Exam Practice Questions and Answers 100% Pass
A nurse is caring for a client following insertion of a permanent pacemaker. Which of
the following client statements indicates a potential complication of the insertion
procedure?
A. "I can't get rid of these hiccups."
b. "I feel dizzy when I stand."
c. "My incision site stings."
d. "I have a headache." - ANSWER✔✔-A. "I can't get rid of these hiccups."
Rationale: Hiccups can indicate that the pacemaker is stimulating the chest wall or
diaphragm, which can occur as a result of a lead wire perforation.
A nurse is caring for a client who has a history of DVT and is receiving warfarin. Which
of the following client findings provides the nurse with the best evidence regarding the
effectiveness of the warfarin therapy?
A. Hemoglobin 14 g/dl
B. Minimal bruising of extremities
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,C. Decreased Blood pressure
D. INR 2.0 - ANSWER✔✔-D. INR 2.0
Rationale: The nurse should identify that an INR of 2.0 is within the desired reference
range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin
to reduce the risk of new clot formation and a stroke.
A nurse in the emergency department is caring for a client who had an anterior MI. The
client's history reveals she is 1 week post-op open cholecystectomy. The nurse should
recognize that which of the following interventions is contraindicated?
A. Administering IV morphine sulfate
B. Administering oxygen at 2:/min via nasal cannula
C. Helping the client to the bedside commode
D. Assisting with thrombolytic therapy - ANSWER✔✔-D. Assisting with thrombolytic
therapy
Rationale: The nurse should recognize that major surgery within the previous 3 weeks
is a contraindication for thrombolytic therapy.
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, A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr.
Which of the following client statements indicates a need for further clarification by the
nurse?
A. "My arthritis is really bothering me because I haven't taken my aspiring in a week."
b. "My blood pressure shouldn't be high because I took my BP medication this
morning."
c. "I took my warfarin last night according to my usually schedule."
d. "I will check my BP because I took a reduced dose of insulin this morning." -
ANSWER✔✔-C: "I took my warfarin last night according to my usually schedule."
Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such
as warfarin, for several days prior to the surgery to prevent excessive bleeding.
A nurse is preparing a client for coronary angiography. The nurse should report which
of the following findings to the provider prior to the procedure?
A. Hemoglobin 14.4 g/dl
b. History of peripheral arterial disease.
c. Urine output 200 ml/4 hr.
D. Previous allergic reaction to shellfish - ANSWER✔✔-D. Previous allergic reaction to
shellfish
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