NR-304:
PRACTICE EXAM QUESTIONS WITH
CORRECT DETAILED ANSWERS |
ALREADY GRADED A+<RECENT
vERSION>
1) A nurse is caring for a client who has deep vein thrombosis and has been on heparin
continuous infusion for 5 days. The provider prescribes warfarin PO without
discontinuing the heparin. The client asks the nurse why both anticoagulants are
necessary. Which of the following statements should the nurse make?
A. "Warfarin takes several days to work, so the IV heparin will be used until the
warfarin reaches a therapeutic level."
B. "I will call the provider to get a prescription for discontinuing the IV heparin
today."
C. "Both heparin and warfarin work together to dissolve the clots."
D. "The IV heparin increases the effects of the warfarin and decreases the length
of your hospital stay." - ANSWER A. "Warfarin takes several days to work,
so the IV heparin will be used until the warfarin reaches a therapeutic level."
2) A nurse is caring for a client who is postoperative and is at risk for developing venous
thromboembolism (VTE). The nurse should instruct the client to avoid which of the
following unsafe actions?
A. Elevating the feet
B. Massaging her legs
C. Flexing her ankles
D. Ambulating soon after surgery - ANSWER B. Massaging her legs
3) A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr
postoperative. Which of the following surgical procedures places the client at risk for
deep-vein thrombosis?
A. Myringotomy
B. Laparoscopic appendectomy
C. Hip arthroplasty
D. Cataract extraction - ANSWER C. Hip arthroplasty
,4) A nurse is caring for who reports an area of redness, warmth, tenderness, and pain in
the right calf. The nurse anticipates which of the following orders when notifying the
provider of this finding?
A. Obtain a venous duplex ultrasound
B. Obtain impedance plethysmography
C. Monitor Homan's sign
D. Apply cold therapy to the affected leg - ANSWER A. Obtain a venous
duplex ultrasound
5) A nurse is providing discharge teaching ti a client who has peripheral arterial disease
(PAD). Which of the following instructions should the nurse include in the teaching?
A. Apply a heating pad on a low setting to help relieve leg pain
B. Adjust the thermostat so that the environment is warm
C. Wear antiembolic stockings during the day
D. Rest with the legs above heart level - ANSWER B. Adjust the thermostat
so that the environment is warm
6) A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the
following symptoms should the nurse expect to find in the early stage of the disease?
A. Intermittent claudication
B. Dependent rubor
C. Rest pain
D. Foot ulcers - ANSWER A. Intermittent claudication
7) A nurse is providing preoperative teaching for a client who will undergo surgery. The
nurse explains that the client will wear antiembolism stockings during and after the
procedure. When the client asks what the stockings do, which of the following
responses should the nurse make?
A. "They protect your legs and heels from skin breakdown."
B. "They help keep you warm after you're surgery."
C. "They improve your circulation to keep blood from pooling in your legs."
D. "They make it easier for you to do leg exercises after your surgery." -
ANSWER C. "They improve your circulation to keep blood from pooling
in your legs."
8) A nurse is reviewing the laboratory results of a male adult client who is at risk for
peripheral arterial disease from atherosclerosis. The nurse should identify that which
of the following results places the client at risk?
A. Triglycerides 130mg/dL
B. Blood glucose 92mg/dL
, C. LDL 172mg/dL
D. HDL 84mg/dL - ANSWER C. LDL 172mg/dL
9) Where do you find tympani? - ANSWER All 4 quadrants, normal
10) Where do you find dullness? - ANSWER RUQ-high under costal margin-liver
11) Where do you find resonance? - ANSWER lungs
12) How do you percuss liver span? - ANSWER Hold breath or let out all breath -
(liver moves) and percuss downward at L Mid clavicular line - area of dullness Is
measured - 5-10 cm (women smaller than men)
13) How do you percuss spleen? - ANSWER Percuss at Left Mid-axillary line.
Percuss down to dullness, and then up to dullness measuring span.
14) How are the fluid wave and shifting dullness tests performed? What do they indicate?
