MCA II Exam 2 Questions and Correct
Answers
Question 1
Which action will be included in the plan of care when the nurse is caring for a patient
who is receiving nicardipine (Cardene) to treat a hypertensive emergency?
a. Organize nursing activities so that the patient has undisturbed sleep for 8 hours at
night.
b. Keep the patient NPO to prevent aspiration caused by nausea and possible
vomiting.
c. Assist the patient up in the chair for meals to avoid complications associated with
immobility.
d. Use an automated noninvasive blood pressure machine to obtain frequent
measurements.
Correct Answer
d. Use an automated noninvasive blood pressure machine to obtain frequent
measurements.
frequent monitoring of BP is needed when the patient is receiving rapid-acting IV
antihypertensive medications. This can be most easily accomplished with an
automated BP machine or arterial line. The patient will require frequent
assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When
patients are receiving IV vasodilators, bed rest is maintained to prevent decreased
cerebral perfusion and fainting. There is no indication that this patient is nauseated
or at risk for aspiration, so an NPO status is unnecessary
Page 1 of 31
,Question 2
The nurse teaches a patient with chronic bronchitis about a new prescription for
Advair Diskus (combined fluticasone and salmeterol). Which action by the patient
would indicate to the nurse that teaching about medication administration has been
successful?
a. The patient shakes the device before use.
b. The patient rapidly inhales the medication.
c. The patient attaches a spacer to the Diskus.
d. The patient performs huff coughing after inhalation.
Correct Answer
b. The patient rapidly inhales the medication.
The patient should inhale the medication rapidly. Otherwise the dry particles will
stick to the tongue and oral mucosa and not get inhaled into the lungs. Advair
Diskus is a dry powder inhaler; shaking is not recommended. Spacers are not used
with dry powder inhalers. Huff coughing is a technique to move mucus into larger
airways to expectorate. The patient should not huff cough or exhale forcefully after
taking Advair in order to keep the medication in the lungs.
Question 3
Which action by a new nurse who is giving fondaparinux (Arixtra) to a patient with a
lower leg venous thromboembolism (VTE) indicates that more education about the
drug is needed?
a. The nurse avoids rubbing the injection site after giving the drug.
b. The nurse injects the drug into the abdominal subcutaneous tissue.
c. The nurse ejects the air bubble from the syringe before giving the drug.
d. The nurse does not check partial thromboplastin time (PTT) before giving the drug
Correct Answer
c. The nurse ejects the air bubble from the syringe before giving the drug.
The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The
other actions by the nurse are appropriate for subcutaneous administration of a low
molecular weight heparin (LMWH). LMWHs typically do not require ongoing PTT
monitoring and dose adjustment.
Page 2 of 31
,Question 4
Which patient statement to the nurse is most consistent with the diagnosis of venous
insufficiency?
a. "I can't get my shoes on at the end of the day."
b. "I can't ever seem to get my feet warm enough."
c. "I have burning leg pains after I walk two blocks."
d. "I wake up during the night because my legs hurt."
Correct Answer
a. "I can't get my shoes on at the end of the day."
Because the edema associated with venous insufficiency increases when the patient
has been standing, shoes will feel tighter at the end of the day. The other patient
statements are characteristic of peripheral artery disease.
Question 5
An older patient with a history of an abdominal aortic aneurysm arrives at the
emergency department (ED) with severe back pain and absent pedal pulses. Which
action should the
nurse take first?
a. Check the blood pressure.
b. Draw blood for laboratory testing.
c. Assess for the presence of an abdominal bruit.
d. Determine any family history of heart disease
Correct Answer
a. Check the blood pressure.
Because the patient appears to be experiencing aortic dissection, the nurse's first
action should be to determine the hemodynamic status by assessing blood
pressure. The other actions may also be done, but they will not provide information
to determine what interventions are needed immediately.
Page 3 of 31
, Question 6
The nurse is caring for a patient with a descending aortic dissection. Which
assessment finding is most important to report to the health care provider?
a. Weak pedal pulses
b. Absent bowel sounds
c. Blood pressure of 138/88 mm Hg
d. 25 mL of urine output over the past hour
Correct Answer
c. Blood pressure of 138/88 mm Hg
The blood pressure is typically kept at less than 120 mm Hg systolic to minimize
extension of the dissection. The nurse will need to notify the health care provider so
that b-blockers or other antihypertensive drugs can be prescribed. The other
findings are typical with aortic dissection and should also be reported but do not
require immediate action.
Question 7
After the nurse teaches the patient with stage 1 hypertension about diet
modifications that should be implemented, which diet choice indicates that the
teaching has been most effective?
a. The patient avoids eating nuts or nut butters.
b. The patient restricts intake of chicken and fish.
c. The patient drinks low-fat milk with each meal.
d. The patient has two cups of coffee in the morning.
Correct Answer
c. The patient drinks low-fat milk with each meal.
For the prevention of hypertension, the Dietary Approaches to Stop Hypertension
(DASH) recommendations include increasing the intake of calcium-rich foods.
Caffeine restriction and decreased protein intake are not included in the
recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly
are recommended in the DASH diet.
