RN ADULT MEDICAL SURGICAL 2025 EDITION
Question 72:
A nurse is caring for a client who has an arterial line for blood pressure monitoring. Which of the
following actions should the nurse take to ensure a reliable reading?
• A) Close the stopcock.
• B) Flush the line with dextrose 5% in water.
• C) Zero the transducer.
• D) Elevate the head of the bed to 45°.
Answer: C) Zero the transducer.
Explanation: To ensure an accurate reading from an arterial line, the nurse must zero the transducer. This
calibrates the device to ensure accurate blood pressure measurements. The other options are not directly
related to ensuring a reliable reading for blood pressure monitoring.
,Question 85:
A nurse is reviewing the laboratory results of a group of clients. Which of the following client conditions
requires reporting to the local health department?
• A) Clostridium difficile
• B) Genital herpes
• C) Tuberculosis
• D) Varicella zoster
Answer: C) Tuberculosis
Explanation: Tuberculosis is a communicable disease that must be reported to the local health
department for monitoring and control to prevent outbreaks. Clostridium difficile, genital herpes, and
varicella zoster (chickenpox) do not require mandatory reporting in all areas.
,Question 70:
A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the
following findings should the nurse report to the provider as a contraindication to receiving heparin?
• A) Rheumatoid arthritis
• B) Thrombocytopenia
• C) Thalassemia
• D) COPD
Answer: B) Thrombocytopenia
Explanation: Thrombocytopenia, or low platelet count, increases the risk of bleeding and is a
contraindication to receiving heparin, an anticoagulant. Heparin could exacerbate bleeding in clients with
thrombocytopenia. The other conditions listed (rheumatoid arthritis, thalassemia, and COPD) do not
inherently prevent the use of heparin.
, Question 74:
A nurse is caring for a client who is postoperative and is being admitted from the emergency
department (ED).
Vital Signs:
• 1000: Temperature 37.6°C (99.7°F), Heart rate 54/min, Respiratory rate 20/min, Blood pressure
98/41 mm Hg, Diagnosis: Small laceration 9% on right arm.
• 1115: Temperature 36.5°C (97.7°F), Heart rate 84/min, Respiratory rate 22/min, Blood pressure
120/70 mm Hg, Diagnosis: Surgical incision 16% on right arm.
For each body system below, click to specify the nursing interventions that could be appropriate for the
care of the client on the medical surgical unit.
Body System:
• Cardiovascular
• Integumentary
• Gastrointestinal
Answer:
• Cardiovascular: Monitor vital signs regularly.
Question 72:
A nurse is caring for a client who has an arterial line for blood pressure monitoring. Which of the
following actions should the nurse take to ensure a reliable reading?
• A) Close the stopcock.
• B) Flush the line with dextrose 5% in water.
• C) Zero the transducer.
• D) Elevate the head of the bed to 45°.
Answer: C) Zero the transducer.
Explanation: To ensure an accurate reading from an arterial line, the nurse must zero the transducer. This
calibrates the device to ensure accurate blood pressure measurements. The other options are not directly
related to ensuring a reliable reading for blood pressure monitoring.
,Question 85:
A nurse is reviewing the laboratory results of a group of clients. Which of the following client conditions
requires reporting to the local health department?
• A) Clostridium difficile
• B) Genital herpes
• C) Tuberculosis
• D) Varicella zoster
Answer: C) Tuberculosis
Explanation: Tuberculosis is a communicable disease that must be reported to the local health
department for monitoring and control to prevent outbreaks. Clostridium difficile, genital herpes, and
varicella zoster (chickenpox) do not require mandatory reporting in all areas.
,Question 70:
A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the
following findings should the nurse report to the provider as a contraindication to receiving heparin?
• A) Rheumatoid arthritis
• B) Thrombocytopenia
• C) Thalassemia
• D) COPD
Answer: B) Thrombocytopenia
Explanation: Thrombocytopenia, or low platelet count, increases the risk of bleeding and is a
contraindication to receiving heparin, an anticoagulant. Heparin could exacerbate bleeding in clients with
thrombocytopenia. The other conditions listed (rheumatoid arthritis, thalassemia, and COPD) do not
inherently prevent the use of heparin.
, Question 74:
A nurse is caring for a client who is postoperative and is being admitted from the emergency
department (ED).
Vital Signs:
• 1000: Temperature 37.6°C (99.7°F), Heart rate 54/min, Respiratory rate 20/min, Blood pressure
98/41 mm Hg, Diagnosis: Small laceration 9% on right arm.
• 1115: Temperature 36.5°C (97.7°F), Heart rate 84/min, Respiratory rate 22/min, Blood pressure
120/70 mm Hg, Diagnosis: Surgical incision 16% on right arm.
For each body system below, click to specify the nursing interventions that could be appropriate for the
care of the client on the medical surgical unit.
Body System:
• Cardiovascular
• Integumentary
• Gastrointestinal
Answer:
• Cardiovascular: Monitor vital signs regularly.
