ANCC Med-Surg Certification (2025) UPDATE
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A nurse is reviewing the d
medical record of a client
who is receiving heparin
therapy for treatment of
DVT. Which of the
following interventions
should the nurse
anticipate taking if the
client's aPTT is 96
seconds?a. Increase the
heparin infusion flow rate
by 2 mL/hr b. continue to
monitor the heparin
infusion as prescribed c.
request a prothrombin
time d. stop the heparin
infusion
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A nurse is providing a
teaching for a client who is
2 days post-op following a
heart transplant. Which of
the following statements
should the nurse include
in the teaching?a. "you
may no longer be able to
feel chest pain."b. "your
level of activity tolerance
will not change."c. "after 6
months, you will no longer
need to restrict your
sodium intake."d. "you will
be able to stop taking
immunosuppressants after
12 months."
A nurse is assess a client in a
the emergency room who
has a bradydysrhythmia.
Which of the following
findings should the nurse
expect?A. confusionB.
friction rubC.
hypertensionD. dry skin
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A nurse in the emergency d
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
sulfateB. administering
oxygen at 2 :/min via nasal
cannulaC. helping the
client to the bedside
commodeD. assisting with
thrombolytic therapy
A nurse is caring for a D
client who has
endocarditis. Which of the
following findings should
the nurse recognize as a
potential complication?A.
ventricular
depolarizationB. Guillain-
Barre syndromC.
myelodysplastic
syndromeD. Valvular
disease
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A nurse is caring for a C
client who presents to the
ER with a BP of 254/138
mmHg. The nurse
recognizes that the client
is in a hypertensive crisis.
Which of the following
actions should the nurse
take first?A. obtain blood
samples for laboratory
testingB. Tell the client to
report vision changesC.
Place the head of the bed
at 45 degreesD. initiate an
IV
a nurse is caring for a a
client who has HF and is
experiencing AF. The
nurse should plan to
monitor for and report
which of the following
findings to the provider
immediately?a. slurred
speechb. irregular pulsec.
dependent edemad.
persistent fatigue
A nurse is assessing a b
client who has left-sided
HF. Which of the following
manifestations should the
nurse expect to find?a. inc
abdominal girthb. weak
peripheral pulsesc. jugular
vein distentiond.
dependent edema
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