Page 4 of 31
Answers
Question 1
Which action will be included in the plan of care when the nurse is caring for a patient
who is receiving nicardipine (Cardene) to treat a hypertensive emergency?
a. Organize nursing activities so that the patient has undisturbed sleep for 8 hours at
night.
b. Keep the patient NPO to prevent aspiration caused by nausea and possible
vomiting.
c. Assist the patient up in the chair for meals to avoid complications associated with
immobility.
d. Use an automated noninvasive blood pressure machine to obtain frequent
measurements.
Correct Answer
d. Use an automated noninvasive blood pressure machine to obtain frequent
measurements.
frequent monitoring of BP is needed when the patient is receiving rapid-acting IV
antihypertensive medications. This can be most easily accomplished with an
automated BP machine or arterial line. The patient will require frequent
assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When
patients are receiving IV vasodilators, bed rest is maintained to prevent decreased
cerebral perfusion and fainting. There is no indication that this patient is nauseated
or at risk for aspiration, so an NPO status is unnecessary
Page 1 of 31
,Question 2
The nurse teaches a patient with chronic bronchitis about a new prescription for
Advair Diskus (combined fluticasone and salmeterol). Which action by the patient
would indicate to the nurse that teaching about medication administration has been
successful?
a. The patient shakes the device before use.
b. The patient rapidly inhales the medication.
c. The patient attaches a spacer to the Diskus.
d. The patient performs huff coughing after inhalation.
Correct Answer
b. The patient rapidly inhales the medication.
The patient should inhale the medication rapidly. Otherwise the dry particles will
stick to the tongue and oral mucosa and not get inhaled into the lungs. Advair
Diskus is a dry powder inhaler; shaking is not recommended. Spacers are not used
with dry powder inhalers. Huff coughing is a technique to move mucus into larger
airways to expectorate. The patient should not huff cough or exhale forcefully after
taking Advair in order to keep the medication in the lungs.
Question 3
Which action by a new nurse who is giving fondaparinux (Arixtra) to a patient with a
lower leg venous thromboembolism (VTE) indicates that more education about the
drug is needed?
a. The nurse avoids rubbing the injection site after giving the drug.
b. The nurse injects the drug into the abdominal subcutaneous tissue.
c. The nurse ejects the air bubble from the syringe before giving the drug.
d. The nurse does not check partial thromboplastin time (PTT) before giving the drug
Correct Answer
c. The nurse ejects the air bubble from the syringe before giving the drug.
The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The
other actions by the nurse are appropriate for subcutaneous administration of a low
molecular weight heparin (LMWH). LMWHs typically do not require ongoing PTT
monitoring and dose adjustment.
Page 2 of 31
,Question 4
Which patient statement to the nurse is most consistent with the diagnosis of venous
insufficiency?
a. "I can't get my shoes on at the end of the day."
b. "I can't ever seem to get my feet warm enough."
c. "I have burning leg pains after I walk two blocks."
d. "I wake up during the night because my legs hurt."
Correct Answer
a. "I can't get my shoes on at the end of the day."
Because the edema associated with venous insufficiency increases when the patient
has been standing, shoes will feel tighter at the end of the day. The other patient
statements are characteristic of peripheral artery disease.
Question 5
An older patient with a history of an abdominal aortic aneurysm arrives at the
emergency department (ED) with severe back pain and absent pedal pulses. Which
action should the
nurse take first?
a. Check the blood pressure.
b. Draw blood for laboratory testing.
c. Assess for the presence of an abdominal bruit.
d. Determine any family history of heart disease
Correct Answer
a. Check the blood pressure.
Because the patient appears to be experiencing aortic dissection, the nurse's first
action should be to determine the hemodynamic status by assessing blood
pressure. The other actions may also be done, but they will not provide information
to determine what interventions are needed immediately.
Page 3 of 31
, Question 6
The nurse is caring for a patient with a descending aortic dissection. Which
assessment finding is most important to report to the health care provider?
a. Weak pedal pulses
b. Absent bowel sounds
c. Blood pressure of 138/88 mm Hg
d. 25 mL of urine output over the past hour
Correct Answer
c. Blood pressure of 138/88 mm Hg
The blood pressure is typically kept at less than 120 mm Hg systolic to minimize
extension of the dissection. The nurse will need to notify the health care provider so
that b-blockers or other antihypertensive drugs can be prescribed. The other
findings are typical with aortic dissection and should also be reported but do not
require immediate action.
Question 7
After the nurse teaches the patient with stage 1 hypertension about diet
modifications that should be implemented, which diet choice indicates that the
teaching has been most effective?
a. The patient avoids eating nuts or nut butters.
b. The patient restricts intake of chicken and fish.
c. The patient drinks low-fat milk with each meal.
d. The patient has two cups of coffee in the morning.
Correct Answer
c. The patient drinks low-fat milk with each meal.
For the prevention of hypertension, the Dietary Approaches to Stop Hypertension
(DASH) recommendations include increasing the intake of calcium-rich foods.
Caffeine restriction and decreased protein intake are not included in the
recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly
are recommended in the DASH diet.
Page 4 of 31
