ANCC Medical-Surgical Nursing Certification
Questions and Answers| Latest Update
,1. A nurse is caring for a client with acute ST-elevation myocardial infarction
(STEMI). Which action is the priority?
A. Obtain a 12-lead ECG and prepare for reperfusion therapy
B. Administer a stool softener
C. Teach the client about cardiac rehabilitation
D. Schedule an echocardiogram for the next morning
Answer: A
Rationale: Time is muscle in STEMI. The priority is rapid ECG confirmation and
initiation of reperfusion therapy (PCI or fibrinolytics) within the recommended
door-to-balloon time of 90 minutes. The other actions are appropriate later in the
plan of care but do not address the immediate need to restore coronary blood
flow.
2. A client with heart failure has a new order for spironolactone. Which
laboratory value requires the nurse to notify the provider before administering
the drug?
A. Potassium 6.1 mEq/L
B. Sodium 138 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mEq/L
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic. A potassium level of 6.1
mEq/L indicates hyperkalemia, and administering spironolactone would worsen
this dangerous electrolyte imbalance, risking life-threatening dysrhythmias. The
provider should be notified before giving the dose.
3. Which finding in a client with cardiac tamponade would the nurse expect?
A. Widened pulse pressure
B. Muffled heart sounds, jugular venous distention, and hypotension
C. Bradycardia with bounding pulses
D. Hyperresonant lung sounds
Answer: B
,Rationale: Beck's triad—muffled/distant heart sounds, jugular venous distention,
and hypotension—is the classic presentation of cardiac tamponade caused by fluid
accumulation in the pericardial sac compressing the heart and impairing filling
and cardiac output.
4. A client is receiving intravenous heparin for a deep vein thrombosis. Which
laboratory test is used to monitor therapeutic effect?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count only
D. D-dimer
Answer: B
Rationale: aPTT monitors the effectiveness and safety of unfractionated heparin
therapy. The therapeutic range is typically 1.5 to 2.5 times the control value.
PT/INR is used to monitor warfarin, not heparin.
5. The nurse auscultates a new S3 heart sound in a client with heart failure.
What does this finding indicate?
A. Normal finding in all adults
B. Ventricular filling into a noncompliant or volume-overloaded ventricle
C. Mitral valve stenosis only
D. Pericardial friction rub
Answer: B
Rationale: An S3 (ventricular gallop) occurs during rapid ventricular filling and is a
classic sign of fluid overload or decreased ventricular compliance, commonly
heard in heart failure. It is considered a normal variant only in children and young
adults, not in older adults with cardiac disease.
6. A client post cardiac catheterization via the right femoral artery reports
numbness and coolness in the right foot. What is the nurse's priority action?
A. Elevate the leg and apply a warm blanket
B. Assess pedal pulses and notify the provider immediately
C. Document the finding and reassess in 4 hours
, D. Encourage ambulation to improve circulation
Answer: B
Rationale: Numbness, coolness, and pallor distal to a femoral arterial access site
suggest arterial occlusion or hematoma compromising blood flow. The nurse must
assess distal pulses immediately and notify the provider, as this is a limb-
threatening emergency requiring prompt intervention.
7. Which teaching point is most important for a client newly prescribed warfarin?
A. Increase intake of green leafy vegetables daily
B. Maintain consistent vitamin K intake and report unusual bleeding
C. Warfarin has no interactions with other medications
D. Stop the medication if a dose is missed and double the next dose
Answer: B
Rationale: Vitamin K antagonizes warfarin's effect, so clients should maintain
consistent (not necessarily reduced) intake to keep the INR stable. Clients must
also be taught to report signs of bleeding, such as bruising, blood in stool, or
bleeding gums, and to have regular INR monitoring.
8. A client in hypertensive crisis is started on an intravenous nitroprusside
infusion. What is the priority nursing action?
A. Administer the infusion via gravity drip
B. Continuously monitor blood pressure via arterial line or frequent cuff checks
C. Withhold all other antihypertensives permanently
D. Position the client supine with legs elevated
Answer: B
Rationale: Nitroprusside is a potent, rapid-acting vasodilator that can cause
profound hypotension. It must be given via infusion pump with continuous or very
frequent blood pressure monitoring, ideally through an arterial line, to titrate the
dose safely and avoid dangerous drops in pressure.
9. Which client is at greatest risk for developing an abdominal aortic aneurysm
(AAA)?
