:
a. in the aqueous humor.
b. between the lens and the retina.
c. between the cornea and the lens.
d. in the space between the iris and the lens.
49. The nurse is obtaining the result of the tonometry performed to the client. The result is 23mmHg.
This result may be due to:
a. edema of the corneal stroma.
b. dilation of the retinal arterioles.
c. blockage of the lacrimal canals and ducts.
d. increased production of aqueous humor by the ciliary process
50. While obtaining the nursing health history, the nurse should question the client using eyedrops to
treat their glaucoma about which of the following?
a. use of corrective lenses.
b. their usual sleep pattern.
c. a history of heart or lung disease.
d. sensitivity to opioids or depressants
51. You are the nurse assigned to perform an eye assessment on an 80-year-old client. Which of the
following findings during the assessment is considered normal?
a. Absence of the red reflex
b. Edematous eyelids with matted eyelashes
c. Equal pupillary constriction in response to light
d. Inflamed conjunctiva
52. Lolo Celso has presbyopia. The nurse is expects which physiologic changes in the client’s eye?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased distance vision abilities
d. Decreased adaptation to darkness
53. A 76-year-old client tells the nurse that she notices that she is having trouble hearing, especially
in large groups. She continues, saying she cannot always tell where the sound is coming from, and
the words often sound "mixed up." The nurse should suspect which of the following as the cause
for this change?
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a. Atrophy of the apocrine glands
b. Cilia in the ear becoming coarse and stiff
c. Nerve degeneration in the inner ear
d. Scarring of the tympanic membrane
54. You are the nurse assigned to care for an elderly client. While assessing the ears of the patient,
you observed dry, hard cerumen developing in the ear canal. Which of the following actions
should you take?
a. Do nothing, since this a normal finding in the older adult.
b. Ask the patient if he is experiencing any discomfort.
c. Document finding and report your concern to the physician.
d. Irrigate the ear canal with a mixture of hydrogen peroxide and normal saline.
55. During a hearing assessment, the nurse finds that sound lateralizes to the client's left ear with the
Weber and Rinne tests. What should the nurse conclude from this finding? The patient has:
a. A conductive hearing loss in the right ear.
b. Either a sensorineural or conductive hearing loss.
c. Lateralization is a normal finding with the Weber test.
d. The steps in assessing the patient's hearing were done incorrectly.
56. Which of the following statements about the visual pathway is incorrect?
a. “The optic nerves are cranial nerves formed of the same axons of ganglion cells.”
b. “The two optic nerves meet at the optic chiasm, just posterior to the pituitary
gland in the brain.”
c. “The crossing of the axons results in each optic tract carrying information from both eyes.”
d. “The left optic tract carries visual information from the lateral half of the retina of the left
eye and the medial half of the retina of the right eye.”
57. Which of the following techniques would need to be corrected during the visual field
assessment?
a. The nurse is sitting opposite of the client at a distance of 3-6 inches to measure the
visual fields.
b. The nurse asks the client to cover one eye with the opaque cover while covering their own
eye opposite to the client.
c. The nurse moves the penlight from the periphery toward the center from right to left, above
and below, and from the middle of each of these directions.
d. The nurse requests that the client look directly at them.
58. The nurse is assessing the client for hearing noticed that the client’s bone conduction is greater
than the air conduction. The result is an abnormal as indicated in which diagnostic test?
a. Weber test
b. Whisper test
c. Tympanogram
d. Rinne test
59. The nurse in an eye clinic is performing a functional health pattern interview with a client. The
nurse asks the client, “Do you have any difficulty focusing on objects? If so, do you have more
difficulty with near objects or far objects?” Which functional health pattern is being assessed here?
a. Health Perception – Health Management
b. Cognitive – Perceptual
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c. Role – Relationships
d. Coping – Stress – Tolerance
60. A client is diagnosed with Meniere’s disease. Which of the following nursing diagnosis should
take priority for the client?
a. Altered body image
b. Risk for injury
c. Impaired social interaction
d. Ineffective coping
61. It is an eye disorder characterized by lessening of the effective powers of accommodation:
a. Myopia
b. Presbyopia
c. Hypertropia
d. Presbycusis
Liver, Pancreas, and Biliary Tract Problems
62. A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B
virus (HBV) through a needle stick from an infected patient. The infection control nurse informs
the individual that treatment for the exposure should include
a. baseline hepatitis B antibody testing now and in 2 months.
b. active immunization with hepatitis B vaccine.
c. hepatitis B immune globulin (HBIG) injection.
d. both the hepatitis B vaccine and HBIG injection.
63. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the
patient’s illness, the nurse would expect serologic testing to reveal
a. hepatitis B surface antigen (HBsAg).
b. anti-hepatitis B core immunoglobulin M (anti-HBc IgM).
c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
64. During evaluation of a patient at an outpatient clinic, the nurse determines that administration of
hepatitis B vaccine has been effective when a specimen of the patient’s blood reveals
a. HBsAg.
b. anti-HBs.
c. anti-HBc IgM.
d. anti-HBc IgG
65. A patient in the outpatient clinic has positive serologic testing for anti-HCV. Which action by the
nurse is appropriate?
a. Schedule the patient for HCV genotype testing.
b. Teach the patient that the HCV will resolve in 2 to 4 months.
c. Administer immune globulin and the HCV vaccine.
d. Instruct the patient on self-administration of -interferon.
66. A homeless patient with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with
viral hepatitis and has just been admitted to the hospital. In planning care for the patient, the
nurse assigns the highest priority to the patient outcome of
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a. maintaining adequate nutrition.
b. establishing a stable home environment.
c. increasing activity level.
d. identifying the source of exposure to hepatitis.
67. A patient with acute hepatitis B asks the nurse if treatment is available for the condition. The
nurse explains to the patient that
a. because no medication is available to treat acute viral hepatitis, adequate nutrition and rest are
the most important treatments.
b. lamivudine (Epivir) can decrease viral load and liver damage in patients with acute hepatitis
B, but it must be taken for at least 1 year.
c. patients with acute hepatitis B can be given HBIG to help reduce the symptoms.
d. various antiviral drugs are available to treat acute hepatitis B, but serious side effects limit
their use.
68. Combination therapy of -interferon and ribavirin (Rebetol) is being used to treat hepatitis C in a
patient with human immunodeficiency virus (HIV). The nurse will plan to monitor
a. blood glucose.
b. lymphocyte count.
c. potassium level.
d. serum creatinine.
69. When taking a health history for a new patient, which information given by the patient would
indicate that screening for hepatitis C is appropriate?
a. The patient had a blood transfusion after surgery in 1998.
b. The patient reports a one-time use of IV drugs 20 years ago.
c. The patient eats frequent meals in fast-food restaurants.
d. The patient recently traveled to an undeveloped country.
70. A patient is admitted with an abrupt onset of jaundice, nausea and vomiting, hepatomegaly, and
abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which
question by the nurse is most appropriate?
a. “Have you been around anyone with jaundice?”
b. “Do you use any prescription or over-the-counter (OTC) drugs?”
c. “Are you taking corticosteroids for any reason?”
d. “Is there any history of IV drug use?”
71. When teaching a patient recovering from hepatitis B about management of the illness, the nurse
determines that additional teaching is needed when the patient says
a. “I should not drink alcohol for at least the next year.”
b. “My family members should be tested for hepatitis B.”
c. “When the jaundice is gone, I have recovered from my illness and the infection is cured.”
d. “Until my tests for the virus are negative, I should use a condom for sexual intercourse.”
72. A patient with cirrhosis has 4+ pitting edema of the feet and legs and massive ascites. The data
indicate that it is most important for the nurse to monitor the patient’s
a. temperature.
b. albumin level.
c. hemoglobin.
d. activity level.
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73. A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. When planning
patient teaching, the priority information for the nurse to include is the need for
a. vitamin B supplements.
b. abstinence from alcohol.
c. maintenance of a nutritious diet.
d. long-term, low-dose corticosteroids.
74. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide
(Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3.2 mEq/L
(3.2 mmol/L). Before notifying the health care provider, the nurse should
a. administer the furosemide and withhold the spironolactone.
b. give both drugs as scheduled.
c. administer the spironolactone.
d. withhold both drugs until talking with the health care provider.
75. When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the
nurse asks the patient to
a. stand on one foot.
b. ambulate with the eyes closed.
c. extend both arms.
d. perform the Valsalva maneuver.
76. When lactulose (Cephulac) 30 ml QID is ordered for a patient with advanced cirrhosis, the
patient complains that it causes diarrhea. The nurse explains to the patient that it is still important
to take the drug because the lactulose will
a. promote fluid loss.
b. prevent constipation.
c. prevent gastrointestinal (GI) bleeding.
d. improve nervous system function.
77. A patient who is admitted with acute hepatic encephalopathy and ascites receives instructions
about appropriate diet. The nurse determines that the teaching has been effective when the
patient’s choice of foods from the menu includes
a. an omelet with cheese and mushrooms and milk.
b. pancakes with butter and honey and orange juice.
c. baked beans with ham, cornbread, potatoes, and coffee.
d. baked chicken with french-fries, low-fiber bread, and tea.
78. A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for
the patient, the nurse gives the highest priority to the goal of
a. controlling bleeding.
b. maintenance of the airway.
c. maintenance of fluid volume.
d. relieving the patient’s anxiety.
79. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal
varices, which nursing action will be included in the plan of care?
a. Encourage the patient to cough and deep breathe.
b. Insert the tube and verify its position q4hr.
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c. Monitor the patient for shortness of breath.
d. Deflate the gastric balloon q8-12hr.
80. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible
complications of the bleeding episode, it is most important for the nurse to monitor
a. prothrombin time.
b. bilirubin levels.
c. ammonia levels.
d. potassium levels.
81. The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with
cirrhosis who has ascites and 4+ pitting edema of the feet and legs. An appropriate nursing
intervention for this problem is to
a. restrict dietary protein intake.
b. arrange for a pressure-relieving mattress.
c. perform passive range of motion QID.
d. turn the patient every 4 hours.
82. A portocaval shunt is considered for a patient with cirrhosis following an episode of bleeding
esophageal varices. The nurse plans to teach the patient that this procedure
a. is likely to improve the patient’s life expectancy.
b. will increase the risk of hepatic encephalopathy.
c. will help to decrease the incidence of peritonitis.
d. is a first-line therapy for portal hypertension.
83. A patient with cancer of the liver has severe ascites, and the health care provider plans a
paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the
procedure, the nurse
a. asks the patient to empty the bladder.
b. positions the patient on the right side.
c. obtains informed consent for the procedure.
d. assists the patient to lie flat in bed.
84. A patient with end-stage liver disease who is to undergo a liver transplant tells the nurse, “I have
a friend who has already rejected two kidney transplants. I am concerned that I will reject this
liver.” The nurse’s best response to the patient is
a. “Perhaps your friend did not have a good tissue match with the kidney transplants.”
b. “You would not be scheduled for a transplant if there was a concern about rejection.”
c. “The problem of rejection is not as common in liver transplants as in kidney transplants.”
d. “It is easier to get a good tissue match with liver transplants than with kidney transplants.”
85. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and
vomiting. The nurse would expect the diagnosis to be confirmed with laboratory testing that
reveals elevated serum
a. calcium.
b. bilirubin.
c. amylase.
d. potassium.
86. In planning care for a patient with acute pancreatitis, the nurse assigns the highest priority to the
patient outcome of
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a. developing no acute complications.
b. maintenance of normal respiratory function.
c. expressing satisfaction with pain control.
d. having adequate fluid and electrolyte balance.
87. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. The nurse
explains to the patient that the major purpose of this treatment is
a. control of fluid and electrolyte imbalance.
b. relief from nausea and vomiting.
c. reduction of pancreatic enzymes.
d. removal of the precipitating irritants.
