CertifiedvnMedical-SurgicalvnRegisteredvnNursevn2025vnSamplevnQuestions
ThevnnursevnreceivesvnallvnofvnthevnfollowingvnstatvnordersvnforvnMr.vnPalmer.vnWhichvno
nevnshouldvnthevnnursevnquestion?
1)vnOxygenvnpervnnasalvncannulavnatvn4vnLvnpervnminute.
2)vnEnoxaparinvn(Lovenox)vn40vnmgvnsubcutaneously.
3)vnTroponinvnlevel.
4)vnComputedvntomographyvn(CT)vnangiogram.vn-vncorrectvnanswer✔ ✔
Rationale:vnThevnnursevnshouldvnquestionsvnthevnordervnforvnLovenoxvnbecausevnthevn
patientvnisvnreceivingvnavnheparinvndrip.
ChristinevnWarren,vn45vnyearsvnold,vnhasvnavnlongvnhistoryvnofvnulcerativevncolitis,vnandvn
non-
surgicalvntreatmentvnnovnlongervnrelievedvnhervnsymptoms.vnShevnunderwentvnavntotalvnp
roctocolectomyvnandvnavnpermanentvnileostomyvn12vnhoursvnago.
ThevnnursevnshouldvncontactvnthevnphysicianvnimmediatelyvnifvnMrs.vnWarrenvnhasvnwhi
chvnofvnthesevnfindings?
1)vnThevnstomavnappearsvnpalevnandvndry.
2)vnThevnstomavnappearsvnredvnandvnshiny.
3)vnTherevnisvn200vnmLvnofvndarkvngreenvnoutputvnfromvnthevnstoma.
4)vnTherevnisvn50vnmLvnofvnserosanguinousvndrainagevnfromvnthevnstoma.vn-
vncorrectvnanswer✔ ✔ 1)vnThevnstomavnappearsvnpalevnandvndry.
Rationale:vnIfvntherevnisvnanvnadequatevnbloodvnsupplyvntovnthevnstoma,vnthevncolorvnisvnpi
nkvnorvnred,vnandvnthevnstomavnisvnmoistvnasvnavnresultvnofvnmucousvnproduction.vnAvnpale
, dryvncolorvnsuggestsvnischemiavnofvnthevnstomavnorvnbowelvnandvnmustvnbevnreportedvni
vn
mmediatelyvntovnthevnphysician.vnWithvnanvnileostomyvninitiallyvnaftervnsurgery,vnthevno
utputvnisvnavnloose,vndarkvngreenvnliquidvnthatvnmayvncontainvnsomevnblood.vnThevnileosto
myvnusuallyvnbeginsvntovndrainvnwithinvn24vnofvnsurgeryvnatvnmorevnthanvnonevnlitervnpervn
day.
WhenvnchangingvnMrs.vnWarren'svnileostomyvnbag,vnthevnnursevnnoticesvnthatvnthevnperi
stomalvnskinvnisvnirritated.vn
Whichvnofvnthesevnactionsvnbyvnthevnnursevnwouldvnbevnappropriatevnbeforevnreapplyingv
nthevnappliance?
1)vnWashvnthevnareavnwithvnantisepticvnsoapvnandvnwater.
2)vnCleanvnthevnsitevnwithvnDakin'svnsolution.
3)vnUsevnavnsolidvnskinvnbarrier.
4)vnObtainvnanvnordervnforvnavntopicalvnantibiotic.vn-vncorrectvnanswer✔ ✔
3)vnUsevnavnsolidvnskinvnbarrier.
Rationale:vnThevndrainagevnfromvnthevnstomavncanvnquicklyvnirritatevnthevnsurroundingvn
tissue.vnTherefore,vnavnsolidvnskinvnbarrier,vnwithvnavnpectinvnbasevnorvnkarayavnwafervnth
atvnhasvnavnmeasurablevnthicknessvnandvnhydrocolloidvnadhesivevnproperties,vnshouldvnb
evnapplied.
Whichvnofvnthesevncomments,vnifvnmadevnbyvnMrs.vnWarrenvnbeforevnhervnsurgery,vnwou
ldvnindicatevnthatvnshevnhadvnconcernsvnaboutvnhervnbodyvnimage?
1)vn"Ivnwillvnhavevntovnstopvnmyvnaerobicsvnclasses."
