NURSING 326Med Surg Exam 2
Q&A.
1. Q: A nurse has administered several blood transfusions over 3 days to a client with
Thalassemia. What lab value would be MOST IMPORTANT for the nurse to monitor closely
during t
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NURSING 326Med Surg Exam 2
Q&A.
1. Q: A nurse has administered several blood transfusions over 3 days to a client with
Thalassemia. What lab value would be MOST IMPORTANT for the nurse to monitor closely
during this therapy?
A: Hemoglobin Level
2. Q: A major goal for the client during the first 48 hours after severe burn is to prevent
Hypovolemic shock. Which of the following is THE BEST indicator of adequate fluid balance
during this period?
A: Urine output of 30 to 50 ml/hr.
3. Q: A client with hemophilia has a nosebleed. Which nursing actions is MOST APPROPRIATE
to control the bleeding?
A: Pinch the soft lower part of the nose for a minimum of 5 minutes.
4. Q: A patient is admitted with a venous stasis leg ulcer. The nurse assesses the ulcer, which
of the following would the nurse EXPECT on the ulcer?
A: The ulcer has brown skin-color around it
5. Q: The nurse is teaching a client with atrial fibrillation about the use of Coumadin (Warfarin)
at home. Which of the following is MOST IMPORTANT for the nurse to teach to the patient to
avoid?
A: Foods rich in Vitamin K
6. Q: A patient with angina complains that the angina pain is prolonged and severe and occurs
at the same time each day, most often at rest in the absence of precipitant factors. How would
the nurse best describe this type of angina pain?
A: Variant Angina (Which is also known as Prinzmetal Angina)
7. Q: A patient who was admitted with a myocardial infarction experiences a 45-second episode
of Ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute.
Which of the following actions should the nurse take next?
A: Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.
8. Q: Packet red blood cells have been prescribed for a patient with low hemoglobin and
hematocrit levels. The nurse’s measured the patient’s temperature before hanging the bloodtransfusion and found it to be 100.6 F orally. Which of the following is the MOST
APPROPRIATE nursing action?
A: Delay hanging the blood and notify the physician
9. Q: Which PRIORITY nursing intervention will be included in the care plan for a patient with
thrombocytopenia?
A: Avoid intramuscular (IM) injections
10. Q: A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure
(BP) of 80/42 mm Hg, and reports feeling “faint and dizzy”. Which is the nurse’s PRIORITY
action?
A: Apply the transcutaneous pacemaker (TCP) pads
11. Q: A patient’s cardiac rhythm is sinus bradycardia with a heart rate of 34 beats/minute. If the
bradycardia is symptomatic, the nurse would expect the patient to exhibit which clinical
symptoms? (SELECT ALL THAT APPLY)
A: Dizziness, Hypertension, Shortness of breath
(This rationale is a bit confusing it states “Signs and symptomatic bradycardia include
pale, cool skin, hypotension, weakness, angina,dizziness or syncope, confusion or
disorientation, and shortness of breath.)
12. Q: The nurse is assessing an African American male with sickle cell anemia and notes the
sclera of his eyes to be yellow. Which of the following would be the BEST nurse’s interpretation
of this finding?
A: The patient is presenting Jaundice
13. Q: Which nursing intervention is MOST APPROPRIATE following a bone marrow aspiration
on the left posterior iliac crest from a patient with pernicious anemia?
A: Apply pressure to the site for 5 minutes with an ice pack.
14. Q: Which of the following if the nurse’s BEST interpretation of the below arrhythmia?
A: The photo was not shown but the answer is ATRIAL FLUTTER/FIBRILLATION
15. Q: The nurse is caring for a patient in atrial fibrillation. The atrial heart rate is 250 and the
ventricular rate is controlled at 75. Which of the following findings is cause for MOST
CONCERN?
A: A cold, pale lower leg.
16. Q: The nurse is caring for a client in the coronary care unit. The cardiac monitor shows the
below rhythm. How should the nurse identify this rhythm?A: Ventricular Fibrillation (Could not add photo of the strip)
17. Q: A patient with heart failure has a prescription for Digoxin. The nurse is educating a
patient taking Digoxin about including sufficient potassium in the diet. Which of the following
complications of hypokalemia in combination with Digoxin is MOST IMPORTANT to prevent?