- ANSWER Fluid wave - push on one side of patient's abdomen - with patient
supine - put patient hand in middle and feel wave (if there is fluid) on other side of
abdomen.. if not fluid but fat, the patient hand will stop the "wave" - Shifting dullness
- percuss as patient is supine from tympani to dullness then have lay on side and do
same. IF fluid, the fluid shifts and dullness shifts - both indicate ascites = 3rd space or
extracell. Spacing of fluid from VEINS and PROTEIN which pulls more fluid from
the veins = edema
15) What is purpose of light palpation? - ANSWER Light for superficial masses,
muscle tone, symmetry, pain
16) What is the purpose of deep palpation? - ANSWER Deep palpation for
organomegaly
17) What is rebound tenderness? IF + = - ANSWER Done by pushing into abdomen
and quickly bringing hands up - the reflexive bounce causes peritoneal spasm - PAIN
if inflamed = +Blumbergs test
, 18) What examination findings would you expect with each condition? Obesity -
ANSWER -Obesity - protruberant abdomen with negative fluid wave- probable
striae
19) What examination findings would you expect with each condition? Ascites -
ANSWER + fluid wave and shifting dullness and history of liver or cancer issue -
See LOW albumin in their blood levels - other edema?
20) What examination findings would you expect with each condition? Gaseous
distention - ANSWER tons of tympani with a distended abdomen - common with
ileus where intestinal motility stops/slows and gas-producing bacteria is hanging in
one place of intestine.
21) What examination findings would you expect with each condition? tumor -
ANSWER area of organomegaly or mass palpable with deep palpation - dullness
on percussion
22) What tests are done for a person with suspected appendicitis? - ANSWER Psoas -
right leg lift -
Obturator - bent R leg - ab and adducted
Rebound Tenderness- If ruptured
23) What tests are done for a person with suspected cholecystitis? - ANSWER Murphy
- palpation of gallbladder with the inhalation of breath - liver moves up - fingers touch
gallbladder - + liver function tests and ultrasound for stones
24) What are the symptoms of Crohns and Ulcerative colitis? - ANSWER Bloody,
mucousy, diarrhea, bloating, gas, urgency to have stool - abdominal pain - may have
anal and rectal ulcers
25) Melena - ANSWER black tarry stools are sign of blood that HAS been digested by
HCL acid (stomach) or upper GI
26) Bright red stool - ANSWER blood in stool has not been digested-lower GI-
hemorroids
PRACTICE EXAM QUESTIONS WITH
CORRECT DETAILED ANSWERS |
ALREADY GRADED A+<RECENT
vERSION>
1) A nurse is caring for a client who has deep vein thrombosis and has been on heparin
continuous infusion for 5 days. The provider prescribes warfarin PO without
discontinuing the heparin. The client asks the nurse why both anticoagulants are
necessary. Which of the following statements should the nurse make?
A. "Warfarin takes several days to work, so the IV heparin will be used until the
warfarin reaches a therapeutic level."
B. "I will call the provider to get a prescription for discontinuing the IV heparin
today."
C. "Both heparin and warfarin work together to dissolve the clots."
D. "The IV heparin increases the effects of the warfarin and decreases the length
of your hospital stay." - ANSWER A. "Warfarin takes several days to work,
so the IV heparin will be used until the warfarin reaches a therapeutic level."
2) A nurse is caring for a client who is postoperative and is at risk for developing venous
thromboembolism (VTE). The nurse should instruct the client to avoid which of the
following unsafe actions?
A. Elevating the feet
B. Massaging her legs
C. Flexing her ankles
D. Ambulating soon after surgery - ANSWER B. Massaging her legs
3) A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr
postoperative. Which of the following surgical procedures places the client at risk for
deep-vein thrombosis?
A. Myringotomy
B. Laparoscopic appendectomy
C. Hip arthroplasty
D. Cataract extraction - ANSWER C. Hip arthroplasty
,4) A nurse is caring for who reports an area of redness, warmth, tenderness, and pain in
the right calf. The nurse anticipates which of the following orders when notifying the
provider of this finding?
A. Obtain a venous duplex ultrasound
B. Obtain impedance plethysmography
C. Monitor Homan's sign
D. Apply cold therapy to the affected leg - ANSWER A. Obtain a venous
duplex ultrasound
5) A nurse is providing discharge teaching ti a client who has peripheral arterial disease
(PAD). Which of the following instructions should the nurse include in the teaching?