,2)vn"I'mvnsovnafraidvnIvnmayvnnotvnsurvivevnthevnsurgery."
3)vn"Ivnneedvntovngovnshoppingvnforvnsomevnloose,vnbaggyvnclothes."
4)vn"I'mvnconcernedvnthatvnthisvnmayvnbevnonlyvnthevnfirstvnofvnmanyvnsurgeries."vn-
vncorrectvnanswer✔ ✔
3)vn"Ivnneedvntovngovnshoppingvnforvnsomevnloose,vnbaggyvnclothes."
Rationale:Bodyvnimagevnrefersvntovnavnperson'svnperceptionvnofvnselfvnandvndeterminesvn
howvnthevnpersonvninteractsvnwithvnothers.vnOnevndoesvnnotvnneedvntovnpurchasevnspecial
vnclothingvnaftervnileostomyvnsurgery,vnalthoughvnsomevnminorvnadjustmentsvnmayvnbevn
neededvnforvncomfort,vne.g.,vnstretchvnunderwearvnorvnpantyhosevnforvnsupport.
TovngetvnTESTvnBANKvnforvnMedical-
SurgicalvnNursing:vnConceptsvnforvnClinicalvnJudgmentvnandvnCollaborativevnCarevn11t
hvnEditionvnbyvnDonnavnD.vnIgnatavicius,vnAllvnchaptersvn1vn-vn74
banks.vnEachvnlinkvnhasvnavndifferentvnversionsvnhttp://www.stuvia.com/doc/7290675
http://www.stuvia.com/doc/8342084
http://www.stuvia.com/doc/9267657
http://www.stuvia.com/doc/7153071
, http://www.stuvia.com/doc/7069048vn-vncorrectvnanswer✔ ✔
http://www.stuvia.com/doc/7290675
LewisvnPalmer,vn45vnyearsvnold,vnhasvnavnhistoryvnofvnmultiplevnmyocardialvninfarctionsv
nandvnisvnavnheavyvnsmoker.vnHevntakesvnwarfarinvnsodiumvn(Coumadin)vndaily.vnTwovn
weeksvnago,vnhevnhadvnavnrightvnfemoral-
poplitealvnbypass,vnwhichvnbecamevnoccludedvn24vnhoursvnago.vnHevnisvnadmittedvnfollo
wingvnanvnangioplastyvnofvnthevnfemoral-
poplitealvnbypassvngraft.vnMr.vnPalmervnisvnreceivingvncontinuousvnIVvnheparin.
BecausevnMr.vnPalmervnisvnreceivingvnheparin,vnitvnisvnessentialvnforvnthevnnursevnto
1)vnmonitorvnhisvnprothrombinvntime.
2)vnobservevnhimvnforvnsignsvnofvnpulmonaryvnembolism.
3)vnlimitvnhisvnintakevnofvnfoodsvnhighvninvnvitaminvnK.
4)vncheckvnthevnfemoralvnpuncturevnsitevnatvnfrequentvnintervals.vn-vncorrectvnanswer✔
✔ 4)vncheckvnthevnfemoralvnpuncturevnsitevnatvnfrequentvnintervals.
Rationale:vnSincevnbleedingvnisvnavncommonvnsidevneffectvnofvnheparin,vnitvnisvnvitalvntovn
checkvnthevnoperativevnsite,vnthevnfemoralvnpuncturevnarea,vnforvnsignsvnofvnbleeding.
AttemptsvntovnrevascularizevnMr.vnPalmer'svnlegvnarevnunsuccessful,vnandvnMr.vnPalmerv
nhasvnavnbelow-
kneevnamputationvn(BKA)vnofvnhisvnrightvnextremityvnandvnisvnreturnedvntovnthevnmedica
l-
surgicalvnunitvnwithvnanvnintravenousvninfusionvninvnplace.vnHisvnordersvninclude:vnhepar
invndrip,vnmorphinevnsulfatevn10vnmgvnIVvnpushvnq4hvnprnvnforvnpain,vnandvnampicillinvns
odiumvngvn1vnIVvnq6h.
