ANCC Med-Surg Certification
d - ANS A nurse is reviewing the 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/hrb. continue to monitor the heparin infusion as prescribedc. request a
prothrombin timed. stop the heparin infusion
a - ANS A nurse is providing 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 - ANS A nurse is assess a client in the emergency room who has a
bradydysrhythmia. Which of the following findings should the nurse expect?A.
confusionB. friction rubC. hypertensionD. dry skin
d - ANS A nurse in the emergency 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
D - ANS A nurse is caring for a 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
C - ANS A nurse is caring for a 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 - ANS a nurse is caring for 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
b - ANS A nurse is assessing a 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
b - ANS a nurse is caring for a client who is being treated for HF and has prescriptions
for digoxin and furosemide. The nurse should plan to monitor for which of the following
as an adverse effect of these medications?a. SOBb. lightheadednessc. dry coughd.
metallic taste
c - ANS a nurse is monitoring a client following coronary artery bypass graft surgery.
Which of the following findings can indicate cardiac tamponade?a. sternal instabilityb.
inc WBC countc. BP 140/82 mmHg on inspiration and 154/90 mmHg on expirationd.
sinus rhythm with occasional premature atrial contraction and HR 88/min
d - ANS A nurse is preparing a client for coroncary angiography. The nurse should
report which of the following findings to the provider prior to the procedure?a.
hemoglobin 14.4 g/dLb. history of peripheral arterial diseasec. urine output 200 mL/4
hrd. previous allergic reaction to shellfish
a - ANS A nurse is caring for a client following insertion of a permanent pacemaker.
Which of the following client statements indicates a potential complication of the
insertion procedure?a. "I can't get rid of these hiccups."b. "I feel dizzy when i stand."c.
"My incision site stings."d. "I have a headache."
b - ANS A nurse is providing discharge teaching for a client who has a prescription for
the transdermal nitroglycerin patch. Which of the following instructions should the nurse
include in the teaching?a. apply the new patch to the same site as the previous patchb.
place the patch on an area of skin away from skin folds and jointsc. keep the patch on
24 hr per dayd. replace the patch at the onset of angina
c - ANS A nurse is caring for a client in the first hour following an aortic aneurysm
repair. Which of the following findings can indicate shock and should be reported to the
provider?a. serosanguinous drainage on dressingb. severe pain with coughingc. urine
output of 20 mL/hrd. increase in temp from 36.C (98.2F)- 37.5C (99.5F)
,d - ANS A nurse caring for a client following an abdominal aortic aneurysm resection.
Which of the following is the priority assessment for this client?a. neck vein distentionb.
bowel soundsc. peripheral edemad. urine output
b - ANS A nurse is watching a client's ECG monitor and notes that the client's rhythm
has changed from a normal sinus rhythm to supraventricular tachycardia. The client is
conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should
anticipate assisting with which of the following interventions?a. delivery of precordial
thumpb. vagal stimulationc. administration of atropine IVd. defibrillation
a - ANS A nurse is providing discharge teaching for a client who has HF. The nurse
should instruct the client to report which of the following findings immediately to the
provider?a. weight gain of 2 lb in 24 hrb. inc of 10 mmHg in systolic BPc. dyspnea with
exertiond. dizziness when rising quickly
c - ANS A nurse is admitting a client who has a leg ulcer and a history of DM. The
nurse should use which of the following focused assessments to help differentiate
between an arterial ulcer and a venous stasis ulcer?a. explore the clients family history
of peripheral vascular diseaseb. note the presence or absence of pain at the ulcer sitec.
inquire about the presence or absence of claudicationd. ask if the client has had a
recent infection
c - ANS A nurse is reviewing the laboratory results of several clients who have
peripheral arterial disease. The nurse should plan to provide dietary teaching for the
client who has which laboratory values?a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL
90 mg/dLb. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dLc. Cholesterol 190
mg/dL, HDL 25 mg/dL, LDL 160 mg/dLd. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL
125 mg/dL
b - ANS a nurse is providing health teaching for a group of clients. Which of the
following clients is at risk for developing peripheral arterial disease?a. a client who has
hypothyroidismb. a client who has DMc. a client whose daily caloric intake consists of
25% fatd. a client who consumes two bottles of beer a day
a, b, e - ANS a nurse is planning a presentation about hypertension for a community
women's group. which of the following lifestyle modifications should the nurse include
(select all that apply)a. limited alcohol intakeb. regular exercise programc. dec Mg
intaked. reduced K intakee. smoking cessation
, b - ANS A nurse is caring for a client in the first 8 hr following coronary artery bypass
graft surgery. Which of the following client findings should the nurse report to the
provider?a. mediastinal drainage 100 mL/hrb. BP 160/80 mmHgc. Temp 37.1 (98.8)d. K
3.8 mEq/L
d - ANS A nurse is caring for a client who has a history of angina and is schedules for a
stress test at 1100. Which of the following statements by the client requires the nurse to
contact the provider for possible rescheduling?a. "I'm still hungry after the bowl of cereal
I ate at 7am."b. "I didn't take my heart pills this morning because the doctor told me not
to."c. "I have had chest pain a couple of times since I saw my doctor in the office last
week."d. "I smoked a cigarette this morning to calm my nerves about having this
procedure."