A. Apply a heating pad on a low setting to help relieve leg pain
B. Adjust the thermostat so that the environment is warm
C. Wear antiembolic stockings during the day
D. Rest with the legs above heart level - ANSWER B. Adjust the thermostat
so that the environment is warm
6) A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the
following symptoms should the nurse expect to find in the early stage of the disease?
A. Intermittent claudication
B. Dependent rubor
C. Rest pain
D. Foot ulcers - ANSWER A. Intermittent claudication
7) A nurse is providing preoperative teaching for a client who will undergo surgery. The
nurse explains that the client will wear antiembolism stockings during and after the
procedure. When the client asks what the stockings do, which of the following
responses should the nurse make?
A. "They protect your legs and heels from skin breakdown."
B. "They help keep you warm after you're surgery."
C. "They improve your circulation to keep blood from pooling in your legs."
D. "They make it easier for you to do leg exercises after your surgery." -
ANSWER C. "They improve your circulation to keep blood from pooling
in your legs."
8) A nurse is reviewing the laboratory results of a male adult client who is at risk for
peripheral arterial disease from atherosclerosis. The nurse should identify that which
of the following results places the client at risk?
A. Triglycerides 130mg/dL
B. Blood glucose 92mg/dL
, C. LDL 172mg/dL
D. HDL 84mg/dL - ANSWER C. LDL 172mg/dL
9) Where do you find tympani? - ANSWER All 4 quadrants, normal
10) Where do you find dullness? - ANSWER RUQ-high under costal margin-liver
11) Where do you find resonance? - ANSWER lungs
12) How do you percuss liver span? - ANSWER Hold breath or let out all breath -
(liver moves) and percuss downward at L Mid clavicular line - area of dullness Is
measured - 5-10 cm (women smaller than men)
13) How do you percuss spleen? - ANSWER Percuss at Left Mid-axillary line.
Percuss down to dullness, and then up to dullness measuring span.
14) How are the fluid wave and shifting dullness tests performed? What do they indicate?
- ANSWER Fluid wave - push on one side of patient's abdomen - with patient
supine - put patient hand in middle and feel wave (if there is fluid) on other side of
abdomen.. if not fluid but fat, the patient hand will stop the "wave" - Shifting dullness
- percuss as patient is supine from tympani to dullness then have lay on side and do
same. IF fluid, the fluid shifts and dullness shifts - both indicate ascites = 3rd space or
extracell. Spacing of fluid from VEINS and PROTEIN which pulls more fluid from
the veins = edema
15) What is purpose of light palpation? - ANSWER Light for superficial masses,
muscle tone, symmetry, pain
16) What is the purpose of deep palpation? - ANSWER Deep palpation for
organomegaly
17) What is rebound tenderness? IF + = - ANSWER Done by pushing into abdomen
and quickly bringing hands up - the reflexive bounce causes peritoneal spasm - PAIN
if inflamed = +Blumbergs test
, 18) What examination findings would you expect with each condition? Obesity -
ANSWER -Obesity - protruberant abdomen with negative fluid wave- probable
striae
19) What examination findings would you expect with each condition? Ascites -
ANSWER + fluid wave and shifting dullness and history of liver or cancer issue -
See LOW albumin in their blood levels - other edema?
20) What examination findings would you expect with each condition? Gaseous
distention - ANSWER tons of tympani with a distended abdomen - common with
ileus where intestinal motility stops/slows and gas-producing bacteria is hanging in
one place of intestine.
21) What examination findings would you expect with each condition? tumor -
ANSWER area of organomegaly or mass palpable with deep palpation - dullness
on percussion
22) What tests are done for a person with suspected appendicitis? - ANSWER Psoas -
right leg lift -
Obturator - bent R leg - ab and adducted
Rebound Tenderness- If ruptured
23) What tests are done for a person with suspected cholecystitis? - ANSWER Murphy
- palpation of gallbladder with the inhalation of breath - liver moves up - fingers touch
gallbladder - + liver function tests and ultrasound for stones
24) What are the symptoms of Crohns and Ulcerative colitis? - ANSWER Bloody,
mucousy, diarrhea, bloating, gas, urgency to have stool - abdominal pain - may have
anal and rectal ulcers
25) Melena - ANSWER black tarry stools are sign of blood that HAS been digested by
HCL acid (stomach) or upper GI
26) Bright red stool - ANSWER blood in stool has not been digested-lower GI-
hemorroids