Twelvevnhoursvnpostoperatively,vnMr.vnPalmervnisvnfoundvntovnbevnshortvnofvnbreathvnan
dvndiaphoretic.vnHevnsays,vn"Myvnchestvnhurts."vnHisvnpulsevnisvn140/min,vncomparedvnto
ThevnnursevnreceivesvnallvnofvnthevnfollowingvnstatvnordersvnforvnMr.vnPalmer.vnWhichvno
nevnshouldvnthevnnursevnquestion?
1)vnOxygenvnpervnnasalvncannulavnatvn4vnLvnpervnminute.
2)vnEnoxaparinvn(Lovenox)vn40vnmgvnsubcutaneously.
3)vnTroponinvnlevel.
4)vnComputedvntomographyvn(CT)vnangiogram.vn-vncorrectvnanswer✔ ✔
Rationale:vnThevnnursevnshouldvnquestionsvnthevnordervnforvnLovenoxvnbecausevnthevn
patientvnisvnreceivingvnavnheparinvndrip.
ChristinevnWarren,vn45vnyearsvnold,vnhasvnavnlongvnhistoryvnofvnulcerativevncolitis,vnandvn
non-
surgicalvntreatmentvnnovnlongervnrelievedvnhervnsymptoms.vnShevnunderwentvnavntotalvnp
roctocolectomyvnandvnavnpermanentvnileostomyvn12vnhoursvnago.
ThevnnursevnshouldvncontactvnthevnphysicianvnimmediatelyvnifvnMrs.vnWarrenvnhasvnwhi
chvnofvnthesevnfindings?
1)vnThevnstomavnappearsvnpalevnandvndry.
2)vnThevnstomavnappearsvnredvnandvnshiny.
3)vnTherevnisvn200vnmLvnofvndarkvngreenvnoutputvnfromvnthevnstoma.
4)vnTherevnisvn50vnmLvnofvnserosanguinousvndrainagevnfromvnthevnstoma.vn-
vncorrectvnanswer✔ ✔ 1)vnThevnstomavnappearsvnpalevnandvndry.
Rationale:vnIfvntherevnisvnanvnadequatevnbloodvnsupplyvntovnthevnstoma,vnthevncolorvnisvnpi
nkvnorvnred,vnandvnthevnstomavnisvnmoistvnasvnavnresultvnofvnmucousvnproduction.vnAvnpale
, dryvncolorvnsuggestsvnischemiavnofvnthevnstomavnorvnbowelvnandvnmustvnbevnreportedvni
vn
mmediatelyvntovnthevnphysician.vnWithvnanvnileostomyvninitiallyvnaftervnsurgery,vnthevno
utputvnisvnavnloose,vndarkvngreenvnliquidvnthatvnmayvncontainvnsomevnblood.vnThevnileosto
myvnusuallyvnbeginsvntovndrainvnwithinvn24vnofvnsurgeryvnatvnmorevnthanvnonevnlitervnpervn
day.
WhenvnchangingvnMrs.vnWarren'svnileostomyvnbag,vnthevnnursevnnoticesvnthatvnthevnperi
stomalvnskinvnisvnirritated.vn
Whichvnofvnthesevnactionsvnbyvnthevnnursevnwouldvnbevnappropriatevnbeforevnreapplyingv
nthevnappliance?
1)vnWashvnthevnareavnwithvnantisepticvnsoapvnandvnwater.
2)vnCleanvnthevnsitevnwithvnDakin'svnsolution.
3)vnUsevnavnsolidvnskinvnbarrier.
4)vnObtainvnanvnordervnforvnavntopicalvnantibiotic.vn-vncorrectvnanswer✔ ✔
3)vnUsevnavnsolidvnskinvnbarrier.
Rationale:vnThevndrainagevnfromvnthevnstomavncanvnquicklyvnirritatevnthevnsurroundingvn
tissue.vnTherefore,vnavnsolidvnskinvnbarrier,vnwithvnavnpectinvnbasevnorvnkarayavnwafervnth
atvnhasvnavnmeasurablevnthicknessvnandvnhydrocolloidvnadhesivevnproperties,vnshouldvnb
evnapplied.
Whichvnofvnthesevncomments,vnifvnmadevnbyvnMrs.vnWarrenvnbeforevnhervnsurgery,vnwou
ldvnindicatevnthatvnshevnhadvnconcernsvnaboutvnhervnbodyvnimage?
1)vn"Ivnwillvnhavevntovnstopvnmyvnaerobicsvnclasses."
