Med-Surg I; Unit 4 Exam Questions
and Correct Answers
After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the
emergency department, the nurse will anticipate that the patient may require? - <CORRECT
ANSWER >>Electrocardiographic (ECG) monitoring
When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79 year old patient who is
having an annual physical examination, what will be of most concern to the nurse? - <CORRECT
ANSWER >>The heart rate is 42 beats/minute
During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal
impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most
appropriate action for the nurse to take next will be to: - <CORRECT ANSWER >>Assess the
patient for symptoms of left ventricular hypertrophy
To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the: - <CORRECT
ANSWER >>Bell of the stethoscope with the patient in the left lateral position
To determine the effects of therapy for a patient who is being treated for heart failure, which
laboratory result will the nurse plan to review? - <CORRECT ANSWER >>B-type natriuretic
peptide (BNP)
While doing the admission assessment for a thin 76-year-old patient, the nurse observes
pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take? -
<CORRECT ANSWER >>Document the finding in the patient chart
A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test,
the nurse informs the patient that: - <CORRECT ANSWER >>A flushed feeling may be noted
when the contrast dye is injected
,While assessing a patient who was admitted with heart failure, the nurse notes that the patient
has jugular vein distention (JVD) when lying flat in bed. Which action should the nurse take
next? - <CORRECT ANSWER >>Observe for JVD with the patient upright at 45 degrees
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor
to: - <CORRECT ANSWER >>Keep a diary of daily activities while the monitor is worn
When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The
nurse documents this finding as: - <CORRECT ANSWER >>Bruit
The nurse has received the laboratory results for a patient who developed chest pain 4 hours
ago and may be having a myocardial infarction. The most important laboratory test result to
review will be: - <CORRECT ANSWER >>Troponins T and I
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal
border. To document more information about the murmur, which action will the nurse take
next? - <CORRECT ANSWER >>Determine the timing of the murmur
The nurse hears a murmur between the S1 and S2 heart sounds at the patients left fifth
intercostal space and midclavicular line. How will the nurse record this information? -
<CORRECT ANSWER >>Systolic murmur heard at mitral area
A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a
patient. The RN will need to intervene immediately if the student nurse: - <CORRECT ANSWER
>>Palpates both carotid arteries simultaneously to compare pulse quality
Which action will the nurse implement for a patient who arrives for a calcium- scoring CT scan?
- <CORRECT ANSWER >>Teach the patent about the procedure
Which information obtained by the nurse who is admitting the patient for magnetic resonance
imaging (MRI) will be most important to report to the health care provider before the MRI? -
<CORRECT ANSWER >>The patient has a permanent ventricular pacemaker
, When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a
treadmill, which assessment finding requires the most rapid action by the nurse? - <CORRECT
ANSWER >>Newly inverted T waves on the electrocardiogram
The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial
pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about
the: - <CORRECT ANSWER >>Postoperative patient with a BP of 116/42
When admitting a patient for cardiac catheterization and coronary angiogram, which
information about the patient is most important for the nurse to communicate to the health
care provider? - <CORRECT ANSWER >>The patient is allergic to shellfish
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis.
Which action included in the standard TEE orders will the nurse need to accomplish first? -
<CORRECT ANSWER >>Place the patient on NPO status
The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four
patients. Which nursing action can be delegated to the UAP? - <CORRECT ANSWER >>Placing
electrodes in the correct position for a patient who is to receive ECG monitoring
The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular
unit. Which patient laboratory result is most important to communicate as soon as possible to
the health care provider? - <CORRECT ANSWER >>Patient with increase in Troponin T and
Troponin I level
When the nurse is screening patients for possible peripheral arterial disease, indicate where the
posterior tibial artery will be palpated - <CORRECT ANSWER >>3
Posterior tibial site is located behind the medial malleolus of the tibia
and Correct Answers
After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the
emergency department, the nurse will anticipate that the patient may require? - <CORRECT
ANSWER >>Electrocardiographic (ECG) monitoring
When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79 year old patient who is
having an annual physical examination, what will be of most concern to the nurse? - <CORRECT
ANSWER >>The heart rate is 42 beats/minute
During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal
impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most
appropriate action for the nurse to take next will be to: - <CORRECT ANSWER >>Assess the
patient for symptoms of left ventricular hypertrophy
To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the: - <CORRECT
ANSWER >>Bell of the stethoscope with the patient in the left lateral position
To determine the effects of therapy for a patient who is being treated for heart failure, which
laboratory result will the nurse plan to review? - <CORRECT ANSWER >>B-type natriuretic
peptide (BNP)
While doing the admission assessment for a thin 76-year-old patient, the nurse observes
pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take? -
<CORRECT ANSWER >>Document the finding in the patient chart
A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test,
the nurse informs the patient that: - <CORRECT ANSWER >>A flushed feeling may be noted
when the contrast dye is injected
,While assessing a patient who was admitted with heart failure, the nurse notes that the patient
has jugular vein distention (JVD) when lying flat in bed. Which action should the nurse take
next? - <CORRECT ANSWER >>Observe for JVD with the patient upright at 45 degrees
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor
to: - <CORRECT ANSWER >>Keep a diary of daily activities while the monitor is worn
When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The
nurse documents this finding as: - <CORRECT ANSWER >>Bruit
The nurse has received the laboratory results for a patient who developed chest pain 4 hours
ago and may be having a myocardial infarction. The most important laboratory test result to
review will be: - <CORRECT ANSWER >>Troponins T and I
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal
border. To document more information about the murmur, which action will the nurse take
next? - <CORRECT ANSWER >>Determine the timing of the murmur
The nurse hears a murmur between the S1 and S2 heart sounds at the patients left fifth
intercostal space and midclavicular line. How will the nurse record this information? -
<CORRECT ANSWER >>Systolic murmur heard at mitral area
A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a
patient. The RN will need to intervene immediately if the student nurse: - <CORRECT ANSWER
>>Palpates both carotid arteries simultaneously to compare pulse quality
Which action will the nurse implement for a patient who arrives for a calcium- scoring CT scan?
- <CORRECT ANSWER >>Teach the patent about the procedure
Which information obtained by the nurse who is admitting the patient for magnetic resonance
imaging (MRI) will be most important to report to the health care provider before the MRI? -
<CORRECT ANSWER >>The patient has a permanent ventricular pacemaker
, When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a
treadmill, which assessment finding requires the most rapid action by the nurse? - <CORRECT
ANSWER >>Newly inverted T waves on the electrocardiogram
The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial
pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about
the: - <CORRECT ANSWER >>Postoperative patient with a BP of 116/42
When admitting a patient for cardiac catheterization and coronary angiogram, which
information about the patient is most important for the nurse to communicate to the health
care provider? - <CORRECT ANSWER >>The patient is allergic to shellfish
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis.
Which action included in the standard TEE orders will the nurse need to accomplish first? -
<CORRECT ANSWER >>Place the patient on NPO status
The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four
patients. Which nursing action can be delegated to the UAP? - <CORRECT ANSWER >>Placing
electrodes in the correct position for a patient who is to receive ECG monitoring
The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular
unit. Which patient laboratory result is most important to communicate as soon as possible to
the health care provider? - <CORRECT ANSWER >>Patient with increase in Troponin T and
Troponin I level
When the nurse is screening patients for possible peripheral arterial disease, indicate where the
posterior tibial artery will be palpated - <CORRECT ANSWER >>3
Posterior tibial site is located behind the medial malleolus of the tibia