A. A 25-year-old female with no risk factors
Questions and Answers| Latest Update
,1. A nurse is caring for a client with acute ST-elevation myocardial infarction
(STEMI). Which action is the priority?
A. Obtain a 12-lead ECG and prepare for reperfusion therapy
B. Administer a stool softener
C. Teach the client about cardiac rehabilitation
D. Schedule an echocardiogram for the next morning
Answer: A
Rationale: Time is muscle in STEMI. The priority is rapid ECG confirmation and
initiation of reperfusion therapy (PCI or fibrinolytics) within the recommended
door-to-balloon time of 90 minutes. The other actions are appropriate later in the
plan of care but do not address the immediate need to restore coronary blood
flow.
2. A client with heart failure has a new order for spironolactone. Which
laboratory value requires the nurse to notify the provider before administering
the drug?
A. Potassium 6.1 mEq/L
B. Sodium 138 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mEq/L
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic. A potassium level of 6.1
mEq/L indicates hyperkalemia, and administering spironolactone would worsen
this dangerous electrolyte imbalance, risking life-threatening dysrhythmias. The
provider should be notified before giving the dose.
3. Which finding in a client with cardiac tamponade would the nurse expect?
A. Widened pulse pressure
B. Muffled heart sounds, jugular venous distention, and hypotension
C. Bradycardia with bounding pulses
D. Hyperresonant lung sounds
Answer: B
,Rationale: Beck's triad—muffled/distant heart sounds, jugular venous distention,
and hypotension—is the classic presentation of cardiac tamponade caused by fluid
accumulation in the pericardial sac compressing the heart and impairing filling
and cardiac output.
4. A client is receiving intravenous heparin for a deep vein thrombosis. Which
laboratory test is used to monitor therapeutic effect?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count only
D. D-dimer
Answer: B
Rationale: aPTT monitors the effectiveness and safety of unfractionated heparin
therapy. The therapeutic range is typically 1.5 to 2.5 times the control value.
PT/INR is used to monitor warfarin, not heparin.
5. The nurse auscultates a new S3 heart sound in a client with heart failure.
What does this finding indicate?
A. Normal finding in all adults
B. Ventricular filling into a noncompliant or volume-overloaded ventricle
C. Mitral valve stenosis only
D. Pericardial friction rub
Answer: B
Rationale: An S3 (ventricular gallop) occurs during rapid ventricular filling and is a
classic sign of fluid overload or decreased ventricular compliance, commonly
heard in heart failure. It is considered a normal variant only in children and young
adults, not in older adults with cardiac disease.
6. A client post cardiac catheterization via the right femoral artery reports
numbness and coolness in the right foot. What is the nurse's priority action?
A. Elevate the leg and apply a warm blanket
B. Assess pedal pulses and notify the provider immediately
C. Document the finding and reassess in 4 hours
, D. Encourage ambulation to improve circulation
Answer: B
Rationale: Numbness, coolness, and pallor distal to a femoral arterial access site
suggest arterial occlusion or hematoma compromising blood flow. The nurse must
assess distal pulses immediately and notify the provider, as this is a limb-
threatening emergency requiring prompt intervention.
7. Which teaching point is most important for a client newly prescribed warfarin?
A. Increase intake of green leafy vegetables daily
B. Maintain consistent vitamin K intake and report unusual bleeding
C. Warfarin has no interactions with other medications
D. Stop the medication if a dose is missed and double the next dose
Answer: B
Rationale: Vitamin K antagonizes warfarin's effect, so clients should maintain
consistent (not necessarily reduced) intake to keep the INR stable. Clients must
also be taught to report signs of bleeding, such as bruising, blood in stool, or
bleeding gums, and to have regular INR monitoring.
8. A client in hypertensive crisis is started on an intravenous nitroprusside
infusion. What is the priority nursing action?
A. Administer the infusion via gravity drip
B. Continuously monitor blood pressure via arterial line or frequent cuff checks
C. Withhold all other antihypertensives permanently
D. Position the client supine with legs elevated
Answer: B
Rationale: Nitroprusside is a potent, rapid-acting vasodilator that can cause
profound hypotension. It must be given via infusion pump with continuous or very
frequent blood pressure monitoring, ideally through an arterial line, to titrate the
dose safely and avoid dangerous drops in pressure.
9. Which client is at greatest risk for developing an abdominal aortic aneurysm
(AAA)?
A. A 25-year-old female with no risk factors