a - ANS A nurse is caring for a client who has dilated cardiomyopathy. The client
reports increasing difficulty completing her daily 1-mile walks. The nurse should
recognize that this is a finding of which of the following?a. left ventricular failureb.
peripheral vasodilationc. pericardial effusiond. dec vascular volume
c - ANS A nurse is caring for a client who is scheduled for a coronary artery bypass
graft in 2 hr. Which of the following client statements indicates a need for further
clarification by the nurse?a. "My arthritis is really bothering me because I haven't taken
my aspiring in a week."b. "My blood pressure shouldn't be high because I took my BP
medication this morning."c. "I took my warfarin last night according to my usually
schedule."d. "I will check my BP because I took a reduced dose of insulin this morning."
c - ANS A nurse is caring for a client who had an onset of chest pain 24 hr ago. The
nurse should recognize that an increase in which of the following is diagnostic of a
MI?a. myoglobinb. c-reactive proteinc. creatine kinase- MBd. Homocysteine
d - ANS a nurse is caring for a client who has a history of DVT and is receiving
warfarin. Which of the following client findings provides the nurse with the best evidence
regarding the effectiveness of the warfarin therapy?a. hemoglobin 14 g/dLb. minimal
bruising of extremitiesc. reduced circumference of affected extremityd. INR 2.5
b - ANS A client who has a new diagnosis of hypertension has a prescription for an
ACE inhibitor. The nurse instructs the client about adverse effects of the medication.
The client demonstrates an understanding of the teaching by stating that he will notify
his provider if he experiences which of the following?a. tendon painb. persistent coughc.
frequent urinationd. constipation
d - ANS A nurse is reviewing the 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/hrb. continue to monitor the heparin infusion as prescribedc. request a
prothrombin timed. stop the heparin infusion
a - ANS A nurse is providing 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 - ANS A nurse is assess a client in the emergency room who has a
bradydysrhythmia. Which of the following findings should the nurse expect?A.
confusionB. friction rubC. hypertensionD. dry skin
d - ANS A nurse in the emergency 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
D - ANS A nurse is caring for a 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
C - ANS A nurse is caring for a 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 - ANS a nurse is caring for 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
b - ANS A nurse is assessing a 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
b - ANS a nurse is caring for a client who is being treated for HF and has prescriptions
for digoxin and furosemide. The nurse should plan to monitor for which of the following
as an adverse effect of these medications?a. SOBb. lightheadednessc. dry coughd.
metallic taste
c - ANS a nurse is monitoring a client following coronary artery bypass graft surgery.
Which of the following findings can indicate cardiac tamponade?a. sternal instabilityb.
inc WBC countc. BP 140/82 mmHg on inspiration and 154/90 mmHg on expirationd.
sinus rhythm with occasional premature atrial contraction and HR 88/min
d - ANS A nurse is preparing a client for coroncary angiography. The nurse should
report which of the following findings to the provider prior to the procedure?a.
hemoglobin 14.4 g/dLb. history of peripheral arterial diseasec. urine output 200 mL/4
hrd. previous allergic reaction to shellfish
a - ANS A nurse is caring for a client following insertion of a permanent pacemaker.
Which of the following client statements indicates a potential complication of the
insertion procedure?a. "I can't get rid of these hiccups."b. "I feel dizzy when i stand."c.
"My incision site stings."d. "I have a headache."
b - ANS A nurse is providing discharge teaching for a client who has a prescription for
the transdermal nitroglycerin patch. Which of the following instructions should the nurse
include in the teaching?a. apply the new patch to the same site as the previous patchb.
place the patch on an area of skin away from skin folds and jointsc. keep the patch on
24 hr per dayd. replace the patch at the onset of angina
c - ANS A nurse is caring for a client in the first hour following an aortic aneurysm
repair. Which of the following findings can indicate shock and should be reported to the
provider?a. serosanguinous drainage on dressingb. severe pain with coughingc. urine
output of 20 mL/hrd. increase in temp from 36.C (98.2F)- 37.5C (99.5F)
,d - ANS A nurse caring for a client following an abdominal aortic aneurysm resection.
