Certified Medical-Surgical Registered Nurse Exam|
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Elaborations (GRADE A)
The nurse receives all of the following stat orders for Mr. Palmer. Which one should the nurse
question?
1) Oxygen per nasal cannula at 4 L per minute.
2) Enoxaparin (Lovenox) 40 mg subcutaneously.
3) Troponin level.
4) Computed tomography (CT) angiogram.
Rationale: The nurse should questions the order for Lovenox because the patient is receiving a
heparin drip.
Christine Warren, 45 years old, has a long history of ulcerative colitis, and non-surgical treatment
no longer relieved her symptoms. She underwent a total proctocolectomy and a permanent
ileostomy 12 hours ago.
The nurse should contact the physician immediately if Mrs. Warren has which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma.
1) The stoma appears pale and dry.
Rationale: If there is an adequate blood supply to the stoma, the color is pink or red, and the
stoma is moist as a result of mucous production. A pale dry color suggests ischemia of the stoma
or bowel and must be reported immediately to the physician. With an ileostomy initially after
surgery, the output is a loose, dark green liquid that may contain some blood. The ileostomy
usually begins to drain within 24 of surgery at more than one liter per day.
, Certified Medical-Surgical Registered Nurse Exam|
Accurate Sample Questions and Answers with
Rationales | Latest 2025/ 2026 Update | 100% verified
Elaborations (GRADE A)
When changing Mrs. Warren's ileostomy bag, the nurse notices that the peristomal skin is
irritated.
Which of these actions by the nurse would be appropriate before reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic.
3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the surrounding tissue. Therefore, a
solid skin barrier, with a pectin base or karaya wafer that has a measurable thickness and
hydrocolloid adhesive properties, should be applied.
Which of these comments, if made by Mrs. Warren before her surgery, would indicate that she
had concerns about her body image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many surgeries."
3) "I need to go shopping for some loose, baggy clothes."
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Rationales | Latest 2025/ 2026 Update | 100% verified
Elaborations (GRADE A)
Rationale:Body image refers to a person's perception of self and determines how the person
interacts with others. One does not need to purchase special clothing after ileostomy surgery,
although some minor adjustments may be needed for comfort, e.g., stretch underwear or
pantyhose for support.
To medical surgical nursing 11th edition by ignatavicius workman Test Bank or any other Test
Banks email banks and other E books
Lewis Palmer, 45 years old, has a history of multiple myocardial infarctions and is a heavy
smoker. He takes warfarin sodium (Coumadin) daily. Two weeks ago, he had a right femoral-
popliteal bypass, which became occluded 24 hours ago. He is admitted following an angioplasty
of the femoral-popliteal bypass graft. Mr. Palmer is receiving continuous IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals.
4) check the femoral puncture site at frequent intervals.
Rationale: Since bleeding is a common side effect of heparin, it is vital to check the operative
site, the femoral puncture area, for signs of bleeding.
Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee
amputation (BKA) of his right extremity and is returned to the medical-surgical unit with an
, Certified Medical-Surgical Registered Nurse Exam|
Accurate Sample Questions and Answers with
Rationales | Latest 2025/ 2026 Update | 100% verified
Elaborations (GRADE A)
intravenous infusion in place. His orders include: heparin drip, morphine sulfate 10 mg IV push
q4h prn for pain, and ampicillin sodium g 1 IV q6h.
Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says,
"My chest hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure
is105/60 mm Hg, compared to a baseline of 138/70 mm Hg. His respirations are 32/min,
compared to a baseline of 16/min. His O2 saturation is 85%. The nurse immediately calls for
help. Which of the following questions is most important for the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What
1) "Have you ever had this type of chest pain before?"
Rationale: Because of the patient's symptoms and his history of myocardial infarctions, the nurse
should find out if the patient has had this time of pain previously.
Maggie Clark, a 42-year-old female, was admitted with newly diagnosed type 2 diabetes
mellitus. Her blood glucose has been stabilized, and the nurse is preparing her for discharge. Her
discharge orders will include metformin (Glucophage). Mrs. Clark is also being treated for
hypertension.
Because Mrs. Clark is to take Glucophage on a regular basis it is important to
1) monitor her glomerular filtration rate.
2) check her serum amylase routinely.
3) obtain her red blood cell count periodically.
4) examine her urine for casts.
1) monitor her glomerular filtration rate.
