CMSRN ACTUAL PAPER SOLVED
QUESTIONS
◉ Christine Warren, 45 years old, has a long history of ulcerative
colitis, and non-surgical treatment no longer relieved her
symptoms. She underwent a total proctocolectomy and a
permanent ileostomy 12 hours ago.
The nurse should contact the physician immediately if Mrs.
Warren has which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma.
Answer: 1) The stoma appears pale and dry.
Rationale: If there is an adequate blood supply to the stoma, the
color is pink or red, and the stoma is moist as a result of mucous
production. A pale dry color suggests ischemia of the stoma or
bowel and must be reported immediately to the physician. With
an ileostomy initially after surgery, the output is a loose, dark
green liquid that may contain some blood. The ileostomy usually
begins to drain within 24 of surgery at more than one liter per
day.
,◉ When changing Mrs. Warren's ileostomy bag, the nurse notices
that the peristomal skin is irritated.
Which of these actions by the nurse would be appropriate before
reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic.
Answer: 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the
surrounding tissue. Therefore, a solid skin barrier, with a pectin
base or karaya wafer that has a measurable thickness and
hydrocolloid adhesive properties, should be applied.
◉ Which of these comments, if made by Mrs. Warren before her
surgery, would indicate that she had concerns about her body
image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many
surgeries."
,Answer: 3) "I need to go shopping for some loose, baggy clothes."
Rationale:Body image refers to a person's perception of self and
determines how the person interacts with others. One does not
need to purchase special clothing after ileostomy surgery,
although some minor adjustments may be needed for comfort,
e.g., stretch underwear or pantyhose for support.
◉ To medical surgical nursing 11th edition by ignatavicius
workman Test Bank or any other Test Banks email
banks and other E books
Answer:
◉ Lewis Palmer, 45 years old, has a history of multiple myocardial
infarctions and is a heavy smoker. He takes warfarin sodium
(Coumadin) daily. Two weeks ago, he had a right femoral-popliteal
bypass, which became occluded 24 hours ago. He is admitted
following an angioplasty of the femoral-popliteal bypass graft. Mr.
Palmer is receiving continuous IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the
nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals.
Answer: 4) check the femoral puncture site at frequent intervals.
, Rationale: Since bleeding is a common side effect of heparin, it is
vital to check the operative site, the femoral puncture area, for
signs of bleeding.
◉ Attempts to revascularize Mr. Palmer's leg are unsuccessful, and
Mr. Palmer has a below-knee amputation (BKA) of his right
extremity and is returned to the medical-surgical unit with an
intravenous infusion in place. His orders include: heparin drip,
morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin
sodium g 1 IV q6h.
Twelve hours postoperatively, Mr. Palmer is found to be short of
breath and diaphoretic. He says, "My chest hurts." His pulse is
140/min, compared to a baseline of 80/min. His blood pressure
is105/60 mm Hg, compared to a baseline of 138/70 mm Hg. His
respirations are 32/min, compared to a baseline of 16/min. His
O2 saturation is 85%. The nurse immediately calls for help. Which
of the following questions is most important for the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What
Answer: 1) "Have you ever had this type of chest pain before?"
Rationale: Because of the patient's symptoms and his history of
myocardial infarctions, the nurse should find out if the patient has
had this time of pain previously.
◉ Maggie Clark, a 42-year-old female, was admitted with newly
diagnosed type 2 diabetes mellitus. Her blood glucose has been
QUESTIONS
◉ Christine Warren, 45 years old, has a long history of ulcerative
colitis, and non-surgical treatment no longer relieved her
symptoms. She underwent a total proctocolectomy and a
permanent ileostomy 12 hours ago.
The nurse should contact the physician immediately if Mrs.
Warren has which of these findings?
1) The stoma appears pale and dry.
2) The stoma appears red and shiny.
3) There is 200 mL of dark green output from the stoma.
4) There is 50 mL of serosanguinous drainage from the stoma.
