MED SURG EXAM 2 WITH CORRECT ANSWERS
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 blood
transfusion 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
thebradycardia 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)
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 blood
transfusion 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
thebradycardia 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)