Which of the following is the priority assessment for this client?a. neck vein distentionb.
bowel soundsc. peripheral edemad. urine output
b - ANS A nurse is watching a client's ECG monitor and notes that the client's rhythm
has changed from a normal sinus rhythm to supraventricular tachycardia. The client is
conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should
anticipate assisting with which of the following interventions?a. delivery of precordial
thumpb. vagal stimulationc. administration of atropine IVd. defibrillation
a - ANS A nurse is providing discharge teaching for a client who has HF. The nurse
should instruct the client to report which of the following findings immediately to the
provider?a. weight gain of 2 lb in 24 hrb. inc of 10 mmHg in systolic BPc. dyspnea with
exertiond. dizziness when rising quickly
c - ANS A nurse is admitting a client who has a leg ulcer and a history of DM. The
nurse should use which of the following focused assessments to help differentiate
between an arterial ulcer and a venous stasis ulcer?a. explore the clients family history
of peripheral vascular diseaseb. note the presence or absence of pain at the ulcer sitec.
inquire about the presence or absence of claudicationd. ask if the client has had a
recent infection
c - ANS A nurse is reviewing the laboratory results of several clients who have
peripheral arterial disease. The nurse should plan to provide dietary teaching for the
client who has which laboratory values?a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL
90 mg/dLb. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dLc. Cholesterol 190
mg/dL, HDL 25 mg/dL, LDL 160 mg/dLd. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL
125 mg/dL
b - ANS a nurse is providing health teaching for a group of clients. Which of the
following clients is at risk for developing peripheral arterial disease?a. a client who has
hypothyroidismb. a client who has DMc. a client whose daily caloric intake consists of
25% fatd. a client who consumes two bottles of beer a day
a, b, e - ANS a nurse is planning a presentation about hypertension for a community
women's group. which of the following lifestyle modifications should the nurse include
(select all that apply)a. limited alcohol intakeb. regular exercise programc. dec Mg
intaked. reduced K intakee. smoking cessation
, b - ANS A nurse is caring for a client in the first 8 hr following coronary artery bypass
graft surgery. Which of the following client findings should the nurse report to the
provider?a. mediastinal drainage 100 mL/hrb. BP 160/80 mmHgc. Temp 37.1 (98.8)d. K
3.8 mEq/L
d - ANS A nurse is caring for a client who has a history of angina and is schedules for a
stress test at 1100. Which of the following statements by the client requires the nurse to
contact the provider for possible rescheduling?a. "I'm still hungry after the bowl of cereal
I ate at 7am."b. "I didn't take my heart pills this morning because the doctor told me not
to."c. "I have had chest pain a couple of times since I saw my doctor in the office last
week."d. "I smoked a cigarette this morning to calm my nerves about having this
procedure."
a - ANS A nurse is caring for a client who has dilated cardiomyopathy. The client
reports increasing difficulty completing her daily 1-mile walks. The nurse should
recognize that this is a finding of which of the following?a. left ventricular failureb.
peripheral vasodilationc. pericardial effusiond. dec vascular volume
c - ANS A nurse is caring for a client who is scheduled for a coronary artery bypass
graft in 2 hr. Which of the following client statements indicates a need for further
clarification by the nurse?a. "My arthritis is really bothering me because I haven't taken
my aspiring in a week."b. "My blood pressure shouldn't be high because I took my BP
medication this morning."c. "I took my warfarin last night according to my usually
schedule."d. "I will check my BP because I took a reduced dose of insulin this morning."
c - ANS A nurse is caring for a client who had an onset of chest pain 24 hr ago. The
nurse should recognize that an increase in which of the following is diagnostic of a
MI?a. myoglobinb. c-reactive proteinc. creatine kinase- MBd. Homocysteine
d - ANS a nurse is caring for a client who has a history of DVT and is receiving
warfarin. Which of the following client findings provides the nurse with the best evidence
regarding the effectiveness of the warfarin therapy?a. hemoglobin 14 g/dLb. minimal
bruising of extremitiesc. reduced circumference of affected extremityd. INR 2.5
b - ANS A client who has a new diagnosis of hypertension has a prescription for an
ACE inhibitor. The nurse instructs the client about adverse effects of the medication.
The client demonstrates an understanding of the teaching by stating that he will notify
his provider if he experiences which of the following?a. tendon painb. persistent coughc.
frequent urinationd. constipation