Answer: 1) The stoma appears pale and dry.
Rationale: If there is an adequate blood supply to the stoma, the
color is pink or red, and the stoma is moist as a result of mucous
production. A pale dry color suggests ischemia of the stoma or
bowel and must be reported immediately to the physician. With
an ileostomy initially after surgery, the output is a loose, dark
green liquid that may contain some blood. The ileostomy usually
begins to drain within 24 of surgery at more than one liter per
day.
,◉ When changing Mrs. Warren's ileostomy bag, the nurse notices
that the peristomal skin is irritated.
Which of these actions by the nurse would be appropriate before
reapplying the appliance?
1) Wash the area with antiseptic soap and water.
2) Clean the site with Dakin's solution.
3) Use a solid skin barrier.
4) Obtain an order for a topical antibiotic.
Answer: 3) Use a solid skin barrier.
Rationale: The drainage from the stoma can quickly irritate the
surrounding tissue. Therefore, a solid skin barrier, with a pectin
base or karaya wafer that has a measurable thickness and
hydrocolloid adhesive properties, should be applied.
◉ Which of these comments, if made by Mrs. Warren before her
surgery, would indicate that she had concerns about her body
image?
1) "I will have to stop my aerobics classes."
2) "I'm so afraid I may not survive the surgery."
3) "I need to go shopping for some loose, baggy clothes."
4) "I'm concerned that this may be only the first of many
surgeries."
,Answer: 3) "I need to go shopping for some loose, baggy clothes."
Rationale:Body image refers to a person's perception of self and
determines how the person interacts with others. One does not
need to purchase special clothing after ileostomy surgery,
although some minor adjustments may be needed for comfort,
e.g., stretch underwear or pantyhose for support.
◉ To medical surgical nursing 11th edition by ignatavicius
workman Test Bank or any other Test Banks email
banks and other E books
Answer:
◉ Lewis Palmer, 45 years old, has a history of multiple myocardial
infarctions and is a heavy smoker. He takes warfarin sodium
(Coumadin) daily. Two weeks ago, he had a right femoral-popliteal
bypass, which became occluded 24 hours ago. He is admitted
following an angioplasty of the femoral-popliteal bypass graft. Mr.
Palmer is receiving continuous IV heparin.
Because Mr. Palmer is receiving heparin, it is essential for the
nurse to
1) monitor his prothrombin time.
2) observe him for signs of pulmonary embolism.
3) limit his intake of foods high in vitamin K.
4) check the femoral puncture site at frequent intervals.
Answer: 4) check the femoral puncture site at frequent intervals.
, Rationale: Since bleeding is a common side effect of heparin, it is
vital to check the operative site, the femoral puncture area, for
signs of bleeding.
◉ Attempts to revascularize Mr. Palmer's leg are unsuccessful, and
Mr. Palmer has a below-knee amputation (BKA) of his right
extremity and is returned to the medical-surgical unit with an
intravenous infusion in place. His orders include: heparin drip,
morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin
sodium g 1 IV q6h.
Twelve hours postoperatively, Mr. Palmer is found to be short of
breath and diaphoretic. He says, "My chest hurts." His pulse is
140/min, compared to a baseline of 80/min. His blood pressure
is105/60 mm Hg, compared to a baseline of 138/70 mm Hg. His
respirations are 32/min, compared to a baseline of 16/min. His
O2 saturation is 85%. The nurse immediately calls for help. Which
of the following questions is most important for the nurse to ask?
1) "Have you ever had this type of chest pain before?"
2) "How long have you had this pain?"
3) "What pain medication do you usually take?"
4) "What
Answer: 1) "Have you ever had this type of chest pain before?"
Rationale: Because of the patient's symptoms and his history of
myocardial infarctions, the nurse should find out if the patient has
had this time of pain previously.
◉ Maggie Clark, a 42-year-old female, was admitted with newly
diagnosed type 2 diabetes mellitus. Her blood glucose has been