Accurate Sample Questions and Answers with
Rationales | Latest 2025/ 2026 Update | 100% verified
Elaborations (GRADE A)
The nurse receives all of the following stat orders for Mr. Palmer. Which one should the nurse
question?
1) Oxygen per nasal cannula at 4 L per minute.
2) Enoxaparin (Lovenox) 40 mg subcutaneously.
3) Troponin level.
4) Computed tomography (CT) angiogram.
Rationale: The nurse should questions the order for Lovenox because the patient is receiving a
heparin drip.
Christine Warren, 45 years old, has a long history of ulcerative colitis, and non-surgical treatment
no longer relieved her symptoms. She underwent a total proctocolectomy and a permanent
ileostomy 12 hours ago.
The nurse should contact the physician immediately if Mrs. Warren has which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma.
1) The stoma appears pale and dry.
Rationale: If there is an adequate blood supply to the stoma, the color is pink or red, and the
stoma is moist as a result of mucous production. A pale dry color suggests ischemia of the stoma
or bowel and must be reported immediately to the physician. With an ileostomy initially after
surgery, the output is a loose, dark green liquid that may contain some blood. The ileostomy
usually begins to drain within 24 of surgery at more than one liter per day.
, Certified Medical-Surgical Registered Nurse Exam|
Accurate Sample Questions and Answers with
Rationales | Latest 2025/ 2026 Update | 100% verified
Elaborations (GRADE A)
When changing Mrs. Warren's ileostomy bag, the nurse notices that the peristomal skin is
irritated.
Which of these actions by the nurse would be appropriate before reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic.
3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the surrounding tissue. Therefore, a
solid skin barrier, with a pectin base or karaya wafer that has a measurable thickness and
hydrocolloid adhesive properties, should be applied.
Which of these comments, if made by Mrs. Warren before her surgery, would indicate that she
had concerns about her body image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many surgeries."
3) "I need to go shopping for some loose, baggy clothes."
, Certified Medical-Surgical Registered Nurse Exam|
Accurate Sample Questions and Answers with
Rationales | Latest 2025/ 2026 Update | 100% verified
Elaborations (GRADE A)
Rationale:Body image refers to a person's perception of self and determines how the person
interacts with others. One does not need to purchase special clothing after ileostomy surgery,
although some minor adjustments may be needed for comfort, e.g., stretch underwear or
pantyhose for support.
To medical surgical nursing 11th edition by ignatavicius workman Test Bank or any other Test
Banks email banks and other E books
Lewis Palmer, 45 years old, has a history of multiple myocardial infarctions and is a heavy
smoker. He takes warfarin sodium (Coumadin) daily. Two weeks ago, he had a right femoral-
popliteal bypass, which became occluded 24 hours ago. He is admitted following an angioplasty
of the femoral-popliteal bypass graft. Mr. Palmer is receiving continuous IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals.
4) check the femoral puncture site at frequent intervals.
Rationale: Since bleeding is a common side effect of heparin, it is vital to check the operative
site, the femoral puncture area, for signs of bleeding.
Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee
amputation (BKA) of his right extremity and is returned to the medical-surgical unit with an
, Certified Medical-Surgical Registered Nurse Exam|
Accurate Sample Questions and Answers with
Rationales | Latest 2025/ 2026 Update | 100% verified
Elaborations (GRADE A)
intravenous infusion in place. His orders include: heparin drip, morphine sulfate 10 mg IV push
q4h prn for pain, and ampicillin sodium g 1 IV q6h.
Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says,
"My chest hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure
is105/60 mm Hg, compared to a baseline of 138/70 mm Hg. His respirations are 32/min,
compared to a baseline of 16/min. His O2 saturation is 85%. The nurse immediately calls for
help. Which of the following questions is most important for the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What
1) "Have you ever had this type of chest pain before?"
Rationale: Because of the patient's symptoms and his history of myocardial infarctions, the nurse
should find out if the patient has had this time of pain previously.
Maggie Clark, a 42-year-old female, was admitted with newly diagnosed type 2 diabetes
mellitus. Her blood glucose has been stabilized, and the nurse is preparing her for discharge. Her
discharge orders will include metformin (Glucophage). Mrs. Clark is also being treated for
hypertension.
Because Mrs. Clark is to take Glucophage on a regular basis it is important to
1) monitor her glomerular filtration rate.
2) check her serum amylase routinely.
3) obtain her red blood cell count periodically.
4) examine her urine for casts.
1) monitor her glomerular filtration rate.