,2)vn"I'mvnsovnafraidvnIvnmayvnnotvnsurvivevnthevnsurgery."
3)vn"Ivnneedvntovngovnshoppingvnforvnsomevnloose,vnbaggyvnclothes."
4)vn"I'mvnconcernedvnthatvnthisvnmayvnbevnonlyvnthevnfirstvnofvnmanyvnsurgeries."vn-
vncorrectvnanswer✔ ✔
3)vn"Ivnneedvntovngovnshoppingvnforvnsomevnloose,vnbaggyvnclothes."
Rationale:Bodyvnimagevnrefersvntovnavnperson'svnperceptionvnofvnselfvnandvndeterminesvn
howvnthevnpersonvninteractsvnwithvnothers.vnOnevndoesvnnotvnneedvntovnpurchasevnspecial
vnclothingvnaftervnileostomyvnsurgery,vnalthoughvnsomevnminorvnadjustmentsvnmayvnbevn
neededvnforvncomfort,vne.g.,vnstretchvnunderwearvnorvnpantyhosevnforvnsupport.
TovngetvnTESTvnBANKvnforvnMedical-
SurgicalvnNursing:vnConceptsvnforvnClinicalvnJudgmentvnandvnCollaborativevnCarevn11t
hvnEditionvnbyvnDonnavnD.vnIgnatavicius,vnAllvnchaptersvn1vn-vn74
banks.vnEachvnlinkvnhasvnavndifferentvnversionsvnhttp://www.stuvia.com/doc/7290675
http://www.stuvia.com/doc/8342084
http://www.stuvia.com/doc/9267657
http://www.stuvia.com/doc/7153071
, http://www.stuvia.com/doc/7069048vn-vncorrectvnanswer✔ ✔
http://www.stuvia.com/doc/7290675
LewisvnPalmer,vn45vnyearsvnold,vnhasvnavnhistoryvnofvnmultiplevnmyocardialvninfarctionsv
nandvnisvnavnheavyvnsmoker.vnHevntakesvnwarfarinvnsodiumvn(Coumadin)vndaily.vnTwovn
weeksvnago,vnhevnhadvnavnrightvnfemoral-
poplitealvnbypass,vnwhichvnbecamevnoccludedvn24vnhoursvnago.vnHevnisvnadmittedvnfollo
wingvnanvnangioplastyvnofvnthevnfemoral-
poplitealvnbypassvngraft.vnMr.vnPalmervnisvnreceivingvncontinuousvnIVvnheparin.
BecausevnMr.vnPalmervnisvnreceivingvnheparin,vnitvnisvnessentialvnforvnthevnnursevnto
1)vnmonitorvnhisvnprothrombinvntime.
2)vnobservevnhimvnforvnsignsvnofvnpulmonaryvnembolism.
3)vnlimitvnhisvnintakevnofvnfoodsvnhighvninvnvitaminvnK.
4)vncheckvnthevnfemoralvnpuncturevnsitevnatvnfrequentvnintervals.vn-vncorrectvnanswer✔
✔ 4)vncheckvnthevnfemoralvnpuncturevnsitevnatvnfrequentvnintervals.
Rationale:vnSincevnbleedingvnisvnavncommonvnsidevneffectvnofvnheparin,vnitvnisvnvitalvntovn
checkvnthevnoperativevnsite,vnthevnfemoralvnpuncturevnarea,vnforvnsignsvnofvnbleeding.
AttemptsvntovnrevascularizevnMr.vnPalmer'svnlegvnarevnunsuccessful,vnandvnMr.vnPalmerv
nhasvnavnbelow-
kneevnamputationvn(BKA)vnofvnhisvnrightvnextremityvnandvnisvnreturnedvntovnthevnmedica
l-
surgicalvnunitvnwithvnanvnintravenousvninfusionvninvnplace.vnHisvnordersvninclude:vnhepar
invndrip,vnmorphinevnsulfatevn10vnmgvnIVvnpushvnq4hvnprnvnforvnpain,vnandvnampicillinvns
odiumvngvn1vnIVvnq6h.
Twelvevnhoursvnpostoperatively,vnMr.vnPalmervnisvnfoundvntovnbevnshortvnofvnbreathvnan
dvndiaphoretic.vnHevnsays,vn"Myvnchestvnhurts."vnHisvnpulsevnisvn140/min,vncomparedvnto
