Version 17 ) 2022 Questions and Verified
Answers
Question 1 hg
A nurse is caring for a client who is 12 hours postoperative following a colon resection. Which
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of the following findings should the nurse report to the surgeon?
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A) Heart rate 90/min
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B) Hemoglobin 8.2 g/dL
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C) Gastric pH of 3.0
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D) Absent bowel sounds
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Correct Answer: B hg hg
Rationale: Normal hemoglobin levels are approximately 13-18 g/dL for males and 12-
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16 g/dL for females. A level of 8.2 g/dL is significantly low and may indicate postoperative hem
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orrhage, which requires immediate reporting to the surgeon .
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Question 2 hg
A client is using a morphine PCA pump postoperatively. The nurse notes the client is drowsy wi
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th a respiratory rate of 8 breaths/min. What is the nurse's priority action?
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A) Encourage deep breathing and coughing
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B) Administer naloxone immediately
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C) Notify the provider and prepare to reduce PCA dose
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D) Increase oxygen flow rate to 10 L/min
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Correct Answer: C hg hg
Rationale: Respiratory depression with sedation requires dose adjustment and close monitorin
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g before naloxone administration. The priority is to notify the provider and adjust the PCA setti
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ngs to prevent further sedation while maintaining adequate pain control .
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Question 3 hg
Which findings will alert the nurse that stress is present when making a clinical decision? (Selec
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t all that apply.)
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,A) Tense muscles
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B) Reactive responses
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C) Trouble concentrating
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D) Very tired feelings
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E) Managed emotions
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Correct Answers: A, B, C, D
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Rationale: Learn to recognize when you are feeling stressed—
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your muscles will tense, you become reactive when others communicate with you, you have tro
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uble concentrating, and you feel very tired. Emotions are not managed when stressed .
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Question 4 hg
A client has a new diagnosis of tuberculosis (TB). The client asks the nurse why she needs to ta
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ke four different antituberculosis medications. Which reply should the nurse make?
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A) "The organism that causes TB becomes resistant to antituberculosis medications when you o
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nly take one medication."
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B) "People who have a severe form of TB need several antituberculosis medications, but those
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who have less severe TB need just one medication."
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C) "Adverse effects occur more often and are more severe when you take only one antitubercul
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osis medication."
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D) "Taking several antituberculosis medications will protect your liver from toxic effects."
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Correct Answer: A hg hg
Rationale: The nurse should reply that the organism that causes TB becomes resistant to antit
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uberculosis medications when you only take one medication. TB is caused by a slow-
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growing bacteria that can develop resistance to single drugs. Therefore, a combination of drug
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s is needed to prevent or treat drug-resistant TB .
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Question 5 hg
A client is receiving IV heparin. Which laboratory test is used to monitor heparin therapy?
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A) PT/INR
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B) aPTT
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C) Platelet count
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D) Hemoglobin A1c
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Correct Answer: B hg hg
, Rationale: Activated partial thromboplastin time (aPTT) monitors unfractionated heparin therap
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y. Therapeutic range is typically 1.5-2.5 times normal (60-
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80 seconds). PT/INR monitors warfarin therapy .
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Question 6 hg
A nurse is caring for a client who is 2 hours postoperative following a cardiac catheterization vi
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a the femoral artery. Which of the following actions should the nurse take?
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A) Keep the affected leg flexed
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B) Maintain the client on bed rest for 24 hours
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C) Elevate the head of the bed to 45 degrees
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D) Monitor the insertion site for bleeding
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Correct Answer: D hg hg
Rationale: The nurse should monitor the insertion site for bleeding, hematoma formation, or p
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seudoaneurysm. The affected leg should be kept straight (not flexed), bed rest duration is typic
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ally 4-6 hours (not 24), and head of bed elevation is usually limited to 30 degrees .
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Question 7 hg
A nurse is reinforcing teaching with a client who is visually impaired about home safety measur
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es. Which instruction should the nurse include?
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A) Use low-wattage light bulbs
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B) Mark the edges of steps
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C) Leave doors slightly ajar
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D) Place throw rugs over electrical cords
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Correct Answer: B hg hg
Rationale: Marking the edges of steps helps clients with visual impairment identify potential tri
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pping hazards and navigate stairs safely .
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Question 8 hg
A client is receiving IV vancomycin and reports itching and redness on the upper chest during i
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nfusion. Vital signs are stable. What should the nurse do?
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A) Stop the infusion immediately and notify the provider
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B) Slow the infusion rate and monitor closely
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