88. The nurse identifies the collaborative problem of potential complication: electrolyte imbalance
for a patient with severe acute pancreatitis. Assessment findings that alert the nurse to electrolyte
imbalances associated with acute pancreatitis include
a. muscle twitching and finger numbness.
b. paralytic ileus and abdominal distention.
c. hypotension.
d. hyperglycemia.
89. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient
specifically about a history of
a. cigarette smoking.
b. alcohol use.
c. diabetes mellitus.
d. high-protein diet.
90. The health care provider prescribes pancreatin (Viokase) for a patient with chronic pancreatitis.
The nurse teaches the patient that the drug is considered effective if the patient experiences
a. normal-appearing stools.
b. decreased jaundice.
c. improved appetite.
d. reduced abdominal pain.
91. When the nurse is caring for the patient with pancreatic cancer, which nursing diagnosis is a
priority?
a. Chronic pain related to tumor pressure on abdominal structures
b. Imbalanced nutrition: less than required related to anorexia
c. Impaired skin integrity related to itching secondary to jaundice
d. Grieving related to potentially terminal diagnosis
92. A patient who is admitted to the hospital with a sudden onset of severe right upper-quadrant pain
that radiates to the right shoulder is diagnosed with cholecystitis. Which assessment information
will be most important for the nurse to report to the health care provider?
a. The patient has an increase in pain after eating.
b. The patient needs 4 mg of morphine for pain relief.
c. The patient’s stools are clay colored.
d. The patient’s urine is bright yellow.
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93. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse
places the highest priority on assisting the patient to
a. turn, cough, and deep breathe every 2 hours.
b. choose low-fat foods from the menu.
c. perform leg exercises hourly while awake.
d. ambulate the evening of the operative day.
94. An appropriate collaborative problem for the nurse to include in the care plan for a patient with
cholelithiasis and obstruction of the common bile duct is
a. potential complication: bleeding.
b. potential complication: gastritis.
c. potential complication: thromboembolism.
d. potential complication: biliary cirrhosis.
95. When providing discharge instructions to a patient following a laparoscopic cholecystectomy at
an outpatient surgical center, the nurse recognizes that teaching has been effective when the
patient states,
a. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
b. “I can expect some reddish yellow drainage from the incisions for a few days.”
c. “I can remove the bandages on my incisions tomorrow and take a shower.”
d. “I will always need to maintain a low-fat diet since I no longer have a gallbladder.”
96. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of
most concern?
a. The patient’s skin has multiple spider-shaped blood vessels on the abdomen.
b. The patient has ascites and a 2-kg weight gain from the previous day.
c. The patient complains of right upper-quadrant pain with abdominal palpation.
d. The patient’s hands flap back and forth when the arms are extended.
97. A patient with severe cirrhosis has a new prescription for propranolol (Inderal). The nurse will
teach the patient that the medication is ordered to
a. decrease systemic BP.
b. prevent the development of ischemia.
c. lower the risk for bleeding varices.
d. reduce fluid retention and edema.
98. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the
purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate?
a. The medication will inhibit the development of gastric ulcers.
b. The medication will prevent irritation to the esophageal varices.
c. The medication will decrease nausea and anorexia.
d. The medication will reduce the risk for aspiration.
99. Which of these nursing actions included in the plan of care for a patient with cirrhosis can the
nurse delegate to a nursing assistant?
a. Assessing the patient for jaundice
b. Assisting the patient in choosing the diet
c. Palpating the abdomen for distention
d. Providing oral hygiene before meals
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100. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of
the patient’s hand. Which action should the nurse take next?
a. Notify the health care provider immediately.
b. Retake the patient’s blood pressure.
c. Check the calcium level on the chart.
d. Ask the patient about any arm pain.
101. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which
information obtained by the nurse is the best indicator that these therapies have been effective?
a. Bowel sounds are present.
b. Abdominal pain is decreased.
c. Electrolyte levels are normal.
d. Grey Turner sign resolves.
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“NOTHING THAT IS GOOD, COMES EASY”
Dr. Richard D. Pascua