A: Digoxin combined with Hypokalemia predispose to dysrhythmias
18. Q: The nurse is providing home care for a client with left sided heart failure and pulmonary
edema. Which nursing diagnosis should have priority in planning care?
A: Activity intolerance related to oxygen supply and demand imbalance.
19. Q: The patient diagnosed with angina is being discharged home with a prescription for a
daily dose of 81 mg of aspirin. The patient asks the nurse why he has to take aspirin. Which of
the following would be the nurse’s BEST response?
A: “Aspirin will help reduce clotting”
20. Q: The nurse is evaluating the condition of a patient after a pericardiocentesis performed to
treat cardiac tamponade. Which of the following assessment findings would MOST LIKELY
indicate that the procedure was unsuccessful?
A: Rising central venous pressure
21. Q: The nurse is providing education to a group of young patients newly diagnosed with
sickle cell anemia. Which of the following statement made by the patient indicates to the nurse
that the patient with sickle cell anemia needs FURTHER INSTRUCTION?
A: “I am excited about my annual ski trip to Colorado”
22. Q: The nurse is conducting an admission assessment of a client with vitamin B12 deficiency.
Which of the following would MOST IMPORTANT for the nurse include in the physical
assessment?
A: Examine the tongue
23. Q: A patient with heart failure has Lanoxin (Digoxin) ordered. What would the nurse
EXPECT TO FIND when evaluating for the therapeutic effectiveness of this drug?
A: Improved respirations and increased urinary output
24. Q: One week ago, a patient was diagnosed with atrial fibrillation, which has been
unresponsive to calcium channel blockers and beta blockers. The nurse anticipates teaching the
patient about which PRIORITY treatment?
A: Anticoagulant therapy with warfarin (Coumadin)25. Q: Which of the following conditions is the MOST COMMON cause of angina?
A: Inadequate myocardial oxygen supply
26. Q: The nurse is providing education for a patient diagnosed with sickle cell anemia. Which of
the following would be MOST IMPORTANT for the nurse to emphasize in order to prevent sickle
cell crisis?
A: Maintain adequate fluid intake
27. Q: Which clinical manifestation would the nurse expect to see in a patient diagnosed with
immune thrombocytopenia purpura (TIP)?
A: Petechiae on the chest, arms, and neck
28. Q: The nurse observes asystole on a six (6) second rhythm strip on the cardiac monitor.
After confirming the rhythm in two leads, which PRIORITY action should the nurse take?
A: Initiate cardiopulmonary resuscitation (CPR)
29. Q: The patient who had a myocardial infarction (MI) 10 days ago is being easily fatigued
with excretion and has a nursing diagnosis of “Impaired tissue perfusion”. Which of the following
would be the nurse’s MOST APPROPRIATE pathophysiological issue to associate with this
nursing diagnosis?
A: Impaired tissue perfusion related to necrosis of the myocardium.
30. Q: A patient’s electrocardiogram strip shows a heart rate of 110 beats/min. The PR interval
is 0.14 seconds, the QRS complex measures ___ seconds, and the RR intervals are regular.
How should the nurse correctly interpret this rhythm?
A: Sinus Tachycardia
31. Q: The nurse is taking care of a patient who has a heart rate of 125 beats per minute and
complains of shortness of breath. Which would be the nurse’s BEST interpretation of the causes
of this patient’s complaint?
A: Drop in cardiac output
31. Q: The patient with angina asks what to do if the first nitroglycerin tablet (NGT) does not
relieve the pain. Which of the following instruction by the nurse is CORRECT?A: “Take 2 more tablets 5 minutes apart and call 911 if pain is not relieved”
32. Q: After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree
atrioventricular (AV) block, which ___ medication has been effective?
A: Increase in the patient’s heart rate
33. Q: The Nurse determines that a patient who is receiving a transfusion is having a reaction.
The nurse stops the transfusion. Which of the following SHOULD the nurse perform
IMMEDIATELY AFTER stopping the transfusion?
A: This is the answer it states “Run normal Saline at 21 ml/hr”
(Many students are arguing about this answer because they actually picked “Remove
the intravenous (IV) line”)
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